Impact of Telemedicine Modalities on Equitable Access to Ambulatory Gastroenterology Care

Abstract

The coronavirus disease 2019 (COVID-19) pandemic led to widespread adoption of telemedicine for ambulatory care, including videoconferencing (VV) and telephone (TV) visits. In light of this public health emergency (PHE), insurance carriers expanded their telemedicine coverage and the Centers for Medicare and Medicaid Services (CMS) established Waiver 1135 to extend telemedicine in Medicare to routine health care.1Centers for Medicare and Medicaid ServicesCOVID-19 emergency declaration blanket waivers for health care providers.https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdfDate: 2020Google Scholar A more recent Blanket Waiver also broadened reimbursement of telehealth services across additional health care fields.1Centers for Medicare and Medicaid ServicesCOVID-19 emergency declaration blanket waivers for health care providers.https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdfDate: 2020Google Scholar While telemedicine may increase access to care among certain patient populations, it can simultaneously create barriers to access among others.2Gilson S.F. Umscheid C.A. Laiteerapong N. Ossey G. Nunes K.J. Shah S.D. Growth of ambulatory virtual visits and differential use by patient sociodemographics at one urban academic medical center during the COVID-19 pandemic: retrospective analysis.JMIR Med Inform. 2020; 8e24544Crossref PubMed Scopus (13) Google Scholar,3Gray D.M. Joseph J.J. Olayiwola J.N. Strategies for digital care of vulnerable patients in a COVID-19 world—keeping in touch.JAMA Health Forum. 2020; 1e200734Crossref Google Scholar Consequently, telehealth modalities such as VV may create a digital divide and exacerbate existing health care disparities among vulnerable populations, including black, Latino, low socioeconomic status (SES), and older individuals.2Gilson S.F. Umscheid C.A. Laiteerapong N. Ossey G. Nunes K.J. Shah S.D. Growth of ambulatory virtual visits and differential use by patient sociodemographics at one urban academic medical center during the COVID-19 pandemic: retrospective analysis.JMIR Med Inform. 2020; 8e24544Crossref PubMed Scopus (13) Google Scholar,3Gray D.M. Joseph J.J. Olayiwola J.N. Strategies for digital care of vulnerable patients in a COVID-19 world—keeping in touch.JAMA Health Forum. 2020; 1e200734Crossref Google Scholar However, there is a paucity of literature evaluating the uptake of telemedicine through TV vs VV by race/ethnicity, insurance status, and age.2Gilson S.F. Umscheid C.A. Laiteerapong N. Ossey G. Nunes K.J. Shah S.D. Growth of ambulatory virtual visits and differential use by patient sociodemographics at one urban academic medical center during the COVID-19 pandemic: retrospective analysis.JMIR Med Inform. 2020; 8e24544Crossref PubMed Scopus (13) Google Scholar In addition, telehealth may affect subspeciality care differently than primary care. The expanded telemedicine services during this PHE provide a unique opportunity to systematically assess differential telehealth uptake patterns across diverse populations. Considering the role that telehealth will likely play in the future of health care delivery, it is critical that we understand the potential impact that this paradigm shift may have among vulnerable populations. Therefore, we aimed to examine the patient characteristics associated with completion of in-person (IPV) and telemedicine visits in a high-volume gastroenterology (GI) clinic. We analyzed all ambulatory GI clinic visits at a large, tertiary care center in Massachusetts from April 1 to April 15, 2020, with visits from the same period in 2019 serving as control. An electronic health care record (EHR) database query was conducted for all completed GI clinic visits, which were classified into IPV and telemedicine visits. All telemedicine visits were manually reviewed to further sub-classify into those completed as VV or TV visits. This was performed by reviewing the clinic and billing reports for each visit individually. Our institution required inclusion of a standardized statement in each clinic report and a supplementary billing code to identify the