Closing the Digital Divide: Ensuring Patients Have Access to Healthcare Technology Is a Priority

Although many otolaryngology practices were already using telemedicine and other medical technologies prior to the COVID-19 pandemic, the virus escalated the need to rely on technology.

“Using technology has been particularly important in our field because otolaryngologists are at an increased risk for exposure to COVID-19, which resides in the nasopharynx,” said Michael Setzen, MD, an otolaryngologist in private practice and a clinical professor of otolaryngology at Weill Cornell Medical College in New York City. “Many of our procedures generate aerosols that could potentially subject an otolaryngologist, staff members, and patients in the waiting room to the virus.”

But some Americans can’t afford a smartphone or laptop, don’t know how to use technological devices or software, or can’t get Internet connectivity or cell phone service where they live. So where does this leave them?

As the medical director for digital health at University Hospitals in Cleveland, Brian D’Anza, MD, said there has always been a “digital divide” among certain populations. “But since the onset of COVID-19, using technology has become more common between patients and providers out of necessity. For months, there was no choice but to talk with patients virtually due to mandatory lockdowns, which has worsened these disparities.”

Contributors to Digital Divides

Although technologies have proven useful in healthcare in many ways, there are significant disparity-related considerations and concerns created by the shift toward reliance on technology, said Kevin Sykes, PhD, MPH, a research assistant professor and director of clinical research, otolaryngology–head and neck surgery, at the University of Kansas Medical Center, Kansas City, Kan.

The biggest issue that remains is the incorrect assumption that everyone carries a smartphone and has consistent Internet access. When access is assumed, it’s highly likely that someone will be left behind. —Kevin Sykes, PhD, MPH

People living in low-income and rural communities may have less access to broadband, smartphones, WiFi, and other technologies that make staying connected easier. Schools and libraries in these communities have fewer resources to provide early exposure to technology, Dr. Sykes said—and many of these access points were closed during the pandemic. These communities also bear a disproportionate burden of disease in the United States.

According to Pew Research Center, 29% of adults living with annual household incomes of less than $30,000 don’t have smartphones, 44% don’t have broadband at home, and 46% don’t have computers.

When studying 401 patients in a multidisciplinary head and neck oncology team, Samantha Tam, MD, MPH, a staff surgeon in the department of otolaryngology–head and neck surgery at Henry Ford Health System in Detroit, found that patients with Medicaid, no insurance, or other public insurance had a 26% lower chance of completing a virtual visit compared to those with other insurance types. Patients with a low median household income had a 22% to 33% lower chance of completing a virtual visit compared to those with a higher median household income (JAMA Otolaryngol Head Neck Surg. 2021;147:209-211). These socioeconomic discrepancies weren’t seen in telephone visits among the same groups.

“This may be an indicator of a digital divide, as patients with low socioeconomic status may have less access to technologic resources required for virtual visits,” Dr. Tam said. “Or, it might be because insurance coverage of virtual visits may have been unclear to patients, especially at the onset of the pandemic when many patients accessed these services for the first time.”

Other populations that are at a disadvantage for using technology include non-English-speaking individuals, people who lack access to digital literacy training, patients without technical support, people with a low level of education, and those in rural areas where high-speed Internet access isn’t available.

In addition to challenges related to obtaining and using digital tools, communication in healthcare is becoming extensively more technological for multiple reasons, said Jessica W. Grayson, MD, MS, an assistant professor and director of clinical research in the department of otolaryngology–head and neck surgery at the University of Alabama at Birmingham. Some technological advances are thought to increase access to physicians, improve the ability to give opinions (for example, if pictures are provided), and accelerate clinic throughput so more patients can be seen in a timely manner.

It’s critical to think of a patient’s well-being beyond the walls of a doctor’s office; this includes social determinants of health such as digital connectivity. —Brian D’Anza, MD

“The rate of technological changes is becoming more rapid, leaving many people behind, and will continue to do so,” Dr. Grayson said. “This affects not only patients with socioeconomic status disadvantages, but also the aging population—many of whom are not tech savvy. The pandemic brought these issues to the forefront, as technology was really tested, and [we] found that many families lacked technological infrastructure.”

