Jorge A. Rodriguez, MD

The coronavirus disease 2019 (COVID-19) pandemic forced health systems to offer video and telephone visits as in-person visit alternatives. Although video visits offer some benefits compared with telephone visits, they require complex setup, which may disadvantage some patients due to the “digital divide.” Our objective was to determine patient and neighborhood characteristics associated with visit modality.

 This was a cross-sectional study across 1652 primary care and specialty care practices of adult patients at an integrated health system from April 23 to June 1, 2020.

 We used electronic health record and administrative data. Our primary outcome was visit modality (in-person, video, or telephone), which was captured using billing codes. We assessed predictors of using video vs telephone using multivariable logistic regression. We used hierarchical logistic regression to determine the contribution of patient-, physician-, and practice-level components of variance in the choice of video or telephone visits.

 We analyzed 231,596 visits by 162,102 patients. Sixty-five percent of the visits were virtual (31.7% telephone, 33.5% video). Patients who were older than 65 years (adjusted odds ratio [AOR], 0.41; 95% CI, 0.40-0.43), Black (AOR, 0.60; 95% CI, 0.57-0.63), Hispanic (AOR, 0.76; 95% CI, 0.73-0.80), Spanish-speaking (AOR, 0.57; 95% CI, 0.52-0.61), and from areas with low broadband access (AOR, 0.93; 95% CI, 0.88-0.98) were less likely to use video visits. Practices (38%) and clinicians (26%) drove more of the variation in video visit use than patients (9%).

 Telemedicine access differences may compound disparities in chronic disease and COVID-19 outcomes. Institutions should monitor video visit use across demographics and equip patients, clinicians, and practices to promote telemedicine equity.

The coronavirus disease 2019 pandemic prompted a transition to telemedicine, including video and telephone visits. Video visits offer some benefits, but they may disadvantage some patients due to the “digital divide.” Using data from a large, integrated health system, we determined patient, clinician, clinic, and neighborhood characteristics associated with visit modality.

Patients who were older than 65 years, Black, Hispanic, Spanish-speaking, nonportal users, or from areas with low broadband access were less likely to use video visits.

Practice (38%) and clinician (26%) factors largely drove the variation in video visit use.

Institutions should promote equitable access to all telemedicine modalities.

During the coronavirus disease 2019 (COVID-19) pandemic, social distancing requirements compelled health systems, practices, clinicians, and patients to use video and telephone visits as alternatives to in-person visits.

 This shift was further supported by policy changes—for example, CMS offered temporary payment parity across in-person, telephone, and video visits.

 There are concerns that the shift to telemedicine may exacerbate disparities in health care access. Early evidence on telemedicine use overall has demonstrated less use among female and non–English-speaking patients compared with other groups, but no differences among racial/ethnic groups.

Given key trade-offs between telemedicine modalities, there may be additional, potentially concerning differences in access to video and telephone visits. Compared with telephone visits, video visits allow some aspects of a physical examination and a more personal connection between clinicians and patients. However, video requires more complex setup and broadband internet access, which may present barriers for older adults, racial/ethnic minorities, and those with limited English proficiency (LEP) who are on the wrong side of the “digital divide.” The digital divide refers to the gap between those who have access to and can meaningfully engage with technology and those who cannot. For example, at least 21 million people lack broadband internet access in the United States, many from underserved communities that also face worse health outcomes.

 Further, a recent study suggests that 13 million older adults are not ready for video visits due to difficulties using technology.

 Video visits may also present technical and logistical challenges for some practices and clinicians to set up and incorporate into workflows. However, we know little about differences in and drivers of the use of video vs telephone visits. Therefore, we analyzed detailed electronic health record (EHR) data from a large, integrated health system to fill these gaps.

Understanding drivers of differences in use of telephone and video visits would help to inform rapidly changing telemedicine payment policies and practices. In this study, we examined trends in use of outpatient care, including telephone and video visits across 1652 outpatient primary care and specialty practices in a large, integrated health system.

