Centering Health Equity in Telemedicine

1. Make Health and Racial/Ethnic Equity in Telemedicine a Strategic Priority

A key step is to name health equity and racial/ethnic equity²⁷ as strategic priorities of the health care system, including equity in the implementation, delivery, and assessment of telemedicine services. This requires action in at least 3 separate domains.

First, there is a need for committed leaders across the institution who dedicate time, effort, and resources to building organizational competencies and specific initiatives prioritizing racial/ethnic health equity. This is a fundamental step that integrates equity in the entire organizational structure and in all clinical operations, including telemedicine, rather than as a siloed effort without ties to the everyday work and culture of the institution. Committed leadership must apply scrutiny and have the power to change policies, systems, data-gathering infrastructure, and culture that enable inequities to occur.

Second, also at the strategic priority level of the organization, we need data to robustly understand the current state of telemedicine disparities. There are 3 specific sub-activities that underscore the importance of data infrastructure for advancing equity at an institutional level:

A. High-quality data to identify priority patient subgroups. Specific to telemedicine as an exemplar, deep exploration of data on racial/ethnic, linguistic, and socioeconomic status (eg, insurance type) disparities in telemedicine uptake is needed on a routine basis. While many health care systems have improved their data collection and reporting on patient self-reported race/ethnicity and preferred language within the electronic health record (EHR), this needs to be a universal standard for every health care system in the country, with mandated review of performance to assess access gaps and intervene accordingly. For example, recent Transformed Medicaid Statistical Information System (T-MSIS) Data shows that 25 states have “high concern” or “unusable” data on patients’ race and ethnicity—such as high rates of missing data or large discrepancies between health care system and US Census data on race/ethnicity.²⁸

B. Linkage of patient-reported data to population-level data to broaden understanding of disparities. These EHR data can also be linked to gain further insights on disparities or structural barriers to care, such as using patient addresses and zip codes to gain more insight into the neighborhood-level influences on health outcomes²⁹ and creating equity-focused maps. Specific to telemedicine, we know that broadband access at the census tract level is associated with uptake of digital health tools.³⁰

C. Data to target interventions. Once the right types of data are routinely collected, we must then use these data to drive organizational interventions, such as targeting programs to improve health outcomes overall and within specific priority subgroups. In other words, organizations must be clear about measurement targeting overall improvements in outcomes as well as metric strategies that decrease disparities in that outcome. For example, dashboards or quality improvement indicators that look at overall increases in telemedicine utilization may mask widening gaps by patient race/ethnicity, neighborhood, or other factors.^31,32 Therefore, we may need additional or new metrics that target disparities reduction explicitly.

Third, telemedicine leaders must also advocate for local, state, and governmental policies regarding telemedicine access, especially since Medicare and Medicaid telemedicine reimbursement policies will be the key determinant to long-term telemedicine access via telephone and/or video visits.³³ This advocacy involves activities such as: providing statements on upcoming bills at the state or federal level (independently or via professional organizations); publicizing equity data in multiple venues (eg, press articles, social media) for wider public knowledge about real-world implementation and barriers; and clarifying the business case for health equity. For example, because safety-net institutions serving more diverse patient populations have had much lower video visit uptake during the pandemic (despite their extensive implementation work in this space), reimbursement policies post-COVID could hinder progress toward equity if they do not support these sites’ current rollout of telephone visits.²²

2. Build Structures and Processes to Support Telemedicine Equity

The second domain of this health equity framework calls for structures and processes to support health equity work. At the most fundamental level, this means ensuring more direct input from marginalized patients—including Black patients, Indigenous patients, patients of color, and low-income patients—about their needs, preferences, and barriers to care, and then empowering health care leaders and frontline staff to develop potential solutions to meet those needs.^34-36 While these processes may vary in each health care delivery system, there are core elements that will likely be fruitful for telemedicine implementation—now and into the future. For example, sites will need ways to collect input from patients about telemedicine uptake and experiences, such as surveys and screening tools, patient advisory boards, and focus groups. Both utilization data on telemedicine from the EHR as well as experiential data from patients via surveys and group discussions should also be intentionally disaggregated by key patient groups.

Moreover, the structures and processes for telemedicine must provide and/or facilitate the opportunity for all patients to engage with digital care modalities. First, health care systems must have dedicated ways of screening patients for digital device availability, broadband and data plan access, and patient skills and/or confidence in using technology for health care. These are social needs, akin to the many other social needs screenings already happening within health care systems, and we cannot overlook these critical aspects of patients’ everyday lives. Furthermore, for any new digital service or feature offered within a health care system, we must stand up the appropriate technical support within health care settings. This goes beyond call centers with limited hours or capabilities, but rather requires broader education and awareness-building surrounding available digital features and full-service assistance (including in-person support options) for sign-up and registration, review of features and tasks, password and device support, and other major barriers. Finally, we must commit to continually evaluating patients’ expectations, experiences, and satisfaction with telemedicine, both overall and via unique patient care pathways such as medical interpreters. We cannot eliminate disparities in telemedicine use and quality without understanding and being responsive to patient preferences and needs in these robust ways.

