The explosion of telehealth catalyzed by the pandemic is changing healthcare forever.
A hybrid model of care that includes both in-person and telehealth visits has emerged, and it’s here to stay. But a very real digital divide is threatening to exacerbate health equity gaps, and it’s up to healthcare providers to understand and address those disparities now, during telemedicine’s nascent stage.
Here are some startling facts about Internet access. According to Pew Research, 26 percent of Americans earning less than $30,000 rely exclusively on smartphone Internet access, and although most without Internet access live in rural areas, digital barriers also affect urban dwellers. For example, in New York City, almost 50% of low-income households lack internet access, according to the mayor’s office. All told, anywhere between 21 and 42 million Americans lack high-speed Internet access, according to the Federal Communications Commission. Nearly half of Americans without at-home Internet were in Black and Hispanic households, according to the Harvard Business Review. The American Medical Informatics Association (AMIA) has urged the federal government to recognize broadband access as a social determinant of health.
In addition, even among those who are using telehealth, The Los Angeles Times recently reported that many who are not fluent in English do not get telehealth in their preferred language—especially those who do not speak Spanish, according to research by the California Pan-Ethnic Health Network. Its surveys also found that Asian respondents were less likely to have a private place for a telehealth appointment, and that Latinx respondents were most likely to report technological barriers such as an unreliable Internet connection.
As daunting as these challenges sound, John Scott, MD, Medical Director of Digital Health for UW Medicine, urges healthcare providers not to become overwhelmed by the digital divide.
Dr. Scott is an early telehealth pioneer and currently oversees the development of new telehealth applications throughout the Pacific Northwest. He’s seen the gradual development of telehealth as technology became more affordable, cloud-based videoconferencing took hold, and people began using these technologies in their personal lives. He’s seen what once seemed impossible become everyday practice. As healthcare moves into the brave new world of telehealth possibilities and challenges, he’s already seeing providers find solutions to barriers—at warp speed, no less—and knows it’s a harbinger of more to come.
“Healthcare providers are encountering, and will continue to encounter, obstacles in telehealth,” he says. “But we are learning a lot, fast, and finding solutions.”
Fast being the operative word. In February 2020, about 200 UW Medicine healthcare-system providers logged about 200 telehealth visits. In May 2020, 3,800 providers in the system had 33,000 visits. And the numbers keep growing.
“The genie is out of the bottle,” Dr. Scott says. “People tried it to avoid exposure to COVID-19 and realized how convenient and easy it is. There’s no going back.”
The three drivers of future telehealth growth, he says, are increased broadband access, device access, and digital literacy. The $1 trillion infrastructure bill that Congress passed in August will go a long way toward increasing broadband where there are deficits. Device access is being addressed in many different ways—from Medicaid providing tablets to recipients who demonstrate need, to companies like Amazon and Microsoft giving them away as those tech giants lay the groundwork for getting into the business of healthcare themselves. Digital literacy is being tackled at a grassroots level, with opportunities for education arising at local libraries and community centers.
Where providers are concerned, he said, there are three non-negotiables for getting patients to use telehealth: it must be private, reliable, and easy to use for both patients and providers. “You need to create an interface with as few clicks as possible,” he says. “We work hard on the back end to do that.” He says that ideally there’s no downloading of an app; rather, it’s just a link, which can be texted to the patient, where the patient logs in, sees the visit, and clicks to connect.
Dr. Scott explains that it’s important to educate the patient, before telehealth is used, about privacy and how the equipment works. One way to do that is creating a video with instructions, in the language that patients prefer.Contracting with interpreter services ensures straightforward communication once the visits take place. Zoom does provide closed captioning, and sign-language interpreters are an option as well.
“You can have a very good experience connecting with a patient over video, but you have to make them comfortable,” Dr. Scott says. “Show them the actual room, not a background. Show them your badge, that you really are a doctor. Show them that you’re writing notes, so they don’t think you aren’t paying attention. Share your screen, and look at labs and X-rays together. Come close to the camera with your face. Use facial and body language to express caring.”
Just like patients, providers have their own digital learning curves to surmount—and help is out there.Nichole Perisho serves as Program Director at the Northwest Regional Telehealth Resource Center (NRTRC), creating and disseminating information and resources to expand and sustain telehealth in NRTRC’s seven-state region (Alaska, Idaho, Montana, Oregon, Utah, Washington, and Wyoming).
