Introduction
As telemedicine use for healthcare delivery during the COVID-19 pandemic has grown,
access to technology has emerged as a fundamental determinant of access to care. Accordingly,
digital access is now being recognized as a social determinant of health [1]. Over
21 million individuals in the USA lack broadband internet access, limiting access
to telemedicine [2, 3]. New York State (NYS) has been one of the early epicenters
of the pandemic in the USA. While NYS has a 99.9% broadband internet infrastructure,
nearly one-third of New York City (NYC) households, or approximately 2.2 million residents,
lack a home broadband internet subscription [4–6]. Furthermore, significant disparities
in broadband internet access exist for NYC residents who are low income, racial/ethnic
minority, over the age of 65, or have a non-English primary language. Digital literacy
is also lower among these populations [5–7].
In New York City, neighborhood-level disparities in COVID-19 infectivity and mortality
have largely been attributed to race/ethnicity and socioeconomic differences [8].
However, the influence of digital access inequities on these COVID-19 disparities
has not been examined quantitatively. For racial/ethnic minority, low-income, and
other vulnerable populations that are disproportionately burdened by the digital divide,
disparities in digital access may compound other forms of structural disadvantage,
exacerbating COVID-19 and health access disparities [6]. In the following commentary,
we explore policy considerations and solutions to reduce the impact of the digital
divide on vulnerable populations during the COVID-19 pandemic and beyond.
Increasing Access to Broadband
NYC neighborhoods with poor access to broadband internet tend to also have higher
proportions of racial/ethnic minorities, higher poverty rates, and lower educational
attainment, sociodemographic factors that have been linked to excess COVID-related
hospitalizations and mortality [8, 9]. To prevent the exacerbation of pre-existing
disparities, the rapid expansion of telemedicine must be paralleled by a commensurate
expansion of access to broadband internet. In response to the rural–urban digital
divide, the Federal Communications Commission (FCC) launched the Digital Opportunities
Data Collection mapping project to identify broadband coverage gaps in rural areas
and established the Rural Digital Opportunity Fund, which allocated $20.4 billion
to expand broadband infrastructure to rural areas [10]. Additionally, through the
Connect America Fund, the FCC partnered with New York State to provide a combined
$390 million to support rural broadband expansion [10]. Similar broadband mapping
initiatives and federal-state financial partnerships should be enacted to identify
low-coverage regions within urban areas and increase broadband access within those
communities.
Government subsidies for broadband subscribership and data charge subsidies for mobile
health applications will help reduce cost barriers to individual patients [1]. Broadband
access can be further expanded by leveraging existing community infrastructure and
social programs. For example, broadband hotspots should be established in public spaces,
such as libraries, schools, and community centers [11]. Efforts should be made to
relax or waive re-enrollment requirements for initiatives such as the Lifeline Program,
which provides telephone and internet subsidies to low-income individuals and people
enrolled in certain federal assistance programs, in order to prevent subscribers from
losing access due to COVID-related disruptions [12]. Finally, health providers and
health systems can help accelerate broadband deployment in low-resource communities
by supporting policies that reduce financial, bureaucratic, and structural barriers
to the expansion of required infrastructure, such as digital redlining of less economically
profitable neighborhoods [2, 10, 13].
Increasing Access to Technology
During the COVID-19 pandemic, virtual access to providers has become vital for respiratory
symptom screening and triage. Thus, in addition to greater access to broadband internet,
vulnerable communities will require increased access to technological devices to engage
with telehealth platforms. Although significant increases in ownership of both smartphones
and computing devices have been observed in the past decade, disparities persist across
race/ethnicity, income, education, and age groups [14]. During the pandemic, the NYC
Department of Education has provided over 320,000 tablets to students in attempts
to narrow the digital divide in education [15]. Hospitals should support similar device
distribution programs for patients at risk of becoming disconnected from virtual care.
Device ownership screening should occur as part of routine patient intake, similar
to electronic health record–based social determinants of health screening used to
identify other resource gaps [16]. Screening questions should further assess the number
of devices available in the household, the types of devices, and whether those devices
have sufficient bandwidth to support video conferencing for telehealth visits.
