Making Telemedicine More Accessible to Vulnerable, Underserved Populations

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Dr Alejandra Casillas was first struck by the rise of digital health in 2016, when she returned to the
United States from a 4-year stint working in Europe.
Casillas, now an assistant professor of medicine in the division of general internal medicine and health
services research at the David Geffen School of Medicine at UCLA, has had a longtime interest in health
disparities, with a particular focus on health communications among underserved and limited English
proficient communities.
Following her service as chief medical resident at UCSF Medical Center and as a Robert Wood Johnson
Clinical Scholar at UCLA, Casillas went to Switzerland, where from 2012 to 2016 she addressed
immigrant health disparities in the country’s French-speaking region.
When she left the United States, medical records were still largely maintained with paper and pen, she
said. On returning to the states, she was struck by what she called the “digital revolution” with patient
records. She was particularly interested in its use by the Los Angeles County Department of Health
Services, UCLA’s partner in providing safety net health services for the poor and uninsured. She found
that those records were completely electronic, and the county provided digital access to the system’s
patients—making life easier for a population that already had too many social, economic, and health
burdens.
“In our safety net population at the Los Angeles County Department of Health Services, many patients
have to take multiple buses or take a day off work, sometimes for simple things– like a simple question
or refilling a medication,” Casillas said. “Access to a patient portal takes all those burdens away and
streamlines healthcare.” 
Casillas saw both its promise as well as the hurdles that so much of the underserved Latino community
have to leap to benefit from telemedicine. She thought of her mother, a Spanish speaker who
experienced her own difficulties navigating her health care provider’s patient portal. It was difficult
enough that Casillas had to step in to help on several occasions, and her mother did not rely on the
safety net.
“So when I heard about digital health in the L.A. safety net, one of the biggest and most diverse in the
nation, I said to myself ‘We need to study this. I anticipate there are challenges. We need to find
evidence-based interventions to get patients this type of care,’” Casillas said.
This recognition launched her research into making digital health more accessible to non-English
speakers, who have to contend with the language barrier and sometimes their legal status. They often
lack the financial means to own a computer and must master the intricacies of the internet—and their
patient records—when they do have access to one.

To get the message across, Casillas has spoken with community groups and health care workers, at
conferences such as Google’s “Salud con Tech” and more to advocate for more user-friendly solutions
and relevant digital health applications for these populations. 
Providers at other safety net sites appear to agree with the message, and not just for patients. Casillas
recently surveyed leaders and administrators at three large safety net health systems in California,
which work closely with caregivers. The results, published in July in the peer-reviewed Journal of
Medical Internet Research, found that the providers “recognized the potential for portals to improve
information delivery and communication by helping caregivers assist socially and medically complex
patients in the safety net” while noting that many caregivers themselves face some of the same barriers,
particularly with technical and health literacy and language.
Now, in a new paper published October 23 in the same journal, Casillas lays out steps that can lead
toward breaking down these barriers. They are:
1. Remove unnecessary patient process barriers in enrolling for the portal: This would entail
switching from using a social security number to a patient record number as an identifier when
registering or using an online portal. 
2. Redesign engagement materials with a patient-centered approach, such as producing videos in
multiple languages about portal use that could be played in waiting rooms
3. Partner with electronic health record vendors to focus on user interface and usability from a
safety net patient perspective, with an emphasis on improving the mobile app version of the
portal
4. Create a flexible, patient-friendly mechanism for proxy access by making it easier for safety net
providers to connect with the patient’s family and friends, who often also serve as caregivers
and confidants for decisions on health
5. Create a virtual home for patient-centered care that includes addressing social determinants,
preventive care, and chronic care: For example, safety net providers could set up questionnaires
that patients can complete that outline their health goals such as weight loss and address other
needs such as housing. Armed with this knowledge, providers could send this information
directly to the patients.
6. Redefine the metrics of portal success by adding online forms that patients can use to monitor
chronic conditions; track blood sugar and pressure levels; and integrate platforms for food
banks, transportation assistance, and other community-based resources that directly or
indirectly affect these patients’ health

Given that these populations face numerous barriers to in-person visits, such as their need to take
unpaid time off from work, these enhancements could have a significant impact on their access to care,
Casillas noted. In addition, safety net providers may need these innovations now more than ever.
“The arrival of the COVID-19 pandemic, where health systems have had to scale back on physical patient
visits and in-person patient education and engagement dramatically, with no established telemedicine
workflows in place, is a set-up for worsening health disparities for these patients,” Casillas said. “They
are already at higher risk of poor disease management outcomes. Recent events have only come
to prioritize the integral role of the patient portal for care delivery in the Los Angeles safety net.”


Original article
Casillas A, Abhat A, Mahajan A, Moreno G, Brown AF, Simmons S, Szilagyi P
Portals of Change: How Patient Portals Will Ultimately Work for Safety Net Populations
J Med Internet Res 2020;22(10):e16835
URL: https://www.jmir.org/2020/10/e16835
doi: 10.2196/16835

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