We used data from Mass General Brigham (MGB) in Boston, Massachusetts, a large, integrated health system with 16 member organizations across New England. We extracted EHR data from the enterprise data warehouse, which includes patient demographic information collected during registration and detailed clinical encounter and billing data.

We identified a cohort of adult patients 18 years or older who were attributed to an MGB primary care physician (PCP) (defined by the EHR “PCP” field) as of March 1, 2020. We assessed all outpatient encounters occurring between March 1 and June 1, 2020. We excluded encounters that required in-person care (eg, dialysis, procedures, chemotherapy or radiation administration).

Our primary outcome was visit modality (in-person, video, or telephone visit), captured using billing codes. Telemedicine visits were identified by code GT for video visits and GPH for telephone visit. For visits with billing codes that did not clearly indicate modality, we included the visits in total visit counts but not in analyses about types of modalities.

We chose patient characteristics that have been previously demonstrated to influence telemedicine use: age (18-44, 45-64, ≥ 65 years), gender (male, female), race/ethnicity (White, Black, Hispanic, Asian, other), preferred language (English, Spanish, other), insurance type (commercial, Medicaid, Medicare, veteran/military, missing/no insurance), and patient portal access (activated, not activated).

 We merged patient zip codes with the American Community Survey data to capture zip code–level broadband internet access (quartiles based on percentage of the population with broadband internet access), educational attainment (quartiles based on percentage of the population with a high school diploma), and income (quartiles based on median household income).

We performed descriptive statistics to show trends in use of telephone, video, and in-person visits between March 1 and June 1. We then focused on the period April 23 to June 1 (the study period), which began 1 month after the shift to telemedicine (Massachusetts issued a stay-at-home advisory on March 23). We chose this period to bypass transition challenges, including rapid workflow and technical requirements, that could affect initial uptake of video visits. During this period, we examined trends in the percentage of all telemedicine visits done via video by patient sociodemographic categories. We assessed predictors of video vs telephone use with bivariate analyses using χ

 tests as appropriate for the previously described patient- and zip code–level variables. We then built a multivariable logistic regression model in which the outcome was video or telephone visit. Finally, we built a hierarchical logistic regression model to determine the relative contribution of patient-, physician-, and practice-level components to variance in the choice of video or telephone visits. Hierarchical models account for the fact that patients are nested within clinicians and clinicians are nested within clinics. In a sensitivity analysis, we repeated our main analyses among primary care practices alone. The MGB Institutional Review Board approved this study and waived the use of informed consent. Analyses were performed using R statistical software (version 3.5.3).

We examined 746,356 patients with a PCP at MGB. From March 1 to June 1, telephone visits were more common in the early weeks of telemedicine expansion and were then overtaken by video visits (

). During the study period, we found lower video visit use among Black and Hispanic patients (compared with White and Asian patients), among Spanish-speaking patients (compared with English-speaking patients), and among patients 65 years and older (compared with those aged 18-64 years) (

). These trends developed early and grew steadily over time.

During the study period, 162,102 patients (21.7% of all attributed patients) attended 231,596 visits to primary care and specialty practices. Of all visits during this period, 65.2% were telemedicine visits (73,353 [31.7%] telephone and 77,530 [33.5%] video) (

). Among patients with a telemedicine visit, 53,999 (33.3%) patients had at least 1 video visit, 50,576 (31.2%) patients had at least 1 telephone visit, and 8187 (5.0%) patients had at least 1 of each.

