Telehealth provides convenient and—especially during COVID-19 surges—safe access to care that data show is appreciated across all U.S. population subgroups. But financial barriers, access to technology and technical skill levels need to be addressed upfront to ensure equitable delivery of telehealth services.
These keys to implementing innovative solutions with an equity lens were highlighted during a Telehealth Immersion Program webinar that was part of the AMA STEPS Forward™ Innovation Academy. During the webinar, Courtney Lyles, PhD, outlined best practices for implementing telehealth in an equitable, inclusive way focusing on both the impact to historically marginalized and minoritized patients and the clinicians and systems that care for them.
Lyles is co-founder of an effort at the University of California, San Francisco (UCSF) called Surmounting Obstacles for Low-Income and Vulnerable Populations Everyday Using Health Technology—SOLVE Health Tech for short.
“We have a lot of work to do to make sure that the platforms the private sector are offering are equitable and usable and that they really have an emphasis on equity upfront,” said Lyles, an associate professor at the UCSF division of general internal medicine at Zuckerberg San Francisco General Hospital.
“There was really high interest for using online services, among all subgroups, all types of populations in the United States prior to COVID, and I would say we haven't matched that potential and interest with what we've been doing today,” she added. “Everyone has been really realizing over the last year and a half that there is a pretty sizable proportion of the United States population who is not online.”
Those being left behind in the digital health space include older adults who may lack digital health skills and literacy and residents of rural communities who don’t have quality broadband access. Three main barriers to telehealth are shortages of video-enabled devices, high-speed data access and digital literacy.
For many patients with lower incomes, the smartphone may be their main source of internet access. On a limited data plan, they may run out of the capacity to have a quality telehealth visit.
“At the end of the month, it looks like a very different situation for them—in terms of whether or not you'd want to have a video visit with your doctor—than for individuals who have broadband,” Lyles said. “It creates a very different infrastructure for what you might be doing.”
Barriers also exist at the clinician and system level. These include:
- A lack of capacity linked to a need for more video-enabled devices.
- Digital platform issues such as security, privacy and ease of use.
- Workforce issues.
Lyles noted that many safety-net institutions—including her own—had capacity challenges because they could not put video-enabled devices in the hands of every clinician or at every workstation.
Telehealth platforms need to be easy to use for both clinicians and for patients, she said, adding that “the platforms themselves can become important drivers of uptake in use at the clinician and system level.”
“It's not as simple as turning something on and offering it to everybody,” she added. “Implementation issues like staffing models and finances are core to what we're trying to do and affect equity at a very fundamental level.”
Lyle offered these suggestions on how to equitably implement telehealth and other digital innovations:
- Ask patients about specific barriers and perceptions that may impede their ability to use telehealth.
- Emphasize that digital modalities are being offered as an extension rather than a replacement for in-person care.
- Screen patients for their digital literacy and access to video-enabled devices and high-speed internet.
- Provide ongoing technical support.
- Select vendors that support the use of interpreters and easy-to-launch visits.
- Develop workflows that support patients and reduce clinician burnout.
- Connect to existing community digital-inclusion infrastructure supported by libraries, government agencies and local organizations.
- Work to gain support for consideration of broadband as a utility or essential service.
“It's really clear that we need to design our implementation of new innovations for these patient populations from the outset,” Lyles said.
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