Addressing Health Disparities and the Digital Divide as Respiratory Care Goes Virtual
The SARS-CoV-2 pandemic put lives on hold as the country implemented stay at home orders and safely social distanced. Virtual meetings, social and professional, became the norm for many of us. This new virtual life also brought opportunity for expansion of telehealth services to patients and health systems, as well as the respiratory profession. Telehealth allowed us as all to stay safe while also addressing the patients’ needs to assure they were staying healthy while at home. However, this also highlighted the health disparities and digital divide we continue to have in our communities, bringing forth questions on how to address this issue.
An Opportunity for Respiratory Care
For some time, respiratory therapists (RTs) have been advocating through various legislative initiatives to be added as practitioners qualified to furnish telehealth services. In June 2020, the Centers for Medicare & Medicaid Service (CMS) announced respiratory therapists could furnish telehealth services “incident to” the services of an eligible billing practitioner.1 Covered telehealth services added for the duration of the public health emergency (PHE) include home ventilator management supervision, evaluation and demonstration of inhaler techniques, and smoking cessation.2 This created a huge opportunity for our respiratory care profession, and many have seized the opportunity presented to us. Because incident to services are a permanent benefit under Medicare, we are hopeful we will continue to be able to provide telehealth education, monitoring and support after the PHE ends.
In addition to the services noted above, RTs within their interdisciplinary teams have become creative in implementing differing types of telehealth, including pulmonary rehabilitation (PR), or telerehabilitation, and RT TeleICU services. Prior to the pandemic, 98% of clinicians were not providing PR via telehealth technology.3 During the pandemic, this number grew to 50% with the most popular platform being Zoom.3 Due to the vulnerability of our pulmonary patients, telehealth was necessary to lower the risk of COVID-19 in this patient population by keeping them at home, while at the same time continuing to improve exercise capacity and education in this patient population.
The other use of telehealth, the TeleICU service, has allowed RTs to provide e-consult to clinicians at the bedside in ICUs. This offers optimization of resources at a time of rapid expansion during a COVID-19 wave.4 These consultations provided care that included advanced ventilator management, ARDS compliance and ventilator checks, adherence of ventilator settings with orders, and extubation monitoring.4 TeleICU service was implemented in a large academic medical center setting across multiple campuses, advocating an ease of execution, but provides a framework for other departments in health systems to operationalize such an effort.4 TeleICU programs like these can reduce waste and cost while providing intensive care to patients with COVID-19.
Types of Telehealth
Until the pandemic hit the US in March 2020, the use of outpatient visit telehealth was rare and continued to have several limitations.5 Telehealth had been utilized for several years prior, mainly for acute conditions in satellite clinics and hospitals, with the goal now of expansion to home devices to improve access for patients.3 Telehealth can be performed utilizing different platforms, with a common one being the use of videoconferencing. Videoconferencing includes platforms that allow the clinician and patient to speak as well as visualize each other. This offers additional visual support for the clinician to assess and diagnose a patient that other forms of telehealth do not, such as audio only calls which are authorized by CMS for certain services during the PHE, or emails or text messaging which are not reimbursable. Although CMS does not consider remote patient monitoring as a “telehealth” service, many states include it under their telehealth rules. It allows respiratory therapists to perform various care management services under the general supervision of a physician. For example, the RT can educate the patient and/or caregiver about a particular device that helps monitor their respiratory flow rate or breathing via a pulse oximeter while monitoring their treatment plan using such devices.
With all the options of telehealth, clinical barriers remain. These barriers include a difficulty building rapport and trust between the patient and clinician, especially if there is not already an established a relationship.6 Telehealth also has the potential to increase the fragmentation of health care and lead to inappropriate care, such as excessive use of broad-spectrum antibiotics.6 However, one gap we cannot overlook that is affecting our patients, as indicated by patient outcomes, is social health disparities.
Health disparities can be described as preventable differences in the burden of disease or opportunity to achieve health that are experienced by socially disadvantaged populations. To reduce health disparities, increasing access to healthcare is necessary. This can be accomplished by way of telehealth, but not for everyone, not equally. Examining health disparities is the first step in constructing ideas and solutions to address them.
Over half of US residents prefer non-video conferencing forms of telehealth including phone calls, emails, and text messaging,5 which as mentioned has its barriers for assessment, especially when clinicians are not familiar with the patient. Of these residents, Black Americans, individuals ≥65 years of age, and those less educated were less likely to use videoconferencing as a telehealth modality,5 indicating that technological barriers exist in this group. Such barriers can include education and literacy levels, language barriers, and those who have Medicare or Medicaid insurance.7
What has been seen in our older population, who also exhibit lower education levels, telehealth use decreases as age increases,8 indicating that it is far more utilized in the younger, more technologically inclined. Some reasons why older individuals continue to not engage in telehealth include psychomotor and physical limitations such as from arthritis, tremors, or hand-eye coordination.9 Our older population may also face psychosocial barriers, as learning how to use a computer and asking for help can be anxiety-provoking and embarrassing for some.9
Assistance and support of patients must be addressed before we can expect regular use of this technology. Some ideas include a free call center to clinicians whom they have a rapport with or empathetic IT team members who can help walk patients through the initial set up and use of telehealth. Handwritten instructions mailed out to patients is another option, but must be written in simple terms, at a grade-school reading level, with step-by-step illustrations to aid in comprehension. Including family members and caregivers should always be considered with addressing these issues.
