By Melinda Young


Since the COVID-19 pandemic shut down in-person social life across the world, digital solutions in healthcare exploded in use. Healthcare providers found that some patients struggled with digital health literacy.

• Results of one study revealed 70% of people with low health literacy needed help performing simple online tasks.

• Before the pandemic, billing for digital health encounters was problematic.This was temporarily resolved during the pandemic.

• Technological challenges can prevent some patients, including older people, homeless people, and others, from becoming comfortable with digital health solutions.

During the great and spontaneous social experiment of remote and digital patient care during the COVID-19 crisis, healthcare systems have learned patients and staff find virtual visits and digital health services acceptable — sometimes, even preferable.

“Digital solutions provide an opportunity for the patient to stay connected to their healthcare team, following discharge,” says Patrick Dunn, PhD, MS, MBA, FAHA, program director for the American Heart Association’s Center for Health Technology and Innovation in Dallas.

“The pandemic has demonstrated: ‘Wow! Look at what technology can do,’ specifically as it relates to telehealth,” says Devlon N. Jackson, PhD, MPH, assistant research professor and healthy Me/Mi Salud project director, department of behavioral and community health, Herschel S. Horowitz Center for Health Literacy at the Maryland Center for Health Equity.

“We saw before the pandemic that patients can fill their prescriptions digitally and have prescriptions delivered to them,” Jackson adds. “Now, you can connect with providers over digital platforms, whether on your computer or smartphone.”

When the global shutdown started in March, health systems moved to telehealth visits. Some digital technology service providers report business expanded by tenfold or more.

“We went in the month of March from 350 virtual visits per month to 4,000 virtual visits per month,” says Allison Crawford, MD, PhD, associate professor in the department of psychiatry at the University of Toronto. “Prior to COVID-19, we were using virtual health for people in rural and underserved areas. With COVID-19, we quickly scaled it to all our patients, and it was easier to scale in some areas than others.”

Solutions Improved Quickly

The pandemic led to some fast improvements in digital and telehealth solutions. “At the beginning of COVID, we moved everyone to digital platforms,” says Scott Conard, MD, president of Converging Health in Dallas, and consultant to the American Heart Association. “One of the most exciting things coming out of this is those platforms are getting better and simpler. Many elderly patients struggled initially, but now more and more people are adopting it. We’ve made significant progress in the last four months, and will continue to do so.”

Results of a recent study revealed 70% of patients with low health literacy need help with any online task, and 61% need help with printing online. Also, 43% require assistance using a search engine, and 47% need assistance with videos.1

For example, a person with low health literacy might need help from a family member to understand how to use the online dashboard, says Valerie Press, MD, MPH, assistant professor of medicine and pediatrics in the section of general internal medicine at the University of Chicago Medicine.

“The study authors were trying to understand the patient’s access to devices and whether their risk of not having or using devices differs, depending on their health literacy,” Press explains.

There always has been interest in telehealth and digital solutions, but funding it was challenging until the pandemic hit.

“One of the barriers was the lack of ability to bill for that time,” Press says.

During the COVID-19 crisis, the federal government and other payers have temporarily relaxed rules on compensation for telehealth visits. “If we want patients to talk with physicians over a video visit, then we need to compensate them for that time,” Press says. “The pandemic galvanized the ability to provide these televisits, which is absolutely great.”

Previously, video visits were billed at a higher rate than phone visits. But this increases health disparities since some patients do not have access to the technology or broadband required for video visits, Press notes.

Billing phone and video visits at the same rate has rapidly advanced the use of telehealth technologies, she adds.

Technology, Health Literacy Are Barriers

Individuals’ technological challenges also can prevent elderly patients, homeless patients, and others from becoming comfortable with the telehealth. Also, some communities have poor engagement with digital health, which can contribute to negative health outcomes.2

“There were many different kinds of barriers, so we wanted to create a framework that would help us — from a patient’s perspective — determine what those barriers would be,” Crawford says.

The barriers start upstream. “They don’t just start with, ‘Do you have a computer to turn on and off?’” she says.

Providers gained a better understanding of their patients’ digital health literacy after technology took front stage during the COVID-19 public health emergency. (See story in this issue on how to help patients improve digital health literacy.) This is important as health systems move into an era in which digital health is increasingly important. But, there is one problem: How can case managers and others help patients improve their digital health literacy?

“Digital strategies can be a solution or a barrier, based on the patient’s technical literacy,” Dunn says. “It is best if the digital strategy begins in the inpatient setting, ideally before discharge, so the patient and their family can become oriented and ask key questions.”

Digital literacy involves a person’s lifestyle. Structural barriers to digital health literacy include age, geography, gender, socioeconomic status, and disability. “We tried to be as expansive as we could and think about upstream barriers,” Crawford says. “We wanted to create a model so we could think about it systematically.”

Another way to improve digital health literacy is through empowering patients to participate in their own care and health decision-making. This can start with addressing the patient’s emotional state, followed by engagement.3

“The thing that happens so frequently is a person is sick, in the hospital, and they’re not with it — cognitively distracted, at best — and then send them home, and they’re completely confused about what to do,” Conard explains.

The key is to involve them quickly in the transition and self-care process. “Digital solutions offer a whole spectrum of ways to integrate them into the outpatient care process and make sure they’re safe,” Conard says.

Case managers can emphasize self-care knowledge and skills during these critical transitions from hospital to home, Dunn says.

“Self-care behaviors can be reinforced, and prevention strategies can be encouraged,” he says.


  1. Vollbrecht H, Arora V, Otero S, et al. Evaluating the need to address digital literacy among hospitalized patients: Cross-sectional observational study. J Med Int Res 2020;22:e17519.
  2. Crawford A, Serhal E. Digital health equity and COVID-19: The innovation curve cannot reinforce the social gradient of health. J Med Internet Res 2020;22:e19361.
  3. Conard S. Best practices in digital health literacy. Int J Cardiol 2019;292:277-279.