Co-authored by Brian Raymond, MPH
Today 59 percent of people over the age of 65 are online, but they often reject using the Web for their health care, opting for more traditional face-to-face or over the phone "low technology" interactions with their providers. According to a 2014 study, less than a third of Americans age 65 and over use the Web for health information, and just 10 percent of those with low health literacy go online for health-related matters. These findings fly in the face of a boom in information technology use in health care delivery, or eHealth, and raise new concerns about people caught in the digital divide.
Older adults are not alone in this dilemma. Millions of other Americans that might also be online and want access to eHealth either cannot get it or don't know how to use it. Simply owning a computer or smartphone is not enough to create value and improve health outcomes -- eHealth must enable functions that are meaningful in order to promote adoption. That's where the significance to consumers lies.
One of the potential risks to people without meaningful access to eHealth: Being left behind in terms of health care quality improvements. Those with the access, resources, and skills necessary to use eHealth reap disproportionate benefits from the technology. For example, a 2010 study from Kaiser Permanente found that secure email use by patients was associated with a 2 to 6.5 percent improvement in performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures, such as diabetic care, cholesterol screening, and blood pressure control. This finding represents a health care disparity between users and nonusers of secure email. Likely factors include better continuity of care, patient-physician connectedness, and patient self-management.
The health care industry must recognize the potential risks for eHealth disparities and begin to identify actionable strategies -- in partnership with community stakeholders -- to ensure that health information technology addresses the needs of at-risk and traditionally underserved populations. Barriers to eHealth include limited broadband and mobile data access, lack of digital literacy, lack of linguistic and cultural competency, privacy concerns, and distrust of the health system.
In June of last year, ZeroDivide, which helps transform communities through technology, conducted focus groups with low-income women of color in San Francisco and Oakland, California; Washington, D.C.; and Miami. Their report, "Digital Health Equity: Humanizing eHealth," offers insight into the barriers faced by at-risk populations and how to address them to achieve greater equity and inclusion in eHealth access and utilization.
All participants in the focus groups use and have access to the Internet, and some even indicated that personal use of information technology benefited their health. In fact, those living with chronic disease were able to search for health information online to prepare for medical procedures and understand medications.
On the other hand, participants reported that current eHealth tools are not personalized, culturally appropriate, or designed to support the provider-patient relationship. And for participants with limited English proficiency, lack of translation was a major design failure.
"The translation on health on the websites are atrocious, they are terrible. My mom ends up being more confused," one participant said. Another commented on the process of completing tasks: "You have to go through so many phases just to get to where you're trying to go, and it's like, I have to remember this too?"
The barrier that the focus group members most commonly faced was that the technology interfered with the patient-provider relationship -- on the human side of health care. Several participants believed that health technology discouraged holistic patient care or led to harmful errors.
Adding a personal touch that is relevant to all consumers helps to:
- Improve the digital and eHealth literacy of underserved consumers and safety net providers to these populations. This work entails engaging patient navigators and community health workers to act as digital health educators.
- Support eHealth tools for underserved populations that feature user-centered design that enhances communication with providers. This includes establishing patient advisory councils or patient-led collaboratives for designing digital health products together.
- Support technology capacity building for safety-net providers, such as community clinics and county hospitals, to strengthen the eHealth equity infrastructure. Allocating funds to enable safety-net clinics to invest in piloting and implementing digital health tools is an important step to achieving this goal.
"This work shines a light on the tremendous market opportunity to develop digital-health products for underserved consumers," said Tessie Guillermo, president and CEO, ZeroDivide. "It's our hope to start a robust dialogue about ways to design with the needs of underserved consumers in mind."
Evidence suggests that when some or all of these considerations are taken into account, health disparities can be effectively reduced -- even in populations that traditionally might not prefer new technologies, such as older adults. Recent findings from the New England Journal of Medicine reveal that heart risks and diabetes measures between black and white seniors covered by Kaiser Permanente in the Western United States have been nearly eliminated. The study attributed the improvements to implementation of electronic health records, emails between patients and physicians, and a sophisticated program at Kaiser Permanente to improve blood pressure control -- complete with community outreach, video engagement, and coordinated education efforts.
New technologies in health care have the power to broaden the reach of the human touch. But eHealth needs to be more sensitive to language, experience, personal experience, affordability, and environment. Only then will more people adopt these advancements so that they can reduce health disparities rather than widen them.
Caption: "Nothing is more important than your health. Not money, not anything. Without your health you can't do anything. Emotionally, socially, at work; everything goes with health..." -- Focus group participant.
Brian Raymond, MPH, is Senior Health Policy Consultant at the Kaiser Permanente Institute for Health Policy, where he analyzes emerging policy issues and supports the health policy decision making process within Kaiser Permanente. His current areas of focus include eHealth technology to address health disparities, obesity prevention, and health in all policies. In addition to policy analysis, Brian manages projects and round table discussions to produce suggestions for health policy improvement. Brian received a bachelor's degree in community health administration from the University of California, Davis, and a master's degree in public health from the University of California, Berkeley.