Improving Digital Literacy
Access to accurate, culturally sensitive information about COVID-19, much of which
is disseminated online, and the ability to adhere to evidence-based safety guidelines
are fundamental to limiting viral spread during the pandemic. Populations with low
digital literacy are less capable of effectively utilizing technological devices or
accessing the internet to obtain health information, making them less able to remain
updated on official safety recommendations concerning COVID-19 [11, 17]. Furthermore,
racial/ethnic minorities, older adults, and individuals with lower educational attainment
are less likely to engage with online patient portals to participate in chronic disease
management, even with adequate internet and computer access [18]. Thus, digital and
health literacy likely contribute to disparities in the use of mobile health applications
even with sufficient access to technology.
Hospitals should partner with community colleges, public libraries, and other community-based
organizations to develop education and skills-building programs to address digital
and health literacy gaps [11]. These training programs should be designed according
to needs identified by community stakeholders, available in multiple languages, and
implemented in a variety of forms, such as in-person or virtual classes, real-time
online help, and home assistance from trained digital literacy workers [11]. Digital
literacy training will allow vulnerable patient groups to better access and interpret
online health information.
Implementing Equitable Telemedicine Platforms
Although telemedicine provides advantages for medically underserved communities, such
as limiting risk of disease transmission, decreasing time invested in obtaining healthcare,
reducing transportation barriers to attending in-person appointments, and potentially
expanding access to specialty care, it is not a panacea for healthcare access inequities
[19]. Following the widespread implementation of telemedicine during the pandemic,
primary care visits by patients with limited digital access, including racial/ethnic
minority groups, patients over age 65, and patients with non-English language preference,
have disproportionately decreased, raising concern of potential delayed management
of chronic diseases as well as delayed COVID-19 diagnoses [20]. Disruptions in chronic
disease screening, prevention, and treatment will most significantly impact populations
with limited access to telemedicine [21]. Although increasing digital access and digital
literacy will help vulnerable patients obtain virtual visits, language, cultural,
and logistical barriers may impair the quality of care [19, 22].
Additionally, logistical and privacy concerns emerge when patients attend appointments
from home. Access to quiet, private spaces for discussion of sensitive health information
can be limited for patients living in crowded, multi-generational households. Furthermore,
virtually inviting physicians into their home environment may be viewed by patients
as an invasion of privacy [19]. Some patients have also raised concerns about the
security of personal health information that is shared through virtual platforms [19].
Health systems must incorporate flexibility in modalities for virtual visits by allowing
patients to turn their video off or conducting audio-only visits by telephone when
clinically appropriate. Healthcare providers can partner with local organizations
such as public libraries and community centers to supply private office spaces from
which patients can attend telehealth visits. Finally, digital literacy workers can
help patients better understand the privacy policies and security infrastructure of
mobile health services.
Furthermore, health systems should develop culturally and linguistically inclusive
digital health platforms and track their usage among the sociodemographic groups most
affected by the digital divide [23]. These populations should be included in the development
of mobile health tools. Health providers can advocate for federal mandates like the
Culturally and Linguistically Appropriate Service Standards to formalize guidance
on promoting digital health equity, such as by expanding the availability of interpreter
services for telehealth visits [23]. Additionally, conference calls that incorporate
family members or caregivers with higher digital literacy in the medical visit can
help vulnerable patients navigate technical barriers to engaging with virtual platforms,
promote effective communication between patients and providers, and equip patients
with additional home support for chronic disease management during a challenging time.
Finally, as we address virtual health disparities, we must recognize the clinical
limitations of telemedicine. Although virtual visits can be effective in specialties
that primarily utilize verbal communication and visual physical examination, remote
patient assessment may not be clinically appropriate in other scenarios, such as surgical
consultations [19]. Even as telemedicine expands and mobile health technology continues
to advance, there will remain a role for in-person visits for certain clinical problems.
Conclusion
The COVID-19 pandemic has highlighted that digital access is now a social determinant
of health and a prerequisite for access to both COVID-related and non-COVID care [1,
19]. Accordingly, individual providers and health systems must combat digital health
inequities by collaborating with community-based, state, and federal organizations
to increase access to broadband internet and computing devices, improve digital literacy,
and mitigate disparities in telehealth. In order to fully address the disparate impact
of the pandemic and promote equity in the era of telemedicine, we must bridge the
digital divide.