Telemedicine Expansion During the COVID-19 Pandemic and the Potential for Technology-Driven Disparities
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J Gen Intern Med DOI: 10.1007/s11606-020-06322-y © Society of General Internal Medicine 2020
BACKGROUND
Telemedicine use has rapidly increased across the US health system during the COVID-19 pandemic.1 Although telemedicine has been heralded as a way to reduce disparities in healthcare,2 concerns remain that lack of access to technology or digital health literacy can exacerbate technology-driven disparities as telemedicine use expands.2–4 As recent regulatory and policy changes allowed reimbursement for telephonic telemedicine visits in addition to visits facilitated by audiovideo technology,1 there is a unique opportunity to examine technology-driven disparities as manifested through how telemedicine services are accessed differently by different patient populations.
OBJECTIVE
We sought to assess disparities in whether patients received audio-video telemedicine visits or telephonic ones, using data from a telemedicine expansion initiative at a major academic medical center.
METHODS AND FINDINGS
Beginning on March 2, 2020, the Columbia University Irving Medical Center undertook rapid expansion of telemedicine services across all outpatient clinical services through centralized training and support and increased patient outreach and education. All departments were strongly recommended to conduct telemedicine visits through Epic EHR (Epic; Verona, WI) integrated audio-video technology (Vidyo; Hackensack, NJ), but could also use telephone visits if necessary (e.g., if patients lacked smartphone or internet access). We queried Epic EHR for all scheduled outpatient telemedicine visits completed over a 13-week period from February 1, 2020, to May 1, 2020, using visit types and scheduling comments to define audio-video versus telephone visits. We Received June 24, 2020 Accepted October 15, 2020
collected patient demographic information (age, sex, race, and ethnicity) and visit information (specialty, clinic site, and primary insurance). We used descriptive statistics to summarize the number of telemedicine visits over time. A multi-level logistic regression model was used to estimate the odds of having a telemedicine visit through audio-video technology versus telephone, accounting for specialties as fixed effects and clinic sites as random effects. We applied inverse weighting to account for multiple patient visits at practice level. From February 1 to May 1, 2020, 50,101 unique patients (Table 1) received a total of 80,163 telemedicine visits, including 60,712 (76%) visits conducted through audio-video and 19,411 (24%) conducted via telephone. The weekly number of telemedicine visits increased steadily, from 56 during week 1 to 13,985 during week 13 (Fig. 1). In the fully adjusted model, after accounting for specialty area and clinic sites, older age, Black race, Hispanic ethnicity or primary language Spanish, and primary insurance being Medicaid or Medicare were all significantly associated with lower odds of audio-video telemedicine visits (Table 1).
DISCUSSION
Our successful telemedicine expansion in respons
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