visit modality. Variables assessed included race/ethnicity, age, sex, median income by home address zip code, insurance (private, public, public with supplement), and type of patient appointment (new vs return visits) (Supplementary Methods). There were 6120 completed GI clinic visits during the study periods (3589 from 2019 and 2531 from 2020). All visits from 2019 were IPV; 9 visits from 2020 were IPV and were excluded. In total, 2522 telemedicine visits were completed (958 VV and 1564 TV). The mean age of all included patients was 52.0 ± 17.8 years, and 4060 (66.4%) were women. Overall, 4626 patients (75.7%) identified as white, 433 (7.09%) as black, 573 (9.38%) as Latino, and 200 (3.28%) as Asian. The average median income by zip code was $76,372.2 ± 26,577. All patients had health insurance coverage: 56.8% private, 20.0% public, and 23.2% public with private supplement. Comparing IPV from 2019 and all telemedicine visits (VV and TV) in 2020, there were no significant differences in mean age, racial/ethnic distribution, median income by zip code, insurance, or appointment type (new vs return). On univariate analyses, the VV cohort was significantly younger than the IPV group (46.0 ± 17.0 vs 53.1 ± 17.8 years; P < .0001), with fewer patients >60 years old (25.7% vs 39.8%; P < .0001). It also had a lower proportion of black (3.48% vs 7.02%; P < .0001) and Latino (3.48% vs 9.92%; P < .0001) patients, more private commercial insurance coverage (74.1% vs 54.6%; P = 0.0001), and higher income by zip code ($75,850 vs $72,292; P < .0001) compared with the IPV group. The percentage of new patient visits was also lower in VV vs IPV (22.6% vs 29.1%; P < .0001) (Table 1).Table 1Characteristics of All Outpatient Gastroenterology Clinic Visits From April 1 to May 15 in 2019 and 2020, n (%)20192020In-Person Visit (n = 3589)Video Visit (n = 958)P ValueaCompared with in-person visits in 2019.Telephone Visit (n = 1564)P ValueaCompared with in-person visits in 2019.P ValuebTelephone visit vs video visit.Age, y Mean ± SD53.1 ± 17.846.0 ± 17.0<0.000153.5 ± 17.60.414<0.0001 Groups<0.00010.046<0.0001<401069 (29.8)409 (42.7)416 (26.6)40–601092 (30.4)303 (31.6)480 (30.7)>601428 (39.8)246 (25.7)668 (42.7)Male1226 (34.2)323 (33.7)0.797502 (32.1)0.1490.400 Race/ethnicity<0.00010.0002<0.0001White2699 (76.1)830 (87.5)1097 (70.9)Black249 (7.02)33 (3.48)151 (9.76)Latino352 (9.92)33 (3.48)188 (12.2)Other247 (6.96)53 (5.58)111 (7.18)Median income by zip code<0.00010.016<0.0001 Median72,29275,85070,446 Quartiles<0.00010.1264th (>75th percentile)879 (24.5)290 (30.3)341 (21.8)3rd (50th-75th percentile)863 (24.1)251 (26.2)398 (25.5)2nd (25th-50th percentile)888 (24.7)236 (24.6)378 (24.2)1st (<25th percentile)959 (26.7)181 (18.9)447 (28.6)Insurance<0.00010.040<0.0001 Private Insurance1958 (54.6)710 (74.1)796 (50.9) Public Insurance760 (21.2)98 (10.2)366 (23.4) Public with private supplement869 (24.2)150 (15.7)402 (25.7)Appointment type<0.0001<0.0001<0.0001 New1044 (29.1)216 (22.6)142 (9.08) Return2545 (70.9)742 (77.5)1422 (90.9)a Compared with in-person visits in 2019.b Telephone visit vs video visit. Open table in a new tab On multivariable analysis, black (adjusted odds ratio [aOR] 0.56, 95% CI 0.38–0.82; P = 0.039) and Latino (aOR 0.43, 95% CI 0.29–0.63; P = 0.0009) patients, living in zip codes in the lowest quartile of income (aOR 0.72, 95% CI 0.58–0.90; P = 0.017), age >60 years (aOR 0.53, 95% CI 0.43–0.65; P < .0001), use of public insurance only (aOR 0.51, 95% CI 0.40–0.65; P < .0001) or public insurance with private supplement (aOR 0.64, 95% CI 0.51–0.80; P = 0.035), and new patient appointment (aOR 0.72, 95% CI 0.60–0.85; P = 0.0002) were independently associated with lower odds of completing VV compared to IPV (Supplementary Table 1). Compared with IPV, TV was associated with more patients aged >60 years (42.7% vs 39.8%; P < .046), higher proportions of black (9.76% vs 7.02%; P = 0.0002) and Latino (12.2% vs 9.92%; P = 0.0002) patients, and lower income by zip code ($70,466 vs $72,292; P = 0.016). The rates of private commercial insurance coverage (50.9% vs 54.6%; P = 0.04) and new patient visits (9.08% vs 29.1%; P < .0001) were also lower in the TV cohort compared