LinkHealth

Telehealth is the use of information and communication technology by healthcare professionals and patients as a medium of interaction. Telehealth can occur in a synchronous, real-time manner via video, conferencing, or telephone, or by asynchronous pathways like email and other store and forward methods.1 Evidence suggests that telehealth is effective for the routine management of chronic conditions that require regular close interactions with healthcare professionals, and monitoring of patient's symptoms and diagnostic outcomes.2 3

Before the start of the COVID-19 public health emergency, the adaptation of telehealth was slow and fragmented due to a number of reasons, including clinician willingness and acceptance of telehealth4 5, technological limitations and a lack of funding.6 7 8 Consequently, telehealth use was very limited, even by patients in rural and remote locations lacking localized healthcare facilities.9 However, during the COVID-19 public health emergency, there was a rapid and substantial increase in the use of telehealth to provide patients routine care as safely as

1 McLean, S., Sheikh, A., Cresswell, K., Nurmatov, U., Mukherjee, M., Hemmi, A., & Pagliari, C. (2013). The impact of telehealthcare on the quality and safety of care: a systematic overview. PloS one, 8(8), e71238.

2 Khilnani, A., Schulz, J., & Robinson, L. (2020). The COVID-19 pandemic: new concerns and connections between eHealth and digital inequalities. Journal of Information, Communication and Ethics in Society.

3 Gomez, T., Anaya, Y. B., Shih, K. J., & Tarn, D. M. (2021). A qualitative study of primary care physicians’ experiences with telemedicine during COVID-19. The Journal of the American Board of Family Medicine, 34(Supplement), S61-S70.

4 Wade, V. A., Eliott, J. A., & Hiller, J. E. (2014). Clinician acceptance is the key factor for sustainable telehealth services. Qualitative health research, 24(5), 682-694.

5 Green, T., Hartley, N., & Gillespie, N. (2016). Service provider’s experiences of service separation: the case of telehealth. Journal of Service Research, 19(4), 477-494.

6 Smith, A. C., & Gray, L. C. (2009). Telemedicine across the ages. Medical journal of Australia, 190(1), 15-19.

7 Smith, A. C., Thomas, E., Snoswell, C. L., Haydon, H., Mehrotra, A., Clemensen, J., & Caffery, L. J. (2020). Telehealth for global emergencies: Implications for coronavirus disease 2019

(COVID-19). Journal of telemedicine and telecare, 26(5), 309-313.

8 Mehrotra, A., Bhatia, R. S., & Snoswell, C. L. (2021). Paying for telemedicine after the pandemic. JAMA, 325(5), 431-432.

9 Peddle, K. (2007). Telehealth in context: Socio-technical barriers to telehealth use in Labrador, Canada. Computer Supported Cooperative Work (CSCW), 16(6), 595-614.

possible.10 The growth in telehealth during the COVID-19 public health emergency was important as it allowed healthcare providers to serve many of their patients needs, while helping keep them safe from infectious diseases that they could be exposed to in close quarters at healthcare facilities.11 Additionally, the recents COVID associated surge in telehealth has bolstered increased access to care, face-to-face interaction, and the convenience of care. Now, patients can meet with their doctor in a more convenient manner, not just saving valuable time, but also reducing the economic cost associated with taking time off from work or securing childcare.

While the COVID-19 public health emergency stimulated a surge in the adaptation and deployment of telehealth provisions and is generally considered a positive step towards improvements to access, delivery of healthcare, and the management of disease- the social determinants of health have affected the use of these services in certain demographic communities.

In 2005, Michael Marmot introduced the concept of the Social Determinants of Health based on burgeoning research identifying social factors at the root of many inequalities in health outcomes. Marmot noted that “the conditions in which people are born, grow, live, work and age” affected their health outcomes.12 Researchers have spent decades documenting disparities in healthcare.13 14 15 16 As defined by health researcher Dr. Paula Braveman in 2006, a health

10 Samson, L. W., Tarazi, W., Turrini, G., & Sheingold, S. (2021). Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation.

11 Haleem, A., Javaid, M., Singh, R. P., & Suman, R. (2021). Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International, 2, 100117.

12 Marmot, M. (2005). Social determinants of health inequalities. The lancet, 365(9464), 1099-1104.

13 National Institute of Child Health, & Human Development (US). (2000). Health disparities: Bridging

the gap. The Development.

14 Shavers, V. L. (2007). Measurement of socioeconomic status in health disparities research. Journal of

the national medical association, 99(9), 1013.

15 Reiss, F. (2013). Socioeconomic inequalities and mental health problems in children and adolescents: a

systematic review. Social science & medicine, 90, 24-31.

