Disparities In Telehealth Use Among California Patients With Limited English Proficiency

For the 25.6 million people with limited English proficiency in the US, language barriers pose a significant challenge to their health care experience and receipt of high-quality care.¹ Patients with limited English proficiency experience significant disparities in care including increased numbers of hospitalizations, lengths-of-stay, numbers of thirty-day readmissions, and numbers of emergency department (ED) visits and decreased access to preventive services.^2–5 The equitable deployment of technology offers opportunities to ameliorate these gaps.⁶

Telehealth represents an emerging technology that could bridge gaps in care. Evidence suggests that extending care beyond the clinic setting improves access.^7,8 Telehealth has been shown to improve patient satisfaction, care access, and outcomes in multiple diseases, including dermatologic conditions, diabetes, cerebrovascular disease, and alcohol use disorder.^7,9–13 Nationally, telehealth use has steadily increased from 6.6 percent in 2013 to 21.6 percent in 2016.¹⁴ During the coronavirus disease 2019 (COVID-19) pandemic, telehealth use expanded rapidly because of the need for social distancing and changes to reimbursement and the Health Insurance Portability and Accountability Act (HIPAA) of 1996—specifically, the Privacy, Security, and Breach Notification Rules—governing telehealth.^15,16

California not only has the largest population of people with limited English proficiency in the US but also has been supportive of telehealth services. California-based Kaiser Permanente has seen growth in telehealth use, with more than half of its patient interactions occurring through telehealth, although this includes electronic exchanges of secure messages, prescription refill requests, and other asynchronous activities.¹⁷ The state defines telehealth as “a mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.”¹⁸ Telehealth services are covered by Medi-Cal, California’s Medicaid program.¹⁹

For the 6.6 million people with limited English proficiency in California,¹ these policy changes present opportunities to improve both access to telehealth and overall care. However, previous national studies have identified disparities in telehealth use among underserved populations. Jeongyoung Park and colleagues found that Medicaid, low-income, and rural populations have decreased rates of telehealth use.¹⁴ To our knowledge, there are limited studies examining telehealth use among patients with limited English proficiency before the pandemic. Without a specific focus on technology uptake among these patients, telehealth may perpetuate digital divides in patient-facing technologies, as has been documented in patient portals and mobile health apps.^20,21

Given the importance of inclusive technology deployment, we sought to highlight the impact of language barriers on telehealth use. The aims of our study were to assess the association between limited English proficiency and telehealth use and to evaluate the impact of telehealth use on health care access and use among patients with limited English proficiency.

Study Data And Methods

Study Sample

We performed a pooled secondary analysis of data from the 2015–18 adult California Health Interview Survey, a cross-sectional, population-based telephone (landline and cellphone) survey administered biannually.²² The survey is conducted in six languages: English, Spanish, Chinese (Mandarin and Cantonese), Vietnamese, Korean, and Tagalog. The adult response rate was 47.2 percent in 2015, 44.6 percent in 2016, 63.0 percent in 2017, and 42.3 percent in 2018.²² The sample includes both households with landlines and those with cell phones only. Internet use data were collected only for the 2015–16 cycle.

Measures

For the main analysis, our primary outcome was telehealth use as measured by the question: “During the past 12 months, did you receive care from a doctor or health professional through a video or telephone conversation rather than an office visit?” The survey definition of telehealth is often referred to as telemedicine.¹⁸ Our exposure variable was limited English proficiency, defined as participants who stated that they spoke English not well or not at all. In our second analysis, controlling for internet use, we limited our sample to 2015–16, as this question was not asked during the 2017–18 cycle. Internet use was evaluated using the question: “In the past 12 months, did you use the Internet to look for health or medical information?” Finally, in our third analysis, we evaluated the association of telehealth use on health care access and use stratified by English proficiency. For these analyses, telehealth was the exposure. Outcome measures of health care access included delays in medical care (“During the past 12 months, did you delay or not get any other medical care you felt you needed—such as seeing a doctor, a specialist, or other health professional?”) and delays in prescriptions (“During the past 12 months, did you delay or not get a medicine that a doctor prescribed you?”). The outcome measure of use pertained to ED use (“During the past 12 months, did you visit a hospital emergency room for your own health?”).