with IPV (Table 1). On multivariable logistic regression, black (aOR 1.53, 95% CI 1.21–1.94; P = 0.016) and Latino (aOR 1.32, 95% CI 1.07–1.66; P = 0.034) patients independently correlated with higher odds of engaging in TV vs IPV, and new patient appointment (aOR 0.24, 95% CI 0.20–0.29; P < .0001) was a negative predictor (Supplementary Table 2). On sub-group analyses of only telemedicine patients in 2020, TV patients had higher mean age (53.5 ± 17.6 vs 46.0 ± 17.0 years; P < .0001) and were more likely to be black (9.8% vs 3.5%; P < .0001) and Latino (12.2% vs 3.5%; P < .0001) compared with VV patients (Figure 1A). Notably, more than 80% of black and Latino patients completed their telemedicine appointments by means of TV, compared with about half of white patients (Figure 1B). The average median income by zip code ($70,446 vs $75,850; P < .0001) and proportion of patients with exclusively private commercial insurance (50.9% vs 74.1%; P < .0001) or presenting for new consultation (9.1% vs 22.6%; P < .0001) were also significantly lower in the TV group (Table 1). In the adjusted multivariable model, black (aOR 2.95, 95% CI 1.94–4.48; P = 0.015) and Latino (aOR 3.12, 95% CI 2.07–4.71; P = 0.005) patients, lowest quartile of income by zip code (aOR 1.44, 95% CI 1.11–1.88; P = 0.054), age >60 years (aOR 2.05, 95% CI 1.61–2.63; P < .0001), public insurance only (aOR 1.96, 95% CI 1.49–2.56; P = 0.002), public insurance with supplement (aOR 1.62, 95% CI 1.24–2.11; P = 0.028), and new patient appointments (aOR 0.38, 95% CI 0.30–0.49; P < .001) were independent predictors for engaging in TV compared with VV (Supplementary Table 3). The COVID-19 pandemic has led to a rapid paradigm shift toward telehealth. Before this PHE, there was limited coverage for telemedicine practices, with only 0.1% of Medicare primary care visits being conducted through telehealth services before March 2020 compared with nearly 50% in April 2020.4Bosworth A. Ruhter J. Samson L. et al.Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services. Medicare beneficiary use of telehealth visits: early data from the start of COVID-19 pandemic.https://aspe.hhs.gov/pdf-report/medicare-beneficiary-use-telehealthDate: July 28, 2020Google Scholar Similar widespread adoption of telemedicine has been reported in subspecialty practices. While telehealth may increase access to ambulatory care, it may also create barriers for vulnerable populations and worsen existing health care disparities. In the present study of ambulatory visits at a high-volume GI clinic during the initial phase of the COVID-19 pandemic, we found that black and Latino patients, lower SES, noncommercial insurance coverage, and older age were independent risk factors for lower engagement in VV compared with TV or with IPV from 2019. Several potential barriers to telemedicine may contribute to the disparate uptake among various patient groups, including infrastructural or implementation factors and patient-related considerations. Access to electronic devices, availability of reliable internet connection, and usability of digital tools make up the former category, and the latter may include patient health and digital technology literacy, language preferences, educational level, cultural considerations, and personal attitudes.5Khoong E.C. Rivadeneira N.A. Hiatt R.A. Sarkar U. The use of technology for communicating with clinicians or seeking health information in a multilingual urban cohort: cross-sectional survey.J Med Internet Res. 2020; 22e16951Crossref PubMed Scopus (11) Google Scholar,6Veinot T.C. Mitchell H. Ancker J.S. Good intentions are not enough: how informatics interventions can worsen inequality.J Am Med Inform Assoc. 2018; 25: 1080-1088Crossref PubMed Scopus (122) Google Scholar These barriers may disproportionality affect underserved racial/ethnic groups, including black and Latino populations, individuals with decreased educational attainment or limited English proficiency (LEP), lower SES, and older age.5Khoong E.C. Rivadeneira N.A. Hiatt R.A. Sarkar U. The use of technology for communicating with clinicians or seeking health information in a multilingual urban cohort: cross-sectional survey.J Med Internet Res. 2020; 22e16951Crossref PubMed Scopus (11) Google Scholar,6Veinot T.C. Mitchell H. Ancker J.S. Good intentions are not enough: how informatics interventions can worsen inequality.J Am Med Inform Assoc. 