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Some older adults may not be ready for telemedicine [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Dr. Kenneth Lam to discuss a recent study on older adults who are using telemedicine during the pandemic.

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Highlights of this episode include:

  • Background on the study that showed how older adults may be left behind when using technology associated with telemedicine.
  • Ways that older adults may have issues with telemedicine technology such as video conferencing.
  • What study results surprised the study’s authors?
  • What does the study results mean for healthcare providers going forward?
  • And more…

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance Podcast®. The onset of COVID-19 led to a major shift towards telemedicine. However, many older adults may find this shift difficult. A recent study explored the impact on this population, and here to discuss those results is one of the study’s authors, Dr. Ken Lam, clinical fellow at the University of California at San Francisco. Dr. Lam, welcome to the show.

Dr. Ken Lam: Hi, thanks for having me.

Mike: So let’s start out. What did your study examine, and did you have any initial hypotheses when you started?

Ken: Sure. The study’s a descriptive study, and so we don’t start with hypotheses there. We’re just looking and seeking to describe what it is that we’re seeing. And basically, my coauthors and I were concerned that, with this rapid adoption of telemedicine, a lot of our patients and our parents or our grandparents, for that matter– we couldn’t see them necessarily being able to use that way of connecting with their doctors that readily. And so we set out to look for a data set that would help us answer this question as to how many people would not be able to connect with their doctors using the video visit as that had initially been the way that Medicare was reimbursing physicians for seeing their patients during COVID. And so what we set out to do was, again, describe who would have difficulty accessing their doctor via video visits.

Mike: Excellent. And why don’t you tell us a little bit about the data that you did look at and your methods?

Ken: Yeah. So to start out, what we needed to do was try and figure out what would be a description of people who would have difficulty accessing video visits. And some of my coauthors, Amy in particular, had a lot of experience actually trying to connect with people using video visits. She’d been involved in a roll-out for it at the VA. And she was just describing the process, that it requires knowledge and expertise on how to use the internet, to have a device, to have fast enough internet, to also know how to use some of these conferencing software. And from a geriatric standpoint, Ken Covinsky and I were concerned that issues of social isolation, hearing impairment, and vision impairment, or dementia might make it really, really hard to get online. We were also aware that, say you couldn’t do it yourself, you might have a family member who can set it up for you and attend the visit with you. That’s often the case for some of our older patients. That might overcome some of those difficulties. So we set out to look at existing data sets that might contain all this information to start describing how often this problem might occur.

The data set we landed on is one that I’m working on for other projects. It’s the National Health and Aging Trends Study. This is a publicly available data set sponsored by the National Institute of Aging, and it’s published out of the Johns Hopkins University Bloomberg School of Public Health. And essentially, it’s an annual survey of Medicare beneficiaries that is representative of the United States. They go out and they check in with older adults, people over the age of 65. And the framing of their survey is that as you get older, you’re more likely to develop disabilities, but it doesn’t just end there. You’re actually quite creative, and it’s possible that you might adapt to the scenario. So they ask questions not just about people’s function and their health but also how they’re adapting as well. So that’s why we have information from there in terms of what technology people are using and how their telecommunications work. And so we used this data set to then describe how often these problems that I just described earlier were occurring, how often people had experience using the internet or were able to have devices, and alongside that, how many people also have co-occurring hearing impairment, vision impairment, dementia, etc.

Mike: And why don’t you tell us about the results of your research?

