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Solutions for Connectivity and Hardware Barriers to Telehealth Equity from TEC Members

July 14, 2021  •  7 min read

The use and adoption of telehealth rose dramatically during the COVID-19 pandemic, with over half of the US population now having accessed care remotely. Despite its convenience and popularity, barriers to telehealth continue for many vulnerable populations. We spoke to several members of the Telehealth Equity Coalition about their efforts to improve telehealth equity by expanding broadband availability and access to hardware devices.

Advocates for Affordable Broadband Availability and Adoption

As Executive Director of the nation’s only organization advocating for digital inclusion programs,  The National Digital Inclusion Alliance (NDIA)’s Angela Siefer notes that some low income urban areas lack affordable and high speed broadband because federal regulations have not required ISPs to serve every household in their service area, nor to offer high speed service to all.  “We know that digital redlining is occurring in urban areas. Places where networks haven’t been upgraded from DSL to fiber overlap closely with low-income communities of color that remain devastated from decades of economic redlining.” Framing lack of urban broadband as an equity issue, she concluded, “Prior to the pandemic, people would say, ‘oh, they can just go to the McDonalds for internet access.’ Nobody wants to have a telehealth visit at McDonalds.”  In addition to raising awareness about digital equity, NDIA encourages federal officials to make funding decisions that will lead to equitable adoption. The bipartisan Digital Equity Act, which NDIA supports, was introduced in the Senate in June 2021, to ensure that students, families and workers have the information technology capacity needed to fully participate in society. The legislation includes formula-based grants to build digital equity capacity and implement programs in states, and a national competitive grant program to support digital equity projects. This $1B plus commitment, Siefer says, would represent “jump up and down kind of progress.”  When asked whether 5G technology would close the equity gap, NDIA’s Angela Siefer responded with a resounding “No!” Even though deployment uses relatively inexpensive small cells, she continued, “The actual rollout of 5G is not happening everywhere. Not every carrier will have access to optimal parts of the signal spectrum, and 5Gs cells still need a fiber backhaul to achieve high speed to end users.” NDIA sustains an affiliate network of digital inclusion practitioners across the country who can help ensure that the rush to 5G by “smart city” advocates doesn’t disadvantage vulnerable populations.

San José, California Mayor’s Office Addresses Urban Broadband Gaps

In the heart of Silicon Valley, nearly 100,000 San José residents lacked home broadband connections. In 2018, Mayor Sam Liccardo vowed that San José would be the first city in the country to completely close the digital divide in 10 years. City Councilmember Dev Davis noted, “San José is not waiting for someone else to close the digital divide in our city.” Jordan Sun, Chief Innovation Officer leading the San José Mayor’s Office of Technology and Innovation, joined TEC to learn and share equity-based strategies with other communities bridging the digital divide. Through a novel public-private partnership, telecommunication companies and philanthropies helped create a ten year $24 million Digital Inclusion Fund through accelerated permitting and deployment of 5G small cells on the city’s streetlight poles.  The Fund helped to enable San José schools to distribute over 60,000 devices needed by students and, importantly, included funds so that devices could be maintained—an often-overlooked expense. The Fund also supported building a community-based Wi-Fi network to connect people living in low income neighborhoods by running wireless connections from “small cell” devices placed on school buildings to individual dwellings. It also provided 15,800 mobile Wi-Fi hotspots for school and library distribution to residents who could avoid the need for an expensive mobile data plan.  While students and their families in need of digital inclusion resources were reached through schools, informing others required creative outreach methods. The San José Digital Inclusion Fund worked with Kaiser Permanente and AARP to reach seniors, for example, ran messages on city water bills, and used print, radio and TV ads in multiple languages to help other vulnerable populations access resources for getting online.

Bringing Devices to People in Need with Digitunity

As a national organization focused on eliminating the “technology gap,” TEC member Digitunity has collected considerable wisdom over 36 years, including that gleaned from its network of 85 non-profit technology refurbishers. To support affordable and quality telehealth access, Digitunity’s Director of Programs, Karisa Tashjian, recommends that "programs consider refurbished devices as an option.” When planning a large purchase and deployment of devices, she suggests "having similar hardware and software to help minimize the time needed for setup and troubleshooting.” Older devices such as Chromebooks, which are plentiful, can be refurbished. “Make sure,” she advises, “that devices have software configurations known to support needed telehealth functions. They should be internet-enabled, able to run Windows software, if needed, and have a camera for video conferencing."

