In this session, we'll focus on the ways in which telehealth is designed to address health inequities. By the end of this session, we hope that you will one, understand the ways in which telehealth is designed to promote health equity, two, recognize the ways in which telehealth has promoted health equity, and three, understand the importance of monitoring the impacts that telehealth technology has on relevant outcomes. Telehealth is designed to enhance health care delivery by promoting quality, person-centered, equitable access to health care. By providing a means to deliver health-related services and information via telecommunication technologies, it overcomes barriers that would otherwise inhibit care access, such as barriers related to finances, geography, and time. Telehealth service lines such as remote patient monitoring or virtual care visits are examples of delivering or receiving health care in a manner that doesn't require patients and families to travel to clinic and to miss work or school. In this way, telehealth can mitigate work constraints for those who cannot afford to miss work. It can mitigate childcare constraints for those who cannot afford or cannot hire a babysitter. Telehealth can mitigate the numerous travel-related constraints for those who face challenges such as limited transportation access, limited mobility, travel barriers due to being technology dependent, such as individuals on ventilators, and there's weather barriers and far distances that people often face and trying to be physically present in a health care setting. Let's talk a bit about the geography or the distance barriers. This map shows everywhere in the United States that is outside a 30-minute drive from the nearest hospital. About 8.6 million people live in these areas, that is, they live at least 30 minutes away from the nearest hospital. This is important because we know that individuals are less likely to seek care when they need to travel farther to access that care. This is particularly true when that distance is about 30 minutes. The darker areas on this map show where more people live outside a 30 minute drive to the nearest hospital. Who's impacted by this? You can see dark concentrations across Arizona. Access to care in Arizona is especially difficult in Native American tribal areas, and you can see dark concentrations in pockets across Florida. Rural Florida hospital Access is most limited in the farm towns, largely impacting those who live in migrant farming towns. If we can use telehealth to remove distance as a barrier to care, we can promote more equitable health care access. What about barriers related to finances? How can telehealth help to overcome the cost factor? A systematic review of 21 studies examining telehealth use and the post-operative setting found that patients had significant savings. Round-trip miles saved ranged from 80 miles to nearly 400 miles and this translated into monetary travel savings of up to nearly $200. This review also reported that the use of telehealth prevented patients and their families from having to take time off work or other responsibilities, and prevented them from needing to stay at a hotel. These are additional cost burdens on top of the travel costs. Another study on the use of telehealth for post-operative visits found that less work and school were missed by parents and children who use telehealth in comparison with their counterparts who had in-person visits. If you're missing work to attend your health care visit, there's opportunity costs associated with that. When these researchers calculated the direct cost plus the cost of missing work, they found that the opportunity costs associated with an in-person visit, were $24 per minute of FaceTime with their health care provider, and this compared to a little over a dollar per minute for a telehealth visit. Telehealth is a tool that can help to address the health professional shortage in our nation. Most rural counties do not have adequate numbers of primary care nor mental health providers. This table is from the US Department of Health and Human Services. I want to draw your attention to the percentage of need met for primary care and mental health care. These percentages of 44 percent and 27 percent were calculated by taking the number of primary care and mental health care providers available to serve the population and dividing that by the number providers that the population meets. You can see that these percentages are well below a 100 percent. Health professional shortages are a particular problem for rural residents. Rural access to health care is especially problematic when it comes to accessing specialty care. Telehealth can address these issues via service lines such as virtual care visits, which allow patients to access specialty providers, and E console support provider to provider communication for specialty consultations. Research suggests that telehealth provides greater access for patients, particularly for those living in rural areas. Telehealth gives people the ability to access the care they need rather than having location limit their options. For example, substance use disorder providers shared in focus groups that those in treatment who lived too far from a treatment center to commute for outpatient therapies were often unnecessarily given inpatient treatment. In this situation, telehealth could have permitted a means for such clients to satisfy their treatment requirements without doing an inpatient program that isn't medically necessary nor indicated. Other types of specialty care services that have previously been inaccessible due to distance but now are accessible via telehealth, include gender specific care and programs for those with traumatic brain injuries. Why does specialty care access matter? Research suggests that 55 percent of preventable hospitalizations or deaths in rural settings are a result of lack of access to specialty care. This figure shows that preventable hospitalization rates shown on the left and mortality rates shown on the right were highest in rural areas, represented by the turquoise bars, and lowest in metropolitan areas, which are the red bars. Another way in which limited access to specialty care presents is in the form of long wait times. Regarding health equity, wait times have been found to be significantly longer for racial and ethnic minorities, individuals with less education, and for those who are unemployed. Telehealth, however, has been shown to decrease wait times across various healthcare settings, including in the emergency department and for general ambulatory visits, as well as subspecialty care. In one study, the use of teledermatology as a triage tool reduce the wait time for in-person visits. In the study before they launched their teledermatology triage tool, the wait time for an appointment was 6.7 months, after they started their tele-triage the wait time dropped to 1.5 months. This study saw reduction of 78 percent in the wait time for appointments. Another study conducted in rural Alaska demonstrated that offering telemedicine to otolaryngology appointments reduced wait times from four months down to two months. Video remote interpretation is another telehealth solution that can enhance care for those needing medical interpreters. When in-person interpretation is not available, health care professionals can instead use telephone interpretation or video interpretation. However, telephone interpretation is not compatible for sign language and telephone interpretation has been found to be less effective when compared with video interpretation. For example, in a randomized clinical trial conducted at a pediatric emergency department, families with limited English proficiency who received video interpretation, we're more likely to correctly name their child's diagnosis when compared with those who received a telephone interpretation. The video interpretation group also had fewer lapses in interpreter use compared with the telephone interpretation group. Let's talk about privacy. Individuals diagnosed with a stigmatized chronic disease can face barriers to seeking access to care. Stigmatization can be a debilitating stressor for patients. It can have negative impacts on treatment. The distress caused by stigma can prevent individuals from even seeking their necessary medical care. Telehealth, however, provides a way for such individuals to stay connected to their health care providers without having to be in a public physical space. Research on the effectiveness of telemedicine on stigmatization and treatment burden suggests that telemedicine can mitigate some of the treatment burdens of stigmatization for patients with health compromising lifestyles and chronic diseases. In summary, the use of telehealth technologies for the delivery of healthcare services has impressive potential to improve access to care and promote health equity. While telehealth has strong potential to resolve health inequities, it is imperative that we monitor the impacts that this technology has on relative outcomes.