Abstract
Background:
The world continues to expand our digital reliance. Populations are being left behind lacking the necessary knowledge or tools for succeeding in a technologically advanced space. This issue is apparent within both the digital health and telehealth space and has left health professionals wondering what can be done to bridge this gap.
Objective:
In late October 2024, Henry Ford Health (HFH), a health system located in Detroit, Michigan, held a summit titled “Advancing Health Equity—Bridging the Telehealth Divide” to attempt to find solutions for the problems facing patients in accessing their health care digitally. Community engagement sessions were held on the second day of the summit and involved discussions focused on three different age groups among six groups: three groups—older adults (age 55 and older); one group–general adults (ages 18–54); and two groups—children and family (ages 0–17).
Methods:
Initial open coding captured participant language and recurring concerns, while focused coding consolidated these into broader conceptual categories. This process was followed by affinity mapping to cluster-related codes into themes.
Results:
The resulting synthesis revealed seven thematic domains that reflect systemic and experiential factors shaping telehealth and digital health equity. The domains are as follows: Access and Infrastructure; Digital Literacy, Safety, and Confidence; Tech Support Quality and Delivery; Community Anchoring and Trusted Networks; Communication, Advocacy, and Educational Tools; System Design, Ease of Use, and Human-Centered Technology; and Equity, Inclusion, and Systemic Barriers.
Conclusion:
Patients and community members desire and need strong telehealth services that support the notion that health systems have opportunities and responsibilities to address these shortcomings by working with community members.
Keywords
Introduction
Grace is an older adult living in Detroit, Michigan. The year is 2025 and technology is fast-moving, yet Grace has been unable to catch up with all the advancements and is now finding herself struggling to access necessary services. Most notably, Grace has been unable to schedule a telehealth appointment for a recurring cough and chest pain that she has been experiencing because she cannot gain access to her MyChart patient portal and has been unable to get into contact with technical support or the hospital. Her need to schedule a virtual visit is exacerbated by her unreliable transportation situation. She does not have high-speed internet and does not know how to find the instructions on how to download the mobile MyChart app—issues that are preventing her from scheduling an appointment. After three days of struggling to figure out how to schedule a telehealth appointment, Grace decided to go to the emergency room and was admitted for pneumonia. Grace wonders if things might have been different had she been able to get the help she needed sooner. Grace wishes that there was a place she could go within the community to help her learn how to access and use her MyChart patient portal and connect to a telehealth appointment. A place that would welcome her questions and concerns with emotional support and clear communication. With resources such as these, she would feel empowered to set up her own telehealth appointments and seamlessly use the MyChart app or website.
In late 2024, Henry Ford Health (HFH), a health system located in Detroit, Michigan, held a summit titled “Advancing Health Equity—Bridging the Telehealth Divide” to attempt to find solutions for the problems faced by people similar to Grace. The virtual care consultant and project manager within the Virtual Care Department and Department of Family Medicine, Alexandra Hunter, stated that there were three primary goals for the summit: “First, foster an environment of radical collaboration, humility and inclusivity that’s action-focused, and one that leverages assets. Second, leverage the knowledge and lived experience of the participants involved in our community engagement sessions—community members and organizations, city and state employees, physicians, etc. And third, collate ideation content that can be turned into solutions and can be the source of future development through a framework model.” 1 Figure 1 illustrates these goals and objectives. HFH aimed to marry their four guiding principles with a community codesign setup. Figure 2 illustrates these four guiding principles:
Goals and objectives.
Guiding principles. Roberts J, Bright K, Elkhalifa W. Community Codesign Tools and Tactics: An approach to equitable community engagement and action [internet]. Community of Rochester, Minnesota. Available from: https://dmc.mn/wp-content/uploads/2022/01/Community_CoDesign_Booklet.pdf [Last accessed: January 5, 2026].
These four principles were combined with a strategy labeled as community or equitable codesign. 2 This equitable codesign reflects a deeper form of community engagement—one that embodies partnership and empowerment in its approach. 2 Equitable codesign aims to address the most persistent inequalities through addressing disproportionate power structures. 2 The community engagement breakout sessions at the summit utilized feedback from a variety of individuals to gather a rich background and dataset to determine the biggest points of struggle and success within telehealth services. By giving the public a voice and allowing for collaboration, the predicted outcomes are better communication and equality that empower the public. Achieving what they want while working with industry professionals throughout the process, not just at the beginning.
