RECONNECTING THE PATIENT: WHY TELEHEALTH POLICY SOLUTIONS MUST CONSIDER THE DEEPENING DIGITAL DIVIDE.

• Author: Hoffman, Laura C.

TABLE OF CONTENTS I. Introduction 3 II. Understanding Telehealth Generally 5 A. Introduction 5 B. Definition 6 1. What Is "Telehealth"? 6 2. Telemedicine vs. Telehealth: The Interchangeability of the Terms 7 3. Impact of Definition on Public Policy 7 III. Exploring Disparities 9 A. Digital Divide and the Potential to Exacerbate Existing Health Disparities 9 1. What Is the "Digital Divide"? 9 B. Early Evidence of Disparities in Healthcare Access from Use of Telehealth During COVID-19 and Beyond 14 1. Race and Minority Populations 15 2. Aging Adults 15 3. Disability 16 4. Non-English Speakers 18 5. Rural 18 6. Socioeconomic Class 19 7. Children 19 IV. Current Legislative Efforts to Combat the Digital Divide in Telehealth Access 20 A. Telehealth Modality: Expanding Coverage for Audio-Only Telehealth 20 1. Federal Efforts 21 2. Legislation at the State Level 24 B. Addressing Lack of Broadband Access 25 1. Federal 26 2. State 27 C. Digital Literacy 28 D. Addressing the Distinct Needs of Various Groups 29 V. Recommendations for Policy Solutions to Address the 29 Digital Divide Going Forward 29 A. Allowing Coverage for Various Modalities of Telehealth 30 B. Affordability of Technology 30 C. Accessibility in Usability: Education and Design 31 D. Further Research to Inform Policymaking 31 E. A Holistic Approach to Telehealth--and Its Policy 32 VI. Conclusion 32 I. INTRODUCTION

One of the critical lessons already gleaned from Covid-19 is the immense role technology can play in all aspects of our lives for everything from food shopping to healthcare access. But when technology becomes a larger part of our everyday lives, it begets a question: does everyone have access to the necessary technology? Devices such as iPads, smartphones, and laptops can come with a hefty price tag. Access to high-speed internet can also impose a challenge due to cost as well as availability in a given location, a barrier for many living in rural and urban areas. Aside from affordability, there are several other reasons that particular populations may not be able to access technology. These include people generally not feeling comfortable using these devices, such as the elderly or people who find them too complicated; additionally, the technology itself may not be designed in a way that accommodates specific needs, such as individuals with different disabilities or non-English speakers. For those with children, many of these issues impact the family as a unit. Because of this, specific groups of people may have limited access to things like food delivery and healthcare--what we consider basic necessities--when technology has become a replacement or alternative for providing these goods and services.

There is concern that moving forward, already existing disparities, particularly those involving healthcare, will worsen due to the "digital divide" the separation between those with access to technology and those without as described above. As our society continues to evolve beyond the Covid-19 pandemic, much focus will center on how the landscape of providing healthcare can and should change as telehealth has become a prominent part of the healthcare story in the United States.

Since the Covid-19 pandemic began in the U.S. in March 2020, the way in which healthcare is delivered has drastically changed. Even though telehealth was used prior to the pandemic, its use as a delivery method for medical care spiked tremendously as a result of the pandemic based on the need to help curb the spread of Covid-19 and ensure people's well-being by reducing in-person contact as much as possible. But there has been lower utilization of telehealth as the pandemic has progressed. "National survey data from the Census Bureau show a gradual decline in telehealth utilization among adults and children between April and October 2021." (2) Additionally, on the provider side, it is still estimated that only 13% to 17% of healthcare delivery across specialties has involved the use of telehealth. (3) Researchers are currently trying to digest the use of telehealth as a means to deliver healthcare, clinicians are trying to learn how best to incorporate telehealth into their healthcare practice, and policymakers are attempting to determine what this means for the future regulatory implications of telehealth as the end of the pandemic approaches. Thus, there will be a "new norm" for healthcare as well post-pandemic, and the verdict is still out on how the use of telehealth clinically will be incorporated and how it will be regulated from a policy standpoint. While the use of telehealth has declined since the peak of the pandemic, its use is here to stay, and many of the questions of how it needs to be regulated must be explored and answered. (4) Among them, how to ensure policy solutions are mindful of these issues involving the digital divide's impact on various populations, which goes far beyond simply ensuring an adequate infrastructure. (5)

