The U.S. healthcare system, already often inadequate and inaccessible to the vulnerable and marginalized, is now so overtaxed that even physical proximity and insurance coverage can’t guarantee services in an emergency. Telehealth use by physicians jumped from 25 percent in 2018 to almost 80 percent in 2020, according to the American Medical Association Physician Practice Benchmark Survey, while almost 85 percent of psychiatrists connected with the patients via video visit or telephone during the height of the pandemic. Telehealth can bridge accessibility issues, but that leaves out the many who still don’t have reliable broadband access at home. Approximately 19 million Americans—6 percent of the population—still lack access to fixed broadband service at threshold speeds, according to the Federal Communications Commission Eighth Broadband Progress Report. In rural areas, nearly one-fourth of the population—14.5 million people—lack access to this service. In tribal areas, nearly one-third of the population lacks access. Some libraries are stepping up to fill that gap.

Craig Settles, author of the Library Telehealth Guide, experienced the benefits of telehealth firsthand when he had a stroke seven years ago. “If you have a stroke, you have three hours in which to get treatment or you may not recover. Telehealth enabled the neurologist working from home on a Saturday night to take over the ER team and get me treated within 25 minutes.” The experience prompted him to think of the possibilities if telehealth was available through libraries. “I lived in Alameda at the time, and the library was a mile from where I lived. If the library had had telehealth, the mile walk was good for my leg recovery, and rehab software could have helped my arm recovery. An enclosed kiosk could have helped with mental health sessions,” as well as protecting patron privacy in general.

BUILDING THE FOUNDATION

To successfully support this work, libraries need to provide infrastructure, outreach, education, and access. Jessica Rangel, senior vice president of Clinical Innovation at the University of North Texas Health Science Center, Fort Worth, said, “Accessibility support is essential, especially in aging and marginalized communities. It’s imperative that we be in relationship with the community and journey with each individual through their healthcare. Libraries in many communities are the epicenter, the heartbeat of their community. It’s a total win-win to have telehealth embedded within libraries and neighbors that the community trusts. Where lack of digital literacy and health literacy exist, telehealth will fail without ambassadors of access present whom individuals can trust. Library staff are incredible stewards of this very thing.”

Of course, library staff are already tackling a large number of new jobs outside their core work, including distributing COVID tests and masks, at a time of extra stress and burnout. To add telehealth without making it one more burden on an overburdened workforce, Larra Clark, deputy director in the ALA Public Policy and Advocacy Office and of the Public Library Association, recommends partnership. “One of the ways libraries can be successful in navigating and addressing issues and concerns is through collaboration. Library staff do not need to figure this out on our own,” she said. “In fact, I believe we offer better and more holistic programs when we work with subject matter experts (of all kinds, including lived experience) to build services and resources. Fortunately, this ability to collaborate to serve our communities is a library super-power. We know that we don't have to have all the answers, we just need to know how to find them. I expect we will see significant growth related to telehealth with federal investments in broadband infrastructure, and there may be many different ways libraries can engage, inform, and empower people to improve equity.”

Integrating telehealth into libraries will require cooperation between health systems, community-based organizations, and healthcare workers to provide culturally humble and holistic care and wraparound services. Devon Andrews, associate director of community engagement, Charleston County Public Library, SC, said, “Our Community Health Worker works out of our physical library branches and Mobile Library and is responsible for offering health education to patrons and connecting them to appropriate resources, and is also the one who facilitates the telehealth appointment. She gets the library patron set up online with the appropriate physician at our partner hospital, then gives them privacy to engage directly with the provider for their telehealth appointment. She has developed relationships with many faith-based organizations, which is key to reaching the rural areas of our county. Through her relationship with them, we've also been able to partner on other health-based endeavors, like giving out COVID tests and vaccines in these areas that may see barriers in accessing these resources.”

GETTING THE WORD OUT

Libraries have to do extensive and creative outreach to make sure that telehealth and related services are familiar, accessible, and trusted. Dianne Connery, Pottsboro, TX, library director, has been honing the telehealth services the library offers since the beginning of the pandemic. “Borrowing an idea from Salt Lake City Library’s digital navigator program, we are having door hangers made and will literally go door-to-door to promote the program,” she said. “We sent mailers to every address in our zip code, sent mailers home with all school kids, posted flyers in apartment laundry rooms, post office, pharmacies, email blasts, social media, and have been featured on TV.” Understanding that health literacy is also an issue, Pottsboro library has also “recently hired a community health worker who will undergo extensive training through UNTHSC [University of North Texas Health Science Center], and then provided public health outreach in our community,” she said. “We have a focus on aging in place issues.... As part of that initiative, we’ve recently received two grants to hire digital navigators. One grant specifically targets older adults who will receive assistance with connectivity and skills. They will receive a tablet, internet connection for 12 months, and training/one-on-one support. Connectivity is considered a social determinant of health.”

Once patrons are aware of the services, they still need to be convinced to use them. Pamela DeGuzman, associate professor of nursing at the University of Virginia School of Nursing, Charlottesville, said, “In many communities that offer telemedicine visits in their libraries, the most vulnerable patients (those with limited resources, transportation, internet access) are not using the service. It’s not just an issue of marketing. We know that the Delaware libraries, for example, have done plenty of marketing of their services. I suspect that libraries are experiencing something that we have seen in public health for a long time, that in order to serve those in vulnerable communities, you first have to establish trust with people in those communities.”

Tracking and assessing what populations of patients are using the service in a way that protects patron privacy presents a challenge of its own. None of the librarians leading telehealth initiatives that we interviewed for this article were yet able to share demographic data.

CREATING SAFE SPACES

Another key piece is how to handle the issues of space, privacy, staff training, hardware/software resources, data security, and HIPAA (Health Insurance Portability and Accountability Act). Any one of these can be daunting, but they are all important. Nick Martin, emerging technology consultant at Delaware Division of Libraries, explained the approach the division took. “For libraries that do not have the space to handle a standalone telehealth kiosk, we are retrofitting their study rooms. This actually lowers the barrier to entry for interested libraries, because the solution is less capital-intensive.” Kiosks can range from $10,000 to $16,000, while a refitted study room costs more like $500 to $2,000—even less if the library already has a room with good soundproofing and lighting, and a computer and high-resolution camera.

“To ensure privacy and an appropriate telehealth space,” Martin continued, “we optimize for wall color, lighting, soundproofing, and internet connection.… We are not training existing library staff to operate the telehealth spaces. Instead, we are hiring new staff to serve as “Navigators,” who typically have a social service and case management background. That being said, all telehealth-participating libraries receive a “Telehealth 101” training so they are aware of the services in their library. In terms of data security and HIPAA, it is incumbent on the healthcare providers to have secure, HIPAA-compliant online platforms. All library patrons who engage in a telehealth visit are required to sign a HIPAA Acknowledgement Form prior to their visit, which releases the libraries from any liability.

Undertaking telehealth services in a library is complex, and won’t be feasible for everyone. It requires dedication to effective communication and collaboration with the communities to be served as well as the health systems they need to access, and a willingness to solicit, actively listen to, and incorporate the critiques, questions, and feedback that arise. But for those that have the capacity to tackle the challenge, telehealth services have the potential to help reduce health inequities and improve health outcomes for their communities.