2018; 25: 1080-1088Crossref PubMed Scopus (122) Google Scholar It is therefore crucial to understand that adoption of technology-based solutions such as telemedicine can widen these existing health care inequities.6Veinot T.C. Mitchell H. Ancker J.S. Good intentions are not enough: how informatics interventions can worsen inequality.J Am Med Inform Assoc. 2018; 25: 1080-1088Crossref PubMed Scopus (122) Google Scholar Previous studies have shown that black and Latino households have lower rates of home broadband internet access compared with white populations, although smartphone ownership is similar.7Perrin A. Turner E. Smartphones help blacks, Hispanics bridge some—but not all—digital gaps with whites. Pew Research Center.https://www.pewresearch.org/fact-tank/2019/08/20/smartphones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-with-whites/Date accessed: September 3, 2020Google Scholar Black and Latino patients also use smartphones to access health care information more often.7Perrin A. Turner E. Smartphones help blacks, Hispanics bridge some—but not all—digital gaps with whites. Pew Research Center.https://www.pewresearch.org/fact-tank/2019/08/20/smartphones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-with-whites/Date accessed: September 3, 2020Google Scholar One study conducted during the COVID-19 pandemic found that black patients reported higher odds of engaging in telehealth services such as secure messaging compared with white populations.8Campos-Castillo C. Anthony D. Racial and ethnic differences in self-reported telehealth use during the COVID-19 pandemic: a secondary analysis of a US survey of internet users from late March.J Am Med Inform Assoc. 2021; 28: 119-125Crossref PubMed Scopus (18) Google Scholar However, factors beyond smartphone accessibility may affect engagement with digital health tools among black and Latino communities. For example, ownership and usage of smartphones is nuanced by access to affordable WiFi, speed of internet service, or adequate data plans. It is imperative that these barriers be considered when offering telehealth options to ensure equitable access to care. In our study, Latino patients represented the second largest racial/ethnic population seen by our providers. In Massachusetts, approximately 9% of the population has LEP, with the majority speaking Spanish, and 41% of all Spanish speakers report LEP.9United States Census Bureau Census COVID-19 Impact Report: Massachusetts.https://covid19.census.gov/Google Scholar Individuals with LEP have been shown to be less likely to access their patient portals.10El-Toukhy S. Méndez A. Collins S. Pérez-Stable E.J. Barriers to patient portal access and use: evidence from the Health Information National Trends Survey.J Am Board Fam Med. 2020; 33: 953-968Crossref PubMed Scopus (5) Google Scholar The use of trained medical interpreters in LEP populations improves the quality of care and patient satisfaction,11Karliner L.S. Jacobs E.A. Chen A.H. Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature.Health Serv Res. 2007; 42: 727-754Crossref PubMed Scopus (736) Google Scholar and video/telephone medical interpretation is noninferior to in-person interpretation.12Joseph C. Garruba M. Melder A. Patient satisfaction of telephone or video interpreter services compared with in-person services: a systematic review.Aust Health Rev. 2018; 42: 168-177Crossref PubMed Scopus (18) Google Scholar While several 3-way telephone interpretation services are available that allow patients, providers, and medical interpreters to be on the same call, the use of medical interpreters in VV is often more challenging and costly, and many health care organizations have not integrated this technology into their telemedicine workflow. Our results may be explained, in part, by the higher likelihood of necessitating a medical interpreter in Latino populations and providers preferring TV for easier integration of interpreter services. Among black and Latino communities, a history of structural racism has led to medical mistrust and fears concerning the use of personal medical information, which may also affect the uptake of digital health tools.13Hann K.E.J. Freeman M. Fraser L. et al.Awareness, knowledge, perceptions, and attitudes toward genetic testing for cancer risk among ethnic minority groups: a systematic review.BMC Public Health. 