While much of telehealth focuses on providing access to healthcare by means of both audio and visual delivery, this is not possible for many individuals in thinking back to the concept of the "digital divide." Telehealth has already been criticized by some because it can, and potentially will, feed into this digital divide. As those who can afford access to the necessary technologies including iPads, smartphones, and broadband internet, will also have greater access to healthcare through telehealth if it is more fully implemented into the norm of healthcare delivery. However, research has already shown, and what needs to be further explored, is the audio-only option that was used by many to provide telehealth during the pandemic as well as the populations that were reached. This Article hypothesizes that telehealth can and will thrive if telephone or audio-only access continues to some degree to be offered to provide healthcare for the populations who critics are quick to say cannot benefit from telehealth. While the audio-only modality of telehealth is not clinically appropriate for every healthcare situation or every individual's needs, there are many who may still benefit from its availability. Further, in addition to the audio-only telehealth modality option, efforts can and must be made to explore creating alternative places and spaces to offer both audio/visual telehealth options to these same populations. Education to enable individuals to learn how to use technology appropriately will also be a critical component. Finally, designers of these telehealth technologies must make sure inclusion for all is at the forefront of design. In order to implement these mechanisms, policy solutions may come to bear on this to ensure equality. Telehealth is not merely as good as the technology that brings it to us but as versatile as the methods by which we enable people to have access. The regulatory framework likewise needs to allow for its cohesion as demonstrated by issues like how we define telehealth (i.e., if expanded to include audio-only modality) and whether or not reimbursement is offered.

This Article will attempt to untangle the complicated web of providing telehealth to those populations it is potentially capable of further alienating from access to healthcare including: 1) race/minority populations, 2) aging adults, 3) individuals with disabilities, 4) non-English speakers, 5) individuals living in rural areas, 6) socioeconomic class, and 7) children, in order to advance the argument that telehealth can be successful in providing healthcare access to these populations. Rather than suggesting that telehealth simply "cannot work" for these populations, instead this Article considers how telehealth can and must meet the needs of these individuals through technology, access, and policy developments. First, this Article will explain how telehealth is defined and how the definition has and can continue to influence policy development. Next, this Article will explore the issues surrounding the "digital divide" and how this relates to telehealth use. Then this Article will discuss how access to technology impacts particular populations. This Article will then consider legislation and policy developments both at the federal and state level that have emerged thus far that could help overcome challenges of accessibility, affordability, and useability. Finally, this Article will offer policy recommendations for ensuring that the delivery of telehealth can be accessible to those populations with potentially less access to technology to ensure telehealth's successful availability and use for these populations can continue beyond Covid-19.

Principally, the purpose of this Article is to demonstrate that the future is still bright for the use of telehealth, as seen initially in the audio-only option telephone call that can now bridge the gap for those populations that may not have the same access to technology in a variety of ways. Another hope is to encourage the creation of other options for these populations to use both audio/visual options for telehealth, as it is known that the audio-only option cannot cater to every health situation clinically or meet every need of various members of these populations. This author's perspective is that telehealth is supplemental to the in-person delivery of healthcare, and there is no argument here that telehealth should ever replace in-person care or that telehealth, even in its best forms using both audio/visual components, can ultimately act to substitute in-person medical care completely. However, the expansion of options for telehealth from a regulatory standpoint, as well as finding creative ways to make technology available and otherwise accessible for populations most at risk of not benefiting with the known gap of lack of access to technology, can allow for telehealth to thrive and improve these populations and access to healthcare, rather than potentially worsen existing...