Covariates

We chose these covariates because they have been previously demonstrated to influence telehealth use.¹⁴ We controlled for age (categories: ages 18–29, 30–39, 40–49, 50–64, or older than 65), sex (male or female), insurance type (uninsured, Medicare, Medicaid, employer based, private purchase, or other public insurance), education (less than high school, high school graduate, some college, or college graduate), marital status (married or unmarried), federal poverty level (0–99 percent, 100–199 percent, 200–299 percent, or 300 percent or more), self-reported health status (poor, fair, good, very good, or excellent), and whether patients had a usual source of care (yes or no) as a proxy for access to primary care. We included place of residence (nonmetropolitan or metropolitan) as defined by the Office of Management and Budget’s (OMB’s) classification of Metropolitan Statistical Areas. We used the California Department of Finance race/ethnicity classification, which tabulates Latino/Hispanic as a mutually exclusive racial/ethnic category from the non-Latino/Hispanic major race categories specified by the OMB. In our analysis of access and use, we only distinguished between Latino and non-Latino for the race/ethnicity variables and between uninsured and insured for insurance status because of smaller sample sizes.

Statistical Analysis

We performed three analyses in this study: the main analysis assessing the association between limited English proficiency and telehealth use, a second analysis limited to the 2015–16 cycle to control for internet use as a covariate, and an analysis assessing the association of telehealth use and outcomes of access and use stratified by English proficiency. For the main and second analyses, we performed descriptive analysis and bivariable comparisons across our two groups (patients with limited English proficiency and patients who are proficient in English), using chi-square analysis. We then performed weighted multivariable logistic regression to determine the odds of telehealth use based on English proficiency after controlling for covariates. We also examined whether the relationship between English proficiency and telehealth use was modified by selected covariates (race/ethnicity, education, federal poverty level, health status, type of insurance, internet use, and usual source of care) by including pairwise interaction terms in our models. For our analysis of access and use, we stratified our sample by English proficiency, comparing telehealth users with nonusers. We performed three logistic regressions using delays in medical care, delays in prescriptions, and ED visits as the outcome variables. For missing data, we performed a complete case analysis. In all analyses we used survey-supplied weights to produce population estimates. Two-sided $p<0.05$ was considered statistically significant. The weights represent California’s residential population. These analyses were performed using SAS statistical software, version 9.4.

Limitations

Our study had several limitations. We did not assess all telehealth modalities; although the California Health Interview Survey asks about phone or video telehealth applications (synchronous), for example, it does not include store-and-forward (asynchronous) exchange of medical images or information. Further, our study relied on self-reported telehealth use and did not disaggregate video versus telephone visits, although there was significant variation in the use of each modality: During 2013–16 video communication rose threefold but the rate of telephone communication dropped. In addition, we used internet use as a measure of internet access; however, patients who report using the internet might not have consistent access. Our study was limited to California; although state-level telehealth policy variation, Park and colleagues found no association between how restrictive state telehealth policies were and the population’s use of video telehealth.¹⁴ Finally, our study did not account for unobserved patient factors, in addition to clinician- and institutional-level factors, that could contribute to telehealth use among patients with limited English proficiency.

