A Strategy for Boosting Equitable Access to Digital Healthcare

Several studies have reported that healthcare providers who actively engage patients in patient portals to review laboratory test results, schedule appointments, and review visit summaries increase the discovery of medical errors (1). Active patient engagement also improves medication adherence, helps patient-provider communication, allows patients to participate in their healthcare decision-making process, and improves healthcare outcomes and satisfaction (1).

However, patients with limited English proficiency (LEP) find it challenging to reap these benefits if they cannot access or understand the information from their providers. Since the COVID-19 Public Health Emergency declaration has ended, we have had an opportunity to evaluate the experiences we gained during the pandemic. Now we are working to improve the quality of healthcare, in particular digital access for LEP patients and others in disproportionately affected urban and rural areas.

EXPANSION OF TELEHEALTH SERVICES BEFORE AND BEYOND THE CORONAVIRUS PANDEMIC

The landscape of patient portals has changed from stand-alone services used for registration to integration with electronic health records (EHRs). Integrated portals also promote laboratory data sharing. This was one reason the Centers for Medicare & Medicaid Services (CMS) released its final rule (CMS-2319-F) to ensure that every person in the United States could see, obtain, and use all electronically available information that is relevant to their healthcare (2).

During the pandemic, CMS expanded coverage for telehealth, and the availability of portals integrated with EHRs that report laboratory test results increased remote patient care opportunities. This propelled public awareness of test ordering, the availability of different test methods for infectious diseases, and test result reports and interpretations (3).

While some interventions supported digital healthcare access for all patients, protective isolation also highlighted healthcare inequities and unique challenges that LEP patients face in accessing, reading, and understanding their test results. Several healthcare organizations demonstrated how to overcome this barrier. For example, Massachusetts General Hospital (MGH) deployed a portal that improved access for LEP patients and reduced the burden for providers (5).

MGH offered educational materials on the registration process in multiple languages and included low-literacy scripts that dealt with privacy concerns. Privacy was important because of patients’ concern about being identified by U.S. Immigration and Customs Enforcement because of their healthcare-related information in the portals. In addition, MGH portals did not require patients to download an application to their phone or computer to join a telemedicine session, and medical interpreters were able to access patient platforms. MGH integrated the interpreters as a third party with access to EHRs at each facility (3).

INSIGHTS FROM EMERGENCY DEPARTMENT VISITS

Patients with LEP are more likely than English-speaking, non-Hispanic patients to access care in emergency departments (ED) due to a lack of insurance coverage and primary care providers (1). This makes the ED a key location for engaging patients with portals and other digital services.

One study documented the number of individuals enrolled in a portal based on their language characteristics (5). The patients in the study accessed their test results in the EHR while visiting the ED. The researchers observed increased portal-based test result viewing among ED patients over the 1-year study, even among those not enrolled at arrival. This study suggests that patients are inherently interested in viewing their laboratory test results and clinical data during clinical encounters with healthcare providers (5). Similar experiences in EDs in different geographical regions among underrepresented patients may support the generalizable application of this study’s observations.

THE CMS FRAMEWORK FOR HEALTH EQUITY: A LANGUAGE ACCESS PLAN

CMS is committed to taking an integrated approach to health equity. The recently updated CMS Framework for Health Equity encourages healthcare providers to remedy systemic equity barriers so that all patients have a fair and just opportunity to attain optimal health regardless of race, language, or other factors.

A key priority of the CMS Framework for Health Equity includes language access, health literacy, and providing culturally tailored services. The CMS Framework describes opportunities for providers to assess their practice environments and develop plans so that patients can have the highest level of meaningful access to medical services. The guidelines include recommendations for assessing the number of individuals with LEP who interact with the organization to understand the language needs of patients and their caretakers.

Promoting the availability of language and medical services on an organization’s website also is beneficial to LEP patients and their caretakers. CMS recommends that a language access plan include a description of how the organization will train staff on policies and procedures for providing language assistance services. In addition, language access plans should include quality monitoring and a framework for continuous quality improvement (6).

CONTINUING CHALLENGES IN RURAL AND DISPROPORTIONATELY AFFECTED URBAN AREAS

One key requirement for a successful telehealth visit is access to broadband internet. Some people who live in rural areas still do not have equitable access to healthcare given a lack of broadband access. There are also urban pockets, known as Wi-Fi deserts, that lack broadband internet access. Wi-Fi deserts often are in large cities where disproportionately affected populations reside and limited digital literacy is prevalent.

Importantly, while such disparities were evident prior to the pandemic, the increasing reliance on telehealth services postpandemic may worsen the problem (7). A study showed that Hispanic (15%), African American (10%), Asian (6%), and other non-Hispanic (3%) populations continue to fall behind in patient portal access and use compared to non-Hispanic whites (66%) in urban and rural areas (8).

