During the pandemic, I was tasked by our physician in chief with implementing telehealth tools at more than two dozen primary care practices serving over 200,000 patients in eastern Massachusetts. I worked with practices in our downtown Boston campus, in the greater Boston suburbs and, most meaningfully, our community health centers. These health centers are located in communities that have borne the brunt of covid-19 cases and that care for disproportionate numbers of patients with limited English proficiency, immigrants and refugees, essential workers and patients for whom social determinants such as lack of stable income, housing and food are key drivers of poor health outcomes. Most patients are insured by Medicaid.
Early data show that adoption of telehealth in our community health centers has paled in comparison to practices caring for more affluent patients. From April 1 to June 1, the volume of primary care telehealth visits at the three large community health centers owned by Massachusetts General Hospital went from 600 visits to 880 visits weekly. Over that same period, our downtown Boston and suburban primary care clinics nearly doubled their weekly telehealth visit volumes, from 1,100 to 2,080.
The two dominant modes of telehealth delivery are telephone visits and video visits, and early data on video versus telephone care also points to a digital divide. Practices that care for predominantly middle- to upper-middle-class patients are already performing well over 50 percent of their telehealth by video, while poorer patients are receiving their medical care by telephone.
The digital divide is widespread. At Cambridge Health Alliance, a public health-care system caring for 140,000 patients in Massachusetts, only 1 percent of all primary care telehealth visits happened via video in the first week of June. NYC Health + Hospitals Corporation, the largest health safety net provider in the nation, described a similar pattern of using the telephone rather than video to provide telehealth.
I’ve observed that video adds a great deal to patient care: Seeing a patient’s facial expressions, their self-care, their home environment and the way they move around provides crucial clinical context. While there has been very little research examining the effectiveness of care by video versus telephone, I find that with my most complex patients, I am rarely able to get to the heart of the matter by phone.
Why are so many doctors not able to see our most vulnerable patients by video? Many have smartphones and can video conference with family and friends via WhatsApp or FaceTime. NYC Health + Hospitals Corporation recently surveyed their patients and determined that 75 percent of respondents owned a cellphone and 65 percent were interested in telehealth. The problem may be on our end.
We’ve unfortunately made video care much more complicated than it needs to be. In many health-care systems, patients access a video visit via a health system’s patient portal: a secure online website that gives patients 24-hour access to personal health information. This makes sense. It allows for privacy and security as well as integration into the electronic health record. However, these portals are generally not written at the fifth-grade reading level that the Joint Commission — the nation’s largest accrediting body in health care — recommends, and they are generally available only in English or, in a best-case scenario, in English and Spanish. Patient portals have historically had low uptake among patients with limited English proficiency or low health literacy.
Before one can talk to their doctor via video, there may be an onerous onboarding process: cumbersome sign-up requirements to verify a patient’s identity; a clunky user interface that makes it difficult for even the tech-savvy to find what they are looking for; and sometimes even a requirement to download multiple new apps. My own doctor’s patient portal seemed to require the equivalent of a credit check when I first signed up just a few years ago.
A common workaround to help facilitate video visits is to send patients an email linking them directly to their video visit. However, many patients don’t have reliable access to email, and the emails are generally sent in English. It would certainly not be complicated for health systems to adopt language-concordant text message notification systems that include a link to directly connect patients with their doctor, an approach that would meet more patients where they are. Health systems should also offer live virtual care chaperones whose job is to help patients succeed in accessing telehealth.
We’ve also struggled to overcome language barriers during the actual video visits. Care for patients with limited English proficiency requires medical interpreters. It has proven very difficult to implement on-camera interpreter services in many prominent health-care systems, including my own. Until recently, we have really only been able to offer patients interpreter services over the telephone — another bias away from video care for our most vulnerable patients. Health systems should not implement new digital technology that does not support patients with limited English proficiency.
Finally, we do not yet know how to ensure patient confidentiality in video care. Health-care systems spend large sums of money to ensure that video visit platforms meet the appropriate privacy and compliance requirements. But the near guarantee of patient confidentiality offered by the simple closed door of a doctor’s exam room is gone with video. In a household in which there is only one computer available or in which a large family lives in a small number of rooms, we have no idea who is listening or watching our encounters with our patients — and our patients may have no control over it. Far too often, I have been in the middle of a video visit with a patient when an off-screen voice suddenly inserts itself into our encounter saying things like, “He’s not telling you the truth; he hasn’t exercised for the past eight weeks and I just don’t know how to make him take care of himself.” While such intrusions may seem harmless, the potential for uninvited participants in medical care has major implications for disclosure around sensitive issues such as domestic violence, child abuse, substance use and sexual history.
There is no doubt that the rapid deregulation of telemedicine in the United States during the pandemic has allowed millions of patients to access care during a period in which they could not be seen in person, and it really is working well for most people. But we can’t build telehealth systems that exclude the 20 to 30 percent of our patients who are medically vulnerable. Instead, technology should help address long-standing disparities in access to care: A bus driver in a neighborhood like Chelsea, Mass., or a postal worker in the Bronx should be able to complete a video visit with their doctor during a lunch break instead of taking a day off for what amounts to 20 minutes with a doctor.
Additionally, health-care professionals like me need to question whether implicit bias leads us to assume that a certain patient “can’t” connect via video care. If we question our assumptions, we will undoubtedly be surprised by what our patients can do. Perhaps more importantly, our advocacy will play a crucial role in forcing health-care systems to make the substantial investments necessary to ensure telehealth equity. This is the moment when we lay the foundation for telemedicine in the United States. From a health equity perspective, that foundation is already shaky.