Digital disparities: lessons learned from a patient reported outcomes program during the COVID-19 pandemic

Abstract

The collection of patient reported outcomes (PROs) allows us to incorporate the patient’s voice within their care in a quantifiable, validated manner. Large scale collection of PROs is facilitated by the electronic health record (EHR) and its portal, though historically patients have eschewed the portal and completed patient reported outcome measures (PROMS) in clinic via tablet. Furthermore, access to and use of the portal is associated with known racial inequities. Our institution oversees the largest clinical PRO program in the world, and has a long history of racially equitable PRO completion rates via tablet. However, when the COVID-19 pandemic forced us to remove tablets from clinics and rely exclusively on portal use for PRO completion, profound racial disparities resulted immediately. Our experience quantifiably demonstrates the magnitude of inequity that the portal, in its current configuration, generates and serves as a cautionary tale to other health care systems and EHRs.

Impact of the coronavirus disease 2019 pandemic on delivery of and models for supportive and palliative care for oncology patients

“…This ‘digital divide’ not only impacts the immediate care of our patients but also will have long-term consequences on the health of patients from disadvantaged groups. An example of this pandemic-induced exacerbation of inequity has been described by Sisodia et al [ 80 ▪▪ ], who compared PRO completion at the Massachusetts General/Brigham hospitals after March 2020, to that observed prepandemic. As at our own institution, tablets were removed from clinic and the sole platform for collection of PROs became the patient online portal.…”

Implementing patient-reported outcomes in routine clinical care for diverse and underrepresented patients in the United States

“…This is supported by recent research showing that reliance on smartphones for internet access has become increasingly more common among Americans with lower socioeconomic status as well as racial and ethnic minority populations [ 67 ]. However, relying on ePROs alone may not be sufficient to maintain equitable PRO collection, as evidenced by one report demonstrating profound racial and ethnic disparities when transitioning from tablet-based to web-based PRO collection [ 68 ]. Our study highlights several key findings regarding the unique needs and concerns of populations in various clinical settings using ePROs, such as inclusion of bar graphs with “emojis” for symptom reports [ 41 ] or touchscreens with visual and audio components, for example [ 48 ].…”

Implementation strategies to promote measurement-based care in schools: evidence from mental health experts across the USA

“…Due to our focus on identifying implementation strategies for MBC as a clinical practice, the vignettes did not refer to any implementation supports, such as decision support by a measurement feedback system or other digital interface for scoring and viewing progress data. Although clinical decision support tools have been associated with more robust effects of MBC, they are not necessary [ 56 ], and using technology to aid measure completion and review may create disparities in MBC access [ 57 ]. Availability and feasibility of technology-assisted decision support tools is variable in public schools given the ongoing digital divide in education [ 58 ].…”