The Digital Divide Isn’t Just About the Patient—It’s Also the Practice, Study Finds

The coronavirus disease 2019 (COVID-19) pandemic has poured light on the uncomfortable truth about America’s two-tiered health system—one that offers better care and outcomes for whites than for people of color. But the assumption that the disparities occur on the receiving end only doesn’t tell the whole story, according to a new study that looked at the first wave of telemedicine after the pandemic hit.

The fact that Blacks and Hispanics may lack computer access or reliable Wi-Fi is a well-known problem. But sometimes, it’s the providers serving these communities who lack adequate technology, staffing or time to offer a video visit instead of a telephone consult. This gatekeeping effect was something of a surprise to investigators from Harvard Medical School, who used data from Mass General Brigham to examine the how different groups experienced the uptick of telemedicine in the early days of COVID-19.

Investigators examined the period of April 23 to June 1, 2020, starting a month after CMS announced that Medicare would cover telemedicine and pay the same rate for telephone or video visits. The analysis, appearing in The American Journal of Managed Care, covered 230,000 visits by 162,000 patients, of which 65% were virtual—32% by telephone, and 33% by video.

Jorge A. Rodriguez, MD, the study’s lead author, said he had seen the “digital divide” emerge in prior studies of patient portals and mobile health apps. “I was particularly interested in how this rapidly emerging new technology—telemedicine—would or would not reflect these same disparities,” he said in a podcast that accompanied the study.

Results showed that patients who were above age 65, were Black or Hispanic, or who spoke Spanish were more likely to have a telephone visit than a video visit. Patients in areas with low broadband access were somewhat less likely to have a video visit, but this was not as big a driver as the demographic factors.

By contrast, the investigators reported, “practices (38%) and clinicians (26%) drove more of the variation in video visit use than patients (9%).”

Co-author Ishani Ganguli, MD, MPH, said during the podcast that it was interesting to see how quickly the differences emerged, and if providers are deciding whether patients have access to a video or telephone visit, this should be an important consideration for policy makers going forward.

“There’s an important level of control to consider,” she said. If minority patients are relying on practices that don’t have the infrastructure to offer video visits, “We should be focusing on those clinics as well.”

As Rodriguez said, access to technology is not enough—it’s how one engages with it.

When asked to offer a prescription for healing the digital divide, he offered three steps:

• At an organizational level, health systems must measure not only how much technology is being used, but also who is using it.
• “Digital equity” must be among the criteria when chief heath executives select a telemedicine vendor.
• On the payer side, payment parity is essential—smaller payments for telephone visits will work against patients who most need access to care.

Health systems may consider deploying “digital health navigators” to help patients set up portals or figure out telemedicine, just as cancer centers have oncology nurse navigators to help patients connect with all the elements of their care. In fact, the SCAN Health Plan, which serves the senior population in California, added a digital assistance benefit to its plan in 2021.

Quality measurement will be essential as telemedicine matures, Ganguli said. “What is the quality of the care?” she said. “How does it fit into the larger picture?”