16 Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it's time to consider the causes of the causes. Public health reports, 129(1_suppl2), 19-31.

disparity exerts a specific kind of differential influence on health that is frequently shaped by policies; it is a difference in which disadvantaged social groups— including the poor, racial and ethnic minorities, women, or other groups who commonly experience discrimination and social disadvantage—systematically experience worse health or greater health risks than more advantaged social groups.17

Unfortunately, many health disparities or inequalities exert a negative influence on patient outcomes18, even in the realm of telehealth. Early evidence suggests the existence of significant socio-economic disparities in the use of telehealth during the COVID-19 public health emergency.19 A report on telehealth trends in 2020 found that in both urban and rural areas, blacks had the lowest use of services.20 Moreover, these differences in access to telehealth can compound disparities in chronic disease outcomes.21 Research indicates that patients above 65 years, Black, Spanish-speakers, and from areas with low broadband access were less likely to use video visits. Notable factors in these disparities include geography, racial identity, and socioeconomic status, all in relation to inequities in broadband access, which result in a “digital divide”.22 23 24

17 Braveman, P. (2006). Health disparities and health equity: concepts and measurement.

18 World Health Organization. (2016). Global health observatory (GHO) data. Life expectancy. World Health Organization, Geneva. Available: http://www. who. int/gho/mortality_burden_disease/life_tables/ situation_trends_text/en/. Accessed, 20.

19 Pierce, R. P., & Stevermer, J. J. (2020). Disparities in use of telehealth at the onset of the COVID-19 public health emergency. Journal of telemedicine and telecare, 1357633X20963893.

20 Samson, L. W., Tarazi, W., Turrini, G., & Sheingold, S. (2021). Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation.

21 Rodriguez, J. A., Betancourt, J. R., Sequist, T. D., & Ganguli, I. (2021). Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic. American Journal of Managed Care, 27(1).

22 Zahnd, W. E., Bell, N., & Larson, A. E. (2022). Geographic, racial/ethnic, and socioeconomic inequities in broadband access. The Journal of Rural Health, 38(3), 519-526.

23 Samson, L. W., Tarazi, W., Turrini, G., & Sheingold, S. (2021). Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation.

24 Hsiao, V., Chandereng, T., Lankton, R. L., Huebner, J. A., Baltus, J. J., Flood, G. E., ... & Schneider, D. F. (2021). Disparities in telemedicine access: a cross-sectional study of a newly established infrastructure during the COVID-19 pandemic. Applied Clinical Informatics, 12(03), 445-458.

The digital divide is a multi-faceted problem related to people's access to technology and health outcomes that are directly affected by information inequality. Communication researchers Jan Van Dijk and Kenneth Hacker have posited that four interrelated barriers associated with people's access to and use of technology.25 The first is a lack of digital experience, due to a lack of interest or anxiety associated with new technology. The second is a lack of material access to new technologies, or network connections. the third is related to one’s digital skills and a lack of digital competency and social support. The final component is a lack of significant usage opportunities.

Consequently, problems related to the digital divide goes beyond issues associated with access to reliable high-speed internet, and the diversity of both hardware and software needed to properly engage in telehealth, but also includes the divides in Internet skills.26 The multi-layered nature of the digital divide has been reframed by communications scholar Massimo Ragnedda in terms of Digital Capital. Ragnedda defines digital capital as “the accumulation of digital competencies (information, communication, safety, content-creation and problem-solving), and digital technology”.27 Furthermore, digital capital can be thought of as an interplay of adopted digital competencies and externalized technological resources that can be accumulated and transferred from one arena to another.28 Finally, the amount of digital capital that a person accumulates directly influences the quality of their Internet experience, and can be transformed into economic, social, cultural, and political capital.29

Like the health disparities associated with in-person care, evidence suggests a degree of intersectionality associated with inequalities in telehealth. As previously mention, geography, race/ethnicity, native-language, socioeconomic status, gender-identity, and digital capital all exert

25 Van Dijk, J., & Hacker, K. (2003). The digital divide as a complex and dynamic phenomenon. The information society, 19(4), 315-326.

26 Van Deursen, A. J., & Van Dijk, J. A. (2019). The first-level digital divide shifts from inequalities in physical access to inequalities in material access. New media & society, 21(2), 354-375.pdf

27 Ragnedda, M. (2018). Conceptualizing digital capital. Telematics and Informatics, 35(8), 2366-2375. 28 Ragnedda, M. (2018). Conceptualizing digital capital. Telematics and Informatics, 35(8), 2366-2375. 29 Ragnedda, M. (2018). Conceptualizing digital capital. Telematics and Informatics, 35(8), 2366-2375.

a varying degree of influence on individuals’ telehealth engagement and outcomes.30 Because of these various intersectionalities, telehealthcare providers are required to develop new skills in virtual rapport, which includes demonstrating empathy, the ability to facilitate efficacious virtual physical examinations and diagnosis, as well as demographically specific counseling skills. Unfortunately, this is a big challenge and will require a lot of work to achieve.

Although telehealth has huge potential to surmount many longstanding healthcare problems, the digital divide presents a significant challenge to equitable telehealth adoption. To reduce inequalities and improve the effectiveness of telehealth, future telehealth interventions must be developed and implemented with the aim of meeting the needs specific to people in low socioeconomic populations. Successfully building more equitable healthcare systems via telehealth will require the deployment of social capital resources, financial incentives, and political will among care providers, the health insurance industry, and government officials.

30 Chunara, R., Zhao, Y., Chen, J., Lawrence, K., Testa, P. A., Nov, O., & Mann, D. M. (2021). Telemedicine and healthcare disparities: a cohort study in a large healthcare system in New York City during COVID-19. Journal of the American Medical Informatics Association, 28(1), 33-4