COVID-19 vaccination distribution methods exemplified how patients lacking technology could be left behind. Web-based vaccine registration patient portal systems such as MyChart require digital literacy and access. “Some communities struggled to reach vulnerable populations with vaccines due to reliance on digital platforms,” Dr. Sykes said. “Many senior adults needed help navigating registration portals and health systems, and public health agencies weren’t prepared with human or financial resources to provide technical assistance.

“The more expensive a technology is and the more infrastructural demands it requires to support its widespread use, the more likely it is to produce social disparity gaps,” Dr. Sykes continued. “The biggest issue that remains is the incorrect assumption that everyone carries a smartphone and has consistent Internet access. When access is assumed, it’s highly likely that someone will be left behind.”

The Effects on Otolaryngology Care

Technology aside, the effects of racial inequality, poverty, and unequal healthcare access in the United States are well known to otolaryngologists and other surgeons (Health Aff (Millwood). 2013;32:1046-1053). They see higher rates of smoking, head and neck cancer, and delayed disease presentation in patients from vulnerable groups (JAMA Otolaryngol Head Neck Surg. 2019;145:249-250; Head Neck. 2016;38 Suppl 1:E1826-E1832).

Patients who need care the most are often those with the least access to resources, said Dr. Grayson. In her practice, many head and neck cancer patients come from all over the state of Alabama, often with limited resources to return for additional medical care. “It’s vital that we stay updated on their medical status, how to troubleshoot issues at home with the resources available to them, and when early intervention with us is necessary,” she said. “While other patients have improved access with technologies, disadvantaged patients are getting left behind with no end to that separation of access in sight.”

Recent research findings showing worsening inequity in the use of telehealth during COVID-19 wasn’t surprising to Dr. D’Anza, who is also an otolaryngologist and sinus specialist in the department of otolaryngology at University Hospitals in Cleveland and an assistant professor at Case Western Reserve University School of Medicine. University Hospitals analyzed preliminary data looking at which patient populations in Cleveland participated in audiovisual calls versus audio-only sessions or phone calls. They found that among approximately 400,000 telehealth visits in 2020, African American patients used audiovisual visits nearly 40% less than the general population, which was mostly White.

These data line up with a study done by researchers at Mount Sinai Health System in New York City. Mount Sinai researchers analyzed more than 39,000 telehealth visits for COVID-19 and found that Black and Hispanic patients were two to three times more likely to present to the emergency room for an initial COVID-19 visit than were White patients (J Am Med Inform Assoc. 2020;27:1949-1954). Conversely, White patients were nearly twice as likely to present via telehealth for an initial COVID-19 visit rather than go the emergency room. Patients older than age 65 and non-English-speaking patients followed the same trends as Black patients.

In addition, according to data from the U.S. Health Information National Trends Survey, between 2014 and 2020, racial and ethnic minorities, older patients, and those with lower socioeconomic status were much less likely to access and use patient portals (National Cancer Institute. April 2021.).

Lessening the Gaps

Some institutions and individuals that are aware of disparity gaps in technology use have ideas and are taking steps to lessen these gaps.

Dr. D’Anza recommends directly engaging with communities. During the pandemic, University Hospitals experienced a 3,000% increase in virtual patient visits (from 11,000 in 2019 to more than 400,000 in 2020). However, the virtual option wasn’t accessible to many families the health system serves because they lacked Internet-connected devices. This led the health system to team up with a nonprofit organization called PCs for People that provides patients with resources to connect virtually with providers.

In July 2021, PCs for People donated 500 laptop computers, 500 hotspots, and three months of broadband service to University Hospital patients meeting certain criteria, such as those that are 200% below the poverty level or on a federally supported program such as Medicaid or the Supplemental Nutrition Assistance Program. In return, University Hospitals donates its used desktop and laptop computers to PCs for People for recycling and refurbishing. University Hospitals hopes to use this program as a pilot to expand to larger groups of patients and area communities.

