At the patient level, the success of telehealth and its flexibility will depend on the patients’ baseline level of digital literacy, as well as consistent access to a computer, internet, data services, and time. These resources are not guaranteed with underserved populations and risk further alienating low-income patients. While access and use of technology, cellular phones, and wireless services seem ubiquitous particularly in urban areas, the Pew center estimates that up to 16 percent of Americans are not digitally literate, with this rate much higher among Black and Hispanic adults, and roughly a quarter of adults with household incomes below $30,000 annually don’t own a smartphone.⁴ Given that the poverty rates for Black and Hispanic Americans are more than double that of non-Hispanic whites, plus the education gap that already exists along income levels, telehealth services risk disproportionately benefiting a narrow demographic while hurting low-income patients, particularly from minority backgrounds.

Even setting aside the issue of social justice, it is unclear if telemedicine can offer patients high quality care. Physicians spend years in training learning how to hone their clinical gestalt by observing patients in person and differentiating between sick and healthy patients. For instance, on oral boards, physicians are rewarded points for asking in the first 30 seconds what the patient looks, feels, and smells like, in recognition of the key information that comes from assessing the patient in real time. In telemedicine, with the loss of the softer aspects of patient encounters such as body language and non-verbal cues, a key factor in the clinician’s history and assessment will be lost. Even if systems can find ways to collect information to address this deficit, the concern on how to complete the medical workup, with simple orders such as EKGs, imaging, or even administering crucial medications cannot be ignored. For telehealth systems to be effective, they must be limited to patients with low acuity, urgent care level complaints who don‘t need further workup, or be within a larger health care system that would allow patients quick transfer for in-person evaluations. In the current health ecosystem, where health literacy and health care access levels vary across geographic and income levels, it is unclear if telehealth systems will be useful for a majority of ED patients who will need further evaluation in person.

Lastly, while cost savings are often touted as a reason for expansion of telehealth programs, it is unclear if services would indeed lower costs. Theoretically, the expansion of telehealth programs could prevent unnecessary ED visits by freeing up scarce resources and allowing physicians to focus on critical illnesses, but it is also possible that telehealth could increase costs due to high costs of implementation and supplier-induced demand driving greater patient utilization. Successful implementation and maintenance of telemedicine depend on pre-existing technology infrastructure, including working IT systems, internet access, and staffing. The costs associated with necessary investments, maintenance, as well as hours of clinical time necessary (and possibly lost) in staff training and upkeep of standards of practice, may be significant. Furthermore, telehealth systems may simply lower the barrier for patients to seek care for visits and lead to greater inefficiencies. For instance, the rise of urgent care centers focusing on lower-acuity visits have not reduced health care costs or ED volumes. As many of our patients do not know how to appropriately self-triage or the appropriate time to seek care, telehealth systems may simply attract patients from urgent care visits, or even raise ED volumes by encouraging patients who would’ve never sought care at all to seek care, leading to a situation where patients are evaluated three times: in telehealth, the ED, and in their primary care offices, further overburdening an already strained system.