I would think the opposite is more likely true... that if we don't advocate, utilize and demonstrate the value add we can be pretty assured that payment will go the way of phone calls. Patients are the drivers -- we need to ensure they are connecting with continuity that drives value. Clinicians will lose if we are the barrier to access and if dollars are paid for poor/fragmented care.

Before we label any implementation addressing cultural competency a success, we must initially define success. In doing so, we must first acknowledge there are levels to this principle:

1) Cultural Destructiveness addresses forced assimilation, subjugation, rights, and privileges for dominant groups only.
2) Cultural Incapacity pertains to racism, the maintaining of stereotypes, and unfair hiring practices.
3) Cultural Blindness ignores our differences and treats everyone the "same" only meets the dominant groups' needs.
4) Real success starts with Cultural Pre-Competence, actually exploring cultural issues, with a commitment to assessing the needs of organizations and individuals not in the majority groups.
5) Only then can we get to Cultural competency, thus recognizing individual and cultural differences, seeking stakeholder advice from diverse groups, and employing culturally unbiased staff.
6) Cultural Proficiency, the ability to implement changes to improve services based upon cultural needs.

I would argue most of the Telemedicine products on the market are between the first phase of cultural destructiveness and the third phase of cultural blindness. Before something becomes accessible, it is first marketed to those who can most easily acquire it. To achieve cultural competence, we need to be less concerned with the product and more focused on who is implementing the product and how these implementations address the desired need. Unfortunately, I don't believe we have any accurate measures for success in Telemedicine and its ability to address cultural competence. At least not yet.

Unfortunately, there has not been a proactive effort by most founders/management teams to address culturally competent care in telemedicine. First, we must acknowledge that cultural competence is more than race/ethnicity and secondly, this type of care can not be an add-on - it has to be a part of the company, brand, acquisition strategy, and product DNA (each alert, button, suggestion, sentence structure, imagery, etc.) from the very beginning, ideation of the company.

Trauma Informed Care and Equity Centered Design are two complementing trainings that can encourage healthcare providers to engage community members in rethinking care delivery to improve health equity. Making sure that the work does not stop with a Patient Advisory Council that provides feedback on already conceptualized ideas, instead engage the PAC and more community members to define the opportunities and co-design.

The kind of training necessary to increase equity practices amongst physicians and care for the treatment of patients entails reducing the intellectual content of conversations we have with patients. In other words, we need to dumb ourselves down. By simplifying the words we use, we make ourselves more relatable and accessible to the very people we say we want to treat. The entire medical field has put the onus of health literacy on the patient, and that's wrong. When we use medical jargon to speak to patients, we turn our unwillingness to talk plainly into their burden and make them feel inferior while alienating ourselves when they need us most. Every day I see colleagues use "big word" after "big word" to describe a patient's medical condition or treatment, only to go back later and plainly explain to them what was actually said.

Think about the years and years of higher education and clinical training it takes to learn the language we use. But, unfortunately, we make the mistake of simply giving patients select reading material as we discharge them out the door, assuming it is enough to offset our failure to dumb ourselves down.

Agree w the need to focus on health literacy. Beyond asking clinicians to do this, we also need to ask organizations to become health literate organizations (see cdc.gov/healthliteracy/planact...). We often just put the onus on not only patients but individual clinicians and instead these changes also need to happen at a higher level.

Nicholas: I'd like to urge you to reframe this thought, flipping it on its head. If you think of the patient as being the smartest person in the room about the patient, then the opportunity is for the provider to learn from the patient how to help them. One important dimension is around digital readiness. Before offering any solutions that involve anything electronic, the provider may need the patient to enlighten them on their access to devices, internet, and digital skills.

What comes to mind first is incorporating this level of training where physicians are being trained - in medical school, continuing education courses/seminars, etc. The current system is built on an unenlightened past which has led to the equity caps we see today. The foundation needs to be examined of which the patient should not bear the burden of these gaps in care, they should be treated as partners in their care. As we move toward more DTC and the consumerization of healthcare, patients' expectations will change and so will the behavior of physicians, payors, etc.

