OPINION
published: 26 October 2020
doi: 10.3389/fpubh.2020.601595
Telemedicine in Long-Term Care
Facilities During and Beyond
COVID-19: Challenges Caused by the
Digital Divide
Alexander Seifert 1,2*, John A. Batsis 3 and Anthony C. Smith 4,5,6
1Center for Gerontology, University of Zurich, Zurich, Switzerland, 2 School of Social Work, Institute for Integration and
Participation, University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland, 3Division of Geriatric
Medicine, Department of Nutrition, Center for Aging & Health, Gillings School of Global Public Health, University of North
Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States, 4Centre for Online Health, The University of
Queensland, Brisbane, QLD, Australia, 5Centre for Health Services Research, The University of Queensland, Brisbane, QLD,
Australia, 6Centre for Innovative Technology, University of Southern Denmark, Odense, Denmark
Keywords: older adults, telehealth, COVID-19, nursing care, telemedicine, long-term care
BACKGROUND
Edited by: The COVID-19 pandemic has especially limited older adults from engaging in personal contact
Sonu Bhaskar, with others, as they have been classified as a high-risk population (1, 2). Increasing evidence shows
NSW Health Statewide
that COVID-19 has taken a particularly heavy toll on older adults in long-term care facilities
Biobank, Australia
(LTCFs) (3). Older residents of LTCFs (e.g., nursing homes, retirement homes) often have daily
Reviewed by:
care needs and are at especially high risk of COVID-19 due to the existence of multiple medical
Alma Nurtazina,
comorbidities and pre-existing conditions (4). As such, measures have often been put in place
Semey State Medical
University, Kazakhstan where such patients must shelter in place, maintain physical distancing from others during the
pandemic and be subject to quarantine if they need to leave the facility for medical care. The context
*Correspondence:
Alexander Seifert of living in LTCF means that older adults may be subject to even more protective measures that are
alexander.seifert@fhnw.ch administratively mandated, more so than the general population, including preventing their loved
ones from visiting.
Specialty section: Telemedicine (also referred to as telehealth) has been recently shown to play an important role
This article was submitted to in distance-based treatment during this pandemic (5–8), despite the lack of quality, evidence-based
Digital Public Health, trials that exist (9). Telemedical solutions are often feasible and acceptable in delivering care to older
a section of the journal adults in LTCFs, even in those with sensory impairments such as hearing or visual loss (9). However,
Frontiers in Public Health
older adults are less likely than younger people to be able to take advantage of the opportunities
Received: 01 September 2020 enabled by modern information and communication technology (ICT) or telemedicine (10–14).
Accepted: 05 October 2020 Older adults living in LTCFs often (a) opt not to use the internet, (b) cannot afford internet access
Published: 26 October 2020
or ICT devices, (c) lack technical solutions with which to use telemedicine to connect virtually
Citation: with doctors or other health professionals, (d) have physical or cognitive limitations that may limit
Seifert A, Batsis JA and Smith AC possible telemedicine use or prevent them from using telemedicine at all without assistance, and (e)
(2020) Telemedicine in Long-Term
lack the skills to use ICT or telemedicine even if they do have access (9, 11, 15–18). Furthermore,
Care Facilities During and Beyond
COVID-19: Challenges Caused by the the institutional may prevent the individual use of telemedicine; for example, individual use may
Digital Divide. depend on internet availability, ICT access, and telemedicine tools/software at a given facility.
Front. Public Health 8:601595. This article will outline and discuss the problems in this field and make recommendations for
doi: 10.3389/fpubh.2020.601595 future discussion.
Frontiers in Public Health | www.frontiersin.org 1 October 2020 | Volume 8 | Article 601595
Seifert et al. Telemedicine in Long-Term Care Facilities
ICT USE IN LONG-TERM CARE FACILITIES is not provided by every LTCF; however, Switzerland’s ICT
infrastructure and internet use of people aged 65 years and
While modern ICT use (such as the use of the internet, older are more equipped than other countries where individual
smartphones, and tablets) in healthy older adults has increased residents need to pay for such services (33). Nevertheless,
precipitously in recent years, the situation differs for those with the results also show the degree of missing infrastructure
multiple medical comorbidities and functional impairments and for widespread telemedicine solutions within LTCFs (e.g.,
those with advanced age who are the primary residents of free internet access or mobile devices to use telemedicine
LTCFs (19–23). Seifert and Cotten (19) showed in their 2019 apps privately).
study that 21% of retirement home residents used the internet, The above-mentioned study (32) also asked the LTCF
13% used a smartphone, and 5% used a tablet. Compared with managers if they already used telemedicine (teleconsultation
non-users, internet users within LTCFs were more likely to of doctors and/or health practitioners) within their facilities;
be younger, healthier, and more functionally unimpaired (23, only 3.9% of all 466 participating LTCFs used telemedicine.
