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Digital redlining: How telehealth can exacerbate inequalities

During Covid-19 surges, health systems replaced most in-person visits with video visits or phone calls to stop the spread. The rapid switch to telehealth has many potential advantages for expanding access of care; for example, patients no longer have to find transportation or childcare to see their doctor. However, if not done with an intentional eye toward equity, telehealth can leave many behind.

At Boston University Center for Antiracist Research’s symposium earlier this month, Dr. James Feigenbaum, Assistant Professor of Economics at BU, Dr. Lance Laird, Assistant Professor of Family Medicine at the BU School of Medicine, and Dr. Jayakanth Srinivasan, Research Associate Professor of Information Systems at the BU School of Business shared their insights into how “digital redlining” keeps some of the most vulnerable patients from accessing telehealth.

The practice of “redlining,” government-led discrimination in home loan offers based on neighborhood racial makeup, was made illegal in the 1960s. But more than 60 years later, internet providers still discriminate against customers based on where they live, a practice referred to as “digital redlining.” Comparisons of broadband internet access and poverty rates by census tract show that network providers systematically exclude low-income neighborhoods from broadband service, giving them much slower internet access.

The switch to telehealth makes these digital divides much more apparent, experts noted. When Boston Medical Center asked their patients if they had access to a reliable internet connection, more than 20% said no. Some may have internet access, but not have the technological skills or knowledge to navigate programs easily. Others may have access and knowledge, but they have competing priorities — for example, their children needed to use the internet to attend virtual classes.

“We’re asking families to ration broadband, to choose between closing the education gap or the health gap.”

Dr. Jayakanth Srinivasan, Research Associate Professor of Information Systems, at the BU School of Business

Some families had to choose which meeting or class to attend, or use their phone data to access both, which can be expensive. In some cases, families who had previously missed an internet bill were not given access even when the school system subsidized it. “For some patients, seeking health care is taking away their wages,” said Baird.

Another challenge is fragmentation of care through telehealth. A clinician and patient may have a long-standing relationship, but when it comes to virtual visits during Covid-19, patients were not always given a choice of provider. They had to see whichever doctor was available, not their doctor. This breaks apart the continuity and trust that is so important to high-quality care.

The issue of privacy in tech is another challenge. It’s one thing to see your doctor in the clinic, it’s another to let them into your house through video calls. Especially if you don’t get to choose which doctor you see, this can further create tension and reduce trust.

What can we do to solve the problem of digital redlining? First of all, we need to recognize that internet access is a necessity, not a luxury. “The federal government is accountable,” said Srinivasan, “The US government should be able to fund broadband access for everyone.” Federal and local officials must ban digital redlining and demand the same speed and quality of internet access for all.

Health systems should also be sure to ask their patients about their internet access and knowledge, to see where there are gaps in access. Health systems should work toward making patients’ preferred clinicians available for virtual visits, and think about how to create more private virtual spaces to build trust.

The rapid rollout of telehealth led to disparities in access, some more avoidable than others. As the pandemic recedes in certain regions, now is the time to make sure that these inequalities do not become embedded in the health system. “We have to correct these inequalities before it calcifies,” said Srinivasan, “Don’t let the concrete set.” Telehealth presents a massive opportunity to expand health care access — but it will only work if we can expand digital health equitably.

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