For patients to participate in telehealth encounters, they have to use a number of proprietary, health system-specific portals and platforms. That can be challenging for many older adults and minority groups. Effective virtual care depends on digital fluency, meaning they need to be able to engage in all aspects of digital technologies, from accessing the internet to navigating telehealth applications and performing basic troubleshooting. Many people cannot do this, creating significant barriers to care and telehealth disparities for a large segment of the population.
Boston researchers say the technology has the potential to reduce health disparities, but it also is exacerbating structural inequities. “Telehealth is here to stay, and has the potential to actually improve care outcomes, enhance the patient experience, reduce costs, and address health care inequities,” said Rebecca G. Mishuris, MD, MPH, an assistant professor of medicine at Boston University School of Medicine and Chief Medical Information Officer of the Boston Medical Center Health System in Massachusetts. “This, of course, will only be realized if we can address equity in engagement with telehealth, and fully incorporate it into a holistic care delivery model that employs both virtual and in-person care.”
Prior to the COVID-19 pandemic, telehealth was hampered by a lack of reimbursement and liability concerns. Those barriers, however, have largely come down. Dr Mishuris and colleagues conducted a study in which all patients scheduling appointments were asked: Do you have a smartphone or computer with a camera and microphone? Is that device connected to the internet? The answers to these questions and follow-up interviews suggested some worrying trends leading to telehealth disparities.
At her institution, which is a safety net hospital, 21% of Black/African American patients, 20% of Hispanic/Latino patients, and 22% of White patients reported lacking access to a connected device with a camera or microphone. The study on telehealth disparities, published in the Journal of General Internal Medicine, also showed that 67% of White patients opted to schedule their telehealth visits by video compared with only 60% of Black and Latino patients.
To overcome the barriers of device and broadband access, digital fluency, and health advocacy, she and her colleagues propose a multi-pronged approach of creating federal and state policies to democratize access to telehealth and reduce telehealth disparities. Important first steps include establishing platform standards for accessing telehealth as well as supporting societal and health system investments to increase health literacy, advocacy and technology fluency.
“We found that our patients in the safety net engage with telehealth, but there is inequity in the channels through which they engage by race and language,” Dr Mishuris said. “More must be done to address digital access, digital literacy, and health advocacy through telehealth. As clinicians in the safety net, none of this was surprising to us, but we suspect it may surprise those who do not work in the safety net.”
Telehealth equity cannot be the sole responsibility of health care institutions, Dr Mishuris said. Public policy, regulations, and other sectors of the economy may need to come together to reduce telehealth disparities and ensure equitable digital engagement. “For the individual physician or practice, it is crucial to ensure that telehealth is offered equitably, on a platform that perpetuates equity, such as interpreter services and bandwidth variability.”
David Markowitz, PhD, an assistant professor in the School of Journalism and Communication at the University of Oregon in Eugene, said training patients, families, and healthcare teams is possible, but major barriers must be addressed. First, patients need to have the appropriate hardware and the skills to use the hardware competently. “Training can only be successful if they are inclusive, meaning they are available and approachable to people of different digital literacy levels, plus those with mixed access to communication technology,” Dr Markowitz said.
Setting a standard might appear equitable at the onset, but a patient-centered model may be better and more inclusive. “Physicians and health care providers should consider meeting patients where they are in terms of technology access and digital literacy. This might make for a more effective and agreeable patient-physician experience,” Dr Markowitz said.
Yalini Senathirajah, PhD, of the Department of Biomedical Informatics at the University of Pittsburgh in Pennsylvania, said broadband access is a major determinant of telehealth use and only 43% of households have it. “There is also a great need to improve patient engagement for all groups and really understand and invest in the patient experience, which can differ so widely,” Dr Senathirajah said.
Patient experience may vary greatly for different patients, and patients themselves can have preferences around what technologies they want to use. Some patients may not want to have video calls because they are shy about the doctor seeing their living conditions, not because of a lack of access, she said.
“Standard definitions are needed in telehealth so patients and caregivers know what is available,” said Deborah R Levy, MD, MPH, a post-doctoral research fellow in informatics at VA Connecticut Healthcare System in West Haven. “In our work, we identified a great discrepancy between how different states and institutions define telehealth and telemedicine.”
Barnett KG, Mishuris, RG, Williams, CT, et al. Telehealth’s double-edged sword: Bridging or perpetuating health inequities? J Gen Intern Med. Published online March 23, 2022. doi:10.1007/s11606-022-07481-w