Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review

Abstract

Background Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities. Objective This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities. Methods A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O’Malley Scoping Review Framework and focused on PCORI’s active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study. Results PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI’s priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information. Conclusions Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

Doctoring from home: Physicians’ perspectives on the advantages of remote care delivery during the COVID-19 pandemic

“…For example, during in-person visits where the use of electronic health records places a focus on completing predetermined tasks and clinical documentation, opportunities for providers to develop a personal understanding of the patient may be curtailed due to the limited time available. Previous studies have found that telehealth has the potential to enhance providers’ understanding of the patient [ 30 , 31 ], which suggests that remote care delivery could, in practice, improve the delivery of patient-centered care and help patients and providers make more informed decisions based on the needs, goals, and expectations of patients and their families [ 32 ]. In contrast, when care is delivered in person, there may be a need to gather and incorporate more personal information into these visits (e.g., a person’s current living conditions, family support needs, and personal preferences for using technology to monitor vital signs) to ensure providers’ understanding of their patients and their preferences.…”

A multi-stakeholder approach is needed to reduce the digital divide and encourage equitable access to telehealth

“…As described by Yellowlees, 21 enabling equitable access to telehealth services should involve more than just investment in telecommunications and communications technology. 14,22 A recent scoping review by Bailey et al 23 included studies designed to address telehealth access barriers in populations with comorbidities, limited English proficiency, and from ethnically diverse populations. This review supports measures to ensure telehealth best practice including (1) patient-centred design of care, (2) culturally appropriate solutions, (3) trusted relations between care providers, and (4) confidentiality of patient information.…”

“…This review supports measures to ensure telehealth best practice including (1) patient-centred design of care, (2) culturally appropriate solutions, (3) trusted relations between care providers, and (4) confidentiality of patient information. 23 Bailey's review also highlights the need to promote policy-level changes to help with the uptake of telehealth services. 23 Specifically, they highlight the relevancy of involving multiple stakeholders to implement effective and culturally competent telehealth solutions addressing equitable access to healthcare.…”

Coronavirus disease pandemic and adolescent substance use

“…However, challenges remain, including preservation of confidentiality, optimization of safety assessment, and disparities in access that may worsen inequities [41 ▪▪ ,44]. The expansion of telemedicine care provides valuable opportunities to research these questions and to create innovative, patient-centered, and culturally tailored programs to address healthcare disparities [45].…”