Thank you, everyone, for joining us. Today we are going to discuss bridging the digital divide, the interplay of innovations in digital mental health and healthcare disparities. My name is Dr. Nicole Christian-Brathwaite. I am a child, adolescent, and adult psychiatrist and head of medical and clinical strategy at Headway. I am joined today by my exceptional colleagues, Dr. Hassan Mahmoud, clinical assistant professor at Tufts University School of Medicine and consulting psychiatrist at Array Behavioral Care. And Dr. Leroy Arenovar, vice president and medical director of engagement for outpatient services at Array Behavioral Care. So just to start briefly to go over what the plan is for the next hour, so we're going to look at the role of digital health solutions and expanding access to care, looking at how that's changed over the last few years during COVID, but also recognizing how digital access and technology can both support and even potentially hinder access to more marginalized groups like racial, linguistic, or sexual and gender minorities. We're certainly going to explore the complexity of what it means to deliver telehealth or using digital health technologies to implement psychiatric care and also thinking about how do we solve for some of the barriers and challenges. The COVID-19 pandemic has really facilitated a digital revolution in healthcare as the pandemic and subsequent public health emergency forced massive and very rapid scaling of telebehavioral health across the country. This occurred due to a combination, of course, of increased demand for behavioral health services, barriers to accessing care, lockdowns, increase in substance abuse and use, certainly an increase in rates of depression and suicide amongst adolescents, even more so amongst LGBTQ and adolescents of color. And while these challenges affected everyone, obviously, they also exacerbated underlying healthcare disparities among many marginalized groups. The stressors certainly of the pandemic, including the economic challenges, social unrest, racism that we've seen all over social media and TV, and anti-LGBTQ legislation really worsened the already escalating mental health needs of members of underrepresented groups. So the expansion of telebehavioral health and digital solutions expanded access to care. But what we're realizing is that it actually may have hindered or harmed certain marginalized groups. And that's really what we're going to focus on today. So now I will pass this over to Dr. Mahmoud. Hi, everyone. Thank you so much for joining us today. So I'll kick it off by talking about the role of digital health technologies and the way that's been shaping the experience of sexual and gender minorities when accessing behavioral health care across the U.S. I have no conflict of interest to disclose. I typically like to start by just going over some terminology, making sure that we're all speaking the same language and level set on what some of the terms mean. So throughout this presentation, I'll be using the term digital health and telebehavioral health interchangeably. The two are very closely connected. Really, there's a large Venn diagram there. Strictly speaking, or if we were to go by the definition, digital health is the use of computing platforms, softwares, devices, connectivity, and sensors for health care provision and health care promotion. An example or a subcategory under digital health is telehealth. While we have been using them interchangeably over the past three or four years, the term digital health has become a bit more prominent to emphasize the diversification of delivery of remote care to include not just video conferencing, but video conferencing, audio, text-based interventions and care that's delivered in both synchronous and asynchronous manner. The other term I want to clarify is sexual and gender minorities, which refers to individuals who identify as lesbian, gay, bisexual, transgender, queer, questioning, asexual, intersex, non-binary, and others who identify as belonging to a sexual or gender minorities. I do want to emphasize that my colleagues and I, we recognize that sexual and gender minorities also belong to a wide range of communities, be it urban, suburban, or rural, identifies belonging to different races, ethnicities, faiths, different ages and socioeconomic backgrounds. We recognize there's a certain degree of intersectionality, of course, that leads to SGM individuals experience interdependent disadvantages or at times advantages and barriers in accessing behavioral health services. So focusing, though, on the SGM perspective. So SGM individuals are considered one of the most marginalized and underserved groups when it comes to health care in the United States. On the one hand, they experience an elevated prevalence of mental health and substance use conditions due to increased risks and risk factors such as stigma, discrimination, and denial of rights, which lead to higher rates of depression, anxiety, substance use disorders, and suicidality. On the other hand, they experience multiple barriers in accessing care. Just to provide one example, according to the Trevor Project, 60% of SGM youth were unable to obtain mental health care when seeking it. That's a survey done in 2022. Unfortunately, when they are able to access care, the quality of care provided and the experience of accessing care can be significantly suboptimal. An example that I have is that 32% of trans individuals said that their provider intentionally misgendered them when seeking care, according to a 2020 survey. Now in 2018-2019, I collaborated with a couple of co-authors to publish a paper on telebehavioral health and SGM mental health. And we looked at both barriers to care and the potential for telebehavioral health to overcome these barriers. We categorized them into individual level, clinical level, and systemic level barriers. So I'm going to go over these briefly and give some examples. So at the individual level, SGM folks report a double-tiered stigma. There's a stigma of mental illness that continues to persist, as well as the stigma of belonging to a sexual or gender minority. And that stigma, unfortunately, is associated with nondisclosure of certain sexualities, certain symptoms, certain behaviors. And that nondisclosure is associated with suboptimal care. At the clinician level, we have a shortage of culturally competent slash culturally affirming clinicians. And that is in part at least due to the fact that training on SGM health care remains the exception rather than the rule. It is getting better. However, it is not mandatory in most training programs within health care training programs. And that can lead to, of course, suboptimal care. But it can also lead to discriminatory behavior, dissatisfaction of patients, and lack of engagement in treatment. At the systemic level, there's a shortage and uneven distribution of behavioral health professionals overall that affects the country overall. And many medical institutions continue to demonstrate prejudice and discrimination against SGM individuals. And this was published in 2019, I believe. And so anti-SGM legislations were just starting to tick up. Situation right now is much more challenging. In that paper, we argued that telebehavioral health has significant advantages at the individual level treaty facilitated access to care for individuals who had certain mental health conditions that really affected their ability to travel or interact with people in person, including social anxiety, paranoia, agoraphobia, and PTSD. Also studies show that SGM individuals felt more at ease communicating with providers remotely via in-person and led to them feeling more comfortable to disclose more details about their symptoms. And it was a way to bypass stigma. At the clinician level, telebehavioral health facilitated access to clinicians who are able to deliver SGM-affirming care, regardless of the patient's geographical location. And at the systemic level, there was overall more efficient use of the clinician time, which freed them up to be able to deliver care to more patients. It was overall less costly for patients, especially patients that had to travel long distances because there's that burden and cost of travel, which is some rural areas is up to 70% of the cost of healthcare. One added benefit was being able to bypass the risk and harassment and negative attitudes that people experience when traveling to seek care and within healthcare systems in general. Now this was all before COVID. The pandemic was very challenging for all of us. It was particularly hard for SGM individuals. There were higher rates of mental health and substance use conditions. And there was a significant fracturing of the community because of that loss of space and support systems that existed in person. Also for many youth that identify as SGM, they had to move back into their parents' home. And their parents were either unaware or not supportive of their sexual orientation or gender identity. And now beyond COVID, anti-SGM legislations have really increased exponentially, not just significantly, just exponentially over the past three years. Between 2021 and 2022, there were over 306 anti-trans bills that were introduced by state lawmakers. I last updated this slide in April of 2023, and ACLU was tracking 452 anti-SGM bills. I checked it today. It was closer to 500. It had actually gone above 500, and sadly some of these bills have become laws, which is why ACLU is not currently tracking them. But what we wanted to do is really examine digital health and telehealth beyond scratching the surface and looking at the benefits and look at the experience of SGM individuals while they are in situations where they were accessing care remotely. And so we conducted a review of peer-reviewed publications from 2018 to 2022. 