In a year, the Covid-19 pandemic transformed telehealth from an underutilized niche into a mainstay of care provision. Proponents hold up digital platforms as a means to provide convenient, accessible, and cost-effective healthcare. The benefits telemedicine offers should not be ignored. But amid a too-rapid expansion, providers may risk inadvertently exacerbating access disparities.
The idea that telehealth could restrict access might sound odd at first, given its role as a connective tool during the pandemic. Quarantined patients flocked to digital care, viewing it as a socially-distanced alternative for appointments they would normally have in person. The Urban Institute estimates that one in three US adults scheduled a telehealth appointment during the first six months of the pandemic.
According to recent survey data from Amwell, the number of consumers who experienced a virtual visit in 2020 was roughly three times the number reported the year before. Of those, a remarkable 91 percent reported being “very” or “somewhat” satisfied with the experience. When taken in conjunction with the notable convenience and cost-effectiveness that digitally-facilitated healthcare provides, these adoption rates indicate that telehealth will continue to be a major avenue of care delivery even after the pandemic ends.
“We will never go back to 50 [telehealth] visits a day,” Dr. Paul Testa, NYU Langone’s Chief Medical Information Officer, told Healthcare IT News. “That genie’s out of the bottle.”
But while telehealth’s popularity has spiked, it remains notably underutilized among certain patient groups. One recent study published in an October 2020 issue of Population Health Management found that those in rural and low-income areas are less likely to have access to or use telehealth. This is somewhat ironic, as telehealth has long been held up as a solution for expanding rural healthcare.
These discrepancies appear across racial demographics, too. A study shared in the Journal of the American Medical Informatics Association (JAMIA) noted that during the height of the pandemic, Black patients were 4.3 times more likely to use the ER over telehealth than white patients, and Hispanic patients were 2.5 times more likely to do so.
As the researchers concluded, “Disparities in digital access, digital literacy, and telehealth awareness, as well as issues of cost and coverage and mistrust of digital appointments where physical examinations, labs, and vitals cannot be taken are all potential barriers to telehealth. Future research should explore these barriers in the context of the new telehealth explosion.”
While much of that research remains to be conducted, providers do have some insights into the immediate technical barriers affecting these demographics — i.e., internet unavailability, device inaccessibility, and limited digital literacy.
Factors Limiting Telehealth Access
The lack of connectivity in rural areas is not a new or small problem. According to the FCC, a third of rural Americans do not have access to the high-speed broadband Internet necessary to facilitate a video-based care appointment. The connectivity rate disparities between rural and urban areas are stark. In Michigan, for example, only three percent of urban residents lack internet connection; in rural areas, that number rises to almost 40 percent.
Given that internet access is a prerequisite for any telehealth appointment, it’s not all that surprising that studies associate a lack of broadband with fewer telehealth visits and reduced patient portal use. After all, these disconnected rural residents lack the basic framework necessary to access digitally-facilitated healthcare.
Another aspect of this framework is device accessibility. According to Census data, one in five rural households do not have access to a computer or handheld device. Not having a computer is more common among older households; nearly a third of households led by people over 65 reported not having an at-home device. This lack is less extreme but still notable in certain racial demographics. The same dataset indicates that 20 percent of Black households and 16 percent of Hispanic households didn’t have a computer or handheld device at home. These numbers stand in notable comparison to the lack experienced by 12 percent of white and six percent of Asian households.
But even when a patient has a device, there’s no guarantee that they know how to access healthcare services. As researchers for a study recently published in Telemedicine and e-Health noted, “We identified lower use of the inpatient portal among African American and older patients, relative to White and younger patients, respectively. […] These findings suggest that the availability of the technology alone may be insufficient to overcome barriers to use and that additional intervention may be needed to close the digital divide.”
Another factor to consider is how effective conversations are when patients manage to connect with their provider. In August of 2020, the Agency for Healthcare Research and Quality published a brief that noted electronic communications “may not enhance a patient’s ability to obtain, process, and understand relevant health information.” In other words, a simple Zoom conversation may not be enough to educate a patient about their diagnosis or engage them in their treatment plan.
To borrow a summation of the situation from Shantanu Agrawl and Tejal Gandhi, who recently authored a Health Affairs article on telehealth access, “Technology does not necessarily ameliorate any shortcomings of our flawed and fragmented system, thus addressing equity is much more about culture and strategy than technology per se. For telehealth, that means implementation with supporting policies to ensure reach to underserved populations.”
Simply expanding telehealth offerings will not ensure increased — or even equal — access to telehealth services. If telemedicine is to become a significant part of the American healthcare system, our roll-out process will need to be a collaborative, well-funded undertaking.
Broadband infrastructure, as an example, will need to be expanded until rural areas enjoy the same connectivity as their metropolitan peers. Providers may forge partnerships with community-based nonprofits to increase data literacy and bolster underserved patients’ access to telehealth-compatible devices. Healthcare organizations may also consider launching educational initiatives to help providers guard against digitally-exacerbated bias and facilitate constructive, engaging virtual appointments.
Over the last year, telehealth has proven its potential to support providers and patients alike. However, we cannot allow our enthusiasm to overshadow the real risks a thoughtless roll-out could pose to underserved patients. If we want to provide a genuinely equitable telehealth experience, we must approach the challenge thoughtfully and with socioeconomic concerns in mind.