Aw

Issue Brief

CHCF

 

FEBRUARY 2022

by Courtney R. Lyles, Adrian Aguilera,
Oanh Nguyen, and Urmimala Sarkar

Bridging the Digital Health Divide:

How Providers and Plans Can Helo Communities
Better Adopt Digital Health Tools

plethora of digital health tools for patients
Ar been developed in the United States
over recent years, including mobile phone
applications, wearable devices, and technology linked
to health care data, such as patient portals.' However,

there are large inequities in who is using these digital
tools.

The goal of this two-part series, "Bridging the Digital
Health Divide," is to provide key stakeholders with
action-oriented recommendations to ensure digital
health technology meets the needs of diverse patients.
The goal is to ensure all patients benefit from digital
health tools regardless of their cultural background,
language, income, race, or ethnicity. The audience for
this issue brief includes those who implement digital
health products and services, including health care
providers; leaders of hospitals, clinics, and health sys-
tems; information technology staff; and payers. The
challenges described in the series - including the
digital divide as well as digital health inequities - are
multifaceted. Approaches to address these challenges
must reach patients where they are, whether at the
doctor's office, at home, or on the go.

The other brief in the series discusses the challenges
for technology developers in ensuring equitable digi-
tal health design and suggests design principles that
can help them overcome these challenges.

With a focus on equity and inclusion during imple-
mentation and design, health care providers, health
plans, and developers can create technology that bet-
ter reaches everyone.

Why Change Is Needed

It has never been more apparent that digital health
in the US needs to be more inclusive. The COVID-19
pandemic amplified the need for remote and digital
approaches to complete everyday tasks, such as going
to school or seeing the doctor. The rapid conversion
to remote health care delivery via telemedicine also
highlighted key pitfalls of our existing digital health
infrastructure."

In particular, the shift to telemedicine meant that
people already suffering from health inequities were
left even further behind due to limited access to
digital health services. This included rural residents
who lack reliable broadband, people from racial and
ethnic minority groups who are alienated from the
health care system, older adults who have lower digi-
tal literacy skills, those with low incomes who have
unaffordable cell phone data plans, and those with a
preferred language other than English who could not
effectively use English-only digital health platforms.°
Without focused attention, the health care system will
continue to see uneven adoption of digital tools such
as telemedicine, resulting in worsening health inequi-
ties, even beyond the pandemic.*

Multiple underlying drivers of digital health equity
exist. Within the US, 93% of American adults use the
internet and 85% own smartphones.® However, access
and use are not distributed equally, a disparity known
as the digital divide. Among adults over age 65 in
the US, only 55% to 60% own a smartphone or have
home broadband access, and only 60% can send an
email, fill out a web form, and find a website. Similarly,
the nearly one in eight Americans living in poverty
have markedly lower rates of smartphone ownership
(71%), home broadband access (59%), and internet
use (82%), and they also report having only basic digi-
tal skills (53%).?

These issues are systemic and include a lack of invest-
ment in broadband infrastructure in systematically
excluded rural and urban neighborhoods.® In addi-
tion, many groups have received unequal access to
computers and digital literacy education. Considered
together, at least one in four adults in the US may not
have the digital literacy, access to the internet, or the
necessary devices to meaningfully engage with digital
technologies.

The digital divide extends into digital health (Figure 1).
Digital health includes all of the technologies and sys-
tems that health care providers and payers use with
patients, including telemedicine (e.g., telephone and

video visits with a physician or other health care pro-
vider), patient portals, remote monitoring devices,
apps, health trackers, and electronic health records.

The Healthy People initiative, a 10-year federal pro-
gram meant to improve the health of Americans,'
found that while the general population increasingly
used mobile devices for health care and had steadily
increasing online communication with health care pro-
viders, inequities across different populations persist."
These disparities are most pronounced among older
adults, those with limited English proficiency or health
literacy, those facing poverty and other economic
barriers, and those with limited digital literacy. These
groups use digital health tools at significantly lower
rates than other groups."

