Technology-based structural racism and telehealth video usage among primary care patients

We tested whether technology-based structural racism mechanisms (digital redlining, path dependency, technical difficulties) were associated with lower telehealth video visit rates (versus audio-only; in-person visits excluded) among Black compared to White patients. Using structured and unstructured electronic health record data from 137,297 patients with completed telehealth visits over 26.5 months linked with broadband market data, we examined correlates of racial differences in video versus audio-only visits. Patient race had no significant unadjusted effect, but adjustment for individual and zip code level confounders revealed a 6% reduction in video visit rate ratios for Black patients, widening to 7–9% with interaction terms. For digital redlining, broadband market conditions were worse in areas with high neighborhood disadvantage and Black residential composition. However, broadband conditions were not associated with video visit rates. For path dependency, portal nonenrollment was more common among Black patients but had a stronger negative association with video visit rates among White patients. For technical difficulties, Black patients experienced more difficulties, which were associated with greater odds of a subsequent audio-only visit—particularly among Black patients. Findings suggest technology-based structural racism may operate through conditional and sequential mechanisms across telehealth stages. Health systems should monitor multilevel telehealth inequities across care stages.