27 articles met our inclusion criteria, and interestingly, most of them were published after 2020, so 2021 and 2022. We categorized the findings also based on patient-level advantages—oh, sorry, patient-level, clinician-level, and systemic levels. So at the patient level, there were significant advantages reported by patients. Tele was found to be significantly effective for a wide range of symptoms, be it for depressive symptoms, anxiety symptoms, trauma-related symptoms, or suicidality. It was measured through the reduction in symptomatology that was either self-reported or using measurement-based care with significantly higher levels of patient adherence. Tele was also reported to have high levels of acceptability for patients across different age groups, different sexual orientations, gender identities, different conditions, as well as different treatments and interventions, be it medication management, individual therapy, group psychotherapy, or online support forms. And then from a patient experience perspective, it was actually reported that telebehavioral health was superior to in-person care. Some of the examples or areas that were emphasized were the degree of privacy and comfort that folks felt when accessing care remotely. Tele was found to be more convenient, safer, more private, and offered the diversification of accessing care, again, be it through peers, be it through psychotherapists or medication management. And a couple of examples that really stood out to me that I want to share with you is how important it was for trans folks to be able to display their pronouns during virtual visits, and the fact that their pronouns were displayed were very important to them. The other added benefit to the patient experience was the patient reported they were less likely to encounter staff who may misgender them. Now, it's not all rosy, of course. This rapid transition to tele was also associated with technical difficulties. Folks would be able to access care. Not everyone was tech-savvy or had the technical know-how to be able to access care remotely. Not everyone had access to broadband, high-speed internet, or to the software or hardware required to access care remotely. And unfortunately, many folks with unstable internet connection experienced a lot of frustration, and even some of the sessions had to be terminated early because the conversation became unintelligible. And there were ways that the facilities were able to get around that, either by transitioning to audio sessions as an alternative or to provide tech support and some training to patients. And well, overall, there was a lot of satisfaction with the quality of care. Some patients—I mean, tele is not for everyone. Some patients reported that they didn't like the experience. They felt that it was impersonal or depersonalized to access care remotely. And while overall, the responses were overwhelmingly positive when it came to privacy and tele being perceived as more private, there were still some concerns about privacy, especially among survivors of intimate partner violence, youth who really were not comfortable with having someone overhear their conversation or the possibility that someone could overhear their conversation during tele. And there were concerns about cybersecurity overall. At the provider level, there were also significant advantages. Providers reported that they were happy about being able to have that capacity to continue to provide services during COVID. It really caused significant improvements of flexibility and satisfaction of providers. And there was a high degree of engagement from both the clinicians and the patients with the clinicians were very happy about that high degree of engagement. At the same time, clinicians were very happy to be able to access resources to improve the quality of care they're providing to SGM individuals. And a lot of online training were conducted, especially early on during COVID, to enhance that ability and training in being able to deliver SGM affirming care. Providers were also exposed to the range of solutions that are available. So they felt that they were more empowered to support their patients because patients could access care through peers, through online forums, in between sessions, and providers reported they were very happy about these added resources. On the other hand, that rising demand for behavioral health services that we experienced over the past couple of years really overstretched smaller organizations serving SGM individuals. They were placed in an impossible situation to try to accommodate and with very limited resources. At the same time, some of what we saw reported by patients about frustrations about the quality of the interaction or the quality of the connection was also mirrored by clinicians who felt lower satisfaction and had lower session completion rates at times because of tech difficulties or privacy concerns leading to having to terminate the session or move to audio. There were also a lot of concerns about burnout with that erosion between personal life and professional life and feeling that there's this expectation to be available all the time with the technology. Because of that limited quality of the interaction when there was technological difficulties, a lot of providers reported that it made it difficult, like that lack of quality of the video interaction made it more difficult to assess certain nonverbal cues and certain facial expressions, which was a point of dissatisfaction. At the systemic level, there were, of course, significant advantages. Overall, TELA allowed us to continue to serve our patients, so it made behavioral health services more accessible during COVID, also more affordable. There was decreased transportation costs, decreased absenteeism, decreased no-show rates, overall healthcare costs associated with travel were decreased, and there were newer, more diversified ways to access care, such as professionally moderated virtual safe spaces, and the fact that we're now delivering care via video, via audio, text-based, self-navigated tools, as well as synchronous and asynchronous care. Now, there were shortcomings, of course, that abrupt transition to virtual healthcare delivery during COVID exacerbated the digital divide. The digital divide is a divide that is caused by disparities in access to technology or broadband connectivity or tech literacy, causing significant limitations to being able to access the technology, and therefore, being able to access healthcare, so it's a double disadvantage there, and my colleagues will be expanding more on the digital divide. We had some recommendations. We had a lot of recommendations. I'll summarize some of them today. At the patient level, really, it's our responsibility to continue to raise awareness among our patients about the availability of remote care and the different ways in which patients are able to access care. It's important to communicate with SGM patients about the framework of treatment, issues of privacy, confidentiality, and have backup plans when technology does not work or when privacy becomes an issue. At the provider level, we need to train more behavioral health provider. We can all agree on that. We also need to train behavioral health providers on digital health solutions. I know a lot of providers have become much more comfortable using tele or digital solutions, but I think more training needs to be conducted, and of course, more training on SGM-affirming care. We need to improve cultural competency training and culturally-affirming care standards for providers working with SGM, and that needs to apply both to clinicians and to support staff, and to reaffirm the roles of providers as advocates for health equity, human rights, and patient autonomy. At the systemic level, I think we need to work with our professional organizations, with policymakers, with different healthcare organizations, be it in mental health or in telehealth, in order to collaborate on introducing and incorporating SGM-affirming guidelines and best practices to support health equity. And it's important to urge our policymakers and professional organizations to introduce evidence-based healthcare policies that combat discrimination, decrease healthcare inequities, and mitigate the digital divide. Thank you so much. I'll pass it on, Dr. Brathwaite. --. Thank you. So I am going to briefly discuss looking at the digital divide, specifically in African American and Latino communities. No conflicts of interest. As Dr. Mahmoud mentioned, the digital divide is essentially the gap created between different demographics of people and their ability to understand, access, and effectively use technology. And evidence actually shows that being an impoverished black woman is correlated with the greatest probability of not completing a telehealth visit. The UN Secretary General once said, the digital divide is now a matter of life and death for people who are unable