Review: Achieving Equity in Telemedicine in Obstetrics
Key findings
- The ability to expand access to care while also increasing convenience is a clear advantage of telehealth in obstetrics
- However, equity needs to be centered in telemedicine services so disparities observed in many obstetrical outcomes won't continue to worsen
- Clinicians should screen patients for broadband and technology access, take care with their "webside manner," and keep in mind some patient populations distrust video visits and have special concerns about privacy and confidentiality
- Healthcare systems should ensure cultural competency in telemedicine programs and make patient satisfaction with remote visits a quality metric
- Federal programs are available to improve the affordability of broadband for eligible families
The benefits of telemedicine have become widely apparent, but substantial barriers exist to achieving equity for certain communities.
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Allison S. Bryant, MD, MPH, a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Massachusetts General Hospital and senior medical director for Health Equity at Mass General Brigham, and Mark A. Clapp, MD, MPH, also a maternal–fetal medicine specialist at Mass General, recently reviewed these barriers and potential solutions in AJOG Global Reports.
Access and Satisfaction
The "digital divide" results from a lack of necessary technology for certain groups of people or specific communities. The American Medical Informatics Association has deemed broadband access a social determinant of health because of the close association between telehealth and clinical outcomes.
Technology illiteracy and the unavailability of devices for virtual visits are other important barriers. Some clinics create their own barriers by offering only phone visits.
Concerns about the acceptability of telemedicine—One study published in the Journal of General Internal Medicine found individuals report feeling rushed in virtual visits and that providers seem less engaged. A study of obstetrics patients at San Francisco General Hospital published in Obstetrics and Gynecology suggested some believe virtual visits are used to reduce costs.
Black patients and patients from undocumented immigrant backgrounds in Los Angeles expressed higher rates of concern about the confidentiality of conversations and privacy of personal information for remote visits. The San Francisco study notes these concerns may relate to the history of policing Black individuals in their homes and undocumented immigrants' fears of being recorded.
Distrust—The physical absence of physicians concerns some individuals in Black and Latinx populations. The Los Angeles study showed they may not trust their physician is telling the truth or can make the right diagnosis without seeing them in person.
Potential Solutions
Payment reform for telehealth services—Under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, Medicaid covers phone telehealth visits at a lower rate than video visits. Yet, in some communities, landlines are more reliable than cellular or internet service.
During the COVID-19 pandemic, some states created Medicaid payment parity between video and phone visits. Such legislation needs to become permanent state and federal law.
Acknowledge and adapt to the digital divide—Universal device and internet access are unlikely, so practices offering telehealth services should consider screening all patients for those two essential components.
Sample screening questions:
- "Do you have reliable access to a phone or device that connects to the internet? If so, which is your preferred mode for virtual visits?"
- "How often do you have reliable access to the internet? Does your connection support video?"
If reliable access to a device and connection is unavailable, care models should be adapted for each individual.
Link Health helps connect patients to the Affordable Connectivity Program, one of several federal programs that improve the affordability of broadband for eligible families.
Patient-centered design—As with in-person visits, healthcare systems should strive to create culturally sensitive protocols for telemedicine and connect patients with providers of similar backgrounds. Patient reports on their experiences with remote visits and their preference for or disinclination toward telehealth services should become a quality metric.
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