Telehealth has become essential to healthcare during the pandemic and is popular with patients.  However, lack of digital literacy creates an equity issue for telehealth because it is concentrated among groups of people who already experience worse health than others. About one-third of the 32 million Americans who cannot use a computer are seniors, but digital illiteracy is also common among people of Black or Hispanic origin, with low income, or no college education.  Telehealth may require diverse digital literacy skills, including connecting to the internet, using a specific browser and email, downloading an app, and updating settings for security. It may also require use and calibration of computer hardware components, such as the camera, microphone and speakers.
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TEC Member Spotlight: Improving Equity by Addressing Digital Literacy

Dr. Ryan Jelinek, M.D., is one of several people who responded to our request for examples of ways that TEC members are addressing digital literacy.  As the Medical Director of Telehealth and Patient Access at Hennepin Healthcare, Dr. Jelinek, M.D., noted that low digital literacy was a barrier to telehealth that it could exacerbate disparities among Hennepin Healthcare’s vulnerable patients.  To measure this concern, Hennepin’s informatics and equity teams collaborated to create a dashboard to assess and monitor socioeconomically-based telehealth disparities. To close the disparities, Dr. Jelinek began looking for ways to improve  digital literacy among Hennepin’s patient population.

He connected with a fellow TEC member, the Great Plains Telehealth Resource and Assistance Center, and initiated conversations with the Minnesota Department of Health and private sector organizations with aligned interests. Dr. Jelinek noted resources that would help these organizations to collaborate around  building a digital literacy program: “Access to community partners, a roadmap for organizations that didn’t yet have a plan around digital inclusion, and regional partnerships to advocate for legislators to develop relevant policies and provide funding for digital literacy.” Although Dr. Jelinek characterized Hennepin Healthcare’s digital literacy efforts as nascent, he offered an insightful vision for the future: “Integrated clinical decision support tools will identify who would benefit from referral for digital literacy training. Referrals will become commonplace, with providers prescribing training directly from the electronic health record.”

Telehealth Equity Through Digital Inclusion

The strategies Dr. Jelinek mentioned align well with the digital inclusion model shown in the figure below. The model was developed by Public Health Innovators, the consulting firm through which the author advises health innovators and health systems on equitable development and deployment of digital health technology.
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Adopt the right technology:

Organizations purchasing technology should ensure that it meets the needs of patients with digital literacy barriers. People with newly acquired skills and connectivity could be further trained to help technology developers make their technology more user friendly and help institutions plan to deploy it.
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Monitoring:

Telehealth providers should look at who is using video versus audio telehealth, and who continues with higher risk in person visits or skips care altogether. Compare use among groups with equity-based barriers to telehealth, such as age, race, ethnicity, income, language, literacy, health literacy and digital literacy. Looking at use by geography is important, given the lack of affordable broadband in some rural and urban areas.
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Advocacy:

Until we have frictionless technology and digital equity, advocacy is needed to ensure that all people are able to use the optimal telehealth modality for every encounter. Health systems can be powerful advocates at local, state and national levels for increasing access to affordable broadband and devices by highlighting the value of connectivity for health.
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Community Partnerships:

Partnerships such as those being explored in Minnesota are crucial for enabling health systems to help patients to develop digital literacy skills. Organizations across the country that collectively comprise a  "digital inclusion ecosystem” are a great place to start. Many are affiliates of the National Digital Inclusion Alliance, a TEC member.
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Encourage Adoption:

Providers should recommend that patients use telehealth, but be prepared to help patients understand the value and appropriate situations for using it. In addition, tech support resources must be in place to help patients that encounter difficulties with their appointments.
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Universal Screening:

Consider using a low bar to identify people lacking the devices and skills needed for digital equity. Having mobile only, sporadic, or unpredictable internet access is insufficient. Patients should be asked if they have a device that meets the system’s requirements, and if they use email, can download an app, or can change browser or camera settings, if these actions could be needed for a successful telehealth visit.
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Referral to Digital Navigators:

Trained individuals who are trusted by the community, such as community health workers, can help households identify devices and broadband plans that meet their needs, and also to address barriers to getting online. Rather than training staff to serve in this role, health systems may want to partner with organizations that already employ digital navigators.
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Digital Health Coaching:

Even patients with digital literacy may need help learning to use telehealth or home monitoring devices. Consider partnering with community institutions, such as libraries, or literacy and immigrant service programs, that are experienced in teaching people to use an array of digital devices and tools. Alternatively, a published curriculum for digital navigation and health coaching could be used to train digital health coaches to work within healthcare settings.
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Implementing Strategies to Increase Digital Literacy

Organizations that create, support, fund, deliver and utilize telehealth comprise a “telehealth ecosystem.” Figure 2 below highlights equity strategies that different telehealth ecosystem stakeholders could use to support digital literacy.
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TEC Member Spotlight: Community-based Telehealth Training

People that lack internet or digital skills have long turned to libraries to access the internet or learn new skills. Even while operating remotely earlier in the pandemic, many libraries began trying to meet requests for help using telehealth. Marian Christmon, a TEC member and Manager of the Nashville Public Library’s Digital Inclusion Initiatives, partnered with Vanderbilt University Medical Center to convene focus groups to help understand patients’ telehealth barriers. Together with Comcast, Christmon’s team is also helping seniors learn digital skills for patient portals and telehealth services. Activities include providing devices, broadband and skill training through a mix of remote, live and one-on-one training.
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Conclusion

TEC members have many options for improving telehealth equity. Monitoring telehealth use disparities and screening patients for digital literacy and access are crucial first steps. Screening should be accompanied by referral to community partners from the digital inclusion ecosystem to equip patients with devices, broadband connections and basic digital skills. Digital navigators are increasingly being used for these efforts. Digital health coaches, who could work in health systems or community settings like libraries, can then help “telehealth ready” patients to use telehealth and other digital health tools. TEC Members can also advocate for reimbursement strategies that optimize provider and patient preferences.

Amy R. Sheon, PhD, MPH

Telehealth Equity Coalition’s Research Director. Leading the digital health equity consulting practice at Public Health Innovators, LLC, Amy connects and advises organizations that are in the telehealth equity and the digital inclusion ecosystems.
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