During the height of the coronavirus pandemic, hospital edicts issued to protect patients would expose institutional frailties. The drastic implementation of nationwide telehealth measures would detrimentally affect patients who lacked access to health care and were unaccustomed to using digital technology. Many of these “digitally unprepared” patients were single, older, low-income, black patients who relied on landlines and flip phones to independently access the health care system.
My 82-year-old grandmother was alone when the hospital staff instituted the COVID-19 checklist. “Do you have a cough? Fatigue? Weakness? Shortness of breath?” She answered, “yes.” In an instant, the biopsy for an invasive lung mass was canceled, and an immunocompromised, coughing patient was whisked away to the COVID clinic.
She protested, “I’m here for a biopsy – for something in my chest. I know I can’t breathe, but it’s not corona.” Six months prior and 60 pounds heavier, she had been fiercely independent, employed, and adventurous. Now, a shell of her former self, her 90-pound body was deemed invisible and voiceless in an overburdened medical system. After sitting in the COVID clinic for hours and testing “negative,” she was escorted outside and left alone in a wheelchair unattended. Another hour would pass before a concerned security guard asked if she needed anything.
“Call my granddaughter. I don’t have a phone.”
My grandmother was a part of the digital gap. A widow that was now social security-dependent, she canceled her cell phone service because it was an “unnecessary” expense she could no longer afford. She is amongst the blacks, Hispanics, and lower-income cell phone users who are twice as likely as whites to disconnect service because of the cost. She is also among the 41 to 47 percent of elderly Americans, most likely to need chronic disease management, that lack smartphone or home internet access.
Restrictive visitor policies, unconscious biases, and dismissive thoughts had defeated the best practices of trained medical professionals. As a physician, I was able to intervene and get my grandmother the attention she desperately needed. She was readmitted and subsequently hospitalized. However, when she was released several days later, no one was notified again.
While I wanted to believe that COVID-19 was responsible for the alarming errors in her management, a part of me questioned: Was it because she old, black, and alone?
In her possessions was her discharge summary comprising several pages of medications, treatment plans, and her follow-up “virtual” visits. Before she was discharged, no one assessed if she had a smartphone or broadband internet access at home. No one asked if she had an email account or ever sent an email. No one asked if she video chats. No one even asked if her landline was still in service.
My grandmother had no idea of what virtual visit meant. She is part of that vulnerable American class—elderly, low health literate, and low-income—that has been thwarted into a tech-savvy matrix amidst a national health pandemic. Yet she was scheduled for three virtual visits. And I was scared. If the patient-provider relationship buckled in the conventional hospital setting, what would happen to the care of the vulnerable in the digital interface?
As the Centers for Medicare & Medicaid Services changed its telemedicine reimbursement policies to accommodate the medical necessity for social distancing, and hospitals scrambled to transition patients to telehealth services, no one was addressing the obvious disconnect.
COVID-19 illuminated the impact of allostatic stressors, disparities in health care access, and race-based discrimination on the increased likelihood of mortality in minority communities nationwide. Yet, millions of minorities, low-income, elderly, and rural patients were now being segued into telemedicine applications that were intrinsically biased and exclusionary. As a partner in a telehealth investment startup, I work with a team that focuses on providing female health and allied health practitioners in developing economies with methods to connect with indigenous and rural communities remotely. We routinely assess the challenges in utilizing technology to connect with these vulnerable populations in low health index countries and offer viable solutions tailored to the unique ethnic, community, or tribal needs. Yet, this wasn’t being done in one of the wealthiest nations where payers and providers were eagerly pushing patients into telehealth management.
Smartphones and computers in households are not ever-present. One study reported 42 percent of black library users rely on libraries for computer and internet access compared to only 25 percent of whites. Hence, as access points for internet service remain closed, the impact of relegating the marginalized to telehealth serves can be lethal.
I rushed to order my grandmother a smartphone and tablet before her first scheduled appointment. But I was fooling myself. My grandmother struggled to proficiently use a flip phone. She could not check voicemails or store phone numbers. FaceTime, Skype, Zoom, and “virtual” are not in her index of familiarity. Simply put, she does not possess the requisite skills to navigate or troubleshoot the virtual health care system without assistance. Yet, she wasn’t given another safe alternative.
Thus, I commute every two weeks for her virtual visits and attend to all application messages and results.
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.
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