Case Study Comparison: Limitations in Telehealth Relating to Poverty and Family Support

Abstract

Telehealth appointments have grown in popularity due to the COVID-19 global pandemic. Three cases presented in this article show several different perspectives where telehealth was utilized. For the first patient, appointments were successfully completed via telehealth; however, the patient's family opted to continue with an unsecure internet connection at a local laundromat. For the second patient, a stable internet connection could not be obtained in his home, thus making telehealth appointments unavailable. The caregiver of this patient ended up driving to the clinic to have adjustments made in person. For the third patient, telehealth appointments were unavailable due to unstable internet connections as well as difficulty setting up video interpreting services. These cases highlight the idea that telehealth can be incredibly beneficial, when used correctly. For some, the option to attend appointments virtually gives them access to specialists that otherwise may not be available. For other patients, aspects such as access to smart devices and steady internet access must be considered to ensure a successful connection. The hope is that this article sheds light on some of the potential setbacks that can come from the use of telehealth appointments in a practice and provides discussion regarding for whom telehealth may be appropriate, even in pediatric patients. After reading this article, readers should be able to discuss ways in which there could be solutions for these barriers that may prevent some patients from utilizing these types of virtual appointments.

Technology has become an integral part of our lives in a variety of settings. One of those settings is health care where telehealth appointments are widely being used. Telehealth, or sometimes referred to as telemedicine, is the use of electronic information and telecommunication technologies to provide care when the patient and their doctor are not in the same place at the same time. This requires the patient to have a phone or device with internet access to receive these services through telehealth. ¹ Using telehealth, patients are able to communicate with their healthcare provider live over the phone or through video chatting. Other options for communication include being able to send and receive messages from their healthcare provider using chat messaging, email, secure messaging, and secure file exchange. In some instances, the use of remote patient monitoring also can be utilized so that the healthcare provider can check in on the patient from the comfort of their own home. ¹ Historically, telehealth appointments were most commonly used for patients in rural locations with barriers to accessing medical care. ² With the current global pandemic, telehealth is seen by some as an optimal solution for patients being able to see their provider while maintaining safe social distancing measures. By participating in telehealth, patients are reducing everyone's potential exposure to COVID-19. ¹ There are, of course, several additional benefits that come from telehealth appointments such as limiting the amount of time it takes to commute, traveling in bad weather, and taking time off of work. These virtual telehealth appointments can shorten wait times to see a provider while also expanding the range of access to specialists who live farther away. ¹ For others, there are several barriers that stand in the way of telehealth being an ideal solution; for example, telehealth-compatible devices or access to the internet may be unattainable to low-income households. ³ Additionally, the person receiving care needs to be tech-savvy enough to connect their devices to the internet and connect to the provider-secured link. Given the need for HIPAA-secured connections and conversations, even commonly used communications like FaceTime may not be used by physicians for secure connections. Therefore, patients may have to connect through unfamiliar links or technology, making this mode of appointment less accessible for some patients. Finally, for pediatric patients, there needs to be an involved guardian to ensure that the child is with the communication device, at the right time, with the appropriate devices, and that they stay engaged in the appointment; this is not possible for all patients and guardians.

An important disparity that needs to be recognized is a lack of access to healthcare for those who are poor and/or living in poverty. Persons living in poverty are at a greater risk for deterioration in health status, chronic illness, and premature death than those who are not living in poverty. ⁴ The inverse care law suggests that persons living in poverty receive the least amount of healthcare. This is true even for children whose healthcare needs may impact their educational ability. They are less likely to have a family physician and to obtain preventative and secondary care, and more likely to report negative experiences of care. ⁵ Compared with populations of moderate and high income, those in poverty experience a greater need for support to access preventive care and improved care services. ⁵ The lack of access to healthcare is a factor in poor health of those who are living in poverty. This needs to be taken into consideration when considering telehealth and access to the technology and other materials that are necessary to conduct these appointments.

