Notes on Telehealth, Health Equity, and the Digital Divide

Telehealth: Definition, modalities, and purpose

• Telehealth defined as the provision of health care at a distance using technology; umbrella term for multiple technologies and interaction methods. Core idea: care is delivered when the patient and clinician are not in the same room.
• Primary modalities used to deliver health care in telehealth:
  • Telephone (audio-only)
  • Video conferencing (video-enabled)
• Other telehealth modalities that exist but are less central in funding/recognition:
  • Store-and-forward (asynchronous transmission of health data, e.g., images, data)
  • Remote monitoring (wearables, home devices sending data)
  • Websites and mobile applications
  • Internet of Things (IoT) and connected devices
• Despite many options, the two main funded/recognized methods are telephone and video conferencing.

Why telehealth? Effectiveness and impact

• Telehealth has demonstrated positive effects across multiple disciplines and telehealth modalities; overall, telehealth is effective and there is broad evidence of its benefits.
• The central questions have shifted from “does telehealth work?” to:
  • “How do we implement telehealth effectively?”
  • “With whom should we use telehealth, and under what circumstances?”
• Context: the COVID-19 pandemic accelerated adoption; pre-pandemic telehealth was often framed as a way to reach people with limited access due to geography or opportunity gaps.
• A key paper from the University of Queensland (2022) outlined strategies for sustaining telehealth after momentum, focusing on five areas (see below).

Momentum and sustainability: What happened post-pandemic

• A data-driven graph (Medicare data) shows:
  • Early 2020 peak telehealth usage around $36 imes\%$ (i.e., about one in three consultations via telehealth).
  • Over time, telehealth use declined and stabilized around $20 imes\%$ (about one in five consultations), predominantly among GPs; allied health subscriptions remained low (around 1.5\ ext{ to }2 ext{ extbackslash%}).
  • A second peak occurred during the Omicron wave, but the high uptake did not persist after the wave, returning toward the $20\%$ level.
• Interpretation: the health system was not fully prepared or competent in using telehealth broadly; training and readiness contributed to the decline.
• The decline raises questions about whether telehealth adoption was reaching those who would not otherwise access face-to-face care; a steep decline suggests telehealth was mainly substituting for in-person care rather than expanding access for underserved groups.
• The phrase by Jeff Watsu: any health care development that does not rapidly become available to all individuals risks unintentionally fueling health inequality. In telehealth, this is described as the digital divide.

The digital divide and telehealth paradox

• The digital divide refers to disparities in access to and use of digital technologies, which can exacerbate health inequities if telehealth is adopted without inclusive design.
• Vulnerable groups often cited:
  • The elderly
  • People with low income (economic barriers to devices, data plans, connectivity)
  • People from culturally and linguistically diverse (CALD) backgrounds, including those with limited English proficiency
• Why telehealth can widen gaps:
  • Not everyone has reliable internet or devices; digital literacy varies; infrastructure may be lacking.
  • Even when technology is available, user proficiency and comfort with digital tools vary.

Australian Digital Inclusion Index (ADII) findings

• Digitally excluded population in Australia: approximately >10\% to $11\%$ of people (about one in ten), with higher risk in certain groups.
• Groups with higher exclusion risk include:
  • People who have not completed secondary education
  • People in the lowest income quartile
  • People living in single-person households
  • People with a disability
  • People who are unemployed or not currently in the labor force
• Implication: health services must design telehealth to reach these groups rather than assuming universal access.

Key strategies to sustain telehealth (from the momentum paper, five core areas)

• Five key strategies to sustain telehealth:
  1) Workforce training – ensure clinicians and staff are equipped to deliver telehealth effectively
  2) Consumer engagement – involve patients and communities in telehealth design and delivery
  3) Reforming funding – align financial models to support sustainable telehealth services
  4) Digital ecosystem design – build an inclusive digital infrastructure and platforms that support health delivery
  5) Long-term sustainability and planning – address ongoing adoption, evaluation, and support mechanisms
• These strategies emphasize moving beyond initial adoption to creating a resilient, equitable telehealth system.

Designing for equity: two core enablers

• Two key factors underpin equitable access to telehealth:
  • Digital literacy – individuals’ ability, confidence, and attitudes toward using digital technologies for health care
  • Infrastructure – access to devices (computer, smartphone), internet connectivity, and reliable broadband
• These factors interact with broader societal differences (income, education, household composition, disability, etc.) and must be considered when designing telehealth programs.
• Holistic, community-tailored approaches are needed rather than one-size-fits-all solutions.

Population needs and preferences: don’t assume, ask

• Practical design principle: assess population needs and attitudes toward seeking care and toward technology use.
• Do not assume that a person who requires an interpreter or who is not English-speaking will prefer or be able to use telehealth without support.
• A multi-layered approach is required: provide devices or connectivity, or improve broadband; provide literacy support; and ensure interpreters or language assistance as needed.
• Example thought experiment: Even if a university provides devices (tablets/computers) and broadband, some users may still be unable to access telehealth due to location (bus, home, or a facility) or due to lack of digital literacy. Conversely, improving digital literacy without access to devices or internet is insufficient.
• Equity-orientation means offering choices and removing barriers, not forcing telehealth as the default option.

