Telemedicine delivery for urban seniors with low computer literacy: A pilot study

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Abstract

The rapid development of health information technologies has been touted for its potential to address health disparities and create a more equitable healthcare system. However, most system designers do not understand the needs and preferences of members of underserved communities and fail to take these factors into consideration when developing applications. Although an increasing number of studies examine consumers' attitudes towards telehealth, there remains a dearth of information from consumers residing in underserved, urban areas. This pilot study used a mixed methods approach to assess the perspectives of consumers and nurses toward a specific telemedicine application. Consistent with prior studies, the findings suggest a general receptivity toward telehealth but with reservations related to discomfort with computers and the equivalency with face-to-face care. The study suggests the need for larger-scale studies that can help to identify the needs and preferences of members of underserved communities in the design of telehealth applications. Telehealth has been defined broadly as the remote delivery of health-related services through telecommunications technology and its use has been expanding rapidly in the past two decades (Dorsey & Todd, 2016; Dinesen et al., 2016). Telemedicine (often used synonymously with "telehealth") has been defined as health-related communication occurring between patients and providers in different geographic locations (George, Hamilton, & Baker, 2009). The World Health Organization (2009) used the term "telehealth" to refer to telemedicine offered through non-physician providers. In the United States, however, nurse practitioners provide most of the same services as physicians in wellness and acute care visits and with equivalent quality of care; therefore, this distinction is largely irrelevant in the U.S. context. This study focused on telemedicine services provided by a nurse practitioner and, therefore, uses the term "telemedicine" to refer to the intervention tested in this pilot study and "telehealth" to refer to more general technology-based health services (including telemedicine), as appropriate. Although numerous studies and editorials suggest great promise for telehealth to improve health equity and advance the goals of the Triple Aim (i.e., enhanced patient satisfaction, improved population health, and reduced costs), studies examining the efficacy of these models of care have reported inconsistent findings, with the clearest benefits seen for patients living with chronic health conditions (Dinesen et al., 2016; Berwick, Nolan, & Whittington, 2008; Dang et al., 2008; Wootton, 2012). A problem with the current evidence base is the insufficient focus on consumers' perspectives of telehealth technologies. Dorsey and Topol (2012) citeD Ray Kurzweil's "law of accelerating returns" to describe how the "exponential evolution" of technology can lead to dramatic declines in cost (Kurzweil, 2001), but if technology is seen as an inadequate substitute for in-person care, or as untrustworthy, consumers may be resistant to its use. This risk is particularly pronounced among historically underserved groups (i.e., those who have been disadvantaged due to factors such as ethnicity, age, gender, and socioeconomic status, including individuals with limited access to broadband internet service, smart phones, and other developing technologies) that have been excluded consistently from telehealth research and development (Dinesen et al., 2016; Call et al., 2016; Isaacs, Hunt, Ward, Rooshenas, & Edwards, 2016; James, Harville, Sears, Efunbumi, & Bondoc, 2017). As noted in a 2013 report to the Department of Health and Human Services, those who design telehealth services generally do not understand the needs of historically underserved communities and do not seek the input of these consumers when developing health technology applications (NORC at the University of Chicago, 2013). Without a concerted effort to understand the needs and priorities of members of these groups, the health information technology infrastructure risks exacerbating, rather than reducing, health disparities (NORC at the University of Chicago, 2013; McAuley, 2014). Efforts to address these risks include expansion of the use of health information technology (HIT) in federally qualified health centers under the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the 2009 American Recovery and Reinvestment Act (ARRA), as well as ARRA's emphasis on the Meaningful Use of HIT (Heisey-Grove, Hufstader, Hollin, Samy, & Shanks, 2012; Heisey-Grove, Hawkins, Jones, Shanks, & Lynch, 2013). In addition, a growing number of studies have begun to examine attitudes toward the acceptability of HIT among rural and urban residents and members of ethnic minority groups (especially those with chronic health conditions), and a recent review examined research on efforts to improve the cultural competency of electronic health services to improve uptake among Latino consumers (Montague & Perchonok, 2012; Grunbaugh, Cain, Elhai, Patrick, & Frueh, 2008; Carter, Nunlee-Bland, & Callender, 2011; Price, Williamson, & McCandless, 2013; Victorson, Banas, & Smith, 2014; Call et al., 2015). In their review of the research on HIT among historically underserved consumers, Montague and Perchonok (2012) highlighted the importance of tailoring technology to the preferences and needs of specific target populations to ensure greater uptake and more meaningful use. In general, although results of research on underserved groups have been mixed, findings suggest a general receptivity to the concept of telehealth services, but with reservations relating to the confidentiality and security of such applications. Many of these studies failed to assess attitudes in the context of any specific application or model of care. Finally, few studies have examined the feasibility of telehealth services for the provision of general preventive or primary care, as opposed to patient monitoring for chronic health conditions. This study used a mixed methods approach to address the following two research questions: (1) What is the feasibility of implementing a specific telemedicine service among residents of an underserved urban area? and (2) What are the perspectives of these consumers and health care providers on the efficacy and acceptability of this model of care? Specifically, this study was designed to determine whether residents in an impoverished urban community with high healthcare access needs (e.g., transportation barriers and limited access to specialists) would view telemedicine as a viable alternative to inperson primary care. This pilot research was intended to lay the groundwork for further larger-scale studies into more effective means of addressing health service shortages in underserved urban communities.

Original languageEnglish (US)
JournalOnline Journal of Nursing Informatics
Volume22
Issue number2
StatePublished - Jun 1 2018

All Science Journal Classification (ASJC) codes

  • Health Informatics
  • Nursing (miscellaneous)

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