In bivariate analyses, patients using video visits were more likely to be White, portal users, enrolled in commercial insurance, and living in areas with higher income and broadband access. In adjusted analyses, patients who were older than 65 years (adjusted odds ratio [AOR], 0.41; 95% CI, 0.40-0.43), Black (AOR, 0.60; 95% CI, 0.57-0.63), Hispanic (AOR, 0.76; 95% CI, 0.73-0.80), Spanish-speaking (AOR, 0.57; 95% CI, 0.52-0.61), and not active patient portal users (AOR, 0.39; 95% CI, 0.38-0.40) were less likely to use video visits (

). Additionally, patients living in areas with the lowest broadband internet access (AOR, 0.93; 95% CI, 0.88-0.98), lowest median income (AOR, 0.49; 95% CI, 0.46-0.52), and lowest educational attainment (AOR, 0.84; 95% CI, 0.80-0.88) were less likely to use video visits. The hierarchical model revealed that practice (38%) and clinician (26%) factors accounted for more of the variance in video visit use than patient-level factors (9%), whereas 27% of the variance was unexplained. In our sensitivity analysis examining primary care visits, we found similar results (

At a large, integrated health system scaling telemedicine visits in response to the COVID-19 pandemic, we found lower use of video vs telephone visits among older, Black, Hispanic, and Spanish-speaking patients that developed almost immediately and persisted. We also found that clinicians and practices largely drove this variation in the use of video vs telephone visits, suggesting an important target for intervention.

Various factors likely influence the choice between a telephone and video visit, including patient access to technology, an organization’s telemedicine infrastructure, and patient and clinician preferences. To the extent that video is better than telephone, it is important to expand access to video visits. At the same time, given that telephone visits may be more accessible for some and are often reasonable substitutes, it will be important to offer patients flexibility and ensure payment parity for both visit types.

We found that Spanish-speaking patients were less likely to use video visits. This extends prior findings that showed decreased telemedicine use among patients with LEP.

 For example, Eberly et al found that non–English-speaking patients were 50% less likely to use telemedicine, although they did not find differences in video visit use.

 Given these findings, practices might develop video visit workflows that integrate interpreter services and assign dedicated language-concordant guides to train patients in the use of video visits.

We found that patients in areas with lower levels of broadband internet access were less likely to engage in video visits, corroborating prior work showing that internet access predicts telemedicine use and patient portal adoption.

 Importantly, internet access is necessary yet not sufficient for use of video visits. Patients must also have a video-enabled device, as well as digital literacy, or the ability to navigate telehealth platforms, which underserved and older patients often lack.

Clinician- and practice-level factors contributed to the gaps in video visit use. Clinicians and practices that serve primarily underserved patients may be less equipped to provide video visits given additional implementation requirements. Thus, a focus on supporting video visit infrastructure and training clinicians on using video visits may help address these challenges. Due in part to implicit biases, clinicians may also offer telephone over video visits for some patients based on assumptions about their ability or desire to engage in video visits.

 A structured approach to screening patients for video visit readiness can help check these assumptions. Further, practices should develop efficient workflows to make it easy for both patients and clinicians to use video visits.

Addressing differences in use the of visit modalities will require a multilevel approach. To ensure that greater telephone visit use among underserved populations does not contribute to decreased access to medical care, payment parity for telephone and video visits is critical. In March 2020, CMS extended parity for both telephone and video relative to in-person visits; these changes should persist beyond the pandemic, and commercial payers should follow suit. In addition, policy initiatives to narrow digital divides, such as investments in telemedicine and broadband infrastructure, are essential. Policy makers should establish universal broadband laws and funding to ensure that patients have essential digital access and to mitigate pressures faced by health systems to connect their patients. The recent COVID-19 Telehealth Program, which provided $200 million for health care organizations to expand their telemedicine infrastructure, is a start.

 At the organizational level, effective workflows are important to ensure that patients and providers feel satisfied with care in the digital setting. Additionally, collaboration with community organizations already focusing on digital literacy will address digital divides in local communities. Finally, EHR and telemedicine vendors should develop inclusive platforms that account for the varied literacy, numeracy, and usability needs of underserved and older populations.

