By Melinda Young
Digital solutions make it easier for patients to access health information and improve their self-care, but some barriers and disparities remain. These challenges are particularly acute for older patients, some ethnic and racial minority groups, and others.
“Not all individuals have easy access to smartphones, the internet, or to a laptop, let alone have access to understanding the health information they’re processing,” says Devlon N. Jackson, PhD, MPH, assistant research professor and healthy Me/Mi Salud project director in the department of behavioral and community health, Herschel S. Horowitz Center for Health Literacy at the Maryland Center for Health Equity. “Maybe they have access to technology, but their health literacy level is not adequate. You’re sending them home, and maybe they’re not equipped for that.”
The COVID-19 crisis revealed a solution to in-person care — telehealth. But it also exposed existing disparities that allow some patients to fall behind, Jackson explains.
Jackson and digital health literacy researchers offer these suggestions for how case managers and hospitals can help patients improve their health literacy:
• Always ask patients to describe how they will follow instructions. One of the objectives of the Office of Disease Prevention and Health Promotion’s Healthy People 2020 national health goals is to “increase the proportion of persons who report their healthcare provider always asked them to describe how they will follow instructions.” This same objective now is recommended to be a highlighted goal for the proposed 2030 Healthy People initiative.1 “The target was not met for Healthy People 2020,” Jackson says.
Another objective in the Healthy People 2020 goal involved increasing the proportion of people who use electronic personal health management tools. The 2030 version includes a proposal to “increase the proportion of persons who use health information technology (HIT) to track healthcare data or communicate with providers.”1
There are many ways case managers and others can meet this objective. One of the common methods is through teach-back, Jackson says.
• Use digital solutions to teach the basics. “Learning how to manage a chronic condition, such as diabetes or heart failure, is a process that begins with foundational knowledge, building to mastery,” says Patrick Dunn, PhD, MS, MBA, FAHA, program director of the American Heart Association’s Center for Health Technology and Innovation in Dallas. “It is similar to learning a new language, learning how to play a musical instrument, or learning a new game. It is rare for someone to demonstrate mastery initially.”
Digital solutions help by allowing people to learn the basics and grow in their knowledge. “Think about how computer games go from one level to the next,” Dunn says. “It is the same idea.”
Case managers, and the healthcare system in general, do not have the time and capacity to work with patients while they grow in their knowledge, he explains.
“Digital solutions allow us to leverage the healthcare system workforce capacity,” Dunn says.
• Steer people to easier technology. For patients who struggle with phone apps, there is other technology that could make their access to health information easier.
“You meet the person where they are,” says Scott Conard, MD, president of Converging Health in Dallas, and consultant to the American Heart Association. “If they’re techno-savvy, then you say, ‘Log into this, and this is how it synchronizes,’” he explains. “But maybe the person has dementia and significant difficulty moving around.”
For patients with low digital health literacy, the easiest solution is to give them technology that works automatically or more simply. For example, Amazon’s Alexa and Apple’s Siri voice-operated technology can answer questions and send health information to providers.
“I see Siri and Alexa as being more what people would gravitate toward,” Conard says. “You can say, ‘Siri, what is the weather today?’” Conard says. “That’s more realistic than expecting the elderly to download apps and learn a digital platform.”
There also are digital solutions that send patients’ information, such as weight, blood pressure, temperature, and blood glucose levels to their providers automatically. “This technology is being employed in age-in-place scenarios,” Conard says.
• Identify people who need support. “Low health literacy puts people at risk,” says Valerie Press, MD, MPH, assistant professor of medicine and pediatrics in the section of general internal medicine at University of Chicago Medicine. “We need to identify people who need support in using digital interventions,” she says. “Screen people for low health literacy, or you can take the precautions approach, where you assume everyone has low health literacy.”
Interventions should be developed with digital health literacy needs in mind. “Case management can provide initial training,” Press says. “Take the hospital-to-home scenario: Perhaps X intervention comes with a practice scenario, and a case manager or any clinician could help walk the patient through it.”
Once patients are discharged home, they can receive support through technology. If they need help setting up the technology, case managers or other professionals could give instructions by phone.
• Provide hands-on experience for patients and simulation programs for staff. Case managers can help patients with digital self-care solutions by teaching them how to access the apps on their phones or laptops. They could learn how to help patients through simulation programs.
“We have a simulation program where people run through cases with an actor who can model things like a patient saying, ‘I can’t hear you,’” says Allison Crawford, MD, PhD, associate professor in the department of psychiatry at the University of Toronto. “We play around with different problems and digital barriers that can happen. We let them practice, and teach them how to [perform self-care] in a virtual environment,” Crawford says.
• Use new digital technologies to improve well-being and health literacy. Bluetooth technology and sensor devices enable patients’ scales, blood pressure cuffs, clothing, jewelry, and other wearable or household devices to send health data to case managers and other providers or monitoring companies.
“New biometric sensors can detect a number of factors, such as heart rate, respiratory rate, sleep, ECG, gait, temperature, speech, and others,” Dunn says.
These sensors detect problems before patients and clinicians know what is happening. Researchers are studying whether wearable sensors can discover heart attacks and other health problems early, he notes.
For example, researchers are studying whether some devices can discover COVID-19 infection through detection of subtle vital sign changes. The devices may find an infection several days before symptoms appear. Several devices, including a smart ring that take a person’s pulse, temperature, and assesses sleep and exercise patterns, are under investigation as early-warning systems for COVID-19. (More information is available at: https://www.washingtonpost.com/technology/2020/05/28/wearable-coronavirus-detect/.)
• Teach staff how to improve virtual visits. Researchers found that effective patient-clinician encounters require better quality of care in equity, safety, person-centeredness, effectiveness, efficiency, and timeliness.2
Providing optimal quality of care through digital solutions can be challenging. For example, a case manager might transition an elderly patient home, but the patient needs a virtual mental health visit. If the patient does not know how to use his or her tablet or phone for a video visit, then the case manager might have to walk the patient through the process.
“We have clients with developmental disabilities who found it hard to use the equipment. We used peer support workers to help them access the video visits,” Crawford says. “We also tried to make it very easy so it’s just a link they have to follow and don’t have to download an application.”
Education also should include tips on how to make patients feel safe and comfortable. For instance, the camera angle can make a big difference during a video call, Crawford notes. “You don’t really make eye contact in a virtual call, but when the camera angle is slightly downward-pointing and a certain distance away, that simulates the experience of eye contact,” she explains.
Clinicians who use two screens, one with the virtual session and the other with the patient’s health record, might show the patient their profile, making it look as though they are not connecting with the patient, Crawford adds.
Technical glitches that freeze frames or put the video and audio out of synch can increase the patient’s feelings of not being connected.
“If you don’t feel connected, then you don’t feel the clinician is there to help you,” Crawford says. “We have ways to train people on how to repair this problem.”
- Jackson DN, Trivedi N, Baur C. Re-prioritizing digital health and health literacy in Healthy People 2030 to affect health equity. Health Commun 2020;1-8.
- 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.