Can you hear me now?

COVID-19 turns the spotlight on equity issues linked to telepsychiatry

Avrim Fishkind, MD, current Chief Executive of Empathic Soul Health and past president of the American Association for Emergency Psychiatry, has been involved with telehealth for about 15 years. During that time, he watched e-health and technology evolve simultaneously. Although, he added, the grandest telehealth advancements he’s seen thus far occurred only recently – triggered by the pandemic. 

The data agree:

  • Nearly 1/3 of health visits in the United States between June 26 and November 6, 2020, were conducted via telehealth.1
  • Nationwide, telehealth claim lines skyrocketed 3,060% between October 2019 and October 2020, according to private healthcare claims data released in January 2021 by the healthcare research organization Fair Health.2

That said, as Dr. Fishkind explained during a 2021 American Psychiatric Association Annual Meeting session, there’s work to be done before telepsychiatry can be considered an equitable mental healthcare service across all American populations. That’s largely because simply scheduling a video chat between patient and doctor won’t cut it. Too many Americans don’t have the tools to follow through on a telehealth appointment. According to the Pew Research Center.3 

  • Roughly three-in-ten adults with household incomes below $30,000 a year (29%) don’t own a smartphone.
  • More than four-in-ten don’t have home broadband services (44%) or a traditional computer (46%).
  • A majority of lower-income Americans do not own a tablet.

By comparison, each of these technologies, including smartphones, traditional computers, and tablets, is nearly ubiquitous among adults in households earning $100,000 or more a year.3

Telemedicine Patient Characteristics

A giant first step toward correcting the inequities that plague telehealth would be to identify the patients who most often experience these inequities, explained Dr. Fishkind. To do that, he dove into a recent study published in JAMA and titled Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic.4

The study included 148,402 patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic. About 80,000 completed their actual telehealth visit, with 35,824 doing so by video and 42,715 by telephone.

“The preponderance of telephone visits most likely related to people not actually having access to the ability to do video and defaulting to a telephone,” Dr. Fishkind said.

The study found that older age, Asian race, non-English language as the patient’s preferred language, and Medicaid were independently associated with fewer completed telemedicine visits. Older age, female sex, Black race, Latinx ethnicity, and lower household income were associated with lower use of video for telemedicine care.

Dr. Fishkind highlighted barriers beyond access, income, and age. For example, elderly patients can have impaired eyesight, hearing, and motor skills, which affect the ability to use technology even if they have it. But when these barriers are addressed, “the older population actually has the highest satisfaction scores for telemedicine,” Dr. Fishkind added.

Dr. Fishkind also mentioned that while a lower income directly impacts one’s access to technology, being financially challenged may also require working multiple jobs – so the barrier becomes a lack of time. “Scheduling telemedicine appointments with people in this population has to be convenient for them – and maybe not during traditional working hours.”

With every population, there will likely be things that are rarely discussed or thought about, Dr. Fishkind explained. Adjusting telepsychiatry to reflect different populations’ needs likely requires a broader approach than simply looking at economic status, access to technology, and age.

A Few More Patient Characteristics

Another study that caught Dr. Fishkind’s attention, called Advancing health equity and access using telemedicine: a geospatial assessment,5 looked at inequities specific to North Carolina. This study results included several novel factors that challenge telehealth equity. 

To begin with, researchers saw a previously unidentified correlation between not having access to broadband and receiving food stamps. The study also reported a link between stay-at-home single mothers without childcare options, which makes it difficult to find a quiet time for telemedicine appointments.

Vehicle access is another barrier to telehealth, the study concluded. While driving to a telehealth appointment may sound illogical, Dr. Fishkind and the geospatial assessment say otherwise. Patients without reliable access to the internet are often scheduled for telehealth appointments at a community clinic, where the patient can have access to the internet and connect with a remote physician. It appears to be solution. But what happens when the patient doesn’t have a vehicle? “If we can give these patients access to broadband in their own home, then they can be seen by a physician direct-to-consumer,” Dr. Fishkind said.

Meeting the Challenges

The US government built a website that is dedicated to telehealth: Dr. Fishkind summarized and interpreted the government’s suggestions to create equitable telehealth services. The caveat, he added, is that these are “pretty difficult things to do” and may be impossible due to budgetary restraints.

  1. Create a realistic workflow that accommodates times when community members are most likely to be available.
  2. Initiate tech support for patients, which may include testing equipment and providing equipment if needed.
  3. Offer tech support to staff members, who often need additional skills when moving from solely in-person to telemedicine services.
  4. Consider various communication formats to accommodate all patient populations, including audio recordings, Braille, larger print, and other means of communication for those with disabilities.
  5. Measure patient satisfaction often, quickly, and then adapt.

That’s what the US government suggests. Here are a few ideas that Dr. Fishkind feels deserve equal consideration.

A “brilliant idea” that Dr. Fishkind would like to see come to fruition involves what he referred to as a prescription connection package. The physician writes a prescription for a smartphone, tablet, or desktop computer and broadband access. These tools would be a legitimate benefit for psychiatric patients on disability in need of telemedicine appoints with a psychiatrist.

To accomplish this, the doctor added, will take an immediate and hefty investment in the US broadband infrastructure. “Equity comes with costs, but we have to make sure that everybody in the farthest regions has broadband.”

Dr. Fishkind also brought up a new wave of products called prescription digital therapeutics, which could impact telehealth equity. This type of prescription-only software delivers evidence-based therapeutic interventions to prevent, manage, or treat a medical disorder or disease.

Consider, for example, a patient with a substance use disorder. That person would get a prescription from a physician for an FDA-approved software program. The patient would  complete lessons, answer quiz questions, submit scheduled reports, review exposure to triggers, record negative drug screens, and send all this information digitally to their psychiatrist. The psychiatrist can monitor the data and adjust accordingly. The patient, of course, continues regular outpatient therapy.

“This gives patients the tools and technology they need in between visits to continue their treatment and care,” Dr. Fishkind said.

Another path to equity involves adding hub and spoke systems. “This essentially ensures that rural primary care doctors have access to counsel – so these doctors better understand how to provide the best possible care to mental health patients,” Dr. Fishkind explained.

In the end, though, Dr. Fishkind emphasized that no proposal to improve telemedicine equity will work if we can’t put the right technology into every patient’s hand. “For those of us today who are doing something like telemedicine, technology is just routine. But remember– 4 in 10 adults, or 44% of the US population, can’t do this because they don’t have broadband. So even with all the ideas put forward today, without fixing that particular problem, it’s going to be hard to fix the inequities in our mental healthcare system.”

  1. Demeke HB, Merali S, Marks S, et al. Trends in Use of Telehealth Among Health Centers During the COVID-19 Pandemic — United States, June 26–November 6, 2020. MMWR Morb Mortal Wkly Rep 2021;70:240–244. DOI: icon.
  2. Fair Health. Telehealth Claim Lines Increase 3,060 Percent Nationally When Comparing October 2019 to October 2020. January 6, 2021. Accessed on May 24, 2021.
  3. Pew Research Center. Digital divide persists even as lower-income Americans make gains in tech adoption. MAY 7, 2019. Last accessed May 24, 2021
  4. Eberly LA, Kallan MJ, Julien HM, et al. Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(12):e2031640. doi:10.1001/jamanetworkopen.2020.31640
  5. Khairat S, Haithcoat T, Liu S, et al. Advancing health equity and access using telemedicine: a geospatial assessment. J Am Med Inform Assoc. 2019;26(8-9):796-805. doi:10.1093/jamia/ocz108