In light of the benefits of telehealth, and especially during the pandemic, attention to the adoption of telehealth in underserved communities is of urgent importance. The very populations that most lag in telehealth use (e.g., seniors, people with economic or social vulnerabilities, and those living in rural areas) stand to benefit the most from the convenience it offers. Since populations with low telehealth use already experience higher rates of chronic disease and premature death, the disparity in telehealth use is likely to increase, rather than decrease health disparities.
Healthcare only explains a small fraction of differences in health outcomes. Poverty, education and other social determinants of health, including access to healthy food, safe places for physical activity, transportation, and employment opportunities--are far more influential. Thus, people with a college diploma live nearly 14 years longer than those with less than a high school education. Having a high income adds 10 years to life expectancy for vulnerable populations.
The excess burden of disease experienced by Black and Brown people reflects differences in access to resources and environmental factors. Whereas 29.5% of all white adults have less than a high school education, that is true of 38.4% of Black adults. Black households are twice as likely as white households to be living below the poverty level (25.0 versus 12.2 percent). Additionally, pervasive racism has a marked toll on physiologic and psychological health.
Taken as a whole, we cannot explore solutions to telehealth disparities without also addressing the social determinants of health that exacerbate health disparities.
Cleveland, Ohio was ranked by the National Digital Inclusion Alliance as the Worst Connected City in 2019. In Cuyahoga County Ohio, home to Cleveland, one can see that at least in about one-fifth of the County’s neighborhoods, fewer than one-half of households have a broadband subscription. Many assume that people without home broadband use smartphones instead. However, many of the neighborhoods with low broadband subscription rates also have the lowest levels of smartphone ownership-- between 37% and 68% of households.
Affordability is a tremendous barrier to internet adoption, but cost does not explain everything. The overlap of digital disconnectivity with segregation is striking. In the neighborhoods with the darkest red, at least 84% of residents are Black whereas in the neighborhoods with the lightest color, 3% or fewer residents are Black. About 80% or more residents in the suburban neighborhoods have broadband subscriptions and/or smartphones.
Because internet use is now recognized as a “super social determinant of health,” efforts to close digital barriers to telehealth in rural and urban communities could have an outsized impact on health disparities overall. In addition to the need for broadband and the tools needed to access it (hardware, affordable financial plans, digital literacy, etc.), real-time virtual visits also require that patients have a range of additional items:
A device with a camera and software that can accommodate streaming video
A fast internet connection with minimal lag time
A data plan that will not make a video visit a costly undertaking
Digital skills needed to make the appointment, launch the visit, adjust the camera and microphone, ete
A private, well-lit place to conduct the visit
If people encounter technical difficulties, it's good to have someone in their household or at the doctor's office who is available to help them at the time of the visit. The appropriate use of lower tech solutions, such as audio-only and non-real time modes of telehealth, should be encouraged when they are preferred by patients while communities work toward addressing lack of broadband and other physical barriers to realtime, audiovisual telehealth adoption.
Physical Barriers Don’t Tell The Entire Story
Even when the physical barriers to telehealth are addressed, long standing distrust in the healthcare system by some underserved populations could also have an impact on telehealth adoption. According to 2020 Health Information National Trends Survey (HINTS) data, Whites are more likely to rate their healthcare quality as excellent (34%) than are other minority groups (26-28%) and less likely to rate it as fair or poor. Additionally, whereas 65% of White patients say that their providers have offered them online access to their electronic medical records, fewer Black (57%), Hispanic (46%) and Asian (53%) patients have received such offers.
Patients also express some concerns about digital interaction with providers, questions about privacy and security, or uncertainty about whether their doctor can make an accurate diagnosis by telehealth. They may fear losing their personal relationship with their provider when telehealth is prioritized. It is incumbent upon health systems and telehealth platforms to address these concerns by sharing information with patients about state and federal privacy laws, and regulations that require telehealth providers to implement the same standard of care using telehealth as they would in-person. Finally, a history of systematic racism in the healthcare industry, from the Tuskegee syphilis experiments conducted from the 1930s to the 1970s, to pervasive concerns about discriminatory or judgmental treatment experienced by Black women regarding pregnancy and reproductive health care, impact the level of trust that communities of color have in healthcare systems, and telehealth by extension. Health literacy efforts are especially important in underserved communities to improve telehealth adoption. Informal channels, such as social media, should be embraced as mediums to educate, inform and reach out to new communities about the value of digital health. Reports have already emerged showing preferential access to the COVID-19 vaccine for individuals who do not fall into the priority groups identified by official regulatory and advisory bodies. Those lacking internet and telehealth access are especially being left behind as they are unable to be notified about or book appointments online to receive the vaccine. State-level vaccine distribution strategies could further disadvantage the populations that have borne the highest burden of COVID-19. While 18 states have incorporated a measure of Social Vulnerability into their vaccine distribution priorities, only half of the 16 states with the largest proportions of vulnerable residents have done so. A failure to address a budding vaccine disparity will only compound trust issues with vulnerable communities. We urge states to recognize and address the profound impact of telehealth disparities on vaccine distribution. Finally, when new communities do utilize telehealth, they should have an experience that encourages them to adopt it as a regular part of their care. For example, the National Bureau of Economic Research found that Black men seen by Black doctors agreed to more preventive services than those seen by nonblack doctors. This finding suggests that our healthcare systems should provide patients with more opportunities to select providers that share their ethnic or national background. Telehealth has the potential to amplify these efforts by eliminating physical and geographic barriers to accessing a provider, but only if health systems invest in provider diversity. Further, telehealth platforms should undertake efforts to incorporate implicit bias and other training to reduce disparate outcomes for patients in underserved communities.
Ways to Increase Telehealth Adoption
Telehealth is a critical component of delivering care, especially post-pandemic. It has the potential to provide convenience, greater insight, and accountability for patients and providers in all communities, but only if systemic physical and trust barriers are addressed. Government, community and private sector leaders should continue partnering to advance broadband infrastructure in rural and urban communities, and address other barriers to internet adoption (hardware, cost, digital literacy). Asynchronous or audio-only modes of telehealth can also help mitigate these barriers for underserved populations.
In addition to the physical barriers, lack of trust remains a roadblock for underserved communities to fully invest in healthcare, and telehealth by extension. Health systems and platforms that utilize telehealth must proactively reach out to debunk misinformation that prevents people from adopting telehealth and explore new channels to inform and educate communities about telehealth. Finally, to retain underserved communities on telehealth platforms, efforts should be made to create a positive experience through actions such as investing in provider diversity, implicit bias training and technology support. The newly-launched Telehealth Equity Coalition (TEC) is one project working to advance the important recommendations outlined above. TEC was formed to bring diverse stakeholders together to develop policies and advocate for equity in telehealth. By using a data-driven approach, TEC will help more people access this unique method of care. If your organization is interested in joining TEC, please contact firstname.lastname@example.org.