barrier we encounter is lack of access to
the necessary technology. Our observations
are not unique; Nouri et al3 recently
found that patients with socioeconomic
disadvantage were significantly underserved
by telemedicine visits in March
2020. Citing poor access to technology as
a major factor, they described lower rates
of telemedicine uptake among patients
who were non-White individuals, were older,
had low English proficiency, and lacked
commercial insurance.3
Alexander et al2 considered both telephone
and video visits in their analysis,
and they did not distinguish between these
two methods of care delivery. While telehealth
is often used as an umbrella term
for all patient care conducted by phone or
audiovisual technology, it is important to
note that these two methods have very
different implications. For example, the
Centers for Medicare & Medicaid Services
specifies that “the provider must use an
interactive audio and video telecommunications
system”4 to conduct a virtual visit.
We do not have to look far for an example
of the inequity encoded by this strict definition.
Recently, a patient under our care
was denied home health services because
his telephone visit with his primary
physician did not qualify as a face-to-face
encounter. Unable to leave his house
8 DALLAS MEDICAL JOURNAL • June 2021
easily—or safely, as rates of coronavirus
disease 2019 (COVID-19) are still not suppressed
in our area—and unequipped with
the technology for a telemedicine visit as
defined by his insurer, he was prevented
from accessing the same care available to
his neighbor with an internet connection.
Beyond implications related to reimbursement,
there may be qualitative differences
between care provided over the telephone
and that conducted via audiovisual technology.
For example, patients with limited English
proficiency have been shown to have
worse understanding of diagnoses when
interpretation was facilitated by audio
alone compared with using video technology.
5 More research comparing the content
and quality of audiovisual to telephone-only
visits is needed. Although we acknowledge
the potential of telemedicine for many patients,
we are concerned by the systematic
introduction of a new mechanism of health
inequity.
Regarding which patient visits are best
conducted in person rather than virtually, it
is difficult to rely on a common algorithm.
Our approach as primary care physicians
is to share that decision-making with patients.
There are some patients we would
strongly prefer to examine in person, but
many of those are most susceptible to
COVID-19 or live far away or have out-ofpocket
expenses that make an in-person
visit prohibitive. Ultimately, we weigh the
risks and benefits of virtual care with our
patients, falling back on the imperative
to provide patient-centered primary care.
Pivoting toward a hybrid model, wherein
more patient visits are conducted at a
distance, would preserve a safer physical
space for those with conditions or barriers
that preclude telehealth. However, we must
mitigate the hidden costs of in-person
visits via meaningful policy change.
Access to digital services is important
not just for health care but also for
education, housing, other social services,
job applications, and food delivery in
communities with COVID-19 outbreaks.
Cross-sector collaboration among
health care systems, local governments,
telecommunication companies, schools,
community-based organizations, and
philanthropic organizations is needed to
address inequitable access to critical
resources and provide assistance for
the members of our communities with
the most risk.6 We must advocate for
broadband infrastructure and internetcapable
devices for underserved patients.7
Prospective systematic studies of the
effects of policies and access to telehealth
on health inequities will be needed.
The expansion of telehealth has great
potential, both for good and for harm. It is
imperative that physicians engage in the
stewardship of this change. DMJ
References
1. Mehrotra A, Ray K, Brockmeyer DM, Barnett ML, Bender JA.
Rapidly converting to “virtual practices”: outpatient care in the
era of COVID-19. NEJM Catal. Published online April 1, 2020.
Accessed September 11, 2020. https:// catalyst.nejm.org/doi/
pdf/10.1056/CAT.20.0091
2. Alexander GC, Tajanlangit M, Heyward J, Mansour O, Qato DM,
Stafford RS. Use and content of primary care office-based vs
telemedicine care visits during the COVID-19 pandemic in the
US. JAMA Netw Open. 2020;3(10): e2021476. doi:10.1001/
jamanetworkopen.2020.21476
3. Nouri S, Khoong EC, Lyles CR, Kalriner L. Addressing equity
in telemedicine for chronic disease management during the
COVID-19 pandemic. NEJM Catal. Published online May 4, 2020.
Accessed September 11, 2020. https:// catalyst.nejm.org/doi/
full/10.1056/CAT.20.0123
4. Centers for Medicare & Medicaid Services. Telehealth. Accessed
August 6, 2020. https://www.cms.gov/ newsroom/factsheets/
medicare-telemedicine-health-care-provider-fact-sheet
5. Lion KC, Brown JC, Ebel BE, et al. Effect of telephone vs video
interpretation on parent comprehension, communication, and
utilization in the pediatric emergency department: a randomized
clinical trial. JAMA Pediatr. 2015;169(12):1117-1125.
doi:10.1001/jamapediatrics.2015.2630
6. Katzow MW, Steinway C, Jan S. Telemedicine and health disparities
during COVID-19. Pediatrics. 2020;146(2): e20201586.
doi:10.1542/peds.2020-1586
7. US Congress. S.4211—Facilitating Reforms that Offer
Necessary Telehealth In Every Rural (FRONTIER) Community
Act. Accessed August 20, 2020. https://www.congress.gov/
bill/116th-congress/senate-bill/4211?q=% 7B%22search%22%
3A%5B%22s+4211%22%5D%7D&s=9&r=1
Article Information
Published: October 2, 2020. doi:10.1001/jamanetworkopen.
2020.21767
Corresponding Author: Lisa Chew, MD, MPH, Division of General
Internal Medicine, Department of Medicine, University of
Washington, 325 Ninth Ave, Box 359704, Seattle, WA 98104
(lchew@uw.edu).
Author Affiliations: Division of General Internal Medicine, Department
of Medicine, University of Washington, Seattle; Harborview
Medical Center, Seattle, Washington.
Patients with limited English proficiency have been
shown to have worse understanding of diagnoses
when interpretation was facilitated by audio alone
compared with using video technology.