My first telemedicine project, by even the most generous assessment, was a disaster on multiple levels. It was supposed to be a simple project — an academic study in geriatrics funded by federal grant money. We were going remotely hold exercise classes for aged patients and measure their progress over a certain period of time. The grant proposal was far more detailed than that, I’m sure. But the gist of it was we were going to “Zoom” patients into multiple weekly exercise classes and see if their vital signs and health improved over the duration of the program.

Simple enough…except Zoom didn’t exist at the time and video conferencing was still a relatively spotty technology with Skype leading the effort.

It was the summer of 2010 and I was the guy in charge of getting all that “technical stuff” set up for patients who were participating in the study. This included everything from managing the hardware to establishing internet connections and ensuring they could remotely log into each exercise session.

It’s hard to wrap your mind around how much technology has changed since 2010. Today, we could have set this study up with smartphones and tablets using commercial software. But in 2010, smartphones were in their infancy, most people still carried flip phones and internet connections weren’t as ubiquitous as they are today.

In 2010, I was hauling computer towers and monitors up flights of stairs to patients' apartments, setting up secure internet connections and patching together a very loosely coupled system of software programs to get them dialed in to their workout sessions. It was an absolutely terrible user experience — one in which I often had to remotely control users’ computers to get them logged in on time. But my primary objective was to just make it work and to do so with limited funds.

Adding to my challenges was the never-ending support for more than a dozen outdated PCs running Windows XP (XP was nearly 10 years old in 2010). Our study participants were more than eager to gain access to both a computer and the internet for the duration of the study. Our sample consisted of economically repressed individuals who typically did not have computers and could not afford access to something as frivolous as the internet. This resulted in the computers being heavily used to surf every nook and cranny of the net.

In turn, I would spend days removing spyware and viruses from returned computers — sometimes re-imaging the machine when I encountered stubborn malware. Malware infections would sometimes occur in the middle of the study, requiring me to return to the patient’s home, switch out the computer and head back to the office with the infected one. Incidentally, the most infected computers seemed to come from study participants who were male. Unsurprisingly, browser history and logs indicated heavy traffic on multiple porn sites. There were ways to lock the computers down more tightly. But at the time, those methods were either expensive or created conflicts with other software we were trying to run.

I learned a lot in the process of supporting that study and had some fun while I was at it. The patients were gracious and true characters. But it wasn’t a process I’d ever want to replicate again.

That wasn’t the only telemedicine study I worked on during that time period. It does, however, represent telemedicine in 2010 in all its clunky glory — a bad Zoom meeting.

While technology has moved at the speed of light over the past decade, telemedicine hasn’t moved nearly so fast. To be fair, there have been improvements in technology, making telehealth less of an aspiration and more of a reality. But until the pandemic, interest in and the use of telemedicine has been relatively low. Why bother with telemedicine when all your patients seem perfectly willing to travel to your office?

When everything is working just fine as it is, we are less likely to make any changes. Don’t fix it if it isn’t broken seems too often to be the prevailing logic in healthcare (and many other industries). But this is the equivalent of avoiding routine maintenance on your house or vehicle. The longer you let maintenance go, the greater likelihood it will become a costly problem or cause catastrophic damage.

That’s where healthcare is right now. They should have done an overhaul about 10,000 miles ago. There are reasons they haven’t — the primary being compensation.

Medicare, Medicaid and many major insurance companies traditionally have not reimbursed at the same rate for telehealth visits. That is, a physician will likely receive far less money for a telehealth appointment versus the same services performed in person. In that light, it hasn’t made much financial sense to pursue telehealth. That issue is currently being evaluated as a result of the pandemic.

Telehealth is now booming for obvious reasons. In a pandemic with limited hospital space and physical distancing rules in place, it makes sense. But what we’re experiencing is a boom of necessity for which healthcare was not prepared. As a result, the patient experience has suffered and some patients have undoubtedly lost their lives.

And that is where telehealth has historically failed. It is rarely user-centric or patient-centric. The little regard given to the user experience in telehealth can be attributed to the same problem I experienced above. Telehealth often amounts to little more than a series of loosely coupled technologies with the objective of just making it work. That approach often relegates the user experience to a convoluted set of hoops a patient must jump through, essentially placing the burden of effort squarely on the user.

This is the reason my telehealth project was such a disaster. I was mature enough at the time to know I had strung together a system of products and services far too complicated for our sample population to ever navigate (or mitigate). The workaround was crude. I would ensure I was at my desk before the start of each exercise session so I could remotely log into patients’ computers to get them connected.