A recent analysis found that more than one in six
people are not able to engage in telemedicine. Older
adults, Black and Latinx individuals, those with public
health insurance (i.e., Medicaid and Medicare) or no

Figure 1. Primary Care Visits, by Visit Type, Academic Medical Center vs. Public Delivery System, August 2020

 

The Digital Divide. Some public and safety-net settings differed substantially from other settings in

use of telemedicine modalities during the COVID-19 pandemic.

| UCSF Health (academic medical center)

 

Video Phone

 

Mi San Francisco Health Network (public delivery system)

 

In Person

Source: The Commonwealth Fund, "Launching a Toolkit for Safety-Net Clinics Implementing Telemedicine During the COVID-19 Pandemic," October 27, 2020,

with data from the authors.

 

California Health Care Foundation

www.chcf.org 2
insurance, respondents with lower levels of education,
and those experiencing food insecurity or social isola-
tion have a much lower ability to access telemedicine.
These findings highlight how differences in digital
health readiness threaten to widen existing disparities
among populations already at risk.'

Mistrust stemming from historical and current exclu-
sion and discrimination within the health care system
also can have a profound impact on the acceptance
and use of digital products and services that health
care providers or plans offer. Because many in the US
have been excluded from digital health innovation
and have experienced discrimination from health care
more generally, it is critical to explicitly focus on the
needs and preferences of these groups'? rather than
assume current approaches and products are suffi-
cient. Decisionmakers in digital health must therefore
be intentional and thoughtful about acknowledging
historical and current exclusion, as well as including
diverse populations throughout all phases of develop-
ing and implementing programs.

Ensuring Digital Health

Readiness

Although a wide range of digital health solutions have
been developed in the US over the past decade,
including both patient apps and wearables, as well
as technology such as patient portals, people have a
range of needs and preferences that influence digital
health use from the outset.

Addressing the major technology-related barriers that
hinder people from using new digital health tools -
such as providing broadband and computer access
- is necessary to ensure greater adoption of such
tools. In addition, it is important that health care pro-
viders and health plan leaders understand something
more: whether people are ready and able to adopt a
digital health tool.

Health care providers and health plan leaders there-
fore need to ask a range of questions on topics that go
to the heart of digital readiness, such as the following:

> Motivation and trust. Do members of a specific
population believe that they have a problem that
can be helped or solved with a digital health
tool? And do individuals trust using available
digital health tools, in general, as well as in com-
bination with in-person health care interactions?

> Access. Do patients have the appropriate device
and connectivity to engage with a digital health
tool?

> Digital literacy. Do patients have the necessary
abilities to use digital health technology?

Some of these questions are similar to health and
health care promotion more broadly. To promote posi-
tive health behaviors - whether to take a pill, check
one's blood pressure, or attend a follow-up appoint-
ment - requires an understanding of the patient's
needs, motivation, and capabilities. The same is true
for patient engagement in digital health technology.

Motivation and Trust

Technology has a greater likelinood of being used
if it meets a pressing need that a specific group of
people consider relevant."4 Digital health stakeholders
should partner with populations to understand what
is important to them. This could range from culturally
responsive health education to integrated community
support (i.e., public libraries, churches, or other key
community organizations collaborating with health
systems to provide education and support for digital
health tools). Health providers and health plan lead-
ers should pay particular attention to defining specific
needs that the proposed technology addresses (e.g.,
addressing food access or locating food resources
versus providing dietary recommendations within a
digital tool) and communicating how a digital health
solution links to other important aspects of care."®

 

Bridging the Digital Health Divide: How Providers and Plans Can Help Communities Better Adopt Digital Health Tools 3
Health care providers and health plan leaders also
must seek to establish greater trust that underlies the
relevance and use of digital health solutions. The US
health care system has a fraught history of mistreat-
ment, discrimination, and racism directed toward
people of color, which continues to adversely affect
care and treatment today, including ongoing mistrust
of the health care system. In terms of digital health,
trust is further complicated by well-publicized data
breaches involving health care and other digital sys-
tems.' Therefore, digital health cannot be separate
from ongoing health equity programs and _inter-
ventions within health care settings. At the core of
health equity efforts must be ongoing and reciprocal
relationships in the community, including direct rela-
tionships with community members, partners, and
organizations.