Several hearing healthcare providers today have integrated telemedicine into their daily practices, and given COVID-19 circumstances, many have had to convert to telehealth sooner than they may have liked. Luckily, many manufacturers now have the ability for patients to remotely meet with the hearing healthcare provider to make changes on their hearing devices. These appointments are most often completed through a smart phone application that already have the devices connected. The one caveat to this is that many significant acoustic changes cannot be made during these appointments. Telehealth audiology appointments are particularly useful if the patient lives far away from an audiology clinic and minor adjustments are necessary. However, as previously mentioned, these telehealth appointments require a smart device with internet access. Other hearing healthcare practices that can be performed via telehealth include aspects of diagnostic testing such as case history through video conferencing and computer-based audiometers for pure tone and speech testing. ⁶ While this route may not be ideal for all patients, it is an option that can be considered given the current climate of COVID-19 and many may see this continue after the pandemic is controlled. For many patients, this is now seen as the preferred method of communication with their hearing healthcare provider and will continue for minor necessary changes. Additional consideration for billing and reimbursement needs to be considered and are discussed in another article in this edition of Seminars .

Case Presentation

Tyler is a 10-year-old boy with a severe sloping to profound sensorineural hearing loss in the right ear and normal hearing in the left ear. Tyler is typically accompanied by his mother at various appointments. This patient had a history of ear infections growing up and, as a result, received pressure equalizing tubes which fell out within a year; he has had no continuing conductive hearing concerns. Tyler's mother reported that the cause of his hearing loss is unknown; however, it is suspected that it is related to virus or trauma; he passed his newborn hearing screening. His mother reported normal pregnancy and birth without any complications. Tyler did not pass his school-related hearing screening and was seen at the clinic and diagnosed with hearing loss. Tyler's parents, particularly his mother, are incredibly attentive and participate in every appointment by asking several questions to ensure they understand the information provided to them. They also follow up via email with any concerns. After being diagnosed with hearing loss, Tyler and his family decided that they wanted to pursue amplification for Tyler, and he was fit in March 2020. The devices were ordered, and the fitting was completed in person with real-ear verification despite the pandemic shutdown given the necessity for Tyler to hear during the transition to remote schooling. One of the main reasons that the family decided to pursue these particular hearing aids was because of the option for telehealth appointments through the company-provided app and to easily make adjustments without having to travel to the clinic.

At the time of his scheduled follow-up, the University of South Dakota (USD) Speech and Hearing Clinic suggested that patients attend their appointments using telehealth and we followed up with Tyler regarding his progress using his devices. Tyler's mother had been monitoring her son's progress and making sure that his devices were in proper working function. A brief telehealth appointment was held to make minor adjustments based on the patient and his mother's observations. Tyler's family does not have stable internet at their house; however, they went to the neighborhood laundromat that has free internet for the appointment. Despite our concerns and discussing with them about the concerns of HIPAA privacy, they opted to continue the appointments via telehealth. They noted that they had a family member who was high risk of COVID-19 and needed to limit their exposure.

In June 2020, his mother reached out to our clinic to request new tubing to be sent to their home. Another telehealth appointment was held to walk her through how to properly cut the tubing for her son's devices. This was done while instructing his mother and father, demonstrating how to pull out the hard tubing, put in the new one, and cut it to the right length. As with new audiology students, the most difficult thing for the parents was putting the tubing back on the ear hook. Through demonstration and encouragement, the parents were successful in changing the tubing. No additional acoustic changes were requested. Since then, Tyler has been consistently wearing his devices and has reported satisfaction in a variety of situations. Follow-up with the mom has been conducted via email and Tyler has seen significant growth in school since being aided and the mom occasionally emails questions. Tyler's individualized educational program (IEP) meeting was held in the spring of 2020 with the audiologist attending via Zoom and no additional services were needed, since he has caught up to his normal-hearing peers. Since school has started in the fall of 2020, Tyler has participated in traditional education without any additional services. He has been seen a few times via telehealth and once in person just to ensure that the devices were working well and a “deep cleaning” was done on the devices.

John is an 11-year-old boy with a severe sloping to profound sensorineural hearing loss in the left ear and normal hearing in the right ear. John is typically accompanied by his father or his grandmother to appointments. It was reported that his birth mother is currently not directly involved in his life while incarcerated. When he first came to our clinic, his father accompanied him and it was reported that John was living with him and his wife, John's stepmother. It was later discovered by social services that John's grandmother had primary custody of him rather than his father. At various appointments, John sometimes does not show up, shows up late, and it is unclear as to who is going to attend the appointment with him—his father, his grandmother, and on occasion a social worker. With regard to case history, no family history of hearing loss was reported nor were there any concerns of ear infections that were noted. It is unknown about pregnancy or birth history because he was born while his mother was incarcerated.

