The COVID-19 pandemic, which rocked the planet in unprecedented fashion, accelerated our journey into an increasingly digital age, forcing us to embrace new technologies and innovations to ensure safety in a world where face-to-face contact is limited.
Telehealth, already a growing trend, emerged as a solution for providing healthcare amid mandated isolation policies, offering people efficient and high-quality healthcare service within the safety and comfort of their homes.
Today, telehealth is seen as a solution for patients who no longer have to travel long distances, or deal with potential wait times at crowded offices. But despite its promise of improving healthcare access, telehealth does come with limitations that can particularly affect the Black community.
“Technology can be a great equalizer [but] it can also be a great discriminator,” says Dr. Neil Calman, a family physician and the CEO of The Institute for Family Health, a health organization that delivers patient-centered primary healthcare to medically underserved communities in New York City.
“It’s an equalizer when it gives people access to things that might have been difficult for us to access before. But it can be a discriminator because not everybody has access to telehealth with that nice video screen and camera, and not everybody knows how to use it.”
With health centers established across the boroughs – homes to historically neglected populations (notably Black, Latinx, and impoverished people) – Calman says ensuring adequate remote healthcare access becomes essential for the survival of these communities.
“Having a cell phone these days is a life and death situation. There are things you can’t even access [without one]. I mean, where are you going to go? There are no payphones on the street anymore. If you need to call 911 and you don’t have access to a cell phone, you’re going to experience a different level of problem than somebody who does.” says Calman.
Several studies support Calman’s observations, highlighting prevailing disparities in telehealth access.
A study from the JCO Oncology Practice medical journal uncovered racial disparities related to accessing video telehealth services for patients seeking cancer care. Of the nearly 21,000 total patient visits at the East Carolina University Health System, — which serves 29 counties in eastern North Carolina – 43 percent were conducted with Black patients, while 57 percent were with white patients. While the total number of patients shows smaller racial differences, telehealth visits reveal a significant disparity, with 29 percent of telehealth visits conducted with Black patients and nearly 71 percent conducted with white patients out of a total of 3,031 visits.. Black patients also were more likely to report inadequate internet access.
Another study from the Journal of the American Medical Informatics Association examined the characteristics of NYC patients seeking COVID-related care through telehealth, emergency room, or office visits at the height of the pandemic and found that 60 percent of Black patients were more likely to utilize the emergency room than telehealth compared to nearly 47 percent of white patients.
The study further revealed potential barriers preventing Black people from accessing remote healthcare, including “disparities in digital access, digital literacy, and telehealth awareness.”
However, these healthcare disparities don’t begin with telehealth; they are part of a larger systemic issue.
Evans Rochaste, a board-certified nurse practitioner in psychiatry and founder & CEO of ReKlame Health, says stigma and distrust are also significant barriers, exemplified by systemic discrimination, such as the Tuskegee experiment and elevated Black maternal mortality rates.
“Part of the reason stigma is really high in healthcare is because of all of the systemic and structural racism that the system has,” Rochaste says. “Then, more importantly, with stigma, going to a provider [is] already a very anxiety-provoking process – not trusting and feeling that more harm may be done.”
Dr. Cohall, a physician and Professor of Public Health and Pediatrics at the Columbia University Medical Center and the Mailman School of Public Health echoes similar sentiments, noting systemic challenges like lack of insurance coverage, cultural awareness by providers, and knowledge of health services. He says these problems can affect health outcomes within the Black community.
“[People that] don’t have access, if they have a health issue, they’re not going to get that problem addressed. If they have access but don’t trust the health institution or the health provider, they may not go in for services, or they may not respect the information provided to them or act on that information. So it affects the whole gamut of the healthcare process.”
He also notes the trivialization of Black people’s pain as an obstacle, referencing the 2020 case of a Black physician who died from COVID-19 after her repeated pleas for medication were dismissed.
“She wasn’t adequately treated and, as a result, succumbed to her illness. That’s not a unique situation. The literature is filled with studies showing that people of color have their health needs underestimated by physicians. There’s a lot of explicit and implicit bias that is part of the healthcare delivery system,” Cohall says.
ReKlame Health, a behavioral health and addiction medicine startup, addresses those biases by providing culturally competent psychiatric care to people suffering from mental health conditions through telehealth. Rochaste says empathy is at the core of their services, and that they prioritize facilitating relationships of understanding between providers and patients.
“Meeting people where they are on their journey, and having patience and empathy for all of the other challenges that may be occurring, that are not even in the four walls of appointment,” Rochaste says. “It helps us really unlock breakthroughs just by being really empathetic and understanding.”