Access

In addition to motivation and trust, the people who
use a health care tool or platform must have the nec-
essary equipment and internet connections to use
technology for their health care. They need access to
an internet-ready device, such as a smartphone, tab-
let, laptop, or desktop computer. Ideally, the device
should not be shared, and it should therefore enable
privacy and security. The device also should have the
latest software needed to operate the technology with
ease.

Those implementing digital health tools should under-
stand the types of devices that individuals will use for
access and any limitations that they face. With this
awareness, health care providers and plans can target
approaches to user needs and connect communities
with existing resources, such as those identified in the
Additional Resources section of this brief.

Digital health solutions also should be smartphone-
friendly, including features such as mobile optimization
of websites and availability of apps in both Android
and iOS platforms. Fifteen percent of US adults access
the internet exclusively via a smartphone. These users
are more likely to be individuals under the age of 30
and come from extremely low-income households
(with less than $30,000 in annual income), or come
from Latinx backgrounds."

Patients also require adequate internet connectiv-
ity. Ideally, internet access would come through
affordable, high-quality broadband at home that has
enough speed and bandwidth. While a growing share
of Americans have a high-speed internet connection
at home, almost a quarter (23%) do not. Among those
without a high-speed internet connection at home,
nearly half (45%) cite financial barriers as the reason
for not subscribing to high-speed internet.'® Those
without high-speed internet at home may either have
options for internet access outside of the home (such
as at school or a public library), rely on limited cellular
data plans through their smartphones, or lack internet
access entirely.

In addition to understanding whether intended users
have available internet access, health care providers
and health plan leaders must understand existing and
potential issues that may affect connectivity. These
issues include:

» Interruptions in internet access. Intermittent
access to the internet often stems from an unaf-
fordable internet subscription or cell phone bill
some of the time.

» Limitations on bandwidth. Users often face
limits on how much data can be downloaded or
uploaded from their device.

>» Limitations on data speed. Many times, digi-
tal health technologies require high-speed
connections.

 

California Health Care Foundation

www.chcf.org 4
Digital Literacy

Even among those who are interested in using digital
health solutions and have sufficient access to comput-
ers and other devices, 52 million adults in the US do
not have the digital literacy skills needed to use them
properly.'" Digital literacy includes having confidence
and experience with using digital health solutions.
Digital literacy skills range from basic, such as being
able to find a website or send an email, to more
advanced, such as being able to navigate multiple
interfaces and share data between platforms. Digital
literacy can encompass not only skills but also positive
attitudes and beliefs about one's ability to use and get
value from using digital technology."

Those who lack the abilities to use existing platforms
and tools on their own are more likely to be older,
experience increased challenges accessing education,
and come from a racial or ethnic minority background
- given similar underlying structural barriers within
our society. Health care providers and payers need to
identify training or support needs for specific popula-
tions and deliver training that is tailored to that group's
needs (see case study).

Health care providers and payers should understand
the range of skills required for specific populations to
engage with digital health tools and identify potential
skill or knowledge gaps that can lead to insufficient
adoption of technology. The list in Table 1 offers a
pragmatic approach to assessing users' digital skills
(see page 6)."!

 

 

CASE STUDY

Improving Digital Health Readiness

A federally qualified health center based in urban
Los Angeles mostly cares for patients at or below
the federal poverty line. The center's patient popu-
lation is racially and ethnically diverse, and nearly
half of its patients are better served in a language
other than English. The staff knew from prior evalua-
tions that most of their patients preferred in-person
to remote visits. To avoid an interruption in critically
needed medical care during the COVID-19 pan-
demic, it was crucial for the center to develop effec-
tive strategies to understand and address existing
and emerging barriers to telemedicine.

The health center assessed these barriers by survey-
ing a representative sample of patients. The staff
made sure to conduct outreach and data collection
in the patients' preferred language, and to include
patients with varying levels of engagement in their
care.

Through this survey, the health center learned that
many patients were not able to schedule telephone
or video visits because they had difficulty logging
on to and using the patient portal. Patients com-
municated that the password requirements were
difficult and that not all of the web pages were
translated into their preferred language. Some
patients were not able to participate in video visits
because they did not own a device with a camera,
so staff connected them with the city library, which
provides low-income members of the community
with free and low-cost devices.