We found differences in telemedicine access that may compound existing racial, ethnic, and language-based disparities in chronic disease outcomes and COVID-19 case rates and mortality. With the pandemic still ongoing, institutions should carefully monitor video visit use across patient demographics and equip patients, clinicians, and practices to promote equitable access to all telemedicine modalities.

The authors would like to thank Harrison T. Hubbell, BS, of Mass General Brigham, for his help with data extraction.

 Harvard Medical School (JAR, JRB, TDS, IG), Boston, MA; Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital (JAR, TDS, IG), Boston, MA; Division of General Internal Medicine, Massachusetts General Hospital (JRB), Boston, MA; Mass General Brigham (TDS), Boston, MA.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (JAR, JRB, TDS, IG); acquisition of data (JAR, JRB, TDS, IG); analysis and interpretation of data (JAR, IG); drafting of the manuscript (JAR, IG); critical revision of the manuscript for important intellectual content (JAR, JRB, TDS, IG); statistical analysis (JAR, IG); and supervision (IG).

 Jorge A. Rodriguez, MD, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, Boston, MA 02120. Email: jarodriguez1@partners.org.

1. Mehrotra A, Ray K, Brockmeyer DM, Barnett ML, Bender JA. Rapidly converting to “virtual practices”: outpatient care in the era of Covid-19. 

NEJM Catalyst: Innovations in Care Delivery

. Published online April 1, 2020. doi:10.1056/CAT.20.0091

2. Trump administration makes sweeping regulatory changes to help U.S. healthcare system address COVID-19 patient surge. News release. CMS; March 30, 2020. Accessed March 30, 2020. https://www.cms.gov/newsroom/press-releases/trump-administration-makes-sweeping-regulatory-changes-help-us-healthcare-system-address-covid-19

3. Eberly LA, Khatana SAM, Nathan AS, et al. Telemedicine outpatient cardiovascular care during the COVID-19 pandemic: bridging or opening the digital divide? 

. 2020;142(5):510-512. doi:10.1161/CIRCULATIONAHA.120.048185

4. Verma S. Early impact of CMS expansion of Medicare telehealth during COVID-19. 

. July 15, 2020. Accessed August 17, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/

5. 2019 broadband deployment report. Federal Communications Commission. May 29, 2019. Accessed August 17, 2020. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2019-broadband-deployment-report

6. Lam K, Lu AD, Shi Y, Covinsky KE. Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. 

. 2020;180(10):1389-1391. doi:10.1001/jamainternmed.2020.2671

7. Park J, Erikson C, Han X, Iyer P. Are state telehealth policies associated with the use of telehealth services among underserved populations? 

. 2018;37(12):2060-2068. doi:10.1377/hlthaff.2018.05101

8. American Community Survey (ACS). United States Census Bureau. Accessed August 17, 2020. https://www.census.gov/programs-surveys/acs

9. Reed ME, Huang J, Graetz I, et al. Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. 

. 2020;3(6):e205873. doi:10.1001/jamanetworkopen.2020.5873

10. Rodriguez JA, Lipsitz SR, Lyles CR, Samal L. Association between patient portal use and broadband access: a national evaluation. 

. Published online January 10, 2020. doi:10.1007/s11606-020-05633-4

11. Wilcock AD, Rose S, Busch AB, et al. Association between broadband internet availability and telemedicine use. 

. 2019;179(11):1580-1582. doi:10.1001/jamainternmed.2019.2234

12. Anderson M. Mobile technology and home broadband 2019. Pew Research Center. June 13, 2019. Accessed March 15, 2020. https://www.pewresearch.org/internet/2019/06/13/mobile-technology-and-home-broadband-2019/

13. Nouri S, Khoong EC, Lyles CR, Karliner L. Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic. 

. Published online May 4, 2020. doi:10.1056/CAT.20.0123

14. Anthony DL, Campos-Castillo C, Lim PS. Who isn’t using patient portals and why? evidence and implications from a national sample of US adults. 

