Implementing the Digital Equity for Stroke Approach (DESA): A Qualitative Study of Multilevel Barriers and Facilitators to Equitable Telehealth Implementation in Safety-Net Settings
This qualitative study identifies multilevel barriers and facilitators to telehealth adoption in safety-net settings to guide the implementation of the Digital Equity for Stroke Approach (DESA), concluding that equitable implementation requires coordinated investments in policy, infrastructure, and workforce support beyond mere technology access.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine a world where a doctor can check your blood pressure or discuss your health from the comfort of your living room, saving you a long bus ride and hours of waiting in a clinic. This is the promise of telehealth, a way of delivering medical care through phones and computers that has grown rapidly in recent years. For people who have survived a stroke or are at risk of having one, managing blood pressure is critical to preventing another life-threatening event. In theory, digital tools should make this management easier and more consistent for everyone. However, the reality is often more complicated. Just as a road is only useful if it leads to a destination, a digital health tool is only helpful if the person using it can actually access it. When the people who need care the most—those with lower incomes, limited English skills, or older age—face barriers like broken internet connections or confusing technology, these tools can accidentally widen the gap between the healthy and the sick, rather than closing it.
Researchers at SUNY Downstate Health Sciences University in Brooklyn set out to understand exactly how these barriers play out in the real world. They focused on a specific group of hospitals known as "safety-net" systems, which serve communities that are often low-income and racially diverse. The team, led by Dr. Efekona Nuwere, wanted to know why telehealth sometimes fails to reach the people who need it most. To find the answers, they did not look at computer code or patient statistics alone. Instead, they sat down with nineteen doctors and hospital administrators who work every day in these busy clinics. Between 2021 and 2025, the researchers conducted long, detailed conversations with these professionals, asking them to describe their experiences, their frustrations, and the moments when technology helped or hindered their work.
The conversations revealed that the problem is rarely just about a patient not having a smartphone. While some patients do struggle with devices or internet access, the doctors and administrators described a much deeper issue rooted in how the hospitals themselves are set up. They found that the system often relies on a single, overworked staff member to teach patients how to use the technology or fix technical glitches. When that one person is busy or unavailable, the whole process breaks down. One doctor described a situation where a front-desk worker could not help a patient connect to a video call because they did not know how the system worked, forcing the patient to wait while the doctor tried to find someone else who could. This lack of a reliable support team meant that even patients who had the right equipment often could not get the care they needed.
Another major finding was that the rules for how doctors get paid often work against the people who need help the most. In many cases, insurance companies pay less for a phone call than for a video visit. However, for many patients in these safety-net clinics, a video call is impossible because their internet is too slow or they do not have a quiet, private place to talk. For these patients, a simple phone call is the only way to stay connected with their doctor. The researchers heard from providers who felt forced to choose between following the rules of the system or actually helping their patients. They noted that when a doctor has to speak through a translator, the conversation takes much longer and loses some of its nuance, yet the payment system does not account for this extra time and effort. This creates a situation where the system is designed for a patient who has everything, leaving behind those who are already struggling.
The study also highlighted a surprising preference among both patients and doctors for phone calls over video chats. While the public image of telehealth is often a face-to-face video meeting, the people in these clinics found that a simple voice call was often more reliable and less stressful. Patients with older phones, or those who were worried about their privacy, felt more comfortable speaking on the phone. Doctors agreed, noting that they could still build trust and get the information they needed without the technical headaches of a video connection. Yet, the current policies often treat the phone call as a second-class option, paying less for it and offering less support for it. The researchers argued that this is a mistake. They suggested that to make digital health truly fair, hospitals need to invest in people, not just machines. This means hiring more staff specifically to help patients navigate technology, training teams to work together smoothly, and changing payment rules to value the phone call just as much as the video visit.
Ultimately, the study suggests that fixing the digital divide is not just about handing out tablets or improving internet speeds. It is about recognizing that technology does not exist in a vacuum. For telehealth to work for everyone, especially in communities that have been left behind for too long, the entire system needs to change. The doctors and administrators in Brooklyn showed that when the support is there—when there is a team ready to help, when the payment rules make sense, and when the technology fits the reality of the patient's life—digital health can be a powerful tool for saving lives. Without these changes, however, the very tools meant to bridge the gap between doctor and patient risk becoming another wall that keeps the most vulnerable people on the outside.
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