It's 2020, and millions of Americans – now trapped in their homes – don't have reliable internet access. In a pandemic, that is a public health problem.
These days, Dr. Susan Kressly begins recruiting thanks to patients for bringing her into their homes. Like many other doctors during the covid-19 outbreak, Dr. Kressly, a pediatrician in Warrrington, Pa., Has begun practicing medicine by telephone or v.Ideo – or personal visits are important to children's experience, for good reason. “For young children, it's like a tele-animal drug,” she laughs. “They turned the phone down and knocked it down. They are also not good at accurately reporting their symptoms. ”
Whether it is delivered on screen or with a speaker, child care remains a critical time during the epidemic when families find themselves home Without their daily lunch, some children cannot access sufficient food. Previous recommendations for high daily screen time have been mocked. And children, like all of us, struggle with anxiety, insomnia, and fear of the future. Above all, Dr. Kressly worries patients who do not have internet access at home will not be able to contact pediatricians during covid-19 violence. "We have to look at what technology is in the family," he said, "and we have to make the best of what we have."
In the past months, healthcare providers from psychologists to family physicians have rushed into telemedicine through video conferencing or healthcare applications. Treating patients in the home is likely to alleviate the burden of communicable diseases such as Covid-19, experts say, by reducing congestion in hospitals and doctors' offices that already have problems with hazardous materials and high risk of infection. It works the other way, too; Telemedicine allows isolated physicians to work from home. "If we talk about social networking with the goal of reducing our healthcare facilities, telehealth will play a big role," said Christopher Ali, a University of Virginia associate professor of psychology and Benton Institute for Broadband & Society who looks for connection.
But how telemedicine should work for the tens of millions of Americans who have no reliable, affordable, home Broadband (minimum acceptable speed limit and download speed)? Ali says the answer is simple: “Telehealth is impossible without Broadband. Both are the same. ”He and others lament that internet inequality is now a public health problem, as rural and urban households are scarce – or unable to pay – at home, the high-speed Internet is left without a major disaster, driven by the epidemic switch to telemedicine. “Earlier, the digital divide has been a big problem. It is now a health and death problem, ”said Angela Siefer, Executive Director of National Digital inclus Alliance, representative group. “This is not rocket science. If a person does not have the Internet, or a computer, or knows how to use an app, they will not use telemedicine. And when they are not, they leave home or receive no care. ”
It has been proven that it is difficult to accurately measure the breadth of the digital divide of this country. State Communications Commission – namely it spends about $ 8 billion every year on a network connection—reported by 2019 that 21.3 million Americans will need cable, DSL, fiber, or wireless to access Broadband speed. In February, when the acquisition of Broadband tracking monitored the FCC's handwriting, it twice that number reaches about 42 million Americans. According to Microsoft, it's much more straightforward than that: many 157.3 million it can only reach download speed below the current FCC limit, 25Mbps. Technology policy analyst John Horrigan estimates more than 18 million homes across the country (some or most containing more than one person) are in need of Broadband. "That's 12 percent of people who don't want to access the Internet at home or on a mobile phone," Horrigan said. "But it's bigger than & # 39; you have it or you don't. & # 39;"
First, the digital divide plagues in rural and urban areas. In rural America, where the 2018 Pew Center data raises Only 58 percent of residents have a local Broadband subscription, the debate remains infrastructure-related: Providing high-speed Internet in remote, densely populated areas means investing in expensive fiber or mobile tower installations to benefit a few consumers. In cities, that same data for the 2018 Pew exhibitions
And smartphones can't and won't fill the gap. Areas with poor radio coverage often suffer from poor mobile reception, Ali said. And do research to show that those who rely on smartphones for their Internet access — low income, low education, and white people — are more likely to have access to their program data and have their phones turned off due to financial difficulties. "There is not just one digital divide: it is low income, it is small, young and tourist communities," Ali said. "There is this perception that Broadband is rampant in the U.S. The idea that everyone has it, and that everyone's speed is equal to city speed. This is a time of connection."
Now, we see all this play out during the epidemic. A Cleveland woman – where nearly a third of households are in need of Broadband – recently done Articles after his telephone service were decided during a telemedicine visit. Some of the world connected cities at least it is now about covid-19 hotspots, including Detroit, where about 60 percent of households do not have Broadband, and Miami, where about half are. In an American covid-19 piece, New York City, one in four cities it is not have a home subscription. On the main beach, in the tech mecca San Francisco, 1 in 8 does not have high speed internet service. Under those circumstances, telemedicine cannot be considered as a complete solution to providing health care during the violence. "In the coming weeks it will unveil the clever truth of digital sharing," he wrote FCC Commissioner Geoffrey Stark on March 19 New York Times Ok, "tens of millions of Americans can't access or can't afford the home broadband connection they need."
The covid-19 epidemic has completely changed the daily medical practice of Drs. Colen Krajewski.
