Telehealth: Bridging the Trust Divide


Summary

Trust is the foundation for provision of healthcare to patients and affects patient outcomes and care quality. Patients who trust their providers are more likely to follow treatment recommendations and have better overall health. Trust in healthcare reflects care quality and access, and interpersonal dimensions of communications. Beyond financial barriers, the lingering influence of historic research and treatment abuses continue to erode trust for vulnerable communities. To leverage the potential for telehealth to improve trust and accountability in the healthcare system, access must be expanded for vulnerable populations and patients should be empowered to make informed choices regarding their healthcare. Measures for providing more sensitive and equitable telehealth care delivery are suggested.

The Seeds of Distrust

While the data suggests that most people like their doctors, overall trust in the healthcare system has eroded significantly in the last half-century. Historic research and treatment abuses sustain distrust among marginalized populations in particular. The infamous Tuskegee experiments, “an iconic symbol of racialized medical abuse within the African-American Community,” built on research abuses that began in this country with forced experimentation on enslaved people. Other examples reflect abuses by the healthcare system such as the forced sterilization of Latinx women in Puerto Rico, California and elsewhere, and the egregious disenfranchisement of Henrietta Lacks. Ongoing activities that honor her non-consensual contribution to science are intended to ensure continuing awareness of the imperative need for consent and integrity. Pandemic-induced changes to healthcare delivery have the opportunity to reset the trust imbalance by addressing the needs and preferences of vulnerable populations.

Do People Trust their Doctors?

According to a recent survey conducted by the National Cancer Institute, about three-quarters of all adults would trust information about cancer “a lot” if it came from their doctors, whereas 20% would trust the information “some” and just 5% would trust the information just “a little” or “not at all” if it came from their doctors. About the same number believe that they get high quality healthcare. In other words, even if people don’t trust the healthcare system as a whole, most people trust their doctors a lot.
However, people who are Black or Hispanic, and those with low income, Medicaid insurance or without a high school degree have lower levels of trust, and believe their care quality to be lower than others. The variation in care quality is especially striking for people with these characteristics.

Aspects of Care that Affect Trust

“I tell them to say his name. My son’s name is D’Antoni.” 

Nicole B. had a normal pregnancy but noticed her son wasn’t eating properly.  

“So, I told the nurses that I thought something was wrong. They kept pushing my concerns aside, not really taking me seriously. It was only when I told them that I was a nurse did they take any type of action. That’s what really upset me: what about these other Black women who have less income, less education?”  
Stories like Nicole’s, where communications from medical providers are disrespectful and patient concerns are ignored with dire consequences, illustrate well-documented disparities in healthcare for people of color and other vulnerable groups. In one recent national survey, one in five patients reported that they had been subject to discriminatory treatment by the healthcare system, with most such incidents attributed to race. This and other surveys show that Black adults, followed by Hispanic adults, are the most likely to report such treatment, possibly reflecting unconscious biases or discriminatory beliefs by providers and healthcare workers that Black and Hispanic patients do not comply with treatment, are at greater risk for substance abuse, or are less educated and intelligent.
Care Quality
The National Healthcare Quality and Disparities Report tracks progress on more than 250 different aspects of healthcare quality. While quality is improving overall, disparities in access to care are especially notable for Hispanic people, who were three times more likely than White adults to have been uninsured for the entire prior year. People who lack insurance are only one-half as likely as others to have a regular doctor, an important factor in both care quality and trust. Care coordination was especially lacking for Black patients, resulting in higher rates of amputations for diabetes and sepsis infections after surgery.
Communication
Trust requires patients to believe that their caregivers and institutions act in their best interest and share their values. Patients’ ratings of communications with their healthcare providers may reflect these underlying trust perceptions. Overall, the National Healthcare Quality and Disparities Report shows that 11% of all patients said that their providers sometimes or never spent enough time with them, while 8% said that their providers did not listen, explain things well (7%) or respect them (7%) (shown in yellow highlight in figure). The type of insurance people had was most closely associated with how people rated these elements of care, with patients with no insurance or Medicaid insurance especially reporting that providers did not spend enough time with them. 
For example uninsured patients were more than twice as likely (20%) to report that doctors did not spend enough time with them compared with patients with Medicare insurance (8%). The largest communication-related disparities by race or ethnicity were for Hispanic and Asian patients who were more likely than White and than Black patients to report that doctors did not explain things to them or spend enough time with them.
Provider Diversity
Some patients prefer to have a provider of the same background, and have better outcomes from such encounters. These preferences may reflect a belief that a provider who shares their identity shares their values and understands their lived experiences. This concordance could result in treatment recommendations that are tailored to the realities of the patient’s life, such as lack of access to healthy food and transportation or reluctance to seek mental health treatment.
Figure: Patient and Provider Race/Ethnicity
The underrepresentation of Black and Hispanic healthcare providers precludes much patient choice in the matter (see Figure). Just 5% of all physicians are Black and 6% are Hispanic, versus 12% and 18%, respectively, of the entire US population. Asians, by contrast, were significantly over-represented as physicians (17% versus 6% of the population). Similar patterns were seen for Black and Hispanic dentists, registered nurses, pharmacists and psychologists.  Representation of Asian people differed by specialty.

