Will Digital Health Remedy or Reinforce Healthcare Inequities?

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Over time, healthcare disparities in the US have widened along lines of age, race, gender, language, location, and socioeconomic status. [1] Despite rising broadband infrastructure and mobile technology over the last decade, digital adoption in rural areas has lagged behind urban communities. [2] As such, there is real concern that growth in digital health and telehealth will compound the effects of digital healthcare disparities in our most vulnerable populations. This has invoked a call to action among digital health leaders and developers to align the future of digital health design around healthcare equity for all individuals.

Thirty seven percent of the US population (121 million Americans) live in “healthcare deserts.” More specifically, 80% of US counties lack adequate access to healthcare resources including pharmacies, primary care providers, hospitals, hospital beds, trauma centers and low-cost health centers. This translates to almost half of all US counties have less than 2 hospital beds per 1000 people. [3] The figure below helps conceptualizes the geographic distribution of healthcare deserts, notably which are heavily weighted in rural areas.

Image credit: https://www.goodrx.com/blog/wp-content/uploads/2021/09/GoodRx_Healthcare_Deserts_White_Paper.pdf

Image Credit: Wood BR, et al. Advancing digital health equity: a policy paper of the Infectious Disease Society of America and the HIV Medicine Association. Clin Inf Dis, 72(6):913–919.

  • Video visits were under-utilized in disadvantaged communities during the COVID-19 pandemic. Audio visits were the most utilized alternative to in-person care according to data from California-based Federally Qualified Health Centers (FQHC) that service low income individuals. [10]
  • A University of Pennsylvania study found profound discrepancies in telemedicine use at a large academic health center during the COVID pandemic. Unsurprisingly, older, non-English speaking females with low incomes were at risk for reduced telehealth utilization. [11]
  • The digital infrastructure for online vaccine appointments created barriers for marginalized populations (older, non-white, low income) without technical resources to utilize it, contributing to the low vaccine rates of communities most affected by COVID-19. [12] In fact, in digital deserts, vaccine appointments were usurped by internet-savvy nonresidents over residents in their own communities. [13]

Image Credit: https://rockhealth.com/insights/building-toward-equity-a-working-model-for-digital-health/

  • Design systems that allow for access across varied communities
  • Design at common language and literacy benchmarks
  • Design technologies to avoid bias
  • Develop innovative workflows with mixed forms of contact to heighten patient engagement. 90% of texts are read within 90 seconds, suggesting mobile texting as a reliable communication format.
  • Develop measures to track inequities and monitor progress
  • Develop education around digital literacy that is scalable
  • Ensure high level cybersecurity measures are in place to protect privacy
  • Engage in advocacy related to extending and expanding broadband access
  • Learn from international solutions that regularly work in resource limited settings and barriers to communication. Consider how international digital solutions can be repurposed in the US.
  1. Gibbons, MC. A historical overview of health disparities and the potential of eHealth solutions. JMIR 2005;7(5):e50.
  2. https://www.pewresearch.org/fact-tank/2021/08/19/some-digital-divides-persist-between-rural-urban-and-suburban-america/
  3. https://www.goodrx.com/blog/wp-content/uploads/2021/09/GoodRx_Healthcare_Deserts_White_Paper.pdf
  4. https://aspe.hhs.gov/reports/medicare-beneficiary-use-telehealth-visits-early-data-start-covid-19-pandemic
  5. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/eighth-broadband-progress-report
  6. https://www.pewresearch.org/internet/fact-sheet/internet-broadband/
  7. Wood BR, et al. Advancing digital health equity: a policy paper of the Infectious Disease Society of America and the HIV Medicine Association. Clin Inf Dis, 72(6):913–919.
  8. https://www.fcc.gov/health/maps
  9. https://www.fcc.gov/reports-research/maps/connect2health/background.html
  10. Uscher-Pines L , et al. Telehealth use among safety-net organizations in California during the COVID-19 pandemic. JAMA. 2021;325(11):1106–1107.
  11. Eberly et al. Telemedicine outpatient cardiovascular care during the COVID-19 pandemic: bridging or opening he digital divide? Circulation 2020:142:510–2.
  12. https://www.kff.org/policy-watch/early-state-vaccination-data-raise-warning-flags-racial-equity/
  13. https://www.propublica.org/article/memphis-area-residents-without-internet-must-wait-days-for-vaccination-appointments-while-others-go-to-the-front-of-the-line
  14. Story MF . Maximizing usability: the principles of universal design. Assist Technol. 1998;10(1):4–12.
  15. https://rockhealth.com/insights/building-toward-equity-a-working-model-for-digital-health/
  16. https://www.pewtrusts.org/en/trust/archive/summer-2019/americas-digital-divide
  17. https://arstechnica.com/tech-policy/2021/11/congress-oks-42-billion-to-deploy-100mbps-broadband-in-unserved-areas/

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