Ken: Yeah. Sure. And so the complex survey interviews about 4,500 individuals in the US, and then they use this weighting mechanism to make sure that you can estimate how many people are represented by that smaller group. And what we found is if you expected someone to just use video visits alone, we anticipated 38% of people over the age of 65 would struggle with that. And the main reason why that was the case was due to inexperience with technology. That comprised 30% of the population. But 20% also had some kind of physical disability. And again, we defined this as difficulty hearing, difficulty communicating, difficulty seeing, and probable or possible dementia. Then we said, “Well, if you just use the phone visit, what would you see?” And here, technology-related issues wouldn’t be a problem. And again, that’s where that 20% becomes important, recognizing that these other disabilities would also get in the way of people connecting. And I guess the real concern that we had here and the reason why we organized our study this way was everyone was moving to telemedicine so quickly. You had to rely on older data to get a sense of who wasn’t being seen. We can’t help people if– we don’t even know if there’s a problem if you can’t get in touch with people, and so we were trying to find out who was missing. And some of this information has actually been corroborated by a recent study published in the Annals of Internal Medicine showing, at least in the VA, there’s been a 30% reduction in outpatient visits. Usually, about 10 million people get seen every 10 weeks, and basically, 30% of those visits have gone missing. We don’t know where they’ve gone, but they just haven’t been seen.

Mike: Was there anything about what you found that surprised you?

Ken: I think it wasn’t surprising that 38% would probably have difficulty with video visits. That sort of feels in line with my clinical experience, at least. When I look at my data more closely, one thing that is a little bit puzzling is that difficulty hearing only made up 2% of the population. We know that clinically significant hearing impairment is much more prevalent than that. But I will highlight that the survey that we used asks functional questions. The question that was answered was, “If you are using your hearing aids, if you have them, do you have difficulty hearing over a telephone?” And so on the one hand, it doesn’t really match to sort of our clinical epidemiologic studies of the population and how often hearing impairment occurs in older adults, but it does answer a very functional question as is relevant for telemedicine, namely these are people who say, “No, I actually can’t use the phone that easily.”

Mike: So what do you think this means for healthcare providers moving forward?

Ken: I think it means a couple of things. In the near term, I hope that people are doing a little bit more outreach to try and find people who might have fallen through the cracks, particularly if they’re older patients, and that they are asking geriatrics groups local to them on strategies on how they can reach out because it is our group that often has experience doing things like home visits because we know that the aging process can be difficult, but we still think that it’s worthwhile caring for this population. So one, I just hope people are trying to do a little bit more outreach now that they know that some people have gone dark. And that takes some proactive action as opposed to just waiting for patients to arrive.

I think for the longer term, I’ve heard a lot of excitement about how telemedicine is the way of the future. And I agree that it’s actually very helpful for older adults with mobility impairments, but [inaudible] concerned that we are building in new disparities. I know that the study– just anecdotally, I’ve heard that my study has given some people pause in how they’ve been planning their telemedicine in the future, that they are starting to recognize that they can’t have just telemedicine. They will also need to have other services to make sure that people don’t go missing. So I really hope that– the analogy that I’ve been thinking of a lot is that when you build medical facilities, there are rules where you have to build ramps and elevators to make sure people can get in. And it’s great that we are making medical care virtual now, but we really need to make sure that we’ve got the right laws and policies and thought around what those ramps and elevators now look like because worst comes to worst, we build a system that when we get old ourselves starts to push us to the margins. And I’m just concerned that we are doing this as thoughtfully as we could, especially because a lot of groups have thought long and hard about possible solutions for some of these disabilities.

Mike: Dr. Ken Lam, thank you for adding to this important discussion around telemedicine. If someone wanted to learn more about this study or other work that you do, where can they go?

Ken: They can follow me on Twitter. I’m working still on assembling resources. Annals of Internal Medicine just put out an editorial by Carrie Nieman, I believe, describing some strategies on how you can overcome hearing impairments with a little bit of talk also about cognitive and visual impairments. And I think that’s the first resource that I’ve seen to date published in medical literature. I will also boost other groups. I know that hearing loss societies and local seniors organizations have also been trying to tackle this on the ground, and I just wanted to applaud their work because that is really the work that is fixing this last mile problem to get access to our seniors in need. So all of those would be helpful resources, and I know that because this has garnered so much interest on continuing to assemble resources and speak to people to see what we can do about it as well.

Mike: Excellent. Thank you so much for joining us on the show today.

Ken: Thank you.


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