Now it's not only about simply using Telehealth, but it is also about effectively using this technology. Are these telehealth encounters as effective as in-person encounters? Telehealth researchers are increasingly trying to identify who struggles to use telehealth. The first step of this work is to define this outcome. Possible relevant outcome measures can include telehealth no-shows later rivals to telehealth visits due to access or use barriers. Similarly, reschedule to telehealth visits due to access or use barriers, conversion to telephone, or engagement. For example, it's hard for children to engage for extended periods of time on a virtual encounter. These barriers to use and or engage in the telehealth format are relevant because they limit the ability for health professionals to provide quality care. As research continues to show similar patterns of differences and telehealth use by patient characteristics. We must also understand the contextual factors influencing these patterns. Contextualizing the findings in telehealth uptake differences are necessary in order to address the sources of inequities and to improve health care delivery. As research continues to show similar patterns of differences in telehealth used by patient characteristics, we must also understand the contextual factors influencing these patterns. Contextualizing the findings in telehealth uptake differences are necessary in order to address the sources of inequities and improved telehealth delivery. Identified Systems of factors that inhibit equitable telehealth access across diverse populations include factors such as the design of available telehealth platforms. Experts have criticized that telehealth was not designed for individuals with limited English proficiency. Without language appropriate platforms, our non-English speakers cannot equitably utilize telehealth services like their English-speaking counterparts. Similarly, materials and communications that advertise telehealth as a service line or that provide instructions on how to sign up for the telehealth portal or how to navigate the visit. This lack of language, appropriate materials contributes to lower telehealth access among our non-English speakers. Complicated materials with poor readability. This is another factor potentially explaining the patterns of differential telehealth uptake. Additionally, if telehealth workflows are inflexible, providers cannot adopt or improve them to address the unique needs of the communities being served. Finally, telehealth reimbursements and state licensure restrictions are additional factors potentially influencing telehealth usage patterns. My colleagues and I conducted one-on-one interviews with stakeholders at our institution to understand the contextual factors influencing our own telehealth usage patterns. One of the qualitative themes that emerged was that we needed to adopt our processes to mitigate selective offering of telehealth visits. Our interview participants shared that providers offered telehealth visits less frequently to certain groups of patients and families. For example, they avoided offering telehealth to our non-English speakers and those they thought might not be tech-savvy because these groups were thought of as less likely to successfully navigate the telehealth visit process. Another research supports this pattern of selective offering. According to data from the 2020 health information national trends survey, greater proportions of non-Hispanic white patients reported that their providers had offered them online access to their electronic health records when compared with black, Hispanic, and Asian patients. Well, this association did not examine telehealth offering. These data represent providers offering patterns to patients to engage in their health care via online formats. Another important factor to recognize is the representativeness of telehealth research across different dimensions. As the body of telehealth research expands, our research studies need to include participants that represent our diverse populations in regards to various dimensions. This is important because prior research, for example, has suggested that white individuals are twice as likely to engage in technology-based health care research, than non-white individuals. Also, non-English speakers, lack representation in major and digital technology ownership and use of surveys. The implications of lack of representativeness in telehealth research are that non-representative data will lead to an inability to generalize our findings for populations excluded from telehealth. Telehealth technologies will not be established to serve these diverse patient groups. Digital literacy or proficiency in using technology is a recognized barrier for patients and families. The digital skills needed include tasks such as creating a portal account, making an appointment, launching the virtual encounter, adjusting the camera and sound. There are numerous tasks required that not all individuals can proficiently navigate. How has this impacted different populations? Research has found that patient portals are less likely to be created for publicly insured and uninsured individuals than their commercially insured counterparts. These portals are often required to conduct a telehealth encounter. A study led by the Department of Human Services in Minnesota. Focus groups with health care providers suggested that telemedicine is ideal for young to middle-age adults who have both fluency in using the technology, as well as access to the technology. The focus group participants shared that seniors and children face greater barriers than young and middle-aged adults in using technology. It wasn't just about using technology, but there were also barriers to engage in telehealth visits. The focus group participants explained that it was difficult to engage children in this format for extended periods of time and this engagement challenge limited their ability to provide care. The same focus group participants highlighted that one of the greatest challenges was the availability and reliability of internet connectivity. They share that cellular coverage and access to affordable technology that interfaces with the telehealth platform were significant issues. This problem is supported by other findings. For example, broadband now research, they estimated that 42 million Americans do not have access to broadband Internet service. Now, quality Internet access is largely a problem in rural areas. But we also need to remember that it's an issue for those who live in urban areas but cannot afford it. Impoverished urban neighborhoods can lack broadband infrastructure investments. These residents do not have the same options for high-speed, affordable Internet that residents in other areas do have. There's also another factor, preference for in-person encounters. Patients might choose to have an in-person visit instead of a telehealth visit. However, we must ensure that information about telehealth is being disseminated equitably to all patients and families. Our own qualitative research that we conducted locally identified that misinformation about the cost of telehealth visits and lack of information regarding the access of professional medical interpreters during telehealth visits were among the reasons patients and families preferred in-person visits. Other things to think about. Individuals might prefer in-person visits because they lack spaces with adequate safety and privacy, such as those who are homeless or living in shared spaces. These individuals might not have equal opportunity to have a private telehealth encounter with their provider. Also, reluctance to use telehealth among certain populations may also be rooted in harmful historical experiences that have caused mistrust and negative perceptions of unfamiliar health technologies. Research supports that differences exist in telehealth usage by patient characteristics. But are these differences creating health disparities? More research is needed that examines the impact of the differential uptake of telehealth on health outcomes, both individual and population health outcomes and we also should be measuring the impact on the patient-family experience. Finally, we need to assess the heterogeneity and telehealth effects. For example, if telehealth use is associated with improved health outcomes, we want to know if that improvement is achieved. Similarly, among both the English-speaking and the non-English speaking subjects. In summary, although telehealth technologies have the potential to promote health equity, we must be aware of the possible unintended consequences of these tools so that these innovative technologies improve rather than exacerbate existing disparities.