24). The residents in this study (19) were also asked about When asked if the managers evaluated telemedicine as useful
their difficulties with modern technology with the statement, for their facilities, 21.7% found it “rather useful” and 14.5%
“Do you have difficulty operating modern technical devices?” found it “very useful”; the rest (63.8%) found it rather not
Respondents rated the statement based on a 5-point Likert scale so useful or very non-useful. For this study, the authors
format (1 = “No, not at all” to 5 = “Yes, very much”). Among did not have information related to the barriers or attitudes
the respondents, 6.3% answered “No, not at all,” 10.1% answered toward telemedicine; nevertheless, the authors demonstrated that
“Not very much,” 26.9% answered “Partly,” 34.3% answered “Yes, telemedicine solutions were available in the minority among
somewhat,” and 22.5% answered “Yes, very much.” Schlomann LTCFs in Switzerland, with few managers (36.2%) finding
et al. (22) recently conducted a study using data from North- telemedicine useful. Only 11.1% of the managers in this study
Rhine–Westphalia, Germany, involving people aged 80 years and (32) said they involved their residents in decision-making
older living in private households and LTCFs. The researchers about purchasing new technology for the institution. This
found that fewer than 3% of people in LTCFs used internet- corroborates the assumption that LTCFs are contextual settings
connected ICT devices. ICT-device adoption was associated with with potential elements of a self-contained institution (34) with
the living environment and individual characteristics, including modest participation of residents in the process of initiating new
functional health, chronological age, education, and technology technology solutions such as telemedicine.
interest (22). These results indicate that individual characteristics
and the living environment are both related to technology usage
among the oldest age groups (21, 24). RECOMMENDATIONS
Based on the presented data, we recommend (1) education
TELEMEDICINE AND DIGITAL and training of staff and residents, (2) a solid telemedicine
INFRASTRUCTURE IN LONG-TERM CARE infrastructure, and (3) a system that promotes and integrates
telemedicine in daily workflows within LTCFs.
Whether LTCF residents have access to using telemedicine First, given the rapid expansion of telemedicine, it is
is highly dependent on an underlying telemedicine paramount to educate both LTCF staff and residents about
infrastructure (e.g., internet availability, ICT access, telemedicine how to use telemedicine, which could be useful in their daily
tools/software, ICT skills). The availability of modern ICT is lives during and beyond the current pandemic. The LTCF staffs
limited within LTCFs, thus highlighting a significant deficiency are the coordinators and attend consultations with the patient;
in ICT infrastructure (25, 26). This deficit, in part, also includes therefore, they are very important to include in all learning
a lack of technical skills among LTCF staff and potentially settings of telemedicine. It would be helpful to offer support
their apprehension of using technology within care facilities and training to these people to increase their digital literacy
(27, 28), all inhibiting opportunities for telemedicine. The skills. Establishing a workforce within LTCF environments with
ongoing COVID-19 pandemic has prompted discussions of telemedicine competencies is important; this has not yet been
the positive outcomes of telemedicine for residents of LTCFs anchored in education or evidence-based training (35). Learning
(29, 30). However, these discussions have also created awareness new technical skills can even foster a certain sense of competence
of the existing limitations of these facilities’ current telemedicine and autonomy (36) within older adults that can encourage
infrastructures (11, 31). the efficient use of other digital interventions. The special
Based on a Swiss representative national study (32) among learning needs and cognitive resources of older adults need to
managers of 466 LTCFs conducted in winter 2019, 14.6% of the be considered in these educational services, with attention paid
LTCFs in Switzerland did not provide internet access to their to things such as the tempo of the learning session and the
residents. The survey was carried out as a standardized online technological skill background of the older participants (37).
survey of inpatient old-age homes throughout Switzerland. The These learning tools can be generally provided by LTCFs with the
respective managers were interviewed (32). Of the institutions help of technical and management experts in telemedicine.
