Understanding Telehealth Barriers for Limited English Proficiency Patients

December 29, 2022 - The benefits that telehealth adoption and use can provide patients are well-documented. From increasing healthcare access to reducing exposure to infectious diseases to enhancing convenience, the patient care benefits of telehealth are myriad.

As a result, though telehealth use has leveled off since its peak in 2020, usage has stabilized at higher rates than before the COVID-19 pandemic. In 2019, under 2 percent of patients used telehealth only or a mix of telehealth and in-person care services, according to data from market research firm Trilliant Health. That figure rose to about 28 percent in 2020 and dropped to 19 percent in the first and second quarters of 2022.

But even with telehealth remaining a popular mode of care delivery, the pandemic threw into sharp relief the hurdles facing certain patients when trying to access virtual care. These relate to various social determinants of health (SDOH), ranging from race- and age-related barriers to the digital divide to having limited English proficiency (LEP).  

LIMITED ENGLISH PROFICIENCY HINDERS TELEHEALTH USE

People with LEP have a primary language other than English resulting in limited English-speaking ability. Overall, language use in the US has changed significantly over the last few decades. Nearly one in five, or 67.8 million, spoke a language other than English at home in 2019, up from 23.1 million in 1980, according to recent data from the US Census Bureau.

LEP can hamper patient use of telehealth in various ways. Patients with LEP had lower rates of telehealth use overall. A study published in Health Affairs in March 2021 found that patients with LEP had half the odds of using telehealth compared with their counterparts who spoke English fluently.

Researchers assessed data from 84,419 respondents in the 2015-18 California Health Interview Survey. They found that the rate of telehealth use among patients with LEP was 4.8 percent versus 12.3 percent among proficient English speakers.

Another study published last year in JAMA Network Open shows that patients with LEP were less likely to participate in video visits during the pandemic compared to patients who were comfortable speaking English.

Researchers analyzed primary care telehealth visits within Kaiser Permanente Northern California between March 16 and October 31, 2020. The data included 955,352 telehealth visits among 642,370 patients. More than half (60.3 percent) of the visits were telephone appointments, and 39.6 percent were video visits.

Researchers found that patients with LEP used video visits less frequently than patients who did not have LEP, with only 7,765 patients who had a documented need for an interpreter attending a video visit, compared to 371,237 patients without LEP.

ADDRESSING ACCESS CHALLENGES AMONG LIMITED ENGLISH PROFICIENCY PATIENTS

Recognizing the barriers to telehealth access created by LEP, government departments have issued guidance to help mitigate the issue.

Earlier this year, in honor of the anniversary of the Americans with Disabilities Act, the Department of Health and Human Services (HHS) worked with the Department of Justice (DOJ) to publish new guidance that seeks to eliminate discrimination in the telehealth arena, including potential discrimination against people with LEP.

"Recipients of federal financial assistance must take reasonable steps to ensure meaningful access for LEP persons in all aspects of care, including telehealth services," the guidance states.

These steps can include providing access to interpreters and offering information about telehealth services in non-English languages.

Further, HHS notes that healthcare providers can further mitigate barriers by identifying their LEP patients' primary languages to determine the most relevant languages for their patient population. From there, the provider can create multilingual patient resources and plan for interpreter support.

HHS also recommends including medical interpreters in LEP patient encounters as soon as possible and having an expert available via phone or email after a virtual visit to translate or interpret if the patient has additional questions.

According to recent research, including language interpreters in virtual visits can support telehealth use. In a study published in the American Journal of Managed Care at the beginning of the year, clinicians from Massachusetts General Hospital described the steps they took to bolster telehealth access. The hospital utilized Doximity, an application that allowed interpreters to join a telehealth visit, and paired LEP patients with a bilingual student intern who could help with registering the device, setting up an email account, enrolling in the patient portal, and attending a telehealth visit via videoconferencing.

"Our findings suggest that as health systems continue to address such needs, patients with limited English proficiency should be able to have an active role in managing their own health which, in turn, may positively impact their health," said Esteban A. Barreto, PhD, director of evaluation of equity and community health at Massachusetts General Hospital and senior author of the study, in the press release.

Another study revealed that employing staff members who speak the patient's preferred language can help increase access to telehealth and improve patient experience in safety-net settings.

Published in SSM - Qualitative Research in Health in March, the study was based on 24 in-depth interviews with healthcare workers and patients at two federally qualified health centers (FQHCs) that primarily serve Chinese and Latino immigrants. Interviewees cited LEP as a barrier to telehealth.

Based on the data gathered, researchers concluded that incentives to expand the availability of bilingual providers who can deliver both cultural- and language-appropriate services should be prioritized in safety-net settings.

Increasingly, healthcare providers are gathering language data to address telehealth access hurdles.

Community Care Cooperative (C3), a nonprofit accountable care organization governed by 18 FQHCs in Massachusetts, gathers telehealth utilization by race, ethnicity, and language to develop interventions. One key intervention is employing telehealth navigators who focus on mitigating care gaps.

North Shore Community Health, a C3 FQHC, is specifically using language data to outline its telehealth navigator responsibilities.

"They see an inequity in terms of the rate of telehealth utilization between their English-speaking patients and their Spanish-speaking patients," said Jenny Azzara, senior director of performance improvement and organizational development at C3, in a phone interview with mHealthIntelligence. "So, their patient navigator is going to be focused on this disparity and how to close the gap."

Amid the ongoing use of telehealth, efforts to mitigate SDOH barriers, like LEP, are critical. As providers work to close health equity gaps, telehealth's potential to truly expand access to needed care could be realized.