Background Data
HFH is not the only organization that is thinking about how telehealth barriers are impacting their patients. Ladin et al. 3 used 60 interviews with “purposively sampled patients (aged 70 years or older, chronic kidney disease stages 4 to 5), care partners, and clinicians in Boston, Massachusetts; Chicago, Illinois; Portland, Maine; and San Diego, California” to analyze perceptions and feelings surrounding telehealth visits. The results from this study found that there was a lower satisfaction “associated with telehealth among older patients with lower socioeconomic status and among patients identifying as Black, Hispanic, and Native American. Drawbacks to telehealth included care quality concerns because of limited physical examination and laboratory tests and loss of social connection, while benefits included convenience, greater care partner engagement, and clinicians’ understanding of patients’ home environment.” 3
Furthermore, both Fisher et al. 4 and Amagai et al. 5 argue that “telehealth has the potential to bridge healthcare inequity and increase access for vulnerable and disadvantaged populations. But there is, paradoxically, potential to exacerbate existing inequity.” For example, according to Amagai et al., 5 “Despite these positive trends, the anticipated levelling of the healthcare playing field through telehealth has not been fully realized, as indicated by persisting disparities. Previous studies have shown that telehealth reduces no-shows and, thereby, deeming it a success; however, it is equally important to explore the ongoing disparities within telehealth, which highlight persistent challenges that need to be assessed for more improvement. Specifically, Black and Hispanic patients continued to experience higher no-show odds relative to White patients even when using telehealth.”
The background literature regarding telehealth services and the current barriers aligns with the data gathered from the summit held by HFH. Patients and community members desire and need strong telehealth services that support the notion that health systems have opportunities and responsibilities to address these shortcomings by working with community members.
Methods and Results
Methods
The “Advancing Health Equity—Bridging the Telehealth Divide” summit was held over two days on October 29 and 30, 2024. As shown in Figure 3, Day 1 featured knowledge-building panels on digital health equity, industry collaboration, and innovative models, setting the stage for action. Day 2 focused on community engagement sessions designed to capture lived experiences and prioritize solutions through an equitable codesign approach. The summit consisted of a variety of activities and speakers ranging from a “Sciences: Digital Health Panel” moderated by life sciences to a presentation on the Detroit Area Agency on Aging organization presented by their RN/telehealth support coordinator. The summit supported community engagement, providing the opportunity for networking and information sharing between attendees. The first day of the summit was held at HFH’s Innovation Institute to develop a spark among participants and then followed up with a second day at Focus: HOPE, a nonprofit located in the Hope Village neighborhood of Detroit, to ensure the event took place within the community.
Advancing Health Equity—Bridging the Telehealth Divide agenda.
Hope Village was chosen because it is a tight-knit, resilient community marked by a strong sense of togetherness. Organizations such as Hope Village Revitalization and Focus: HOPE play a key role, providing educational programs, sustainable housing programs, access to community farmer’s markets, and job training that uplift the area. However, the neighborhood faces significant challenges, including economic hardship, vacant properties, and limited access to services. Once affected by industrial decline, Hope Village struggles with infrastructure issues, including digital disparities tied to broadband, device and digital literacy access. During the COVID-19 pandemic, the neighborhood experienced a 45-day internet outage. Hosting the event in Hope Village allowed the industry, research, and healthcare attendees to be in the community and see and hear directly from those impacted by digital inequities.
The community engagement sessions held on the second day of the summit and involved discussions focused on three different age groups among six groups: three groups—older adults (age 55 and older); one group—general adults (ages 18–54); and two groups—children and family (ages 0–17). The activities conducted throughout the two days were done for the purpose of quality improvement and not research. Invitees and attendees were selected based on existing relationships between the health system and community organizations in the digital equity space, clinical and administrative champions within the health system with alignment to virtual care, health system patients on digital advocacy advisory boards, community members identified through community organizations, and life science companies with interest in the telehealth space. Not all those who were invited were able to attend. The event attendee capacity was limited in size based on budget and space restrictions. Attendees were invited through emails and phone calls from event organizers, with some introductions being made through community organizations. The two-day event provided breakfast, lunch, and dinner to all those who attended. One hundred invites were extended, 87 individuals registered, and 80 individuals attended. The attendee list consisted of the following number of representatives from each area invited: (32) HFH, (24) community organizations, (5) research, (8) life sciences, (5) industry, and (6) patient advocates. This attendee list with area of focus and role is illustrated in Table 1.
