When David Velasquez went home to California for a week in April, he found out that his parents didn’t have internet access anymore. Velasquez, a medical student at Harvard, needs Wi-Fi for work. However, his parents don’t own a computer. “They don’t shop online, they don’t watch Netflix,” he says. So when the connection got too expensive, they stopped paying for it.
With the COVID-19 pandemic ravaging the country, that decision worried Velasquez. His parents also speak very little English, and doctors and clinics in the US were canceling in-person appointments and asking patients to schedule virtual visits for any health problems instead.
Without internet access and with limited English, Velasquez’s parents wouldn’t be able to make that switch. “I knew that as our healthcare system started transitioning over to telehealth as opposed to in-person, in-clinic care, their access to health care — and other individuals like them — would be disrupted,” he told The Verge.
Telehealth is convenient for some people: it cuts out the drive to an office and the time in a waiting room, trimming an hours-long event down to minutes. But it isn’t easily accessible to the 25 million people in the United States who speak little English, who are more likely to live in poverty, often work service or construction jobs, and may be more at risk of exposure to COVID-19. Even if they are able to get online, most of the systems that support telehealth — like hospital portals and video visit platforms — are hard to access for people who primarily speak other languages.
Those barriers could limit their access to care during the pandemic. The challenges are already reflected in hospital data. At one University of California at San Francisco primary care clinic, 14 percent of visits are usually from non-English-speaking patients. After the pandemic forced a switch to telehealth, that dropped to 7 percent. Experts are worried that drop-off in care for these groups could exacerbate health disparities — not just around COVID-19, but also in chronic conditions like diabetes.
Even though they’re worried, experts aren’t surprised. “I think what we’re seeing is what the system was built to do. We had built this system where these extra tools, these virtual care tools, weren’t for the limited English population,” says Jorge Rodriguez, a health technology equity researcher at Brigham and Women’s Hospital in Boston. “These tools were for the privileged. When we made the shift from these being privileged care to standard care, you see all the people who aren’t able to access them.”
Navigating the health care system is challenging enough if you don’t speak English. Walking into a clinic can cause more anxiety if the person at the desk struggles to understand you, for example. If your doctor doesn’t speak your language, they’re legally required to provide an interpreter, but many try to squeeze by without them — which could lead to miscommunication about the dose of a medication you need to take or put you in more danger of a bad outcome. The barriers pile up: doctor’s notes in English, an inaccessible prescription refill system, a wheelchair company can’t call to give you a delivery date.
The pandemic sets up additional roadblocks. As COVID-19 spread across the US, doctors suddenly changed how they practiced medicine. Many canceled in-person visits and told patients they’d switched to telemedicine — a fragmented umbrella term that includes everything from text messaging to an integrated video chat.
Some of Elaine Khoong’s patients at Zuckerberg San Francisco General Hospital didn’t get the message. At the start of the pandemic, the policies and practices were changing every day, Khoong, a general internist and assistant professor of medicine also affiliated with the University of California at San Francisco (UCSF), told The Verge. “All this was communicated to our patients, but it was really only being communicated in English,” she says. Automated texts to remind patients of their visits were updated to say that the appointment would be by phone, but those were initially only in English and Spanish.
Many of Khoong’s patients speak Chinese and responded to the text messages saying that they wanted to cancel their appointment because they didn’t want to come into the office out of fear of COVID-19. “They didn’t realize it was a reminder about a telephone visit, rather than an in-person visit,” she says.
For her patients, telemedicine means phone calls. Leveling up to video calls requires extra infrastructure (webcams, computers, software) for both patients and doctors, and some degree of tech savvy. Even with a computer and internet access, it takes a lot of steps to download and use a new app — and it’s even harder if the instructions are in a language the user doesn’t speak.
“A lot of the technology, the applications themselves, are not in other languages. So just getting access to talk to a provider requires additional language support from a family member, or additional coaching from the provider,” says Carolina Valle, policy manager at the California Pan-Ethnic Health Network, an organization that works to reduce health disparities.
