A Need for Digitally Inclusive Health Care Service in the United States: Recommendations for Clinicians and Health Care Systems

Abstract

The COVID-19 pandemic led to digital health service expansion that widened the existing digital divide. Residing in areas of limited broadband internet connectivity, lacking access to smart devices, and/or having low digital health literacy (ease, comfort, and skills to use technology) pose barriers to receiving health care remotely. This unequal access to health care is further exacerbated for older adults, those with lower income and less education, racial and ethnic minorities, and those who do not speak English. Because an individual’s digital access (broadband internet connectivity and access to smart devices) and literacy can affect health care quality and outcomes, it is proposed that those 2 factors should be categorized as a key domain of social determinants of health. In this commentary, the authors highlight digital access and literacy barriers in the context of the United States health care service delivery. They underscore the importance of screening every patient during regular clinical visits for digital access and literacy as social determinants of health, using the electronic health record. The authors believe this will enhance digital health care by creating a more person-centered, inclusive method for clinicians and health care systems to digitally connect to patients of all backgrounds.

Introduction

SARS-CoV-2, the virus that causes COVID-19, is known to spread through exposure to respiratory fluids. ¹ Because of the virus’s mode of transmission, face-to-face health care was disrupted for many months in 2020. Health care systems had to redesign their strategy to deliver services to their patients during the pandemic. The use of technology to reach and provide health care to patients existed before COVID-19 but took a sharp rise in popularity and accessibility during the pandemic. ² With societies across the globe continuing to grapple with COVID-19, technology-based remote health assessments and interventions are likely to persist.

The pandemic has widened existing health care gaps, especially for people of color, those with low socioeconomic status, or those living in rural areas. ³ Inequalities in health care are further compounded by the digital divide (ie, limited broadband [BB] internet access in many areas, lack of access to smart devices, and poor digital health literacy). ⁴ Consequently, when digital solutions were applied to health care services during the pandemic, they inadvertently worsened disparities. ⁵ In this commentary, the authors highlight the existing digital divide in the nation and offer measures that can be taken by clinicians and health care systems to deliver digitally inclusive and competent health care to all patients.

The Digital Divide

Mounting evidence suggests that patient and caregiver satisfaction with telehealth is high. Technology-based interventions, such as video communication, patient portals, online patient education resources, and mobile apps, have been shown to improve patient engagement and outcomes. ⁶ However, a large segment of the United States (US) population may not have access to these alternate patient care opportunities. ⁵ For example, access to smart devices to engage in technology-based health care differs among individuals and communities. In rural areas, approximately 80% of the population owns a smartphone compared with 89% ownership in urban areas. ⁷ National surveys indicate that desktop/laptop computer ownership is lower compared with smartphone ownership in the US population. Access to smartphones, health care apps, and a computer or tablet is further limited among older adults, those with lower income and less education, racial and ethnic minorities, individuals with disabilities, and those who do not speak English. ⁸

Another example of the digital divide is limited access to BB internet speeds necessary to engage in digital health care. According to a 2018 Federal Communications Commission report, ⁹ 21 million Americans lacked fixed terrestrial BB internet speeds of 25 Mbps for downloads and 3 Mbps for uploads. The BroadbandNow Study ¹⁰ estimated this number closer to 42 million. Microsoft researchers questioned these numbers by citing data collection problems and reported that approximately 162.8 million Americans have no access to the internet at BB speeds. ¹¹ Digital health care service delivery would likely fail in the communities where these standards are not met. Individuals who cannot access high-speed BB internet often rely on expensive data plans offered by mobile phone companies that further add to their financial worries and barriers to accessing health care through digital technology.

Digital access has limited significance if an individual lacks digital health literacy. Digital literacy refers to the ease, comfort, and skills to access technology. ⁵ In the context of health care services, a lack of digital literacy presents barriers to obtaining, processing, and comprehending digital health services and information, despite having digital access. Therefore, digital access does not guarantee one’s comfort in using digital health services/apps and programs. Emerging evidence shows that underserved or rural locations are at an increased risk of poor digital health literacy because of low education, income, and elderly population. ¹² Language barriers additively contribute to poor digital health literacy. ^12,13 In addition, digital user interfaces are not always designed to account for cultural and ethnic factors contributing to further inequality, poor patient experience, and patients’ reluctance to use technology in the future. ¹⁴ A nationwide study of 3473 adults surveyed showed that digital health literacy is a predictor of digital health technology adoption, ¹⁵ underscoring the importance of assessing digital literacy of patients, especially for those residing in underserved areas. Future population-based studies are required to fully understand the scope of this problem, especially in underserved areas.

Overall, unequal digital access and literacy follow a paradigm similar to that of unequal distribution of resources, wealth, and opportunities. In addition, the intersection of factors such as age, education, race, geography, and psychological stressors shape health-related beliefs that govern behaviors toward engagement in technology-based care. The limited access to BB internet, smart devices, and digital literacy do not work in isolation and often interactively contribute to digital inequities for accessing health care. For example, people with limited digital literacy have little motivation to acquire a smart device and/or identify internet sources and vice versa. Therefore, it is important to screen for BB internet access, access to a smart device, and digital health literacy concurrently among patients. In this world and age, especially during the ongoing pandemic, digital access and digital health literacy—and thus the ability to engage in digital health care—present as social determinants of health (SDOH) and could affect patient needs and satisfaction (Figure 1).

Figure 1:

Interaction between SDOH and digital health care technology. Digital access, literacy, navigation, and technical support correlate with domains of SDOH. Clinicians, medical staff, and institutions can improve digital acceptance and accessibility among patients. BB = broadband; SDOH = social determinants of health.

