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COVID-19: Beyond Tomorrow
March 26, 2021

Bridging the Digital Divide to Avoid Leaving the Most Vulnerable Behind

Author Affiliations
  • 1Department of Urology, Michigan Medicine, Ann Arbor
  • 2Department of Radiology, Michigan Medicine, Ann Arbor
JAMA Surg. Published online March 26, 2021. doi:10.1001/jamasurg.2021.1143

The COVID-19 pandemic provided a springboard for telemedicine use as a necessity to deliver care while social distancing affected all aspects of health care. The declaration of a public health emergency in March 2020 resulted in a rapid expansion of telehealth services with a relaxing of regulations at the state and national levels. Nationally, there is mounting evidence that many aspects of patient care can continue virtually,1 including a more prominent role across surgical disciplines in preoperative and postoperative care and management of chronic wounds. More widespread use of telemedicine and the ability to engage in new patient evaluations can help reduce geographic barriers and allow hospital systems to create capacity for patients with more severe illness to be seen in person, while patients who are stable and healthier can engage from home. Combining virtual and hands-on care will undoubtably persist beyond the pandemic.

However, reliance on technology brings forth pressures that can widen the gap in access to care for vulnerable populations; the COVID-19 pandemic has undoubtedly redefined what it means to be vulnerable in society. A recent study of more than 600 000 Medicare beneficiaries dwelling in communities from the 2018 American Community Survey demonstrated that 26% did not have access to either a computer with high-speed internet or a smartphone with a wireless data plan. Among other factors, individuals who were older, Black or Hispanic, widowed, or lacking more than a high school education reported more limited digital access.2 Furthermore, during this time, millions of individuals in the US are facing financial, emotional, and physical constraints that are unique and life changing. How can we move forward while not leaving the most vulnerable behind?

Improving Access to Resources via Community Outreach

Telemedicine, particularly video-only encounters, can worsen health disparities if we do not proceed with care. Much of the US lacks reliable broadband connectivity. In fact, as of 2019, approximately one-quarter of individuals in the US still lack fixed home broadband.3 In response, a number of interventions have been implemented in an effort to ensure patients have access to telehealth. For example, tablet loan programs for veterans and identifying Wi-Fi hot spots have helped patients connect virtually, while other community outreach programs have also assisted patients with technical issues.4-6 These are important considerations as local, state, and federal governments look to narrow the digital divide and address inequities in health care delivery.

Health Policy and Medicare Coverage

Crucial to large-scale telemedicine efforts, expanded insurance coverage and updated reimbursement practices were initiated during the initial COVID-19 surge. Changes in reimbursement and regulation remain temporary and are directly tied to the declaration of a public health emergency in the US. Moving forward, health advocacy efforts are needed to ensure that patients have the option of connecting with their physicians virtually. A monolithic view of telehealth that reimburses video visits only for established patients could leave the most vulnerable populations at risk of falling through virtual cracks.

According to the 2021 finalized Medicare payment policies surrounding telemedicine, evaluation and management rules have been simplified to streamline telehealth billing. Of note, telephone call billing codes (99441-99443) will no longer be reimbursed after the public health emergency. The Medicare program will allow patient-initiated virtual check-ins, but these will be reimbursed at lower levels than video visits and may not be reimbursed by commercial payers.7 This change may discourage clinicians from scheduling any form of telehealth, knowing that an in-person evaluation could lead to roughly double the compensation without the risk of technical issues. Lobbying and legislative efforts to ensure adequate reimbursement for telephone visits would aid in providing care for patients unable to connect with video because of a lack of hardware or reliable broadband internet. If audio-only visits are not reimbursed equally, this may result in clinician organizations avoiding video visit use because of the risk of losing revenue, which could worsen health disparities and affect access to care for certain patients. Additionally, financial support to improve marketing and outreach efforts of established clinics may help individuals benefit from available services. Furthermore, the convenience of telephone encounters has been appreciated by patients, especially in the context of a dropped video call, while the information exchanged is often equal. To this point, future research should help quantify the number of dropped calls and the outcomes on patient care, efficiency, and revenue. Regardless, advocacy for refining these policies is needed so that the benefits of technology can flow to all, including the most vulnerable.

Focused Avenues for Improvement

A future with equitable telehealth usage will surely require proactive, intentional change. Helpful strategies for doing so are provided.