Video visits may be better for patients, Rodriguez says, because doctors can actually see their patients and get a sense of their environment. Relying on phone calls because video systems aren’t accessible shouldn’t be a long-term solution. “Saying, well, we can’t figure out the technology piece, so let’s just do let’s just do audio — I don’t think that’s good enough,” he says.
Khoong has been able to see some patients through Zoom, but only after a medical student called to walk them through the process of downloading the application. “We tried creating YouTube videos that show the process in five to seven different languages. But again, I don’t know how accessible that is to our patients anyways — they’d have to find our website,” she says.
Navigating Zoom may be one of the easier ways to set up video visits. Health care systems, including UCSF, can also integrate video visits directly into their patient portals, the online web applications people can use to access their health records. Most patient portals, though, are only available in English. Research shows that non-English speakers are far less likely to use portals than English speakers, thanks to a combination of tech and language barriers.
Portals are convenient, says Alejandra Casillas, a primary care physician and assistant professor of medicine at UCLA Health. They’re already hubs for someone’s health information, and running a virtual visit through them keeps everything in one place. Enrollment in the UCLA portal has gone up since the pandemic started, as patients tried to handle their health care from home. But Casillas also works with LA’s safety net health care system, which serves a much more linguistically diverse population. There, they’ve seen enrollment in the patient portal drop.
That’s not surprising, she says. Efforts to enroll low-income and non-English-speaking patients in portals rely on in-person outreach and educational sessions — all of which are on hold. “Now we have to rely on the portal, but our enrollment is actually going in the opposite direction,” Casillas says.
Hospital-run patient portals may still be more accessible than platforms run by private virtual care companies, which offer online visits through insurance plans or for a fee. They’re like urgent care, but digital (and many also have a la carte therapy sessions, dermatologist appointments, or other specialties). Some health care systems also use their systems to support their internal virtual visits.
Most of those platforms don’t seem to have been designed with non-English speakers in mind, Rodriguez says. “You have to look at who’s being targeted,” he says.
The website for American Well, one major telemedicine company, is in English. Spanish-speaking doctors are available once you get past the sign-up page, but that’s not immediately clear from the outset. The company offers a Spanish-language module, but only to health care clients who purchase it, a representative told The Verge.
Rodriguez combed through the website for Teladoc, another major virtual provider. Teladoc did not respond to two requests for comment on their non-English language accessibility.
“I searched Spanish — nothing. Language — nothing,” Rodriguez says. Their mobile app only has English and French listed as options. He admits that he didn’t do a very extensive search, and Teladoc does ask for language preferences during signup. But he points out that a patient just passing through may not get that far. “If I’m a patient, and I say, I’ve heard of this Teladoc thing, but I’m Spanish speaking, can I access that?” he says. “The website isn’t really built for non-English speakers.”
For limited English speakers, figuring out the tech on the patient end is just the first step. Once a patient gets set up on a Zoom call at UCSF, Khoong has to turn to the next logistical challenge: integrating a medical interpreter onto that call who is trained to serve as the linguistic go-between for the visit. To make it happen, she has to call the interpreter on her personal phone and conference them into the Zoom line. Then, she has to rename that caller so that the patient doesn’t see her phone number.
“You can navigate it, especially if you’re somebody who’s done a ton of Zoom, but it’s not easy to navigate, especially in the middle of a visit,” Khoong says.
She worries that doctors who aren’t as experienced with the system might skip the step entirely and not bring in an interpreter. “People could weigh it as how much they can get away with,” she says. “Not anything against the clinicians, it’s just the reality of the difficulties of figuring this out.”
Interpreting for a doctor’s visit requires more than just a passing grasp of another language — medical interpreters are specially trained in medical terminology and patient privacy, and cultural awareness. When they’re part of a visit, limited-English proficient patients have fewer communication errors, better outcomes, and shorter hospital stays.
