Digital Health Equity Starts With A Technology-Enabled Foundation

Digital health equity is becoming a frequent topic of discussion. However, before we can engage people in their health via digital channels, we must address the inequities surrounding technology — access, use, and literacy. Addressing these challenges, putting the right laws and policies in place, and choosing creative solutions to barriers are foundational to every other modern health goal.

In a recent American Hospital Association (AHA) blog article, the author declared digital as the next frontier of health equity. The experience may only be a shared realization if we create an equitable, technology-enabled foundation for digital health. Karen DeSalvo, chief health officer at Google, said that the digital world gets excited about innovative tools, “And in their excitement about pushing the ceiling, they lose sight of the floor."

Technology is the super social determinant of health

Does achieving one's best level of health require elements of technology? It's a question worth pondering.

Digital literacy and Internet connectivity have been called “super social determinants of health" because so much of today's healthcare is reliant on digital or web-based technologies as a matter of convenience, scale, or timeliness — connected care tools, patient portals, remote patient monitoring (RPM), digital therapeutics, electronic instructions and after-visit summaries, SMS/text reminders, and online or digital forms, to name a few.

Inadequate hardware, technology know-how, and lack of connectivity add other barriers to quality healthcare. When these three areas are sufficient, patients have increased opportunities for access to healthcare services, education, tools, and social connection.

Technology can advance health equity with the proper foundation

The Advancing Health Equity Through Technology policy, created by the Health Equity and Access Leadership (HEAL) Coalition, identifies three critical barriers to widespread digital health adoption:

• Access to broadband, hardware, and software
• Health literacy, particularly as it applies to digital health
• Data privacy protections

Here we'll focus on the first two. For our purposes, it may be more fitting to think of this aspect of digital health as technology-enabled healthcare.

Technology-enabled healthcare is built on a foundation where patients have affordable, reliable broadband access, adequate technology and hardware to use, and a level of digital literacy that enables individuals to carry out essential health-related functions using technology.

Affordable broadband access

Thirty million Americans lack broadband services altogether. For example, 24% of Georgia's residents do not have broadband internet access, and more than 30% of rural residents in the U.S. don't. In the Black Rural South (counties with populations that are 35% Black or higher), 38% of Black Americans lack high-speed Internet access.

The Federal Communications Commission (FCC) determined that racial and ethnic minorities, people living on tribal lands, older adults, and people with lower education and income levels are less likely to have broadband at home. FCC data also shows that areas with lower broadband connectivity feature residents with higher rates of obesity, diabetes, unnecessary hospitalizations, and sick days than national averages.

There has been progress with the several FCC programs that support low-income individuals, veterans, rural communities, and others to access more affordable broadband services. As of early 2022, over 10M U.S. households were enrolled in the Affordable Connectivity Program, providing $14B in long-term benefits for consumers with household incomes 200% the Federal Poverty Guidelines.

Adequate technology and hardware

The Pew Research Center found that only 24% of people living in rural areas own a cell phone, but they're not smartphones. Other studies show that ~40% of adults ages 65+ and ~25% of low-income households don't own a smartphone. Some are forced to share smartphones with family or friends. Only 58% of Black and 57% of Hispanic individuals own a desktop or laptop computer, compared to 82% of White individuals.

Providing Internet-accessible devices would be an answer to improving digital health equity; however, there are obstacles to offering technology for free. For example, giving free technology to a Medicare beneficiary can trigger the Civil Monetary Penalties Act (CMP) under federal fraud and abuse laws. While the CMP law has allowed certain goods or services to be distributed without cost if they facilitated access to care, it's a gray area.

Hospitals that provide free or less than fair market value goods or services to a physician or others with authority to influence referrals could trigger the Stark Law or the Anti-Kickback Statute. If a hospital wants to provide tablets to physicians or their patients, as part of a population health or chronic care program, it will require careful legal review and guidance.

Health and digital literacy

About half of American adults struggle with low health literacy, making it difficult for patients to find, process, or comprehend the basic health information they need to make appropriate health decisions. According to the Agency for Healthcare Research and Quality (AHRQ), only 12% of American adults have proficient health literacy— the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. Over one-third of adults struggle with everyday health tasks like understanding medication instructions or labels, completing healthcare forms, or using charts like a childhood immunization schedule.

Complicating health literacy is low digital literacy. Patients may not know how to use computers or navigate website functionality and mobile apps. Educational, cultural, or linguistic barriers can limit their comfort and use of technologies, mainly digital health solutions.

Existing technology-enabled healthcare programs

As examples, four programs currently demonstrate the power of addressing technology-related inequities as part of digital health programs.

Ochsner Health: The O Bar offers physician-recommended digital products and is staffed by full-time technologists who help patients choose the right digital technology, providing setup guidance and support.

Nemours Children's Health: During the pandemic, the health system offered staff as digital health navigators who helped patients and families with various technology challenges like completing online forms, troubleshooting connectivity issues, and accessing telehealth visits.

Moffitt Cancer Center: The center conducted a pilot around breast cancer screening in Black communities where women are disproportionately diagnosed with breast cancer. The program increased engagement by ~25 times. The Moffit pilot team anticipates that screening will increase by 1,300 women.

Boston Medical Center: Blood pressure cuffs and a QR code were distributed to mothers who had recently given birth and were at risk for hypertension. The new mothers monitored their blood pressure remotely each day for six weeks. The program provided device instructions in simple terms and three languages. The team ensured that features were simple and required little data in the event data plans of new mothers were limited, or their cell phones didn't support video conferencing. The organization provided web portal support by high-risk obstetric nurses who could triage and provide technical troubleshooting. The program saw a significant decrease in readmission rates for postpartum mothers with high blood pressure.

Out-of-the-box thinking can break through digital health equity barriers

Health equity challenges can appear complex and overwhelming. Yet, they don't always require complex solutions. Like many aspects of addressing health inequities, it starts with who and why. Who is facing the health disparity that we want to address? And why do we want to address it? Having clarity around the root causes and ways that you can influence a better outcome can lead to creative technology ideas and solutions.

For example, consider intelligent speakers or magnification features for patients who struggle with reading and eyesight. If there aren't enough translators for your patient population, consider using – or creating – a language translation app that includes medical terms.

• Think of the physical, social, and medical barriers your patients could face and bridge the gap between where they are and the next step towards better health. What are the obstacles faced by your patient population, stratified by race?
• Use more videos with demonstrations to make medication, treatment, or test preparation instructions more accessible.
• Use non-digital tools and existing or required communication to introduce and raise awareness around your technology-enablement programs and opportunities.
• Consider having devices in the waiting room that patients can experiment with to try out the patient portal or mobile app.
• Looking into hubs of activity of the communities you serve. Is there a way to set up technology, access, and digital literacy services related to healthcare? Libraries, churches, pharmacies, and senior centers all provide places where the community can access technology-enabled healthcare support.

During a recent digital health equity panel discussion hosted by the NCQA, one panelist shared a valuable reminder, “The path of least resistance should connect everyone that needs to be included in the way that is least costly for patients – in time off from work, the expensive of childcare, etc."

Technology access and use can create a positive ripple effect

Enhancing technology use, confidence, and access will not only positively impact equity issues but also have a ripple effect in other areas that greatly influence health. Access to broadband, adequate hardware, and digital skills support an individual's ability to apply for employment or housing, request public assistance, attend online high school, and research healthy habits or medical conditions.

RTI Health Advance works with provider and payer organizations, enabling strategies, technologies, and programs that get to the heart of health inequity. Contact us to discuss how technology-enabled healthcare can lead to better health equity.