Objectives We have shown that, in a randomized trial comparing adherence to different colorectal cancer (CRC) screening strategies, participants assigned to either fecal occult blood testing (FOBT) or given a choice between FOBT and colonoscopy had significantly higher adherence than those assigned to colonoscopy during the first year. However, how adherence to screening changes over time is unknown. Methods In this trial, 997 participants were cluster randomized to one of the three screening strategies: (i) FOBT, (ii) colonoscopy, or (iii) a choice between FOBT and colonoscopy. Research assistants helped participants to complete testing only in the first year. Adherence to screening was defined as completion of three FOBT cards in each of 3 years after enrollment or completion of colonoscopy within the first year of enrollment. The primary outcome was adherence to assigned strategy over 3 years. Additional outcomes included identification of sociodemographic factors associated with adherence. Results Participants assigned to annual FOBT completed screening at a significantly lower rate over 3 years (14%) than those assigned to colonoscopy (38%, P<0.001) or choice (42%, P<0.001); however, completion of any screening test fell precipitously, indicating the strong effect of patient navigation. In multivariable logistic regression analysis, being randomized to the choice or colonoscopy group, Chinese language, homosexuality, being married/partnered, and having a non-nurse practitioner primary care provider were independently associated with greater adherence to screening (P<0.01). Conclusions In a 3-year follow-up of a randomized trial comparing competing CRC screening strategies, participants offered a choice between FOBT and colonoscopy continued to have relatively high adherence, whereas adherence in the FOBT group fell significantly below that of the choice and colonoscopy groups. Patient navigation is crucial to achieving adherence to CRC screening, and FOBT is especially vulnerable because of the need for annual testing.

Despite the implementation of internet patient portals into the safety net after the introduction of the Affordable Care Act in the United States, little attention has been paid to the process of engaging vulnerable patients into these portals. The portal is a health technology tool that was developed with a mainstream, English-speaking audience in mind. Thus, there are valid concerns that such technologies will actually exacerbate health care disparities, conferring further advantages to the already advantaged. In this paper, we describe a framework for portal engagement (awareness, registration, and use) among safety net patients. We incorporate the experiences in the Los Angeles County Department of Health Services to illustrate important contextual factors for portal outreach in our safety net. Finally, we discuss considerations for moving forward with health technology in the safety net as the next version of patient portals are being developed.

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems’ integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention—stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Objectives Driven by beneficial patient-centered outcomes associated with patient portal use and the Affordable Care Act, portal implementation has expanded into safety nets—health systems that offer access to care to a large share of uninsured, Medicaid, and other vulnerable populations. However, little attention has been paid to the factors that affect portal accessibility by the vulnerable patients served by these health systems—including those who are limited English proficient (LEP). Materials and Methods The Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net system in the nation, launched its first patient portal, and one of the few bilingual English-Spanish interfaces in existence, in March of 2015. To explore portal awareness and perceptions, we conducted focus groups with LAC DHS patients, in English and Spanish (LEP). The Technology Acceptance Model was used to guide thematic analysis of focus group data. Results Of the 46 participants, 37 were patients and 9 were caretakers; 23 were English-speaking and 23 Spanish-speaking LEP. All patients had diabetes or hypertension. Over half had an annual household income <$10 000, yet 78% of English-speaking and 65% of Spanish-speaking LEP participants reported at-home Internet access. Participants’ discussion centered around 3 major thematic narratives: (1) participants’ awareness or attitudes about the LAC DHS portal; (2) role of culture, language, or community with regard to portal accessibility and utility; and (3) perceived needs for successful portal implementation. Conclusions Safety net participants identified concrete benefits to the portal and emphasized the need for portal engagement that offered accessible education, support, and resources in clinical and community settings. The portal offers an additional opportunity to engage the patient and family with trusted and validated health information, and should be further developed in this capacity. This study provides a better understanding of preferred improvements of patient portal engagement that guide broader health technology efforts to address electronic health disparities.

Background Patients within safety-net settings are less likely to access health information on patient portals, despite expressed interest. Family and friends are important resources to assist these patients (ie, Medicaid recipients, older patients, patients with limited English proficiency) in navigating health systems, and provider support of the use of patient portals among these groups may also facilitate caregivers’ use of their patients’ portal. Objective Because safety net providers work closely with caregivers to care for their patients, we used qualitative methods to explore safety net providers’ perspectives on portal use among caregivers for their patients, especially as there is limited literature about caregivers’ use of portals in the safety net. Methods We conducted 45- to 60-min semistructured telephone interviews with providers from three large California safety-net health systems. The interviews focused on providers’ experiences with caregivers, caregiver roles, and how the portal could be leveraged as a tool to support caregivers in their responsibilities. A total of three coders analyzed the interview transcripts using both deductive and inductive approaches and established a consensus regarding major themes. Results Of the 16 participants interviewed, 4 specialized in geriatrics, and all held a leadership or administrative role. We described themes highlighting providers’ recognition of potential benefits associated with caregiver portal use and specific challenges to caregiver engagement. Conclusions Providers recognized the potential for portals to improve information delivery and communication by helping caregivers assist socially and medically complex patients in the safety net. Providers in safety net sites also discussed a clear need for better ways to keep in touch with patients and connect with caregivers, yet security and privacy are perhaps of higher importance in these settings and may pose challenges to portal adoption. They noted that caregivers of patients in the safety net likely face similar communication barriers as patients, especially with respect to digital literacy, health literacy, and English proficiency. Further research is needed to assess and support caregivers’ interest and ability to access portals across barriers in health and digital literacy, and English proficiency. Portal platforms and health systems must also address specific strategies to uphold patient preferences while maintaining privacy and security.

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ObjectivesThe start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a “digital divide” that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits.MethodsThis qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes.ResultsTwenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels.ConclusionsPatient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.

Background: Electronic health (eHealth) literacy may affect telehealth uptake, yet few studies have evaluated eHealth literacy in underserved populations.Objective: The objective of this study was to describe technology access and use patterns as well as eHealth literacy levels among English-speaking and LEP patients in a Los Angeles safety net health system.Methods: Patients, aged ≥18 years with a diagnosis of diabetes mellitus and/or hyper­tension, and their caregivers were recruited from three primary care safety-net clinics in Los Angeles County (California) between June – July 2017. Participants’ electronic health literacy was assessed by the eHealth Literacy Scale (eHEALS); participants were also asked about technology access and use. We examined these measures in English-speaking and limited English proficient (LEP) Spanish-speaking patients.Results: A total of 71 participants (62 pa­tients and 9 caregivers) completed the ques­tionnaire. The mean age of the respondents was 56 years old. More than half of partici­pants used a phone that could connect to the Internet (67%). The mean score for 10 eHEALS items was in the moderate range (26/50 points). There was no difference in mean eHEALS between language groups. However, 47% of Spanish-speaking partici­pants “agreed/strongly agreed” that they knew how to use the Internet to answer their health questions, compared to 68% of English-speaking participants (P<.05).Conclusions: In this sample of patients from a diverse safety net population, perceived skills and confidence in engaging with electronic health systems were low, particularly among LEP Spanish-speakers, despite moderate levels of electronic health literacy. More studies are needed among diverse patient populations to better assess eHealth literacy and patients’ digital readi­ness, and to examine how these patient metrics directly impact telehealth utilization.Ethn Dis. 2022;32(1):21-30; doi:10.18865/ed.32.1.21