Paradox of telemedicine: building or neglecting trust and equity
Rigorous efforts to minimise disease transmission in the COVID-19 pandemic have catalysed the development of comprehensive telemedicine systems.1 Beyond enabling contactless health care, telehealth increases the convenience of routine health care, expands access to specialty care, and allows for more diligent regimen monitoring. These transformational changes will probably endure, with the potential of an estimated US$ 259 billion in health care spending to be shifted to virtual health care.1 Telehealth offers immense promise in bridging health disparities.2 Yet, simultaneously, telehealth might exacerbate existing inequities because of disparities in broadband and technology access by race and household income.2 However, we argue that the promises and pitfalls of telehealth are rooted in something more fundamental—trust.
Analysis of the Mount Sinai de-identified COVID-19 database found that Black patients were more than four times more likely than White Americans to seek health care in the emergency department over telehealth services, even when adjusting for comorbidities and preferred language. This study, as well as other literature, offers the potential explanation that the lack of pre-established relationships with physicians, as well as mistrust of digital platforms, could drive this reluctance to pursue telemedicine.3, 4 Indeed, Black Americans are less likely than White Americans to have strong relationships with their primary care physicians, potentially contributing to scepticism that high-quality care can be provided over telehealth. Weber and colleagues’ findings urge consideration regarding how patient-clinician relationships through telemedicine can impact health equity, especially given institutionalised distrust among Black communities. 3
To be certain, this paucity of trust is nothing new. Transgenerational trauma experienced by Black communities has created the perception—and often reality—that health care entities do not have their best interests at heart.5 Black Americans have historically adopted novel medical technologies at lower rates than their White counterparts, due in large part to inaccessibility and well founded suspicion towards medical innovation.6 Although distrust negatively affects telemedical outcomes, the inverse also holds true Orrange and colleagues note that patient satisfaction with telehealth was primarily influenced by the “degree of trust in their physician”.7 As such, a paucity of trust is likely to undermine the potential for telemedicine to mitigate health disparities, underscoring why trust and telemedicine must be developed and bolstered simultaneously. Although all could benefit in the absolute, mistrust among Black Americans around telemedicine, and the medical establishment more broadly, might only exacerbate deep-rooted health disparities.
Paradox of telemedicine: building or neglecting trust and equity - The Lancet Digital Health