A 10-year veteran in the telehealth field, Perisho is working to develop telehealth’s critical role in achieving the quadruple aim of reducing cost, improving quality, enhancing the patient experience, and bettering the work life of healthcare staff.
Created in 2005, NRTRC is a Health Resources and Services Administration (HRSA) grant–funded program that assists healthcare providers and organizations throughout the region through technical assistance, tools, and training. It has a particular focus on telehealth programs in rural and medically underserved communities and has developed a guide on telehealth for critical-access hospitals.
“When COVID first hit, so many providers scrambled into telehealth to keep hospitals and patients safe,” Perisho says. “But now that most have been doing this for the last year and a half, it might be time to reevaluate and optimize their existing telehealth programs—and address digital divide issues.” (A provider might begin at nrtrc.org by using NRTRC’s new telehealth program assessment tool, a scorable PDF tool that helps gauge where they are in terms of telehealth maturity and what areas could be improved.)
Due to the speed with which providers had to ramp up their telehealth, “a lot of creative wheels are turning right now,” Perisho says—and those are exciting opportunities for providers to share with and learn from each other. “If patients don’t have devices, can providers send them home with devices for eight weeks of follow-up? If they don’t have Internet access at home, is there a library or a police or fire department in town that has a private kiosk set up for telehealth visits? If there is a cultural divide, how do we learn to communicate effectively and appropriately?”
One of the ways NRTRC helps providers and clinicians navigate challenges and gain practical knowledge is by housing online telehealth training courses on its website that are open to the public and free to anyone at nrtrc.catalog.
instructure.com. Offerings include:
- Telehealth 101 Online Training - Gain practical knowledge with this comprehensive overview, for those new to telehealth or looking for a refresher.
- TeleBehavioral Health 101 Series - This six-part series provides basic information and knowledge for delivering behavioral-health and mental-health services via telemedicine.
- Connecting Care Through Telehealth: Long-Term Services and Supports - Designed to inform and improve best practices when using telehealth and virtual services in long-term-services and support settings.
The NRTRC tracks state-level policy on telehealth in the Northwest region. They collaborate with the Center for Connected Health Policy (CCHP), a nonprofit, nonpartisan organization working to maximize telehealth’s ability to improve health outcomes, care delivery, and cost-effectiveness.
Perisho urges providers to visit the Center for Connected Health Policy’s website at cchpca.org to get to know how the laws, regulations, and Medicaid programs work in their state, and to find policies and regulations that impact them.
Whether the various telehealth services initially reimbursed during the pandemic will continue to be reimbursed is up in the air, and the group is highlighting telehealth successes in its advocacy.
Molly Shumway works with Dr. Scott as Director for Digital Health at UW Medicine. She has 20 years of experience in healthcare administration, all at UW Medicine, and transitioned to telehealth in January 2020—so she can certainly relate to the experiences of many healthcare providers who had to innovate when the pandemic hit.
“At UW Medicine, we had good infrastructure, technology, and partnerships and support from IT and compliance in place, but it was still a tremendous ramp-up, and we’re still moving so quickly,” she says. “We’re increasing efficiency while providing care to patients in ways that meet their needs. Telehealth is forcing healthcare to be more of a service industry, because it creates more options for patients.”
In the name of service, though, remember that not everyone who has access to telehealth necessarily wants it.
“There is a risk of implicit bias,” Shumway says. “For example, you might assume that certain patients, such as those who are older or without stable living situations, aren’t interested in telehealth, but when it’s offered, they’re thrilled to be able to use it. On the other hand, some patients prefer in-person or telephone. It’s important that these services are made available to all patients for whom it’s appropriate.”
“Equity is giving people access to appropriate and high-quality care in the way they want it,” Shumway says. “We need to make it easy to connect with us, regardless of the modality. Education and outreach tactics should include all the ways people communicate. What is it you want, and how can we meet you there?”
- John D. Scott, MD, MSc, FIDSA, Medical Director, Digital HealthProfessor, MedicineUniversity of Washington School of Medicine
- Molly Shumway, Director, Digital Health, UW Medicine
- Nichole Perisho, BA, BSN, RN, Program Director, Northwest Regional Telehealth Resource Center