What is Telehealth?
In addition to the benefits of telemedicine that pre-existed COVID-19, the pandemic has demonstrated the unique benefits of telemedicine to provide quality care while keeping patients and healthcare providers safe. With such dramatic growth of telehealth, it is important to understand who is using telehealth and what it means for ensuring everyone has access to this type of care. Telehealth services come in many varieties and are used by patients and medical providers based on need and preference.
Telehealth enables a healthcare provider at one location to deliver care through the use of telecommunications technologies to a patient at a different location. Telehealth can be delivered in two types of modalities -- synchronous (real-time, interactive) or asynchronous.
Synchronous modality involves patients and providers interacting “in real-time” through audio or video. Audio-only telephone appointments may be offered to patients who lack internet access and/or are uncomfortable utilizing the technology needed to complete an internet-based visit with a provider. Video calls can involve one or both parties being able to see each other. Synchronous visits enable the following:
- Live dialogue with a provider
- Opportunity for real time diagnosis and treatment recommendation
- The ability for patients to easily include a family member or caregiver in the conversation
Asynchronous, sometimes also referred to as “store-and-forward,” modality allows the patient and provider to interact at their own convenience. These communications can be offered to populations that lack devices, connectivity, digital skills; or that prefer this type of visit in lieu of a scheduled appointment. Although not appropriate for all matters such as conditions needing urgent attention, asynchronous telehealth can be used for conditions that range from sexual health (ex: obtaining birth control) to managing diagnosed mental health or chronic conditions (ex: prescription management). There are many benefits to asynchronous telehealth:
- Convenience and efficiency that contribute to high levels of patient and provider satisfaction
- The ability to overcome language and cultural barriers
- The opportunity to provide greater privacy for patients, possibly allowing for increased disclosure of embarrassing or stigmatized behaviors
- It enables the provider and patient to interact at a time that works best for them
- It allows underserved communities, who may not have access to high-speed broadband, the ability to obtain convenient quality care
Health systems, insurers and regulators can take steps that would improve the digital readiness of vulnerable populations to use virtual health. Reimbursement for digital readiness screening would enable health systems to hire and/or train staff to serve as digital health navigators to screen patients to identify barriers, refer them to community organizations that are focused on adult digital literacy and connectivity, and then train patients to use digital health tools. The National Digital Inclusion Alliance serves as a national resource for digital navigator training and is an invaluable means of identifying digital inclusion organizations across the country.
What Telehealth Means for Providers
Telehealth offers convenience, greater insight into the lifestyle of patients, and accountability. Through either synchronous or asynchronous telehealth providers are able to better control their work schedules, balance home and family responsibilities, and minimize burnout. Telehealth also allows providers standardized examinations through dynamic questionnaires and easily provides patients with a record of the visit. Finally, providers are able to attract patients who might otherwise not seek care, for example patients who have sensitive conditions, and they are able to give care to more patients on any given day.
What Telehealth Means for Patients
Telehealth is especially convenient for people who have limited access to transportation, have childcare needs, or cannot get off of work during business hours to see a doctor. Text and chat features can also enable people who do not speak English to more easily communicate with a provider in their language. It has long been known that people are more willing to disclose sensitive and stigmatized behaviors or conditions when there is a computer intermediary rather than a face-to-face interaction. Now, advanced forms of non-audiovisual communication encourage patients to seek treatment for stigmatized conditions, like sexual or behavioral health matters, from the comfort and privacy of their homes. Non real-time modes of communication enable patients to access medicines like birth control from a licensed healthcare provider without having to schedule an appointment.
Telehealth Usage has Increased Dramatically During COVID-19
Telehealth use has skyrocketed during the COVID-19 pandemic as health systems made significant efforts to deploy systems, and regulators eased rules and reimbursement policies. Significant financial resources have been made available to health systems and internet service providers to ensure that patients have the devices and connectivity needed to use telehealth. Yet we know that not everyone is benefitting.
The National Health IT Collaborative for the Underserved recently launched the Data Fusion Center, a new platform with curated, de-identified data and tools that allow a far more granular understanding of telehealth and COVID-19-relevant disparities.
Source: NHITC
The use of telehealth in the early months of the COVID-19 pandemic varied widely by state. The most visits were in New York, California, Florida and Pennsylvania whereas the fewest calls were made in Montana, Idaho, Vermont and Puerto Rico.
