key: cord-0749446-bt7j7zz9
authors: Bakhtiar, Mina; Elbuluk, Nada; Lipoff, Jules B.
title: The digital divide: how Covid-19’s telemedicine expansion could exacerbate disparities
date: 2020-07-16
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.07.043
sha: 6c12c1b0ac795ed0b749e9ecb8eec0199dc024ad
doc_id: 749446
cord_uid: bt7j7zz9

nan

differences between those with and without broadband internet. 5 Though most without internet 59 access live in rural areas, digital infrastructure barriers also affect urban settings: in New York 60 City, almost 50% of low-income households lack internet access. 6 Not only does poor 61 infrastructure limit access, but also wealthier consumers' use could drive up costs and crowd out 62 physicians' limited clinical time from the underserved patients who need it most. 63 64 Beyond digital access, telehealth services must meet quality standards, and inconsistent quality 65 may burden vulnerable populations more. The American Telemedicine Association's guidelines 66 for teledermatology emphasize the importance of high quality images, lighting, and positioning, 67 with challenges for evaluating moles (especially in difficult to photograph areas, e.g. hair-68 bearing skin). As we expand, we must ensure that high quality standards (including technologic 69 and HIPAA-compliance) remain paramount. 70

We concede that while we strive to provide excellent care, ensuring internet access for everyone 72 is beyond our reach. Still, as telemedicine is poised to transform the clinical landscape, to 73 encourage health equity, we must advocate for digital equity, and we must anticipate and address 74 disparities before they grow. Solutions may include greater use of store-and-forward 75 telemedicine compared to video visits that require greater bandwidth, additional clinical 76 appointments for those without proper devices, and nonprofit partnerships to redistribute 77 refurbished devices as in public education. Beyond devices, physicians should encourage digital 78 literacy as an acquired skill, providing educational training on telemedicine and consider 79 technical support staff for practices. Further, as Congress considers increased broadband 80 infrastructure in rural areas, we must remind lawmakers that cities also have digital inequities. 81 82 Doctors and public health advocates should encourage equitable telemedicine access as it 83 expands now. Dermatology is especially poised to lead the way, given its large body of research 84 and experience. We must anticipate the risks of exacerbating disparities and of delivering less 85 and lower quality care to our most underserved patients. If we do not, internet access and device 86 ownership could become social determinants of health. 87

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