101 © Springer Nature Switzerland AG 2021 A. B. Bhatt (ed.), Healthcare Information Technology for Cardiovascular Medicine, Health Informatics, https://doi.org/10.1007/978-3-030-81030-6_8 Chapter 8 Optimizing Telehealth for Special Populations and Closing the Digital Divide: Addressing Social Determinants of Health in Virtual Care Samantha Gonzalez, Ami B. Bhatt, and Jaclyn A. Pagliaro 8.1 Elderly Populations There are certain preconceptions about the elderly and their capacity for evolving technology. While it is acknowledged that patients in the 80+ range were bred in an era of when telephone calls required an operator, they are also historically a generation of resilience and adaptability, particularly with regard to medical treatment and technology. Patients in their 80s and 90s at the time of this publication lived through development and expansion of medical advancements such as the first use of penicillin in the 1940s and the onset of routine vaccinations for disease prevention. It is important not only to understand elderly patients’ existing familiarity with technology prior to recommending virtual visits, but also to frame the introduction of technology in their care and yet another medical advancement they participate in during their lifetime. Improving their confidence in their ability to use technology and the potential service it offers may position all players for success. Patient perceptions about telemedicine can be tackled head on in the elderly. Use of the internet and other forms of communication via cellular phones, tablets, and computers have emerged as points of access and improved convenience for several instrumental activities of daily living such as shopping, using transportation, managing medications and finances at one’s fingertips in a population with varying degrees of dependence, interdependence and independence which is evaluated at S. Gonzalez Telehealth Implementation COVID Response, Holy Cross Health, Silver Spring, MD, USA University of Miami Internal Medicine Residency Program, Miami, FL, USA University of Miami Miller School of Medicine, Miami, FL, USA A. B. Bhatt · J. A. Pagliaro (*) Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA e-mail: abhatt@mgh.harvard.edu; jaclyn.pagliaro@mgh.harvard.edu
102 least annually at medical appointments for the elderly. It may be helpful to leverage the inevitable increased utilization of real-time audio and video communication during the COVID-19 pandemic for purposes not only in the workplace, but also for many as a form of regular communication among family members and acquaintances regardless of age. We have some information about its uses in the medical space by older patients. Existing data, while limited, suggests high rates of patient satisfaction in participants over the age 65 with telemedicine models, improved confidence in technology use in those who had nursing assistance, improved cost compared to in-person alternates, and a decline in emergency room visits. Some of the biggest barriers included patient and technology based audio-visual complications, in addition to adapting to utilizing a telemedicine portal [1]. Some tips for success as seen with the palliative care population include informing patients and caregivers about telemedicine navigation tools and communication etiquette including mute function if not actively engaged in conversation, and inform patients that there are reasons you may deem an in-person evaluation necessary, such as a change in patient’s clinical status, or need for cardiovascular or pulmonary exam, for example [2]. Reassuring patients who are hesitant to participate in virtual visits that in- person visits are still an option may increase their confidence in the virtual encounter. There are clear opportunities for video visits in older adults. On the one hand, video visits can be effectively used for prescription renewals, health promotion, and advanced care planning; to limit travel for those unable to commute to clinic independently, which may prove especially helpful for patients undergoing palliative care; for routine follow-up after device implantation, such as pacemaker and defibrillators; and for care coordination among clinicians. In this model, low acuity needs can be readily achieved, and aspects of care delivery focused on cost reduction and for convenience can be enhanced. On the other hand, video visits are emerging as a potential vehicle for complex care delivery. Data from clinical trials and meta analyses of telehealth in conditions such as stroke [3] and heart failure [4] have demonstrated confidence in self-care, improvements in measures of patient reported outcomes, and in select cohorts, a lower risk of hospitalizations (stroke and HF ref. above). For example, Comin-Colet et al. investigated the role of video visits with daily assessment of signs and symptoms compared with usual face-to-face encounters on the quality of care and outcomes among an older adult cohort of heart failure patients. Compared with usual care, patients randomized to video visits (mean age 77 years, 25% identified as frail) experienced a lower risk of heart failure readmission at 6 months and conferred a lower net reduction in direct hospital costs. Although the aggregate of these data is reassuring in that there were no safety signals or untoward risks of video-based care alone, it does raise questions as to how a model of frequent video visits, or a hybrid model, can be pragmatically adopted, and if this level of non–face-to-face care is required to mitigate adverse outcomes among a high risk older adult cohort with complex diseases. “Tele-assistance” is a model in which counseling services with different health care professionals over video is combined with remote monitoring of vital signs and functional assessments over time. De Cola et al. [5] assessed the feasibility of tele- assistance among 131 patients with multiple comorbidities (mean age 80 years, S. Gonzalez et al.
