While there is more work to be done, there are several experiences and examples to date that suggest that health IT may be an integral part of broader solutions to address disparities in the health and well being of underserved Americans. There is broad acknowledgement among key stakeholders that moving towards a more digital environment where health data, information and knowledge is generated, captured and shared securely, efficiently and in a targeted manner (right information to the right person at the right time) is an important structural step in improving the nations health care delivery system and public health system. It is important however, as these efforts get 1underway, that appropriate attention is given to the particular needs of the most vulnerable Americans and the institutions that serve their needs to ensure that they are not left behind. We end with a set of conclusions for consideration by policy makers, payers and purchasers, providers and other health care stakeholders as the nation grapples with new approaches to address the health and health care needs of underserved Americans.
Health IT is a means to an end, not a magic bullet. It is important to recognize that health IT does not represent a magic bullet for improving health and health care to the underserved. As with use of health IT to improve quality of care in general, it is just an important component for facilitating these improvements and must be integrated into broader initiatives that focus on understanding and addressing root causes of these disparities, including structural barriers.
The promise is there, but structural and financial challenges persist. Work to date shows that attention to health IT use as it relates to improving health care and the health of the underserved can reap important rewards, in terms of access to care, quality and the patient-centeredness of health care. Federal, state and community based efforts have begun to show anecdotal evidence of improvement.
However, health IT generally, and patient facing health IT in particular, is still in the early stages of use among the underserved and the institutions serving them, and there has been limited formal study of its use and impact among underserved populations. One reason for the relative slowness of adoption relate to structural and financial challenges faced by this population and providers that serve them.
For example, most federally funded health centers and other safety net health care providers have limited financial margins with which to pursue solutions based in health IT adoption and lack the time and staff necessary to pursue federal grants to initiate this work either individually or as part of a consortium. Similarly, many underserved families are faced with a myriad of daily challenges to assure their own immediate safety and financial health and are less likely to have time to access to online tools to help manage their health and health care and may be less able to use these tools effectively.
Evidence of a digital divide diminishing but still may be a factor. There is still a clear relationship between income and access to the Internet.47 However, there is increasing evidence that the digital divide, especially as it relates to age, income and education is diminishing.48 There is also evidence, that among, individuals who regularly use the use Internet, there is no correlation between key income or education and one’s likelihood to communicate electronically with providers.49 However, other studies do suggest that individuals who have less access to traditional health care are also less likely to use online tools to get or exchange information about their health. What is clear, is that even at the lowest income levels the majority of adults in the United States now have access to and use the Internet and that this represents an important opportunity for patient facing health IT.
Training and education are essential to achieve potential benefits. As the underserved as a whole begins to get better access to IT and online tools, the question will become how to translate better access to these resources to improvements in health and health care. Pairing technology initiatives with human support and training appears to be the most significant way to increase adoption and promote effective use over time. In many pilot programs, in-person assistance helped to address unexpected barriers and population-specific challenges. It appears that few if any have been able to develop purely automated approaches to culturally appropriate training and support, although some have tried to make educational resources more culturally relevant. In some cases, in-person training and assistance also appears to overcome the negative effects of lower computer ownership and internet usage rates. It remains to be seen whether similar results can be duplicated by building training and support into the technology itself.50
Personal computers are not the only mechanism for reaching the underserved. Lack of computer literacy may not be as large a problem as anticipated because of increased access to computers and the Internet among all families in the United States.51 Still, stakeholders should take lessons learned from other parts of the world where SMS, text messaging, and use of cell phones have been employed to facilitate improvements in population health.52
Greater engagement between the community of providers, case workers and social workers serving the underserved and the health IT industry is needed. Community-based systems that facilitate sharing of individual level information across health care and social service providers offer the most promise for being able to address structural and multi-factorial barriers to health and health care improvement. However, these are difficult to sustain because of the need for centralized coordination among distinct entities with limited financial incentive to coordinate and integrate.
Underserved communities are different from other communities and from each other. Evolving EHR and PHR certification efforts may be able to help address potential disconnects between the design of health IT applications and the needs of communities, safety net providers and the underserved themselves by offering special certificates to applications that meet requirements around treating patients with limited English proficiency or who may have special needs with respect to culturally competent care. However, it is also important to note that the underserved represent an array of different segments of our population and that health IT based interventions or approaches that work among one segment of the underserved will not work for all other segments. Understanding differences across segments of the underserved is particularly important for designing patient facing technologies that can be effectively used by a particular community for improving behaviors associated with better health.
Additional research is needed. Existing evaluation data focus on specific interventions and their impact on specific populations. More evaluation is needed on this level. In addition, more research is needed to systematically review and synthesize these studies and to draw broader conclusions regarding the potential impact of health IT on the underserved. Finally, it may be advisable for funders to work closely with researchers to identify consistent domains and measures for evaluation of the impact of health IT on the underserved to allow for meta-analyses or more robust syntheses across distinct evaluation efforts over time.