Practical Guidance for Early Identification of Barriers in Surgical Telehealth Clinics

Michael T. Kemp, MD; Aaron M. Williams, MD; Craig S. Brown, MD; Daniel R. Liesman, BS; Sriganesh B. Sharma, MD, PhD; Glenn K. Wakam, MD; Ben E. Biesterveld, MD; Jesse K. Wilson, BS; Mark S. Cohen, MD; Hasan B. Alam, MD


Annals of Surgery. 2021;273(6):e268-e270. 

In This Article

Background on Telehealth Utilization

Telehealth can be an important tool for increasing access to care and has become key during the pandemic.[1–3] During the initial implementation of our surgery department's telehealth program, we had stringent criteria to identify appropriate patients for this program.[4] After demonstrating the safety of this program, we expanded the criteria to all postoperative patients except those meeting exclusion criteria (eg, postoperative surgical complications, open wounds/drains/staples/sutures/pathology requiring in-person evaluation/discussion, and so on). Although there are numerous benefits of telehealth that even our group has reported on, we have also demonstrated patients may still encounter barriers that affect utilization and their ability to access these programs.[1,4–6]

As part of an ongoing quality improvement effort at our institution, we evaluated patient utilization of our telehealth program before the pandemic to identify possible barriers or disparities.[5,6] This analysis revealed several important findings that suggest patients still encounter barriers when trying to obtain surgical care virtually. In fact, surgical patients had 2× increased odds of not showing up for their telehealth visit as compared to an in-person visit.[6] We also identified notable disparities in utilization among various demographic groups.[5,6] For instance, married patients were more likely to show up for their visit with a no-show odds ratio (OR) of 0.60 (compared to patients who are single).[6] Similarly, when we evaluated cancellations, approximately 12% of married patients and 32% of single patients failed to complete their telehealth visits, respectively.[5] These findings suggested that patient support systems may play a powerful beneficial role in access to healthcare, including telehealth access.[5,6] Furthermore, our data show that racial disparities may not be alleviated by telehealth programs. For example, in our analysis of cancellations, almost 40% of non-White patients never completed their telehealth visit as compared to 19% of Whites.[5] Additionally, our group identified African Americans at greater risk of no-showing for either traditional or telehealth visits (OR >2.4; with Whites as reference).[6] Age also was inversely correlated with no-show rates in a telehealth clinic, as younger patients were more likely to no show for their visit as well.[6] Finally, our institution's statewide county data showed similar trends in no-show rates between traditional and telehealth clinics, suggesting that nongeographic factors likely still impact a patient's ability to receive telehealth care.[6]

Even when patients are able to access the telehealth platform, some patients may still have a preference against telehealth visits.[5,7] Others may still experience technical difficulties (eg, lack of equipment, portal access to the electronic medical record, or technology skills) that limit the effectiveness of these platforms.[5,7] Screening patients for barriers that they may encounter while trying to obtain care in a telehealth setting is vital to the success of such programs. Overall, our previous experience shows that telehealth care is not without its limitations and should not be considered a cure-all for surgical access issues.[5,6]

Our group created the following recommendations based upon our institutional experience to identify potential barriers that patients may encounter in a telehealth setting. These recommendations are meant to offer suggestions surrounding potential screening techniques to identify surgical patients requiring additional assistance or resources to optimize their access to telehealth. They should not be used to exclude any particular demographic or group from being seen via telehealth, thereby creating additional disparities for those requiring additional assistance or resources.