Using Telehealth to Address Disparities: A Scoping Review of Early Patient-Centered Outcomes Research Experience (Preprint)

BACKGROUND Increasingly, health systems and providers across America are employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at highest risk for health disparities. The Patient Centered Outcomes Research Institute (PCORI) has invested $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding best practices in using telehealth to address disparities. OBJECTIVE This paper describes preliminary lessons from this body of research using study findings and case studies drawn from these seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose is to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities. METHODS A systematic scoping review of telehealth studies addressing disparities was performed, guided by the Arksey and O’Malley Scoping Review Framework, focused on PCORI’s active portfolio of telehealth studies and key PCOR identified by investigators of these studies. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through review of both the extracted data and illustrative examples using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study. RESULTS PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 were identified and assessed use of telehealth to improve outcomes for populations at risk for health disparities as part of this scoping review. These 41 studies employed various overlapping modalities including: mobile devices (n=29), web-based interventions (n=30), real-time video (n=15), remote patient monitoring (n=8), and store-and-forward (asynchronous electronic transmission) interventions (n=5). The studies targeted one or more of PCORI’s priority populations, which include racial and ethnic minorities, people living in rural areas, people with low-income or low socioeconomic status, people with low-health literacy, and people with disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information. CONCLUSIONS Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that best practices in telehealth implementation include delivering telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.