Research also shows that tests are the top reason patients access portals—87% in urban areas and 81% in rural areas (8). Despite similar rates of providers maintaining a patient portal system, adjusted analyses found that people who live in rural areas had lower odds of being offered access by their healthcare provider compared wtih their urban counterparts (8).

Another challenge is that third-party language interpretation services can be difficult to integrate into telehealth video visits. In research, bilingual, language-concordant personnel often were essential for efficient, high-quality patient experiences. Audio-only visits were optimal in reaching patients of older age, and those with LEP and limited digital literacy. Continued use of telemedicine by these populations is likely to be contingent on reimbursement policy decisions.

Community-level support also can increase patient digital literacy and the availability of technological resources for high-quality language services in telehealth (9).

WORKING TOWARDS HEALTH EQUITY

Although digital healthcare access has many proven benefits and offers promising solutions to many public health barriers, our experience during the pandemic has proven that their success depends on solving the problem of widening disparities for different populations/geographical regions (4).

The government may need to expand subsidized wireless internet access in communities with limited resources. But education and training by healthcare systems and community health workers also can increase telehealth uptake and patient portal usage (10). Such efforts also may improve digital literacy and understanding of test results in disproportionately affected communities (6).

Multilevel barriers to digital healthcare access remain at the patient, health system community, and policy levels (10). Patients need our concerted efforts to evaluate successes and barriers in various patient populations in diverse urban and rural geographical regions (10).

Bereneice M. Madison, PhD, MT(ASCP), is a health scientist at the Centers for Disease Control and Prevention, Quality and Safety Systems Branch in Atlanta. + Email: [email protected]

Víctor R. De Jesús, PhD, is branch chief of the Quality, and Safety Systems Branch at the Centers for Disease Control and Prevention in Atlanta. + Email: [email protected]

REFERENCES

1. Madison BM, Lazaro GR, Scott MS, Greene DN, Lorey TS, De Jes'us VR. 2023. Effective Access to Laboratory Test Results: A Health Equity Issue that Enhances Diagnostic Excellence. J Appl Lab Med 2023; doi: 10.1093/jalm/jfac128.
2. Centers for Medicare and Medicaid Services. CLIA Programs and HIPAA Privacy Rule; Patients' Access to Test Reports (CMS-2319-F) Final Rule. http://www.gpo.gov/fdsys/pkg/FR-2014-02-06/pdf/2014-02280.pdf (Accessed August 2023).
3. Tan Mc Gory A, Schwamm LH, Kirwan C, Betancourt JR, Barreto EA Addressing Virtual Care Disparities for Patients With Limited English Proficiency. Am J Manag Care 2022; doi: 10.37765/ajmc.2022.88814.
4. Mahtta D, DaherM, Lee MT, Sayani S, Shishehbor M, Virani SS. 2021. Promise and Perils of Telehealth in the Current Era. Curr Cardiol Rep 2021; doi: 10.1007/s11886-021-01544-w.
5. Turer RW, Martin KR, Courtney DM, Diercks DB, Chu L, Willett DL, Thakur B. Real-Time Patient Portal Use Among Emergency Department Patients: An Open Results Study. Appl Clin Inform 2022 Appl Clin Inform 2022; doi: 10.1055/a-1951-3268.
6. Centers for Medicare & Medicaid Services. The CMS Framework for Health Equity 2022-2032. https://www.cms.gov/files/document/cms-framework-health-equity.pdf (Accessed August 2023).
7. Ekwegh T, Cobb S, Adinkrah EK, Vargas R, Kibe LW, Sanchez H et al. Factors Associated with Telehealth Utilization among Older African Americans in South Los Angeles during the COVID-19 Pandemic. Int J Environ Res Public Health 2023; doi: 10.3390/ijerph20032675.
8. Bhavsar GP, Robertson AS, Pena D, 2021. Rural Access and Usage of Patient Portals: A 2019 Health Information National Trends Survey Analysis. Perspect Health Inf Manag 2022; PMID: 35692853.
9. Payan DD, Frehn JL, Garcia L, Tierney AA, Rodríguez HP. Telemedicine Implementation and Use in Community Health Centers During COVID-19: Clinic Personnel and Patient Perspectives. SSM Qual Res Health 2022; doi: 10.1016/j.ssmqr.2022.100054.
10. Zheng H and Jiang S. Frequent and Diverse Use of Electronic Health Records in the United States: A Trend Analysis of National Surveys. Digit Health 2022; doi: 10.1177/20552076221112840.