WASHINGTON — Telehealth visits should be made easier for people with disabilities, low health literacy, and other conditions that can make such visits challenging, argued speakers at an event sponsored by the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Health Literacy.
In a study of nearly 700 patients, including those with chronic comorbidities, kidney transplant recipients, and patients enrolled at academic medical centers or federally qualified health centers in Chicago, “patients with low and marginal health literacy compared to patients with adequate health literacy were less likely to have a video visit, more likely to have difficulty recalling what was discussed during the visit, less likely to recommend telehealth to someone else, and less likely to find telehealth very useful,” said Marina Serper, MD, of the University of Pennsylvania in Philadelphia.
In addition, “those with limited English proficiency were half as likely to have a video visit, half as likely to think a telehealth appointment was just as good as an in-person appointment, and less likely to find telehealth very useful,” she said at last week’s event. “Those with poor self-reported health are twice as likely to have difficulty recalling what was discussed during the visit, which has significant implications for the quality of healthcare delivered via telehealth.”
Serper recounted her own institution’s pandemic experience in adapting a telehealth program that usually supports less than 100 virtual visits per day to one that would service 6.7 million patients mostly by telehealth. The university responded by selecting a new telehealth vendor and opening a telehealth “command center” to help support patients and clinicians.
“We also developed a wraparound telehealth platform we called Switchboard — it integrates patient messaging with the scheduling function of the electronic health record (EHR) — that allowed us to automatically message patients and providers,” she said. The telehealth platform allows for on-demand two-way text translation for telehealth visits. Patients and providers can select from 65 languages, and there is capability for a third-party live translator if needed, she said.
At the time the telehealth visit is scheduled, the system sends patients a message about their appointment with “large buttons that patients can click on and they can actually make sure that their technology — whether it’s on their phone, tablet, or computer — works, and that they’re able to do the video visit,” said Serper.
Then, 3 days before the visit, “they get a similar reminder, with a visit guide, and they do not need to be logged into a patient portal to access these materials, which is very important,” she added. “The visit guide also provides the patient with some information about what kind of lighting you want, that you don’t want to be in a noisy area, and ideally you would like to have access to good broadband internet, and to have your camera available.”
Ten minutes before the visit, “they get another reminder, so they don’t have to look through their phone or email in case they lost the messages,” Serper added. “All they have to do is click on this link, and they can join the visit.”
She noted that “earlier in the pandemic, we required a download of specific software, and we found that patients were having difficulty downloading the software and that what was best was actually a direct link” for the visit. “It took us a while to get to that point, but once we got there, it made the visits a lot more seamless.”
Penn Medicine also surveyed more than 500 of its providers; some of the principles they endorsed for telehealth visits included:
- No patient app download required
- Reliable, high-quality audio/video connections
- Integrated provider experience, including a single sign-on
- Use of telehealth not connected to the patient portal
- Virtual waiting area for patients
- Ability for the provider to send a message into the virtual waiting area if, for example, they’re running late
- Ability for the provider to see the status of the visit, i.e., how long the patient has been waiting
- Capability for multi-party connections, so family members or translators can join the visit
- Capability for screen- or image-sharing
When it comes to using interpreters during telehealth visits, care must be taken about who is used, said Lisa Bothwell, JD, a program analyst in the Administration for Community Living at HHS. “You have to be careful about using the persons who are there with the patient as an interpreter, because of their ability to remain neutral, which may not meet the qualifications for a qualified interpreter,” she said. “For example, we can think of the Britney Spears case that’s happening now … when she has certain persons with her who may have a stake in what she’s saying, and so that person may not be neutral.”
In addition, “if it’s someone’s child or family member, they may not actually know the specialized vocabulary and be able to provide an interpretation at a high quality level,” she added.
Remember that it takes time to learn telehealth technology, she urged. “It’s important to sit down with individuals and train them on your platforms, and how to achieve a good quality telehealth visit.” Some states may offer programs to help clinicians with this training.
Those who design telehealth and web content for patients with disabilities might want to investigate some common design considerations, such as the internationally recognized Web Content Accessibility Guidelines, Bothwell said.
For example, standards on contrast of colors, alternate text, and being able to hit the tab button to move a screen reader down the page quickly “can be very helpful for people who are hard of hearing, people who are blind, and how they use technology,” Bothwell noted. “There are great explainers out there that can help you get a better understanding of that.”
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