Language access and CALD communities: a case example

• A Queensland study examined telehealth use by language background:
  • English-first-language users: about $60\%$ of services in person; $40\%$ via telehealth.
  • Non-English-first-language users: about $71\%$ in person; $29\%$ via telehealth.
• Adding interpreters further changes these numbers:
  • If interpreters are required, telehealth drops to less than $19\%$, with in-person visits exceeding $81\%$.
• Interpretation: addressing language needs is necessary but insufficient on its own to ensure equitable telehealth access; other access factors (distance, literacy, device/internet access) must be addressed.
• Practical takeaway: do not assume. Use patient-centered questions to determine preferences and feasibility; provide interpreters and user-friendly telehealth options as needed.

Don’t assume—ask and tailor the experience

• A simple resource was developed for clinicians to assess telehealth feasibility without relying on assumptions (screensaver-style guidance): advise clinicians to ask patients about preferences, capabilities, and support at home (e.g., whether someone at home can assist and whether the patient has a phone or internet access).
• The core message: offer choices (telehealth or in-person) and align with patient preferences, while ensuring the necessary supports are in place to enable telehealth if chosen.

Accessibility for people with disabilities: WHO-ITU Global Standard for Accessibility of Telehealth

• Disability-inclusive telehealth is essential; the WHO-ITU standard outlines challenges and recommendations for disability groups:
  • Vision impairment or blindness: captioning, high-contrast interfaces, screen-reader compatibility
  • Deaf or hard of hearing: captioning, text messaging, remote sign language options
  • Speech difficulties: alternative communication approaches and supports
  • Mobility impairments: accessible hardware and interfaces
  • Psychological disabilities: user-friendly, non-overwhelming design, supportive features
  • Developmental, intellectual, or learning disabilities: simplified interfaces, clear instructions, and support
• The standard also covers security considerations to protect patient data in accessible telehealth systems.
• Practical impact: use these guidelines to plan and implement telehealth services that are accessible to people with a wide range of abilities.

Practical implications: designing equitable telehealth systems

• Reaffirm the right to health and health equity: equitable access means enabling patients to use telehealth to obtain care, not simply offering technology that some can access.
• Plan with population needs in mind: identify target groups, assess digital literacy and infrastructure, and tailor interventions.
• Consider multi-layered solutions:
  • Provide devices to those who need them and ensure connectivity where possible
  • Invest in broadband and infrastructure improvements, especially in rural or underserved communities
  • Build digital literacy programs and patient education
  • Ensure language support (interpreters, multilingual interfaces, captioning)
  • Implement accessibility features for disabilities
• Emphasize hybrid models: combine in-person and telehealth options; choose modality based on clinical need and patient preference
• Engage with communities to co-design telehealth solutions and reduce stigma or biases in booking and access

Ethical and practical implications

• Equity vs. equality: providing everyone with the same resource is not enough; equity requires giving more support to those with greater barriers to ensure comparable outcomes.
• Avoid reinforcing existing disparities: telehealth should actively reduce barriers for underserved groups rather than widen gaps.
• Data and measurement: monitor telehealth use across populations, track access disparities, and adjust programs accordingly.
• Privacy and security: ensure patient data protection in all telehealth modalities, especially when expanding access via devices and internet connectivity.

Summary: equitable telehealth as a long-term goal

• Telehealth offers a unique opportunity to improve access to health care and health equity, but its success depends on intentional design, implementation, and ongoing evaluation.
• The digital divide is a real barrier; actions must target both digital literacy and infrastructure, and must be tailored to population needs.
• Practical strategies include: workforce training, consumer engagement, funding reform, digital ecosystem design, and sustainability planning.
• For CALD and disability communities, ensure language access and accessibility standards; avoid assumptions; empower patients with choices and supports.
• The World Health Organization ITU standard provides actionable guidance for making telehealth accessible to people with disabilities.
• Ongoing evaluation and patient-centered design are essential to ensure telehealth reduces, rather than exacerbates, health inequities.

References and further reading (context from the transcript)

• Momentum and sustainability paper from University of Queensland Center for Online Health (early 2020s) outlining five strategies: workforce training, consumer engagement, reforming funding, digital ecosystem design, and sustainability planning.
• Australian Digital Inclusion Index findings on digitally excluded populations (education, income, household type, disability, unemployment).
• World Health Organization and ITU Global Standard for Accessibility of Telehealth (disability-focused accessibility guidelines and security considerations).
• Case studies on language access in telehealth (interpretation and patient preferences) and the importance of not assuming patient capability.