The virtual care company Onduo is widening its reach: On Tuesday, the Alphabet-owned company announced it was bringing its chronic disease management platform to patients with certain cardiometabolic conditions, including hypertension and prediabetes.
The move marks a significant expansion of the mission of the company, which was spun out of Alphabet’s life science unit Verily and initially targeted patients with type 2 diabetes. But it’s not the only change aimed at broadening the company’s user base: Onduo will also start providing its services in Spanish.
Digital medicine in the U.S. has long fallen short when it comes to caring for non-English-speaking patients.
“We’ve seen study after study after study showing that Spanish speakers are less likely to use digital health portals,” said Jorge Rodriguez, a hospitalist and technology equity researcher at Brigham and Women’s Hospital.
Those inequities have become more pronounced during the pandemic. As telemedicine visits increased over the last year, Spanish-speaking patients were about 40% less likely to complete video visits than average, based on an analysis Rodriguez and his colleagues conducted of more than 200,000 doctor’s visits during the pandemic.
To support care for the 5% of Americans who speak Spanish but are not fluent in English, some digital health providers have added Spanish-language services in recent years, including complex networks of third-party interpretation services. “Before it was a nice to have,” said Rodriguez. “Now it’s like, ‘Oh shoot, we need to move fast.’” A full half of the employers served by one of Onduo’s large health plan clients have requested Spanish-language services, according to a company spokesperson.
In some ways, Onduo’s self-contained virtual care system is easier to adapt than entrenched telemedicine systems. The company is adding Spanish-language capabilities to both its app and its team of health coaches, which help users establish long-term habits to support their general health and manage their chronic conditions.
“We brought on Spanish-speaking coaches as of the end of last quarter,” said Vindell Washington, Onduo’s chief executive officer. The spokesperson said that 20% of its coaches are now bilingual.
“The software piece was more straightforward, as an Alphabet spinoff,” said Washington. “They know how to do languages.” Onduo worked with Google’s localization team on the new Spanish language services.
Onduo’s sister company, Google Cloud, is also offering automated translation as just one part of its $100 million investment in telehealth company Amwell, announced in August.
Making an app accessible to a new population isn’t as simple as translation. Many digital health platforms start in English, and are then adapted for non-English-speaking users, but their updates may not account for other differences in populations.
“Oftentimes when we speak of Spanish speakers, not only is there limited English proficiency but there’s also lower health literacy and often lower digital literacy,” said Rodriguez. “If you’re developing something for an English-speaking audience you’re automatically targeting a slightly different perspective. It’s not so much the Spanish that makes a big difference, it’s all the other associated pieces.”
Ideally, developers would be able to show that digital health platforms worked equally well for patients regardless of language. But even the methods used to determine how well digital health tools work can bring their own set of limitations. Digital care portals like those provided by Onduo are often vetted using the System Usability Scale (SUS) to make sure they’re easy for patients to use. But the SUS was originally developed in English.
When Magdalena del Rocio Sevilla-Gonzalez, a postdoc at Massachusetts General Hospital’s clinical and translational epidemiology unit, wanted to test the usability of a digital health app with a patient population in Mexico City, “we didn’t find anything to measure the usability in our population.” So she and her team set out to verify that a Spanish-language SUS questionnaire can accurately gauge usability of digital tools in Spanish. It’s that kind of tool that will be necessary to validate both the usability of an app — and ultimately, the health outcomes it supports.
“I care about tech equity, but only so much as it gets me to health equity,” said Rodriguez. “It doesn’t matter if everyone has a phone and a portal if their diabetes outcomes are not better.”
Now that Onduo has made a step toward tech equity, it can collect the data to show how its platform impacts health outcomes across populations.