A recent editorial in Stat co-authored by Walter K. Clair, M.D., Chief Medical Officer of Vanderbilt Heart and Vascular Institute, argues that regulatory concessions and other measures to fast-track telehealth under COVID-19 could undercut the need to fully weigh the technology’s impact on health disparities.
“We are concerned that this crisis-driven acceleration in the adoption of virtual visits and use of algorithmic tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities in health,” wrote Clair and co-authors Matthew Clair, Ph.D., an associate professor of sociology at Stanford University, and Brian W. Clair, M.D., an orthopaedic and hand surgeon at Beth Israel Lahey Health.
Telehealth is not the only digital health innovation seeing landmark growth spurred by the pandemic, the authors note. Venture funding in digital health in the first half of 2020 reached record investment above any previous year, despite the larger recession.
The present moment could be a pivotal one, Clair explained further in an interview. “I’m anxious about the idea that we’ll race to adopt technologies like telehealth, promising lawmakers and legislators they are necessary to provide care for the underserved without proof. If we are not advocating for and including those people in a deliberate way, we are making a leap of faith,” Clair said.
“We are concerned that this crisis-driven acceleration in the adoption of [digital] tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities.”
Tracking Telehealth’s True Reach
Due to the urgency of responding to COVID-19, telehealth expansion was allowed without mandates or guidelines to collect potentially useful data on patient demographics, access and outcomes, Clair says.
“We need to be tracking ethnicity and other demographics. For example, of patients who sign up for an online account required for many telehealth visits, what is their insurance status? I am willing to bet that individuals who are relatively well-insured are more likely to sign up and successfully use telehealth.”
Clair believes several patient groups are potentially vulnerable to a digital divide in accessing telehealth. Many patients, especially in largely rural states like Tennessee, have the technology and aptitude but struggle with unreliable internet or cellular service. He said another group has access to the technology but won’t adopt due to personal or cultural factors.
“Finally, you have that group of people that we’re most concerned about, and that’s the people who basically don’t have the technology or the digital literacy that would allow them to do it,” Clair said. Substantial research is needed into how to engage all these groups successfully, he added, and that research should inform post-COVID-19 policies on telehealth and other digital health technology.
Building Health Equity into the Digital Future
“The adaption to COVID-19,” wrote Clair and co-authors in Stat, “has realigned the power of and positions of physicians, nurses, insurance companies, hospitals and telehealth startups in providing health service to diverse communities. … Technology companies [that] have sought to disrupt the health sector with algorithms and other patient-centered digital innovations … are now rushing to consolidate their positions.”
As doors are opened further to reimburse telemedicine and other digital health services, there are concerning signs already of fraud and preying on certain patient groups.
“We can’t just change a few pieces of legislation and think it’s going to automatically help all communities.”
Health systems like Vanderbilt with a mission to serve diverse communities have a responsibility to research, establish best practices and advocate, Clair says. The measures needed to ensure health equity as more clinical care becomes digitally mediated could be wide-ranging.
“If we are going to invest billions of dollars in these technologies, we may need to begin writing prescriptions for a smartphone or consider discounted access to high-speed internet service a component of reimbursable care,” Clair said. “We can’t just change a few pieces of legislation and think it’s going to automatically help all communities.”
