New Practice

This is part two in a series of posts on digital health equity and innovation. A version of this content recently appeared as a guest post: Innovation for all: Adapting patient-facing tools to promote digital health equity and podcast episode on KevinMD.com. 

More often than not, ground-breaking health care advancements are disproportionately accessible for those who already have favorable social determinants of health.

Improving cost, access, and quality, but for whom?

The boom of telehealth and digital health during the pandemic was a necessary shift to bridge the critical access gap while also supporting the public health measures implemented to slow the spread of COVID-19 – but did this change unintentionally widen the health equity gap? 

During my research, I was surprised to learn about a health equity concept I had never heard of, digital determinants of health (DDOH), born from the traditional social determinants of health (SDOH) model. These include  “access to digital resources, use of digital resources for health seeking or health avoidance, digital health literacy, beliefs about potential for digital health to be helpful or harmful, values and cultural norms/preferences for use of digital resources, and integration of digital resources into community and health infrastructure.” Similar to traditional SDOH, DDOH are believed to interact with other intermediate health factors, such as biology and pre-existing conditions. The DDOH are generally formed in the context of an individual’s relationship with, and fundamental understanding of the crossroads between technology and health, an extension of the foundational conditions established in the SDOH. 

The pandemic and subsequent acceleration of telehealth usage widened the already inequitable “digital divide.” Patient-facing tools have been proven to further drive disparities in cost and access with lower adoption of patient portals in “older adults, racial or ethnic minorities, and those with low socioeconomic status, low educational attainment, limited health literacy, and chronic illness” when compared with advantaged populations. Research also suggests digital health tools that are patient-facing might even exacerbate health disparities. Despite this fact, there is little evidence that health systems and technology organizations have “incorporated approaches to address health disparities in the development, implementation, and use of patient portals.” Considering vulnerable populations are disproportionately less likely to benefit from digital health efforts, and are already disadvantaged in terms of cost, access, and quality of care, the benefits associated with health technologies are not reaching the very populations who could benefit from them the most.

Digital health equity’s secret weapon

Electronic health records’ (EHR) patient portals contain tremendous untapped potential to bridge the growing digital health equity gap and the technology industry knows it. Reimagining patient portals as a key tool for serving disadvantaged populations is possible, but only if extended beyond the concept of meaningful use. In terms of the iron triangle, advancements to patient portals’ scope, capabilities, and interoperability lies at the intersection of access and quality. Evaluations of patient portals find lower usage among racial and ethnic minorities, with factors like access and usability determining whether digital health tools “will be successful in improving health and ensuring health equity.”  

To mitigate disparities in access and cost, it is imperative for any patient-facing digital health platform to leverage mHealth (mobile health) opportunities alongside any platforms offered on a computer. Though 40 percent of low-income households report not having access to a computer or internet services, 76 percent of U.S. adults who can be considered low-income (less than $30,000) own a smartphone. Ensuring patient portals incorporate mHealth compatible with a variety of mobile devices, configurations, and without internet access is integral to ensuring equitable access and cost. 

A 2020 research study of patient portal interventions identified the most common barriers in patient portal usage to be “the need for support in understanding the medical content presented and the need for improved digital skills and confidence” as well as the “desire for more ways to contribute their own feedback or data into the EHR.” Despite these observed barriers and little data available linking patient portals to health outcomes, several self-report studies found patients still expressed a strong interest in using patient portals. The study also emphasizes that patients with the greatest barriers to use could (and should) be specifically targeted for product development, with the predetermined goal of increasing health equity. The authors validated my findings by noting that most systems have not targeted patient portal engagement efforts based upon potential impact, even though these patient groups have the most to gain from access to robust personal health data and routine health care communication.

Methods of prioritizing health equity in the digital era

Any strategy or initiative to improve health equity must be as personalized to the community as the SDOH and DDOH are, and be intentionally flexible to meet the distinct needs of every population. The following enhancements to EHR patient portals involve simple modifications that create an opportunity to further transform traditional platforms into a powerful instrument of prioritizing digital health equity:

1. Optimizing accessibility through mobile health (mHealth) opportunities.
2. Ensuring a linguistically appropriate, up-to-date, comprehensive plan of care. 
3. Enhancing patient engagement by providing self-scheduling, secure messaging, and an opt-in feature for text messaging.
4. Optimizing health literacy through tying diagnosis and lab results to educational explanations and resources.
5. Leveraging community resources that map to specific elements of the care plan. 
6. Providing interoperability in different health care settings and integrations to other mobile apps and remote patient monitoring devices.
7. Expanding resources to include locating a primary care physician nearby and insurance coverage options. 
8. Ensuring a reconciled medication list, with prescribing instructions and information about each drug.

Bolstering the power of patient portals in these eight ways can maximize patient engagement, autonomy, health literacy, and likely even encourage positive health outcomes through improved patient self-management. If executed properly, health care leaders will first identify their patient populations who stand to gain the greatest positive impact from this strategy, take action on the data to optimize the strategy for its target demographic, and even leverage community resources to strengthen the strategy. 

As technology continues to transform the health care industry, it will also continue to introduce new threats to the already polarized health equity landscape and digital divide. Without investing in intentional health equity strategies, digital health innovations have the unfortunate potential to widen the disparity gap, compounded by the existing digital divide.