**2. COVID-19: background and description**

In December of 2019, a new coronavirus was identified in Wuhan, China. Based on symptom presentation, it was called SARS-CoV-2, and based on the date of identification was later called COVID-19. COCVID-19 spread rapidly. On January 30, 2020 the World Health Organization (WHO) officially declared COVID-19 a public health emergency of international concern, assigning it the status of a pandemic [2]. The first identified symptoms of COVID-19 included fever, cough, fatigue, dyspnea, sore throat, headache, conjunctivitis and gastrointestinal issues. Loss of the senses of smell and taste were soon added to the symptom list. More severe reactions included acute respiratory failure and death [10]. Disproportionate severe acute respiratory symptoms appeared in patients with cardiovascular comorbidities [19–21], which were eventually understood as a consequence of SARS-CoV-2 infecting the host using the angiotensin converting enzyme 2 (ACE2) receptor [22], which is expressed in several organs, including the lung, heart, kidney, and intestine, as well as endothelial cells [23]. It was found that SARS-CoV-2 can directly infect engineered human blood vessel organoids in vitro, and vascular derangements in COVID-19 might reflect endothelial cell involvement by the virus [22].

#### **2.1 COVID-19: epidemiology and treatment**

COVID-19 transmission appears to occur primarily from direct person to person contact, but infection can also occur through contact with contaminated environmental surfaces. Hand hygiene, wearing personal protective equipment (especially masks covering the nose and mouth) and maintaining social distance (of at least six feet) were soon recommended. COVID-19 testing rapidly evolved using nasal swab, tracheal aspirate or bronchoalveolar lavage samples [11]. A variety of interventions have been employed, but as of the time of this writing, there are no clinically approved vaccines or specific therapeutic drugs available for COVID-19, and quarantine is the only intervention that appears to be effective in decreasing the contagion rate [7–11]. COVID-19 is currently treated with available antiviral drugs, and in severe cases, supportive care including oxygen and mechanical ventilation [24, 25].

The genetic structure, pathogenic mechanism, and clinical characteristics of COVID-19 have been studied extensively [26, 27]. Vaccination against COVID-19 is widely believed to be the most promising path to resolution of the pandemic [28]. Having proven effective against similar coronaviruses SARS-CoV and MERS-CoV, monoclonal antibody vaccination is being pursued by a number of laboratories [29–33].

#### **2.2 COVID-19: psychological impact**

In addition to the physical threat posed by COVID-19, the pandemic has also had a significant worldwide psychological impact. During the initial stage of the CoViD-19 pandemic, acute psychological reactions were observed among the general population, healthcare workers, clinical populations, and other at risk groups [34–36]. Psychological triage has long been recognized as an essential care component before, during and after emergencies and disasters [12, 37]. Care delivery during the COVID-19 pandemic has been complicated by efforts to shelter in place and minimize personal interactions, leading to a rapid increase in the utilization of telehealth [12].

#### *COVID-19,Telehealth and Access to Care DOI: http://dx.doi.org/10.5772/intechopen.99300*

As the duration of the pandemic grew, increased autonomic arousal in response to fear of contagion soon translated to chronic stress, with consequent elevation in adrenaline and cortisol production, activation of the amygdala, and consequent suppression of activity in the pre-frontal lobe, impairing judgment and impulse control [38–41]. Stress resulting from the effects of the disease itself was multiplied by extended periods of social isolation, further complicated by what has been called an "infodemic:" around the clock news about the pandemic, distributed not only by news media, but also by social media. The widespread use of social media also provided a platform for unprecedented expression of racism, stigmatization, and xenophobia. The intense psychological impact of these combined factors has produced acute panic, anxiety, obsessive behaviors, hoarding, paranoia, and depression, and post-traumatic stress disorder (PTSD) [42].

Populations especially at risk for chronic stress related to COVID-19 include frontline healthcare workers who are at higher risk than other for contracting the disease, and are prone to burnout, anxiety, fear of transmitting infection, feelings of incompatibility, depression, increased substance-dependence, and PTSD. Along with psychiatric patients and marginalized communities, children isolated by school closures and parents responsible for additional child care during school hours, as well as assisting children with distance learning have also been identified as at-risk populations for chronic stress. The psychosocial needs of older adults have been significantly affected by the pandemic [42].