. 2018;37(12):1948-1954. doi:10.1377/hlthaff.2018.05117

15. Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. 

. 2014;29(2):364-387. doi:10.1007/s11606-013-2583-1

16. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. 

. 2013;28(11):1504-1510. doi:10.1007/s11606-013-2441-1

17. van Ryn M, Saha S. Exploring unconscious bias in disparities research and medical education. 

. 2011;306(9):995-996. doi:10.1001/jama.2011.1275

18. COVID-19 Telehealth Program. Federal Communications Commission. Accessed August 17, 2020. https://www.fcc.gov/covid-19-telehealth-program

Articles

During the coronavirus disease 2019 (COVID-19) pandemic, we found lower use of video vs telephone visits among older, Black, Hispanic, and Spanish-speaking patients, driven largely by clinician and practice factors.

Differences in the Use of Telephone and Video Telemedicine Visits During the COVID-19 Pandemic

The coronavirus disease 2019 pandemic is magnifying preexisting health disparities whereby patients with limited English proficiency receive lower-quality health care and experience poorer outcomes. To address these realities, language interventions to date have focused on interpreter services and linguistically tailored health information. But these limited solutions fail to target a more upstream, overlooked, and modifiable factor: a patient’s access to improving their English proficiency and health literacy. We present recommendations for addressing language as a social determinant of health by improving access to English as a Second Language programs. This article outlines steps that health systems and policy makers can take to more directly treat upstream causes of language disparities.

We introduce how English as a Second Language (ESL) courses can address inequities in access to care and health outcomes—many of which have been magnified during the coronavirus disease 2019 pandemic. Further, we present solutions that health systems and policy makers can adopt to improve access to these programs. We anticipate that this article will catalyze debate and quality improvement work for patients with limited English proficiency. We also believe that our piece is of critical importance to health care administrators, clinicians, and other health professionals who affect the care trajectory of these patients, especially during a pandemic that has disproportionately affected communities of color.

The pandemic has further highlighted the importance of mitigating language-based disparities. By following the 3 points below, health care leaders can improve their health care delivery practices for patients with limited English proficiency:

improve health care delivery for populations with limited English proficiency,

partner with community-based organizations that teach ESL, and

leverage Medicaid and work with insurers to better manage the care of non–English-speaking patients.

Coronavirus disease 2019 (COVID-19) mortality data show that Latinxs are disproportionately dying in the United States.

 These findings parallel known health disparities for Latinxs, which can be attributed in part to language barriers. More than 25 million individuals in the United States have limited English proficiency (LEP), including 16 million Spanish speakers, and they are more likely to receive worse health care and experience poorer outcomes.

 COVID-19 is now magnifying these disparities that continue to persist in part because current language interventions, such as interpreter services and linguistically tailored health information, offer limited solutions to a more upstream, overlooked, and modifiable factor: a patient’s access to improving their English proficiency and health literacy.

When patients and their clinicians do not speak the same language, patients receive less health education and experience more testing, more readmissions, and longer lengths of stay, resulting in higher health care utilization.

 Beyond the clinical setting, language, like other social determinants of health, affects patients’ lived environments, including their ability to understand food labels, apply for public housing services, and access reliable community health information. This reality puts them at increased risk of downstream consequences such as mental health problems and chronic health conditions. When language barriers are present, patients suffer, clinicians fail to effectively deliver care, and the health care system faces increased costs.

Traditionally, language barriers have been addressed only by interpreters at the point of care. Interpreters improve patient satisfaction and clinical outcomes.

 However, interpreter use has been hampered by variable clinician use, patient disenfranchisement, limited availability in rural geographies, and absent or insufficient reimbursement.

 The increasing demand on clinician time during COVID-19 has likely only decreased interpreter use. Furthermore, the financial impact of COVID-19 on places with already strained financial budgets could lead to the deimplementation of poorly reimbursed interpreter services.

