Telehealth and The Digital Divide: Two Lessons Learned in 2020
The COVID-19 PHE highlighted issues surrounding telehealth and digital divide
As society turns to the internet for civic and business transactions, those without internet access — or without the skills to use this access — are at a disadvantage
Rural and underserved communities are greatly affected by the digital divide
Telehealth program developers need to include digital divide consideration to the process
January 20, 2021 — The COVID-19 public health emergency (PHE) of 2020 exposed the impact of the digital divide in telehealth programs. Mandates such as wearing a mask and social distancing meant that patients were staying home. Most patients were reluctant to visit health care facilities, and in-person visits began to decline.
In response, most health care centers and clinics transitioned to telehealth visits to replace in-person visits. An unintended result was that many patients could not access or use telehealth services. It didn’t take long to realize that telehealth services were in fact a barrier for a certain population of patients, which exacerbated health inequality.
This transition to telehealth had a significant impact in rural and underserved communities. These communities are known to have limited broadband infrastructure — especially high-speed broadband. They also have limited access to health care services, and/or face geographic and distance barriers to access health care services.
Any health-care development that doesn’t rapidly become available to all individuals has the unintended but inevitable consequence of fueling health inequality (1)
Rural and Underserved Communities are Greatly Impacted by the Digital Divide
In 2016, the Federal Communication Commission’s (FCC) Broadband Progress Report (2) found that:
10 percent of all Americans (34 million people) lack access to 25 Mbps/3 Mbps service
39 percent of rural Americans (23 million people) lack access to 25 Mbps/3 Mbps
In contrast, only 4 percent of urban Americans lack access to 25 Mbps/3 Mbps broadband
In 2020, the FCC reported that the number of Americans lacking access to fixed broadband at 25 Mbps/3 Mbps declined, going down by more than 30% between 2016 and 2018 (3). However, this decline likely favored urban areas, and areas with better infrastructure and greater economic resources.
Ramsetty et. al (2020) published the impact of the COVID-19 PHE in an outpatient clinic that treats uninsured adult patients and underinsured children (4). She noticed that the transition to telehealth services in this clinic became a barrier for the patients, given that most patients could not access the telehealth services. There were many factors leading to this, including:
Limited access to free public Internet
Inability to purchase devices to access telehealth services
The Digital Divide is More Than Lack of Access to Internet
eHealth literacy is the ability to seek, find, and understand health information from the internet, and then apply the knowledge to solving a health problem (5). These skills are essential to operate and navigate computers and the internet, and to choose and evaluate the available information.
Low eHealth literacy is a problem for remote and underserved communities. These communities have higher incidence of poverty, low education, lack of insurance, and limited English proficiency (5).
Offering telehealth services to these communities to replace in-person visits may worsen health inequality issues. Simply providing access to the internet and equipment will not solve the problem of low education and low eHealth literacy.
Next Steps
The American Medical Informatics Association (AMIA) recommends the digital divide to be included as a social determinant of health (4)
To avoid discriminating against those affected by the digital divide, telehealth program managers and operators need to consider the digital divide during the development of a telehealth program:
Assess the adequacy of bandwidth infrastructure in the communities being served
Assess community ability to afford equipment and infrastructure need to access the internet
Assess community needs for adequate education and training (eHealth literacy) to benefit from the telehealth program
2020 was a fruitful year for telehealth-friendly policy, and the COVID-19 PHE will certainly bring the digital divide to the attention of lawmakers.
As always, feel free to contact me if you have any comments or questions.
References
Watts G. COVID-19 and the digital divide in the UK. Lancet Digit Health. 2020;2(8):e395-e396. https://doi.org/10.1016/s2589-7500(20)30169-2
FCC. 2016 Broadband Progress Report. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2016-broadband-progress-report Accessed: 01/19/2021
FCC. 2020 Broadband Deployment Report. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2020-broadband-deployment-report
Ramsetty A, Adams C. Impact of the digital divide in the age of COVID-19. J Am Med Inform Assoc. 2020;27(7):1147-1148. https://doi.org/10.1093/jamia/ocaa078
Chesser A, Burke A, Reyes J, Rohrberg T. Navigating the digital divide: A systematic review of eHealth literacy in underserved populations in the United States. Inform Health Soc Care. 2016;41(1):1-19. https://doi.org/10.3109/17538157.2014.948171
