Digital Health Equity as a Necessity in the 21st Century Cures Act Era

Abstract

The release of final rules from the Office of the National Coordinator for Health Information Technology's (ONC) Cures Act in March 2020 places a new focus on patients' access to their health data. 1 The ONC rules make "health data more computable and [give] patients more control of their medical record." 1 Hopefully, patients will be able to interact more easily with their data through patient portals and mobile health apps, and "shop for care by comparing costs, understanding possible treatments, and expected health outcomes." 1 The new rules intend to increase the pace of innovation and investment in patient-facing tools. Building on more than 300 000 health apps and $7.4 billion in digital health investments in 2019 alone, this policy environment may significantly transform the ways patients access care. 2 In light of the current coronavirus disease 2019 (COVID-19) pandemic, and the success in Taiwan and Singapore in using health information to identify, trace, track, and quarantine individuals, a more user-friendly system has become even more important. 3,4 However, improvements in patient self-management, care coordination, quality, and cost-effectiveness may be stymied by persisting digital divides. Given the recognition of the higher morbidity and mortality for underserved patients with COVID-19, including African Americans, understanding and eliminating these digital divides are critical. 5 Thus, the benefits of these innovations will require active efforts to ensure the needs of diverse groups are included in design and implementation strategies.Two patient-facing tools, patient portals and mobile health apps, represent patients' primary digital touch points with the health care system, and the importance of these tools is expanded with the new rules. These modalities also serve as means to access telehealth services, collect data, and address population health, patient-reported outcomes, and social determinants of health. Patient portals are one of the earliest investments in telehealth technology, yet uptake has lagged among underserved populations, including patients of racial/ethnic minority groups, limited English proficiency, low socioeconomic status, older age, and low literacy. 6 For example, Anthony et al 6 found that patients on Medicaid or with less than a high school diploma were about twice as likely to be nonportal users. This is not only relevant for clinical care, but also for research as portals become trial recruitment tools.Similarly, mobile apps have not been designed for underserved populations. 7 The ONC rules should prompt renewed efforts aimed at digital health equity. This will require guiding the commercial and regulatory landscape that currently influences the design and implementation of these technologies. In this Viewpoint, we highlight inequities in these digital health tools and opportunities to apply an equity framework in the era of expanded patient access to data.

Patient interest in and barriers to telemedicine video visits in a multilingual urban safety-net system

“…[18,19] Given the growing importance of telemedicine and patient portals, our findings reinforce the need to advocate for digital infrastructure to ensure equitable telemedicine and healthcare access. [6,7] Our study also highlights that digital access is a concern not only in rural populations but also for the 35 million Americans who live in poverty in urban areas.…”

“…The greater prevalence of barriers among older patients in this study supports work documenting a digital divide in older adults, specifically with regard to device access and digital literacy. [6,12,16,17] Therefore, it is crucial to support efforts to teach older individuals (and others with lower digital literacy) about how to access video visits. [7] Without system workflows or payor incentives to provide support to patients, equity in telemedicine access will be impossible; in our work, two-thirds of calls lasted <5 minutes, suggesting the feasibility of targeted support to patients who need it.…”

“…Authors * Elaine C Khoong, MD MS 1,2 * Blythe A Butler, BA 3 Omar Mesina, MD 3,4 George Su, MD 5 Triveni B DeFries, MD MPH 1 Malini Nijagal, MD MPH 6 Courtney R Lyles, PhD Before the COVID-19 pandemic, telemedicine video visits were uncommon, especially within safety-net settings. A 2018 survey found only 44% of community health centers used any telehealth.…”

“…These populations already face disparities accessing healthcare and are already less likely to use digital health tools due to disparities in device ownership, broadband access, and digital literacy. [6][7][8] To understand the interest and accessibility of video visits among safety-net patients, we conducted an in-depth survey in a public healthcare system to inform strategies to ensure equitable access.…”

Measuring eHealth Literacy in Urban Hospitalized Patients: Implications for the Post-COVID World

“…The COVID-19 pandemic has catalyzed use of technology in healthcare. 1 This increased emphasis on technology requires adequate access and capability for optimal outcomes. Characterizing the current digital divide is essential to ensure novel technological advances do not exacerbate disparities.…”