Virtual care needs to be designed for equitable usage and accessibility [PODCAST]

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“Although technology and disruptive innovation theoretically diminish systemic barriers and geographic isolation, in practice, they frequently widen chasms in access for vulnerable populations. The reality is telemedicine disproportionately caters to younger, wealthier, and more educated patients.

Hospital systems need to ensure every patient has access to remote health care services, whether through offering landline phone visits, examining pitfalls in digital skill requirements, providing devices and/or application tutorials, or simply assessing if patients are capable of sending or replying to an email. Telehealth applications need to be designed for equitable usage and accessibility instead of automatically expecting rural, poor, minority, and elderly people to just ‘get with the digital program’ during a crisis.”

Shantel Hebert-Magee is a pathologist.

She shares her story and discusses her KevinMD article, “During COVID-19, not everyone can get with the digital program.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Shantel Hebert-Magee. She’s a pathologist, and she wrote the KevinMD article “During COVID-19, not everyone can get with the digital program.” Shantel, welcome to the show.

Shantel Hebert-Magee: Thank you for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Shantel Hebert-Magee: I’m a Southern girl, bayou born and bred, but I’m also the product of consequential policies, federal legislation enacted to uplift communities. Growing up in the Bayou State of Louisiana, health, education, and opportunity have always been a challenge. So programmatic efforts such as Head Start, Title I, Medicaid, and food stamps were essential to my blue-collar, working-class household. Not only did they provide basic provisions, but they also helped to disrupt generational cycles of poverty.

In particular, Kevin, I grew up in Tremé. It’s an area of New Orleans that’s very famous for its Afro-Creole heritage, for second lines and jazz funerals, but it’s also an area that is considered to be dangerous. Serendipity uplifted me, as my mayor, another term for grandmother, would say. She would say, but for God, I wouldn’t have gone to college or to medical school.

So I entered academia, and I focused on disparities research. Then I started working with industry for a while, on cutting-edge technology, but I realized that all the products I was bringing to market never reached my personal village, the people in New Orleans. So I shifted and segued into policy. Currently, I am a minority health strategist, a physician consultant, and the CEO of a small nonprofit.

Kevin Pho: We are now talking in the third week of August. How is the pandemic affecting Louisiana?

Shantel Hebert-Magee: I think that Louisiana still has room for progress. At one point in time, we were the epicenter of the pandemic, but I think that people are on board. We have enacted policies making people wear masks in public and in places where they may have exposure. Akin to the rest of America, we have experienced pain, we have experienced the loss of family members, we’ve experienced the loss of wages, and just a loss of normalcy. So I’m hoping that we will turn over a new leaf soon as we get a better handle on the pandemic.

Kevin Pho: So let’s talk about your KevinMD article, “During COVID-19, not everyone can get with the digital program.” Now, for those who haven’t read your article, can you walk my audience through it and share the story of why you decided to write it?

Shantel Hebert-Magee: Sure, Kevin. Clearly, I could have presented an article with a bunch of empirical data. I could have talked about how the implementation of digital health and telemedicine has impacted rural communities that don’t have 5G and broadband access. I could have talked about how, in urban hubs, people may have smartphones but don’t have data. But the fact is that people don’t remember statistics; what they remember are stories.

So I used my mayor’s narrative. Her circumstances transcend the various tiers of health care. She’s elderly, under-resourced, undereducated, digitally illiterate, and does not have internet access at home, and ultimately, she has been undervalued by this health care system. The point is that when you have disruptive innovation, when you bring about new technology, you have to consider all sectors of the population, even those that are marginalized and on the fringes. Oftentimes, it’s those who are marginalized who actually need the most access. So I felt it was time to illuminate this problem, and I’m happy that you gave me the platform.

Kevin Pho: So go a little bit deeper into your story. Tell me about your grandmother. How is she isolated digitally? How did she access health care, especially during the pandemic?

Shantel Hebert-Magee: On March 4th, my grandmother was diagnosed with stage four lung cancer in the emergency room. For about six months, she had significant weight loss, maybe about a 60-pound weight loss. She is very autonomous and independent, and even though she’s not health literate, she was very wise. She had all her medications written on a list, and she never missed a doctor’s appointment. They had screened her for everything. She had a chest X-ray, and they didn’t see anything. She had a colonoscopy. She had a mammography exam done.

Ultimately, after she became extremely fatigued, we brought her to the emergency room because we knew something was wrong. They went on to imaging, which revealed a 19-centimeter mass, and they kept her for a few days in order to stabilize her. She was discharged with paperwork, and she was like, “I’m so excited. The doctor’s coming over to the house.” I was confused. I was like, “Huh?” She said, “Yeah, right here, it says doctor visit, virtual visit.”

“Virtual” and “digital” were not part of her lexicon. When he explained it to her in the hospital, they didn’t say that it meant using some computer interface. So she thought that when they said she would have a visit at home, it meant a home visit, and I had to clarify to her that that’s not what it meant. She never had a smartphone. The most she’s ever had was a flip phone, the kind with the big buttons for elderly people, and she didn’t even own that anymore. There was no internet access.

