Telemedicine and Health Disparities During COVID-19

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has resulted in rapid and large-scale expansion of telemedicine. At a time when physical contact with the medical system poses a risk of infection, telemedicine offers a vehicle for delivering medical care at a safe social distance. It allows for attention to acute concerns as well as routine screening for medical and social needs, which may be heightened during this time. For families with limited resources, telemedicine offers particular advantages, obviating the need for transportation, child care, and additional time needed for in-person office visits. For these reasons, telemedicine has been proposed as a solution to health care inequities in the past and implemented with success in select populations.1 Although the promise of telemedicine is an expansion of access, reliance on technology is likely to highlight existing vulnerabilities and widen disparities if precautions are not taken. Previous reports have outlined how technology-based solutions are highly susceptible to intervention-generated inequalities driven by underlying inequalities in access and uptake.2 Because rollout of telemedicine on this scale is unprecedented, the use of telemedicine in ambulatory settings during this time may illuminate important lessons for the field of telemedicine as a whole.As medical systems have shifted resources to COVID-19 management, acute concerns and preventive care unrelated to COVID-19 are at risk of being foregone. Several health systems have recently reported large increases in telemedicine use, particularly as a mechanism to screen for COVID-19 and provide appropriate guidance on follow-up care.3 As a general pediatrics practice, we are also using telemedicine to provide vital preventive and chronic care, including newborn follow-up visits, developmental screening, nutrition counseling, asthma management, behavioral health, and management of children who are medically fragile and technology dependent. After initial implementation of telemedicine for our large, academic, pediatric primary care practice, we have identified barriers to telemedicine that may exacerbate existing health inequities.A successful telemedicine encounter requires access to an Internet-enabled device compatible with the platform that the medical practice is using. Although 80% of adults in the United States have access to a smartphone and 75% have access to broadband Internet at home, these numbers are lower among those with lower educational attainment and those with a low income, precisely those who already suffer from various health disparities.4,5 In our practice, only two-thirds of patients have an e-mail address in the health system database. As an example, we received a call from the mother of a toddler with a complex, chronic illness reporting that he was vomiting up blood. Before COVID-19, this family would have been directed to go to the emergency department (ED); but the risk and benefit calculation of ED use in the COVID-19 era is different, so we planned for a telemedicine visit. The patient’s mother was undocumented, did not speak English, and did not have an iPhone, data plan, or e-mail address. However, this mother did have an alternative, free and internationally popular chat application that functions on all mobile devices. Typically, applications not designed for telemedicine would not be available options for communication of personal health information, but, given the state of emergency and relaxed restrictions,6 the provider was able to use this application to place a video call, easily see the slightly blood-specked sputum on a paper towel, and visualize the happy, well-appearing, playful child wrestling with his cousins, clearly not in need of emergency medical attention. Not only was an ED visit avoided, but the patient did not have to leave his home to be adequately evaluated that evening. Our practice has put a policy in place to prioritize patient access over the use of any one specific application; this degree of flexibility is necessary to deliver quality care to communities across the spectrum of socioeconomic status and digital proficiency. Once the state of emergency is lifted and regulations on allowable digital platforms is more restrictive, strong advocacy efforts will be required to maintain this level of access to medical care for vulnerable populations.Limited English proficiency and the need for appropriately trained medical interpreters add an additional layer of complexity to delivering care via telemedicine. Although the applications designed for telemedicine theoretically have the functionality to use interpreters, adding a third party to the call requires additional resources and time. For the patient discussed above, there was no simple way for the provider to use an application familiar, acceptable, and accessible to the patient and use an interpreter simultaneously, so she improvised, calling the patient by phone with a medical interpr