Attendee List with Role Details and Count
The specific age ranges of the age-related groups were determined based on differences in needs or issues regarding telehealth usage. Structuring the groups with an age-related focus was done with the intention of determining if any glaring insights came from one age-related group over the other. Each group had an average of 10 people with one facilitator and a cofacilitator assigned to them before the event. Cofacilitator responsibilities included collecting the data from the conversations through recordings via laptops, notetaking, and group activity notes and artifacts. On the day of the community engagement sessions, each group averaged seven group members due to some planned individuals not attending.
To ensure that each group had a fair distribution of representation from each area invited, organizers took an intentional approach to group selection. Pre-event registration forms required attendees to self-select their desired age group for the community engagement sessions. Each group had at least one individual who represented HFH, a community organization, a research organization or institution, a life sciences company, an industry partner, and a patient advocate. Once all attendees had been assigned to a group, organizers reviewed the roles among the organizations represented in each group. Further adjustments were made to diversify the distribution of organizational roles, for example, HFH had attendees with various roles (physician, administration, researcher, etc.) (see Table 2). If some attendees’ work or organization was associated with an age-related population, organizers took this into consideration when placing them in a group. This approach to group selection attempted to support a more diverse conversation throughout the community engagement sessions.
Community Engagement Session Breakout List
Fostering one of the event’s guiding principles of humility and inclusivity, other measures were put into place to ensure that voices were heard, and that power was shared equally among all members at the summit. HFH removed all job titles and credentials from name badges and ensured that all facilitators were up to date on the Association of American Medical Colleges Center for Health Justice’s Principles of Trustworthiness. 6 Removing job titles and credentials from name badges was done with the intention to further support a safe space for dialogue and alleviate unconscious bias potentially preventing participants from contributing to the conversation. Without titles, individuals were able to come to the table discussion as a representative of an organization with relevance or connection to telehealth. Taking these steps and maintaining an intentional methodology of mindfulness and community engagement set a tone of empowerment for all attendees to share their perspectives.
After transcriptions of the breakout group conversations were created, two anthropologists conducted qualitative research to discover trends and insights that stood out from the conversations. This research was grounded in qualitative coding conducted using data from the six breakout group sessions that were held during the “Advancing Health Equity—Bridging the Telehealth Divide” summit. The six breakout groups analyzed were “General Adults Group 1,” “Older Adults Group 1,” “Older Adults Group 2,” “Older Adults Group 3,” “Peds and Family Group 1,” and “Peds and Family Group 2.”
For data analysis, the anthropologists used open- coding and focused coding and utilized an iterative process of affinity mapping to identify key insights. Initial open coding captured participant language and recurring concerns, while focused coding consolidated these into broader conceptual categories. No deductive coding from underlying theories was used to assess the data as the structure of the community engagement sessions was designed to facilitate more of an organic result of themes rather than testing a formal hypothesis. The open-coded and focused-coding process was followed by affinity mapping to cluster-related codes into themes. For the affinity mapping, the team used Google Sheets to organize and color code their thoughts based on what was revealed in the data and found common themes that arose among each team member’s thematic analysis to then shape and refine the major ideas within the dataset.
The resulting synthesis revealed seven thematic domains that reflect systemic and experiential factors shaping telehealth and digital health equity.
Quality Improvement Determination
The study is a QI project involves reviewing non-identifiable, aggregated notes collected during conference breakout group discussions with Southeast Michigan community members, community-based organizations, providers, and government representatives. The information collected does not include individually identifiable private information, nor was it obtained through systematic data collection designed to contribute to generalizable knowledge. The purpose of the activity is to identify themes related to barriers and opportunities to support future discussions between HFH and partner community organizations. The intent is internal program improvement and planning, not research intended to produce generalizable conclusions.