Study Results

This study included 84,419 respondents, representing a population estimate of 29,406,792 people; 15 percent were patients with limited English proficiency (n = 8,063, representing 4,410,605 people). Patients with limited English proficiency were more likely to be older, female, less educated, poorer, uninsured, and Medicaid recipients and to lack a usual source of care (exhibit 1). They reported worse health status and lower rates of internet use (41.1 percent versus 67.2 percent). In bivariable analysis, patients with limited English proficiency had a lower rate of telehealth use (4.8 percent versus 12.3 percent). This difference persisted in adjusted analysis, in which patients with limited English proficiency had a lower odds of using telehealth (odds ratio: 0.56; exhibit 2). In further analysis, none of the interaction terms between English proficiency and the selected covariates was significant; thus, we concluded that the effect of English proficiency on telehealth use was not modified by these covariates (see online appendix exhibit A6).²³

We also found that the odds of telehealth use varied across multiple factors (exhibit 2). Asian patients (OR: 0.76) had lower odds of telehealth use compared with White patients. Patients with poor (OR: 3.01), fair (OR: 2.02), good (OR: 1.58), or very good (OR: 1.25) health status had higher odds of reporting telehealth use compared with patients reporting excellent health status. Patients who were uninsured (OR: 0.55) or were covered by Medicaid (OR: 0.66) had lower odds of telehealth use compared with patients with employer-based insurance. In addition, patients residing in nonmetropolitan areas (OR: 0.60) also had lower odds of using telehealth compared with patients living in metropolitan areas.

In the analysis limited to data from 2015–16 to control for internet use, we still found that patients with limited English proficiency had a lower odds of reporting telehealth use (OR: 0.60). In addition, we found that for all patients there was an association between internet use and telehealth, with patients not reporting internet use being less likely to report telehealth use (OR: 0.47).

Among patients with limited English proficiency, bivariable analysis demonstrated that non–telehealth users with limited English proficiency were more likely to be uninsured (22.9 percent versus 12.8 percent; $p=0.05$) and more likely to lack a usual source of care (27.5 percent versus 16.1 percent; $p=0.05$), although these differences were not significant (appendix exhibit A3).²³ The proportion of internet use was greater among telehealth users compared with non–telehealth users (64.0 percent versus 40.1 percent; $p<0.001$). Otherwise, there were no significant differences between patients with limited English proficiency using and not using telehealth.

In the access and use analysis, telehealth use was associated with higher odds of having an ED visit in the past year both for patients with limited English proficiency (OR: 2.77) and for patients who are English proficient (OR: 1.84) (exhibit 3). For patients with limited English proficiency, the use of telehealth was not associated with delays in medical care (OR: 1.77; $p=0.12$; appendix exhibit A4).²³ Although unadjusted analysis initially suggested an association between telehealth use and prescriptions delays, this was not significant in adjusted models (OR: 1.30; $p=0.44$; appendix exhibit A5).²³ For patients who are English proficient, telehealth use was associated with delays in medical care (OR: 1.37; $p<0.001$) and prescriptions (OR: 1.61; $p<0.001$) in adjusted analysis.

Discussion

In a representative sample of California adults, we found that patients with limited English proficiency had half the odds of using telehealth services compared with English-proficient patients, even after we accounted for other sociodemographic factors and health status. This suggests that this group does not yet have access to telehealth, revealing a missed opportunity given the existing gaps in their care. Even after we controlled for internet use, telehealth disparities across English proficiency persisted. Moreover, all patients with lower internet use were less likely to use telehealth.

In addition to language barriers, we found that having a usual source of care was essential to having access to telehealth. Notably, only Asian patients reported lower rates of telehealth use compared with other races. Further, patients who were female, were insured, were living in a metropolitan area, and had a higher income were more likely to use telehealth services—factors that have been predictive of telehealth use.^24,25

Among patients with limited English proficiency, telehealth use or lack thereof demonstrated no significant association with experiencing delays in obtaining medical care or prescriptions. Although the results were not significant, given the increased odds, an alternative consideration is that telehealth use may be higher among those having trouble accessing routine care. Ultimately, these data highlight an opportunity to assess the impact of telehealth on access to care more broadly.

In addition, among both patients with and without limited English proficiency, telehealth use was associated with increased ED use. Two potential reasons are that urgent care telehealth visits could lead to more ED referrals rather than in-person visits and that the current telehealth infrastructure makes it challenging to deliver remote care effectively. Telehealth has been promoted as an innovative approach to bridging health care gaps by increasing access to services, but these findings highlight the challenges of using this technology.

