No Patient Left Behind: Considering Equitable Distribution of Telehealth


Apr 20, 2021

Older couple using a mobile phone for a telemedicine appointment, photo by FatCamera/Getty Images

Photo by FatCamera/Getty Images

By Rama A. Salhi, Mahshid Abir, Bisan A. Salhi

The COVID-19 pandemic has revealed telemedicine's potential to improve health care delivery and access. In the past year, we have seen rapid expansion of telemedicine, in the form of video and telephone services, the extent of which our health system has never experienced. This expanded access has been most notable for patients with private insurance and ready access to digital technology. However, some historically marginalized populations may also be experiencing improved health care access with the advent of increased telemedicine services. Complicating this trend are recent reports showing persistent disparity in telemedicine uptake based on age, poverty, and urbanicity. As health care professionals, we have a critical opportunity to leverage telemedicine in a way that addresses and closes historical access gaps to achieve health equity.

It's critical to understand that digital connectivity is a basic necessity and a human right as declared by the United Nations. However, access to digital connectivity and its advantages is not evenly distributed within the United States—a condition commonly described as “the digital divide.” We contend, however, that the increasing complexity of digital connectivity (for example, smartphones, tablets, and so forth) renders this term inadequate. Rather than describing people as “technology rich” or “technology poor,” we use “digital equity” to better describe conditions in which populations have access to hardware, internet, viable connection speeds, and skills needed to effectively use these technologies.

Digital connectivity is a basic necessity and a human right.

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Equity is integral to realizing telemedicine's full potential and was recently declared the cornerstone of successful pandemic recovery. In the following, we discuss challenges to equitable engagement with telemedicine services and identify opportunities to improve access for our most vulnerable and disenfranchised patients, with particular attention to the reality that people's inclusion in these categories is dynamic and context dependent.

Challenge 1: Digital Inequities Do Not Neatly Conform to Societal Inequities

In extending frameworks of equity into telemedicine, it is important to recognize when and how digital inequities diverge from broader social inequities. For example, there are no significant differences between white and Black people in terms of cellphone ownership, except among those earning less than $30,000 a year, where rates of cellphone ownership among Black people is higher than among white people. Similarly, a Harlem-based study found that 67 percent of Black people and 73 percent of Latinx people report using their cellphones to find information about health conditions, compared with 58 percent of white people. In one recent survey, Black patients were found to be more likely than white patients to use telemedicine services due to the COVID-19 pandemic.

Telemedicine has the potential to improve engagement with Black and Latinx patients in the form of cellphone-based communications.

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These trends represent important opportunities to bridge known health inequities (for example, access to primary care and specialists) with the intentional, patient-centered use of telemedicine platforms. Telemedicine has the potential to improve engagement with Black and Latinx patients in the form of cellphone-based communications. However, this is contingent upon health care providers departing from implicit biases and assumptions (for example, assuming patients are “unreliable” or “noncompliant”) as well as systems readiness to reach out to diverse patient populations by instituting universal screening of digital accessibility (for example, patients' access to broadband internet, mobile data, text messaging, phone services) and implementing flexible engagement tools (for example, text messaging, app-based services) that adapt to varying patients' needs. Sustained patient engagement may be enhanced by partnerships with key stakeholders and community organizations such as community health centers, mobile and street outreach providers, local and state departments of public health, and faith-based organizations.

Challenge 2: Overcoming Structural Barriers to Digital Connectivity

The starkest divisions in internet connectivity manifest along socioeconomic lines. Nearly 100 percent of people making more than $75,000 per year have access to smartphones, compared with approximately 70 percent among people making less than $30,000 per year. Similarly, greater than 95 percent of people who have attended some college or graduated from college report using the internet compared with less than 75 percent of people who have not graduated high school.

A surprising success with telemedicine has come from our most economically disenfranchised patients: those experiencing homelessness, who are often believed to be either unwilling or unable to be digitally connected. However, experiences with the COVID-19 pandemic and rapid expansion of telemedicine, particularly telephone visits, among homeless patients has shown a decline in rates of missed appointments and reports of telehealth as a safer alternative to in-person encounters (PDF) (for example, remaining in familiar surroundings or not leaving belongings on the street to access care). Based on work conducted by researchers at the RAND Corporation, similar patterns for telephone-only visits have been seen in other underserved populations. While these changes were largely enabled by expansion of video and telephone visit reimbursement, they have shed light more broadly on the impact of these reimbursement policies on care access and highlight the importance of inclusion of digital equity in the development and evaluation of such policy measures.

Furthermore, engaging these patients has required creative approaches and stakeholder involvement, including distribution of cellphones or data plans using local (for example, shelter-based), state (for example, managed care organizations), or federal (for example, the Federal Lifeline program) services. In other cases, this meant providing a safe physical space for provision of telehealth resources at designated community access points. These solutions provide us with important examples of the critical lens with which we must approach issues of digital and health equity. Health care providers' assumptions about patients' ability or preferences about telehealth use may pose additional unnecessary barriers.

Challenge 3: Breaches in Data Security/Management May Undermine Trust in Health Care Providers

Any work with disenfranchised populations includes an inherent tension between the need to gather complete and accurate data and the need to protect patients from discrimination. This is a persistent concern in caring for historically disenfranchised populations and is complicated by evolving issues in digital security and well-publicized ransomware attacks on health care systems. Moreover, recent rollbacks of the Health Insurance Portability and Accountability Act (HIPAA) enforcement by the Office of Civil Rights have increased access to telemedicine services during the COVID-19 pandemic but have left health care systems vulnerable to cyberattacks. It is paramount that we consider digital security in relation to the historical mistrust in the health care system harbored by many patients.

It is paramount that we consider digital security in relation to the historical mistrust in the health care system harbored by many patients.

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Although the cybersecurity risks of telemedicine are complex, there are important steps that can be undertaken to reduce risks and engender trust in the health care system. First, hospitals could transparently communicate cybersecurity risks to patients. Patients could be informed of how to recognize, avoid, and report phishing and other scams relating to their medical records, billing, and other potentially sensitive information. Second, health care organizations could work to transition from commercially available conferencing tools to health care–specific products that offer key security features and are HIPAA compliant (for example, or SimpleVisit) or work with other commercially available brands (for example, Zoom for Healthcare) to institute ongoing improvements to ensure HIPAA compliance. Finally, health systems should work with leading experts to develop surveillance and prevention strategies consistent with current best practices while minimizing their impact on health care operations and patient safety.

Whether through community-based programs or federal policy changes, telemedicine could be integrated into many strategic initiatives to expand reach to patients who would normally either be excluded or alienated by the traditional structure of the health system. To do this, we must appreciate the nuances of patients' experiences and innovate with them rather than for them. Telehealth infrastructures could include mechanisms for evaluation and could be implemented within an organizational culture of humility and patient-centeredness. This requires that we health care professionals frame our approach as being in the pursuit of digital equity to reach our overarching goal of achieving health equity.

Rama A. Salhi is an emergency physician and a fellow in the University of Michigan, Institute for Healthcare Policy and Innovation, National Clinician Scholars Program. Mahshid Abir is a senior physician policy researcher at the nonprofit, nonpartisan RAND Corporation. She is also an emergency physician and director of the Acute Care Research Unit (ACRU) at the University of Michigan. Bisan A. Salhi is an emergency physician and associate professor at Emory University.

This commentary was first published on April 20, 2021 on Health Affairs Blog. Copyright ©2021 Health Affairs by Project HOPE — The People-to-People Health Foundation, Inc.

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Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.