Health and health care disparities are frustratingly persistent. This is widely known, in great part, because of the landmark report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care that then spurred the Agency for Healthcare Research and Quality (AHRQ) to track and report on disparities for 250 measures since the early 2000s.
The latest National Healthcare Quality and Disparities Report [pdf] by AHRQ from 2018 finds that while “some disparities” (an underwhelming phrase) had become smaller over the 15-year period, disparities persist — particularly for the poor and uninsured in “all priority areas” (p.1).
From these reports and others, it’s clear that health and health care disparities by race/ethnicity, socioeconomic status, insurance coverage, and many other characteristics have many complex, deep-rooted, and upstream causes. The search for solutions to disparities is equally complex. And it is meaningful work.
A recent issue of Medical Care considers some creative options
A recent supplement in Medical Care examines the idea of technology-based solutions to the problem of health disparities. With a thoughtful introduction by Dr. Eliseo Perez-Stable–the director of the National Institute on Minority Health and Health Disparities–and colleagues, the issue considers health information technology (HIT) interventions designed to help the underserved. These include studies of electronic health records (EHRs), patient portals, and mobile apps.
For example, a unique study by Dara Sorkin and colleagues evaluated an HIT intervention for identifying depression and post-traumatic stress disorder (PTSD) among Cambodian patients of a large community clinic. Physicians received online training and access to a web-based clinical decision-making tool, and patients were screened for depression and PTSD using an iPad. Doctors in the treatment group received printed copies of the screening tool results (a surprisingly low-tech approach!), which led to a greater likelihood of diagnosing depression or PTSD and delivering guideline-based and trauma-informed care.
Another study by Bharat Narang and colleagues examined a mobile app to facilitate language services in an urgent care setting. When the app was used by providers, patients with limited English proficiency used phone-based translation services three times as often during the intervention period (vs. before the intervention). Providers also used the application for phone-based services more so than pre-translated written or spoken phrases that were also available. It was interesting that changes were not maintained after the intervention, which the authors attributed to challenges with technology acceptance and difficulty changing norms.
You might also check out a study by Melinda Krakow and colleagues in this supplement on geographic differences in HIT that was reviewed earlier at The Medical Care Blog.
There is room for some skepticism
As Dr. Perez-Stable noted, there is certainly some room for skepticism about technology. We agree. Three areas in particular stand out to us:
The digital divide is not necessarily shrinking. Although EHRs and patient portals have been increasingly adopted, there is still much to do to encourage more use by both providers and patients. Facilitating the sharing of health information between patients and providers is almost certainly beneficial. EHRs offer a two-way stream of information and can deliver education materials that can be modified for different communities and demographics. But deeper use often requires greater bandwidth (e.g., for streaming education videos or conducting online office visits) and assumes that both providers and patients have the right resources, such as high quality (fast) and stable internet access. Up-to-date internet-linked devices are not cheap, and data limits on mobile devices can be problematic for those who rely on prepaid or pay-as-you-go services.
The digital experience differs by socioeconomic status. A report by Pew Research Center [pdf] noted that racial/ethnic minorities are the most frequent users of mobile phones to access and obtain health information. Lower-income individuals were also found to rely on their mobile phones to look up “general” health information, especially if there is no home broadband. Mobile phones come with issues that are often overlooked by HIT developers, such as fatigue from reading content on small screens, privacy concerns with online office visits conducted in places where mobile devices travel, and difficulty managing materials that require downloading or uploading (e.g., forms/files).
People have real concerns about trust, privacy, and motives. Knowledge, trust, and time invested are key components in unlocking digital disparities. Most patients and health consumers want to know who can access their data online, be comfortable with database security, and trust both the system and their doctors who endorse digital health platforms. But with so many lapses in privacy (and revelations about alleged data uses) by Facebook, Google, Yahoo, and others, there is reason to be concerned that HIT is designed to increase profits — not to improve lives, much less address disparities. Health professionals and patients should consider the trade-offs when using HIT and should implement and effectively communicate reasonable safeguards.
The potential of technology lies in how we use it.
Technology has made it easy to stay in touch with family and friends nearly constantly (though not necessarily deeply) and to find information nearly instantly (though the information is not always trustworthy). Can HIT can help disparities without making similar trade-offs?
The adoption of EHRs is helpful for record-keeping for both patients and providers, but using the data to make patient care better is the next important level. Online doctor visits are useful and in-demand, but can they replace the relationship and physical presence of a dedicated personal health care provider, especially for high-need patients? Many people are comfortable with mobile apps, but should patients trust developers of apps enough to allow them to record, transmit, and make recommendations about their health? And most of all, these technologies are expensive to develop and adopt — is this the right way to spend our money to address disparities?
It may be that the best technologies to reduce disparities are those that operate behind the scenes to help facilitate or guide behaviors. Like technology that reminds drivers to stay in their lane or to stop (and actually brake for them when needed), technologies that nudge providers and patients toward the best course of action may have the biggest impacts. For example, apps that help patients remember to take their pills, refill medications, communicate with their physicians, or schedule appointments may have the best chance of reducing disparities because they help make the right choice the easy choice.
Ultimately, HIT approaches to addressing disparities are promising and worth exploring. The studies in this new issue do just that, offering glimpses of potentially effective HIT approaches. But technology can only take us so far. The question remains: is HIT really capable of improving health and reducing disparities among underserved and marginalized communities? And to what extent are HIT platforms facilitating behavior change and improved quality of care, particularly among those who need it most? We look forward to future studies that examine whether and how changes in HIT affect disparities over time.
Gregory Stevens
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Melanie Sabado-Liwag