The Digital Divide
The digital divide is a continued obstacle to telehealth use, which includes access to high-speed internet and cost of gaining digital devices. Although we may see many individuals in public with smart phones and laptops, we need to remember that not everyone is afforded these devices and the lack of access to video conferencing platforms is something to be cognizant of moving forward.
One study looking at a cohort of chronic disease patients who accessed their individual healthcare portal, which enabled them to communicate their healthcare team and view important lab results, observed that the digital divide remains high to this day.10 They found that older adults, lower education levels, and certain racial and ethnic minority groups were less likely than younger, more educated, and White, non- Latinos to initially access their patient portal,10 consistent with other studies we’ve seen. Furthermore, among those who gained access to their portal, the same ethnic minority groups and those with lower educational achievement were less likely to utilize the functions of the portal.10 This illustrates that low technology literacy and poor access remains high in this group.
Patients with limited English proficiency demonstrate half the odds of using telehealth services compared with English-proficient patients, even after accounted for other sociodemographic factors and health status.11 This suggests that the digital divide persists in this group revealing a missed opportunity with gaps in their care.11 Resources for interpretation among those who do not speak fluent English are necessary and must be addressed to support and provide care to these patients.
High-speed internet is something many of us within an urban community and with consistent, moderate incomes take for granted. 97% of Americans in urban areas currently have access to high-speed internet services, but only 65% and 60% have access in rural areas and tribal lands.8 This is proof that a clear geographical divide exists, in addition to the other numerous divides mentioned. Resources and support in these areas can support access for all patients to receive the care they need.
As our profession continues to march toward providing reimbursable remote patient monitoring or outpatient respiratory care, we have enthusiastically taken the opportunity to provide these services. Prior to the pandemic it sometimes felt discouraging and often like we were somewhat of a forgotten or insignificant profession, which we are not. In fact, now is the time to prove we are not. We must provide these services and report outcomes to sustain telehealth access well after the pandemic. However, we must not allow expanded telehealth to perpetuate existing health disparities based on age, race, socioeconomic status or English-language proficiency. These are the patients who have been left behind during this digital health access boom. As we move forward and advocate for our profession, we must also take the time to advocate for these patients.
- Billing IT, Policy R, Market AC, Medicare A, Market A, Type AC. RP-010 Incident To Billing. Published online 2021. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf. Page 73
- Tsutsui M, Gerayeli F, Sin DD. Pulmonary rehabilitation in a post-covid-19 world: Telerehabilitation as a new standard in patients with copd. International Journal of COPD. 2021;16:379-391. doi:10.2147/COPD.S263031
- Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect , the company ’ s public news and information . 2020;(January):2020-2022.
- Fischer SH, Ray KN, Mehrotra A, Bloom EL, Uscher-Pines L. Prevalence and Characteristics of Telehealth Utilization in the United States. JAMA network open. 2020;3(10):e2022302. doi:10.1001/jamanetworkopen.2020.22302
- Dorsey ER, Topol EJ. State of Telehealth. New England Journal of Medicine. 2016;375(2):154-161. doi:10.1056/nejmra1601705
- Wegermann K, Wilder JM, Parish A, et al. Racial and Socioeconomic Disparities in Utilization of Telehealth in Patients with Liver Disease During COVID-19. Digestive Diseases and Sciences. Published online 2021. doi:10.1007/S10620-021-06842-5
- Jaffe DH, Lee L, Huynh S, Haskell TP. Health Inequalities in the Use of Telehealth in the United States in the Lens of COVID-19. Population Health Management. 2020;23(5):368-377. doi:10.1089/pop.2020.0186
- Nguyen A, Mosadeghi S, Almario C v. Persistent digital divide in access to and use of the Internet as a resource for health information: Results from a California population-based study. International Journal of Medical Informatics. 2017;103(September 2016):49-54. doi:10.1016/j.ijmedinf.2017.04.008
- Sarkar U, Karter AJ, Liu JY, et al. Social disparities in internet patient portal use in diabetes: Evidence that the digital divide extends beyond access. Journal of the American Medical Informatics Association. 2011;18(3):318-321. doi:10.1136/jamia.2010.006015
- Rodriguez JA, Saadi A, Schwamm LH, Bates DW, Samal L. Disparities in telehealth use among california patients with limited english proficiency. Health Affairs. 2021;40(3):487-495. doi:10.1377/hlthaff.2020.00823
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