I was doing the hard work to improve the user experience the only way I could. It wasn’t pretty. But it worked and was only sustainable with the small sample size of patients I had to manage in the study.

This is one of the reasons I become so irritated when an engineer or product manager tells me a requested feature designed to improve the user experience is “too much work.” Too much for who, I often ask. It’s usually a feature that will ease the user’s burden, streamline the interface or reduce unnecessary or repetitive work. We have to build it once. The customer may have to use the feature hundreds of times per day. I reason it’s a pretty good trade-off if we can do a couple of weeks' worth of work to reduce hundreds of hours in user labor.

But the prevailing attitude is often to assume it isn’t possible — it’s too expensive, it’s too much work. In part, that’s how we got to where we are with telehealth. Ten years ago, it was too much work. Ten years ago, it was too expensive. The technology was convoluted. The payoff or compensation wasn’t enough. Ten years ago is when we should have started, regardless.

You build the ark before the storm.

Case in point: Epic, the largest electronic health record vendor in the United States with 28% of the market, has only begun heavily investing in telehealth over the past few years. One of their major efforts to push telehealth forward on their platform only started this year…after the pandemic was in full swing.

Given the potential for telehealth to transform the way medicine is practiced, the way patients receive treatment and the enormous impact it has on the user experience, I find this more than a little baffling. For more than a decade, healthcare has essentially sat on a user experience goldmine and has done little to capitalize from it. Sure, you can email your doctor now and get your lab results online. So, there is that level of telehealth available. But we have not made much progress in remotely caring for patients with anything more than a rash or common head cold — at least not in comparison to technological advances in other industries.

The majority of low-level telehealth solutions available like email and texting were put in place as cost-saving measures. Receiving your lab results digitally, for example, reduces paper and labor costs. The user experience, while it did improve, was more of an afterthought or added benefit with these solutions.

It’s unfortunate, but the patient often does not have a face in healthcare. There is so much effort expended to fix a broken system, provide a basic level of care using basic technology or to streamline programs for maximum economic benefit. There is so much effort expended to just making it work that there is no effort left to expend on the patient to improve their experience. What is truly unfortunate is the impact this has on socioeconomically challenged populations.

Those are the patients who stand to benefit the most from telehealth.

I still think about that telehealth study I worked on back in 2010. I often wonder how far we really could have gone in the past decade had we even had an inkling of a forward-thinking mindset. Would we have been better prepared for a pandemic? I like to think so.

But I also think about the patients who participated in that study I worked on. I still remember the poverty they lived in — the government-subsidized housing units they called home. I think about how excited they were to have a computer and internet access in their home. I must have looked like Santa Claus knocking on their door with a cart full of computers, monitors, peripherals and wires.

Most of them wouldn’t have been able to travel to exercise classes due to their age, condition or, in some cases, the expense. Telehealth was a perfect solution for them. They were not unlike patients I encountered later in my career when working on a telehealth project for hearing aids.

In 2015, I was part of an effort to build a solution that would allow someone with a hearing aid to receive adjustments to their devices no matter where they were in the world. Their audiologist could use a desktop software we designed to remotely fine-tune and tweak a patient’s hearing aids. It was the perfect solution for the aged person or any patient who needs their hearing instruments adjusted on a snowy winter day when travel could be hazardous or when they had traveled to Florida for the winter (a “snowbird,” as they are often referred to).

Almost every position I have held as a healthcare designer has involved some aspect of telehealth. And all of those patients had something in common. There was something that prevented them from receiving the care any other citizen of the United States should have been afforded. In some instances it was age. In others, it was their financial situation caused by perhaps a lack of coverage, the color of their skin or their status as a citizen. Still, others simply had a disability. Those were the faces I saw on all those telehealth projects — the tired, the poor, the huddled masses.

Indeed, this is where telehealth stands to have the greatest impact — the populations most marginalized.

In the summer of 2010, I was entering the homes of those who were marginalized. Their medical conditions varied, but none were in good health. They came from all ethnic backgrounds but those who were caucasian seemed to be in the minority. They lived in government housing projects, apartment buildings run by slum lords and places so unkempt it sometimes turned my stomach while also breaking my heart.

My partner and I would routinely slather ourselves in hand sanitizer after leaving many homes. I was reminded of my youth. It had been a long time, but I had seen this level of poverty before.

