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Op-ed

Telemedicine flourished amid the pandemic, here’s how to keep it going - and why | COMMENTARY

In 2014, the Maryland Health Care Commission (MHCC) issued a comprehensive report, with excellent recommendations to help expand the use of what is known as telemedicine or telehealth. Here’s the basic idea: Since most people have access to smartphones or computers, some aspects of health care can and should go online.

This wasn’t a revolutionary notion, given the general migration of most industries, such as retail and travel, to online platforms. Health care had been slow to the game, however, and MHCC noted that in the prior year, only 16 practitioners in the state had submitted telemedicine claims to payers, representing a very small percentage of annual health care visits by Marylanders.

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Fast forward to 2020, and relatively little had changed; elevating telehealth was still among MHCC’s top five planned strategies through 2022.

Then the COVID-19 pandemic hit and made us all more comfortable with the virtual world. In the final six months of 2020, physicians and other health care providers at the University of Maryland Medical System (UMMS) participated in almost 40,000 telemedicine visits with patients, driven almost entirely by the necessity for people to maintain physical distance. It’s been an astonishing change for us as physicians to witness.

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But you can’t have effective telemedicine without high-speed internet access, and those without broadband may be the same people who already struggle with health disparities.

Maryland legislators are considering several bills this legislative session that would continue the support of telehealth coverage in the state. From an equity perspective, extending the allowance of audio-only telehealth visits merits serious consideration.

At UMMS, we recognize that telemedicine will be a critical component of how care is delivered even after the pandemic has subsided. We know that many patients will continue to opt for in-person visits, while many others — especially working parents and those with limited mobility — will want to take advantage of telemedicine. For those who are comfortable with virtual environments and have reliable internet access, telemedicine is a tremendous leap forward.

However, many others will be left out, especially in communities already negatively impacted by social determinants of health, such as joblessness and poverty. In a study published by JAMA Open Network, researchers from the University of Pennsylvania analyzed telemedicine data between March and May of 2020, showing that non-English-speaking people, older people, and Black and brown people are using telemedicine at much lower rates.

Here in Maryland, we need not look any further than public education to understand how some groups are left behind. According to a report issued in December 2020 by the Maryland General Assembly’s Department of Legislative Services, 98% of Maryland households have access to internet services, but only 64% have access to the types of high-speed service needed for video conferencing and other essential applications. In rural areas, the problem is acute: 17 Maryland counties have reported that fewer than 80% of their students have reliable internet access. In Somerset and Wicomico counties, internet access for students can fall to as low as 20-40%.

But it’s not just rural areas that struggle. It is estimated that 52,000 Baltimore City households lack reliable broadband access, and 35% of Baltimore City residents with an annual household income of less than $25,000 do not have internet access.

Indeed, the COVID-19 pandemic has exposed the glaring disparity that exists when it comes to health outcomes. It is estimated that Black Americans are about a third more likely to die from COVID-19 than white Americans, and they are significantly more likely to contract the disease. But even before COVID, disparities in health outcomes were well documented. Infant mortality among Black babies is 2.5 to 3 times as high today as white babies, and Emergency Department visits for Black people with asthma and diabetes are 3 to 4 times as high as the rates for those who are white.

As we collectively look to find ways to address the social determinants that lead to disparity in health outcomes, ensuring that people can easily access doctors and other specialists will be a fundamental challenge to overcome. Telemedicine could be a differentiator in rural and low-income communities. But unless we address the Digital Divide, telemedicine could represent yet another imbalance in health care, exacerbating long-standing inequalities in how care is delivered.

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Dr. Michelle Gourdine (Michelle.Gourdine@umm.edu) is interim chief medical officer and senior vice president for population health and primary care for the University of Maryland Medical System and clinical assistant professor of epidemiology and public health at the University of Maryland School of Medicine. Dr. Joseph L. Wright (Joseph.Wright@umm.edu) is senior vice president and chief medical officer for the University of Maryland Capital Region Health and an adjunct professor of pediatrics at the University of Maryland School of Medicine.


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