August 18, 2020 | More than one-third of U.S. adults over age 65 may face difficulties seeing their doctor via telemedicine, for reasons ranging from poor hearing and eyesight, dementia, to owning no internet-enabled devices. To build a more accessible telemedicine system will require taking steps to overcome both disability and the high prevalence of inexperience with technology in the senior population, particularly among those 85 and older, according to Kenneth Lam, M.D., a clinical fellow in geriatrics at the University of California, San Francisco (UCSF).
Lam and his UCSF colleagues presented their estimate on telemedicine unreadiness among older adults in a recent research letter published in JAMA Internal Medicine (DOI: 10.1001/jamainternmed.2020.2671). Finding were based on 2018 data on 4,525 patients from the federally funded National Health and Aging Trends Study, which annually interviews a representative sample of Medicare beneficiaries to assess how daily life changes as they age—including, Lam says, how they adapt to disease and disability.
Unreadiness was defined by functional measures of disability and inexperience with technology pulled from those interviews, specifically: difficulty hearing well enough to use a telephone (even with hearing aids), problems speaking or making oneself understood, possible or probable dementia, trouble watching television or reading a newspaper (even with glasses), owning no internet-enabled devices or being unaware of how to use them, and no use of email, texting, or internet in the past month.
About 38% of older adults (13 million) were not ready for video visits as of 2018, based primarily on inexperience with the technology, says Lam. Even with the availability of support (a child in the household or at least two individuals in their social network) who could theoretically help set up a video visit, 32% (10.8 million) were still unready. An estimated 20% of older patients were unready even for telephone visits due to difficulty hearing or communicating, or dementia, he adds.
Older age was “far and away” the biggest factor when it came to being cut off from care by the shift to video visits, he says. Telemedicine unreadiness was also, to varying degrees, more prevalent in patients who were men, unmarried, black, Hispanic, had less education, lower income, and poorer self-reported health. Altogether, 72% of adults who were 85 years or older met criteria for unreadiness.
“If you’re a medical director thinking telemedicine is going to be great for everyone, I would ask you to first look for who is falling through the cracks,” says Lam. “It is probably going to be these people.” Surveys of primary care physicians also indicate that older people are being disproportionately left behind by the telemedicine craze, and other groups have described their concerns about rural populations and those who are poor and unable to afford internet-enabled devices.
If anything, estimates of “the unready” are low because issues such as broadband connectivity and the ability to sustain a video visit, weren’t factored into the calculation, Lam says. Another new study, appearing in the Annals of Internal Medicine (DOI: 10.7326/M20-3026), reports a 30% decline in the number of visits (in-person, telephone and video) to VA outpatient facilities during the initial 10 weeks of the COVID-19 pandemic, he points out.
It’s understandable that when COVID-19 hit, and provider organizations went into survival mode, few noticed patients had gone “missing”—aka stopped showing up for appointments—let alone who they were, he adds. “That’s part of the reason we published this paper.” Another motivation was that Medicare payment parity between video and phone visits had not yet been established when the research was getting underway earlier this spring.
This evidence was important to show medical directors why the need to rethink the way they’re rolling out their telemedicine programs, says Lam. “We need to make sure accurate data on aging informs the implementation of telemedicine. It is too easy to have overly rosy or overly pessimistic views of what aging looks like.”
Many patients over the age of 65 are well equipped to get online and do a video visit, perhaps more than some people might expect, Lam continues. “But the reality is that when you start creeping above 85 the likelihood of doing telemedicine visits with no problems gets smaller and smaller. I don’t want us to… end up designing systems that don’t work for people who are older.”
Some elderly patients are understandably scared to leave their home, says Lam. He therefore recommends that providers do outreach with patients who repeatedly fail to show up for their appointments to investigate why. “I have friends who have done [this] by phone and patients are so thankful that someone is looking out for them.”
At UCSF, some students have volunteered to train seniors on how to get connected with their video visits, says Lam. Community-based senior services also tend to offer free digital literacy programs with which doctors may want to become familiar. “Just making those calls is important so [senior organizations] know there’s demand for help… if you don’t speak up, the problem doesn’t exist.”
Recent waivers to HIPAA regulations allow the use of everyday communication platforms such as FaceTime or Google Meet for virtual visits. Google Meet might be a good option for patients with hearing impairment because the platform has an option to turn on automatic speech recognition (ASR) captioning to show the text of conversations, continues Lam. Vision impairments are relatively manageable provided Medicare continues to equitably reimburse audio-only visits, he adds, though this is up for review after COVID-19 ends.
The impact of hearing loss on the life of older adults, including those who also suffer from cognitive impairment, is among the expertise of Carrie Nieman, M.D., MPH, and Esther Oh, M.D., Ph.D., core faculty members at the Cochlear Center for Hearing and Public Health, part of the Johns Hopkins Bloomberg School of Public Health. They just published a comprehensive Telemedicine Communication Checklist in the Annals of Internal Medicine (DOI: 10.7326/M20-1322) to help real-world clinicians effectively connect with patients regardless of their hearing status, health, or comfort with technology.
