wireless internet. That makes video visits a lot more challenging. Cell phone wireless signals might suffice but doing a visit on a smartphone is less than ideal. A hot spot, then? Maybe, but video calls eat up data. Not everyone has unlimited data. These kinds of technological barriers may seem minimal if you’re tech savvy—but seniors who weren’t raised in the digital age may have difficulty trying to figure it all out. “The whole device thing is a barrier,” says Tanner Nissly , a family practitioner at a Minneapolis clinic run by the University of Minnesota, where he is an assistant professor. The clinic serves a population of predominantly Black and Asian immigrants, the majority of whom are “under-resourced” and receive federal or state-aided health insurance. When Covid hit, he could only connect with patients remotely. Since many lacked either a proper device or access to internet, telephone visits became the norm even before government insurers paid for them. Nissly, who co-authored a commentary on achieving equity in telehealth based on his practice’s experiences, believes that “if you really care about equity, then you need to start with groups that have traditionally been marginalized and let it trickle out to the people who are less vulnerable.” Camille Clare is an obstetrician/gynecologist at SUNY Downstate in Brooklyn, NY. Her patients, who have government-based health insurance, often lack access to broadband or wifi, making virtual visits logistically challenging if not impossible. In the last year, access to high-speed internet has thus become an aspect of “social determinants of health”—the circumstances in which we are born, live, age, and die, that impact the kind of care we receive and, in turn, our health and well-being. “Telehealth is a social determinant of health,” Clare argues, just like food security, housing stability, transportation, and other situations that pose day-to-day difficulties in marginalized communities. Telemedicine in All its Variants The popular image of telemedicine is a doctor on a big screen chatting with the patient in real-time interactive audio and video. But the reality encompasses other, simpler modalities. The Centers for Medicare and Medicaid Services (CMS), which sets payment guidelines for federal healthcare programs (and are usually followed by private insurance payers), acknowledges and pays for a suite of services under the umbrella of telemedicine. These include “telehealth visits,” “virtual visits” and “e-visits,” each with its To some degree, the problemboils down to a new iteration of an old problem, the so-called DIGITAL DIVIDE.
is about how the healthcare system works, Barnett points out. “There are many important structural factors that limit health care access in ways that telemedicine won’t fix all on its own. It’s only one piece of what is needed to reform healthcare to address the long-standing disparities we have.” Access to broadband is the most solvable part of the problem. According to the Federal Trade Commission, some 46 million Americans don’t have high-speed
THIS IS TELEMEDICINE A 93-YEAR-OLD MALE SUFFERED a six-inch laceration when a tree he cut down grazed his head. He refused to go to the E.R., so his daughter emailed a photograph of the injury to his doctor. Within five minutes the doctor called and strongly urged the patient to get to the E.R. immediately. Patient complied and received stitches and a CT scan before being released. A week later, the doctor removed the stitches in a “curbside” appointment in the parking lot of his clinic.
38 DANA FOUNDATION CEREBRUM | Winter 2022
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