Originally published at covid19healthtech.com

“We will not bring the COVID-19 pandemic under control until we see and address gaps that keep tens of millions of people from meaningfully using technology.”

— Amy Sheon

Healthcare’s Looming Disaster is Hidden in Plain Sight

Health systems and technologists have a vital opportunity to mitigate the ravages of the COVID-19 pandemic by addressing a looming but hidden patient need.

The single-most important COVID-19 mitigation strategy is for people to remain in their homes. This fostered a virtually instantaneous shift to online school work and employment. The sudden realization that 6 million kids faced “the homework gap” set off a scramble in school systems around the country to get devices to families and help them get connected to the internet. Workplaces are following suit.  

Healthcare systems are just beginning to confront an even harsher reality, albeit one that will unfold more slowly: “the telehealth gap.”  To reduce the number of people needing care, to preserve the health of healthcare workers, and to conserve scarce health system resources, individuals who have or suspect COVID-19 illness are urged to remain at home unless hospitalization is urgently needed. With telephone systems overwhelmed, medical, public health and government authorities refer patients to websites and telehealth. This approach is destined to miss up to three-fourths of the population due to a lack of internet and devices, general digital skills, and the specific skills needed to use telehealth. 

Q. The Digital Divide–Does it really still exist? 

Yes!  U.S. Census data show that nearly 37 million (30.4%) households do not have broadband at home, 30 million households (24.3%) do not have a smartphone with a dataplan, and 18 million households (14.7% or 37 million individuals) have neither home nor mobile data access. Those who most commonly lack the internet are seniors (24%), people with less than high school education (30%), or households with less than $20,000 in annual income (37.3%).  As alarming as these figures are, the disparities in internet access are even more extreme when you look at neighborhoods. For example, across my entire urban/suburban county (Cuyahoga, Ohio), all but 5.6% of households have internet access, but in the least connected neighborhoods, fewer than 50% of households have internet. 

Q. What are the main barriers for shifting people to using telehealth?

The most important barrier is easily solved: increasing awareness among health systems and technology providers regarding reasons that many people will be unable to use telehealth:

First, people must have an internet-connected device to use video-enabled telehealth.  Recent changes to telehealth have allowed audio-only connections, but the visual feed includes invaluable information for providers on a patient’s affect, movement and environment, among other things. Nearly 10 million (8.2% of) households do not have a single computer, tablet or smartphone and 19 million (15.6%) households do not have a smartphone.    

Second, people must have a robust internet connection.  Although the digital divide is widely considered to be primarily a rural problem, more than twice as many urban versus rural residents do not have internet connectivity.  There are three main reasons that people don’t use the internet: discomfort with technology (mostly seniors); not seeing a need to use it; and not having access to affordable internet.  My colleagues at the National Digital Inclusion Alliance (NDIA, where I am a Senior Fellow) discovered that internet service providers did not upgrade the internet in impoverished Cleveland neighborhoods from dial-up service to broadband.  As a result, high speed broadband may not have been available at any price.  Tragically, this practice of “digital redlining” was subsequently found in many other cities. 

BTW, smartphones are not necessarily the answer here either.  The same neighborhoods lacking fixed broadband may also lack coverage from mobile providers.  Many people with lower income purchase “pay as you go” mobile data plans. The high cost and slow speed of mobile data are incompatible with telehealth.   

Third, to use telehealth, people must have basic digital skills, such as using email and navigating web browsers.    

Finally, even people with basic digital skills may need specific coaching to use telehealth insofar as it requires them to do things they don’t do frequently such as downloading software, running system tests and working with an unfamiliar browser. Only 5% of people age 45+ have used telehealth, less than one-third of the use level among younger adults.  Health systems would thus be wise to look at patient/technology-related barriers.   

Q. Why are you so pessimistic?

I’m actually cautiously optimistic!  Even prior to COVID-19, I lauded the patient portal to electronic health records (EHRs) as a disruptively powerful public health tool. Most portals enable patients to learn about their conditions, communicate asynchronously with providers, check lab results, request prescription refills and make appointments. 

Yet despite their tremendous convenience, security, and high quality health information, only about 40% of patients have taken advantage of free EHR portals. Research presented annually at National Digital Inclusion Alliance (NDIA) annual meetings revealed enormous disparities in patient portal use and strategies for overcoming barriers that have suppressed use. This research highlighted the importance of internet access, digital skills, provider encouragement, coaching and assistance in using portals.  

Q. How do these findings help us introduce telehealth?  

Responses to COVID-19 have positioned healthcare to solve the telehealth gap! Just as schools and employers took responsibility for providing students and employees with devices, health systems must do so with patients. NDIA can help health systems source and configure large numbers of devices and identify sources of low-cost internet service.. 

Health systems should not wait until patients need a telehealth appointment to discover that they lack a smartphone or internet connection.  Rather, they should immediately screen all of their patients to identify barriers to telehealth use. Due to the COVID-19 emergency, I am making available to health systems at no cost the Digital Equipment, Skills, Connectivity Assessment and Referral (DESCARS) tool I developed for this purpose.  NDIA and I can help you identify local and national organizations to help your patients address these gaps. And, as noted, pre-COVID-19, by a J.D. Power executive, “major initiatives in both patient education and consumer experience are the next steps” to expand telehealth adoption.

Q. That sounds like a lot of work.  Who can help?

Many health systems are screening patients for social needs and digitizing referrals to social services using online platforms such as NOWPOW and Aunt Bertha. Adding DESCARS to those processes would be a simple matter. Referral platforms should team up with NDIA to connect with local and national organizations that can address digital gaps. Community Health Workers (CHWs) are optimally positioned to screen and refer patients to address equipment, skill and connectivity gaps and to coach patients to successfully use telehealth. These tasks are perfectly aligned with their scope of practice but they may need training to complete these specific tasks. NDIA is also compiling training resources for these purposes. 

Q. But will patients actually use telehealth?  And how can health technology companies help?

One of the biggest contributors to patient adoption of portals is provider encouragement.  We know that providers are encouraging telehealth now, but they must offer resources to help patients overcome their barriers, such as through the screening and referral discussed above.  

Once patients are connected and trained, providers should encourage them to adopt portals for a broad array of functions which can foster greater patient engagement.  Provider encouragement of portals has not been universal however, for several reasons. First, health systems need to adjust workflows to accommodate responding to patient messaging, including use of CHWs where appropriate. EHR developers should  incorporate input from diverse patients and better accommodate patient language, literacy, visual, auditory and tactile barriers. Finally, EHR developers should collaborate with digital literacy, health education, health literacy and public health experts to develop tools for training various user groups including patients and health professionals.

Q.  But will this effort to support patient digital engagement with healthcare pay off?

Working together, we can at least ensure that we benefit from the COVID-19 epidemic’s silver linings: health systems partnering with local and national digital inclusion organizations to ensure that every patient is connected, digitally skilled and engaged with their health; health systems using community health workers to mitigate the effects of patients’ social needs; and digital technology that is better aligned with patient needs. COVID-19 isn’t how I would have chosen to achieve these long-held dreams, but I won’t turn away the gift in the grim reaper’s mouth.