To help patients use remote care tools, such as the
patient portal and video visits, staff developed and
conducted trainings in multiple languages. They of-
fered trainings online and in-person, when possible.
The health center also continued to prioritize hiring
and retaining staff fluent in priority languages to in-
crease the cultural relevance of their work. Through
approaches like these, the health center used
patient experiences to inform their implementation
of telemedicine and improved adoption among
patients who would have otherwise been excluded.

 

 

Bridging the Digital Health Divide: How Providers and Plans Can Help Communities Better Adopt Digital Health Tools

 
Table 1. A Digital Literacy Checklist
CAN THE USER DO THE FOLLOWING?

Foundational
» Turn on device.

» Use available device controls, such as a touchscreen,
mouse, and keyboard.

» Use menu settings, such as changing the volume or
increasing the font size to make text easier to read.

» Connect to a Wi-Fi network.
» Find and open apps.
» Use an internet browser.

» Update and change passwords.

Communications

» Use email, messaging apps, text messages, social
media, and video to communicate with others.

Information

» Use a search engine to find news, health information,
and other information of interest.

» Recognize the trustworthiness of online information.

» Stream or download online movies, music, games,
books, and other content.

Transactions

» Access and use public services and assistance online,
such as applying for services and paying bills.

» Purchase goods or manage money and financial
transitions securely online.

Problem solving

» Use online resources, including online tutorials,
FAQs, and forums, to solve problems and search
for information.

Safety and privacy

» Keep online accounts secure and private using robust
passwords and privacy settings.

» Assess risks and threats involved in being online.

» Recognize and avoid suspicious links in emails,
websites, and social media.

Many digital literacy skills also are gained or supported
through relationships, such as the availability of tech-
nical support from a trusted friend or family member.
Other people can teach individuals specific skills that
help bridge gaps and help them gain confidence in
their abilities. For example, an adult child might help
an older parent create a user account and password
and log in to an online patient portal. Over time, after
going through the process with their children, older
parents may learn to log into the patient portal on
their own.

More direct consideration of the processes for engag-
ing loved ones or trusted individuals is critical for
addressing digital health inequities. In parallel, health
care providers and health plans must be prepared
to support users who do not want to share sensitive
information with those who provide them with digital
support. They can do this by asking patients if they
need help accessing their health information, who
helps them with this access, and if they need support
retaining control of their personal information.

While family members and caregivers may help with
specific applications, health care providers and health
plans should still pay attention to developing and
maintaining long-term and ongoing organizational
support for digital health solutions. At a minimum,
organizations can provide robust and well-trained
technical support for the digital health solutions that
they implement, such as through a health system help
desk. Even with these support structures in place, it
is important to note that ensuring universal access
to digital health technology also requires alternate
channels, when needed, such as through call centers
or other support offered to all patients. For example,
users who lack the digital literacy to engage in video
telemedicine visits may prefer to engage in telephone
or face-to-face visits.

 

California Health Care Foundation

www.chcf.org 6
To meet individuals where they are across the digital
skills spectrum, organizations also can partner with
public libraries and other community organizations to
provide comprehensive digital skills as well as literacy
education and training (see the Additional Resources
section for various organizations' ideas to support this
work). Trainings within these organizations are often
tailored to the needs of specific populations, such as
trainings provided in patients' preferred languages.
Overall, a longer-term view on digital skill building and
support - both within and outside of the health care
setting - is critical to reinforcing access, interest, and
motivation to adopt and use digital health.

Finally, sufficient digital literacy skills are enabled by
a suitable physical environment in which to use a tool
or platform. For example, people living in crowded or
congregate settings may be reluctant to participate in
video visits with a clinician due to the potential for oth-
ers to overhear sensitive conversations. Alternately,
some people may only have online access in a pub-
lic space, such as a library or a common area in their
residence, which poses privacy and security issues.
Therefore, the context and environment should be
considered up front when planning for technology
implementation (e.g., combining video visits with
secure chat or texting functionality).

Conclusion

Digital health equity depends on technology imple-
menters enabling diverse communities to engage with
and use digital health. As health providers and health
plan leaders devise ways to implement these digital
health products and services, they must keep top of
mind the strategies presented in this brief.