Telehealth Resource Centers Working to Improve Telehealth for Vulnerable Populations

The Mid-Atlantic Telehealth Resource (MATRC), part of a national network of regional Telehealth Resource Centers, provides technical assistance and develops resources to help organizations addressing underserved populations in its 8-state region. TEC member Kathy Wibberly, MATRC’s Director, is especially proud of the forthcoming Correctional Facility Toolkit that highlights the use of telehealth to expand prisoner access to healthcare while saving the high cost of transporting guarded patients to medical appointments. This will be featured on MATRC website, along with lessons learned and best practices responding to COVID-19 that were gathered from multiple settings across the Mid-Atlantic region. MATRC’s COVID Telehealth Toolkit includes curated, credible resources for meeting the needs of people with visual and audio barriers, and highlights creative solutions for addressing digital health literacy, device equity and broadband access, such as the Delaware public libraries initiative. Another TEC member, also part of the national resource center network, the Great Plains Telehealth Resource and Assistance Center, has highlighted success stories from their technical assistance efforts, including providing telehealth services to hard-to-reach temporary agricultural workers.

Telehealth at a Rural Public Library

The Pottsboro Public Library is offering telehealth to the rural town’s 2,500 residents who lack home broadband. Notes librarian Dianne Connery, “We have very little to do with books. I had a semi haul away books that hadn’t been checked out in 15 years.” Yet the library’s own 15 mbps connection was so minimal that if one patron was watching a video on a library computer, the circulation desk staff could not check books out. Funding from the Gates Foundation enabled them to align their technology resources with community priorities, while Institute of Museum and Library Services funds were used to beef up the connection to 500 mbps. A grant from the National Library of Medicine then helped them answer patron requests for telehealth assistance. They established protocols and processes to create a sanitary and private telehealth facility, and partnered with the University of North Texas Health Science Center for scheduling, billing, and obtaining pre-appointment intake information. Currently, they are looking to equip a van to bring mobile telehealth to veteran homes.

Sustaining Telehealth Equity Measures

These examples are just a small sampling of the remarkable work of TEC members. While federal pandemic investments for devices and connectivity have “been incredible,” NDIA’s Siefer wonders what will happen when this temporary funding ends. Devices quickly become obsolete and “the need for the internet is not temporary. We must find long-term ways of ensuring that vulnerable populations can obtain and use internet service.” New technologies are promising, especially for reaching urban populations. Citizen’s Broadband Radio Service (CBRS), a mid-3.5 GHz band opened in 2020 by the FCC, for example, efficiently brings broadband to residents of high-rises. But demonstrating the value of digital inclusion is also important. San José’s Digital Inclusion Fund was designed with sustainability in mind, where digital equity will lead to advanced long term economic and quality life opportunities for residents. If this holds, San Jose’s efforts could be seen as powerful ways of improving the upstream social determinants of health.

Thanks to TEC Members

Angela Siefer and Paolo Balboa, National Digital Inclusion Alliance
Jordan Sun, San José Mayor’s Office of Technology and Innovation
Dianne Connelly, Pottsboro Library
Kathy Wibberly, Mid-Atlantic Telehealth Resource Center
Karisa Tashjian, Digitunity


New Broadband Technologies
New York City Internet Master Plan
Connected Nation's state by state progress
Pew Trust: How States are Expanding Broadband Access

Connecting People
FCC’s Emergency Broadband Benefit Implementation Dashboard
NDIA Digital Inclusion Webinar Series
Digital Inclusion Week, October 4-8, 2021
NDIA affiliates help connect people across the country

Device Distribution/Refurbishing
Digitunity provides computers to pre-qualified community organizations
Emergency Connectivity $7.1 billion fund for broadband service and devices at schools and libraries

Community-based Telehealth Resources
American Libraries—telemedicine brings house calls to local libraries
Library Telehealth Community of Practice
Pottsboro PSA for library telehealth
Libraries as telehealth providers
Delaware Libraries and Telehealth webinar:  Part 1Part 2
Telehealth Resources for COVID toolkit
Telehealth for Seniors

Amy R. Sheon, PHD, MPH

Research Director, Telehealth Equity Coalition, and Digital Health Equity Consultant, Public Health Innovators, LLC

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