2017; 17: 503Crossref PubMed Scopus (98) Google Scholar Moreover, health care tools are generally not designed for underserved racial/ethnic populations, including black and Latino groups.14Antonio M.G. Petrovskaya O. Lau F. Is research on patient portals attuned to health equity? A scoping review.J Am Med Inform Assoc. 2019; 26: 871-883Crossref PubMed Scopus (22) Google Scholar It is imperative that investments be made in infrastructures that allow for the development of telehealth options specifically designed to serve black, Latino, LEP, and low-literacy populations.14Antonio M.G. Petrovskaya O. Lau F. Is research on patient portals attuned to health equity? A scoping review.J Am Med Inform Assoc. 2019; 26: 871-883Crossref PubMed Scopus (22) Google Scholar This may include health care tools created in languages most predominantly spoken by local patient populations. Patient navigation has also been shown to help decrease health care disparities across multiple cancer screening initiatives and can potentially be leveraged to increase telehealth literacy.15Dickerson J.C. Ragavan M.V. Parikh D.A. Patel M.I. Healthcare delivery interventions to reduce cancer disparities worldwide.World J Clin Oncol. 2020; 11: 705-722Crossref PubMed Google Scholar Investment in patient navigation services to guide patients through the telehealth continuum may help instill trust in the technology, improve usability, and reduce health care disparities. Our results also found that patients from lower-income neighborhoods are more likely to engage in TV, independently from race/ethnicity, age, and visit types. Individuals with lower income level may have less technology adoption, including smartphones.16Anderson M. Kumar M. Digital divide persists even as lower-income Americans make gains in tech adoption. Pew Research Center.https://www.pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-even-as-lower-income-americans-make-gains-in-tech-adoption/Date accessed: December 19, 2020Google Scholar Even among low-income families with access to these technologies, they may worry about out-of-pocket expenses such as home broadband or smartphone data use charges.17Vogels E.A. Perrin A. Rainie L. Anderson M. 53% of Americans say the internet has been essential during the COVID-19 outbreak. Pew Research Center.https://www.pewresearch.org/internet/2020/04/30/53-of-americans-say-the-internet-has-been-essential-during-the-covid-19-outbreak/Date accessed: December 19, 2020Google Scholar Although our study was unable to specifically assess the impact of education level on telemedicine use on a patient level, because this information was not consistently recorded, the average educational attainment on a population level by zip codes generally parallels that of income. Moreover, close to half of individuals with a high school degree or less reported internet nonadoption,18Anderson M. Perrin A. Jiang J. Kumar M. 10% of Americans don’t use the internet. Who are they? Pew Research Center.https://www.pewresearch.org/fact-tank/2019/04/22/some-americans-dont-use-the-internet-who-are-they/Date accessed: December 19, 2020Google Scholar and individuals with less than vocational/some college education are less likely to access their EHR.10El-Toukhy S. Méndez A. Collins S. Pérez-Stable E.J. Barriers to patient portal access and use: evidence from the Health Information National Trends Survey.J Am Board Fam Med. 2020; 33: 953-968Crossref PubMed Scopus (5) Google Scholar With the increasing adoption of telehealth, institutions and providers should recognize the potential economic burden on and limited resources of patients with lower socioeconomic backgrounds. Some studies have shown that telehealth may help to overcome barriers to health care access for older adults, such as limited transportation and geographic isolation.19Batsis J.A. DiMilia P.R. Seo L.M. et al.Effectiveness of ambulatory telemedicine care in older adults: a systematic review.J Am Geriatr Soc. 2019; 67: 1737-1749Crossref PubMed Scopus (49) Google Scholar However, the present study, similar to some recent reports, found that older patients are more likely to complete TV than VV despite availability of both.20Schifeling C.H. Shanbhag P. Johnson A. et al.Disparities in video and telephone visits among older adults during the COVID-19 pandemic: cross-sectional analysis.JMIR Aging. 