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How the telemedicine boom threatens to increase inequities

Elaine Khoong, MD
December 14, 2020

The recent explosion in telemedicine is great for those with the technology and skills to use it, but what about people with limited English, income, and digital access? An expert describes steps to protect some of the nation’s most vulnerable patients.

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Internal medicine physician Elaine Khoong, MD, pictured meeting remotely with a San Francisco Health Network patient, worries about patients who can't easily use telemedicine.
Internal medicine physician Elaine Khoong, MD, pictured meeting remotely with a San Francisco Health Network patient, worries about patients who can't easily use telemedicine.
Courtesy: Elaine Khoong, MD

Editor's note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members. 

I call Ms. Lee*, an immigrant in her late 50s, for a follow-up appointment to see how she's doing with her several chronic conditions, including anxiety and high blood pressure. After we say our hellos, I ask if we can switch to a video visit. She sounds uncertain and tells me that her son, who helped her access the app last time, isn’t available.

“That’s okay,” I say patiently. “Do you know how to find the program he used on your phone?”

“I think so,” she replies. I help her find the app and enter the meeting number for the appointment. A few minutes later, she declares triumphantly: “I can see you.”

I can’t see her, though. “Oh,” she replies, slightly disappointed. “Is my video not on? How do I do that?”

I talk her through the steps. A few minutes later, we finally see each other. Unfortunately, the sound quality is poor. “Do you know how to join the program’s audio?” I ask, but she doesn’t. “That’s alright,” I reassure her and proceed to guide her through the steps for using speakerphone.

Finally, about seven minutes into our scheduled 20-minute visit, we’re ready to discuss her many health concerns.

I am worried that people like Ms. Lee, who may lack the devices, internet access, or skills to take advantage of telemedicine, will get left behind as remote care takes firm hold in this country.

I certainly don't mind helping patients like Ms. Lee navigate telemedicine visits. In fact, as a primary care physician at a safety-net clinic in San Francisco, I’m used to helping many older, immigrant, or low-income patients use digital health tools. Also, as a researcher at the University of California, San Francisco (UCSF), I focus on digital health and health equity.

But I am worried that people like Ms. Lee, who may lack the devices, internet access, or skills to take advantage of telemedicine, will get left behind as remote care takes firm hold in this country.

Telemedicine clearly exploded in the face of COVID-19. In mid-April, remote visits were up nearly 140 times compared to before the pandemic. This growth was fueled partly by the need for social distancing and partly by significant changes in from the Centers for Medicare and Medicaid Services, some of which the agency has agreed to make permanent.

Once the pandemic is over, telemedicine will play a much larger role than before. That has its upsides. Telemedicine could help improve access for patients who struggle to get care, including those in remote areas and those with transportation issues or disabilities that make attending in-person visits tough.

Yet numerous potential pitfalls loom as clinicians and health care institutions rapidly develop the necessary infrastructure for expanding telehealth.

So, as the telemedicine train rolls forward, we have an obligation to ask a crucial question: How can we ensure that those who already suffer health inequities don’t get left further behind?

Obstacles to accessing telemedicine

Ms. Lee’s difficulties in accessing her telemedicine appointment are common, the data show.

65 years and older and more than 60% of those without a high school education don’t own a video-enabled device like a smartphone. People experiencing homelessness also frequently have their possessions stolen or face challenges in charging their phones.

Even if patients have a device, they may not have access to a high-quality video stream. Increasingly, low-income and minority populations only from smartphones. That’s a problem because cellular data is often lower quality than a wired internet connection, and it’s expensive once you go over your monthly data limit. At my clinic, lack the internet or data access necessary for a video visit.

Nearly half of people 65 years and older and more than 60% of those without a high school education don’t own a video-enabled device like a smartphone.

Also crucial for telemedicine visits are digital literacy skills like completing an online form. In the United States, are very confident when using computers and similar devices. Others face obstacles as well. For example, only 53% of the report using the internet and having basic digital literacy skills. I’ve met many such individuals, including one who didn’t know she could access the internet on her cellphone.

And these are just the basics. Patients with hearing loss, vision impairment, or other communication issues may face additional challenges.

Preventing telemedicine inequities

Certain steps are essential for ensuring that access to telemedicine is shared equitably. Here are some of them.

Help individual patients get what they need

Institutions should ask patients what prevents them from using telemedicine and then help address those barriers.

In our clinic, we’re starting a pilot program in which appointment schedulers will ask a few short questions to determine whether patients can access a video visit. If patients face challenges, schedulers connect them with staff who guide them through the steps for a visit.

In addition, our health system is developing a process to connect patients who need additional help to our technology education program. Institutions that can’t support such efforts can instead partner with organizations that focus on digital inclusion, such as local libraries, community-based nonprofits, and patient advocacy groups.

Another great way to provide support is short videos like the ones my colleagues at UCSF Health created in showing how to download the video app they use.

For patients who don't have devices, clinicians can suggest government program, which provides low-income individuals with free or low-cost devices and discounted . At our institution, we’ve also begun to explore whether our social workers can be certified to enroll qualifying individuals in local free smartphone programs.

When building systems, keep all users in mind

As institutions adopt tools for telemedicine, they need to consider the obstacles that some of their most vulnerable patients may face.

For example, many health systems have required enrollment in a patient portal in order to access a telemedicine visit. This additional step is an unnecessary barrier for some patients and should be removed.

Also, some telemedicine platforms do not easily allow a third person to join the visit, which effectively excludes patients with limited English proficiency or hearing impairment who rely on interpreters.

Keep an eye out for health inequities

As we ramped up telemedicine during the pandemic, my colleagues at UCSF and I worried that certain groups might suffer, so we began to track relevant data. We found that older patients, those insured by Medicaid or Medicare, persons of color, and those with limited English proficiency started accessing care at lower rates after our transition. From February to March, for example, the percentage of Medicare patients .

Such steps to identify struggling populations allow institutions to create targeted solutions for them. Then institutions must repeatedly monitor whether the solutions are working to prevent health disparities from becoming further entrenched.

Advocate for broader changes

We can and should use our voices to describe the challenges our patients face to local, state, and federal leaders.

Policymakers need to hear that internet access is not a luxury — a fact highlighted by the pandemic. Development of the necessary infrastructure, especially in rural areas, is central to equity.

Insurers need to know that institutions that care for older, low-income, immigrant, and minority patients often must work hard to help these patients access telemedicine, and they should consider creative ways to support those activities.

If we succeed in these and other equity efforts, millions of patients who face challenges to telemedicine will be able to enjoy its many benefits. Some will be able to use telemedicine for the first time. Others, like Ms. Lee, will be able to focus on their health rather than wasting precious time fiddling with the technology.

*Not her real name

Elaine Khoong, MD, is an assistant professor of medicine at the University of California, San Francisco, School of Medicine who researches digital health and health inequities. She is also a primary care clinician at the Richard H. Fine People's Clinic, a safety-net clinic affiliated with the San Francisco Health Network.

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