Outlook: Newsletter of the Society of Behavorial Medicine

Fall 2022

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No Patient Left Behind: Ensuring We Continue Overcoming Barriers in the Age of Telehealth

Brett Ankawi, PhD✉; Jaylyn Clark, PhD✉; Emily A. Walsh, MS✉; and Danielle M. Wesolowicz, PhD✉; Pain SIG


Telehealth treatment, such as synchronous video/voice calls with providers and web-based treatment platforms, became a necessity during the COVID-19 pandemic to ensure the safety of all patients and providers. However, telehealth platforms had already been receiving increased attention as a way to expand access to treatment.1-4 Telehealth platforms can remove common barriers for treatment including cost, transportation, mobility, and competing time demands.5-7 For patients in rural or other underserved settings, these barriers are often compounded by other factors, including poverty and distance to medical centers that provide specialized treatments.8,9 However, as these barriers are addressed, an understanding of new barriers created by telehealth delivery is needed.

Despite the benefits of telehealth in expanding treatment to underserved (often rural) areas, the actual resources to support these platforms may not be accessible to those who live in these regions. Many telehealth interventions are being developed to be delivered via website or smartphone/tablet application.4,10 However, the use of these apps require a stable, high-speed internet connection, in which 33% of the rural population and 10% of the population in the United States lacks.11,12 This is not exclusively a rural problem; a 2018 report by the Chief Technology Officer of New York City noted that 31% of New York City households do not have a home broadband subscription, and that these rates are higher for Black and Hispanic residents than White residents. As a result, telehealth may in fact be maintaining or even increasing treatment disparities.13 In addition to internet access, telehealth interventions often require expensive electronics such as a computer, tablet, or smartphone for treatment, and any cost savings of a telehealth intervention for the patient may be offset by the new financial burden of necessary expensive electronics. Some clinics and studies may offer access to these electronics; however, the underserved areas that would most benefit from borrowable electronics are also likely to have less funding to support these programs within their clinics, and clinical trials with a limited timeline do not offer long-term equipment availability.14 Although these resources may be available in community settings such as a library, patients may elect not to use these services because they do not wish to discuss private information with their provider in a public setting. The final consideration is digital literacy which may impact one’s ability to use telehealth platforms even if other barriers are not present.15 This concern may diminish naturally over time as the required use of technology platforms for occupational, social, educational, and healthcare purposes is improving digital literacy across the board.10

This may seem like a pessimistic view on the strides made in increasing access via telehealth. Instead, it is a call to action in considering these telehealth-specific barriers when designing and implementing telehealth platforms for treatment. For example, interventions delivered by phone, either synchronously (i.e., talking to a patient in real time) or asynchronously (i.e., using interactive voice response or automated messages) may reach a wider audience than one delivered via the internet.16 If designing a website or app, consider identifying other methods that might cater to those who only have access to lower speed internet; for example, using images rather than videos, or options for voice only communication if a patient’s internet cannot handle video chat.17 Finally, there is the opportunity for advocacy; petitioning for public broadband at the local, state, or even federal level would provide numerous benefits, including improving healthcare equity as more services shift to telehealth platforms.

 

References

  1. Dorsey, E. R., & Topol, E. J. (2016). State of telehealth. New England Journal of Medicine, 375(2), 154-161.
  2. Monaghesh, E., & Hajizadeh, A. (2020). The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health, 20(1), 1-9.
  3. Tuckson, R. V., Edmunds, M., & Hodgkins, M. L. (2017). Telehealth. New England Journal of Medicine, 377(16), 1585-1592.
  4. Shigekawa, E., Fix, M., Corbett, G., Roby, D. H., & Coffman, J. (2018). The current state of telehealth evidence: a rapid review. Health Affairs, 37(12), 1975-1982.
  5. Ankawi, B., Kerns, R. D., & Edmond, S. N. (2019). Enhancing Motivation for Change in the Management of Chronic Painful Conditions: a Review of Recent Literature. Current Pain and Headache Reports, 23(10), 75.
  6. Becker, W. C., Dorflinger, L., Edmond, S. N., Islam, L., Heapy, A. A., & Fraenkel, L. (2017). Barriers and facilitators to use of non-pharmacological treatments in chronic pain. BMC Family Practice, 18(1), 41. 7.    Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., . . . Turner, J. A. (2016). Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. Journal of the American Medical Association, 315(12), 1240-1249.
  7. Ehde, D. M., Dillworth, T. M., & Turner, J. A. (2014). Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. American Psychologist, 69(2), 153-166.
  8. Brown, E. M. (2013). The Ontario telemedicine network: a case report. Telemedicine and e-Health, 19(5), 373-376.
  9. Gajarawala, S. N., & Pelkowski, J. N. (2021). Telehealth benefits and barriers. The Journal for Nurse Practitioners, 17(2), 218-221.
  10. Mahtta, D., Daher, M., Lee, M. T., Sayani, S., Shishehbor, M., & Virani, S. S. (2021). Promise and perils of telehealth in the current era. Current Cardiology Reports, 23(9), 1-6.
  11. Drake, C., Zhang, Y., Chaiyachati, K. H., & Polsky, D. (2019). The limitations of poor broadband internet access for telemedicine use in rural America: an observational study. Annals of Internal Medicine, 171(5), 382-384.
  12. Pew Research Center. (2021). Mobile Technology and Home Broadband 2021.
  13. New York City Mayor's Office of the Chief Technology Officer. (2019). Truth in Broadband: Access and Connectivity in New York City.
  14. Coughlin, J. (2021). Accessible Health: An Evidenced Based Approach to Improve User Experience and Clinical Sustainability within Rural Healthcare.
  15. Foster, M. V., & Sethares, K. A. (2014). Facilitators and barriers to the adoption of telehealth in older adults: an integrative review. CIN: Computers, Informatics, Nursing, 32(11), 523-533.
  16. Lee, H., Friedman, M. E., Cukor, P., & Ahern, D. (2003). Interactive voice response system (IVRS) in health care services. Nursing Outlook, 51(6), 277-283.
  17. Steele, R., & Lo, A. (2013). Telehealth and ubiquitous computing for bandwidth-constrained rural and remote areas. Personal and Ubiquitous Computing, 17(3), 533-543.