Our results identify language as an important barrier to telehealth use. Patients with limited English proficiency have documented disparities in care access, satisfaction, utilization, and quality. Professional interpretation is a standard part of care for patients with limited English proficiency.²⁶ Federal law requires health programs that receive federal funds, such as Medicare and Medicaid, to provide language services to patients in their preferred language. The legal rights of patients with limited English proficiency have been protected as part of nondiscrimination laws for decades, such as Title VI of the Civil Rights Act of 1964.²⁷ These rights were recently broadened under Section 1557 of the Affordable Care Act.²⁸ Despite these mandates, about a third of US hospitals do not offer language services.²⁹ The provision of linguistically appropriate care already presents a challenge to health systems, making it unclear how diligently hospitals would establish or maintain compliance when providing telehealth services. This is especially relevant given policy changes implemented during the COVID-19 pandemic that led to the rapid increase in telehealth use.^15,30

A limitation of existing telehealth literature is the lack of information on incorporating interpreters into telehealth workflows and whether different interpretation modalities affect patient satisfaction with telehealth. For example, one study of thirty-two Spanish-speaking Latino patients found that they rated professional video interpretation as being of higher quality than in-person professional and ad hoc interpretation.³¹ It remains unclear how this would be experienced in the telehealth context, where the workflow could require two co-occurring phone or video conferences for interpreter participation. Further research could elucidate how physician-patient communication is altered in telehealth visits, particularly for patients who are vulnerable to communication barriers. In one study comparing the ratio of physician to patient talk time in telehealth versus in-person visits, telehealth visits were found to be more physician centered, with the patient taking a relatively passive role.³² This is concerning, as even in-person visits with an interpreter can influence physician-patient communication.³³ If telehealth is to achieve its full potential, equity and patient-centeredness should play a central role in its implementation.^34,35

Given the varied levels of telehealth use among racial/ethnic groups, our findings highlight the importance of assessing minorities’ perceptions of new innovations to explore unique factors associated with diffusion and adoption.^24,36 For example, in one study of African Americans’ and Latinos’ perceptions about telehealth, African American patients expressed more concerns about confidentiality, privacy, and physically being unable to see the physician than Latino patients. This is potentially due to lower levels of trust resulting from a legacy of historical abuses in the US medical system.³⁷ Understanding community-specific factors influencing the acceptance of new care delivery technologies could help inform telehealth implementation among diverse populations.

The importance of having a usual source of care makes sense conceptually, as many telehealth services center on access to specialty care, which could be contingent on primary care referral.³⁸ One 2016 consumer survey conducted by the American Telemedicine Association found that accessing telehealth was associated with whether providers even offered telehealth services.³⁹ Patients with limited English proficiency may have limited access to providers who offer telehealth services, seeking care at clinics that lack the resources to establish and maintain telehealth equipment and infrastructure. This barrier may be addressed by approaches similar to the recent grants programs by the Federal Communications Commission (FCC), which allocated $200 million toward supporting telehealth programs.⁴⁰ However, it is also possible that providers are making assumptions about whether patients with limited English proficiency want to or can use telehealth services. Future research could clarify the mechanisms of the disparities identified in our study.

Overcoming patient barriers to using telehealth must include addressing multiple facets of the digital divide, including internet access, digital literacy, and linguistically appropriate online information. Our study found that internet use was positively associated with telehealth use, consistent with previous studies.⁴¹ With at least twenty-one million people in the US lacking broadband internet access, this divide remains a critical piece of expanding telehealth services.⁴² Internet connectivity depends on both geographic availability and a patient’s adoption of internet services. However, internet use did not completely explain the telehealth disparities of patients with limited English proficiency. This suggests that other factors, such as digital literacy and linguistically appropriate content, must be investigated. Digital literacy ensures that patients can meaningfully engage with online tools such as telehealth.⁴³ Further, the lack of online information in their preferred language may limit patients’ ability to use telehealth platforms. For example, previous studies have found a lack of linguistically appropriate mobile apps and clinic websites.^44,45 Thus, the mechanisms underpinning these digital divides deserve special focus as telehealth expands.