Rochaste founded ReKlame in 2020, driven by his experiences as a young Black man navigating the healthcare system and his professional background as a psychiatric nurse practitioner. Most of their services are provided virtually, with a small in-person presence in Manhattan for sessions if needed.
For patients unfamiliar with the telehealth system, Rochaste says they provide step-by-step instructions at the start of the intake process.
“Our care navigators are there every step of the way to answer questions via text or over the phone,” he says. “From the moment they start, [we] pair them with [a] care team and have someone who’s dedicated and responsible to ensuring [that they have] everything they need from manipulating the technology to figuring out their insurance benefits; how is this going to work, co-payments – everything that is outside of the four walls to make them comfortable.”
At New York-Presbyterian Hospital, the intake process is similar. Their program, the Community for Tele-Paramedicine, delivers remote healthcare service to vulnerable populations across the NewYork-Presbyterian health system. With a focus on active outreach, the program performs services like home visits and walking patients through how to use telehealth technology.
Dr. Brock Daniels, the Medical Director of Community Tele-Paramedicine and assistant professor of emergency medicine and population health science at Weill Cornell Medicine, says that two-thirds of the home visits occur in communities that are most negatively impacted by social determinants of health, which are social factors (like economic status, housing stability, and access to healthy food) that influence health outcomes or quality of life – several of which are pressing concerns within the Black community.
“By sending paramedics to the home [and] by bringing all the technology needed to do [those] telehealth visits, we’re able to circumvent a lot of those barriers and [are] able to get the technology to the people that are most likely to benefit from it,” Daniels says.
Calman says most of the behavioral health services at the Institute for Family Health are performed via telehealth because of its convenience for patients – one of the prime advantages of telehealth services.
“For people who are working in entry-level jobs where they don’t get a lot of time off, where they might get a half-hour break for lunch and don’t want to miss work because they won’t get paid, people like that can get behavioral health services by scheduling them during their times off,” Calman says.
Zayin Tilley, a 23-year-old telehealth user, finds that the process has simplified obtaining mental health assistance. Last summer, while interning for a Fortune 500 company, he experienced heavy anxiety after being required to travel to help a client. He credits his therapist, whom he connected with via telehealth, for contributing to his success during the trip.
“I was out for maybe a week, and that’s a situation where normally I wouldn’t have been able to do therapy,” Tilley says. “Luckily, because we were doing telehealth, I was able to meet with my therapist during the week over the computer, and his advice was really important in getting me through to the end of the internship. But I think that if it hadn’t been for him, there’s a small chance I would have even left earlier and gone back home.”
But that doesn’t mean telehealth is without its pitfalls. Tilley, who has been using telehealth for two years and started during COVID, says that while he is pleased with his experience, the virtual nature sometimes feels superficial. He notes that the lack of physical contact can affect the quality of care, particularly for remote mental health services.
“If you’re meeting over Zoom, you can only see your patient from the [middle of their chest] and up. I know, for me, at least, I’m the kind of person who, if I’m nervous, it won’t really show on my face. I’ll start tapping my hands and moving my feet. My therapist doesn’t get all that information about my body language and everything. I think that impacts his ability to provide care that’s responsive to the situation I’m in.”
Not only that, according to data from the U.S. Census Bureau, in 2019, more than one million homes in New York lacked access to broadband internet or a subscription. A 2021 report by the Office of the New York State Comptroller about broadband access in New York, which utilized the census data, found that Black households had the highest rate of no broadband access compared to other racial demographics.
With many folks without access to the internet, telehealth becomes a nonviable option for receiving healthcare services, having the potential to further perpetuate disparities given the disproportionate amount of Black homes without broadband internet.
As we advance into the digital age and continue to create and utilize technologies, ensuring equitable implementation becomes crucial, Rochaste explains, using A.I. as an example.
“What we have to be mindful of as we’re building these different A.I. advancements is how A.I. is being ethically applied. How is it taking into consideration people’s different backgrounds, such as some of the cultural nuances that someone who is Black and maybe from a Caribbean family?” says Rochaste. “That’s really a discussion that is at the forefront of innovators. And I really believe that we have to stay on top of that to ensure that we’re not doing more harm while we’re trying to advance these groundbreaking technologies.”
This story is part of the Digital Equity Local Voices Fellowship lab. The lab initiative is made possible with support from Comcast NBCUniversal.
Great article on telehealth. Very informative. Another issue is senior citizens who do not want to use the new technologies; like text messaging, Zoom, and other technologies.