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The Future of Telemedicine. Pandemic Lessons to be Learned

The COVID-19 pandemic has changed the ways we communicate and interact, with social distancing and virtual communications such as telehealth and telemedicine establishing themselves as the new normal. The pandemic is also revealing substantial issues of health care disparities and inequalities, realities that the pandemic-induced communication changes are exacerbating.

Pandemic and Health Disparities

Nancy Krieger, professor of social epidemiology at Harvard’s T.H. Chan School of Public Health, said that the virus “is pulling a thread that is showing … the very different conditions in which we live because of social structures that are inequitable, both within the United States and between countries. By pulling the thread, it’s revealing patterns that have long been known in public health.”

For example, according to Health Affairs:

“In California, Pacific Islanders face a death rate from COVID-19 that is 2.6 times higher than the rest of the state, while in South Dakota, the rate of COVID-19 among Asian Americans is six times what would be predicted based on their share of the population. Other minority communities are also disproportionately affected, including in New Mexico, where Native American people comprise about 11 percent of the population yet account for more than half of COVID-19 cases.”

Telemedicine Use and Virtual Communications Increase

With the various pandemic stay at home orders, shutdowns, and related COVID advisories, virtual communications have become much more de rigeur, the expected method of widespread communication. According to the American Medical Association, “[P]hysicians [have] turned to telemedicine as a way to remain engaged with their patients. This form of real-time, audio-video communication allows physicians and patients to connect from different locations existed prior to the pandemic, but certain restrictions limited widespread usage.”

While telehealth and other virtual communications are becoming more and more standardized, they often do so to the exclusion of millions of people, an exclusion that raises significant issues of discrimination and health care inequality.

Telemedicine and Health Care Disparities

Telehealth is convenient for some people. It eliminates the need to drive to an office and the time in a waiting room, trimming a potentially hours-long event in a fraught pandemic world down to minutes. But telehealth is not easily accessible to the more than 25 million people in the United States who speak little or no English.

Even if limited English proficient (LEP) people are able to go online to access telemedicine, most of the systems that support telehealth are virtually and practically inaccessible to people who primarily speak other languages.

Take David Velasquez’s experience, for example. As reported by The Verge, when David Velasquez went home to California for a week in April 2020, “he found out that his parents didn’t have internet access anymore. Velasquez, a medical student at Harvard, needs Wi-Fi for work. However, his parents don’t own a computer” and have no Internet access in their home.

“Without internet access and with limited English, Velasquez’s parents wouldn’t be able to make that switch to telehealth. “I knew that as our healthcare system started transitioning over to telehealth as opposed to in-person, in-clinic care, their access to health care — and other individuals like them — would be disrupted” 

Dr. Elaine Khoong’s patients, many of whom speak only Chinese, did not understand the switch from in-person care to the virtual world of telemedicine.

As The Verge reports:

“[Her patients] didn’t get the message. At the start of the pandemic, the policies and practices were changing every day, Khoong, a general internist and assistant professor of medicine also affiliated with the University of California at San Francisco (UCSF), told The Verge. All this was communicated to our patients, but it was really only being communicated in English, she says. Automated texts to remind patients of their visits were updated to say that the appointment would be by phone, but those were initially only in English and Spanish.”

Prior to the pandemic, there was recognition of the communication limitations of telemedicine and research confirming a digital divide (unequal access to technology) and inequity of health care that telemedicine largely did not address. However, since telehealth was in its infancy with low usage by physicians who preferred in person care and communication, health care disparity issues were just not sufficiently addressed.

Now, with the explosion of telehealth reliance, the problems remain at a critical time for the health and lives of people seeking health care during a national emergency.

According to The Telemedicine Journal’s Use of Communication Technologies to Cost-Effectively Increase the Availability of Interpretation Services in Healthcare Settings:

“Poor patient–provider communication due to limited English proficiency (LEP) costs healthcare providers and payers through lower patient use of preventive care, misdiagnosis, increased testing, poor patient compliance, and increased hospital and emergency room admissions.

There is a growing body of research documenting the adverse impact of language barriers on access to and quality of care.Persons with LEP have greater difficulty accessing managed care systemsand use fewer preventive services such as cancer screening, immunization, eye and dental examinations, and others.

Even after controlling for literacy, health status, health insurance, regular source of care, ethnicity, and economic indicators, researchers find that LEP persons make fewer physician visits and receive fewer preventive services.

Language barriers result in poor understanding of diagnosis, treatment, and medication instructions; poor understanding of and compliance with recommendations for treatment and follow-up; a significantly greater likelihood of a serious medical event; and lower patient satisfaction.”

What the Future Must Hold

Telehealth and increased virtual communications are here to stay. Even when governments have brought the pandemic under relative control and life slowly returns to accustomed normalcy, the seeming ease of virtual communication that became the new normal in the past year will continue.

However, as such communications continue and grow, they must address and resolve the problem that virtual communications simply do not work for everyone.

In health care, education, and other federally subsidized parts of our lives, the law is clear – communications and services must be accessible to everyone, regardless of limited English proficiency or communication disability.

Telemedicine and virtual communication can only be viable parts of the permanent new normal by becoming available to all and complying with federal civil rights laws. The virtual health and communication experience of Alejandra Casillas, a primary care physician and assistant professor of medicine at UCLA Health, must become the rare exception as we move forward during the pandemic and transition to a time when COVID is in our collective rear view mirrors:

“Digital health is a great thing. But we haven’t been as good or intentional in thinking about how it works in different populations. The limited English speaking population isn’t a small group. And we’ve left them out.”


© Bruce L. Adelson 2021. All Rights Reserved The material herein is educational and informational only.  No legal advice is intended or conveyed.

Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise.  Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney.  Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.

Mr. Adelson’s blogs are a Bromberg exclusive

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