 

 

Screening Questions to Assess Digital

Health Readiness

Equitable access to digital tools means that health
care providers and health plans maximize the poten-
tial benefit so that the people most likely to use a
digital tool or service are motivated, can access that
tool, and have the right digital literacy skills to use
it. Health care providers and health plans can ask
potential users the following questions to determine
the best fit:

Interest. How interested are you in using this tool
[for the benefit intended]? (Not at all, somewhat,
very). Follow-up question: What would make you
very interested?

Trust. How concerned are you about the privacy,
security, or confidentiality of your health information
being available online?

Access. Do you currently have a device that allows
you to get on the internet, such as a smartphone,
tablet, or computer?

Connectivity. In the past 12 months, how often
have you had your telephone [and/or internet] ser-
vice turned off at any time?

Skills (communication). In the last month, how
often did you send messages by texting? Email?
(Most days, some days, or rarely)

Skills (information, transactions, or problem
solving). In the last month, how often did you use
your device (smartphone, tablet, or computer) for
something besides texting or email? (Most days,
some days, or rarely)

Accessibility (environment). Do you have a private
and secure place to [use digital health]? Private
means not at risk of someone inadvertently seeing
or hearing anything you don't want them to see

or hear while you are [using digital health]. Secure
means not using a public internet connection or a
public shared computer terminal, such as at a public
library.

Sources: "Guidance: Essential Digital Skills Framework,"

updated April 23, 2019. Digital Instruction Guide for Health
and Care in Wales (PDF). Wales Co-operative Centre. July 2019

 

 

Bridging the Digital Health Divide: How Providers and Plans Can Help Communities Better Adopt Digital Health Tools

 
About the Authors

Courtney R. Lyles, PhD, is a health services researcher
and associate professor in the UCSF Department
of Medicine as well as in the Department of
Epidemiology and Biostatistics. Adrian Aguilera,
PhD, is an associate professor in the School of
Social Welfare at UC Berkeley and the Department
of Psychiatry and Behavioral Sciences at UCSF. He
directs the Digital Health Equity and Access Lab
(dHEAL). Oanh Nguyen, MD, MAS, is an assistant
professor in the UCSF Department of Medicine and
hospital medicine physician at San Francisco General
Hospital. Urmimala Sarkar, MD, MPH, is a professor
in the UCSF Department of Medicine and a primary
care physician at Zuckerberg San Francisco General
Hospital's Richard H. Fine People's Clinic. Drs. Lyles
and Sarkar cofounded UCSF S.O.L.V.E. Health Tech,
an academic program that partners with digital health
companies to adapt technology for marginalized and
minoritized patients and the settings that serve them.

Acknowledgments. The authors would like to thank
Marika Dy and Sarah Lisker for their support with this
issue brief.

About the Foundation

The California Health Care Foundation is dedicated
to advancing meaningful, measurable improvements
in the way the health care delivery system provides
care to the people of California, particularly those
with low incomes and those whose needs are not
well served by the status quo. We work to ensure that
people have access to the care they need, when they
need it, at a price they can afford.

CHCF informs policymakers and industry leaders,
invests in ideas and innovations, and connects with
changemakers to create a more responsive, patient-
centered health care system.

ADDITIONAL RESOURCES

The following resources were developed by health
care providers, government, academia, nonprofits,
foundations, and community groups to provide fur-
ther guidance on helping patients better adopt digital
tools.

Digital Health Readiness

> San Francisco Mayor's Office of Housing and
Community Development: Digital equity
intake questions

Access to Devices and Internet

> National Digital Inclusion Alliance: Free and
low-cost internet plans

> PCs for People
> Lifeline Support program

> Local libraries: Access to digital resources
and services"?

>» AT&T Access program

> Comcast Internet Essentials program

Basic Digital Literacy Resources

> Goodwill Community Foundation: How-tos on
internet skills in English and Spanish

> Public Library Association: Computer courses

> San Francisco Mayor's Office of Housing
and Community Development: Tips

 

California Health Care Foundation

www.chcf.org 8
Endnotes

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Bridging the Digital Health Divide: How Providers and Plans Can Help Communities Better Adopt Digital Health Tools