Digital Divide-Telehealth's Achille's Heel

Telehealth has become a life-saving defense against COVID-19 because it enables infected individuals to be treated from home, reducing the number of contagious people circulating in the community, reducing exposure of health care workers, and preserving scarce PPE resources.

Healthcare providers have transitioned to telehealth at breakneck speed, taking advantage of loosened federal and state regulations and a financial influx for these services. However, the digital divide represents telehealth’s unseen Achilles’ Heel.  Thirty-seven million people in the U.S. do not have a computer and internet subscription needed for video-based telehealth.  The AMA and its members alone cannot solve this problem but neither should they accept the status quo. While nearly every U.S. household could engage in “cellehealth” over a landline or a mobile telephone, health care providers must speak out about audio-only encounters being second class care compared with the value of a video-enhanced visit. 

There is much more that could be done.  If ever there was a moment to end the digital divide, this is it.  Schools and employers are highly motivated to help their students and employees connect so they can serve their missions.  Yet no sector is as motivated as the health care sector SHOULD be to ensure that they can provide first-class care—via telehealth—to all of its patients.

AMA’s Chief Health Equity Office, Dr. Aletha Maybank, recently wrote in the New York Times about the alarming disproportionate risk of COVID-19 infection and death for Black Americans.  Cautioning against the “poisonous argument” of increased biologic susceptibility, she highlighted the pernicious role of structural inequalities in the risk of exposure and death.  This argument should be extended to highlight the digital divide as reflecting and reinforcing these inequalities. The AMA has done an amazing job helping providers overcome barriers to offering telehealth.  They should extend this effort to helping health systems help patients to address their telehealth barriers. Immediate steps to take include:

• Screen and refer all patients to identify needs for equipment, connectivity, and technical support. This can be automated with existing technologies.
• Partner with local and national organizations to get people the computers or smartphones, internet data plans, and basic digital skill coaching needed to use the internet.
• Provide technical support for patients that need assistance to use telehealth.

Recognizing that “telehealth is here to stay,” there are some longer-term measures that I hope the AMA and its members will also consider:

• Incorporate screening, referral, and technical support into the definition of reasonable and necessary telehealth services that can be reimbursed by public and private insurance.
• Develop billing codes for these functions.
• Allow community health workers, patient navigators, and information technology staff to enroll as telehealth providers to coach patients to use telehealth and to address hardware and software problems.
• Advocate for appropriating money to the Public Health Emergency Fund to provide allowances for patients to purchase the devices and data plans needed to use telehealth.

If COVID-19 proves to have a silver lining, it will be because we equipped, connected, and trained the most economically and medically vulnerable members of our communities to use the internet to challenge and circumvent structural inequalities, and to manage their health.  This will save lives and may even lead to more efficient, effective, and equitable care for years to come.