Source: NHITC
Many of the states with the lowest number of claims are rural and/or have low populations. But other factors must be considered. When we adjust for population size, the greatest telehealth use per 100,000 residents is seen in the Northeast US: Washington DC, Delaware, New York, Rhode Island, Massachusetts and Vermont. States with the lowest penetration include states that are largely rural, less dense, and/or poor: Hawaii, Montana, North Dakota, Idaho, Mississippi, Alabama, Oklahoma and Kansas. While there are certainly other factors to consider, such as state investments in broadband and regulations that affect telehealth (such as Medicaid reimbursement to providers), state-level trends disguise large disparities that occur among populations within states.
Who's Being Left Behind?
Direct Evidence
Because national level claims data are not available to the public broken down by population groups, we can gain a window into who is and is not accessing telehealth by looking at high quality data from other sources. Studies published in highly regarded journals such as the Journal of American Medical Association, and the Journal of American Medical Informatics Association, have highlighted the disparities in telehealth that have come to light during COVID-19. Because such studies reflect only the patients at a single institution, the findings may not apply elsewhere. On the other hand, because the studies reflect the experiences of all patients seen by three large health systems, they paint a compelling picture of disparities that points to the urgent need to address telehealth access and use from an equity lens.
Even with real-time technical support and technology available to patients, a group that cares for underserved patients in the Seattle area reported that virtual visits were completed for only 11 of 2632 visits (0.4%%) by unhoused patients, for 2.6% of 2617 visits by patients with limited English, and 7.3% of 4477 visits by a racially diverse safety-net population. By contrast, 30.5% of visits to the general medicine clinics in that system were virtual. Mount Sinai Health System provided data on 39,229 COVID-19 related visits that occurred during the initial New York City COVID-19 peak, between March 20 and May 18, 2020. White and Asian patients were most likely to use telehealth whereas Black and Hispanic patients, seniors above age 65 and non-English speaking patients were more likely to use the Emergency Room than to use telehealth.
The University of Pennsylvania health system reported that among 78,539 patients with non-face-to face visits, 45.6% had video visits and 56.9% had audio-only telephone visits. Patients in every age group from 55 years and higher had fewer video visits, as did Black, Hispanic patients, and those with household incomes below $50,000. Even patients with incomes in the mid-range were significantly less likely to have had video visits than those whose income was $100,000 or higher. Collectively, these studies point to the need to look at a range of factors:
- Where people obtain care
- The modality used to conduct the visits (e.g., video, audio-only, or store-and-forward)
- What are the differences in patient populations between use of different modalities (i.e., video, audio-only, or store-and-forward)
Indirect Evidence
As a complement to the information about actual telehealth disparities that we have from small studies, important information can be gleaned from nationally representative surveys on closely related topics. Since 2003, The Health Information National Trends Survey (HINTS) has offered valuable data on the growth in adoption of digital technology for health purposes.
For example, seeing who does and does not use online portals to electronic health records is an indirect way to infer trends in telehealth usage and disparities. Online portals have been promoted for the last decade as a convenient way for people to access their health information online, communicate with their physicians about non-urgent matters, request prescription refills, or find high-quality information about health conditions of interest. Dramatic disparities in portal use have been reported in many studies. Efforts to close those disparities reveal some challenges that must be confronted to address telehealth disparities.
A published analysis of responses to the 2017 HINTS survey reported that only 37% of the 2,325 respondents with health insurance had used their online patient portal in the prior 12 months. Nonusers were more likely to have Medicaid insurance, lack a regular provider, and have less than a college education compared to other users. These groups, and people who were not White, were also less likely to have had providers offer portal access to them. Data from the most recent rounds of the HINTS survey are available on the Fusion Center where disparities can be viewed directly. Since then, portal use has risen slowly, reaching 41.3% of adults surveyed in June 2020, but disparities remain large. As shown in the figure below, Hispanic patients have far lower portal use (71% haven’t used in the last year) than White patients (53%); Black and Asian patients had intermediate levels of non-use (60% and 58%). Whereas 29% of White patients used the portal at least three times in the prior year, only 16% of Hispanic patients, and 21% and 22% of Black and Asian patients, respectively, did so.
