Could Telehealth Improve Equity During the COVID-19 Pandemic?

Patients Have Different Experiences With Stay-at-Home Orders and Other Recommendations Designed to Reduce Risk of Exposure

We know that some groups face greater challenges in complying with stay-at-home orders. People living in population-dense areas are less able to practice physical distancing. Those who cannot afford 2 weeks of groceries must shop more frequently, increasing their risk of exposure. Essential workers reliant on public transportation face greater risks than those who can drive their own cars. Patients without the technology and/or skills to access telehealth services may risk in-person visits when not necessary for their medical condition, rely on more limited communication methods to interact with their providers, or simply delay care. Even when in-person care is possible, telehealth options will remain, but some populations will still be at higher risk of infection or have concerns about seeking in-person care.⁵ Understanding equitable access to telehealth options is critical to the ability of family medicine physicians to plan an appropriate course of care for these patients.

The Right Tools, Access, and Skills Are Necessary for Full Use of Telehealth

Patients need a device that supports audio and visual communication and access to home internet to communicate using that device. Telephone consultations are useful; however, visual communication expands assessment opportunities.⁶ There are also a number of tools that support remote health care delivery that rely on access to appropriate medical devices and technologies. For example, remote symptom-monitoring tools such as blood pressure cuffs and pulse oximeters may reduce the need for in-person visits. However, access to such tools and individuals’ abilities to remotely transmit the data to a primary care office are not the same across the United States. Whereas 81% of the US population overall owns a smartphone, that percentage drops to 53% for older adults.⁷ Furthermore, those with smartphones may have limited data plans or may share a device across family members, making reliance on this device for telehealth a burden. In addition, nearly 40% of low-income households and 37% of rural households lack a broadband internet subscription.^8,9 Whereas programs are available to connect patients to needed devices and the internet,¹⁰ screening patients to ensure they have both internet and device access will remain critical.

Digital Skills and Literacy Are in Addition Necessary

Literacy, the ability to read and write, and health literacy, the ability to obtain, process, understand, and communicate health-related information, are critical skills to engaging in one’s health care.¹¹ Digital literacy in the context of health care extends these concepts and refers to the ability to access and understand health information online and use health information technology tools to participate in one’s health care. Tools to screen for digital literacy can identify who needs help and what type of help. Some patients may need help learning to use any technology, whereas others may be able to use a computer or smartphone but need training to use specific tools. Currently, digital literacy training is available from a variety of sources including libraries, community centers, and others—and many programs have quickly adapted in this pandemic to provide remote access to their services.¹⁰ Partnering with these organizations now and in the future may preserve the ability to screen patients for digital literacy as well as target needed training focused on the use of telehealth tools—important steps toward reducing disparities in access to and use of telehealth. In the current pandemic situation, providers are using multiple platforms out of necessity, but these platforms vary for both patients and providers in terms of usability as well as integration with electronic health records. Moving forward, examining usability and ensuring telehealth platforms work for both these groups is key to ensuring a sustainable, equitable system.

Partnerships in Vulnerable Communities Can Help Address Needs

Recent policy articles highlight how multistakeholder partnerships can address a patient’s broader needs to maintain their health. For example, health care systems and social services are becoming increasingly integrated through the use of social workers and community health workers, the incorporation of social risk screening into medical care, and the introduction of polices that expand coverage for social services.¹² Specific to older adults, partnerships between area agencies on aging and health care organizations can support transitions from hospital to home.¹³ Partnerships such as these can also be leveraged to increase digital literacy and access by linking patients in need of training, access, and devices with appropriate organizations. Notably, these partnerships can help to meet immediate needs in this critical time as well as serve patients made vulnerable well into the future.

Policy Changes Facilitate Access Now, but They Are Temporary

Currently health care providers have significant flexibility in how they are able to remotely interact with patients. Restrictions on software used for telehealth visits as well as policies related to documentation have been relaxed in the face of the need to get patients and providers online quickly.¹⁴ Whereas few would advocate for all relaxed policies to remain, we must consider how such policies may benefit at-risk populations. The Federal Communications Commission is offering grants to health care systems allowing them to pay for internet services and devices for patients and has temporarily allowed use of additional space in the broadband spectrum to support the increase in internet use.¹⁵ Many internet service providers agreed to temporarily suspend service terminations, waive late fees, and open local WiFi hotspots as well as having expanded their offerings to lower-income households and adjusted eligibility requirements during the pandemic.¹⁰ These changes are helping children stay connected to their school work, helping employees continue to work remotely, and helping patients use telehealth services. However, these options are in place only until September 30, 2020, begging the question of what happens next?

Family Medicine Physicians Play a Vital Role in Promoting Digital Equity to Improve Their Patients’ Health and Health Care Experience

Telehealth care has quickly gained ground in this pandemic, and it calls on the ingenuity, flexibility, and patient-centered mentality of the family medicine physician to assure our patients are receiving equitable and high-quality care both now and moving forward. Advocating for office practices that allow health literacy screening, as well as digital literacy screening, can help reduce disparities in health care as well as in education and employment opportunities.^16,17 Whereas screening alone is not sufficient to solve issues of equity, it is a critical starting point that allows the identification and documentation of the extent of challenges and can help practices better target their limited resources. Workflows that structure these screenings outside the office visit are key to ensuring our patients, and providers are best equipped during subsequent clinical consultations. Notably, the recent surge in telehealth use has significantly increased the number of patients and physicians who now have experience using this modality of care. This experience allows family medicine physicians to view telehealth as an important location of care and understand its usefulness in addressing a variety of medical conditions. Assuring our practices are partnering with community agencies that can provide digital literacy services will allow us to both leverage our time and expertise for efficient and effective care.

Offering telehealth services comes at a cost both for patients and physician practices and particularly for outpatient care delivery.¹⁸ Calling on our national organizations to push for private, state, and federal reimbursement strategies both for the provision of telehealth services and the coverage of tools necessary for our patients and physicians, and especially for those living and practicing in rural and underserved areas, is vital for long-term viability. In this pandemic, we are learning a great deal about how to interact with each other remotely. We have the opportunity to apply a health equity lens to this learning to ensure that the technologies, tools, and policies that remain in place moving forward are accessible to everyone.