to access essential healthcare information. It is threatening to become the new face of inequality, reinforcing the social and economic disadvantages suffered by women and girls, people with disabilities, and minorities of all kind. And when I read that quote, it really resonated with me, and frankly was surprising that this is considered not only a United States problem, but a worldwide problem. And social determinants of health, as Dr. Arenovar will talk about a little bit more as well, are actually really not considered when implementing new technology. We're not asking the question of who can't access this when we're building technology or even creating interactive options for patients with measurement-based care. I mean, in theory, integrating technology into healthcare delivery should benefit vulnerable populations. As Dr. Mahmoud mentioned, it eliminates barriers like transportation, access to distant clinical offices where clinicians decrease time lost at work or school, and certainly can reduce challenges for people with disabilities or even new parents. However, the persistence of structural, societal, institutional, and individual racism continues to exacerbate these disparities. This digital divide is ultimately a consequence of historical and current oppression of marginalized groups and socio-political barriers. This is a quote from a social scientist at Harvard, Dr. David Williams, and he stated, and he's done a lot of research looking at inequality and disparities in healthcare. 200 black people die every single day in the US who would not have died if the health experience of African-Americans was equivalent to that of whites. And, you know, COVID honestly shined the light on these disparities in a major way on a certainly much larger scale and stage. And there was this assumption that the evolution and implementation of telemedicine would expand access and reduce disparities and we would address all of these concerns via technology. However, again, disparities did not just persist, they worsened and they were exacerbated. And I don't know how many people, show of hands, have read the recent JAMA study that came out over the last few weeks looking at mortality rates in African-Americans. If you haven't, certainly please do. So the study actually found that the mortality rate of African-Americans resulted in 1.63 million excess deaths related to white Americans over the last two decades simply because of disparities in access and screening and care. And honestly, if you think about it, just about any disease, illness, the rates of morbidity and mortality are greater across the board in communities of color than in white communities. If you remember, I mentioned the people least likely to access telehealth are poor black women. And if you look at the rates of morbidity and mortality in black women, particularly in women's health or pregnancy, those rates are astounding. Black women are also less likely to be screened for behavioral health concerns. Certainly when we're looking at fields of medicine, that's the case. I think often in psychiatry, we tend to assume that we're not included in that group, but unfortunately we are. There are certainly a number of disparities in behavioral health and psychiatry. Even, for example, thinking about rates of diagnosis of psychosis, it's much higher in African-American men, even when they present with symptoms consistent with depression. And so I essentially, I'll get off my soapbox, but I say all that to say the discrimination and disparities are rampant in psychiatry, in medicine, in therapy. So this feels urgent, it is urgent. We really can't afford to add tools to our field that only furthers the challenges for the most vulnerable groups that we serve. And COVID again, COVID-19 and the immediate integration and adoption of telehealth dramatically impacted the practice of psychiatry. And actually in some ways, decentralized healthcare. It increased accessibility overall to the general public. I live in Boston, I had a clinic in very rural Illinois where I was the only psychiatrist within at least an hour of the community. So I was able to treat families and children that otherwise would never have had access. So I don't want to imply in any way that telepsychiatry or technology is not beneficial, it is. We just again, have to ensure that it's beneficial across the board. And certainly there are numerous reasons for the digital divide. And again, many of which are directly connected to societal and structural racism. I think oftentimes we're almost afraid to say the term racism, but it's important to recognize that it's the basis, it's the foundation for all of the disparities that we're witnessing. And so these reasons behind the digital divide certainly include poverty, poor digital literacy, lack of access, lack of interest, lack of trust in the systems and many other social determinants of health. And there are actually three levels of the digital divide. So access and coverage, usage and skill and then outcomes. So access and coverage is the possibility that an individual can access and use the internet. For example, that's the basic level. Like, can you even get to the technology? Can you access the internet? Do you have a computer? Do you have a smartphone? And so really access is the minimum level of necessity. That's the baseline. And I think often, again, when we're looking at the digital divide, all three levels must be addressed. If you just give someone a phone, but you don't teach them how to use it or how to access their online visit, it's not helpful. My mother has plenty of online visits and no matter how many times I teach her, she just cannot seem to figure it out. So every visit, it's on my calendar as well because I know I have to set her up. But if she didn't have me, she would not have access to those visits. She just literally doesn't understand the technology. The second level is usage and skills. So again, patients who have access to more information, more resources, gain digital skills. It's a very clear connection, unfortunately, between the resources and access and understanding. And so when you don't have access to that education, obviously those disadvantages increase. And then last are the outcomes. So what is the ultimate impact of not having access or understanding? And again, these impacts are both socioeconomic and cultural, certainly impacted by social determinants of health. However, if you're thinking about ultimately outcome, it's not even just in the appointment, but certainly not having access to technology or understanding technology can impact every area of life, which we'll talk about. And so digital literacies and internet connectivity have been called the super social determinants of health because they address all other determinants of health. So if you think about it, is there any area of your life that isn't in some way impacted by technology? Applying for an apartment, applying for a job, banking, groceries, healthcare, I mean, just about anything you purchase or engage with nowadays has some level of technology involved. And so if you're someone that struggles with access or usage or understanding, it's not just your healthcare that's impacted. And as we know, everything is connected, right? If you can't find adequate housing, then you certainly can't conduct a telehealth visit from home. If you're not able to access money from a bank very easily, then how are you managing your co-pays? How are you paying your basic bills? And so we really need digital equity, essentially meaning all individuals and communities have the information technology capacity needed for full participation in society because this is society, right? Like technology access is being able to engage in society. Even something as simple as voting requires some level of technology and understanding. So digital equity is necessary for access to all forms of medical care at the least, but employment, education, and access to the most basic services that I think we often take for granted. To achieve digital equity means that every person would have the technologies, the tools, and the skills needed to access affordable, high-quality internet anywhere. And again, I think many of us don't realize how necessary technology is because it's just, you know, you wake up and you turn on your phone, or you wake up and you get on the computer. We're all experts in Zoom, semi-experts in Zoom. But I think we forget the benefits because it's a standard for us. And Pew Research indicates that black and Latino individuals remain less likely than their white counterparts to own traditional computers or have access to high-speed internet. 