The checklist isn’t “rocket science,” says Nieman, but offers simple, helpful reminders about how to recognize and address adoption barriers—which need to be separated from ageist perceptions about the tech-savviness of older adults. “I have had many encounters with patients in their late 80s and 90s who have no problem joining a video visit. They’re able to navigate it well and we get what’s needed done without any difficulty.”
Like most providers, Drs. Nieman (an ear surgeon) and Oh (a geriatrician at the Johns Hopkins Memory and Alzheimer's Treatment Center) didn’t do any telemedicine prior to the COVID-19 pandemic. With the forced shift to virtual visits, they quickly recognized that telemedicine comes with all the same struggles as in-person visits in addition to some new concerns they never before had to think about, says Nieman. “How am I going to connect with older adults who may not own a computer or smartphone? What do their Wi-Fi package and data plans look like?”
Among recommendations on the checklist are to confirm patients' preference regarding visit format, says Nieman. If they favor a telephone visit, bear in mind that they may use a TracFone with limited minutes. The goal is to “at least have some sense that patients are ready and comfortable” for their encounter. A visit that includes video is best, but not always feasible, she adds.
To optimize the signal-to-noise ratio, Nieman continues, the checklist advises that providers ask patients to wear headphones or a headset and avoid relying on built-in microphones or confirm that they are wearing their hearing aids or amplification device. Headphones or a headset may still be needed if the t-coil in patients’ hearing aids doesn’t directly connect to their landline phone and may benefit patient-provider communication even for individuals who don’t have hearing loss by minimizing background noise.
As underscored in the journal article, about two-thirds of adults aged 70 years and older have clinically significant hearing loss. “Many people with mild to moderate hearing loss may not even think they have a problem,” she notes.
If all else fails, providers could have patients boost the volume using the speaker function of their telephone if they’re struggling to hear, Nieman says. “It’s by no means perfect and there are obvious limitations to it if they’re not in a quiet location or someplace private, so it really is a backup.”
For some older adults who have “very strong feelings about how they want to present themselves and their surroundings,” video visits can raise privacy concerns, says Nieman. But providers can and should still transmit video from their end whenever possible so patients can view their doctors’ face, read their lips, and observe their gestures. “It’s not the same as in person before COVID, but at least different cues can come from that [to aid comprehension].”
The checklist also offers a series of commonsense tips for clinicians during virtual visits—e.g., light your face evenly and from the front to minimize shadows, position the camera to focus on your face, and speak slowly and clearly. It also points out that a raised voice won’t assist understanding and could trigger noise reduction algorithms on a computer or smartphone that may cut out parts of what a provider is saying, she says.
Surprisingly underutilized during video-based encounters is ASR captioning, says Nieman, who sits on the board of directors for the Hearing Loss Association of America (HLAA). ASR captioning is usually behind paywalls and “not freely available but ideally should be,” reflecting a position espoused by the HLAA. “Institutions should ensure their available video conferencing programs include ASR captioning,” she adds. These include Zoom, frequently used by institutions when the regular in-house system isn’t working. “We should be using all available technology, and not just for people with hearing loss, because connection issues happen, and the sound may jump in and out a bit.”
When having trouble getting a point across, whether virtually or in face-to-face communication, simply repeating the same words over and over again won’t help, Nieman says. She suggests rephrasing since certain words may be understood better than others depending on a person’s specific hearing loss.
Another good rule of thumb is to use the teach-back technique throughout a telemedicine visit to confirm patients understand what is being explained to them, says Nieman, adding that it is an often-overlooked best practice for every type of patient visit. “It takes a little extra time but can be powerful to ensure that everybody has gotten what they need out of the visit.” At a minimum, she advises, be sure patients can accurately recite next steps at the end of the encounter.
In-person visits often end with patients being handed after-visit summaries. Telemedicine visits can instead be capped off with a summary of visit highlights that might alternatively be delivered via an online portal, a phone call from an office coordinator or the U.S. mail. The availability of a loved one or advocate can be a huge help in this arena, she adds.
When advocates are involved in a patient’s care, providers need to be thinking about how to give those care partners the private space and time during telemedicine visits to share their perspective as they normally would at a bricks-and-mortar clinic, Nieman says. That may be a bit tricky to navigate in a virtual setting, especially if the conversation needs to happen out of earshot of the patient.
The bottom line with the checklist, says Nieman, is that providers and patients reach agreement that communication matters and patients feel empowered to say, “I didn’t quite understand you and this is important to me.” Communication breakdowns are easy to ignore but better addressed sooner rather than later. Openly expressing that shared value and mission is a great way to start hardwiring good telemedicine communication practices between patients and everyone involved in their care, she says.