103 60% in rural locations) in a design that included monthly neurophysiological and nutritional services to address cognitive needs and those factors related to anthropometric parameters in various chronic diseases. Nearly all participants viewed the combined video and counseling services as the preferred method to video alone, and with appropriate education toward telehealth utilization they demonstrated high usability of the technology platform. In the aggregate, codesigns and teleassistance are novel examples of the implementation methods older adult patients require to overcome common telehealth barriers such as frailty, cognitive decline, and a lack of caregiver support. As we continue to expand telehealth implementation in older adults, within current models of care, there will be situations in which video visits alone cannot sufficiently address the complexity of care required. These connections harness five core competencies important for digital technologies when used for older adult care: (1) identification (entry point in to care); (2) education (benefits and risks of services); (3) engagement (patient empowerment for self-care); (4) service delivery (usable information to inform care and decisions); and (5) remote monitoring (determine the health of a patient away from a clinic visit). A cohesive ecosystem of information technology and patient participation in remote monitoring such as this aims to identify the right patients for the right services at the right time. While the use of telemedicine in the elderly may not be the right fit for every patient, pre-visit considerations for enrollment in a telemedicine model should include the following: comfort or prior use with current technology, whether there is existing home support for technology during the televisit such as availability of nursing or family members, development of clear instructions for optimizing the audio-visual experience-including nuances such as testing that speakers are functional and that a hearing aid or other device is both adequately battery-powered where appropriate, and will not cause interference with audio input. Many older adults are already incorporating technology for daily use such as smart home technology with voice assistance in addition to wearable fitness monitors to measure activity, smart scales, home blood pressure, oxygen saturation and sleep monitors, in addition to medication reminder alerts on their personal devices. There has also been an emergence of senior tailored technology such as gait assessment tools for fall risk alerts and connected hearing aids which can provide clinician feedback [6]. Increasing utilization by providers was further supported by the decision to expand reimbursement for remote patient monitoring by the Centers for Medicare & Medicaid Services in 2019. With this surge of tech use, it is helpful to have a plan for common technical pitfalls, which may be increasingly important for telemonitoring strategies. Older patients may not have the experience with technology to deal with device troubleshooting issues. Some of these include sensor failure and battery life for wearables, network connectivity or privacy failure. Monitoring program integration will also include clinical decision support issues related to translating collected data in appropriate algorithms into a concise recommendation for both patients and providers, and communication of sensor data and recommendations in a usable, easily interpreted form. Other practical considerations are associated with frequency of 8 Optimizing Telehealth for Special Populations and Closing the Digital Divide…
104 assessment of captured data and need for follow up to help balance the need for risk assessment over time in addition to avoiding dreaded “data overload” seen with continuous data sets such as heart rhythm and intracardiac pressures [6]. Some of this may need to be tailored to the patient’s current clinical status, individual health literacy, and ability to facilitate both in person and/or real time telemedicine follow ups as needed. 8.2 Disabilities Cardiovascular virtual care management also requires proactive processes to address visual, auditory, cognitive and physical impairments. Despite video format becoming more predominant in modern society’s communication, accessibility for disabled patients among digital platforms remains limited. Currently the technical standards for telemedicine as it relates to patients with disabilities are voluntary. Certain disabilities will require development of custom features and technology in addition to patient information tools targeted for disability accommodations. The Americans with Disabilities Act (ADA) mostly protects patients with disabilities in physical spaces as it was developed earlier than the emergence of broad use of the virtual space for health care delivery. This unfortunate truth may be a source of poor consequences for patients with certain disabilities, and will need to continue to be a topic of further development as digital platforms become further tailored for medical care in order to promote inclusivity in telemedicine and to honor patients’ civil rights to equal access to healthcare. The COVID-19 pandemic did force some of these virtual spaces and produced data to suggest that telemedicine in patients with disabilities lowered cost of care and need for paid personal assistance, lowered transportation cost, decreased exposure to communicable diseases and improved medication reconciliation [7]. In the following segment we will review some specific considerations. Slight visual disturbances, color blindness, photosensitivity, peripheral vision loss and total blindness are some examples of the wide variety of visual impairments experienced by older patients. In