key: cord-0051776-mtvakc7s
authors: Menendez, Mariano E.; Moverman, Michael A.; Puzzitiello, Richard N.; Pagani, Nicholas R.; Ring, David
title: The Telehealth Paradox in the Neediest Patients
date: 2020-10-20
journal: J Natl Med Assoc
DOI: 10.1016/j.jnma.2020.09.144
sha: cbe662bd2cadaabf1ce8571941de61893fac598f
doc_id: 51776
cord_uid: mtvakc7s

nan

W e realize we are stating the obvious at this point. Telehealthd the use of telecommunications technologies to deliver health-related services and informationdrepresents the biggest example of disruptive change associated with the COVID-19 outbreak. 1 Initial concerns regarding billing complexities and insurance resistance have abruptly evaporated as everyone is now striving to keep clinicians and patients separate. There is no question that longlagging telehealth is a welcome innovation that promises timely, improved access to care and better health in more cost-effective ways. Indeed, most chronic conditions can be addressed and monitored virtually. In this instance, telehealth may be a "virtually" (note the wordplay) perfect solution. 2 But simply recognizing the potential and benefits associated with telehealth is not enough; patients must want to engage with it and know how to engage with it. Certain patients struggle more than others with the digitization of healthcare. 3 Take, for instance, an elderly Spanish-speaking patient with poorly controlled diabetes and limited social support: failure to effectively navigate the tangles of telehealth may lead to worse health. While most have a smartphone (or access to one) with cellular data or internet, some may not be aware of the telehealth options available to them, or may be intimidated by the complexity of telehealth apps and need to be walked through by someone who speaks their language or has the time to go over the steps with them. 4 Instead of assuming that patients know how to interact with technology, we may need to take "universal digital health literacy precautions" by assuming that they do not know how unless proven otherwise. It is possible that patients who haven't adopted telehealth are ashamed to admit that they don't know how. In fact, even highly educated patients may have difficulty using newer technologies when dealing with an unexpected and frightening diagnosis.

The ability to engage in telehealth may be a social determinant of health in itself. In some ways, it is possible that high-needs patients with multiple chronic conditions and complex psychosocial needsdwho arguably stand to benefit the most from continued virtual caredmight be the ones being unintentionally left out of this digitization boom. If so, telehealth may be paradoxically exacerbating preexisting health disparities in the more vulnerable.

There is mounting evidence that minorities and people with unmet psychosocial needs are disproportionately dying during this pandemic, 5 but little data as to why. Maybe because they are more susceptible to severe forms of the virus given their higher prevalence of underlying medical conditions. 6 Or maybe because they are facing challenges engaging with technology. The latter would not be that surprising considering that over one third of the U.S. population struggles to find and use information to make health decisions. 7 These patients might actually be caught in a "limbo", as they try to avoid hospitals over fear of contracting severe forms of the virus but are unable to effectively participate in telehealth services and stay healthy. The pandemic toll might be much worse with this type of collateral damage.

Simplicity is essential when it comes to adoption. It is pivotal that telehealth applications prioritize ease of use and maximize compatibility with existing electronic devices, while ensuring data security and privacy standards are met. As a start, it might be useful to send patients a virtual visit checklist, and encourage them to confirm a number of items (e.g. patient positioning, equipment, internet connection) prior to the virtual encounter. The ª 2020 by the National Medical Association. Published by Elsevier Inc. All rights reserved.

https://doi.org/10.1016/j.jnma.2020.09.144 adoption of simple applications and virtual visit checklists might also increase physician adoption and clinic efficiency. Telehealth services can prove inefficient at first when compared to in-person visits. In particular, the physical exam is understandably more difficult in a remote visit. As such, it might be useful for clinicians to demonstrate aspects of the exam on themselves if patients are having difficulty understanding instructions. Pamphlets or videos with important aspects of the physical exam could also be sent out to patients prior to their virtual encounter.

Garnering patient trust in telehealth in the communities that have been traditionally more mistrustful of the healthcare system is important. Ironically, these patients may stand to benefit the most from virtual caredby avoiding, for instance, public transportation and time off workdbut may have the most reluctance and mistrust of it.

Ideally, everyone is taking advantage of the valuemaximizing opportunities associated with telemedicine. But effective use of such services presupposes that patients have access to and can engage with technology, and trust the system. Digital isolation may be more of an issue than we think. And it may be silently responsible for the many more deaths that we are seeing among the neediest. In the midst of enthusiasm and rapid expansion of telehealth, we must ensure that our efforts to facilitate adoption, access to, and trust in digital care are deliberate and strategic.

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