Patient engagement: a digital divide in health technology accessibility

click to enlargeGuest editor Sarianne Gruber (@subtleimpact) scopes the ‘digital divide’ separating those who need health services the most from the patient engagement and other tools they need in this article. The studies are US, but the lessons apply anywhere in the world. This Editor notes that many patient engagement tools are over-designed and over-complicated for users, even if they are fairly competent and frequently use online and mobile. (I entered a ‘pilot’ of a stress reduction program which proved to be anything but–and quitting because it is invasive and the reporting is ludicrously burdensome.)

To developers: Imagine your patient engagement platform being used by a person on the less sophisticated, less educated and disconnected end of the spectrum–or by someone less able due to physical (vision, touch) or cognitive impairment. Put on bad glasses and gloves–and start. Better yet, find a few people and put it in front of them. If we can make the mental shift in developing mobile apps for Africa or India, certainly we can do so for Americans, Britons and Europeans.

What the Studies are Showing

Hallmarked as a solution to improve healthcare quality, cost and safety, studies are showing health technology is up against a “digital divide” when it comes to patient engagement. At the Internet Governance Forum, Pew Research Center’s Lee Rainie, Director of Internet, Science and Technology Research presented the Fact Tank Report discussing the “digital divide” that exists in 2016. The report documents that lower income, less educated, non-white, seniors and rural communities are the least likely to have home internet, home broadband, mobile connectors and smartphones. This summer’s medical publications, the Journal of the American Medical Association and the Journal of the American Board of Family Medicine, released studies where demographic and socioeconomic data marked the root causes to limited or no access to digital technology, thus hindering the benefits and improved outcomes it can bring to the neediest and most costly populations. Here are the highlights from each study.

Trends in Seniors’ Use of Digital Health Technology in the United States, 2011-2014, a research letter submitted from Harvard Medical School’s Brigham and Women’s Hospital, appeared in the August 2, 2016, JAMA. Authors, David M. Levine, MD, MA, Stuart Lipsitz, ScD, and Jeffrey A. Linder, MD, MPH,FACP made mention that this study, based on the National Health and Aging Trends survey (NHATS), was exempted from the Partners HealthCare Human Research/IRB Committee. The research team included participates to the longitudinal NHATS survey in 2011. The participants were re-surveyed annually on everyday (nonhealth) and digital health use until 2014. The research team acknowledged that this may be the first nationally representative study to examine trends in the adoption of digital health technology by seniors age 65 years and older who are community-dwelling Medicare beneficiaries.

Here are some the reported statistics from the study:

  • In 2011, the total number of participants was 7609. The mean age was 75 years (SD, 7.4); women were the majoritywith 57%. By 2014, the number of participants decreased to 4355 seniors (1430 due to deaths and 1824 lost to follow-up).
  • In 2011, senior cell phone usage was 76% and computer usage was 64%. 2012, 2013 and 2014 saw little or no significant change. In comparison, the general population had approximately 90% internet use and owned cell phones.
  • In 2011, the seniors reported everyday technology such as internet usage at 43% and email/texting at 40%. Less than 20% of the seniors used internet banking, internet shopping, social network sites (from 2013 data) and tablets (from 2013 data). Yet, by 2014, marginal but statistically significant everyday technology usage started to increase.
  • In 2011, the rates digital health usage was low with 16% for health information, 8% for prescriptions, 7% for clinician interactions and 5% for managing insurance online. By 2014, the proportion of seniors who use digital health technology for health information, contacting a physician, or filling prescriptions increased 4% from 21% to 25%.
  • 2011 socioeconomic and demographic data categorized by digital health modalities had shown due cause for a “digital divide”. Participants who were older in age, Latino and “other” race/ethnicity, divorced and poor health had lower use rates of digital health technology. And variables associated with greater use included college education, higher annual income, taking medications, and more comorbidities.

“Digital health is not reaching most seniors and is associated with socioeconomic disparities raising concern about its ability to improve quality, cost, and safety of their healthcare. Future innovations should focus on usability, adherence, and scalability to improve the reach and effectiveness of digital health for seniors,” wrote the authors in their closing discussion.

Original research on Patient Portal Use and Blood Pressure Control in Newly Diagnosed Hypertensionfrom the Department of Family and Community Medicine at the Saint Louis School of Medicine was published in the July-August 2016 edition of the JABFM. The research team, William Manard, MD, Jeffrey F. Scherrer, Ph.D., Joanne Salas, MPH and F. David Schneider, MD, conducted a study to determine whether a patient portal use was associated with controlling blood pressure in hypertensive patients. Inadvertently, a covariate adjustment to their outcomes model presented the socioeconomic factors as being the influencers on controlling blood pressure (BP), not patient portal use

Here are some of the reported statistics from the study:

  • A study sample of 1,571 patients, ages 21 to 89, with an incident hypertension diagnosis between 2008 and 2010, was identified from an academic medical center primary care patient data registry.
  • Portal use and the incident BP control were tracked for all patients from 2011 to 2015.
  • Cox proportional hazard models were used to estimate the association of portal use and BP control.
  • Sociodemographic variables included race, sex, age, marital status, socioeconomic status index, and clinic type, volume of healthcare utilization, smoking, depression, obesity and comorbidity index.
  • The results of the first Cox proportional hazards model, which adjusted for age only, showed that portal users were more likely than nonusers to achieve BP control.
  • Interestingly, when a second model was built adjusting for all the sociodemographic variables, portal use was no longer associated with controlling blood pressure.
  • A “digital divide” was evidenced given that race showed only 28% of non-whites used the portal; also in socioeconomic status with the lowest tier having 18% portal usage and 19% in the lower-middle segment.

On an analytic note, transparency reporting has become exceedingly important in research. Kudos to Dr. Manard and team for reporting both the unadjusted models and the covariate adjustment. Their analysis uncovered that “a health disparity exists in the use of patient portals and its benefits for BP control”. The authors recommended further “research to determine which sociodemographic groups would benefit most from access to patient portals and what conditions and what outcomes are most sensitive to improvement via portal use”.

Recommended reading:

Pew Research Center:  Internet, Science & Tech Digital Divides 2016 by Lee Rainie
Trends in Seniors’ Use of Digital Health Technology in the United States, 2011-2014, August 2, 2016 JAMA 2016,316(5) 538-540 doi 10. 1001/jama 2016.9124
Patient Portal Use and Blood Pressure Control in Newly Diagnosed Hypertension, July-August 2016 J Am Board Fam Med 2016;29:452-459

This article was originally published in RCM Answers and is republished here with permission and with appreciation to Sarianne plus Answers Media’s Roberta Mullins and Carol Flagg.

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