80% of white Americans report owning computers compared to 69% of black Americans and 67% of Latino or Hispanic Americans. And, you know, most mobile health technology requires a data plan, right? So it's not just access, right? You have to get it, but you have to keep it. You have to sustain the plan. You have to be able to pay for it in an ongoing way. Yet the American Community Survey shows that 40% of low-income households lack a subscription, requiring them to use limited cell phone plans or accessing internet via public Wi-Fi. However, during COVID, we realized that there was something occurring called internet gatekeeping. So essentially, that's where Wi-Fi access was being restricted and the police were being weaponized against individuals who did not have access to high-speed Wi-Fi in their homes. So it led to a substantial increase in quality-of-life phone calls to police, particularly in higher-income or white communities. And it was really only seen in higher-income or white communities. Low-income communities were not receiving calls about concern about people loitering in Starbucks. And so it was essentially internet access was being policed in public places to protect, and these were the terms used, they were being policed to protect access at the expense of the most vulnerable. And I'm not sure if anyone remembers, in 2018 in Philadelphia, there was a big story where two African-American men were in Starbucks using their phone on the Wi-Fi, waiting for a business partner to come. And someone was not comfortable with their presence there. So the police were called and they were arrested for loitering. And again, how many of us sit in Panera, Starbucks, Dunkin' and work for hours at a time? You may buy one drink, sometimes you may buy none, but I don't think any of us would ever think about being arrested for working in a public place with free Wi-Fi. There is a paper that I would certainly recommend if you have any interest in learning more about this. It's entitled Policing the Digital Divide, Institutional Gatekeeping and Criminalizing Digital Inclusion. And essentially this paper in a very real way connected ongoing conversations about the role of institutions perpetuating white supremacy and the privilege of being able to stand in a position where you don't have to worry about one, access to internet or two, being arrested for trying to access public free Wi-Fi. And so when we're kind of bringing it back to psychiatry and bringing it back to healthcare, if you really think about the most basic requirements of a telehealth visit, we recognize that there are many individuals who have baseline or just added a disadvantage. So as Dr. Mahmoud mentioned, so risk of a poor connection, freezing video, audio coming in and out can certainly lead to frustration. We've all been there. How many times like you're muted, you're muted, please unmute yourself. Like it just, at some point it just, it becomes not worth it, the effort for both the patient and the clinician. I've had so many visits where like I can only see like the ear or the eye or like up someone's nose because just the basics of how to hold the phone to have a conversation via video is foreign to those individuals. And so I've had so many conversations with an eyelash because that's all I could see for the entire visit. But then this also, it risks the care, right? Because if the clinician can't understand what the patient is communicating, or if the patient is in having safety concerns and they're speaking quickly or they're not speaking loudly enough, you're not able to actually conduct an adequate visit. You're not able to get the HPI that you need or to do an appropriate safety assessment. And then also even thinking about privacy. Receiving therapy or psychiatry, the most basic requirement is that you're safe and it's private. However, many families of color live in intergenerational homes. I live with my husband, my kids, my mother, my father-in-law lived with us. I had to buy a lock to put on my office door because no one respected that space as being like my personal space. But because again, we live in a home where there's no such thing as privacy. And many families of color, many intergenerational homes, that's the expectation. So as a 16-year-old who's struggling with identity or gender, how can you talk about that? Where can you go to have that conversation? And so we certainly, we can't assume that the patients have that safe space. And again, telehealth is primarily useful and accessible to people who can afford it and who understand it. And now, just thinking about all the bad news, like what can we actually do? And there are a number of things we can do, and there certainly have been, over the last couple of years, significant research looking into how to address the digital divide and the disparities. So there are community-based efforts that can be implemented to address, and again, every level of the digital divide. I think often we make the mistake of picking one. We need to look comprehensively at all three. So one, we just need to meet our patients where they're at. So for example, Array Behavioral Care has something called a scheduled care model. So we are going to the patients, we're not expecting them to come to us. So we are using technology to provide care in schools on Native American reservations in their primary care doctor's office, so that the patient doesn't need to look for us or have the technology to access the care. They go to a community environment where they feel safe, and they're supported, and that technology is there. Certainly, also thinking about going outside of even just video visits. I realize that's the gold standard, but recognizing that phone-based interventions can certainly be implemented. It will be an ongoing fight to get insurance companies to pay at parity, but realizing for some people, that's what they understand, that's what they're comfortable with, and that's how they can access care. So if you're thinking about, if you had to choose between a broken, inconsistent connection via video, or a clear phone call, obviously the care and the information is much better delivered via phone. Certainly, also thinking about just overall infrastructure. I do a lot of work in communities, and when I looked at certain FQHCs, Community Mental Health Care settings, the technology that they had access to was not equal to the technology that was in wealthier suburban clinics or private practices. It simply wasn't the same. So even if we do meet patients where they're at, if the clinic doesn't have access to high-quality technology, it still leads to disparities and impacts care. Thinking even long-term and bigger, clinics or clinicians can partner with community organizations. There have been efforts where clinics have partnered with the library, and the library designated certain spaces as private healthcare delivery spaces for telehealth and technology. And if you go to the National Digital Inclusions Alliance, it actually offers a list of organizations that provide digital literacy training for patients, and even for clinicians in local community settings. And just one last thing that I say that I think we sometimes forget in the clinical setting is that we should know in advance what our patients understand and can do. So actually conducting a digital assessment, or in advance having someone from the IT team check in with the patient to ensure that they can actually access the visit, and doing some of that legwork in advance. And when we're thinking about and when we're thinking about individual patient-level interventions, again, the IT intervention is both structural and individual because we would have to have a team set up to support, but also having that contact with patients and making sure, even something as simple as having the right phone number to ensure that they, to reach out to them to make sure that they can access that appointment. And actually, text messaging has been really shown to be a potential useful intervention. So text messaging is the most frequently used form of mobile communication. Texting is highest amongst Latino and black communities, so about 76 to 80% compared to 70% in white communities. And studies have actually shown that text messaging healthcare interventions improve patient self-worth, self-efficacy, and healthcare management. So there have been studies looking at weight loss, smoking cessation, medication adherence, and even safety assessments and check-in via text messaging have been shown to be effective. And then, of course, education. At a baseline for clinicians, providers, excuse me, for clinicians, patients, and even on the institutional level, education is required because, again, if you don't understand the challenges, if you don't recognize your own personal challenges and the challenges in your community, you certainly won't be able to address them. But also, when you give patients information and education, you equip them with the tools so that they feel more empowered. And from, excuse me, and overall, we just need to address the fact that, again, systemic and structural racism and oppression have led to the position that we're in. I often, when I have discussions with people about disparities, I will say every other word except for racism. I think there's this fear of admitting and acknowledging that that's the root cause. But, again, if you're not willing to identify it, how can you actually solve it or change it? So, you know, thinking, again, about how do we address these overall systemic-level disparities. One, we can't ever get rid of in-person visits. You know, they won't ever go away completely, but recognizing that some populations need those in-person visits. The care is just received or delivered better. So, again, being flexible and being willing potentially to do a hybrid in different community settings. Always considering patient voice and patient choice. Waiting for feedback, eliciting feedback from patients about their experience and actually acting on that feedback. And then measuring what your clinic is doing, looking at outcomes. I love