Getting an interpreter looped into a doctor’s appointment is already hard for non-English-speaking patients, even though health care systems are legally required to provide qualified medical interpreters to patients. Around one-third of hospitals don’t provide interpreters for patients who need them, one 2016 analysis found. The challenges are only exacerbated by the shift to telehealth.
“We’re hearing the same things, it’s just worse,” Valle says.
In theory, it should be easier to loop an interpreter into a telehealth visit. For a virtual visit, doctors don’t have to go through the logistical steps of getting an extra person into a room (if they have interpreters on staff) or fumble with an iPad or phone while they’re examining a patient (if they rely on remote interpreting services).
In reality, though, there aren’t seamless ways to add a third person to video calls. At UCSF, some interpreters are on the hospital staff; they’re a bit easier to integrate because they’re also using Zoom. Others, though, are contracted through remote interpreting services, which usually provide interpreters over a phone line or unique video app. The company’s video platforms aren’t easy to patch through to something like Zoom. “It’s completely different,” Khoong says.
Those remote interpreting companies, like Certified Languages International (CLI), are scrambling to make sure their interpreters can be patched through on all types of video visits. CLI has its own complete telemedicine platform, but now, it’s working to make sure its interpreters can be used on any video service, says CEO Kristin Quinlan. It’s helping clients troubleshoot, but it’s also working directly with major telehealth and videoconferencing platforms like Zoom and Doxy.me. “[The tech platforms] truly had not considered the fact that there were other components that should have been folded into these platforms,” Quinlan says.
Like Khoong, Quinlan thinks that clinicians are skating by without interpreters as they make the transition to virtual care and try to navigate the pandemic. “They’re not doing anything on purpose, they’re just scrambling,” she says. “Everybody’s trying to figure this out. But the limited English speaking population oftentimes gets left in the dust.”
Fixing the problem
David Velasquez knows how his parents would respond if they were asked to see a doctor through a digital platform. “They would be very lost,” he says. “What they would do is call me.” They’re fortunate to be able to call someone who works in medicine and has the skills to navigate the process. “But that’s not the case for a lot of families,” he says.
The COVID-19 pandemic didn’t create the barriers between non-English speakers and virtual care, but the overnight switch to telehealth illuminated inadequacies that doctors, patients, and advocates knew existed. “It’s just bringing them to the light,” Rodriguez says. For years, he says, clinicians and developers may have assumed that non-English speakers aren’t interested in or able to use telemedicine. “It’s self-fulfilling. They say, this person isn’t going to use it, so I’m not going to build it, so they can’t use it. And then it’s, well, told you,” he says.
There’s no overnight fix to untangle those assumptions and open up existing systems to those communities, Rodriguez says. It’s easy to identify problems, but it’s hard to translate portals into different languages and to commit resources to updating multilingual webpages. “Which languages do you choose? Do you choose all the languages?” he says. It takes attention, work, and investment to engage more closely with non-English-speaking communities. So far, that hasn’t been a focus.
As a consequence of inaction, millions of people in the US aren’t as able to navigate the newly online health care system. Casillas is worried about her patients’ exposure to COVID-19, but she’s also worried about their other health conditions. Non-English speakers in the US already are more likely to have chronic conditions like diabetes and hypertension, and they’re more often poorly controlled. Any disruption in care could widen the gaps.
“If we don’t figure out a way to sort of make sure that outreach is packaged in a way that patients can still access care, I really worried that their chronic conditions are going to get worse and we’re going to see all those gains around health disparities for chronic conditions go away,” she says.
That’s the concern with digital health, Casillas says — that it’ll improve health care for some people, but for others, it’ll throw up more barriers. “Digital health is a great thing. But we haven’t been as good or intentional in thinking about how it works in different populations,” she says. “The limited English speaking population isn’t a small group. And we’ve left them out.”
Update June 8th, 12:38PM ET: This story was updated to include Elaine Khoong’s Zuckerberg San Francisco General Hospital affiliation.