Screening tool to improve telehealth access and equity

The COVID-19 pandemic facilitated many rapid changes in healthcare, including a shift to using telehealth services across the U.S. instead of traditional in-person doctor's visits. This ensured that patients continued to receive vital care, while only needing access to a mobile device or computer with a webcam. But just because a patient has a smartphone or tablet does not mean they will be able to access their health information or engage in other health services. Differential uptake of telehealth across populations can lead to worsening health disparities, thus necessitating close attention to understanding and addressing patient barriers to telehealth use.

Previous studies have demonstrated that uptake of telehealth is variable depending on a patient's level of digital and health literacy as well as other factors such as trust. Yet there are no current tools designed to incorporate the full scope of these barriers. As such, the research team undertook work focused on developing a tool to identify and quantify the full range of factors impacting a patient's ability and willingness to use telehealth.

"Do they trust the use of technology to engage in private conversations, like medical conversations? Do they have a private place in which they can engage in telehealth? All of these are really important aspects of someone's readiness to engage in telehealth that are newer to the conversation and are things that we need to be able to quantify and figure out interventions to address," says Kristin Rising, MD MSHP, executive director of the Jefferson Center for Connected Care and professor of emergency medicine, population health and nursing at Thomas Jefferson University, and senior author of the research.

The research team analyzed data from 367 patient and clinician participants in a single healthcare institution in the Jefferson Health system. They first conducted focus groups and interviews to understand all the factors making up the concept of "digital health readiness," then they developed initial screener items to measure all the identified factors, refining those items based on patient input, and finally tested use of the screener with 304 patients. The final "Digital Health Readiness Screener" consists of 24 items that measure two primary domains: technical readiness and quality of care concerns. The participants were mainly Black (47%), male (56%) and had a high school degree or some college completed (50%). The researchers found patients with higher levels of education and younger patients had higher technical readiness, and patients with high health literacy scores had higher overall readiness.

Even though these questions are a good first step towards digital health equity, Dr. Rising says that more work needs to be done to test this screener with different patient populations, including those who don't speak English as their first language. Significant work is needed to develop interventions specifically to address the various barriers assessed within this screener.

"My goal is to make sure that everyone receives the tools and education they need to make informed decisions about when and whether they use telehealth," says Dr. Rising. "Ultimately, it's going to be everyone's decision, and some people are still going to decide they never want to use telehealth."

"Digital health equity is something that health systems are interested in addressing, and to date, there has been a lack of clarity about how to do so," says co-author and population health researcher, Amy Leader, also an associate director of the Office of Community Outreach of the Sidney Kimmel Comprehensive Cancer Center -- Jefferson Health. We hope that this screener provides a tangible starting point"

In addition to developing this screener, Dr. Rising and her team have been doing direct outreach to address another barrier to telehealth use among hospitalized patients. The Jefferson Digital Onboarding Taskforce which is comprised of staff and students, has been providing one-on-one support to hospitalized patients to help with signing up for and using the patient portal since early 2023. More recently, as an expansion of the Taskforce, the team established the Jefferson Bedside IT Training group to provide one-on-one digital literacy training to hospitalized patients. Dr. Rising hopes that in addition to increasing skills among the patients served, this work can help build their trust in the health system overall and telehealth specifically. But this is not the first screener that Dr. Rising and her team have developed. In 2023, Dr. Rising received a $400,000 grant from the MANNA Institute to help refine the Nutrition Support Assessment Tool to improve patient access to nutrition support and identify nutrition needs.

Dr. Rising's ultimate goal for the Digital Health Readiness Screener is to develop a shorter form for routine use across healthcare settings. "Ideally, in the future, we can administer this screener as a standard part of healthcare encounters and target interventions to each person's specific needs. Access, digital literacy and trust barriers all require different interventions, and this screener can help inform how to most efficiently and effectively deploy those interventions."'