Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA.
Center for Vulnerable Populations, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
J Gen Intern Med. 2023 Nov;38(14):3123-3133. doi: 10.1007/s11606-023-08304-2. Epub 2023 Aug 31.
Telemedicine care dramatically expanded during the COVID-19 pandemic. We characterized facilitators and barriers to telemedicine implementation among safety-net primary care clinics serving patients with limited English proficiency (LEP).
We collected data on telemedicine volume and patient demographics among safety-net clinics participating in a telemedicine learning collaborative. Data on various metrics were reported to the collaborative from February 2019 through August 2021. We conducted semi-structured interviews with clinical and quality leaders, purposively sampling clinics serving high proportions of patients with LEP. We analyzed interviews with a mixed inductive-deductive approach applying the Consolidated Framework for Implementation Research.
By September 2020, the 23 sites served 121,589 unique patients with in-person and 120,338 with telephone visits; 47% of these patients had LEP. Of 10,897 unique patients served by video visits, 38% had LEP. As a proportion of total visits, telemedicine (telephone and video) visits increased from 0-17% in October 2019-March 2020 to 10-98% in March-August 2020. We conducted 14 interviews at 11 sites. Themes included (1) existing telemedicine platforms and interpreter services were not optimized to support patients with LEP; (2) clinics invested significant labor iterating workflows; (3) sites with technological infrastructure and language-concordant staff were best suited to serve patients; (4) patients speaking less-represented languages or experiencing intersecting literacy barriers were underserved with telemedicine. Interviewees recommended innovations in telemedicine platforms and community-based access.
Safety-net sites relied on existing resources to accommodate patients with LEP, but struggled providing access for the most marginalized. Proactive, data-driven strategies to address patient and community barriers as well as optimize clinical workflows with high-quality, certified medical interpreters are needed to ensure equitable access.
在 COVID-19 大流行期间，远程医疗服务大幅扩大。我们描述了为英语水平有限的患者服务的医疗保障初级保健诊所实施远程医疗的促进因素和障碍。
我们收集了参与远程医疗学习合作的医疗保障诊所的远程医疗量和患者人口统计学数据。从 2019 年 2 月到 2021 年 8 月，向合作组织报告了各种指标的数据。我们对临床和质量负责人进行了半结构化访谈，对服务于英语水平有限的患者比例较高的诊所进行了有针对性的抽样。我们采用混合归纳演绎方法对访谈进行了分析，应用了实施研究综合框架。
到 2020 年 9 月，23 个地点共为 121589 名有门诊和 120338 名有电话访问的患者提供服务；其中 47%的患者英语水平有限。在接受视频访问的 10897 名独特患者中，有 38%的患者英语水平有限。视频（电话和视频）访问量占总访问量的比例从 2019 年 10 月至 2020 年 3 月的 0-17%增加到 2020 年 3 月至 8 月的 10-98%。我们在 11 个地点进行了 14 次访谈。主题包括：（1）现有的远程医疗平台和口译服务没有得到优化，无法为英语水平有限的患者提供支持；（2）诊所投入了大量的劳动力来迭代工作流程；（3）具有技术基础设施和语言一致的员工的诊所最适合为患者提供服务；（4）使用较少代表性语言或遇到读写障碍交叉的患者，远程医疗服务不足。受访者建议在远程医疗平台和社区获取方面进行创新。
医疗保障机构依靠现有资源为英语水平有限的患者提供服务，但在为最边缘化的患者提供服务方面仍面临困难。需要采取积极主动、数据驱动的策略来解决患者和社区的障碍，并通过高质量的认证医疗口译人员优化临床工作流程，以确保公平获得医疗服务。