2020; 3e23176Crossref PubMed Scopus (25) Google Scholar,21Harris R.J. Downey L. Smith T.R. Cummings J.R.F. Felwick R. Gwiggner M. Life in lockdown: experiences of patients with IBD during COVID-19.BMJ Open Gastroenterol. 2020; 7e000541Crossref PubMed Scopus (7) Google Scholar This preference may represent patient-perceived challenges to VV use, including lack of technological confidence.22Hawley C.E. Genovese N. Owsiany M.T. et al.Rapid integration of home telehealth visits amidst COVID-19: what do older adults need to succeed?.J Am Geriatr Soc. 2020; 68: 2431-2439Crossref PubMed Scopus (19) Google Scholar Furthermore, adults >65 years old represent the largest group of internet nonusers.18Anderson M. Perrin A. Jiang J. Kumar M. 10% of Americans don’t use the internet. Who are they? Pew Research Center.https://www.pewresearch.org/fact-tank/2019/04/22/some-americans-dont-use-the-internet-who-are-they/Date accessed: December 19, 2020Google Scholar Despite these challenges, telehealth use in older adults may be increased through targeted interventions. In a pilot study of older patients who received telehealth patient navigation and a technological needs assessment, all 32 participants successfully completed VV.22Hawley C.E. Genovese N. Owsiany M.T. et al.Rapid integration of home telehealth visits amidst COVID-19: what do older adults need to succeed?.J Am Geriatr Soc. 2020; 68: 2431-2439Crossref PubMed Scopus (19) Google Scholar Given the increasing proportion of elderly patients, institutions and providers should ensure availability of various telehealth options and provide resources to navigate technological challenges. Before the COVID-19 pandemic, several studies demonstrated telemedicine to be an effective mode of care delivery in GI, including for services such as nutrition counseling.23Gastroenterology Lancet Hepatology Editorial: The potential of telemedicine in digestive diseases.Lancet Gastroenterol Hepatol. 2019; 4: 185Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar However, telemedicine uptake within GI continued to lag behind other medical subspecialties before 2020.23Gastroenterology Lancet Hepatology Editorial: The potential of telemedicine in digestive diseases.Lancet Gastroenterol Hepatol. 2019; 4: 185Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Among inflammatory bowel disease patients, data suggest that both TV and VV may be appropriate for routine follow-up care during remission and that patients prefer IPV during flares.21Harris R.J. Downey L. Smith T.R. Cummings J.R.F. Felwick R. Gwiggner M. Life in lockdown: experiences of patients with IBD during COVID-19.BMJ Open Gastroenterol. 2020; 7e000541Crossref PubMed Scopus (7) Google Scholar Studies of patients with chronic liver disease showed a predilection for use of VV over TV.24Guarino M. Cossiga V. Fiorentino A. Pontillo G. Morisco F. Use of telemedicine for chronic liver disease at a single care center during the COVID-19 pandemic: prospective observational study.J Med Internet Res. 2020; 22e20874Crossref PubMed Scopus (10) Google Scholar This may be partially due to the benefit of visual assessments in identifying clinical signs of decompensation. However, our study shows that VV use is lower among black and Latino patients, groups that are disproportionately affected by chronic liver disease. More research is needed to assess the impact of telehealth on long-term clinical outcomes in various chronic GI/hepatology conditions, and to identify strategies to increase adoption among vulnerable populations. In the present study, there were significantly lower proportions of new patient encounters with the use of telemedicine