the phrase, you can't manage what you don't measure. And so if we're not actually looking for data, we're making assumptions. So looking at the rates of utilization for certain demographics, for certain populations, looking at their overall satisfaction. We have to have that data to address any specific concerns in an informed way. And so finally, healthcare systems should adopt, again, a digital inclusion-informed strategy regarding overall health. So what does that mean? One, you recognize that your community's level of, you recognize what your community's level of access to devices and internet connectivity is, again, obtaining that data. And then second, you support the patients in understanding, utilizing that data, and again, combating those first two sections of the digital divide. So ultimately, digital inclusion refers to the activities necessary to ensure equitable access to and use of information and communication technologies, including the broadband internet, including internet-enabled devices, including access to digital literacy training, having access to quality technical support. And then lastly, applications and online content designed to enable and encourage self-sufficiency. So that, again, the patients take ownership of their care, and then giving them the opportunity to collaborate with their clinicians. Thank you. And I will now pass this to Dr. Arenovar. Thank you, Nicole. So I'm Leroy Arenovar. I'm a child-adolescent adult psychiatrist, and my parents are both from Mexico. So the first language that I learned was Spanish. I learned English. I've joked sometimes by watching soap operas whenever my mom would have those on, and I was still at home. I'm going to talk about linguistic minorities and just make a definition, and then go into digital determinants of health, which is another slant from Nicole's. I'm going to talk about some information from UCLA, and then I'll go over my slide deck on barriers, and then kind of go more macro and talk about the promise of digital health and digital health applications, but then kind of reinforce the idea of digital health equity as these things are deployed, and I will go over some information from a California study that looked at asynchronous versus synchronous telepsychiatry for Spanish- and English-speaking patients, and then we'll end kind of on a bigger topic, again, of overview of digital health infrastructure with recommendations. I have no conflicts of interest to disclose for this talk. So, a linguistic minority is a group of people whose everyday speech is a language different than spoken by the majority of population within their nation. According to the 2010 census, more than 9% of the US population, or 47 million Americans, do not speak English as their primary language. The census basically asks three questions around this, so they ask if the person speaks another language other than English at home, and then what is that language, and how well does that person speak English, and they can pick very well, not very well, not well, or not at all, and then that's how they come up with the number that you see on this slide. The US census and the government do have this term called limited English proficiency, which I discovered in talking to one of my friends who's an educator that it's not necessarily a favorable term whenever you're talking to educators, but that is what the government uses. Educators prefer terms like emergent bilingual, or patients with emergent English proficiency. About 16% of US children live with at least one parent with a limited English proficiency, including 43% of Latino and Asian American children. I did want to say a word about, the way that I'm approaching this is about Spanish, but there's a lot of other languages. Spanish happens to be the most common, but besides English. And then some term clarification as I move forward. So Latino, Hispanic, and Latinx. So Hispanic refers to language, and those whose ancestry comes from a country where Spanish is spoken. And Latino, you can think more about geography, so like a Latin American country, the Caribbean, South America, and Central America. And not all Latinos speak Spanish. Then Latinx is supposed to be gender neutral, and used primarily for individual identity for those who are gender non-conforming, but we also see it describing an entire population instead of saying something like Latinos. So Latinx is not necessarily a term that's embraced by all. It's usually more used by people that are younger, U.S. born, college educated, to self-identify. And a lot of the most marginalized groups do not use the term Latinx. And notably in July of 2022, Argentina and Spain actually released public statements that for there they banned the use of that term because they said it was a violation of the rules of Spanish language. So I basically, to come up with information from here, this is one of the tools that I use looking at telepsychiatry and Spanish speaking, tele-mental health and tele-behavioral health. So to expand on something that has already been discussed, I'm gonna say a couple words on the social determinants of health. So this is already something that next year and this is already something that Nicole has talked about. And the CDC and the World Health Organization described social determinants of health as conditions in which people are born, grow, live, work, and age that shape health. And those conditions can include things like socioeconomic status and education, neighborhood, physical environment, employment, and social support networks, as well as access to healthcare. And one thing to think about is that a lot of these determinants of health are actually influenced by people in power and people that make policies. So that's something to consider and I'll reiterate that point later on. In terms of what I wanted to highlight here, so digital determinants of health are the conditions in which the digital environment that can affect health, quality of life, and functioning. And so again, this is a little bit repetitive from Nicole where we think about access. So that means that you have the necessary technological equipment availability. Digital literacy is about the skills needed to understand the language of software and hardware and to be able to successfully navigate the technology. And there's this concept about digital confidence that is part of digital literacy, but there's also this concept of self-efficacy. So does that patient feel like they are able to actually not just learn but continue to use the technology and the skills that they have? And then we've already touched upon the community infrastructure that we need like broadband internet and they operate at the different levels that we've been categorizing. So we're gonna look at, or I'm gonna talk a little bit about some information that came from UCLA. I'm gonna summarize this. It came out in January of 2023 from UCLA Latino Policy and Politics Institute. They looked at seven primary care clinics where they were treating chronic conditions like hypertension and type two diabetes and patients with different health coverage. The data came from January 2020 to December 2020 and they had interviews from April 2021 to April 22. They were looking at the role of race, ethnicity and the use of telehealth before and after the March 2020 shutdowns. So the way they did it was basically they had surveys and interviews of 39 healthcare professionals but that did include clinical, ancillary and administrative people. So they basically just talked to the healthcare professionals and asked about how they perceived people and the difficulties that they had. And they found that Latino and Asian patients were perceived by the interviewees to have more challenges with telehealth use compared to white patients likely due to the limited availability of non-English resources during telehealth and in-person visits. And then Asian patients, they had trouble because they were primarily and predominantly serving Spanish-speaking populations. So even though there were interpretation services, it was harder to get interpretation services that were not Spanish. So languages like Korean and Mandarin. The interviewees also perceived that black and white patients experienced fewer technology and language hurdles with telehealth use. Older patients and those with limited technology were perceived to face more challenges with telehealth but family support partly addressed those access issues. And it was interesting to think about how as the pandemic evolved and people, the shutdowns kind of were lifted that when people started going back to work, it might've been harder. So maybe in Nicole's case, it would've been harder if Nicole wasn't available to help parents get online. And then Latino patients were often requested to be seen by providers who understood them linguistically and culturally, which was not always an option due to existing provider staffing at the clinics. And Latino patients were more reluctant than others to opt for telehealth since they were often maybe more invested in the personal connection with the provider. They noted that this population was considered more traditional. And then to me, the most fascinating part about all of this was that providers and administrators who were people of color were actually more likely to report that race and ethnicity of patients impacted telehealth use. And