It's More Than Just Video—Bridging the Digital Divide and Improving Outcomes in Older Adults with Heart Failure

What is the digital divide?

Telehealth has become a part of our daily lives: for many patients and clinicians, new technologies and regulatory changes catalyzed the rapid expansion of digital health services. At the height of the COVID-19 pandemic, 48% of Medicare fee-for-service beneficiaries used telehealth services, and while that proportion has decreased as the pandemic winds down, nearly one-in-three still use telehealth (1). As many areas of the United States lack sufficient primary care and specialty clinicians telehealth represents an attractive option to facilitate access to care and has already seen increased federal, state, and local funding (2). Unfortunately, many of the same social determinants of health (SDOH) tied to worse health outcomes for disadvantaged populations also limit access to digital health services due to language barriers, high cost or lower digital and health literacy (3). Studies demonstrate a significant link between broadband access and community-level health indicators - a startling finding given the Federal Communications Commission estimates approximately 19 million people in the United States lack reliable access to high-speed internet (4). These "pockets" of the US population disconnected from broadband internet make up the "digital divide" and as a result have not benefited equally from the rapid expansion of telehealth services.

 The digital divide, however, is not solely due to lack of broad-band access. Several known SDOH including older age, chronic illness, lower income, female sex and Black race among others are associated with a lower likelihood of using telehealth (5,6). Ultimately, the digital health divide can be thought of as a "piling on" of poor health outcomes where those populations with worse outcomes continue to have poor outcomes despite technological advances in the broader society (7). In this context, the promise, and perils, of using telehealth to help manage heart failure (HF) are outlined in the AHA Scientific Statement "Telehealth and Health Equity in Older Adults with Heart Failure." Importantly, Masterson Creber et al also describe evidence-based strategies for implementing integrated telehealth services to care for patients living with HF. These strategies can bridge the digital divide, reduce health disparities, and provide high-quality, cost-effective care when delivered in the patient's preferred language and at their level of digital competency (8).

Does telehealth work for older adults with HF?

First, we should define telehealth. As noted by the authors, telemedicine refers to the provision of medical care to patients using telecommunications technology. Telehealth, on the other hand, has evolved into a blanket term, encompassing a broad range of digital health services and interventions. This includes not only synchronous video conferencing between patients and clinicians, but asynchronous ("store and forward") communication, electronic health records and patient-facing portals, mHealth (such as wearables and health apps), and both noninvasive (such as Bluetooth connected digital scales) and invasive (implantable cardiac devices) remote patient monitoring. As with many technologies, telehealth is rapidly evolving, and the proliferation of artificial intelligence is likely to further expands the use and effectiveness of telehealth (9)

Patients living with HF require multidisciplinary, integrated care given the complex, unstable, and progressive nature of the disease process. The high prevalence of HF, which exacerbates already-strained healthcare resources, high costs (for both payers and patients) associated with treatment, and significant care coordination-associated burdens (for clinicians and caregivers) offer opportunities to leverage telehealth. Numerous studies have demonstrated the effectiveness of telemonitoring in HF populations to improve survival time, time spent out-of-hospital, and rate of HF-related hospitalizations (10). Although some trials (such as BEAT-HF and OSICAT) failed to show any difference in primary endpoints, when taken together, high-quality systematic reviews and meta-analyses point toward significant reductions in all-cause mortality and HF hospitalizations among older adults when telehealth services are used (11-15).

To date, most studies have focused on the impact of isolated audio-video interactions and remote patient monitoring of basic vital signs and daily weight. Given the complexity of managing HF, which requires synthesis of numerous objective measures, subjective patient experience of HF symptoms and frequently, interactions with caregivers as well as patients, telehealth interventions must incorporate more than video visits and basic vital sign monitoring that is patient-dependent, not sensitive for acute HF exacerbations and prone to false alarms leading to patient mistrust and provider fatigue. Telehealth programs offering comprehensive, integrated, multidisciplinary care and two-way communication with actionable feedback can enhance self-care (16), encourage patient engagement through visualization of patient-reported quality of life measures (17), and provide resources to reduce caregiver burden and stress (18). Electronic health records with patient-facing portals give patients greater access to their health information and can facilitate sharing of health records for more personalized, coordinated and cost-effective care. In this way, integrated care models can utilize telehealth to enhance patient education, care coordination across specialties, medication management and psychosocial support.

How can telehealth bridge the digital divide for patients with heart failure?

Given its effectiveness, how can telehealth be used to decrease health equity among older adults living with HF? The first step is to ensure telehealth interventions are thoughtfully designed for addressing social determinants of health. This requires not only understanding the specific SDOH relevant to the target population but often direct involvement of that population in the design or ongoing evaluation of the telehealth program. Moreover, published studies of successful telehealth programs need to better describe "what's in the box?" - what are the key components of the intervention necessary to replicate its effectiveness in real-world settings. To this end, validated frameworks such as RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) can guide researchers on the best practices for rigorously and systematically describing their interventions so others can translate research into action. Most importantly, new telehealth programs should undergo evaluation using these validated frameworks to ensure that all populations - particularly underrepresented racial and ethnic communities - have access to and opportunities to provide feedback about the intervention.

Mobile Integrated Healthcare (MIH) often referred to as "Community Paramedicine", is one such example. MIH inter-connects multidisciplinary teams, engages patients and their caregivers, and directly addresses known social determinants of health. For example, MIH leverages telehealth to bring specialty clinicians into the home virtually with on-site paramedics who can perform physical exams, diagnostic testing and interventions such as administering diuretics. In doing so, MIH circumvents a lack of broadband internet, access to transportation, or competing demands (needing childcare or time off of work to attend an appointment) that may prevent necessary care by sending a paramedic to the patient's home with the necessary equipment to perform a video visit with a clinician. Studies suggest MIH reduces emergency call volumes and transport rates to emergency departments while improving patient experience and reducing overall health costs and is particularly beneficial in older adult populations (19). Current studies such as MIGHTy Heart (Using Mobile Integrate Health and Telehealth to Support Transitions of Care among Patients with Heart Failure) are evaluating the impact of such programs on healthcare utilization and patient reported outcomes by enrolling a diverse cohort of HF patients into this pragmatic randomized controlled trial (20).

Conclusions

Telehealth (including MIH) offers significant opportunities for bridging the care gap for complex patient populations suffering from chronic illnesses like heart failure. While technological innovation correlates with the digital divide it can also dramatically improve health equity when done correctly. This necessitates including the perspectives of vulnerable populations, caregivers and front-line providers in the design process, consideration of likely SDOH barriers faced by the target population, and thorough assessment of the health system's capacity to implement and sustain the program (particularly reimbursement for services) in order to avoid unintended increases in health disparity. Finally, while robust evidence supports the effectiveness of telehealth in HF, more implementation science studies using validated reporting frameworks are needed to drive wider dissemination and realize the full promise and potential of telehealth to reduce the negative impacts of SDOH on older adults living with heart failure.