Strategies for Digital Care of Vulnerable Patients in a COVID-19 World—Keeping in Touch

The COVID-19 pandemic has catalyzed a seismic shift in health care delivery. Health care systems and physician offices have accelerated digital health solutions at record speed, putting telehealth at center stage as a critical strategy to flatten the COVID-19 curve. Telehealth has moved from being an optional service to an essential one. As health care delivery evolves from a model primarily based on human touch and the nuances that accompany face-to-face interaction to include digital experiences that require a new set of resources, we must focus on who may be left behind. Without action to address the digital divide, existing health and health care disparities will be exacerbated for the nation’s most vulnerable individuals and communities. One of the most powerful tools in a health care provider’s armamentarium—human touch—may also be lost. We explore these potential dangers and offer strategies to mitigate them

As health care delivery evolves from a model primarily based on human touch and the nuances that accompany face-to-face interaction to include digital experiences that require a new set of resources, we must focus on who may be left behind. Without action to address the digital divide, existing health and health care disparities will be exacerbated for the nation's most vulnerable individuals and communities. One of the most powerful tools in a health care provider's armamentarium-human touch-may also be lost. We explore these potential dangers and offer strategies to mitigate them.
The digital divide is a well-described phenomenon that arises from limited access to and utilization of technology such as telehealth platforms. It can result from personal or sociocultural barriers, including limited electronic skills, low health literacy, disability, low income, and limited English proficiency; and structural barriers, including geographic isolation, broadband capacity, and technical hardware. 1 Thus, the adverse consequences of the digital divide most prominently affect low-income, rural, disabled, racial/ethnic-minority, and elderly populations.
Furthermore, whereas a health care provider's touch can express empathy and compassion nonverbally, the lack of touch and physical presence with digital care may compromise trust and interpersonal connections for some patients. For example, the physical exam is an ingrained expectation among many patients that gives them confidence and satisfaction with their health care experience. 2 If absent, such as in the case of telehealth visits, this absence may adversely affect patient communication, 3 the cultivation of a patient-provider relationship, and, consequently, treatment adherence and health outcomes.
While navigating the digital revolution in health care, we cannot afford to lose touch with patients or leave many of the most vulnerable patients untouched and further alienated by the digital divide. To address these challenges, we recommend the adoption of 5 important strategies as described below.

Expansion of Broadband Access
Disparities in broadband access exist namely among racial and ethnic minorities, residents of rural areas or tribal lands, and those with low socioeconomic status. 4 Several states and service providers have begun the expansion of broadband access and services to such underserved communities.
Additionally, many states have started to integrate broadband expansion into legislative priorities, given the high cost of deployment and the important connection to economic growth and health care. These efforts must be supported in the long-term. Federal investment in state-level expansion is needed, specifically to incentivize internet service providers to extend services in areas of need where the cost of doing so may be otherwise prohibitive.

Accommodations for Language, Literacy, and Disability
Given the rapidity with which some telehealth tools and platforms have been designed or reconfigured, there is the risk for insufficient consideration of the need to accommodate patient language, literacy, and disability needs. Thus, as we resolve to bridge the digital divide, it is imperative that telehealth offerings be engineered to provide a patient-centered experience for all patients, adhering to the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. 5 Additionally, there is a dire need for federal legislation that links disability rights to the implementation of telehealth. The Americans with Disabilities Act was signed into law in July 1990, before the first website became public, and provides limited jurisprudence on telehealth that can be enforced.

Telehealth Literacy Training
Health literacy, as defined by the Institute of Medicine, is "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." 6 In contrast, eHealth or digital health literacy extends this definition to include the ability to appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem. 6 Limited health and digital health literacy are welldescribed as barriers to experiencing optimal clinical care.
We introduce a new term, telehealth literacy, as the capacity to understand and have personal and technical comfort with the receipt of health care through technology. This form of literacy may pose an additional challenge for many patients. Leveraging partnerships with public serving entities, such as local libraries, should be a central part of institutional, state, and regional strategy to empower and equip communities with resources and training to utilize new modalities of care.
Organizations, such as the American Library Association, may serve as an invaluable resource, as they already connect communities with evidence-based information and technology access.

Community Health Worker Engagement
Community health workers are a tremendous asset to health systems because of their communityrooted credibility and understanding. 7 They can support telehealth training efforts, assist those with limited telehealth literacy as they conduct their clinical visits, provide culturally and linguistically appropriate information to patients and communities, and coordinate the provision of essential items, such as food, water, cleaning supplies, and masks. Efforts to provide adequate compensation, resources, and protective equipment to community health workers should be accelerated.

Digital Empathy and Webside Manner
The effort to emanate compassion and empathy in a digitally connected world may be more challenging for those who deliver care. As health care professional education programs are being reconstructed, traditional medical education must change and needs to be inclusive of conveying empathy to patients during telehealth care. Just as bedside manner has been central to medical education for over a century, "webside manner" must also be learned and ultimately richly embedded into the fabric of training and practice.
The COVID-19 pandemic has provided widespread and rapid opportunities to embrace digital health, but these opportunities must compensate for the corresponding loss of human touch in health care and be delivered equitably through swift federal, state, and health care organization actions. While a bright light is shining on systemic and structural health inequities during the