Central to effective and equitable implementation of telemedicine care is engaging a diverse patient population.

Some of the most pressing areas of consideration to ensure telemedicine does not worsen existing health disparities include:

  1. Understanding patients’ digital access and skills,
  2. Connecting patients with technical support,
  3. Integrating interpreters into remote/virtual visits for those with limited English proficiency, and
  4. Engaging patients’ caregivers and additional support services and teams.

Finally, it is critical that the interpersonal components of care, built upon a foundation of trust between patients and providers, are at the forefront of all patients’ virtual care experiences.

Screening Patients’ Digital Access and Skills

While smartphone ownership in the US continues to climb, the digital divide in the US persists for many. Groups with the lowest rates of home Internet use and smartphone ownership include low-income Americans, older adults, and those living in rural areas. In addition, more than a quarter of low-income individuals use their smartphone as their only online access point, without home internet, presenting challenges for sufficient data/bandwidth to connect to video visits. Finally, barriers related to digital literacy — the skills to be able to use email, apps, and other online tools — are common for many patients even if they have access to a device. Health care systems can screen patients’ digital access and skills, allowing for improved alignment between workflows and patient needs. Screening could also include patient preferences for communication (in-person, phone, text, email, etc.), to ensure support for digital modalities while simultaneously supporting patient preferences for their care.

San Francisco Digital Equity Initiative

Technical Support for Patients, Especially Those with Limited Digital Literacy

Broadband and Device Access. There are multiple avenues to support patients’ ability to access and use telemedicine services such as video visits. Multiple existing programs exist to help patients sign up for low-cost devices, data plans, and broadband.

Digital Skills Training. In addition, many groups can provide support for patients who need basic training to use a smartphone or computer, such as learning to download apps or conduct online searches. While resources vary within regions and cities, the public library system is often an important place to start for basic skills training, both nationally as well as through your local public library branches to determine offerings.

Public Library Association

  • TeleHealth Access for Seniors — This webpage has multiple guides for digital literacy basics, including translation of guides into multiple languages.

Technical Support for Patients. Finally, health care systems themselves can bolster the technical support they provide for patients. Specific questions about the platforms used within your setting are likely best handled by your organization, such as how to use the patient portal to get into a video visit or how-tos on using a specific video vendor platform.

Use of Interpreters and Non-English Instructions/Prompts in Technology

Patients with limited English proficiency may experience additional communication barriers to engaging with telemedicine. Not only do all how-to and FAQ materials about platforms and systems need to be provided in multiple languages, but the use of interpreters on phone and video visits also needs specific attention. In addition, the use of three-way calling and video medical interpretation is an extremely high priority for safety net health care systems to successfully launch their telehealth programs.

Leena Yin, Fiona Ng, and Elaine Khoong, MD, UCSF

Engaging Caregivers

There are additional considerations for telemedicine that will likely require new resources and knowledge. This includes the best ways to engage caregivers (such as family and friends, as well as case management or in-home support services) who may be integral for telemedicine uptake for certain patients. If patients want to involve others in assisting them with either the technical or the medical components of telemedicine visits, then more proactive caregiver engagement may be needed to expand telemedicine access.

Upholding Patient Trust

Building Trust During the Encounter. Considerations for patient trust must be woven into all efforts to support telemedicine. Previous research has clearly documented patients’ desires to maintain in-person relationships with providers and continued patient concerns about privacy and security related to telemedicine. Developing communication around how telemedicine will be used in conjunction with in-person care and as a way to increase support and connection for patients — as opposed to substitute or replace routine care — will be critical to any program. This is particularly important when caring for patient populations who experience justified mistrust of medical institutions and fears of surveillance because of historical and present abuses. As additional resources become available on engendering trust among specific communities, we will add them here.

  • Advisory Board: Tips to Improve Your “Webside Manner” — This website has an infographic on how to ensure telemedicine care remains patient-centered. Tips include ensuring a clear, well-lit screen view and presenting in the professional attire that works best for you. A visual ID badge may be reassuring especially for a new patient visit. Just as in in-person visits, refrain from eating or multitasking and maintain eye contact.

Advisory Board

Communicating Changing Models of Care. Special attention should be paid to communications regarding changes to protocols and models of care due to the COVID-19 pandemic. Clarity regarding office open hours, in-person availability, safety protocols, and new telemedicine offerings will be crucial to maintaining patient trust.



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