Cultural Competency in Obamacare Implementation: Part II

Cultural Competency in Obamacare Implementation: Part II

Cultural Competency Blog Series Part II


Part II: eHealth Tools and Cultural Competency

This post is the second in a series ZeroDivide has designed to explore some of the opportunities to integrate cultural competency into each stage of the Affordable Care Act enrollment and implementation process. Be sure to read the first post on Linguistic Competency


The United States is on the verge of becoming a country in which racial minorities constitute a majority of our population, while concurrently a nation in which almost everyone is soon eligible to gain some form of affordable health insurance. Given this reality, it’s time for our healthcare system to get serious about cultural and linguistic competency. The Office of Minority Health (OMH) defines cultural and linguistic competency as “a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations.”  

A 2003 study enumerated the best practices. A culturally competent health care setting should include an appropriate mix of the following:

  • A culturally diverse staff that reflects the community(ies) served

  • Providers or translators who speak the clients’ language(s)

  • Training for providers about the culture and language of the people they serve

  • Signage and instructional literature in the clients’ primary language(s) and consistent with their cultural norms

  • Culturally specific healthcare settings

The Office of Minority Health codified those behaviors over a decade ago with the creation of the CLAS standards in 2000. (CLAS stands for Culturally And Linguistically Appropriate Services in health and healthcare.) These standards are based on the premise that many cultural and linguistic factors impact the provision of healthcare services. OMH updated them in 2013 to reflect changes in US demographics, while HRSA provides useful resources for healthcare professionals to improve their linguistic and cultural competency levels.

Those of us who care about the future of healthcare are concerned over the impact of increasingly digitized forms of care delivery and patient engagement. While eHealth holds great potential to empower patients and improve care, without cultural and linguistic competency or something akin to CLAS standards for eHealth tools, existing disparities may widen. Doctors and insurers will increasingly encourage and require patients to use online tools for appointments, Rx refills health education, coaching, and other forms of support. These tools must take into account the cultural lens and linguistic needs of diverse patients.

The great hope offered by eHealth is scalability and the ability of a doctor to choose the applications that best fit the needs of his or her patient panel.  However, if tools are only relevant for certain patients or the average insured patient, eHealth will fail to deliver on its promise.

We have an explosion of new mobile and web applications that range from consumer to physician-facing and with every permutation in between. While most healthcare organizations create educational and promotional materials that reflect the language needs of their population, common eHealth tools are available in English only. Even the best patient portals and personal health records patients use to access their health information are written and translated only in English and Spanish.

Language access is central, yet cultural needs and realities may prove to be the more difficult element to integrate into future eHealth tools. The academic evidence shows a poor track record. Neuhauser and Kreps (2008) conducted extensive literature review of fifteen years of online cancer communication and education tools. They found that overwhelmingly, the tools studied failed to meet the cultural and linguistic needs of diverse populations.

Today’s apps and other online health tools have to acknowledge and take into account how health care and health information are consumed and shared within families and communities. For example, Horan, Botts, and Burkhard (2010) found that among Hispanic migrant workers, typically one family member serves as a health manager for multiple generations. However the personal health record and patient portal tools available to them do not take into account these cultural factors and thus are less relevant. Additionally different populations have cultural barriers to trusting Western medicine or may rely on traditional healing and health knowledge. Notice of privacy policies and other permissions on health apps generally assume patients are comfortable with sharing data, while many underserved groups need reassurance and more explanation of privacy implications.

Because of all of these factors, ZeroDivide has made a center focal point of our eHealth work around cultural and linguistic competencies. Through our various projects, convenings of thought leaders, and ongoing research in this space, we are issuing a call to action to consider these factors when developing and introducing new eHealth technology.

To this end we are pleased to be hosting a roundtable discussion on the topic at the premier digital health conference, Health 2.0 Silicon Valley. Our session Digital Health and the Underserved will bring these challenges to the table with an all-star panel of health IT investors and hospital leaders. By engaging in thoughtful, inclusive design at the earliest stage of tool development, we can begin to ensure the benefits of eHealth are experienced by all. 

eHealth Equity, eHealth, mHealth, cultural competency, ACA, Health 2.0