Despite telehealth’s potential to increase access to and enhance comprehensive healthcare, it will continue to exacerbate historic and present-day health inequities without specific health policy changes. Digital access to devices and broadband is a necessary, but insufficient, foundation to address healthcare access disparities. To provide quality and equitable care through telehealth, policies must be enacted that (1) ensure adequate digital fluency for patients and providers and (2) provide infrastructural support for patients’ health advocacy. Further, it is not enough for systems to address one of these barriers alone. We posit that each of these key factors work in synergy with one another; when any of these needs are absent, the value and promise of equitable telehealth degrade.
Our experiences working at a safety net hospital point to the need for a three-pronged strategy to reduce digital health inequities: (1) create federal and state policies to operationalize telehealth infrastructure; (2) establish national standards for healthcare access portals to deliver a consistent access experience; and (3) support patients and families during the adoption of these technologies. This strategy only works when reimbursement and regulatory barriers are also addressed.
Federal and state policies need to be developed to eliminate broadband infrastructure disparities for telehealth. While current federal efforts are critical, they are short-term solutions; the $3.2 billion Emergency Broadband Connectivity Fund can only be used during the duration of the state of emergency.19 State-level policies such as the Massachusetts Lifeline program provide either phone or internet services at low cost, but not necessarily both.20 The 911 Act, on the other hand, created a nationwide, seamless communication infrastructure, and established policy for underwriting the cost of accessing emergency services.21 A similar act is needed to establish national infrastructure for telehealth access, whereby cellular spectrum or broadband bandwidth is reserved specifically for healthcare services; access to healthcare personnel (similar to public safety officials) would be consistently available to anyone with a connectable device.
Today, anyone can access care by walking into an emergency room, but when it comes to telehealth, patients have to use a number of proprietary portals and platforms that are health system specific. During the pandemic, patients had to learn multiple technology platforms ranging from commercial off-the-shelf platforms such as Zoom to EHR portal–connected telehealth systems. When our patients transition their insurance coverage, they have to rediscover how to use technology to access care. Creating national standards for these platforms (e.g., accessible by browser or app; easily engage other parties such as family, CHWs, or interpreters; support physical privacy) and best practices for digitally engaging patients in their care creates a consistent patient experience that addresses key barriers, supports the need for a team approach to health advocacy, and allows health systems to create innovative, value-added delivery models such as virtual agents.
Finally, health systems must invest in capabilities for training patients, family members, and healthcare teams to use these technologies. It is not sufficient to hand patients a device. In the same way companies have created “Genius Bars®” to offer troubleshooting support, health systems should also offer extensive and efficient support services for patients lacking the digital fluency to navigate telehealth platforms. Additionally, knowing when to access telehealth is a life skill that can be taught through the educational system, building on life skills such as calling 911.
Our experience has taught us that technology access is a social determinant of health (SDOH), with implications for access to address healthcare and other SDOH. We need to establish standards for patient experience when using telehealth. The three-pronged approach of creating federal and state policies to democratize access to telehealth, establishing platform standards for accessing telehealth, and supporting societal and health system investments to increase health literacy and technology fluency can begin to address the disparities in telehealth engagement.