Interpretation: It is almost on a daily basis that I hear about children having to interpret for their family members during healthcare appointments. While that may be convenient when telehealth is accessed from the home, it is not fair to the children and can compromise the quality of care. I am surprised by how hard it is for many organizations to ensure seamless integration with interpretation services. It should in theory be easier to ensure interpretation for e.g. Mayan dialects via telehealth but interpretation during video consultations is not seamless (one click activation is rare). I also think health plans should consider the additional costs including time with interpretation.

Connectivity: Connectivity is a major barrier while there are more and more resources available to support families with connectivity. Many families are unaware of these and I think many healthcare providers can be an important link to these. Beyond the Lifeline program and FCC's Emergency Broad Band Benefit program, there are sometimes county initiatives. Important that healthcare staff are aware of what resources they may refer to.

Lack of cultural competency has always been a part of the healthcare experience surrounding  - gender, race, language, dialect, and more. Telemedicine is not the problem, telemedicine is a solution to problems that have not been overcome.  For us, at K'ept Health it comes down to building our product for the patient first and the physician second. We're able to do this successfully as we have physicians who are personally connected to these competency areas and we involved patients in the development process to find their priorities - internet and literacy are not high on the list of what they want, need, and look for in telemedicine platform. I also don't think it's a one-size-fits-all approach, there will likely be platforms that focus on one to two medical concerns that then connect their patients to other correlating services/care.

Many of the providers we work with have introduced questions to understand patients' ability to connect and their comfort with telehealth. You can find examples here: careinnovations.org/virtualcar... It includes screening questions prepared by UCSF.

Most organizations we work with provide the support for telehealth connectivity in-house. Some organizations successfully use Tech Navigators. Here are some of the areas that are more commonly outsourced:

Internet access:
Healthcare providers can link families with resources for connectivity. The Lifeline program for affordable telecommunications offers access to subsidized cellphones and data plans: fcc.gov/lifeline-consumers
FCC's Emergency Broad Band Benefit program can support eligible families with internet access: fcc.gov/emergency-broadband-be.... There are also opportunities to partner with schools. FCC opened a new window for its massive connectivity fund program (closing today) docs.fcc.gov/public/attachment...

Remote Patient Monitoring (RPM):
Many providers rely on vendors to provide technical support and in some cases connectivity support for remote patient monitoring. Here is a good resource on how providers can get started with RPM caltrc.org/wp-content/uploads/...

Services in other languages than English:
There is much more work needed to make sure that people with a preferred language other than English get the right support. Language Line (languageline.com/) is one of the most common outsourced interpretation services. There is much more work needed, also beyond interpretation to ensure support through the patient journey for people with a preferred language other than English.

# Device & data access: This is something that healthcare teams do in our system in a decentralized fashion. This includes helping patients apply for Lifeline phones. We also applied for grants in healthcare system to try to purchase devices and provide them to patients. Some clinics have purchased devices and set-up locations for patients to come use the devices for telehealth encounters or even gone to patients where they are.

# Digital readiness training: Within our health system we have both tried partnering with local organizations (digital inclusion CBOs, libraries) as well as supporting digital training internally through foundation and grant funding. I think an often underrecognized fact by payors and potentially many health systems is how much 1:1 training and support is needed to get a patient onto our digital health solutions (e.g., patient portals) for someone who does not already have digital literacy skills. Here is a review from my colleagues at UCSF that highlights many of the strategies we have used to increase patient portal usage aren't great and the most successful ones require 1:1 patient training.
acpjournals.org/doi/pdf/10.732...

Thanks so much for these fantastic resources! I know that the UCSF team is a national leader here!

Thanks for sharing these great resources!