so when they talked to people or the healthcare professionals that were not people of color, they would say things that they didn't feel that there was any discrepancy or there was any sort of challenge from people that everyone had the same access to care. Some of the takeaways from UCLA were that the importance of investing in telehealth navigation support, designing hybrid approaches that provided both telehealth and in-person services are very similar to one of the points that Nicole had made. Then addressing technological accessibility and digital literacy and educating providers about the role of ethnicity in telehealth delivery. And then looking at future telehealth state and federal legislation that should address gaps in telehealth use by race, ethnicity, and type. So hopefully, you're kind of already hearing a lot of the same themes among the three of us. And one thing that I wanted to make sure that I reiterated a minute ago was that racism is a social determinant of health. And I think that I know in Nicole that maybe in certain circles, it is not necessarily the most comfortable thing to say, but I wanted to make sure that I had not forgotten to state that explicitly. So coming back to barriers in Spanish-speaking patients to mental healthcare access, we're gonna look at it again from the individual level, the clinician level, and the systemic level. So from the cultural perspective, we can think about just the stigma that already exists within Hispanic and Latino patients, attitudes about Western medicine, maybe the belief that it's better to suffer in silence or that you should not air your dirty laundry. And then in some situations, the belief that maybe these mental health conditions don't exist, that they are a part of life. We do see lower rates of registration for electronic health records. A lot of these electronic health records are in English. Sorry, give me a moment here. Can you see about the... Like I'm trying to scroll down here. Oh, there it is. So what's interesting about the lower rates of registration with the portal is that there's actually information from 2009 to 2015 that there is higher use of internet with Latinos compared to white and African Americans. So it's all about how they're using the internet and the technologies. And then immigration status. So if you're undocumented, you might have uncertainty about how your data is being used and you want privacy. At the clinician level, we know that ADHD medications and antidepressant use is half of the rate for white counterparts. There could also be misdiagnoses or undertreatment because of Latinx and Hispanic and their presentation. They will focus more on physical symptoms instead of emotional symptoms. And then the last point under clinician level, barriers about challenges with the time needed to respond to patient portals and emails. We've already made a point about that and that's just a point about kind of administrative burden. And then not to belabor the other points, but there's still less access to high speed internet and the shortage and uneven distribution of clinicians in general, whether they're bilingual or not. And then the need to collect more data and figure out what is the right data that we want to actually track. So this slide covers the core principles for the stewards of digital health infrastructure. And so this, we think about beyond just telehealth in terms of telepsychiatry, we can think about different digital innovations and tools that are being created and the things that should guide the development of those tools because patients need to know, need to be empowered with the data that they're gonna share. They need to know that it's safe and that we're gonna be protecting them against harm and that the tools are effective because we know we can maybe establish efficacy from a randomized control tile, but is the tool actually effective like in the real world? And then we want efficiency with the different tools that are available. There is a lot of fragmentation and we want to minimize the disruption that that could bring. And so that will be addressed in the future slide where we talk about interoperability. And then we think we need the information to be accessible to different systems, so payers, clinicians, and healthcare systems that need this information maybe for a measurement-based care. So I wanted this slide in here to expand on the fact that there is more to what we're talking about than just telemedicine or telepsychiatry. And in certain areas of medicine, you might already be seeing that these digital health applications are being implemented. But we can look at these digital health applications as being a force multiplier. The figure shows factors that are population health-based and the drivers of health that are upstream digital tools. And so what I think about from all of this is that we have basically a mechanism or a way to eventually get information about the determinants of health and digital determinants of health. And then that helps clinicians and systems learn and then be able to implement preventive and acute care, both in psychiatry and other areas of medicine. So for a couple moments, I'm going to talk about some information from here in California from Peter Yelolis and his colleagues. This paper came out after the pandemic, but the data actually came from before the pandemic. It was a longitudinal study from March 2014 to September 2018. And they had English and Spanish-speaking patients. They looked at 184 patients, or that's actually how many were eligible. And then whenever they enrolled them in randomized, there were about 90 and 90. And so 90 in the control, and then 90 in the intervention. And basically, it was set up through a collaborative care model. And so a lot of us in the room probably have heard of collaborative care model. I'm not going to belabor the point too much, but you'll get the idea from the way that I describe it. There were five UC Davis telepsychiatrists, and they worked with the PCPs. And most of the patients that were enrolled had mild to moderate depression or anxiety. And they were, again, comparing asynchronous versus standard. So for synchronous, you can think of that as being an extension of in-person psychiatry because it's the psychiatrist that's actually evaluating the patient through the video. And they point out that one of the big drawbacks of that is that that psychiatrist is not necessarily seeing the patient face-to-face because they are seeing the patient one-to-one. And so when we think about the asynchronous part, that's a completely virtual care model. And that allows the psychiatrist to be involved with more patients. And the way that that happens is that the psychiatrist is looking at the chart and looking at recordings from a trained mental health clinician who's using a semi-structured interviewed. And in this study, they consulted with the patients for about two years. So whenever it was asynchronous, the psychiatrist would look at the data and then make a written recommendation to the PCP. And the psychiatrist is available by phone and email. And that was for both arms. So their hypothesis was actually that asynchronous care would be superior. And the result was that there was similar improvements to asynchronous and synchronous care. So the conclusion was basically that this could be a way to reach these Spanish-speaking patients through the collaborative care model. So if we look at this, this kind of can start to summarize a lot of the things that we've already been talking about today and applying this to just digital health infrastructure and behavioral, and we start at the top. We think about individual access and engagement and then applying it again through what we've been repeating which is access of widespread broadband internet access. And then that, we think about equity leading to more engagement in digital health and healthcare. So for us, the way that we think about equitable care, that means providing care that does not vary in quality with personal characteristics like gender, ethnicity, or geographic location and SES. As we engage individuals and families, that they contribute to these solutions that support health and well-being. And then that personal information is translated to help inform broader policies. So it's interesting to think about these digital health interventions right now. A lot of them are made without anybody's input except like a developer, a software developer, right? And then we come after the fact and we say to the patient and the clinician, please use this. And I think that if we twist it around and we think about being involved from the beginning and declaring that these are the things that we are expecting that we might be able to come up with more effective interventions. So when we think about things like privacy, there are some concerns there like with wearables those are not things that are covered by HIPAA but HIPAA might need to be expanded to be covering those things. Think about identifier protocols that would need to be used to match individuals across systems that also would end up being a HIPAA issue. Cybersecurity like Nicola talked about needs to not be an afterthought because these challenges require technological governance and legal protocols. And so we need to think about public-private partnerships that are necessary to develop this superstructure