So I found myself, amidst this pandemic, trying to wear multiple hats, including being there for her appointments in order to navigate the system. But more importantly, it wasn’t just my grandmother. Even when we first tried to log in, Kevin, the server was so busy we couldn’t even use the app. Then they said to call the tech line. We called the tech line, and we couldn’t get anyone. We were on hold for 30 minutes, and I was so afraid about her missing this oncology appointment.

So the point is that when you implement this type of technology, there have to be safeguards, particularly for those who are most vulnerable, because even being a physician, I had difficulty trying to use the app. Ultimately, for the first visit, we used FaceTime, the physician and I. My grandmother heard him speaking to her, and she thought it was like a video recording. She didn’t realize he could see her.

What I didn’t speak about in the article was that there are privacy issues when you’re using these digital interfaces, right? There are third parties. You can see into the patient’s home, and while that can be good in certain ways, I wonder, would it further foster implicit bias? So I just really wanted to illuminate the issue and have practitioners start to think and realize that they have to screen patients before automatically shifting them to a modality that they may not necessarily be prepared to use.

Kevin Pho: Now, is this situation with your grandmother common across the state of Louisiana? What is the digital literacy landscape like in Louisiana, and what is internet access like?

Shantel Hebert-Magee: I would say that in the South in general, we have low literacy rates. I mean, education is not a platform. Louisiana has consistently, for years, ranked 49th and 50th in the country when it comes to education. I think that you do have people who know how to use certain things, like Facebook, or they know how to use Instagram, but they are not health literate. Then you compound that with digital literacy, having to use the application. I don’t think that certain sectors of the population are familiar with it. We know the data says that elderly people, particularly those of color, are even more vulnerable, for a multitude of reasons.

So I think when it comes to the landscape of Louisiana, that is something that is significant, even when it comes to rural access. We have parishes where we don’t have broadband. Louisiana also has the worst health metrics. I mean, we have diabetes and obesity and maternal mortality, and these issues are real. So when you try to segue and shift something, you have to consider the impact it’s going to have, particularly on those communities that are most vulnerable.

Kevin Pho: What’s the solution here? Because on one hand, during a pandemic, you don’t necessarily want the elderly to come to health care settings for routine visits, but on the other hand, you have the issues that you talked about regarding digital health literacy and the lack of broadband access. What’s the answer here?

Shantel Hebert-Magee: Well, I think it’s going to take a long-term plan. I don’t think we have a short-term solution. Some of the things that have been happening are that I think hospitals have readily realized, as there have been a number of articles that have come out to address the bias in utilizing this technology. I think that some are not educating, and they’re doing a screening process to see if a patient will qualify to use a digital modality. I think it’s also recognizing that you need to have advocates. So for me, I want to be a caregiver who was able to provide my grandmother with the systems that she needed at home in order to be able to use digital health.

In addition, I think we recognize that we need industry and companies to be able to provide broadband access. I think the mayors and governors in many states have been trying to address this, not only for health care but also in the educational sector, because these same issues overlay with families who don’t have tablets and computers at home for their kids who are in elementary school, and they need access as well. So I think we’re trying to close the gaps, and the issues are being addressed.

I think the other issue that should be addressed is fraud, waste, and abuse. The vulnerable, particularly the elderly, are the most likely to be victimized by fraud. I mean, even when I receive a bill from the insurer, it says, “This is not a bill,” and they say this is what the cost of your care was. Then you receive a separate bill. But I don’t know if I’ve been upcoded. I don’t know if it was the proper charge. I don’t know if the application is actually protected from a third party. So I think these are things that have to be addressed, and it will require public congressional action.

I think what the government wanted to do was to create an avenue for people to have access and mitigate their risk of exposure. But I think before we keep this as a long-term solution, we have to weed out some of the kinks, and that includes privacy issues. It includes making sure that patients truly do have access to, and understanding of, what’s being transmitted.

Kevin Pho: We’re talking to Shantel Hebert-Magee. She’s a pathologist, and she wrote the KevinMD article “During COVID-19, not everyone can get with the digital program.” Shantel, for the other clinicians who may be listening to this podcast, do you have any advice for them as they see patients virtually, or as they’re discharging elderly patients from the hospital with a need for potential digital follow-up?

Shantel Hebert-Magee: One of the things that I realize is that, as a short-term solution for patients who do not have digital capabilities, they’re using the telephone. I want them to be cautious with that, because even though you can charge and code for that, it is not the same as having a visual inspection of the patient. We get so much from the physical exam by looking at someone, and particularly for those who have substance use and behavioral health issues, you have to have that eye-to-eye contact. Oftentimes, as I mentioned before, those are the ones who are most vulnerable, and they don’t have a digital interface.

So even if you’re temporarily using a telephone as a mechanism, I don’t want that to be permanently adopted or considered a substitute for actually laying eyes on the patient and having a comprehensive approach to medicine.

Kevin Pho: And my final question: Do you have a take-home message that you want to share with the KevinMD audience?

Shantel Hebert-Magee: We have to be scrupulous as we honor our patients. Health care is a reflection of society, and as health care mirrors society, it is now a time for atonement. We recognize that there are biases and injustices that exist in health care that have to be addressed. So I would ask every clinician, allied health worker, even layperson: When you see someone across from you, don’t just look at them as a medical record number. Don’t just look at them as a customer. See them as a person, and look at them through the lens through which you think they see themselves.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Shantel Hebert-Magee: OK, thank you.

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