that provided internet access, 66.3% offered residents an internet Second, besides the user side of telemedicine, the results
connection for free. The results show that basic internet access from Switzerland reveal that LTCFs before, during, and probably
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Seifert et al. Telemedicine in Long-Term Care Facilities
beyond the COVID-19 pandemic have low levels of telemedicine connecting with friends and relatives. The pandemic has fostered
infrastructure. This situation has pointed out that although the potential of those social tools for digital connections within
telemedicine solutions would be ideal for medical treatments LTCFs (43), so why not also use those tools to help residents
and consultations during physical distancing; however LTCFs are connect with the world beyond LTCFs? Current projects (44)
not yet ready for this task. It is critical to motivate developers use Skype, for example, for telemedicine under control for
and professional users (e.g., researchers, medical practitioners, privacy and security requirements. However, also potential socio-
and companies within the health sector) of telemedicine to economic inequalities in the use of telemedicine (45–47) or
take a closer look at how different designs and content can be technology in general among older adults should be taken into
tailored in a way that encourages trust and facilitates use among account (15, 19, 33). Telemedicine enables cost savings (e.g., no
older people and LTCF staff. All stakeholders are encouraged transfer to the doctors’ office), but also causes additional costs
to address these challenges and collaborate to promote the for older people (economical cost and acquired technical skills).
safe and evidence-based use of telemedicine during the current Furthermore, potential barriers for digital excluded groups, such
pandemic and future outbreaks (38, 39). The integration of as older adults in LTCF, should be discussed and existing policy
end-users into workflows and the design process increases opinions should be considered when integrating telemedicine in
the usage and effectiveness of interventions, particularly as a everyday practice (48).
partner in community-based participatory research in advance
of developing a new digital intervention (40, 41). During any CONCLUSIONS
intervention, a real-time, support hotline, and contact partner
can be used to assist the older participants when needed. The current pandemic highlights the challenges of providing
Third, telemedicine should not be system only used during LTCF residents with timely medical treatment during physical
a pandemic, but rather a routine method of providing services distancing and the potential of routinely using telemedicine in
in our health system (31, 38, 42), and especially in LTCFs. clinical care. Although the benefits of telemedicine have been
We propose the following hurdles need to be overcome: (a) widely reported, its routine use and its systematic evaluation
stable and high-performance internet access in all areas (cities for residents in LTCFs has been relatively limited. Integrating
or rural areas), (b) computers or mobile devices and software telemedicine is reliant on many complex and interrelated factors
tools capable of engaging in telemedicine, (c) technical and which must be addressed for successful adoption. Aside from
software skills and skills in managing telemedicine processes the technical requirements, it is just as important to ensure that
among all stakeholders (e.g., residents, LTCF staff, doctors, a supportive infrastructure are in place to support telemedicine
medical staff), (d) willingness of all stakeholders to practice services, systems are interoperable between service providers
telemedicine, (e) interoperable communication systems and and recipients of care, staff are trained in its use, procedures
systems of exchange of health-related information and data, (f) are in place to ensure the safe and effective delivery of care,
availability of telemedicine support for staff or time for staff to responsibilities for telemedicine care are clearly articulated, and
do this within the daily business of care duties, (g) guidelines funding is available to support the effort. The current pandemic
regarding the appropriate use of telemedicine, and (h) clinical has reminded us that innovative models of care that include
and economical evidence from longitudinal studies within LTCF telemedicine can be helpful, but organizational readiness to adopt
to support the effectiveness of the telemedicine services. Also, telemedicine needs urgent attention.
user focused studies are needed to better understand practical
experiences from the perspective of resident and staff; and factors AUTHOR CONTRIBUTIONS
influencing uptake and acceptance in the health system.
Telehealth can be considered a “disruptive innovation All authors provided substantial contributions to this article from
process” by implying changing the way we provide service conception to final approval and share the same opinion.
delivery. The importance of managing this change process
well cannot be overstated by including all of the stakeholders FUNDING
associated with successful telehealth are accounted for. One way
to further the “digital connection during physical distancing” JB was supported in part by the National Institute on Aging
idea would be to not limit communication applications such as of the National Institutes of Health under Award Number
chatting or video-calling to doctors, but to use such tools also for K23AG051681 and R01-AG067416.
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15:e0237585. doi: 10.1371/journal.pone.0237585 distribution or reproduction in other forums is permitted, provided the original
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