Telehealth can, theoretically, make healthcare more accessible for people when circumstances (like a pandemic) make in-person visits difficult. But thanks to the accelerated adoption of telehealth in the last 12 months, public health officials have seen a worrying trend: Some of the same limitations of in-person healthcare pervade in telehealth, too.
“This increased reliance on this telehealth presents a really tough challenge, because it impacts the healthcare for minority, older, non-English speaking, less educated [adults], and it can end up exacerbating the disparities that are already existing,” says Sheba George, a sociologist at the Charles Drew University of Medicine and Science in Los Angeles. Without overcoming the digital divide and providing broadband for more households, telehealth will remain inaccessible to the same people who have trouble accessing in-person healthcare.
Telehealth was never meant to replace in-person healthcare entirely. “There are things that can’t be done remotely,” says George Demiris, a researcher at the University of Pennsylvania who studies technology’s role in healthcare. Diagnostic scans—like CT scans or MRIs—can’t be done at home because of the expensive, technical equipment they require.
But a follow-up appointment that just requires talking to a doctor, whether it’s to go over those results or to consult with a specialist, can be done online. For patients managing chronic conditions, online check-ups can also serve as intermediate visits to prevent medical emergencies. If someone can video conference their provider while taking their own blood pressure or other vitals, their provider could intervene if they notice a consistent decline in their patients’ health before it merits a trip to the emergency room.
In order for telehealth to complement in-person visits after the pandemic, it needs to be accessible to everyone—which isn’t at the moment. It’s hard to say how many people don’t have access to broadband in the US; the US Federal Communications Commission (FCC) estimates that there are now about 21.3 million people in the country without broadband access. BroadbandNow, an independent broadband research company, estimates that figure to be twice as high, at 42 million people, because it does additional sampling of homes within the geographic blocks the FCC surveys.
According to Pew Research, the disparities of those who don’t have broadband often run parallel to those who are left out of the in-person healthcare services: As of 2019, roughly 28% of adults over 65 didn’t have home broadband, compared to roughly 10% of younger adults. Roughly 40% of all rural adults didn’t have broadband either, compared to about 20% in urban or suburban areas. And about 40% of Black and Latino adults didn’t have broadband at home, compared to only 20% of white adults. These discrepancies have led groups like the American Medical Informatics Association and other independent doctors to push for access to broadband to be considered a social determinant of health, just like poverty or location.
The US government is trying to alleviate some of these disparities through the FCC. As of 1997, the FCC began collecting Universal Service charge, which telecom companies rolled into customers’ bills. These funds are used for a number of different programs. One of them is the Rural Health Care program, which, in 2020, allowed the FCC to manage $605 million for rural healthcare offices and nursing homes to set up telehealth services (it’s still allocating some of that funding through the end of June this year). These funds went to both providing broadband and internet access, and helping telecom companies provide networks in rural areas. Just after the pandemic began, the FCC allocated $100 million in funding to individuals to pay for broadband access (though not the construction of new networks themselves) through its Connected Care Pilot. And once the pandemic hit, Congress granted the FCC $495 million through two relief acts to help healthcare offices pay to install telehealth services.
Translating broadband access to healthcare takes time; it’s likely there will be a lag before we start to see improvements in health outcomes for people who get online in the coming years. That’s because even after people have stable internet access, telehealth works best when patients trust the doctor on their screens. Demiris’ group works on teaching healthcare providers basic techniques like looking into the camera and reading patients’ tone and facial expressions to build trust. George, of Charles Drew, also pointed out that like in-person medicine, telehealth may require some extra trust building for patients of color. Some of the patients she’s worked with have told her that they’re concerned telehealth will be second-rate care compared to their usual in-person visits, or that the calls or video conferences aren’t secure.
To address these programs, George and her colleagues are working with community health workers, volunteers who act as liaisons between doctors, and those in their immediate communities. These individuals should be able to address basic IT questions and assure patients that the virtual doctors’ visit is safe.
To fully embrace telehealth after the Covid-19 pandemic, public health officials and hospitals are going to have to close the gap on things like hardware—internet access and computers or smartphones—and the more intangible skills, like building up the trust in the digital system. “It’s not as simple as handing people a tablet,” George says.