### **2.3 COVID-19 and older adults**

Older adults have been identified as a high risk population for severe or fatal responses to COVID-19 [43, 44]. Older adults demonstrate higher peaks of viral load in response to COVID-19, and are in the highest risk group for comorbidities including hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease, all of which demonstrate more severe reactions to COVID-19 and higher rates of fatality [3–6]. Increasing the risks associated with COVID-19 for older adults, many patients with hypertension, diabetes, and chronic kidney disease are prescribed medications containing angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers. These medications upregulate the ACE-2 receptor, which (as discussed above) is the specific receptor used by the SARS-CoV-2 virus to enter host cells [3, 22, 23].

### **3. COVID-19 and telehealth**

The unprecedented social, economic and healthcare challenges presented by COVID-19 include the significant strain on medical center resources, and the need to deliver healthcare at a distance. Telemedicine is a growing methodology that makes possible timely healthcare delivery while minimizing exposure to protect medical practitioners and patients. The combination of these factors quickly led to the rapid adoption of telehealth during the COVID-19 pandemic [45]. Following system-wide expansion of virtual urgent care staff at a large health system at the epicenter of the COVID-19 outbreak in the United States, in a six week period between March 2nd and April 14th 2020 telemedicine visits for urgent healthcare delivery increased 683 percent. The majority of urgent care visits shifted to telemedicine (56.2%), and the utilization of telemedicine was found to be highest among patients 20 to 44 years of age [46]. U.S. healthcare organizations report consistent expansion of telehealth adoption during the 3 phases of the U.S.

COVID-19 pandemic: (1) stay-at-home outpatient care, (2) initial COVID-19 hospital surge, and (3) post-pandemic recovery [47].

A retrospective observational cohort study found an 8729 percent increase in telehealth visit utilization between March 4 and March 31, 2020 during the COVID-19 pandemic compared to the same period the previous year (2019), with patients reporting higher satisfaction for telehealth visits than in-person visits. The authors of the study concluded that patient satisfaction with telemedicine is high and is not a barrier toward a paradigm shift away from traditional in-person clinic visits [48]. A literature review of 35 research studies published from 2019 to May 2020 demonstrated the effectiveness of telemedicine as a healthcare delivery platform. The authors of the literature review concluded that the effectiveness of virtual healthcare delivery suggests increased integration of digital technologies into healthcare in the near future [49].

#### **3.1 Disparities in IT utilization**

Significant disparities in IT utilization have long been associated with numerous variables, including ethnicity, age, and socioeconomic status (SES) [15, 17]. People with intellectual and developmental disabilities also utilize IT at a significantly lower rate than the general population [50], despite organized efforts to engage young adults with intellectual disability with social media and other IT [51]. Disparities in IT utilization and access have been described as the digital divide [52], digital inequality [53, 54], and digital diversity [55].

In addition to variables including ethnicity, disability, and SES, everyone is affected by the process of aging. In the United States, the number of adults over the age of 65 is expected to more than double from 46.5 million today to over 98 million (nearly 25% of the population) by the year 2060 [56, 57]. People over the age of 65 utilize health care at a significantly higher rate than members of younger age cohorts: 136% of the under 65 group's use of Emergency Department admissions, 263% for inpatient discharges, and 241% for outpatient office visits [58]. Median health care costs for people over the age of 65 are 167% the costs for people 64 and younger [59]. Although older adults' IT use has increased during the last twenty years, it continues to trail behind that of younger age cohorts by at least 20% [15–17], as shown in **Table 1**.

The current disparity in IT utilization between age groups remains consistent with that reported over a decade ago by the U.S. Census Bureau and Bureau of Labor Statistics [15, 18, 55, 60, 61].

#### **3.2 Default utilization of IT by insurers: potential barriers to care**

Paradoxically, in the face of a substantial and growing body of research data demonstrate disparities in IT utilization between groups associated with numerous variables including age, SES, ethnicity, disability, and educational experience [62],


**Table 1.** *IT access and utilization by age: Data from U.S. Census Bureau, 2016.*

#### *COVID-19,Telehealth and Access to Care DOI: http://dx.doi.org/10.5772/intechopen.99300*

over the past decade Medicare and private insurers have increasingly defaulted to the use of IT (websites, MyChart, text messaging) for communication with patients [63–65]. Similarly, hospitals, regional health centers, university teaching hospitals, and local medical clinics have done so [66, 67], in the absence of any data indicating that the populations they serve have fluency with IT [18].

Based on research data demonstrating disparities in IT utilization [15–18, 50–54], the default use of IT for communication with all patients may create a barrier to care for some patient populations. The potential consequence is that patient populations most in need of health care (including older adults) will find it most difficult to access [18, 55, 60, 61]. For older adults, CMS tracks potential access to care issues including economic disparity [68], but it has not addressed IT fluency among older adults [15–18, 55, 60, 61, 69].
