An increasing number of institutions are relying on telemedicine to continue delivering care to patients in lieu of typical outpatient visits in response to the COVID-19 pandemic. Telemedicine has been lauded as a potential equalizer in health care access. Indeed, it allows for safe and easy access to medical professionals. It especially benefits patients with transportation issues or those seeking specialty care from far away. Some pitfalls such as reimbursement issues and lack of physical exam notwithstanding, telemedicine overall is a helpful service at a time like this. However, telemedicine does not benefit all patients equally. In fact, it exposes and amplifies the existing health care disparity in a subgroup of patients.
Barriers to telemedicine arise from unequal access to technology. Telemedicine should be technically feasible now more than ever given continual advances in communication tools. However, it assumes that patients have a smartphone or mobile device that is compatible with the application or program needed to set up the visit. It also assumes that there is a stable internet connection or cellular data plan enough for the length of a routine visit. While phone ownership is prevalent, smartphone ownership is limited in certain populations. But even in patients with smartphones, challenges come from lack of a stable internet connection during the visit or a limited data plan to download the applications. In these cases, telemedicine is sometimes converted from video visits to telephone visits. While phone calls should provide similar clinical information, the lack of direct feedback from a video does impact the quality of care. In this case, a picture is worth a thousand words. There is a good amount of data providers can gather from seeing a patient’s face and expressions during the visit that can influence decision-making. Telephone visits provide an inferior quality of care compared to video-based telemedicine.
Beyond barriers to technology access, several other factors impact the success of telemedicine. One of them is literacy. The lengthy instructions and steps to set up the telemedicine application can be frustrating. They require a certain level of literacy and technologic competency. Compound this with a lack of in-person troubleshooting that normally takes place at the registration desk in the clinic make telemedicine set-up challenging for some. Moreover, the traditional barriers to access have not gone away during this time. It is still hard to take time off from work to attend a telemedicine visit during the day. The pressure to maintain a job is perhaps even greater at this time. Some people may even take up multiple jobs to make ends meet, making the middle of the day visits impossible to keep. Again, a portion of patients resorts to telephone visits in place of the video visits, at the expense of potentially receiving inferior care because of the limitation in data.
The solutions to the limitations of telemedicine are not straightforward. It requires prompt recognition of the specific problems each patient faces. The solutions also need a multidisciplinary effort. Clinic schedulers need to explore the reason patients cancel the telemedicine visit or change the visit type from video to telephone. They should connect patients with appropriate support for troubleshooting. This admittedly can be hard when resources are scarce during a pandemic. Those patients who cannot attend telemedicine visits as planned need to be tracked. Each department or provider should keep a list of these patients to follow up. There should also be increased flexibility in appointment time for these visits during the current pandemic, to include evening or even weekend slots, in order to accommodate those essential workers who cannot afford times off.
This pandemic is a stress test for our health care system, testing for its capacity and adaptability. We have placed tremendous effort as health providers and health systems to rapidly implement telemedicine to take care of medically necessary, time-sensitive outpatient visits. However, we need to remain cognizant of the disparities even with telemedicine, so that we can provide the best care for all patients.
Wenjing Zong is a pediatric gastroenterology fellow.
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