“Many of our underserved patients don’t have proper access to the resources and technology required for our expanding telehealth options,” Dr. D’Anza said. “It’s critical to think of a patient’s well-being beyond the walls of a doctor’s office; this includes social determinants of health such as digital connectivity, which a program like this helps to address.”

Practices could also lessen the gap by employing technologies that require less of a broadband connection, such as asynchronous chat bots that allow patients and providers to communicate via texting or other technologies that can be sent through e-mail or phone apps, Dr. D’Anza said.

An article by Burks and colleagues suggested adding an equity officer to otolaryngology practices, a person who would focus on ensuring that all patients have equal opportunities and care. “An equity lens may include advocating for access to interpreters for telephone or virtual health care,” among other things, the article stated (JAMA Otolaryngol Head Neck Surg. 2020;146:995-996).

To enable telehealth visits, The Ohio State University Wexner Medical Center in Columbus has considered mailing patients a tablet that’s already equipped for virtual visits. “This may help people who are less technologically savvy,” said Aaron C. Moberly, MD, associate professor of otolaryngology.

During the pandemic, Rakesh Chandra, MD, MMHC, professor of otolaryngology–head and neck surgery and chief of rhinology and skull base surgery at Vanderbilt University Medical Center in Nashville, had an idea to construct telemedicine centers in underserved communities. “A patient could go there and have a qualified technician insert an endoscope or otoscope while an ENT in a remote location could have a live look, examine data, and make medical judgments and recommendations,” said Dr. Chandra, who has not yet implemented his idea.

Traditionally, the treating otolaryngologist operates the scope, but it’s conceivable that another provider, nurse, or technician could do it. “There is a solid precedence for non-ENTs, such as speech pathologists and mid-level providers, to introduce an endoscope,” Dr. Chandra said. “Placing the device isn’t necessarily the difficult part; what matters is seeing and understanding what you’re looking at and making good judgments about observations.”

For follow-up care, some patients could again be seen at the telemedicine center, while others might need to travel. The main barriers would be regulatory and technology infrastructure, Dr. Chandra said.

It might be that insurance coverage of virtual visits may have been unclear to patients, especially at the onset of the pandemic. —Samantha Tam, MD, MPH

Dr. Sykes suggested asking patients about the barriers they anticipate when asked to adopt a new technology. “Some patients can use technologies, but they have privacy concerns or other reasons for being late adopters,” he said.

Given some patients’ challenges with technology, Dr. Moberly said it’s important not to discontinue traditional approaches for scheduling and communicating between patients and providers. “Maintain old-school approaches, because newer methods won’t work for some people,” he advised.

Here to Stay

Dr. Setzen expects telemedicine and the use of other technologies to remain strong long after COVID-19 is a distant memory. “Both physicians and many patients appreciate the ability to communicate this way,” he said.

The big break for telemedicine use came in March 2020, when CMS relaxed its guidelines for using telemedicine and were prepared to reimburse physicians as if a virtual visit were an office visit, consultation, or hospital visit, Dr. Setzen said.

Furthermore, other health insurance carriers went along with CMS and have been reimbursing physicians for using telemedicine. “Hopefully, CMS and insurance companies will continue to reimburse physicians for this important ability to communicate with patients,” Dr. Setzen said. “In the months to come, the use of telemedicine will obviously be less than during the pandemic, but it will continue to be used particularly preoperatively, postoperatively, during emergencies, and when patients are unable to come to the office.”

Dr. Sykes views technology as a way to reduce the costs in time and money, and to increase the convenience of health maintenance in otolaryngology. In some cases, this may mean enabling patients to monitor their symptoms with routine electronic delivery of patient-reported measures and dashboards to calculate significant changes warranting an in-person visit. “I anticipate artificial intelligence will play a significant role in medicine across all specialties,” he said. “We may be able to help outside providers monitor head and neck cancer patients remotely with computer-assisted endoscopic image analysis. I’m optimistic that interoperability of medical records systems will become a priority and increase our ability to coordinate care and appropriately use limited healthcare resources.”

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Karen Appold is a medical writer in Lehigh Valley, Pa.