developing virtual visit environments, providers and patients should be made aware of platform accessibility features including screen magnification, resizing of images and text, audio description aides, text alternatives for images, consistent navigation mechanisms, color contrast settings, and full keyboard navigation. It is helpful to understand if the platform in use is compatible with assistive devices such as Braille keyboards and screen readers [6]. It is also important to understand how stored medical information is shared to patients via patient portals and the methods by which patients and caregivers can access their health information and communicate with providers in less traditional ways. An estimated 466 million people worldwide have disabling hearing loss [8]. Auditory disabilities may also be addressed in virtual care. For those patients with mild auditory dysfunction, ensuring there is no background noise during the visit and confirming the patient is not getting feedback from assistive devices such as their hearing aids may suffice to improve the patient experience. For more severe auditory S. Gonzalez et al.
105 issues or total deafness, captions, transcripts of conversation, or inclusion of ASL interpreters for the video visit may assist in a more comfortable experience. It is also helpful to be aware of and instruct the patient about the volume controls and confirm the media is working for them prior to conducting the medical portion of the visit. Cognitive disabilities pose unique challenges to communication even in live environments, and can range broadly to include mild speech impediments, post- concussive symptoms, neurobehavioral and intellectual disabilities, mental health disorders, dementia and post stroke symptomatology more prevalent in elderly populations. In addition to vision and hearing issues as discussed above, motor skills, expressive and receptive communication issues, and neurologic symptoms whether transient or permanent can affect the success of virtual visits in this population. Very elderly patients over 85 year of age make up 17% of all stroke patients [9], and have higher disability, higher risk-adjusted mortality, and are less likely to be discharged to their original place of residence. A recent study evaluated the impact of confinement in the setting of the COVID-19 pandemic on the health and well-being of community-dwelling older adults (mean age 73.34) with mild cognitive impairment or mild dementia, utilizing a television-based and telephone-based assistive integrated technology. While they found no difference in the physical and mental health and well-being of this vulnerable population, they found participants living alone reported greater negative feelings and more sleeping problems, and the technology allowed for cognitive stimulation by way of engagement in memory games in addition to a useful tool for dissemination of patient-centered information, reinforcing the importance of gauging patients’ tech and health literacy prior to utilization of digital health delivery methods [10]. Determining whether a patient is a good candidate for a virtual visit, whether additional devices are necessary for success and if the presence of a caregiver is recommended for some or all of the encounter is an important early step. For example, in patients with speech disabilities, accessibility aides to consider include voice synthesizers and text to speech generators which should be explored prior to conducting your first visit [6]. Note, some platforms allow for caregivers to be included remotely if they are not physically with the patient at the time of the encounter. It is important that providers obtain patient consent for including caregivers or family members- though this is often considered implied—much like when a patient brings their family member for an in person visit. If there are multiple people included in the virtual visit, it is helpful to start with focused introductions of the role they play in the patient’s life and medical care. Patients with physical impairments, challenges with transport, need for gait assistance or supervision and chronic pain may benefit from virtual care options. Often requiring coordination for transport services depending on degree of disability, virtual visits when appropriate can be more cost effective, take less time to complete, and convenient for patients and caregivers. They also provide a unique opportunity to understand the home environment which can be explored further in a video visit and is instrumental to ensure the physically disabled are adequately equipped and risk stratified to avoid falls and/or other comorbidity. Additionally virtual platforms should have large consistent navigation controls to assist in usability for those patients who may experience fine motor movement disorders. 8 Optimizing Telehealth for Special Populations and Closing the Digital Divide…