Providing Wi-Fi hot spots and publicly available kiosks for patients to improve patient accessibility would be helpful. However, this would not necessarily address the travel issue for some patients, and additional steps would need to be taken to ensure Health Insurance Portability and Accountability Act compliance as well. Nonetheless, with proper guidelines and precautions in place, this could offer community members much-needed means of receiving surgical care and counseling.

Facilities could also offer hardware loan programs. Smartphones or tablets could be mailed to patients prior to their video visits. This model has shown great promise in helping veterans overcome social and clinical barriers to seeking care at Veterans Administration (VA) hospitals across the US.4 Although not without hurdles, this approach could offer an excellent space for Silicon Valley and industry collaboration. For example, the VA has partnered with Apple to create the VA iPad program, which has provided cellular-enabled iPads to more than 50 000 veterans.8 For this vulnerable patient population, these devices open new doors in terms of access to care, especially with data plans helping to negate connectivity issues. Similarly, partnerships with cellular service providers to lower the cost of cell phones and connection plans that support 2-way video calls could significantly change a patient’s ability to receive care.

Finally, facilities could standardize instructions on technology, connectivity, and access for patients at the time of scheduling video visits. Of note, Michigan Medicine (Ann Arbor) has implemented such a system, which includes templated instructions, anticipatory guidance, and the opportunity to conduct video visit dry runs 1 to 2 weeks prior to the appointment. This approach has helped troubleshoot several issues early on, reducing technical issues and video visit cancellations and promoting an improved patient and physician experience.

This is by no means an exhaustive list; our goal is to spark collaboration and innovation so that quality care can be provided based on a community’s unique needs and circumstances. Furthermore, reimbursement for telehealth has been one of the greatest barriers to use in the past, but value-based delivery models, such as Medicare Advantage, may help overcome this obstacle by incentivizing virtual visits, preventive care, and other cost-effective models. Future research is needed on this topic.


With a spotlight on the health disparities that already exist in the health care system, we can leverage different forms of telemedicine (video, telephone, and e-consult) to ensure patients have rapid access to high-quality surgical care. A number of efforts are currently under way in hopes of optimizing telehealth and telemonitoring in surgical planning, execution, and recovery. These applications are likely here to stay, with the potential to further extend care to individuals who are traditionally underserved. Future technology may allow more real-time tracking of vital signs and physiological parameters as part of virtual visits, making it even more important that all have access. While these remote monitoring technologies are in their infancy, such innovative telehealth expansion must be handled with the needs and available resources of patients firmly in mind. Through constant reevaluation, rapid sharing of innovations, and a mindset that success means quality care for all, we can help bridge the digital divide.

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Article Information

Corresponding Author: Nicholas W. Eyrich, MS, Department of Urology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (

Published Online: March 26, 2021. doi:10.1001/jamasurg.2021.1143

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Chad Ellimoottil, MD, MS, Department of Urology, the University of Michigan, for his editorial assistance. Dr Ellimoottil received no compensation for his review of the manuscript.

US Centers for Disease Control and Prevention. Using telehealth to expand access to essential health services during the COVID-19 pandemic. Published 2020. Updated June 10, 2020. Accessed March 9, 2021.
Roberts  ET, Mehrotra  A.  Assessment of disparities in digital access among Medicare beneficiaries and implications for telemedicine.   JAMA Intern Med. 2020;180(10):1386-1389. doi:10.1001/jamainternmed.2020.2666 PubMedGoogle ScholarCrossref
Pew Research Center. Demographics of internet and home broadband usage in the United States. Published June 12, 2019. Accessed March 9, 2021.
Zulman  DM, Wong  EP, Slightam  C,  et al.  Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans.   JAMIA Open. 2019;2(3):323-329. doi:10.1093/jamiaopen/ooz024 PubMedGoogle ScholarCrossref
Block  L, Ruane  K. The future of state telehealth policy. Published 2020. Accessed March 9, 2021.
Nouri  SS, Khoong  EC, Lyles  CR, Karliner  LS. Addressing equity in telemedicine for chronic disease management during the COVID-19 pandemic. Published May 4, 2020. Accessed March 9, 2021.
US Centers for Medicare & Medicaid Services. Final rule and interim final rule. Published 2020. Accessed March 9, 2021.
VA Office of Public and Intergovernmental Affairs. VA expands veteran access to telehealth with iPad services. Published 2020. Accessed March 9, 2021.
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