In Baltimore City, where Johns Hopkins is headquartered, we've found that access to internet connectivity (specifically high-speed broadband internet) can be a barrier for some patients to be able to participate in telemedicine. In some neighborhoods in Baltimore city, less than a third of households have wired broadband internet access. 21cc.jhu.edu/research/current-...

I think one of the key barriers is language -- and the challenge outside the hospital is too few insurers pay for interpreter services and too few practices take the time to use interpreters even when embedded in telehealth. It challenges healthcare outcomes...

I would say getting telehealth platforms into the hands of people who need them most. If certain groups have a long history of distrust and not going to the doctor how then will they find and begin using the platforms - answer this and we can truly increase access to care.

I sometimes find it a bit frustrating that there is such a large focus on digital literacy barriers, which seems to some extent place the blame on the patient and their digital skills.

In our work (pubmed.ncbi.nlm.nih.gov/331640...), we found data access (whether that is through an unlimited data plan or broadband/wi-fi) to actually be one of the most frequent barriers. And we're in an urban setting! Lack of broadband access in particular is an issue that can exacerbate disparities (i.e., digital redlining).

Data from Pew also shows that there are still many populations that don't have access to video-enabled devices, which of course can be costly.

Communication barriers (hearing impairment, language barriers) of course are also important and can impact folks who do have digital literacy skills

Lastly, there are MANY system-facing barriers. Community health centers / safety net settings tend to have fewer resources to support telemedicine care and their patients in accessing telemedicine

In addition to the many great comments above, we also see that many patients want more privacy when they join a telehealth consultation.

Do we want to solve this? Or do we just want to divert low literacy patients to in-person or phone care? To me, our first challenge, is recognizing that we need to address this problem and not work around it. The opportunity of telehealth for those with barriers due to language, technology, transportation and access is too great not to invest in solutions (instead of workarounds.). All patients need equitable access to care.

I have found the model described in this paper "Good intentions are not enough: how informatics interventions can worsen inequality" from JAMIA (pubmed.ncbi.nlm.nih.gov/297883...) very helpful. Well-intentioned digital health interventions can create worsening inequality if precautions aren't taken to ensure accessibility for all populations. These model suggests "universal precautions for literacy burden". Rather than trying to find ways to help patients to adapt to our complex care offerings, we need to find ways to simplify and reduce the complexity of virtual care offerings so they are more accessible patients. One way to achieve this is the employ user-centered design principles and incorporate the expertise of diverse patient groups in designing solutions that work for them.

If we are working off the standard definition of digital health literacy, then someone who is digitally health literate can use a computer, phone or the internet to find and use health services and information. So, it seems that the barriers are found in the products created and how they are "operated". What we have is a patient adoption problem not a literacy problem. Telehealth solutions must have the patient at the center at all times, when we do that we create solutions for the entire patient journey (user journey) even before they download an app or log onto the computer. And the patient/user journey must take into account various types of users, unfortunately they are currently based on one group as the standard and other groups are left out and underserved leading to equity gaps.

Hi Sheena,

Yes! Completely agree with you. Design Justice: Community-Led Practices to Build the Worlds We Need by Sasha Costanza-Chock is a great resource that discusses how design practices can be led by and center marginalized communities and their needs precisely so that the patient/user journey will take into account various types of users because the design team is including different users and not just one standard group. The full text is free and available to all here: design-justice.pubpub.org/

Take a look at the digital inclusion definitions and resources offered by the National Digital Inclusion Alliance, including their digital navigator model. digitalinclusion.org/definitio...
digitalinclusion.org/digital-n...

NDIA is the definitive group that works on behalf of digitally excluded people and communities. Membership is free and I strongly encourage readers to connect. It's a great place to find local affiliates in your community that can help with devices, connectivity and digital literacy.

Sheena: My team recently completed a study that found a huge gulf between people saying that have telehealth ready devices and skills and actually having suitable devices and skills. Digital literacy for telehealth may require having an email address, using the patient portal, being able to use an unfamiliar browser, downloading an app, changing camera and mic settings, etc.