The VA Phoenix Medical Center launched a new telehealth physical therapy (PT) clinic as part of Veterans’ post-op care plans after total knee replacements. Christina Crawford, the telehealth coordinator, is pictured above. Photo from the June 9, 2021, VAntage Point blog
SAN FRANCISCO — Telemedicine offers convenient healthcare for many, but those who could stand to benefit most could be the least able to access it, according to a new analysis.
The VA has dramatically increased use of telemedicine over the last few years, especially during the pandemic. In the first four months of the pandemic, appointments using the department’s VA Video Connect app increased 1,000%—from 2,500 telehealth video sessions daily in February 2020 to nearly 25,000 daily in June.
The increased use of telemedicine—by both VA and non-VA health systems—has been applauded for reasons of safety, efficiency and accessibility for uses as diverse as minor urgent care issues, mental health counseling and post-surgical follow-up. But a new study led by researchers at the San Francisco VAMC revealed that a lot of patients in the demographic who could stand to benefit most from telehealth—including older individuals, racial and ethnic minorities and those with government-sponsored or no insurance—might have the least ability to access it or are “telemedicine unready.”1
To examine inequities in telemedicine access, researchers led by Charlie Wray, DO, performed a cross-sectional analysis (2016-2018) of the National Health Interview Survey (NHIS), a nationally representative telephone-based survey conducted by the Centers for Disease Control and Prevention. “We wanted to take a deep dive into what individual characteristics would impact someone’s ability to connect through digital means, with a specific focus on social vulnerabilities impact digital preparedness,” explained Wray, assistant professor of medicine at the University of California, San Francisco, and one staff at the San Francisco VAMC.
The researchers defined a survey participant as “telemedicine unready” if the participant reported all three of the following criteria: lack of a computer, lack of email, and lack of internet access.
The researchers also extracted data on demographics, social vulnerabilities and comorbid conditions form the survey. Social vulnerabilities were defined by a yes answer to any of 39 survey questions assessing economic instability, disadvantaged neighborhood, low educational attainment, food insecurity, social isolation. The researchers then estimated the national prevalence of all covariates and, finally, examined the association of age, sex, race, ethnicity, health insurance, social vulnerabilities and comorbidity with telemedicine unreadiness using multivariable logistic regression.
Among the 55,220 participants, 17.9%, or over 1 in 6, appeared digitally unprepared to engage in telemedicine, the researchers reported. Compared to the overall population, a higher prevalence of telemedicine unreadiness was seen among those who:
- Were older;
- Were members of a racial or ethnic minority (e.g., Black and Hispanic);
- Had government sponsored insurance (e.g., Medicare and Medicaid) or no insurance;
- Had comorbid conditions; or
- Had certain social vulnerabilities such as lower education attainment, food insecurity and social isolation.
Notably, just more than half of the respondents age 75 and older and those with dual Medicare and Medicaid coverage were telemedicine unready, the study found.
With the recent rapid increase in telemedicine use, Wray acknowledged telemedicine readiness may have improved some since the data was collected. “It’s hard to say. My guess would be that things have improved some, but not dramatically,” he told U.S. Medicine. “Being comfortable using these technologies isn’t going to occur overnight.”
Still, the findings are concerning. While telemedicine has been shown to improve access for hard-to-reach populations, Wray said he fears its use could further exacerbate existing health inequalities. “As a provider at the VA, a healthcare system that primarily cares for older individuals with many risk factors for being digitally unprepared, these findings are concerning,” he says. “It means that many of our patients aren’t ready to engage through digital mechanisms, though the VA is putting a lot of energy, thoughts and resources into spanning this digital divide and not leaving these individuals behind.”
Improving Telemedicine Access
One effort to improve telemedicine access is the VA’s Connected Tablet program, an initiative launched in 2016 to distribute video telehealth tablets to high-need patients with social and clinical access barriers, including veterans in rural areas and patients with mental health conditions. In a 2020 expansion of the program, the VA collaborated with Apple to distribute I-pads to 50,000 veterans. The program can be a model to other health systems as they expand telehealth beyond the pandemic, Wray said.
Healthcare systems will likely need to improve infrastructural support, such as access to high-speed internet and digital devices to the most vulnerable populations. They will also have to provide teaching and support and make sure patients know how to engage and feel comfortable in receiving care through these modalities, said Wray. “Just to note, just because someone can do a telehealth visit doesn’t mean they are prepared to receive a lot of their care through digital means.”
- Wray CM, Tang J, Shah S, et al. Sociodemographics, Social Vulnerabilities, and Health Factors Associated with Telemedicine Unreadiness Among US Adults. J Gen Intern Med. Published online July 30, 2021. DOI: https://doi.org/10.1007/s11606-021-07051-6
National Prevalence and Odds of Telemedicine Unreadiness by Sociodemographics, Social Vulnerabilities, and Health Factors
| Telemedicine unreadiness * | ||
|---|---|---|
| Prevalence, % (95% CI) | Adjusted odds ratio (95% CI) | |
| All respondents | 17.9 (16.8–18.9) | — |
| Age | ||
| 18–39 | 5.2 (4.7–5.7) | Reference |
| 40–49 | 10.4 (9.4–11.4) | 3.0 (2.6–3.5) |
| 50–64 | 16.4 (15.4–17.5) | 6.5 (5.6–7.6) |
| 65–74 | 26.4 (25.0–27.8) | 16.0 (13.6–18.9) |
| >75 | 53.3 (51.6–55.1) | 56.3 (47.6–66.5) |
| Sex | ||
| Male | 15.5 (14.7–16.2) | Reference |
| Female | 15.3 (14.6–16.1) | 0.7 (0.7–0.8) |
| Race and ethnicity | ||
| White | 14.6 (14.0–15.3) | Reference |
| Black | 20.3 (18.6–21.9) | 1.7 (1.5–2.0) |
| Other † | 19.2 (15.9–22.4) | 1.5 (1.2–1.9) |
| Hispanic | 24.4 (22.5–26.2) | 2.9 (2.5–3.3) |
| Health insurance | ||
| Private | 4.5 (4.1–4.9) | Reference |
| Medicare | 34.4 (33.2–35.6) | 2.6 (2.2–3.1) |
| Medicaid | 23.2 (21.4–25.0) | 3.9 (3.3–4.6) |
| Medicare and Medicaid | 57.0 (53.3–60.6) | 5.2 (4.2–6.5) |
| Other‡ None |
10.6 (9.0–12.2) 21.6 (19.7–23.5) |
1.7 (1.4–2.0) 3.6 (3.1–4.1) |
| Comorbidity count § | ||
| 0 | 9.8 (9.0–10.7) | Reference |
| 1–2 | 11.6 (10.9–12.4) | 0.8 (0.7–0.9) |
| 3–4 | 17.6 (16.7–18.5) | 0.7 (0.6–0.8) |
| >5 | 29.1 (27.8–30.4) | 0.8 (0.7–1.0) |
| Social vulnerabilities | ||
| Economic instability | 15.9 (15.2–16.7) | 1.0 (0.9–1.0) |
| Disadvantaged neighborhood | 17.4 (16.3–18.6) | 1.1 (1.0–1.2) |
| Low educational attainment | 21.2 (20.4–22.0) | 6.4 (5.7–7.2) |
| Food insecurity | 24.5 (23.3–25.7) | 2.2 (2.0–2.4) |
| Social isolation | 20.2 (19.3–21.0) | 1.5 (1.4–1.6) |