Can Telehealth Improve Trust?

Access
Telehealth presents both opportunities and challenges for access to care. Telehealth can simplify the delivery of care for patients and providers alike, building trust through improved access and choice. Telehealth can lower barriers to obtaining care, especially for vulnerable populations who have difficulty taking time off of work, getting child care or accessing transportation. The cost for a telehealth visit could be lower than for an office visit, especially if patients choose freestanding services untethered to health care systems. However, we also know that disparities in care expanded during the pandemic despite the dramatic increase in availability of telehealth that was supported by numerous policy and regulation changes. Even if its cost is lower, telehealth may still be unaffordable for patients that lack insurance coverage. Finally, freestanding services may trade care continuity for convenience and choice.
Modality
Offering the full range of telehealth modalities could increase access to and satisfaction with care. Some medical needs can be addressed through secured messaging without requiring a scheduled appointment, and some matters can be handled adequately through audio-only connections. Asynchronous methods like texting or chatting could build trust by offering a more comfortable means of discussing highly personal or stigmatized conditions. Of course, the modality choice should reflect the medical need and patient’s preference, rather than being determined by digital literacy and connectivity barriers, which are more common among seniors, people living in rural areas, and economically vulnerable urban residents. Organizations offering telehealth should help patients address barriers to getting online. The FCC’s  Emergency Broadband Benefit will offer unprecedented subsidies for vulnerable populations to obtain devices and internet subscriptions, giving health systems an incentive to screen patients for digital gaps. Digital navigators can help patients to obtain these resources.
Communication
Telehealth offers other opportunities to address the types of concerns expressed by Nicole, the Black nurse quoted earlier in this story,--concerns that some patients are treated disrespectfully or differently because of the color of their skin, their preferred language, education, income, disability, age or type of health insurance. All modes of telehealth, if delivered through an institutional service, generate a complete log of encounters. Making a record of the transaction available to patients can build trust by supporting accountability. The record also enables patients to review the information discussed for further understanding, an especially valuable benefit for patients with language or auditory processing difficulties.  

Telehealth can reduce the risk of discriminatory treatment by standardizing interactions with artificial intelligence-driven clinical decision support tools. Also, patients should be able to choose providers based on biographical information and to provide immediate feedback through ratings similar to those found on e-commerce platforms. Supervisors could review ratings and videos of telehealth encounters to detect and address insensitive or discriminatory behavior. Anti-bias training could be implemented in response, making system-wide changes such as allocating more time to patients with complex social needs, is another action that can be taken.

Conclusion

In sum, telehealth offers considerable opportunities to improve patient trust and mitigate disparities in care quality and access. Concerted and collaborative efforts will be needed by health systems, medical professional organizations, regulators, payers, telehealth technology and telecommunication providers, patient advocates and community partners to ensure that telehealth is available to all, in a full range of modalities, with consistently high quality and with a broad range of providers. Community partnerships and digital navigation approaches should be considered to ensure that people facing digital literacy and access barriers are able to benefit from telehealth services. The Telehealth Equity Coalition looks forward to hearing and supporting your ideas for enhancing patient trust in health care through telehealth equity.

Resources:
Finding culturally sensitive doctors:  https://blackdoctor.org/find-a-doctor/ 
VR Training to address bias to improve maternal and infant health outcomes:  https://equityvrtraining.org/addressing-bias-to-improve-maternal-infant-health-outcomes/
Find digital inclusion advocates in your community:  https://www.digitalinclusion.org/affiliates/

Amy R. Sheon, PhD, MPH
Research Director, Telehealth Equity Coalition