Promoting Telehealth Equity Through Strategies to Address Social Determinants of Health

Background: Due to the COVID-19 pandemic, health systems rapidly embraced telemedicine for a range of health services. Prior to COVID, approximately 15% of physicians offered telehealth services and less than 10% of patients utilized it. By Spring 2020, 85% of physicians and 46% of patients reported using telehealth, encouraged by federal and state emergency actions. However, without explicit efforts to ensure equity, broad reliance on telemedicine can perpetuate and increase disparities in health care access for vulnerable populations such as patients with Limited English Proficiency (LEP).

Methods: We leveraged an implementation sciences framework to improve telehealth equity for patient families whose preferred language was not English. Our project included 1) pre-intervention planning to define the problem, summarization of the organizational evidence-practice gap and involvement of stakeholders; 2) implementation of change interventions; and 3) post-implementation evaluation at quarterly intervals (Q1, Q2 and Q3).

Our project team assembled Health Information Technology (HIT) solutions to support redesigned clinical workflows that included universal screening for self-reported English proficiency and on-demand integrated video interpretation services. The package of interventions included decision supports to recommend language services utilization, an interpretation platform integrated with our video software, and analytic reports to monitor performance metrics.

Data were collected at baseline and for 9 months post-intervention defined as implementation of the HIT intervention package. We calculated a “Telemedicine Care Gap” by comparing the proportion of non-English-speaking telemedicine encounters to the proportion of non-English-speaking in-person encounters. We tracked the percentage of non-English-speaking patient telemedicine encounters with receipt of documented language services as well as the percentage of non-English-speaking patients with an activated patient portal, which is a prerequisite to conducting a telemedicine visit at our institution.

Results: Shortly after implementation of telemedicine throughout the health system, use of telemedicine favored English-speaking families. At baseline, our “Telemedicine Care Gap” was 2.9%. Overall, the introduction of integrated telemedicine interpretation services did not significantly increase adoption of telemedicine for non-English-speaking patients. However, significant progress was made in the uptake of integrated interpretation services for eligible encounters, which steadily increased from 0% at baseline to 23.9% by the end of Q3. Despite outreach efforts, the percentage of non-English-speaking patients with an active patient portal is much lower at 51.9% than patients who are English-speaking at 69.4%.

Conclusion: The promotion of telehealth equity requires deliberate attention and a commitment to iterative problem-solving by
healthcare organizations. Identifying populations at risk of poor access to telemedicine and monitoring
access disparities are both critical to overcoming societal and systems barriers to care. We plan to eliminate the patient portal requirement for telemedicine which disproportionately burdens non-English speaking patient families.