106 8.3 Palliative Care While telemedicine modalities have been increasingly incorporated in the field of palliative care due to its multidisciplinary nature, its utilization was greatly accelerated by the need for social distancing during the COVID-19 pandemic. There is certainly a role for telemedicine in assisting patients attain their end of life goals with dignity. In Calton et al.’s recent review of telemedicine for palliative care in the time of COVID-19, they discuss high rates (greater than 97%) of comfort in having “sensitive and emotional conversations by video” from an unpublished manuscript conducted at UCSF assessing patient and caregiver satisfaction rates of 35 palliative care patients who had at least one palliative care visit by telemedicine. As patients with complex cardiovascular disease progress, telemedicine visits may offer an appropriate arena for care coordination and a space for often difficult conversations. Some tips recommended by the author for success with telemedicine particularly with sensitive topics include utilizing patient portals to send out a saved set of instructions and expectations for the visit (may use “dot phrases or macros” as allowed by EMR), channel resources to assign a family member or caregiver as a “technical liaison” one to two days prior to the visit to do a test run and troubleshoot technological issues, and remembering to still have personal moments. While virtual visits tend to be shorter and more efficient in terms of time compared to in-person visits, it is recommended to use the time to personalize the experience: acknowledge the barriers of technology, thank patients for their participation in these kinds of visits, and check in with patients about fears, concerns, and personal effects. 8.4 Language Barriers Language barriers impact most facets of health care, including access, patient- clinician communication, quality of care, and patient safety. Nearly a quarter of the US population speaks a language other than English at home, and 25.6 million Americans (8%) have limited English proficiency [11]. Formal pathways for the integration of interpreter services utilization for telemedicine visits are essential to ensure equitable care for patients who speak English as a second language (Fig. 8.1). Patient education regarding the import of interpreter service utilization is also necessary as many tend to defer to family members for interpreter services. Studies have shown that families randomized to receive video interpretation are more aware of medical diagnoses than those who receive telephonic interpretation and have more consistent interpreter use with no significant differential in hospital charges [13]. S. Gonzalez et al.
107 Identify disparities • Evaluate access to care for patients with known limited access to care and digital health Iiteracy • Older adults • Individuals of low socioeconomic status • Limited English proficiency • Low level of literacy/education • Racial/ethnic minorities • Develop patient-educational materials to teach digital skills • Translate materials into multiple languages • Ensure adequate interpreter availability • Screen for patients at high-risk of not being able to engage in telemedicine • If unable to mitigate barriers, offer telephone visits • Expand access to low-cost of free broadband • Funding for telemedicine expansion in health centers with less resources • Conduct clinical research to further understand barriers to care and the Impact of social determinants Dismantle barriers to care Increase Access Fig. 8.1 Mechanism to implement equitable access to telemedicine care. Derived from [12] 8 Optimizing Telehealth for Special Populations and Closing the Digital Divide…
108 8.5 Health Literacy Barriers Elderly patients, those with low health literacy, or those with limited access to technology can be provided tools and teaching to adapt. It is a tactic to help eliminate barriers and increase access. Telehealth has the potential to make healthcare more personalized, efficient, and coordinated; it has the potential to improve efficiency, patient and clinician satisfaction, and health outcomes. Digital and health literacy (See Chap. 9) is the ultimate value proposition. 8.6 Social Determinants of Health The institution of structural racism has been and remains a fundamental cause of the persistent health disparities within racial and ethnic minorities [14]. It concentrates power amongst privileged populations and continually devalues individual’s whose health needs to be equitably improved. By limiting opportunities for social, economic and financial advancement, the racial and ethnic minorities experience reciprocity between social determinants and negative health consequences. The higher prevalence of diabetes, obesity, hypertension and cardiovascular disease in Black and Hispanic populations, has led to disproportionately poorer clinical outcomes during the COVID-19 pandemic. Black Americans experience the highest mortality rates attributable to cardiovascular disease and stroke with approximately 30% higher CVD mortality and 45% higher stroke mortality than non-Hispanic White Americans [15]. Overcoming the digital divide requires increased broadband access, smartphone penetration, digital health literacy and technology education. Rural and urban areas can also emphasize community internet access points such as local pharmacies, libraries, religious organizations and community centers. A New York City study during COVID revealed that when controlling for individual and community-level attributes, Black patients had 0.6 times the adjusted odds (95% CI: 0.58–0.63) of accessing care through telemedicine compared to white patients, though they are increasingly accessing telemedicine for urgent care [16]. This is driven by a younger and female population. COVID diagnoses were significantly more likely for Black versus white telemedicine patients. A new study found that Black and Hispanic Americans experience a “racial tech gap” and in urban areas, these communities are 10 years behinds the white communities. As of 2019, approximately 10% of adults in the U.S. reported no Internet use, which was largely influenced by Black race, Hispanic ethnicity, older age (>65), and low socioeconomic status [17]. The racial tech gap can be narrowed through community outreach, dismantling barriers to care and health promotion education. Proactive efforts to ensure equity in the current wide-scale implementation of telemedicine need to acknowledge and address disparities in healthcare access for disenfranchised populations with limited digital literacy or access to S. Gonzalez et al.