3. Deploy Telemedicine Strategies to Address Determinants of Health

The third domain of the framework focuses on implementing specific strategies and programs to reach an organization’s health equity priorities. These strategies cannot be overly narrow, as the intersection of multiple spheres of exclusion (eg, race/ethnicity, poverty, disability status) requires a broad view of multiple determinants of health, including social factors outside of the walls of the health care delivery system.

Thus, specific to telemedicine, we must first have a strategy for structural barriers—particularly device ownership and the availability and affordability of broadband and data plans—as key determinants of whether and how marginalized groups will be able to use telemedicine in everyday life. These structural barriers persist in urban, suburban, and rural communities throughout the United States and impact older adults and low-income Americans the most.^25,37,38 Therefore, health care systems must develop new relationships and referral programs to tap into local and national programs to directly provide patients with device and Internet access, such as the Lifeline program,³⁹ as well as community programs for digital literacy support, such as public libraries and community-based organizations offering long-standing digital inclusion programs.^19,40-43 In addition, as stated above, health care systems should join other social service sectors in advocacy for improvements and meaningful investments in domains such as broadband access, low-cost device ownership, and digital skill-building programs, including the ease of accessing these programs.

Finally, health equity work within health care settings can look for opportunities to address multiple social determinants of health across their initiatives. For example, programs such as food banks within clinics or medical-legal partnerships may offer additional opportunities to further understanding of the digital divide among patients. Thus, a holistic view on social determinants of health combined with ease of social needs screening and referrals accompanying any interaction with the health care system can further strengthen our health equity approaches.

4. Eliminate Institutional Racism in Telemedicine Provision

In the next pillar of the health equity framework, we must address other institutional practices, such as hiring and promotion practices and equitable investment in fundamental services. For example, hiring can be used to intentionally transform the health care workforce to reflect the diversity of the patients served. Diverse clinicians/providers and staff have been shown to have better cultural, linguistic, and other congruency with patients, which—specific to telemedicine—may help them better understand patients’ needs, build trust, and personalize virtual care in real-time.^44,45 Similarly, prioritizing investment in fundamental services like medical interpretation can improve telemedicine care by ensuring seamless non-English telemedicine visits, rather than ad hoc or multi-step processes.

Health care systems’ strategies must also take into account marginalized patients’ justified mistrust in the medical system, borne from decades of systemic racism and oppression, causing mistreatment and abuse as well as current inequities in health care access, treatment, and outcomes.⁴⁶ Even the most well-intentioned strategies to improve telemedicine uptake among marginalized populations will not succeed if they do not address building trust and authentic 2-way communication between the health care system and patients who have been historically and presently excluded and disrespected by health care leaders and clinicians. Similarly, at the interpersonal level between clinicians and patients, health care clinicians must implement strategies that uphold best practices for patient communication. Not only do we need to ensure we respect patient decisions about what type of visit is best according to them, but we also have to acknowledge biases in these relationships. Clinicians must ensure we are not making assumptions about whether a patient would or would not want telemedicine based on their sociodemographic background. For example, among respondents with low incomes in a recent study, 71% reported they would always like the option for telephone or video visits, and 63% reported that they would likely choose a telephone or video visit over an in-person visit whenever possible.^47,48

Finally, we must address the inherent bias built into the digital platforms themselves. Currently, we offer online patient portals and telemedicine platforms that are not available in the languages spoken by our patient populations, with instructions and content at high reading levels and full of medical jargon that most patients cannot easily understand, and with fundamental barriers to usability such as poor navigation to access core features. We must demand the design and implementation of better products that do not exclude so many patients from the outset.

5. Partner with Patients and Community Organizations to Implement Telemedicine

Although listed last, the patient and community pillar within this framework is a key component of equity applicable to all other pillars. Health equity approaches are likely to be unsuccessful without partnerships and collaborations with patients, community leaders, and organizations whose primary mission is to support and serve marginalized populations.

Community-based organizations, such as neighborhood-based non-profits that assist clients with obtaining housing, employment, or other social and medical needs, understand the structural and person-level obstacles for their communities, and they are effective advocates for prioritizing which strategies need the most immediate attention. More specific to telemedicine, community-based and municipal organizations have been working on digital inclusion strategies for many years, such as public libraries and other organizations (many of which are a part of organizations such as the National Digital Inclusion Alliance).⁴⁹ Health care organizations can serve as referral sites to connect patients with these services as well as directly advocate for these organizations and their work. In the longer term, incorporating community priorities and engaging community members in health care leadership decisions is a key goal to ensure that health care provision, including telemedicine services, is conducted in partnership with communities rather than “for” or “about” them.