Results
Qualitative data analysis was conducted on six community engagement breakout sessions from the “Advancing Health Equity—Bridging the Telehealth Divide” summit. These sessions represented three population segments: older adults, general adults, and children and families. Despite each group having a different age range of focus, there was not a large difference between conversations throughout the data analysis of the transcripts. Similar themes arose throughout each of the groups that transcended any age-related elements. While many of the themes were universal, there was a collection of quotes across all groups that older adults required the most support in telehealth adoption. Data sources included session transcripts, facilitator notes, and participant-generated artifacts such as Post-it notes from activities such as Rose-Thorn-Bud and Start-Stop-Continue, as well as patient journey maps. Questions posed to the participants, shown in Figure 4, were as follows: What are the primary barriers (thorns), assets (roses), and potential approaches (buds) to access Wi-Fi/broadband, devices, digital skills, or technical support in the communities you serve? What successful models or programs have you encountered to address access to Wi-Fi/broadband, devices, digital skills, or technical support? What attributes about these models or programs made them so successful (start)? What attributes about these models or programs made them unsuccessful (stop)? What should we continue doing (continue)? As shown in Figure 5, the community engagement session was broken up into three sections to align with the event’s goals. The first 50 minutes were spent on building community by beginning the session reviewing the guiding principles and ground rules. The next 70 minutes were focused on discovery. This time was spent understanding group members’ perspectives on the current state of resources/assets and challenges and pain points in relation to specific gaps and barriers. The final 30 minutes were spent synthesizing the conversations by collating the ideation content that could be turned into solutions and the source of future development work.
Community engagement session questions.
Community engagement session process flow.
The first theme,
A second theme,
The third theme addressed
The fourth critical theme centered on
Similarly, the fifth theme,
The sixth theme,
Finally,
Together, these themes illustrate the multifaceted nature of telehealth inequities. They point to an urgent need for interventions that combine infrastructural improvements with community-based strategies and human-centered design principles. They also challenge healthcare organizations on their role and responsibility in each of these areas if asking patients to receive their care through telehealth and digital health.
Discussion
As the world continues to expand our digital reliance, populations are being left behind lacking the necessary knowledge or tools for succeeding in a technologically advanced space. This issue is apparent within both the digital health and telehealth space and has left health professionals, such as those working at HFH, wondering what can be done to bridge this gap. The “Advancing Health Equity—Bridging the Telehealth Divide” summit held by HFH was an ode to this issue. Coupling health professionals from Henry Ford Health with community members, the summit built itself on the community codesign structure that involves collaborating and working directly with the public to address disproportionate power structures.
The analysis of summit discussions highlights that telehealth inequities are not limited to connectivity or device access; they intersect with usability, accessibility, and inclusion. While telehealth holds promise for reducing barriers such as transportation and scheduling, its current design often creates new forms of exclusion for individuals with limited digital literacy, older adults, and people with disabilities. The National Center for Education Statistics found that 16% of US adults are not digitally literate—“adults who are not digitally literate are, on average, less educated, older, and more likely to be Black, Hispanic, or born outside of the US.” 7 Furthermore, despite telehealth having “the potential to redesign chronic disease management and enable new directions for better patient outcomes and improved healthcare delivery. Digital health disparities remain a significant challenge, particularly for marginalized groups of people.” 8
A recurring theme in the engagement sessions was the complexity of patient portals and telehealth platforms. Participants described systems such as MyChart as difficult to navigate, particularly for those who are not digitally fluent. The design of these tools assumes a level of familiarity with technology that many patients, especially older adults and caregivers, do not possess. This lack of usability reinforces existing disparities rather than bridging them.
Accessibility emerged as a critical concern, extending beyond general ease of use. Participants emphasized that individuals with hearing loss, vision impairments, or other disabilities face further degree of challenges in accessing telehealth services. Many existing platforms lack built-in accessibility features such as closed captioning, adjustable text size, or screen reader compatibility. Patient-facing health apps have poor usability for populations with limited health literacy; and few digital health tools explicitly consider “digital literacy, health literacy, age, or English proficiency in their design.” 9 These omissions create a double barrier: not only must patients navigate complex systems, but those with sensory, language, or physical limitations must do so without adequate support. Maintaining alternative care options, such as telephone visits, remains essential for ensuring that digital healthcare and telehealth do not inadvertently exclude these populations. In addition, helping patients understand the differences between types of telehealth, for example, e-visits, video visits, and telemedicine visits, is imperative to increased adoption. While the medical community may be more familiar with the different options of telehealth, many attendees expressed being unaware of the variety. This identified an opportunity for education among community organizations to help differentiate telehealth options for a layperson.
Digital inclusion was also identified as a determinant of health equity. Participants underscored that learning to navigate digital tools is more than a technical skill; it is a pathway to empowerment. Without accessible education and training, telehealth will remain out of reach for those who need it most. Strategies that extend beyond health system portals (partnering with libraries, senior centers, and disability advocacy groups) are essential to creating sustainable digital inclusion.
