Tuesday, October 1, 2024
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Telehealth 

Geocode Maps Spotlight Disparities in Telehealth Utilization During the COVID-19 Pandemic in New York City

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Introduction

During the coronavirus 2019 (COVID-19) pandemic, telemedicine has emerged as an innovative vehicle to facilitate access to medical care and reduce nonessential emergency department visits. Although the virus may strike indiscriminately, a disproportionate burden of disease and mortality has been ascribed to areas of lower income and minority communities.1 We reviewed the use of telemedicine in New York City (NYC) during the height of the pandemic, to better understand utilization of this service in these underserved high-risk regions.

Telemedicine enables patients to see a doctor through an online video chat from the comfort of their own home. This technology offers the opportunity for an uninterrupted evaluation, including recommendations for management, education, and guidance for when to seek emergency care. Telemedicine allows patients to limit travel, and thereby reduce community exposure.

The NewYork-Presbyterian (NYP) Direct-to-Consumer telemedicine program, launched in 2016, offers access to an emergency medicine (EM) or a pediatric emergency medicine (PEM) provider through a virtual urgent care (VUC) visit. In response to the pandemic, this program rapidly expanded to meet the increased needs for both COVID-19 and non-COVID-19–related complaints. During the peak of the pandemic, patient volume increased from 20 to >300 calls per day, and the staffing model expanded from 2 EM and 2 PEM providers to >20 EM, PEM, and non-EM/PEM providers available to meet these demands.

As data emerged that COVID-19 seemed to have a greater predilection for underserved and minority communities,1 we examined the use of our telemedicine service by patients in neighborhoods of NYC reported to be at high risk. We generated a telemedicine usage map of NYP VUC visits based on patient address by ZIP code, from March 1 to April 26 (Fig. 1a). We excluded all affiliated employees who were able to receive this service without charge.

Fig. 1.

Fig. 1. Geocode maps comparing VUC visits and COVID-19 cases. VUC, virtual urgent care.

We compared our telemedicine usage map with a geocode map (Fig. 1b), reported by the NYC Health Department,2 of the total count of COVID-19 cases based on patient address by ZIP code.

A visual comparison of Figure 1a and b shows that telemedicine was used less in areas of high COVID-19 case concentration across NYC. To illustrate an example of this discordance, we compared ZIP code 10028 (Yorkville, Manhattan) and 11368 (Corona, Queens), both being < 5000 m in proximity to an NYP hospital site. In ZIP code 10028 (Yorkville, Manhattan), 33% of patients tested were positive for COVID-19 (409/1,239).2 Based on population data, this equates to 8.6 per 1000 people tested positive, of 26.0 per 1000 tested. Figure 1a shows that in this same ZIP code, 44 patients (1.6 per 1000) used NYP telemedicine services during this period.

In contrast, in ZIP code 11368 (Corona, Queens), 66% of patients tested were positive for COVID-19 (3,417/5,156).2 This equates to 30.4 per 1000 people tested positive, of 45.8 per 1000 tested. In the corresponding area, Figure 1a shows only 17 patients (0.15 per 1000) used NYP telemedicine services during this period.

In summary, the geocode map of NYP VUC visits shows low telemedicine use in areas with high case concentrations of COVID-19 across NYC, specifically, East Harlem and areas of the Bronx, Brooklyn, Queens, and Staten Island. A comparison of geocode map data illustrates 10-fold less telemedicine use in Corona, Queens, compared with Yorkville, Manhattan, despite having more than three times the number of COVID-19 test positive cases per 1000.

Although telemedicine has played a critical role in health care’s response to the pandemic, it has not reached its full potential in underserved populations. We propose four domains to focus efforts toward mitigating these disparities and fostering equitable telehealth care for all: (1) language, (2) technology, (3) cost, and (4) marketing strategies.

Language

Although many telemedicine applications are now accessible in multiple languages, and offer translation services for the provider to communicate with the patient, navigating within the application and selecting a provider are, in many cases, still available only in English. To facilitate the use of telemedicine, all aspects of the platform must be available in multiple languages.

Technology

Although high-speed Wi-Fi and broadband connectivity are widely accessible in urban NYC, gaps remain in certain areas that lack subscriptions or cellular data plans to utilize telemedicine services. A 2018 report by the NYC Mayor’s Office states “a large disparity exists …with more than half (56%) of NYC’s lowest-income households lacking a home broadband subscription.”3 On June 25, 2020, Congress introduced the Accessible, Affordable Internet for All Act proposing $100 billion for broadband with 20% allocated toward digital equity programs and broadband service for low-income consumers.4High quality and affordable connectivity plans and access to required technology are essential to close the digital divide and widen access to telemedicine.

Cost

Many telehealth services require patients to pay upfront, before connecting with the provider. Early in the pandemic, the Centers for Medicare and Medicaid Services released statements for states to have “broad flexibility” to cover telehealth services for Medicaid and Children’s Health Insurance Programs during the coronavirus pandemic.5 Despite temporary waivers of restrictions, use by underserved communities has not been fully actualized, as some telehealth programs have not yet incorporated these modified payment plans, and the reimbursement process is not well established. Furthermore, there is no certainty as to how long these waivers will remain in place. Legislation and telemedicine infrastructure that support a flexible payment and/or reimbursement process for all patients will broaden utilization.

Marketing strategies

Broad outreach describing telemedicine resources in multiple languages is needed to enhance digital literacy and make use of digital technologies. Marketing strategies and education targeting underserved communities will optimize access for all.

Summary

The COVID-19 pandemic has magnified existing disparities in health care. We describe inequities within the very tool intended to improve access to health care. Barriers of language, technology, cost, and marketing strategies must be remedied to create equitable access and utilization of telemedicine and virtual care services. COVID-19 has spurred the expansion of telehealth to provide much needed clinical services to patients during quarantine. However, adapting these platforms for all, inclusive of underserved populations, is essential as we strive to level the curve.

Authors’ Contributions

All authors (M.L., D.L., and S.L.P.) met ICMJE requirements for authorship, including substantial contributions to the conception of the work, drafting and revising for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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