It is reported that John did not pass the school hearing screening starting in kindergarten, but grandmother did not know until she received guardianship in 2019 and she scheduled him for a hearing evaluation at the USD Clinic. He was diagnosed with hearing loss in late 2019 and it was decided by John and his grandmother that he would pursue amplification. Similar to the first patient, these devices were chosen for their ability to hold telehealth appointments for minor changes. John's hearing aids were fit in March 2020 in person with appropriate real-ear verification. In the following weeks, the grandmother had contacted the clinic in hopes of setting up a telehealth appointment to make adjustments to the hearing aids as John was reporting that they were too loud. Unfortunately, the appointment was not able to be completed due to an unstable internet connection at John's grandmother's home; while John does have a smart phone, his phone does not have actual phone or internet connection. As a result of lack of internet access, his grandmother drove to the clinic to have the desired changes completed in our clinic in person. After that, John missed several appointments and it was noted that he was back living with his father. In the summer of 2020, John's social worker contacted the clinic asking if John was provided hearing aids and the fitting of aids was discussed. A follow-up appointment was made and was attended in person by John and his grandmother. An IEP meeting was scheduled for early fall and was attended remotely by the USD audiologist via Zoom; it was evident that John's care is constantly changing and it is unknown to the school district where John is living week to week. Additionally, concerns were noted about the care for John in the custody of his father. In this case, John's grandmother is committed to attending his healthcare appointments; however, it is not top priority for John's father. This is not meant to judge John's father as he is working long hours to provide for his son and taking time off for the appointments is difficult. Additionally, John's father's house does not have internet and telehealth appointments would be impossible.

Sharon is a 9-year-old girl who has been seen in our clinic for many years. She has Down syndrome and a moderately severe mixed hearing loss bilaterally. Sharon is typically accompanied by her mother at various appointments and has been very involved in her care. Her mother has limited English language literacy and the native language that is spoken by Sharon's family is not common which has made finding an interpreter difficult. An interpreter has been utilized in all of her appointments via video services. This patient has a history of ear surgery including a cerumenectomy and a right ear myringotomy. She also underwent ventilating tube placement bilaterally following cerumen removal. This patient's hearing loss had initially been diagnosed through auditory brainstem response (ABR) testing where she had a moderately severe mixed hearing loss bilaterally and despite the surgeries, the conductive component remains. When she came to our clinic, she was able to participate in conditioned play audiometry testing where we recorded responses that were consistent with results from the ABR test.

Sharon had previously been fit with an osseointegrated device, which is a device that transfers sound through bone conduction to the inner ear. However, she now currently utilizes traditional air conduction hearing aids bilaterally. These hearing aids were fit in 2018 with appropriate real-ear verification being performed. At this initial fitting appointment, she was accompanied by her mother and an outreach consultant through the South Dakota School for the Deaf. It was reported by her mother and the outreach consultant that Sharon utilizes her hearing aids consistently. Her mother informed us at this time that Sharon speaks her native language at home in a limited fashion and utilizes very little sign language. Sharon attends school only for 3 hours a day. It was reported that her current school is unable to meet her needs and this is all that they were willing to supply for school assistance. When her mother shared this information, she got very emotional conveying that her daughter was unable to attend school full time and she wanted her child to be able to participate in school activities. She wanted either native language interpretation, sign language instruction/interpretation, or to better utilize her devices so she could learn spoken English. During this appointment, we recommended that the mother follow up with a local advocate who could assist her in navigating the special education system and learning about her rights as a parent of a child with a disability.

As previously mentioned, the USD Clinic has provided interpreter services via video during appointments for the mom and Sharon. It was thought that when the USD Clinic went to primarily telehealth as a result of the COVID-19 pandemic, this setup would work as well considering the interpreter was already accessed via video service. Sharon's family does have limited internet via single cell phone in their home. However, after communicating with the family, they do not have the ability to connect via the HIPAA-secured system that is used for interpreting services along with the hearing aid provided app that is used to make changes to the hearing aids. As a result, all appointments have been conducted in person.