 Interpreters are essential, but their services are now constrained more than ever. They also do not directly modify the patient’s primary risk factor for poor outcomes—namely, having LEP.

Driven by risk-bearing payment structures, provider organizations are recognizing the relationship between an upstream cause of disease and patient well-being. But such systems largely overlook a critical opportunity to address language barriers and health literacy by increasing adoption of English as a Second Language (ESL) programs.

ESL programs are interactive didactic courses that teach non-English speakers the basics of the English language. By the end of the course, learners have higher reading comprehension and improved English-speaking skills. More germane to health professionals, however, is the courses’ ability to improve health literacy and, subsequently, patient health. Individuals enrolled in ESL courses that focus on health experience improved understanding of their illnesses (eg, diabetes, hepatitis B) and general nutrition. After course completion, many participants change their diets to avoid unhealthy foods and increase fruit and vegetable intake.

 Benefits even go beyond the individual, as participants report sharing preventive health content with their community. Improvements in clinical outcomes, including hyperlipidemia and blood pressure control, have also been linked with health-focused ESL programs. For individuals with some English proficiency, one 3-hour session improves general health knowledge. Those with more limited English skills typically require a few months.

Despite current policies in support of ESL programs, access to free ESL courses is limited; individuals can wait years for a spot. Demand is so high that almost 3 in 5 ESL providers have waiting lists, and some have discontinued classes due to lack of funding.

 The limited supply also damages the learning quality for those who do get a spot—programs are forced to combine learners with different levels of proficiency, creating challenges for instructors to teach effectively. As health care leaders and policy makers focus on social determinants of health and language services in the postpandemic era, access to health-focused ESL courses should be part of the conversation.

Addressing Language as a Social Determinant of Health

The provision of health-focused ESL courses can mitigate adverse health effects in the LEP population. We present recommendations for expanding the role of the health care system in addressing language as a social determinant of health and reducing language disparities that arise from patient-clinician interactions.

Hospitals can honor their role as anchor institutions by partnering with existing community-based ESL organizations. Expanding ESL health literacy resources through capital investments could allow for more classes and teachers to expand student capacity for high-risk patients. Funding could also be sought through the reintroduction of an Obama administration federal proposal that supported partnerships among states, adult education providers, higher education institutions, and private organizations.

 Bolstering language services with health-focused ESL courses may ultimately reduce health care spending and satisfy mandatory community health needs assessment implementation strategies. Currently, many hospitals prioritize “language” on their community health needs assessment, yet it is likely that none target the upstream opportunity of extending language resources.

More feasibly, hospitals can leverage Medicaid Section 1115 waivers—tickets that allow states to implement new health care delivery programs—to target language as a social determinant of health. For instance, North Carolina recently received $650 million from CMS to address housing instability, transportation security, food insecurity, interpersonal violence, and toxic stress.

 Language barriers could be added to that list for North Carolina and other states that utilize a waiver. Additionally, given the significant portion of privately insured Spanish speakers, insurers could provide vouchers for their LEP population to attend payable ESL courses that are often in lower demand because of their cost. This program could build from wellness initiatives, such as gym reimbursement programs, that provide financial incentives. Health systems can then evaluate the effectiveness of their courses internally or by partnering with the Department of Education, which provides funds for evaluation of adult education programs.

Access to health-focused ESL classes can be improved, but participation can still be hindered by day-to-day patient barriers, such as working multiple jobs and lacking transportation. Thus, ESL programs should not be implemented in isolation but rather as part of a larger infrastructure focused on addressing patients’ social needs. There may also be opportunities to harness virtual classes to meet patients’ varying daily challenges. Once these systems are in place, health care institutions should continue expanding linguistically diverse staff, clinicians should continue practicing culturally competent care, and hospitals should continue offering language assistance at the point of care. ESL programs that patients can opt into should not replace these services but instead augment them.