At one home, I spent the better part of an hour working cables and power cords under carpets or taping them down to avoid causing either of the aged occupants to fall. The last thing we wanted to do was to show up to help and instead cause a trip to the emergency room. When my partner and I returned to our car, I noticed a layer of something on the knees of my jeans and along the sides of my arms. It didn’t take me long to figure out what it was — the crushed remains of cockroaches. Their carpet had been covered with the remains of dead roaches.

I remember rationalizing this thinking back to a time when I was so strapped for cash I couldn’t afford a vacuum cleaner. I’d let the floor of my apartment get as dirty as I could stand it to be before making a trip to my sister’s house to borrow her vacuum cleaner for the weekend. Maybe this couple was in that same situation but couldn’t have gotten a vacuum cleaner up the stairs (due to their age and condition) if they had one to borrow. Maybe, due to their disabilities, they couldn’t have used it if they had one.

The patients in that study had everything going against them. Their lives had been an uphill struggle.

I sometimes wonder how far we might be in telehealth if it would have been a lucrative business from the start. If back in the summer of 2010, those study participants had been a bit richer, a bit more influential or representative of a powerful caste, maybe we would be a little further along with telehealth.

I wonder how far we might be if the primary benefits of telehealth benefited those who are less marginalized. The benefits of telehealth are clear during a pandemic. A virus does not discriminate. But what if COVID-19 only affected the poor, the elderly, those of color, those who are disabled or those who simply don’t have access to reliable transportation? Would we have seen the recent boom in telehealth popularity?

It’s doubtful. In such a scenario, COVID-19 would likely have become our next Katrina. Or worse.

Here is a technology that in any other time would primarily benefit the marginalized populations of our society — the aging, the poor, the disabled, those who need medical care in their homes to avoid institutionalization. Yet we only see its widespread popularity in the midst of a health crisis that does not discriminate. I’ve watched with some amusement and some sadness as telehealth stocks recently climbed — companies like Livongo and Teledoc.

I look back over the last 10 years at what little has been accomplished. Healthcare’s Katrina is COVID-19 in many ways. Even with the recent attention to telehealth, we have still managed to marginalize. We have still managed to show up a day late and a dollar short.

You build the ark before the storm. And like Noah, we should have ensured all passengers were accounted for. We didn’t.

Healthcare is a basic human right. Those who are underprivileged or underserved, have a basic right to accessible healthcare. Telehealth, if designed well, provides a level of accessibility that affords that right.

Of course, one could argue that those who are disabled without transportation or internet access or a telehealth option can simply call an ambulance and take a trip to the ER. That’s an expensive endeavor healthcare likes to avoid. And yet that is the unintended consequence of a healthcare system that has failed to provide alternate means of access during and before a global pandemic.

This isn’t so much a healthcare issue as it is an issue in social justice. As a society, America has a spotty record where the poor, the elderly and the disabled are concerned. Those who stand to benefit the most from telehealth are those who suffer the most as a result of healthcare’s lackluster pursuit of improving remote access to care.

As the pandemic raged and I watched our entire healthcare system scramble to cobble together some form of remote care, I couldn’t help but think of all those telehealth projects I have worked on over the past decade. The current effort wasn’t much different from my early efforts. We were just trying to make it work.

I think we are better than that as a country. Historically speaking, America is a hotbed of innovation — electricity, the assembly line, the desktop computer, the smartphone, just to name a few. The United States has more Nobel Prize winners, by far, than any other nation. There is absolutely no reason we cannot build better solutions for remote patient care. It just hasn’t been a priority until now.

While I am happy to see the recent attention being showered on telehealth, it came too late. The pandemic has been healthcare’s Katrina, affecting those who have been marginalized the most. It is disheartening to think that we have only directed our attention to telehealth out of necessity — because a pandemic does not discriminate.

Nonetheless, I still have hope. Hope that healthcare’s newest love will not become little more than a flash in the pan. That what is important today (telehealth) will remain important in the future.

As designers, we have an obligation to pursue inclusive design — designs that do not marginalize. We have an obligation to design systems and technologies to enable and empower those who cannot care for themselves. How we treat and care for those who need the most and have the least, reflects on us as a nation. It reflects on us as a society. It reflects on us as designers.

In the summer of 2010, I was just trying to make it work. Today, healthcare is doing the same. I can’t really say that is progress. But progress doesn’t always move in a straight line. Progress is often the result of time, place and opportunity.

The time is now. And the place and opportunity are here.