Krajewski, a gynecologist in Pittsburgh, continues to provide abortion care, which, along with cancer procedures, is among the few surgeries is considered important at this time. Pap smears and breast exams have been changed in particular, for now. The needs of his patients have changed fundamentally. Some women are now choosing to stay home and receive tele-diaphragms, Krajewski said, to avoid having to go through long-term contraceptives. Some have risked a personal visit to get an IUD or have a transplant if their condition is more urgent – such as in the case of intimate partner violence where they can now be locked up alone with someone they fear to disturb for their oral contraceptives. He used to see about 20 patients in person a day; on Friday, see four in need of urgent care. Everything else he sees by phone or video. "I was worried it was going to make the wrong person," Krajewski said. "I actually find it close to see someone in their home."
It is one of many silver locksmiths such as Krajewski claim to have been discovered during the broader covid-19-indened fields of telemedicine. "Okay, let's press the meat," said Dr. Joe Kvedar, a Harvard Medical School professor, a skin specialist at Massachusetts General Hospital, and the next presidente American Telemedicine Associareference. “Now the world is different. We want everyone to stay home and take care of them at home. ”Through a video conference, doctors can guide a person through a home-based cuff or sync with instructions from multiple experts. Skin specialists can check for lumps, pediatricians can pigeonhole tissues, and physical therapists can watch patients exercise. Physicians can help diagnose potential covid-19 cases by asking patients to breathe hard and calculate how many seconds they can use (to test their oxygen satellite), and to identify emergencies such as appendicitis, gallbladder infection, horizontal ectopic pregnancy, and spinal pressure by asking patients, jump up and down. It's also easy to do things right by the side of the bed – showing a calm face, not disturbing, expressing empathy – through video, over the phone.
But doctors who need to watch, focus or pay attention to the symptoms quickly get to the edge of the telehealth. For example, kressly, states that comprehensive "pediatric examinations" including immunization and hearing, vision, height, weight, blood pressure checks are not possible over the phone or on the web. Also, he adds, "There is a clinical value in looking the baby in the eye and biting it at the end of the visit." Other experts report similar difficulties. Addiction counselors may not be able to do regular urine tests, and oncologists will not ask patients to work with blood or biopsies at home. For the mentally ill, even video conferencing hides subtle diagnostic methods, such as whether the patient is eye-catching or maintains personal hygiene. "We practice with one hand tied behind our back," said Dr. Gail Basch, director of drug administration at Rush University Medical Center.
Also, many specialists are exposed to the epidemic. "This is a problem," said Mr Kwong, executive director of Connected health policy center, a nonprofit telehealth policy center. In a matter of weeks, thousands of health care providers have installed new applications and renewed their understanding of changing laws regarding interstate licensing, limited authority, and patients' privacy requirements. "Most physicians had a backlog in their minds that there would be times when they couldn't interact with the patients themselves," said Dr. Elie Aoun, a Manhattan-based psychiatrist. "But a lot of people didn't put that up, I'm included."
Patients have had to be flexible. Those with internet at home can download the app and adjust expectations for what a doctor appointment looks like. But things are getting more complicated in homes where the only available telehealth system is on a home phone. Just as the American Medical Informatics Association be warned FCC in 2017: "access to Broadband, or soon will be the basis of health care."
Amy Sheon, executive director of Case Western Reserve University School of Medicine & # 39; s Urban Health Initiative, has been concerned with the digital divide and health disparities in the last decade. The covid-19 epidemic has removed some barriers to foster care, such as travel and childcare, said Sheon, who is also the NDIA's chief executive. But connected people not only lose a live two-way conference, but also patient patients where they can get reliable health information, text doctors, request doctor's prescriptions, blood sugar or hypertension, review their medical history, previous care recommendations, lab results, and vaccines. . "On covid-19, health careers closed their doors and accessed the internet," said Sheon, and now some people can't even knock on the door of the telehealth.
Matthew Faiman, Cleveland Clinic's in-house physician and medical director using the emergency care system, has been waiting for 15 years for: In a matter of weeks, various barriers to preventing widespread adoption of telemedicine – Licensing details, IT, cover and reimbursement, for example – have begun to fall.
"I always knew there would be a light moment, but I was blown away," Faiman said. "For patients, from a safety standpoint, we had to do this, and do it safely, quickly, and efficiently. I didn't think it would come as a smoker."
Take, for example, a telephone consultation. Broadly speaking, pre-covid-19, they could not fit into the "telehealth" definition of many private and public insurance plans, including Medicare and Medicaid. Some programs even stated that, in order to pay for telemedicine, the provider needed to record a video of both themselves and their patient as evidence of fraud and abuse. Others have authorized the use of certain telemedicine applications, not FaceTime or Skype, to ensure patient privacy. And even if you received telephone, pre-epidemic care, not everything The country has allowed insurance plans to pay for telehealth as it can meet the corresponding human services.
Much of that has changed in the matter of weeks (clearly, the speed of light in the health care industry). Public and private health systems, as well as state and federal health systems, have been billed to improve billing and reimbursement for telemedicine. "The biggest problem we had to overcome was a very serious problem," said Mark Fendrick, chief pediatrician and director of the University of Michigan & # 39; s. Center for Value Based Design Insurance. "This problem has moved us from 5 miles per hour to 100 miles per hour."