During this public health emergency, health systems may appropriately focus on clinical operations, but they need to soon turn their attention to addressing the upstream causes of language barriers. This strategy could better prepare us for the next pandemic by minimizing language discordance between a patient and their clinician or public health system. Clinical leaders can begin by partnering with existing community-based ESL organizations, leveraging Medicaid Section 1115 waivers, and providing voluntary at-risk patients with ESL course vouchers. Patient health and institutional financial sustainability could both be positively affected if language is treated like all other social determinants of health.

 Harvard Medical School (DEV, ALB, JAR), Boston, MA; Department of General Internal Medicine, Brigham and Women’s Hospital (JAR), Boston, MA.

 Mr Beckman is a former employee of and has received consulting fees unrelated to this article from Aledade Inc. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (DEV, ALB, JAR); drafting of the manuscript (DEV, ALB, JAR); critical revision of the manuscript for important intellectual content (DEV, ALB, JAR); and supervision (JAR).

 David E. Velasquez, BS, Harvard Medical School, 292 Eliot Mail Center, 101 Dunster St, Cambridge, MA 02138. Email: david_velasquez@hms.harvard.edu.

1. COVID-19 hospitalization and death by race/ethnicity. CDC. Updated November 30, 2020. Accessed December 9, 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

2. Taira BR, Kim K, Mody N. Hospital and health system–level interventions to improve care for limited English proficiency patients: a systematic review. 

. 2019;45(6):446-458. doi:10.1016/j.jcjq.2019.02.005

3. Levas MN, Cowden JD, Dowd MD. Effects of the limited English proficiency of parents on hospital length of stay and home health care referral for their home health care–eligible children with infections. 

. 2011;165(9):831-836. doi:10.1001/archpediatrics.2011.61

4. Juckett G, Unger K. Appropriate use of medical interpreters. 

5. Shah SA, Velasquez DE, Song Z. Reconsidering reimbursement for medical interpreters in the era of COVID-19. 

Health Forum. October 12, 2020. Accessed December 9, 2020. https://jamanetwork.com/channels/health-forum/fullarticle/2771859

6. Jacobs EA, Sanchez Leos G, Rathouz PJ, Fu P. Shared networks of interpreter services, at relatively low cost, can help providers serve patients with limited English skills. 

. 2011;30(10):1930-1938. doi:10.1377/hlthaff.2011.0667

7. Chen X, Goodson P, Acosta S. Blending health literacy with an English as a second language curriculum: a systematic literature review. 

. 2015;2(suppl 2):101-111. doi:10.1080/10810730.2015.1066467

8. Education for adult English language learners in the United States: trends, research, and promising practices—participation of foreign-born adults in adult education programs and outcomes. CAELA Network. March 2, 2010. Accessed April 1, 2020. http://www.cal.org/caelanetwork/resources/adultELLs/participation.html

9. Fiscal year 2015 budget summary and background information. Department of Education. Accessed April 1, 2020. https://www2.ed.gov/about/overview/budget/budget15/summary/15summary.pdf

10. Hinton E, Artiga S, Musumeci MB, Rudowitz R. A first look at North Carolina’s Section 1115 Medicaid waiver’s Healthy Opportunities Pilots. Kaiser Family Foundation. May 15, 2019. Accessed April 1, 2020. https://www.kff.org/medicaid/issue-brief/a-first-look-at-north-carolinas-section-1115-medicaid-waivers-healthy-opportunities-pilots/

11. Federal initiatives: adult education and literacy. Department of Education. Accessed April 1, 2020. https://www2.ed.gov/about/offices/list/ovae/pi/AdultEd/national-activities.html

In the article, we introduce how English as a Second Language courses can address inequities in access to care that have been magnified during the coronavirus disease 2019 pandemic.

Jorge A. Rodriguez, MD

Articles

Differences in the Use of Telephone and Video Telemedicine Visits During the COVID-19 Pandemic

The Missing Strategy in Addressing Language Barriers