NUR 8150 Module 5 Telehealth Paper: Pandemic Use Patterns, the Digital Divide and an Equitable Virtual Care Plan Example

Who Logs In: Building an Equitable Telehealth and Patient Portal Program for a Paterson Health Center Network

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8150: Information Systems and Technology Impacting Healthcare Delivery

Mentor Name

Month Day, Year

Who Logs In: Building an Equitable Telehealth and Patient Portal Program for a Paterson Health Center Network

The Decision

The network in this paper is invented: five health center sites in Paterson and Passaic serving about 38,000 patients, most with Medicaid or no insurance, and many who speak Spanish, Arabic or Bengali at home. During the pandemic, virtual visits rose from almost none to nearly half of all visits within a month, mostly by telephone. Now in-person care has returned, emergency payment rules are changing, and the board must decide what virtual care to keep. The DNP-prepared chief nursing officer was asked to recommend a program.

The staff have mixed views. Behavioral health clinicians want to keep virtual visits because patients who used to miss appointments now keep them. Primary care nurses worry that diabetic patients seen by phone have gone months without a foot exam or an A1c. Front desk staff say older patients call confused about video links sent by email in English. Patients themselves, in a short survey in three languages, said that telephone visits saved them bus fare and time off work, but many did not know the portal existed.

Where Telemedicine Started

Kane and Gillis (2018) used the American Medical Association's 2016 practice survey to produce the first national estimates of physician telemedicine use. Only 15.4 percent of physicians worked in practices that used telemedicine for patient interactions, including video visits and remote reading of images, and 11.2 percent used it for interactions between clinicians. Larger practices used it more, which the authors linked to the cost of setting it up. Before the pandemic, then, telemedicine was the exception rather than the rule, and small practices and safety-net clinics like ours had little of it.

What the Pandemic Showed

Patel et al. (2021) drew on claims for 16.7 million privately insured and Medicare Advantage members across the first half of 2020. In the first pandemic months, telemedicine carried 30.1 percent of visits, a twenty-three-fold weekly increase over the months before. Use varied widely: 68 percent of endocrinologists used any telemedicine compared with 9 percent of ophthalmologists, and 53 percent of depression visits were virtual compared with 3 percent of glaucoma visits. Communities with the most poverty used it least, at 27.9 percent of visits, compared with 31.9 percent where poverty was lowest, and where conditions moved online more, total visits fell less.

The study's population was insured and did not include Medicaid, so the paper notes that our patients may differ. Still, the pattern guides our plan: behavioral health and chronic disease follow-up suit virtual care well, conditions that need examination or testing do not, and poverty limits access.

Our Own Data

The network's data from the past year tell a similar story. Behavioral health visits remain 61 percent virtual, and patients keep them more reliably than in-person visits. Diabetes and hypertension follow-up are 24 percent virtual, but blood pressure and A1c are documented less often at virtual visits. Pediatric well visits are almost all in person. Video use is low: 78 percent of virtual visits are by telephone, and video is rarest among patients past 65 and those who prefer Spanish, Arabic or Bengali.

The Portal Gap

Ancker et al. (2011) followed portal use among 74,368 adult patients of a New York community health center network serving low-income neighborhoods. Over two years, only 16 percent received a portal access code, 60 percent of those activated the account and 49 percent used it more than once. Chronic illness raised the odds of getting and using a code, but so did being white, female, younger, English-speaking or insured, and racial differences in repeat use persisted after accounting for language and insurance.

Our network's portal has 22 percent of patients activated, with activation far lower among Spanish and Arabic speakers. Since video visits run through the portal, the portal gap becomes a video gap.

The Proposed Program

The paper recommends keeping virtual care where it serves patients and closing the access gap. Behavioral health keeps virtual visits as a standard option. Chronic disease visits may be virtual when patients have home blood pressure cuffs or glucose meters, which the network will lend, with readings entered by staff during the call. Telephone visits continue for patients who cannot use video, as payment rules allow. Portal enrollment is offered in person at every visit by bilingual staff, with the portal set to the patient's language. Community health workers help patients set up video on their phones. Interpreters join video visits through the platform. Pediatric and new-problem visits default to in person.

The program is also designed around cost. Blood pressure cuffs cost the network about forty dollars each, and a loan program for 500 patients with uncontrolled hypertension would cost less than one avoided admission. Community health workers are already on staff for other programs, and two will be assigned to digital enrollment for the first year. The video platform the network already licenses supports interpreters at no added fee, so the main new cost is staff time, which the paper estimates and presents to the board.

Measures

The program tracks portal activation and video use by language, age and race, no-show rates for virtual and in-person visits, how often diabetes and hypertension visits record a reading, patient satisfaction in each language and visits per patient for behavioral health. A balancing measure, emergency department visits for conditions managed virtually, will flag problems missed without examination.

Conclusion

Telemedicine went from rare to common in a few weeks, but its use was lower in poorer communities, and portal access in safety-net clinics favors English speakers, younger patients and the insured. This health center network's own data show the same divide. The proposed program keeps virtual care for behavioral health and supported chronic care, keeps telephone visits for those who need them, and closes the portal gap with in-person enrollment, translation and community health workers, measured by language and age so that virtual care widens access rather than narrowing it.

References

Ancker, J. S., Barrón, Y., Rockoff, M. L., Hauser, D., Pichardo, M., Szerencsy, A., & Calman, N. (2011). Use of an electronic patient portal among disadvantaged populations. Journal of General Internal Medicine, 26(10), 1117-1123. https://doi.org/10.1007/s11606-011-1749-y

Kane, C. K., & Gillis, K. (2018). The use of telemedicine by physicians: Still the exception rather than the rule. Health Affairs, 37(12), 1923-1930. https://doi.org/10.1377/hlthaff.2018.05077

Patel, S. Y., Mehrotra, A., Huskamp, H. A., Uscher-Pines, L., Ganguli, I., & Barnett, M. L. (2021). Variation in telemedicine use and outpatient care during the COVID-19 pandemic in the United States. Health Affairs, 40(2), 349-358. https://doi.org/10.1377/hlthaff.2020.01786