Beginning Tuesday, Washington D.C. and in every state but Hawaii took steps such as expanding Medicaid and expanding the license or patient privacy requirements, accordingly at the linked health policy center. The Department of Health and Human Services continues Relax its policies around HIPAA. March 27 FEES (Coronavirus Aid, Aid, and Economic Security) The law, among other things, allowed restricted telemedicine services to be covered, provided before the end of 2021. And the Centers for Medicare and Medicaid Services continue expand its phone-covered services — including allowing only phone credentials when the only options available. "(I) n the context of the intention to reduce the risk of exposure," CMS recently he explained, "We believe that there are many situations where long-lasting, audio-only communication between the therapist and the patient may be clinically appropriate but not entirely favorable for facial visits." Along the same line, Medicare was required to create and implement new billing codes – because pre-covid-19, patients had no way to prove that they were receiving home care.
Private insurers also changed telemedicine policies to respond to covid-19. Aetna, serving 39 million people, says it gives up $ 0 Copay telemedicine tours until June 4, 2020. Anthem has provided us 79 million customers in order you were
But are we witnessing a fundamental change in healthcare, or will all of this disappear by 2021? Pat Keran, vice president of product and innovation at United Health, says the insurance company is committed to telecommunications, and hopes to permanently add policies that allow doctors to see patients from home to the future. "It's an important part of our plan," he said. “We hope that some of these restrictions will continue to be lifted and these policies remain stable, post-covid-19. I think this will be part of a new trend. ”(Keran did not explicitly state which of these policies would last, without allowing physicians to pay for outpatient visits.)
Some are even more controversial, including Dr. Judd Hollander, an emergency medicine specialist and head of health care engagement at Sidney University at Sidney Kimmel Medical College in Philadelphia. Covid-19 insurance coverage, he said, may not be as good as it seems. Without further testing, it is unclear how the costs will be paid to patients; payers say they will cover complaints related to covid-19, he said – what about patients who do not know that they have good or bad posture but have problems with symptoms such as fever and shortness of breath? And because many networks have set a June or July expiry date on their policy change, any relief from insurance providers can be short-lived, says Holland, without any permanent commitment to adjust premium rates or extend coverage to 19 telecare. "I have no doubt that they are doing everything they can," he said. "I think they are doing enough to appear as though they are doing their best."
Hollander, however, is expressing his doubts that insurers will continue to replace telemedicine with the hope that patients will demand it. "Nothing will be able to erase the memories of people who have tried and loved themselves," he said. "Patients will perpetuate this." Just as doctors are finding out how to give the right amount, patients realize that “seeing a doctor” no longer means planning appointments, paying for parking, sitting in a waiting room, and spending 30 minutes with the doctor. "People tolerate all that because they think there is nothing else they can do," Dr Kvedar said. “Very good. Most people did not know that they could take advantage of telemedicine. ”
In the post-Covid-19 world, Dr Fendrick said, "one of the best outcomes is that patients will get the care they need without leaving home." Pregnant women, people with mobility problems, or those who do not have adequate means of transportation can avoid traveling when absolutely necessary. A blood pressure test at home can add more accurate results, as it will show more natural conditions. Subtitles, word-for-word, and rapid language translation tools can change how patients with hearing and speech problems, or those with English as a second language, receive health care. Pediatricians can always test how children with ADHD behave when they are in a normal environment, and help parents decide that a sick child should go to school without asking families to go to the clinic by 5am. a time like this, ”Kressly, a pediatrician. "What we're going to see, I think, is that it's no longer bringing the genie back to the bottle."
But even in the most spectacular televisions, Siefer and other Broadband lawyers worry that millions of patients will be left out. "Both nationally, we are trying to connect people," said Adam Perzynski, professor of medicine and fellowship at MetroHealth System and Case Western Reserve University, Cleveland, who researched the impact of digital health. "We will continue to be a serious threat to certain communities."
During the recent closure, municipal Wi-Fi providers are in favor libraries they fought to maintain their public places. Internet service providers including AT&T, Verizon, T-Mobile, Sprint and Comcast have deleted data data, and some have offered free or at a low cost plans. And, of course, companies can invest in zero tolerance more cell towers to fill in the gaps, Ali suggested. But Siefer said he wants to see who's moving on, such as a federation Broadband sponsorship or waiver to allow patients to use health insurance to pay for an internet connection with a laptop or tablet. years of telemedicine). Sheon said he would like to see more community health workers provide technical assistance to patients with low levels of digital literacy, and also see many health systems buy low-cost smartphones and patients' pills received and identified as discontinued. Until things go wrong, the covid-19 layers that go into digital segmentation "aren't somehow connected to everyone," Siefer said. "These are band-Aids."
Marion Renault is a French-born science journalist, based in the Midwest, and now based in Brooklyn. His work has appeared in The New York Times, Popular Science, and The Atlantic.