Digitization of Patient Engagement—Who Gets Left Behind?

By Michele Sasso, MBA, Director of Clinical Programs & Technology, Department of Accountable Care and Clinical Integration, Boston Children’s Hospital

Connected care or technology-enabled healthcare can improve access to services and empower patients and families to take control of their health. However, who is getting left behind as we move to the digitization of patient engagement in healthcare?

The tech industry frequently touts that over 90% of Americans have smartphones, implying that hardware is no longer the limiting factor to spreading technology-enabled health solutions. As part of my role in an accountable care organization (ACO), I am responsible for our digital and technology solutions that will enhance how we deliver care and engage with patients in order to improve outcomes and quality, and lower costs. When we select patient engagement apps and tools to implement in our pediatric ACO of close to 100,000 Medicaid patients, we must consider the characteristics of and resources available to our entire patient population. We cannot let technology solutions create another barrier to receiving optimal and timely access to care for some of our most vulnerable populations.

Knowing the value that patient engagement technologies can bring to quality and outcomes among our population makes it all the more frustrating when the ability to reliably use these tools is not equal for all patients.

Many of our ACO families live in areas with barriers to reliable transportation, and we see high no-show rates in the clinic. Converting appropriate visits to a virtual option is a promising solution for many of these families. Almost all of our families have smartphones in the household, and sometimes this device is the families’ only way of using online tools or accessing the internet. However, we have learned that only a small proportion of our patients with smartphones also have a consistent data plan, and dependable connections to internet at home are limited. Clinicians often deem this population ineligible for digital programs due to the lack of reliable connections needed for video visits or remote patient monitoring, and will instead book a traditional in-person visit. We, as an industry, have to understand how to combat the underlying access issue to a reliable internet or data connection if we plan to succeed in broadening patient engagement through technology.

In addition to limited data plans, limited space on phones is an issue for many patients and families (honestly, though, who of us has not done a photo purge in order to load a new app?). Downloading new healthcare apps require sufficient storage space that many of our families do not have on their phones. Many individuals lack cloud storage accounts or laptops to offload photos from their phones. We hear from vendors about new tools that will keep families better engaged with their child’s care, or track medication at home to better inform providers to make real-time clinical decisions. These technology solutions sound like promising advancements in care, but for some families, the decision to add a new healthcare app will require deleting photos from the last birthday their child had before a diagnosis, or the app that allows them to check in with grandma who is at home with the other kids while they sit at the bedside with their sick little one. Vendors must consider the size of tools and apps when designing new digital options. And while we have seen a trend toward offering a browser option, some tools are not mobile-friendly.

Lastly, let’s briefly talk about cultural humility in digital health. Technology has facilitated strides in the healthcare industry for providing better culturally informed care, especially in the interpreter services and on-demand translation space (thank you for that!). However, many families can still be left out of some digital offerings because tools are not provided in their native language or are not compatible with third party translation options. Additionally, standard content in many engagement tools does not reflect the diversity of many populations. When a nutrition app does not include a popular dish of a certain culture that a family eats multiple times a week, a family will quickly disengage from tracking food habits, or be forced to identify a meal that sounds similar, providing incorrect information to providers trying to tailor their care.

These critiques, of course, are not intended to suggest outright dismissal of the many technological advances that have entered the healthcare industry. In fact, we celebrate and invest in them. This past year alone, the Boston Children’s ACO has implemented tools that support virtual delivery of initial and follow-up visits, allow patients to report information about their health and symptoms from home, and provide health-related non-emergency transportation rideshare. We have observed modest decreases in unnecessary utilization, better engagement in attending regular primary care visits, and higher than predicted patient and provider satisfaction of the digital experience. Our behavioral health virtual visits program alone has increased access to pediatric psychiatrists, a need that far outweighs the availability of providers in the state, and engaged patients in better following treatment plans.

Knowing the value that patient engagement technologies can bring to quality and outcomes among our population makes it all the more frustrating when the ability to reliably use these tools is not equal for all patients. We need to start to break down the barriers between innovators and our communities. As we move to digitizing the healthcare industry and playing catch up to other industries that are further along in the technology revolution, it is our responsibility as healthcare leaders to influence the investment and implementation of innovative technologies that do not further the unequal distribution of affordable, reliable, and timely care.

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