Telemedicine and Health Disparities

Short abstract

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Abbreviations

HCV

hepatitis C virus

IGI

intervention‐generated inequalities

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Telemedicine offers the opportunity to provide clinical services at a distance, thereby bridging geographic and other barriers to medical care. With the need to socially distance during the coronavirus disease 2019 (COVID‐19) pandemic, clinical practices across the United States rapidly transitioned to telemedicine, which quickly became the predominant mode of outpatient care delivery. ¹ , ² While in‐person clinic visits will resume post‐pandemic, telemedicine will remain a major component to health‐care delivery as it fills gaps and satisfies patient needs in ways in‐person clinical visits cannot. ³ Yet, if the technology is not used equitably and uniformly adopted, the move toward telemedicine will exacerbate the deep underlying health‐care disparities exposed by the pandemic. People with limited digital literacy or who lack access to digital devices or reliable broadband Internet, people experiencing homelessness, and people with limited English proficiency have unique challenges accessing telemedicine. ⁴ It is critical that we identify barriers to telemedicine use and develop solutions to overcome them in order to meet the needs of our patients living with chronic liver disease.

Health Disparities in Liver Disease

A health disparity is defined by Healthy People 2020 as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage”. ⁵ Health disparities arise from numerous factors including structural racism, systemic inequalities in education, housing, and occupational opportunities and access to other resources. Racial, ethnic, socioeconomic, age, and geographic disparities are well documented across all etiologies of chronic liver disease and have been exacerbated during the COVID‐19 pandemic. ⁶ , ⁷

Potential to Generate Inequalities With Telemedicine

On the one hand, telemedicine offers a potential to improve barriers to hepatology care by facilitating access to specialists whom many patients are unable to see in person due to physical distance or other factors. Indeed, telemedicine has been used successfully to manage patients undergoing hepatitis C virus (HCV) treatment, pre‐ and post‐liver transplantation, and other areas of hepatology. ⁸ Yet telemedicine is susceptible to creating “intervention‐generated inequalities” (IGI), a well‐established public health phenomenon referring to when an intervention designed to improve health increases inequality because it disproportionately benefits more advantaged patients. ⁹ Indeed, as demonstrated by the conceptual model proposed by Veinot et al, telemedicine poses a particular risk to producing IGIs through pre‐existing disparities in access, as well as inequalities in uptake, adherence, and effectiveness (Fig. 1). Telemedicine relies on digital access, and yet among adults aged 65 or older, only 53% own a smartphone, 59% have broadband access, and 73% use the Internet. ¹⁰ , ¹¹ Moreover, racial and ethnic minorities, individuals with lower income, those with lower levels of education, and rural residents are less likely to have home broadband service (Fig. 2). ¹¹ Disparities in access to technology may be compounded by inequitable telemedicine uptake and adherence. For example, online patient portals are often required for telemedicine visits but older adults, racial and ethnic minorities, persons with low health literacy, and individuals with low socioeconomic status are less likely to use these portals. ¹² Populations with limited English language proficiency and those with low health literacy may have particular challenges with limited flexibility and poor usability of telemedicine platforms. ¹³ In addition, privacy concerns are more likely to be expressed by patients with limited health literacy, ¹⁴ and distrust in the medical system among Black patients resulting from past and present experiences of racism in health care may adversely impact telemedicine uptake. ¹⁵ , ¹⁶

FIG 1.

Conceptual model of intervention‐generated inequality. Adapted with permission from Journal of the American Medical Informatics Association. ⁹

FIG 2.

Percent of US adults who are home broadband users by race/ethnicity (A), income (B), education (C), and community (D). Source: PEW RESEARCH CENTER.

Solutions to Preventing Telemedicine‐Generated Inequalities

Strategies to prevent or mitigate IGIs resulting from telemedicine require solutions at the individual, health systems, and societal level (Table 1). Individual‐level solutions include providing digital skills and telemedicine education/training and resources to inform patients about free or reduced‐cost Internet access. ¹⁷ Switching from an opt‐in to universal access patient portal policy can eliminate disparities in portal use by age, race and ethnicity (but not income). ¹⁸ Thus, all patients should be offered telemedicine visits and offered more than once. On a health systems level, medical systems must ensure language and interpreter access and user‐centered telemedicine platforms should be designed with reduced structural and technical complexity. ⁴ , ¹² Health systems should utilize a “universal precautions” approach surrounding telemedicine communication. This approach assumes all patients may need health literacy support, and thus provide resources in lay language with visuals and pictographs. ⁹ We also recommend including social determinants of health in ongoing systems evaluations and reporting of telemedicine usage. Health systems should recruit diverse medical staff and provide clinicians education and training on best practices for conducting telemedicine visits among vulnerable populations. In turn, clinicians need to raise awareness of barriers to telemedicine to health systems leadership when they arise. On a societal level, we should recognize that broadband access is a social determinant of health and expand free or low‐cost access to it. ¹⁹ We must invest in device access to facilitate telemedicine visits, technological infrastructure in community‐based settings, and health care navigation services. Finally, we should advocate for greater access to health insurance and payer parity for telemedicine visits. Parity also should be extended between video and audio‐only telemedicine, as eliminating reimbursement for the latter would disproportionately impact certain patient populations.

TABLE 1.

Recommendations to prevent telemedicine‐associated health‐care inequalities at the individual, health systems, and societal levels

Inequality Prevention Level	Recommendations
Individual	Provide language‐inclusive digital skills and telemedicine education and training Inform patients about free or reduced‐cost Internet access Offer telemedicine visits to all patients and offer more than once Assist patient sign‐up for online portal access Ensure a private space for telemedicine visits without others present
Health Systems	Include populations with limited digital and health literacy in platform design Provide language interpreter services Reduce structural and technical complexity of telemedicine platform Recruit diverse medical staff Provide clinician educating and training on telemedicine visits among vulnerable populations Include social determinants of health in evaluation and reporting of telemedicine uptake and outcomes
Societal	Expand free or low‐cost home broadband Invest in device access to facilitate telemedicine visits Fund technological infrastructure in community‐based settings and health‐care navigation services Advocate for greater access to health insurance and payer parity for telemedicine visits

Harnessing Telemedicine to Improve Liver Health Disparities

In this review, we have demonstrated ways in which telemedicine can further disadvantage underserved populations with liver disease, and provided some solutions to mitigate this disadvantage. In addition to recognizing the barriers it can generate, however, we must also focus on the opportunities it can create. Telemedicine, when used and distributed equitably and with social determinants in mind, presents an exciting opportunity to increase access to quality care for these groups and thereby improve liver‐related health disparities. For example, minorities are more likely to rely on public transportation and be essential workers, thus limiting their ability and flexibility to travel for specialty care, which is often outside of their immediate geographic area. ⁶ Telemedicine can make a significant impact upon this disparity in access. Another more specific example includes populations that are significantly less likely to be referred for and receive life‐saving HCV treatment— persons who use drugs and incarcerated individuals. Telemedicine has been successfully used to co‐localize HCV treatment within narcotic treatment programs and within prisons. ²⁰ , ²¹ Health‐care providers, systems, and law and policy makers must begin to recognize that telemedicine in its current form is not a one‐size‐fits all offering, and must work to address the existing and potential disparities. Continued evaluation and reporting with health equity in mind can help achieve this goal.