Unless it’s done carefully, the rise of telehealth could widen health disparities

The Covid-19 pandemic has pushed telehealth — the remote provision of health care resources, tools, and consultation, usually via digital technologies — from the backwaters of medicine to its leading edge.

Though novel to some health care providers, and considered impractical by others, telehealth will likely endure — and become even more appealing — after the Covid-19 pandemic has faded away. We are concerned that this crisis-driven acceleration in the adoption of virtual visits and use of algorithmic tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities in health.

The changes that have made possible the wider use of telehealth appear to be temporary. For instance, health insurers, who once declined to fully reimburse virtual visits to physicians, nurse practitioners, and other health providers, are now making exceptions expressly tied to the nature of the pandemic. Yet research and theory from the social sciences on institutional change would predict that there may not be a clear-cut return to “normal” once this crisis is over.

The adaptation to Covid-19 has realigned the power and positions of physicians, nurses, insurance companies, hospitals, and telehealth startups in providing health services to different communities. Providers are establishing new policies and automated systems around triage, virtual visits, and infection control that may become taken-for-granted work routines going forward. Such practices may be laying the foundation for opportunism in the expansion of telehealth markets above and beyond their value in treating disease and saving lives by allowing compensation for unnecessary visits.

For some time, technology companies have sought to disrupt the health sector with algorithms and other patient-centered digital innovations. These companies are now rushing to consolidate their positions before the opportunities presented by the pandemic abate.

Some providers and hospitals, attracted by potential reductions in cost and in potential improvements in patients’ health outcomes, were early adopters of virtual visits and other telehealth technologies. With the emergence of Covid-19, providers who had once been prudently looking for an evidence-based way to add value to their practices have been pushed into rapidly developing telehealth strategies to keep their practices afloat. Academic medical centers that had previously piloted telehealth as a strategy to expand their referrals or to decrease readmissions are now leveraging this infrastructure to more intentionally maintain contact with patients who have been seen in their outpatient offices.

There’s no question that the expansion of telehealth could be a force for good. These changes may save lives during this crisis by keeping patients out of health care settings where exposure to Covid-19 may be high. In the post-pandemic era, they could provide greater access and convenience for some patients. But they could also worsen health disparities down the road if not implemented carefully.

In its earliest days, one of telehealth’s missions was to ensure greater access to health care services by populations that otherwise would go without proper or timely care and consultation, such as those who are incarcerated or who live in rural areas. Now it is being used as a tool to supplant in-person visits and expand patient markets, partly in response to consumer demand for convenience and efficiency. This emphasis on expanding patient markets and responding to well-resourced consumers’ demand may put marginalized groups with poor health, no health insurance, or few digital resources at risk.

A market-driven, consumer-centered vision of telehealth could have negative implications for marginalized groups that already face discrimination during in-person medical encounters. Marginalized racial and ethnic minorities are more likely to report discrimination within health care settings, influencing their willingness to trust providers and seek medical attention early.

Discrimination and mistrust could be magnified in virtual doctor-patient encounters, in which patients may not feel they can fully communicate and providers may be less mindful of guarding against implicit bias based on attributes such as race, ethnicity, or educational status.

The potential for racism and class bias to be encoded into telehealth algorithms is also worrisome. Predictive tools are imperfect — although they may be able to predict average patterns across groups, they can neither fully account for the complexity of individuals nor incorporate subtle variables that may assist in the identification and treatment of disease. While doctors misuse of these algorithms is mitigated by clinical judgement and training, a patients’ uninformed use of such algorithms in lieu of seeking professional medical advice could be harmful. This is particularly true of patients who belong to social groups underrepresented in algorithmic data.

Hospitals, insurers, policymakers, and health care professionals must carefully consider how the telehealth policies and routines they implement might have durable — and potentially harmful — reverberations. Research into the costs and benefits of specific telehealth applications at the individual and population levels is essential.

Institutional policies created during this pandemic will have long-lasting consequences on health disparities. We must work to ensure they are net positive.

Matthew Clair is a sociologist and assistant professor of sociology at Stanford University. Brian W. Clair is an orthopedic surgeon at Lahey Hospital and Medical Center in Burlington, Mass. Walter K. Clair is a cardiologist, professor of medicine at Vanderbilt University Medical School, and executive medical director of the Vanderbilt Heart and Vascular Institute.