Reprinted from the winter 2021 issue of The Ohio Family Physician
By: Kelsey Ufholz, PhD; Tamer Said, MD; and Goutham Rao, MD; Case Western Reserve University and University Hospitals, and Amy Sheon, PhD, MPH, Public Health Innovators, LLC
Telemedicine in the United States grew an unprecedented 80% in 2020.1 During the COVID-19 pandemic, many non-urgent medical appointments were converted to telemedicine.1,2 Seniors are a high priority for telemedicine given their heightened risk of mortality and the need for frequent health professional contact to manage chronic illnesses. However, the uptake of telemedicine has been uneven with vulnerable groups, including seniors, lagging behind.3,4 Although smartphone use is rising among seniors, their overall device ownership still lags. Early research suggests that even fewer seniors own computers, tablets, and devices with larger screens and keyboards that facilitate telemedicine among those with reduced vision and greater hearing impairment.
We recently surveyed 30 senior primary care patients in our academic family medicine clinic, in which the majority of patients are urban, ethnically diverse, and economically disadvantaged. While 83% said they used the internet and had devices that could be used for telemedicine, a deeper look underscored the importance of querying with more detailed and precise language. For 40% of respondents, texting was the only internet application that they endorsed having used, suggesting that they may have been using cellular service only and not actually going on the internet. The survey found 46.7% of respondents only had a non-iPhone mobile device; only 36.6% had an iPhone, desktop, laptop, or tablet; and only 23.3% had actually completed telemedicine visits. It is noteworthy that individuals with more advanced devices are more likely to use internet applications such as video calling or video streaming. About 13.3% used their devices for emails, an often necessary step for telemedicine. No respondents used their devices to replace in-person activities, such as banking or shopping. These findings suggest that many seniors may require encouragement or assistance to utilize technology for safely meeting everyday needs.
National data and a few surveys showed a more rapid adoption of technology among younger seniors, making them more adaptable to telemedicine. Our younger seniors were more likely to have high quality, internet-capable devices; and use a greater number of internet functions, including email and video messaging, than older seniors.5 Seniors with greater internet use and higher quality devices also had more positive attitudes toward telemedicine. It appears that having devices, connectivity, and basic digital literacy are pre-requisites for telemedicine use. This “telemedicine ready” population could be identified through careful screening and then encouraged to consider telemedicine through email or healthcare portal messages.
Telemedicine has several inherent advantages to patients, such as reducing exposure to COVID-19 through transportation and waiting rooms, and saving time and money by avoiding travel. Our patients were unable to spontaneously name any benefits of telemedicine. Therefore, posters or brochures in clinic waiting rooms may be a low-cost method to educate and initiate conversations between patients and health care professionals about telemedicine. Many patients who did have telemedicine appointments report positive experiences and a willingness to have such appointments in the future. Among patients who had not had telemedicine appointments, 95.6% endorsed at least one telemedicine disadvantage about care quality, loss of relationship with their physician, lack of privacy, or technical difficulties. Physician-patient conversations could be helpful in addressing questions about care quality. One of our seven patients who had had telemedicine visits reported technical problems. Practice log-ins facilitated by digital health coaches are essential for people with devices whose capacity is unknown or who lack the skills to fully utilize them. Nevertheless, if we restrict our efforts to those already connected, telemedicine will fail to reach those who may benefit the most.
Some seniors, particularly those older than 75, may prefer to have a trusted family member assist them. Physicians and other healthcare professionals should encourage others to get connected through referrals to trusted community partners that employ digital navigators. However, it must be recognized that broadband internet remains unaffordable in many urban areas and is unavailable in many rural areas. Disparities in internet access and adoption replicate and compound existing health disparities.6 Health care should add its voice to the hundreds of national and local organizations working toward digital inclusion.7 Partnerships with them may assist with facilitating telemedicine among the underserved.
Some medical care will always require in-person visits, but many aspects of chronic disease management, such as check-ins following medication adjustments, could be accomplished through telemedicine. Therefore, efforts to increase telemedicine readiness will help ensure that the remarkably swift transition to telehealth reaches those who stand to benefit the most. While telemedicine seems to represent a disparity challenge, it can be used to provide a means to reduce healthcare disparities related to access.
References available on the Ohio Academy of Family Physicians website.