This is a golden age for telemedicine, so says health providers and medical researchers as they attempt to provide high quality care during the COVID-19 pandemic. But medical professionals are also concerned that some of the most vulnerable older adults are being left out of this transition to telehealth-based care.

In a study out this week in JAMA Internal Medicine, researchers at the University of California San Francisco tried to pinpoint what percent of Medicare beneficiaries would have trouble navigating telemedicine, whether on the phone or on a computer. The researchers found that more than one third of people over 65 years old would have some degree of problems with telemedicine. These results have left the researchers calling for more intentional accommodations for older adults in telemedicine, especially as the pandemic stretches on and the likelihood of the medical system returning to normal anytime soon grows thinner.

“We have provisions in the Americans With Disabilities Act to make sure that you’ve got a ramp to get into your medical facility,” says study author Kenneth Lam, a clinical fellow in geriatrics at UCSF. “But now that you’ve made [service providers] all virtual, where are our ramps?” Making sure there are programs put in place to help people who are unable to navigate the telemedicine world without them is key.

Using 2018 National Health and Aging Trends data on Medicare users, the most up-to-date information available, Lam and his colleagues tried to quantify how many older adults would have difficulty accessing telemedicine. They analyzed telemedicine readiness under four scenarios: individual video visits; video visits with a social supporter (such as an adult child) who can help navigate the visit; telephone visits with some disability accommodations; or telephone visits with social supports. They found that 38 percent of people—13 million individuals—in their study population would be unable to do a video visit on their own.

Sixteen percent—5.5 million individuals—would have trouble completing even a telephone visit with social support. The majority of that second group presents with difficulty communicating and probable or possible dementia. The demographic that faces the most issues are older men with low incomes who live in remote areas. For these patients, he says, more planning is needed.

That population is normally served by a combination of other methods, including home visits, says Lam. When social distancing measures were first imposed back in March, getting them service wasn’t as urgent, because most people don’t need to see a health care provider multiple times a month.

But now that the pandemic has endured for five months, “This is where it’s going to start getting dicey,” Lam says. These older people are more likely to have chronic conditions that need regular checkups, and accompanying needs like medication refills. He’s concerned that they’re going to have difficulty getting the care they need now.

Of course, telemedicine doesn’t happen in a vacuum. For some of these patients, says Judd Hollander, a physician with Thomas Jefferson University’s Department of Emergency Medicine, doctors may be able to figure out a way to treat them. “There are always ways that you can facilitate things when you get creative,” he says. And telemedicine in one form or another can help many older adults.

But it can’t help everyone, says Lam, who remains concerned about the patients who will still fall through the cracks.