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:
- Understanding patients’ digital access and skills,
- Connecting patients with technical support,
- Integrating interpreters into remote/virtual visits for those with limited English proficiency, and
- 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: SF Digital Equity Playbook — This PDF includes concrete guidance on assessing digital access and skills. This playbook includes sample intake forms which could be used to screen patients’ digital needs on page 16.
- UCSF Center for Vulnerable Populations: Sample Questions to Screen Patient Digital Needs — This PDF includes questions health care systems can adapt and use to assess patients’ digital needs, including internet use, device access, broadband and data plan access, and confidence using technology.
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.
- National Digital Inclusion Alliance: COVID-19 Resources — This webpage has a list of COVID-19 resources, including low-cost broadband programs.
- Federal Communications Commission (FCC): Lifeline Program for Low-Income Consumers — This webpage has an overview of the FCC’s Lifeline Program, which supports smartphone ownership for low-income Americans.
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: Digital Learn Program — This webpage has a collection of online tutorials covering computer and internet basics.
- 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.
- UCSF Center for Vulnerable Populations: Resources for Telehealth at Safety Net Settings — The “For Patients” section of this webpage includes a PDF with Zoom visit instructions, as well as brief video tutorials for patients to download this app in English, Cantonese, Mandarin, Russian, Spanish, and Vietnamese on both Android phones and iPhones. Also, the section on “Considerations for using Remote Visits within Safety Net Healthcare Settings” has workflow considerations for providing care by telemedicine to patients with limited digital literacy.
- Journal of the American Medical Informatics Association: Portal Implementation Activities at Five Community Health Centers in California — This table, from a rapid ethnography of patient portal implementation at safety-net health centers in California shows a range of community health center activities to promote portal use among diverse patients.
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.
- 10 Tips for Caring for Immigrant and Limited English Proficiency Patients in the Age of COVID-19: This PDF, created by UCSF and other health care providers and researchers, outlines best practices for interpreter use when caring for immigrant and limited English proficiency patients via telemedicine during the pandemic.
- Health Information Technology, Evaluation, and Quality (HITEQ) Center: Telehealth Strategies and Resources for Serving Patients with Limited English Proficiency — This PDF provides near-term and longer term strategies to support limited English proficiency patients with telehealth, including the utilization of third-party services for real time interpretation and how to add interpreters on telehealth platforms.
- Mid-Atlantic Telehealth Resource Center: Telehealth Resources for COVID-19 Toolkit — The “Best Practices for Conducting a Telehealth Visit” section of this webpage has a subsection on “What Should I Do If My Patient/Client Needs An Interpreter?” with additional considerations and links to other resources on how to approach this issue.
- TDI: Coronavirus (COVID-19) Resources — This website has specific information about telehealth access for deaf and hard-of-hearing populations.
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.
- AARP: Using Telehealth to Improve Home-Based Care for Older Adults and Family Caregivers — This PDF white paper outlines the critical issues involved in supporting caregivers of older adults in telemedicine implementation.
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.
- Center for Care Innovations: Empathetic Communication in Phone and Video Visits — This webinar by an expert motivational interviewing trainer reviews best practices in empathy-based communication for virtual health care settings. Links to additional PDF resources with tips for empathetic communication when providing care by phone and video can be found online here.
- Cleveland Clinic: COVID-19 Response Digital Health Playbook — This PDF provides guidance from the Cleveland Clinic on the expansion of telemedicine and digital health platforms. It includes a section on “Empathy in Virtual Visits” on pages 43-47 with helpful tips on establishing patient relationships, expressing empathy, and conveying value and respect during virtual visits.
- UCLA Pediatric Psychology Consultation Liaison Service: COVID-19 Tips—Building Rapport with Youth and Adults via Telehealth – These two PDF resources provide tips on setting the scene, introducing telehealth to patients, building rapport, and keeping adult and youth patients engaged in telemedicine visits. While some information is specific to mental health, most is broadly applicable to telemedicine care. The PDF focused on adults also includes a section focused on group telemedicine sessions.
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.
- California Medical Association (CMA): Reopening a Medical Practice: Communicating with Your Patients and Others — This PDF is about communicating with patients and others about re-opening a medical practice during the COVID-19 pandemic. This guide has recommendations and templates to help health systems communicate with patients and other health care organizations about changes via email, social media, and signage. These templates can be modified to suit the needs of your practice.
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