Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic

There has been a massive shift to telemedicine during the coronavirus disease 2019 (COVID-19) pandemic to protect medical personnel and patients, with the Department of Health and Human Services and others promoting video visits to reach patients at home.^1,2 Video visits require patients to have the knowledge and capacity to get online, operate and troubleshoot audiovisual equipment, and communicate without the cues available in person. Many older adults may be unable to do this because of disabilities or inexperience with technology. This study estimated how many older adults may be left behind in the United States in the migration to telemedicine.

We completed a cross-sectional study of community-dwelling adults (N = 4525) using 2018 data from the National Health and Aging Trends Study, which is nationally representative of Medicare beneficiaries aged 65 or older, to assess the prevalence of telemedicine unreadiness. The institutional review board of the University of California, San Francisco, deemed this study not to be human subjects research because the data are deidentified and publicly available. Telemedicine is defined as the use of communications technology to deliver health care to patients at a distance. Envisioning telemedicine as direct-to-patient video visits, we defined unreadiness as meeting any of the following criteria for disabilities or inexperience with technology: (1) difficulty hearing well enough to use a telephone (even with hearing aids), (2) problems speaking or making oneself understood, (3) possible or probable dementia, (4) difficulty seeing well enough to watch television or read a newspaper (even with glasses), (5) owning no internet-enabled devices or being unaware of how to use them, or (6) no use of email, texting, or internet in the past month. National prevalence was determined using analytic weights.³

If a family member or caregiver cannot facilitate physician visits, an alternative is telemedicine by telephone. We thus assessed telemedicine unreadiness under 4 scenarios: (1) video visits as described above; (2) video visits assuming patients who have social supports (defined as having a child in the household or at least 2 individuals in one’s social network) are telemedicine ready; (3) telephone visits with disability criteria reduced to difficulty speaking, difficulty communicating, or dementia and with technology criteria reduced to absence of any telephone; and (4) telephone visits assuming patients with social supports are telemedicine ready.

We used multivariable logistic regression to assess the adjusted odds of not being ready for video visits by age, sex, race/ethnicity, rurality, marital status, educational level, income, and self-rated health.

Of the 4525 adults included in this study, 1925 (43%) were men, 2600 (57%) were women, and the mean (SD) age was 79.6 (6.9) years. The cohort consisted of 3119 (69%) non-Hispanic White individuals, 952 (21%) non-Hispanic Black individuals, and 273 (6%) Hispanic individuals. An additional 181 individuals (4%) self-identified as non-Hispanic other, which consisted of persons who reported their race/ethnicity as American Indian, Asian, Native Hawaiian, Pacific Islander, other, do not know, or more than 1 race/ethnicity.

Table 1 shows the prevalence of unreadiness by reason for not being ready and under different scenarios for delivering telemedicine. For 2018, we estimated that of all older adults in the United States, 13 million (38%) were not ready for video visits, predominantly owing to inexperience with technology. Assuming individuals in the role of social supports knew how to set up a video visit, the estimated number of older adults who were still unready was 10.8 million (32%). Telephone visits may reach more patients. Nonetheless, an estimated 20% of older patients were unready for telephone visits because of difficulty hearing, difficulty communicating, or dementia.

Table 2 shows demographic and clinical factors associated with telemedicine unreadiness. Unreadiness was more prevalent in patients who were older, were men, were not married, were Black or Hispanic individuals, resided in a nonmetropolitan area, and had less education, lower income, and poorer self-reported health; altogether, 72% of adults who were 85 years or older met criteria for unreadiness.

Older adults account for 25% of physician office visits in the United States and often have multiple morbidities and disabilities.⁴ Thirteen million older adults may have trouble accessing telemedical services; a disproportionate number of those may be among the already disadvantaged. Telephone visits may improve access for the estimated 6.3 million older adults who are inexperienced with technology or have visual impairment, but phone visits are suboptimal for care that requires visual assessment.⁵

Policies should recognize and bridge this digital divide. As of early 2020, the Centers for Medicare & Medicaid Services was reimbursing telephone visits at rates matching in-person and video visits, aligning reimbursement with reality for those who cannot use video visits.² As telemedicine becomes ubiquitous, telecommunication devices should be covered as a medical necessity, especially given the correlation between poverty and telemedicine unreadiness. Furthermore, accessibility accommodations, such as closed captioning for those with hearing impairment, should be extended to virtual visits. A major limitation of this study was selection bias resulting from loss to follow-up, which would underestimate the prevalence of unreadiness if loss to follow-up was associated with poor adherence to telemedical care. Although many older adults are willing and able to learn to use telemedicine,⁶ an equitable health system should recognize that for some, such as those with dementia and social isolation, in-person visits are already difficult and telemedicine may be impossible. For these patients, clinics and geriatric models of care such as home visits are essential.

Accepted for Publication: May 17, 2020.

Corresponding Author: Kenneth Lam, MD, Division of Geriatrics, Department of Medicine, University of California, San Francisco, 4150 Clement St, Bldg 1, Room 207, San Francisco, CA 94121 (kenneth.lam2@ucsf.edu).

Published Online: August 3, 2020. doi:10.1001/jamainternmed.2020.2671

Author Contributions: Dr Lam had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lam, Lu, Covinsky.

Acquisition, analysis, or interpretation of data: Lam, Shi, Covinsky.

Drafting of the manuscript: Lam.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lam, Shi.

Obtained funding: Covinsky.

Supervision: Covinsky.

Conflict of Interest Disclosures: Dr Covinsky reported receiving grants from the National Institute on Aging during the conduct of the study. No other disclosures were reported.