Discussion

These three cases are very similar, yet also vastly different. The first two patients were seen at our clinic around the same time, with similar hearing losses, and their families had pursued amplification that had the benefit of telehealth capabilities. The third patient has established care with our clinic but was unable to be seen via telehealth given limited access to multiple devices. We were fortunate enough to still be in communication with patients when COVID-19 caused us to see most of our patients via telehealth, but the goal of this article is to further illustrate the reasons where telehealth would be appropriate for some patients and not others. Initially, we noted that all three of these patients had devices that were compatible with telehealth function to make minor changes. The families of these children have been involved in their care and have demonstrated that they desire to help their children succeed using auditory communication. However, it should be noted that these children all have variable access to internet and family ability to help during the appointments. The ability for a patient to attend a telehealth appointment, particularly if the patient is a child, may be beyond their control; additionally, there are many factors that can contribute to the considerations of recommending telehealth to a patient and patient's family.

One important difference to note between the first two cases is the difference in familial support. From our observations, this appeared to be a very large determinant in the success of telehealth use. Tyler's family has been heavily involved in his appointments. John, on the other hand, had a difficult home life in the sense that he was in the middle of a custody dispute between his father and grandmother. When we conducted our telehealth appointments with John, we did not know where he would be for that appointment. As a result, we were unsure if he would have stable access to an internet connection for the appointment. Additionally, having a scheduled in-person appointment made it easier for John's dad to take the time off as it was seen as more important to his employer. This is a crucial aspect that we must consider when working with patients via telehealth. Sharon's family does have the support and the desire to come to appointments, but patching in an interpreter via the app provided by the hearing aid company is not possible and having two systems running, app from the hearing aid and the interpreter call, proved to be too much of a challenge. For all three of these patients, it is worth noting that stable internet was a concern. For all of these patients, family's financial status played a role in their lack of access to internet. Many patients report not having consistent access to internet and this is something that has been more prominent as schools went to remote learning.

In April 2020, the Pew Research Center conducted a survey that asked parents of children whose schools were closed if it was very or somewhat likely that their children would do their schoolwork at home during the COVID-19 outbreak, and if they would do one of the following: use their cellphone, use a public Wi-Fi, or be unable to complete school work because they have no access to a computer at home. Results from this survey found that 43% of lower income students would have to do their schoolwork from a cellphone, 40% would have to use public Wi-Fi to finish their schoolwork because there is not a reliable internet connection at home, and 36% would not be able to complete their schoolwork because they do not have access to a computer at home. ⁷ Additionally, given the record high unemployment applications that were filed in the United States in April 2020, more and more families are likely facing poverty. ⁸ Lower-income households may not have smartphones, and if they do, the data storage and usage limitations may pose several obstacles ⁹ including reduced access to the internet for telehealth services. The consequences of lack of internet and access to healthcare have a significant impact on the health of persons with low income. Specifically related to audiology, the lack of access to internet could mean that patients are not able to get the hearing-related services necessary for their devices to work and could mean that access to online school for children would be limited.

As previously mentioned, telehealth can be incredibly useful in a variety of situations. For example, telehealth is an excellent solution for patients living in rural areas far away from specialists. Additionally, it takes less time for the patient because of decreased travel as well as makes care accessible for people who do not have access to reliable transportation. However, there can be barriers that stand in the way of a successful appointment using telehealth, some of which have been described in this article. What are some solutions? If patients do not have access to telehealth-enabled devices or internet access due to financial difficulties, perhaps clinics could supply a low-cost device on loan for appointments. ³ Access to these devices could help Sharon and her family have access to two different services—app for the devices and interpreter services or Tyler's family does not have to go to the laundromat for internet access. What about limited accessibility to telehealth visits due to cultural or language differences? Perhaps looking into designing a telehealth program that reflects diversity and translating options, ³ which could also have helped Sharon, it is important that we work with our patients to ensure proper care should they elect to participate in telehealth appointments.

The selection of who would be appropriate for telehealth has been a challenge for all of us during the COVID crisis. However, this crisis has allowed patient to experience the benefits of telehealth and it will likely continue. It is important to take into account the factors that may impact a patient's ability to access the telehealth services.