ABSTRACT
BACKGROUND: The COVID-19 pandemic forced many primary care visits from in-person to remote via telemedicine, including phone and video visits. Health systems face challenges ensuring telemedicine access for patients with limited English proficiency (LEP) who are disproportionately seen in safetynet health settings. METHODS: We examined safety-net health settings delivering primary care via telemedicine during the pandemic and participating in a quality improvement collaborative across California (n=43 sites, n=11 interview sites). All sites reported the number and modality of primary care visits (in-person, phone, video), patient demographics, payer mix, and language needs. For qualitative data, we purposively sampled to capture sites representing geographic diversity, a range of telemedicine maturity, and with large populations of patients best served in non-English languages. We then conducted semistructured interviews focused on barriers and facilitators to use and uptake of telemedicine among patients, providers, and staff. Interviews were audio recorded, transcribed, and analyzed with a focus on language-specific considerations, using a mixed inductive/deductive approach informed by the Consolidated Framework for Implementation Research. RESULTS: The sites cared for racially and ethnically diverse patients with nearly 75% on Medicaid. Over half of patients (52%) across sites were better served in a language other than English (median: 50%, range 39-83%). All sites experienced an immense increase in the number of telemedicine visits conducted in the six months after March 2020 compared with the six months prior (range: 258-8,273,200%). As of February 2021, most sites provided a minority of telemedicine visits over video compared with phone (median: 5% video, range 0-69%). Interview data showed that most sites mapped telephone visits workflows onto pre-existing infrastructure and resources. Telemedicine vendors provided limited language options and sites faced challenges integrating interpretation services into video visits. Interview respondents were concerned that patients with LEP faced intersecting challenges related to technology access and limited digital literacy, exacerbating language-related barriers to telemedicine. Sites relied on language concordant staff and additional technical support to overcome barriers and facilitate access for LEP patients. CONCLUSIONS: While telemedicine has potential to increase access to primary care, care settings must prioritize language concordance among patients, providers, and staff, and telemedicine platform developers must adapt existing tools to improve their accessibility for patients with LEP.