Recommendations for Clinicians and Health Care Systems

To ensure health, social, and digital equality, dramatic health care policy change is required. Often these changes are slow to occur. However, clinicians and medical staff with digital competencies are in a unique position to disseminate knowledge, train colleagues, and educate patients about digital health interventions at their hospital or practice. This approach could mitigate the barriers to accessing technology and creating a more inclusive digital space.

Clinicians and medical staff share a trusting bond with their patients, which ultimately has profound implications on their clinical care decision making. Meeting patients where they are and being thoughtful of their current digital access and literacy would assist in better care through the use of technology. The authors recommend that clinicians and medical staff screen every patient for baseline digital access and literacy at their primary visit and continue to assess status and track changes during subsequent visits (Figure 2). These screening questions could be incorporated into the electronic health record (EHR). In the institution of the authors, efforts have been initiated to include digital access and literacy screening questions (4 total) in the SDOH template already built into the EHR. These screening questions provide an understanding of an individual’s current digital access (types of internet access they use and smart digital devices they operate), and ease and comfort of using technology to manage their health care remotely. Draft questions are 1) Which of the following devices do you use regularly (at least once per month), 2) What type of internet access do you have for personal use (do not include internet access you have through work), 3) How comfortable are you using technology to manage your health care remotely, and 4) How often do you have someone who can help you access health care remotely? The first 2 questions assess digital access, whereas the last 2 assess digital literacy. These screening questions were developed by a team of rural health researchers and patient advocates at our institution. The screening questions were further refined by the Survey Research Center, Office of Health Equity and Inclusion, and the EHR team. The authors are currently in the process of obtaining feedback from community advisory boards of 3 major locations (Midwest [Minnesota, Wisconsin, Iowa], Florida, and Arizona) of our institution. From this feedback, the wording of the questions will be refined as well as determining which questions could be removed or added. Ultimately, the screening questions will be pretested among a group of patients from these 3 locations before incorporating into the SDOH template in the EHR. The authors anticipate that the screening questions would be assessed independently and longitudinally for each patient and that digital solutions described in this manuscript would be implemented and individualized to meet the needs of each patient.

Figure 2:

Patient screening for digital access and literacy. After assessment, patients can be assisted with overcoming digital access and literacy barriers. Those with digital competency can be encouraged to volunteer as digital navigators. BB = broadband; EHR = electronic health record; IT = information technology.

Patients and families with identified digital access and/or literacy barriers could be offered support in locating resources in their community, such as nearby access to smart devices (library computers or loaner devices), Wi-Fi hotspots, or mobile clinic vans capable of serving as hotspots. In addition, clinics and health care systems should consider assigning digital health navigators in their establishment to support patients who may require immediate assistance with mobile health care apps, patient portals, and video communication.

Health care systems have a robust holding in their communities and could collaborate with local policymakers, community and faith leaders, entrepreneurs, and digitally competent patient representatives to establish a digital task force (DTF). The DTF would meet periodically to assess the community’s digital health service needs and offer support and solutions to facilitate digital access and connectivity and engage the community in digital health literacy seminars. For example, local public libraries, public gymnasiums, and places of worship could be venues for such activities. In addition, the DTF could encourage digitally competent community members to volunteer as digital navigators who would assist fellow community members in the adoption and use of smart devices to engage in digital health care. Integrating digital resources within the community adds to the infrastructure and accessibility and has better outcomes. The DTF could also inform health care systems of the unique needs of their communities and assist in digital adaptation within the community.

Another challenge that requires special attention is patients’ concerns for security and privacy. Several third-party health apps exist that could put a patient at risk for security and privacy breaches and may further prevent them from using digital tools. For example, in 2018 it was found that almost 92% of top-ranked apps (33/36) for depression and smoking cessation shared their user data with a third party, and 81% (29/36) shared with Google and Facebook. ¹⁶ This problem could be difficult to solve at an institutional or clinician level given that not all online health platforms could be vetted and approved by health care institutions. A more stringent data protection policy is required in the US to address security and privacy issues and thereby encourage technology use. Hospital or community digital navigators could potentially inform and educate patients about these concerns surrounding digital devices. Assessing these complexities is important when implementing inclusive strategies.

Before the COVID-19 pandemic, the inequalities that create the digital divide went without considerable attention until an acknowledgment by the American Medical Informatics Association in 2017. This organization made recommendations to recognize BB internet access as an SDOH because it, along with digital expansion, dictates patient experience. ¹⁷

More rigorous methodologic research studies are urgently needed to accurately assess digital inequalities, precisely implement solutions, and meticulously measure equity outcomes. Several health promotion studies used virtual delivery formats and reported on patient engagement and relevant health outcomes. ¹⁸ Screening digital access and literacy not only has clinical implications, as highlighted in this manuscript, but also research implications. Studies are needed to assess the effectiveness of digital access (assisting participants with internet access and smart devices) and/or digital literacy (digital literacy coaching support) strategies as the intervention. For example, people who smoke and are living in rural areas could be invited to participate in a study examining their engagement with online smoking cessation programs by providing interventions, such as digital resources (internet access and/or smart device) and digital coaching (targeting digital literacy). The development of these solutions or strategies necessitates community engagement and user-centered design approaches. ¹⁹

Conclusion

Digital access and literacy and their equal distribution are necessities rather than luxuries in our current health care service delivery system. To ensure digitally inclusive care for all individuals and communities, consequential conversations and actions are required to eliminate the historical, institutional, and structural barriers to accessing technology. The reliance on digital tools for health care service delivery during the pandemic has conveyed the important message to public health experts, policymakers, community stakeholders, and researchers that digital access and literacy are also facets of SDOH and, if unmet, contribute to health care disparities.