framework. When we think about data quality and reliability and stewardship, that slide a couple, the slide that I presented a couple of slides ago kind of talked about this already but we need to make decisions about the use of cloud to store information appropriately. Then when we do think about like what is a good digital health product versus another one, that kind of falls into all of this category and a lot of you in the room may already know that the APA does have an app advisor. So if you didn't know about it, the APA app advisor gives you guidelines to determine what might be a good app for a patient. It doesn't rate something as good or bad but it gives you the framework. And I was fortunate to be involved at a collaborative on Friday before the main APA meeting started and the next level of the development for this app advisor is actually gonna be looking at whether an app considers digital health equity in its development. So I talked a bit earlier about interoperability and so for that we think about integrations into EHR. So how do you integrate lab work results? How do you integrate any of this information from digital devices into the electronic health record? And then AI and machine learning, the framework for AI as a medical device and regulatory expectations that come from that as we move to value-based payment models and advanced analytic AI predictive modeling that can be used to look at population risk. Yesterday, Dr. Ruby Castillo-Puentes presented about, from her university I think in Cincinnati, AI algorithms from an AI company called Cultural Intel. And the session was called AI to Analyze Open Source Digital Conversations on Depression and Data. So it's very interesting. So this is, they looked at open source data over 12 months, not from patients but just from people on the internet. This was non-patients and that they made a big deal about this because there is like this concern about the ethical part and like how we're using this information. But the algorithm looked at topical websites, message boards that was de-identified data and then it categorized people and that you could tell if it was someone who was Hispanic or not. And kind of back to the point about stigma. So Hispanic people were posting more about how to cope with depression versus live with depression. And again, kind of like maybe thinking that depression was something they just had to live with and not that it was actually something that could be treated. Versus if it wasn't Hispanic, a lot more of it was actually posting about how to get help for depression, how to find sources of help. And then to kind of round out this whole infrastructure diagram, workforce. So that's us here in the room. Us understanding more things about data management and interoperability and the ethics and process improvement and implementation. So these are the final slides to kind of be taking things away from the diagrams and to reiterate many points. So on the patient and clinician level, we have to have awareness and understanding of the tools that are available for the patient and how do we let the patient engage in this. A lot of it comes down to asking the patient. And then patients having personal agency to use the tools that are available to them and helping them through a risk-benefit discussion. And then training diversity in programs. So attracting minority students to work in psychiatry and other mental health options. And then the last two things are pretty, we've touched on, so I'll just move on to the next slide. So a lot of this really reiterates many of the points that we've already talked about. So digital health equity should be a priority and we've talked about what equitable care means. We need investment in multilingual platforms and multilingual support staff. And we need increased access to digital technology and increased digital literacy training and broadband internet. And then I'm gonna end with this slide, which is a bigger macro view of things and emphasizes a lot of the things that we've been talking about. The theme of APA this year is about innovation, motivation, and collaborating. And so what I like about this slide is that it highlights a lot of the things that we've all talked about. So a lot of these domains are multi-stakeholder and if we go back to things like how do we co-design digital interventions with people involved from the beginning, the people that might be using these digital interventions? How do we train developers to have a human-centered design process? And how do we bring these ideas and data to make policy pushes and discussions with payers about parity and reimbursement? One of the things that I was left with whenever I was at the collaborative on Friday was that we need to be loud about these barriers. We need to identify them, just like Nicole had talked about. And then be able to be part of the process and come to the table with our perspective and collaboration for me even means outside of psychiatry. How do we collaborate with the other stakeholders? And then I wanna just kind of, since I talked a little bit about education, couple of things that I learned whenever I was preparing for these slides. So the APA actually does have a website that is in Spanish with psychiatric information, and it's called lasaludmental.com, so L-A-S-A, L-A-S-A-L-U-D-M-E-N-T-A-L.com. And then, although not specifically related to digital health interventions, SAMHSA and the Department of Minority Health have guidelines called CLAS, C-L-A-S, and it stands for Culturally and Linguistically Appropriate Services, and they define that as services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs, and that these things can be employed by all members of an organization at every point of contact. And if you look that up on the Department of SAMHSA and the Office of Minority Health, you can also find a free two-hour e-learning on cultural competency. So, again, not specific to this topic, and it's about digital mental health, but just cultural competency in general. So, thank you, everyone. I think now we'll open up to any questions. They've asked us that if you have questions, speak into the, yeah, into the mic so that we can record it. Yeah, so I'm all for making access to people who would normally not come to the clinic. I feel somehow, at some point, I usually get offers to do virtual here and there. I said I only have one request, that I should have access to the patient and have a live session at one time, and then after that, once I have established a therapeutic alliance, I mean, you could be in Timbuktu and I don't mind talking to you on the phone or video, but there is something about the communication, both ways, from patient to you, verbal, non-verbal, and you probably also, as a therapist or psychiatrist, convey something verbally and non-verbally to establish that alliance and address all these issues, racial, diagnostic, why I'm asking you questions about three generations, what your grandfather was doing and what your grandson is doing, you know, stuff like that. There is something about that I feel, you know, I usually, when I did work in a clinic, I would keep the new patients, you know, the last, you know, so I could spend an hour, hour and a half, you know, until and unless I have established some kind of therapeutic alliance and made the person comfortable about what we're gonna be going on to do and, you know, address all these other issues, racial, you know, I mean, why am I asking these questions? Why am I asking you questions about your mother and grandfather? Stuff like that. That, I feel, can best be achieved by that. So whenever I get a call that I want to do, I said, I don't, I mean, if you're willing to do it in California, I'll come from New York to California. Once a month, I want to meet everybody and then establish that kind of communications because sometimes it's hard to put into words. Just being in the presence of the patient, the patient feels something and you feel something and it's hard, you know, what is my right brain thinking when my left brain is putting into words, you know, asking for symptoms and stuff like that. I think, you know, I personally feel that I need that one opportunity. And then, of course, you know, I mean, I have done virtual, you know, with COVID and all, you know, people come, don't come. Once you have established that relationship, you know, I mean, it's fine. And, of course, for people who have difficulty accessing, you know, you can start with that and then maybe invite them over, you know, sometime. So maybe I want to see if you guys are going to address that. Well, I think that if I'm hearing it correctly, you're saying that if we are thinking about the collaborative care model sort of approach that you would prefer to have some contact with the patient. At least once. So I think that that... For the first month or so, so that I can convey, you know, myself. And I feel, yes, probably you can do it. I don't know. Maybe you guys have more experience. You know, I just feel I need that. And I need for the person to feel comfortable in my presence and address all issues. You know, what race I am, where I'm from. You know, I'm not a psychoanalyst, so I do address my marriage or, you know, who I've seen or something like that. So, I mean, although I know that psychoanalytic care, you know, people do not disclose that, but I feel sometimes