Disparities in Access to Neurologic Telemedicine During the COVID-19 Pandemic

Discussion

Our data identified demographic differences between patients who underwent telephone vs televideo encounters during the COVID-19 pandemic in Bronx, NY, an underserved area of New York City. Our findings point to a potential underlying disparity in access to televideo care, with a tendency for patients who are older, who have Medicare or Medicaid, and who do not speak English as a primary language, to receive telephone visits instead of televideo visits.

Ambulatory encounters conducted exclusively via telephone, without the benefit of a live video connection, have noteworthy limitations. Most obviously, an encounter without a live video feed precludes the ability of a physician to perform a physical examination. Furthermore, without video, there is less opportunity for nonverbal communication, particularly body language and facial cues that might provide helpful insights during a neurologic evaluation. As such, televideo visits are evidently the preferred method for ambulatory telemedicine care over telephone visits, with the latter being used often as a sort of last resort to provide at least some level of care in patients who are otherwise unable to undergo televideo visits.

There are likely multiple factors, which are contributing to our findings. Recent data support the notion that older adult patients may have, on average, lower levels of technological literacy^5,6 and are less likely to have home internet access⁷ and thus may feel less comfortable navigating the enrollment and login processes of certain televideo services. Younger adults and pediatric patients and their parents may thus be more likely to use televideo platforms due to overall higher levels of comfort and higher rates of digital access. Of interest, the tendency for higher rates of televideo visits among younger patients even within the pediatric population may point to a slight preference among parents with younger children to undergo the more comprehensive evaluation that a televideo visit offers compared with the preference of older children and/or their parents. Patients with public insurance, particularly Medicaid, may be less likely to have access to the required televideo equipment including a video capable device and high-speed internet access. Furthermore, patients who do not speak English as a primary language are likely to run into multiple barriers along the way, including difficulty in navigating televideo platforms, which were initially largely available exclusively in English, in addition to the need for interpreter services, which are not easily integrated into most televideo services without custom programming. Finally, new patients are likely to have a stronger preference for televideo visits over telephone visits and thus may feel more motivated to navigate the various barriers to obtaining such care.

Our study is limited in that it is retrospective and includes a relatively limited degree of demographic information. Although we make several assumptions such that age is likely to be associated with technological literacy in adult patients, and insurance status is associated with socioeconomic status among pediatric and adult patients, these factors are rudimentary measures at best. We could not directly analyze factors such as access to a high-speed internet connection, lack of a video capable device, technological literacy, or individual patient preference for telephone vs televideo visits. Furthermore, although there are likely physician-related factors, including, but not limited to, variation among physicians with regard to comfort level in operating televideo platforms for which we could not account, all physicians in our practice group were fully trained in the operation of televideo equipment and were regularly seeing patients in this manner. Although all patients were offered a televideo visit as the primary means for telemedicine visits during the study period, there exist many nonrandom factors that might influence a patient to choose one visit type over the other for which we could not account. Finally, we could not account for patients who did not access care at all during the study period, including patients who canceled appointments, did not complete appointments as scheduled, or who lacked an operating telephone. Notwithstanding these limitations, this study represents a large-scale examination of telemedicine in an urban care center during the COVID-19 pandemic and offers new insight into some of the factors that may play a role in access to televideo care during this public health crisis.

In conclusion, our findings point to a potential underlying disparity in access to televideo services among the diverse population in Bronx, NY. Targeted public health interventions including expansion of public programs to increase access to both high-speed internet access and video capable devices may ensure that financial factors do not preclude patients from having full access to televideo services during emergency situations and beyond. Expansions of multilanguage support and interpreter services into televideo platforms are likewise necessary. Within physician practices, an opportunity to increase the uptake of televideo visits likely exists at the point of first contact, when patients are being scheduled for their appointments. Scheduling staff should be trained and equipped to assist patients, particularly those who are older, have Medicare/Medicaid, or are non–English speaking, in navigating the practice's televideo system. Interventions could include dedicated staff who can run a test visit with patients over the video platform to ensure that they understand how to use the software and are ready for their appointments in advance. Finally, patient liaisons offering real-time technical support may be needed to assist patients who lack the technological literacy to navigate televideo platforms. Further research is needed to delineate the extent of disparities in access to televideo neurology care and investigations regarding possible differences in the outcomes and satisfaction among patients who use telephone visits without video.