during the PHE. This may have resulted from patients deferring elective new appointments for chronic symptoms. Alternatively, telemedicine may be more acceptable to patients for established follow-up care rather than initial consultations. As such, telemedicine should be viewed as an adjunct to, rather than replacement of, IPV. CMS traditionally defined telemedicine as a face-to-face interaction that used combined audio-video technology.25Centers for Medicare and Medicaid ServicesTelehealth.https://www.cms.gov/Medicare/Medicare-General-Information/TelehealthGoogle Scholar Although this definition of telemedicine did not specifically include audio-only services, CMS expanded their coverage guidelines during the PHE to include TV. However, it remains unclear whether all telemedicine visit modalities will continue to be reimbursed after the current PHE. If coverage for telemedicine reverts to excluding TV, institutions and providers may be discouraged from offering audio-only options for telehealth. Our results suggest that if only VV is offered as a telemedicine option and barriers to VV use cannot be mitigated, underserved and vulnerable populations would be disproportionately affected. However, if equally reimbursed, telemedicine (both TV and VV) has the potential to improve equitable healthcare access beyond this PHE. The present analysis has several strengths. First, our hospital system has a standardized and validated methodology for collecting patients’ self-reported race/ethnicity at the time of registration. Second, all patient data for race/ethnicity, insurance type, and visit modality completed were manually reviewed to minimize misclassification. Finally, this study included data for nearly all patients with ambulatory encounters at our GI clinic during the study periods, thereby reducing potential selection bias. There are also several limitations. First, home address zip code was used as a surrogate marker for patient income because individual income data was not recorded in the EHR. Second, the study was limited to a single-site design at an academic tertiary medical care center in Massachusetts, a state with near universal health insurance coverage after its health care reform in 2006. This may limit our study’s generalizability to safety-net hospitals or community health centers primarily serving underserved racial/ethnic populations including black and Latino groups and uninsured/underinsured patients. However, any potential bias resulting from our cohort would be toward less disparate uptake of telemedicine modalities, given the available resources and health coverage. The significant disparity in VV vs TV utilization found in our population despite available resources and high insurance rates further supports the impact of other social factors on the uptake of different telehealth options beyond health coverage alone. Importantly, our results highlight the need for equal coverage and offerings across telehealth options to avoid disenfranchising already vulnerable populations. Such a need would be even more critical for safety-net and community centers serving a high proportion of underserved patients. We found that black and Latino patients, low SES, non–private commercial insurance, and older age independently predicted lower odds of engaging in VV compared with TV or IPV. Factors such as digital health literacy, resource availability, reliable internet access, and systemic mistrust by vulnerable populations should be considered when using telemedicine technology to decrease health care inequities. Health care stakeholders should ensure equal availability, coverage, and reimbursement across telehealth options to prevent discouraging certain modalities and potentially worsening health care disparities. Patients from vulnerable groups may need additional support, including needs/barriers assessments, culturally congruent patient navigators, and development of culturally/linguistically sensitive technology with high usability for older, black, Latino, low-SES, and LEP populations. Blanket adoption of technology in health care would not address population-specific barriers and could further widen existing health care disparities.