The sessions pointed to the need for integrated technical support throughout the care process. Missed appointments and incomplete visits often result from preventable issues (difficulty logging in or uncertainty about audio or video settings) that could be resolved with timely technical assistance. Providing real-time guidance, whether through digital navigators or on-demand help lines, can reduce anxiety and build confidence among patients with diverse needs.
These findings point toward a future where health systems embed human-centered design, universal accessibility, and community codesign principles into every stage of telehealth and digital health development. This becomes more important as the delivery of healthcare continues to expand in the telehealth and digital health space. Digital technologies provide practitioners with “more effective and user-centered ways to educate, inform, and treat patients.” 10 One systematic review found that providers and older adults found virtual visits to be “more flexible, easy to arrange, and personal than in-person visits.” 10
Congregating these groups of individuals together from different areas supporting digital health equity presented the opportunity to connect the dots. Many of the attendees were unaware of the telehealth equity work HFH had been embarking on. The community codesign sessions fostered dialogue in understanding the health intersection of digital equity and the acknowledgment this was missing from many attendees’ purview. It also showcased the rich assets of community work in this space and the need for collaboration from all parties in tackling this multilayered and complex issue.
An immediate result of the event and relationships formed was HFH creating a “Telehealth 101” digital skills module in partnership with the city of Detroit, Peer 2 Peer University, and Tech Goes Home. Individuals from HFH trained facilitators on how to deliver and educate 200+ Detroit community members on the basics of telehealth. A Telehealth Equity Collaborative was formed with the community organizations as a space to further share about the work of each organization. The collaborative meets quarterly and is tasked with identifying a capacity building opportunity to collectively tackle an area of telehealth inequities. Additional next steps include synthesizing these findings and identifying internal forums within the health system to share with stakeholders to highlight strategic areas of focus in combating these issues as well as partnership opportunities with our Telehealth Equity Collaborative stakeholders.
These actions are some of the many that can be taken from the results of the community codesign sessions. Practical suggestions other health systems can glean from the results are as follows: Codesign telehealth intervention strategies with the community; develop and evaluate telehealth tools that support patients who experience the various barriers 11 ; partner with community organizations to create telehealth educational tools to increase telehealth literacy; identify spaces within the community that can serve as “telehealth hubs” to mitigate device, private space, and internet barriers; and train community advocates/organizations on how to deliver a telehealth training to the community to expand reach and maximize resources and relationships. If community partners and organizations working in the digital equity space have not been identified by health systems, this is a recommended first place to start. If none of these types of organizations exists in specific communities, then partnering with existing community organizations who value health system partnerships is a next avenue.
By addressing the structural and experiential barriers identified in these sessions, health systems can transform telehealth from a technological offering into a truly equitable model of care. “This is just the beginning of our work in this space,” said Dr. Denise White-Perkins. “We will continue to engage with participants to discover and put real solutions into practice. I am grateful for everyone who attended—I cannot wait to see what we will accomplish together.”
Limitations of the qualitative analysis include the limit of attendees due to budget and space constraints, the availability of those invited who could attend, the list of invitees based on existing relationships with the health system or other community organizations, and the makeup of the community engagement session groups.
In this article, we have engaged with themes of community, equity, digital literacy, and more, to illustrate the importance of what a community codesign session centered around digital health and telehealth can look like in a city such as Detroit, Michigan. Thinking about telehealth as a constantly evolving body that can be shaped by community and inclusion offers a crucial and productive way to address the current shortcomings and gaps within health services and can contribute to a radical collaboration between community members and health organizations.
Authorship Contribution Statement
A.H.: Conceptualization, methodology, validation, investigation, resources, writing—review and editing, visualization, supervision, and project administration. D.W.-P.: Conceptualization, methodology, resources, writing—review and editing, and supervision. T.P.: Validation, investigation, resources, and writing—review and editing. K.R.: Formal analysis, data curation, writing—original draft, writing—review and editing, and visualization. F.T.: Formal analysis, data curation, and writing—original draft.
Footnotes
Acknowledgments
The authors thank Vikas Relan, Med, and Alexander Reynolds from Henry Ford Innovations in Detroit, MI, for their contributions to the event.
Author Disclosure Statement
The authors have no real or apparent conflicts of interest to report.
Funding Information
No real or apparent funding sources to report.