Policy Implications

Our study reveals opportunities for multilevel policy changes that can ensure the equitable expansion of telehealth.

Our study reveals opportunities for multilevel policy changes that can ensure the equitable expansion of telehealth. First, national and local policy makers should collaborate with health organizations to apply a comprehensive approach that promotes digital equity, including broadband access, device access, telehealth infrastructure, and community-based digital literacy programs. At the federal level, the FCC could expand programs such as the Lifeline program, which subsidizes the cost of internet service and can mitigate the financial burden of remaining connected. Programs supporting telehealth at community health centers that disproportionately serve patients with limited English proficiency, such as the FCC’s COVID-19 Telehealth program, should be bolstered. This program has allowed organizations to build their telehealth infrastructure, provide patients with technology, and engage community health workers in promoting digital literacy. Health care organizations can partner with community organizations (for example, libraries) to provide digital literacy training, similar to efforts supporting patient portal use.²⁰ Further, a commitment from payers, including the Centers for Medicare and Medicaid Services (CMS) and commercial payers, to payment parity across visit modalities (video, telephone, and in-person) will help maintain telehealth as a part care.

Efforts addressing interpreter workflows are essential to engaging patients with limited English proficiency in telehealth. Telehealth vendors should include functionalities that allow for rapid integration of interpreters as part of the visit; these functionalities are increasingly available. To support these efforts, the Department of Health and Human Services could update guidelines on language equity, such as the National Standards for Culturally and Linguistically Appropriate Services, to explicitly include the provision of interpreters in telehealth visits. Further, payers, such as CMS, should expand reimbursement for interpreters, thus encouraging their use across all visit modalities.⁴⁶ At the institutional level, seamlessly integrating interpreters into telehealth workflows will help with both patient and provider satisfaction. Finally, institutions should monitor telehealth use across patient demographics, including language, to quantify the magnitude of disparities as they are likely to persist.⁴⁷

Conclusion

These findings suggest that patients with limited English proficiency should be included as part of the telehealth equity conversation, especially as telehealth deployment among such patients presents novel challenges to providing linguistically appropriate care. Telehealth has the potential to address disparities, but only if it meets all patients’ needs, no matter what language they speak; otherwise, evidence of digital divides will continue to appear. Policy makers and providers must pursue linguistically equitable care in emerging technologies. The rapid shift to telehealth during the COVID-19 pandemic along with the disproportionate impact on underserved populations heightens the importance of technology equity as a health policy and public health focus.

ACKNOWLEDGMENTS

Similar data and results were presented at the American Public Health Association Conference (October 27, 2020) and the American Medical Informatics Association Symposium (November 18, 2020). Lee Schwamm reports the following relationships relevant to research grants or companies in the telehealth field: scientific consultant regarding user interface design and usability to LifeImage (privately held teleradiology company), stroke systems of care to the Massachusetts Department of Public Health, and principal investigator for StrokeNet Network, National Institute of Neurological Disorders and Stroke (New England Regional Coordinating Center U24NS107243). David Bates reports consulting for EarlySense, which makes patient safety monitoring systems. He also receives cash compensation from CDI-Negev Ltd., which is a not-for-profit incubator for health information technology start-ups. He receives equity from ValeraHealth, which makes software to help patients with chronic diseases; from Clew, which makes software to support clinical decision making in intensive care; and from MDClone, which produces deidentified versions of clinical data. Lipika Samal receives research funding from the National Institute of Diabetes and Digestive and Kidney Diseases (Grant No. R01DK116898). The views expressed in this article are those of the authors and do not necessarily reflect the views and policy of the National Institutes of Health.

NOTES

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