Assessment of a Digital Health Coordination Program to Mitigate Telehealth Access Disparities

Introduction

Aprofound digital divide defined by social and economic factors limits access to telehealth video visits, yet the literature remains lacking both on the characteristics of such barriers and how to address them through empirically supported interventions. ^{1 –3} Enhancing equitable access necessitates not only improvements in digital health literacy but also innovations in telehealth-enabled models of care. ^{4 –6} To clarify barriers and enhance equitable access to telehealth video visits among patients receiving ambulatory psychiatric care at a large, metropolitan academic center, we implemented a pilot digital care access program. A digital health coordinator (DHC) provided person-centered training to patients on how to conduct video visits and utilize the institution's patient portal to navigate their personal health information. Our aim was to proactively identify barriers to access and mitigate digital literacy and resource barriers, evaluating the feasibility and acceptability of this intervention.

Methods

Study subjects were patients receiving behavioral health treatment in the ambulatory division of a psychiatry department at a metropolitan, academic medical center. Patients had reported experiencing barriers to conducting video visits to their treating clinician during ongoing care and agreed to meet with the DHC. Treating clinicians sent patients' identifying information through staff messages to the DHC in the electronic medical record. The DHC then contacted patients by telephone to provide training and coaching consisting of at least one telephone or in-person visit to review and practice how to conduct video visits or use the patient portal. Training was highly individualized with the number and duration of sessions varying for each patient based on their need and interest. Original data were collected for a 1-year duration in 2022.

For enrolled patients, we tracked sociodemographic information, the number of times they met with the digital health care coordinator, and their barriers to accessing digital health resources. The DHC asked sociodemographic questions at the beginning of training and classified barriers based on patient requests for specific types of skills. Zoom literacy referred to a need for assistance with opening Zoom and/or using its features during a visit. Doximity literacy referred to a need for assistance with opening Doximity and/or using its features during a visit. Patient portal literacy referred to a need for assistance with setting up an account and/or using the features of the portal. Language barriers referred to patients reporting that they did not speak English and required a translator. Hardware/device barriers referred to a need for assistance with functions of a computer or mobile phone. WiFi or connectivity barriers referred to a need for assistance with connecting to WiFi or lack of internet access; and privacy concerns referred to inability to conduct visits due to lack of privacy in the home.

We characterized patient data through descriptive statistics, detailed in Table 1. We assessed the impact of DHC training through whether there was a decrease in number of scheduled phone visits, an increase in number of scheduled video visits, and an increase in the proportion of completed to scheduled video visits for a 3-month duration following training. For referring clinicians, we assessed satisfaction with the program and rated a majority response based on the proportion of responses identified as “strongly agree” and “agree.”

The institutional IRB deemed this study exempt given its minimal risk to study subjects and involving only analysis of data recorded such that subjects could not be identified.

Results

A total of 74 patients were referred by 39 providers. The number of patients who completed training was 44 referred by 24 providers, and the number of patients who did not receive training due to either a lack of response to three attempts to outreach and/or refusal to participate was 30, producing a patient engagement rate of 59% with the program. Patient sociodemographic information, barriers to accessing digital care, usage of digital health care coordinator services, and impact of DHC training on digital health literacy are reported in Table 1.

Sociodemographics show that a higher proportion of participants were white, female, non-Hispanic, aged 50s, spoke English, were unemployed, and had a median household income of $25,000. There was a decrease in the number of phone visits among 21% of enrolled patients, an increase in the number of scheduled video visits among 32% of enrolled patients, and an increase in the ratio of completed to scheduled visits among 27% of enrolled patients. While a majority of patients were documented as having signed up for the patient portal before being referred to our program (Table 1, n = 43), a large proportion still reported experiencing barriers to utilizing the portal (Table 1, nef> = 29).

Characterization of barriers revealed that for those who had been unable to conduct video visits before training, difficulty with opening or operating features of Zoom was the most frequent barrier.

Our survey of provider satisfaction with the program showed a 67% response rate (n = 16) among clinicians whose patients participated in the program. The majority of referrals were from physicians (44%; n = 7). Other referring disciplines included social workers (25%; n = 4), psychologists (12.5%; n = 2), community health workers (6%; n = 1), and administrators (12.5%; n = 2). A majority of respondents (64%) reported perception of improvement in the use and quality of video visits with their patients and perception of enhanced patient usage of their portal account to communicate with the provider. A majority of respondents also reported reduced administrative workload related to patient care and enhanced meaningfulness of their interaction with patients (54% and 64%, respectively). Additionally, 57% of respondents reported an increased desire to persist with using video visits rather than transitioning to telephone visits in the middle of the visit due to challenges patients faced. Finally, 71% of respondents noted that they would refer patients to the program again.

Discussion

This feasibility and acceptability study demonstrated that a pilot DHC service had a 59% rate of engagement among referred patients; enabled 32% of patients to increase the frequency at which they scheduled video visits; and 27% of patients to increase the frequency at which they completed the video visits they had scheduled. Among the latter, the mean increase in the number of completed visits was 32%. Training sessions were patient-centered, and the DHC was able to be flexible in both number and duration of sessions they offered. Meeting patients' needs in this way allowed for an individualized approach to the barriers they encountered. However, given that most patients received training over the phone, with only six patients having met with the DHC in-person, a greater frequency of in-person training could have enhanced the quality of education patients received and improved access in the form of increased completed visits for more patients.

Characterization of barriers demonstrated that a majority of patients experienced digital literacy as a primary challenge to conducting video visits: patients specifically reported difficulty with operating features of Zoom, Doximity, or their patient portal account. Given that such barriers were present in a patient cohort with a median income <$25,000, this study validates the importance of digital literacy programs in closing the gap on telehealth disparities. ^{7 –9} The frequency of digital literacy barriers among patients who scheduled video visits and activated a health care portal account before training demonstrates the importance of collecting data which accurately measure virtual visit and digital health proficiency through characterization of barriers.

Additional sociodemographic findings indicated that enrolled patients had a mean age of 59.8. While this cohort was small and vulnerable to selection bias, the older age is consistent with research validating the difficulties that geriatric populations face with virtual care. ^5,7,10

Provider perception of the positive impact of DHC training on patient video visit and portal access was robust (64%), validating the value of our program to treatment teams. Another finding from our clinician survey was the improvement in provider perception of meaningfulness of work and administrative workload. Such data reinforce the close relationship between clinician time spent on direct patient care and professional fulfillment. The impact of the intervention on provider desire to persist with using video visits rather than transitioning to telephone visits also demonstrates how enhanced digital literacy among patients empowers clinicians to further bridge gaps in access.

Study limitations included our inability to access specific metrics to measure patient portal proficiency from training, and thus, we were unable to gauge the impact of this program on patient engagement with their digital personal health information. Additionally, the limited duration for the study resulted in a small sample size, and referrals came from a smaller pool of clinicians, further reducing generalizability. Finally, there were confounders for the completion rate for video visits, including no-shows that may have occurred for reasons unrelated to proficiency in use of virtual care.

Conclusions

To enhance equity in telemedicine access, we implemented a DHC program which proactively identified disparities in access and mitigated digital literacy and resource barriers, demonstrating both feasibility and acceptability among patients and referring clinicians. Digital health care access programs which connect patients to a coordinator who provides training on how to use video visits and navigate patient portals are a feasible and acceptable mechanism to address health care inequities. Such programs also improve meaningfulness of work and reduce administrative workload for clinicians.