that person needs that answer to feel comfortable. Oh, it's okay, it's this, and, you know, maybe I have issues with LBTQ. All that can be addressed in a one-on-one meeting. And then, of course, you know, you can do the rest of... Hmm. Yeah, I look at that as like the development of programs and stratifying patients. So some patients might actually end up seeing people, you know, for a certain amount of time and then they come to psychiatry. I don't know, Nicole, if you wanna say anything about collaborative care model with that and like that's definitely helpful. Yeah, no, I mean, I think even collaborative care and certainly virtual, a lot of people feel that, you know, the feeling that you have when you're in the room with someone is very different. And of course, you know, I think in an ideal world, if we could meet everyone in person, we could monitor body language, we, you know, noticing odor, but noticing the shoes that they're wearing, you know, certain, some of those things, obviously we miss in telehealth. But again, when we're looking at the data and outcomes, they're fortunately very similar. So at the very least we know, even if a person is receiving telehealth care via telehealth, they're still receiving quality care. They're still, we're still seeing outcomes improve. And because unfortunately, they're just, they're not enough psychiatrists, they're not enough therapists. And so we do have to be creative in how we can treat patients. And so as Leroy mentioned, the more mild to moderate patients, they can be supported via collaborative care through their primary care doctor, and we could provide that guidance. Then that leaves the more moderate to severe patients that primary care really can't support and manage to come into psychiatry who may not be appropriate for virtual care, who may not be appropriate for collaborative care. But we do have to kind of unfortunately, or fortunately expand how we think about delivering psychiatric care because the need is just so great and the demand is so great, but the resources are so low. I mean, it's not only the primary care physicians, even sometimes you work in a clinic, you have a primary therapist and stuff like that. And the primary therapist gives me their view, I can read their assessment. And sometimes, I don't always agree, I come to a different diagnosis and stuff like that. And I can communicate that with that, but I just feel that that is important for me to do. I mean, maybe that's my need, but I feel that it is- So I think it's an innate need that a lot of us have, as in the psychiatry therapy world, we like to be with our patients, whether it's through telehealth or in person. And it's just a matter of looking at the program and stratifying patients and having almost somewhat of parameters. So if a patient's PHQ-9 and GAS scores remain elevated after a certain intervention, then do they become someone who needs to be seen directly by the telepsychiatrist? So I think that, yeah, I mean, your point's well taken in terms of the fact that we can develop these models of intervention and then kind of question them and try to improve upon them and have the right patient, the patient be treated at the right level of care. And one thing I'd like to add, just like reflecting on my colleagues' presentations as well, I don't think there's an argument that we're making for universal telehealth implementation. If anything, what we're doing here today is taking a more critical look at areas in which we can continue to improve tele. And it's certainly an evolving field. It certainly has a lot of amazing applications in expanding access to care, but there are always areas for improvement. And there are certainly patients that will never like tele and certainly psychiatrists that will never like tele. It's really about looking for opportunities to expand access to care in a manner that serves as many folks as possible and just creates or relieving some of the bottlenecks that we're seeing. So it's really a field where we can continue to improve on, we can continue to do more research and look at ways in which we can implement effective models of care. We have one, we have about five minutes left so we can do one more question. Thanks, this was very useful to hear about some of the ways that telehealth can be, and other kinds of digital technologies can be a benefit to certain populations. The one worry that I have about it is the group that I'm concerned, I'm a psychiatrist in Center City, Philadelphia. I mainly work in the emergency room and inpatient unit. And we have a lot of folks who have no access to phones at all. And so during the pandemic, we ended up having to get a grant to give people phones at the time of discharge so they would be able to have those virtual appointments. And then another phone, another phone. It became very problematic, but it worked. There was no other way to do it during the pandemic. What I worry about is that for people who have difficulty with the phones and whatever else, that as we have an equivalency and reimbursement for tele and for in-person, which I know is something that APA has struggled with about pushing for the equivalency in billing, will in-person clinics go away? Because they're, of necessity, much more expensive. You don't have to pay rent if you're just rolling out of bed in your pajamas and going on to tele, as I've been known to do. It's a worrisome, because our sickest patients can't really do tele. And so those are the people I worry about the most, that our sickest patients can't do that. So it's struggling as we look at reimbursement rates in particular. I mean, I think it's interesting, when COVID first started and we moved into a lot of, a push for parity, be it through legislative action, be it through executive orders, and the world didn't come to an end. And right now, as we're rolling back some of those flexibilities that took place during COVID, it's gonna be interesting to see the discrepancy in reimbursement and what that's gonna be like. There's no one approach or size fits all, as I hope we were able to convey during our talks. And it's certainly, there's a lot of opportunity to look into reimbursement, into approving these codes and the way the codes are reimbursed, because at the end of the day, ultimately it's about bringing access to more and more folks in a manner that's more equitable. I mean, and when I think about equity, we talked about different perspectives, talked about sexual and gender minorities, linguistic minorities, and maybe racialized minorities. At the end of the day, equity is about what you are doing in order to ensure that folks who need care are able to get it in a manner that meets their needs. And that's ultimately what it's about, regardless of the fact that we took three different perspectives today. So what you're saying, for example, patients who otherwise would never get care, but may benefit from TELA, that might be the priority to expand access to them. That might be the only way, while we continue to work on addressing some of the other inequities or social determinants of health associated with that, that got them to a point where they can't access care. I think you have two more minutes. Yeah, quick, relatively quick question. Joshua Nathan from Illinois. I was wondering, access issues aside, and I know there's been some studies about what patient preferences for telehealth versus in-person. I was wondering if there are cultural differences in preferences, so certain communities, certain cultures prefer in-person versus tele or if there's any directionality with that. Or if we know. That's a great question. I'm trying to go back through the papers I've read. I know certainly there are generational differences. People over the age of 65 do prefer in-person, again, because of the simplicity of it. But also, I've read some studies looking at people with physical disabilities preferring telehealth because not every doctor's office, not every therapy office is handicap accessible. So it certainly can become a barrier there. And Leroy may be able to speak to this a little bit more, but there was a study looking at immigrants, Spanish-speaking immigrants in particular, and many of them either preferred phone or in-person. They did not prefer the video or virtual. But I'll have to do a little bit more. I can't remember off the top of my head specifically for African-American or black populations what the preferences are. Yeah, in the UCLA study that I referenced, I think it was, like I had said, for Hispanic patients, they preferred more the in-person, but I don't have a rate on that from the paper. And then for African-Americans, I think they preferred, well, they actually really quickly adopted to either video or telephone compared to other groups, but the paper postulated that was because of, they didn't necessarily have access to the vaccine at that time. So they had to really quickly adjust and make it work. But yeah, beyond that, I'm not, sorry, I don't have any more specific data, but it's a good question about preference. Well, we're at time. Thank you so much for joining us. Thank you all. I really appreciate it.

digital divide

mental health care

digital health innovations

healthcare disparities

marginalized groups

telebehavioral health

SGM barriers

linguistic minorities

digital literacy

systemic racism

digital inclusion

policy advocacy