109 technology, such as rural residents, racial and ethnic minorities, the elderly, individuals of low socioeconomic status or limited English proficiency. Digital inequity may start as early as middle school and can set individuals back in the digital generation. Lack of access to hardware and broadband data, poor digital literacy and limited English proficiency may foster bias, decrease telehealth access, exacerbate inequities in delivery of care and worsen clinical outcomes in marginalized patients with cardiovascular disease [12]. The etiology of disparate telemedicine uptake are complex and reflect individual, community and structural factors. While digital literacy and hesitancy to adopt new ways of patient-provider interactions have both been shown to widen the digital divide for elderly patients [18], socioeconomic status may serve as a more significant driver for reduced access to health technology, reduced engagement telemedicine, and poor adoption of digital health among Non-Hispanic Black and Hispanic patients. Funding local digital navigators, offering and covering audio-only televisits, providing sustainable discounts for broadband will aid in limiting the digital divide. Many advocacy groups are pushing the government in the US to provide universal broadband access as a basic utility. It will hopefully be expanded to allow healthcare, education and other necessary industries to reach vulnerable populations, however it may also fall on the healthcare industry to offer connected care in clinically vulnerable populations at strategic times (i.e. post hospital discharge, during cardiac rehabilitation, and while titrating medications), or for longitudinal care. Companies need to emphasize that telemedicine platforms should be available in multiple languages at the front end to maximize user experience. References 1. Narasimha S, Madathil KC, Agnisarman S, Rogers H, Welch B, AshokA, et al. Designing telemedicine systems for geriatric patients: a review of the usability studies. Telemed J E Health. 2017;23(6):459–72. 2. Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. J Pain Symptom Manag. 2020;60(1):e12–4. 3. Sarfo FS, Ulasavets U, Opare-Sem OK, Ovbiagele B. Tele-rehabilitation after stroke: an updated systematic review of the literature. J Stroke Cerebrovasc Dis. 2018;27(9):2306–18. 4. ZhuY, Gu X, Xu C. Effectiveness of telemedicine systems for adults with heart failure: a meta- analysis of randomized controlled trials. Heart Fail Rev. 2020;25(2):231–43. 5. De Cola MC, Maresca G, D'Aleo G, Carnazza L, Giliberto S, Maggio MG, et al. Teleassistance for frail elderly people: a usability and customer satisfaction study. Geriatr Nurs. 2020;41(4):463–7. 6. BoIA. Rising to meet the telehealth accessibility challenge in the time of COVID-19. 2020. https://www.boia.org/blog/rising-to-meet-the-telehealth-accessibility-challenge-in-the-time- of-covid-19 7. Annaswamy TM, Verduzco-Gutierrez M, Frieden L. Telemedicine barriers and challenges for persons with disabilities: COVID-19 and beyond. Disabil Health J. 2020;13(4):100973. 8. World Health Organization. Deafness and hearing loss: key facts. 2020. http://www.who.int/ news-room/fact-sheets/detail/deafness-and-hearing-loss. 8 Optimizing Telehealth for Special Populations and Closing the Digital Divide…
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