Telemedicine has been an incredible tool to increase access to healthcare in a safe, remote manner during the COVID-19 pandemic. However, data show it is still susceptible to the effects of health disparities. This must be addressed if telemedicine is to become a permanent fixture of our healthcare system.
Few people participated in virtual medical appointments prior to the onset of the COVID-19 pandemic, but now telemedicine (or telehealth) is one of the most common ways for people to see providers, who can now be accessed from almost anywhere. However, the rapid expansion of telehealth was not without significant growing pains that required new policies and mandates to provide insurance coverage for these visits. Additionally, as investigated by Dr. Yvonne Commodore-Mensah, assistant professor at the Johns Hopkins School of Nursing, telehealth is still susceptible to entrenched health disparities in this country. Data provided by and on telemedicine services could help close access gaps and address health disparities. But that will require continued approval of telemedicine services after the pandemic ends and better, standardized data.
Although telemedicine was in existence prior to theCOVID pandemic, it wasn't nearly as popular as it is now. Less than 1% of pre-pandemic visits occurred via telehealth, primarily because of insurance rules. Then the COVID-19 pandemic made it necessary to pivot to virtual care through telemedicine. Every health system has its own way of looking at telemedicine data. The Office of Telemedicine, led by Dr. Brian Hasselfeld and Dr. Helen Hughes, analyzes the use of telemedicine at Johns Hopkins. They have a dashboard that reports telemedicine visits by volume month-to-month and by specialty, allowing us to look at trends in outpatient care. There's interest in comparing pre-COVID volume to COVID volume as well as better understanding of video versus audio-only visits.
Ideally, patients should be able to connect with audio and video, but some patients are unable to do that. I collaborated with the Office of Telemedicine to create a telemedicine equity dashboard, which revealed that the differences in video versus audio-only visits are not random. We found that Black people were more likely to have audio visits than White people because of underlying issues like access to broadband. People whose preferred language is English are more likely to have video visits: 83% of English speakers were using video, compared to 75% of people who spoke Spanish. In terms of age, people 75 and above were more likely to have audio visits. Oftentimes people who already experience health disparities have less access to video due to the social determinants of health (income, education, zip code, etc.), resulting in lower quality visits.
There’s a lot of interest in data mining, big data, and machine learning. These are all important endeavors, but I think we can start by using the data that we already have to address disparities. However, there are issues surrounding the quality and the completeness of the data that we have, particularly around standardization. There are federal standards for reporting race and ethnicity data, but how they are implemented differs from state to state. There's also a lag in data reporting. Even though the CDC releases data in terms of cases, hospitalizations, and deaths, we know that there may be a six-to-eight-month lag in the availability of some of that data. If we are looking for opportunities to intervene and implement new policies, we can’t be working with incomplete data that's eight months old.
The inability to examine potential disparities within subpopulations is a concern. Our data collection should allow for racial and ethnic granularity to really understand and address disparities. We need to reconsider how we are collecting data and recognize that there is significant heterogeneity even within subgroups of race and ethnicity. We also cannot continue to put people into these standard buckets without also offering the ability to look at intersections of race and ethnicity with other variables, such as socioeconomic status, income, and education.
In 2020, the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) provided temporary insurance measures and waivers linked to the federal public health emergency declaration. This significantly expanded the use of telemedicine. It allowed for additional providers to participate in telehealth — e.g. physical therapists and mental health professionals — and for providers to use different platforms. It also allowed telemedicine visits to be reimbursed at the same rate as in-person visits. Without the public health emergency declaration and these CMS and HHS measures, we wouldn't have seen this expansion of telemedicine.
Insurance claims provide robust data in terms of who's getting healthcare and how they are getting healthcare, which allows us to look at trends over time. The COVID-19 pandemic disrupted care when in-person visits drastically fell at first, but several weeks later — due to the CMS and HHS accommodations — there was then a stark uptick in telemedicine visits. Insurance data allows us to look at who's deferring care, as well as state-level variations. Because insurance claims allow you to study a wide geographical area, you can more easily identify trends in outpatient visits.
There has been excess mortality during the pandemic — deaths from causes apart from COVID-19 infection. I wrote an article with Dr. Lisa Cooper commenting on a paper that defined excess mortality during the COVID-19 pandemic, comparing observed deaths to expected deaths during this period. We now know that more people died due to causes other than COVID-19, many of them cardiovascular disease and chronic conditions, because they delayed getting healthcare. There was a lot of energy spent on curbing the spread of the virus and reducing mortality, but we did not focus on averting other causes of death. We need to keep an eye on many different types of data in the midst of a crisis to ensure that as we are responding to the crisis, people are not dying from other diseases or delays in healthcare.
Telemedicine has the opportunity to close the access gap exacerbated by the pandemic. Now is the time to re-engage people that we've lost. Patients being able to see other members of a healthcare team online can reduce wait times and the burden on primary care providers. Additionally, patients won’t need to cancel meetings with their doctors regarding maintenance of their chronic conditions because they can’t find childcare or transportation if appointments are virtual. However, the data show that the playing field is not level, and not everyone has equal access to reliable Internet, which we need to address if we intend to actually close healthcare access gaps with telemedicine after this pandemic.