As healthcare increasingly relies on digital tools for patient care, digital inclusion has become essential to promoting equity in healthcare. The recently enacted Infrastructure Investment and Employment Act (IIJA) provides for investments that can foster sustainable digital inclusion. Although the law is not focused on health care, it addresses long-standing drivers of digital health disparities, presents new opportunities for community digital inclusion and could be a key lever for improving health. ‘Health care access. We believe it is important for healthcare organizations to understand the opportunities provided by the law, to advocate for its effective and equitable implementation, and to take advantage of improvements in digital infrastructure (see table).
With digital health tools such as telehealth and patient portals becoming important parts of care delivery, barriers to digital inclusion have become increasingly apparent.1 For example, more than 100 studies have found disparities in portal usage based on age, race, socioeconomic status, English proficiency, and other factors.2 Digital inclusion refers to “activities necessary to ensure that all individuals and communities, including the most disadvantaged, have access to and use [digital tools].”3 Structural barriers to digital inclusion, such as digital redlining, have limited the reach of digital health tools. Digital redlining involves “discrimination by Internet service providers in deploying, maintaining or upgrading infrastructure or providing services”.3 The communities affected by digital redlining are usually the same ones that already have poor health outcomes. Health systems have, by necessity, implemented digital tools in communities affected by digital redlining to reach underserved patients and address health disparities.
Beyond digital redlining, limited broadband infrastructure, high prices for broadband services, and lack of access to internet-enabled devices have made it difficult to deploy digital health tools. At least 21 million people in the United States lack access to broadband, which has limited the use of telehealth. People living in areas with low broadband access are less likely to use video tours than people living in areas with more widespread access. The expansion of digital health fueled by the Covid-19 pandemic has also highlighted the importance of digital literacy in empowering patients to engage in this new model of care. Delivering equitable care to underserved patients requires an inclusive system that ensures access to affordable broadband, internet-enabled devices, digital literacy supports and appropriately designed platforms.
In this new digital care environment, healthcare organizations play an important role in bridging digital divides. Organizations are developing dashboards to better measure digital disparities and guide system-wide solutions. Some attempt to bridge access and affordability gaps by purchasing and providing patients with tools to support broadband access (e.g. Wi-Fi hotspots) and internet-enabled devices . The Federal Communications Commission’s (FCC) Covid-19 Telehealth Program has provided financial support for organizational telehealth devices and infrastructure, although resources are limited. Organizations also overhauled their existing platforms and translated content into multiple languages. Digital navigators, which were previously deployed outside of healthcare, have become new members of the care team to help patients use digital tools. However, navigators can be expensive and resource-intensive for healthcare organizations, which limits the sustainability of navigator programs.
The IIJA takes much of the responsibility for building digital infrastructure away from individual healthcare organizations and makes digital inclusion a public concern. The law provides $65 billion for digital inclusion initiatives. It earmarks $42.5 billion for broadband infrastructure investment through state rollout grants, promotes broadband affordability by providing $14.2 billion for $30 grants per month for Internet costs for the underserved and allocates $2.8 billion to create digital literacy programs. It also includes funds to support connectivity in tribal communities and broadband rollout in rural areas.
Although healthcare organizations have begun to screen for digital needs, resources to meet identified needs have been limited or underutilized. For example, the Covid-related Emergency Broadband Benefit, which provides subsidies for internet and device purchases, has not been widely adopted.4 In the future, healthcare organizations, especially those in underserved communities, could not only refer people to digital inclusion programs, but also serve as active stakeholders in targeted outreach initiatives.
In addition to providing funding, the IIJA could address health disparities stemming from digital exclusion. The law directs the FCC to adopt rules to prevent “digital access discrimination based on income level, race, ethnicity, color, religion, or national origin.” These policies attempt to overcome structural barriers to digital inclusion, such as redlining. Healthcare organizations will need to actively support anti-discrimination efforts to ensure telecommunications companies are held to policies requiring fair implementation. Organizations could also partner with community groups and nonprofits, such as the National Digital Inclusion Alliance, to advocate for equitable broadband deployment so that digital health tools can be leveraged. to promote equity in health care.
The IIJA also emphasizes a community-based approach to digital inclusion by establishing state grant mechanisms that encourage collaboration. Digital health initiatives embedded in community programs can be more sustainable than piecemeal digital literacy programs. For example, healthcare organizations could work with groups offering courses for English language learners or with libraries, which have long been essential to digital inclusion, to co-develop literacy training programs. digital for marginalized populations. Additionally, the IIJA supports connectivity for anchor community institutions (eg, schools and libraries), which have become integral to equitable care delivery. By capitalizing on new policies, healthcare organizations could become an essential part of an environment of community actors working towards digital inclusion. In this way, digital inclusion could be presented as a social determinant of health, and support for digital inclusion could have positive effects on other social determinants, including education, employment, civic engagement and housing.5
While adopting the IIJA represents an exciting step towards digital inclusion, we believe healthcare organizations need to overcome additional hurdles to create an inclusive system. First, it’s unclear whether the new funding will be enough to fill the access gaps, given the FCC’s unreliable broadband data. Organizations could collect information about patients who have access to broadband to guide the allocation of infrastructure building resources. Second, the IIJA considers adequate broadband speeds to be at least 100 megabits per second for downloads and 20 megabits per second for uploads. Digital healthcare implementation teams should be aware of bandwidth limitations, which could exclude patients with slower internet speeds. Third, the law does not address necessary changes to the design of digital health platforms (e.g. language translation) or to make workflows more inclusive (e.g. integrating interpreters into health care visits). telehealth). Fourth, it will be essential to assess the effects of digital tools to avoid worsening disparities. Finally, organizations should continue to offer multimodal care options, as access to digital tools may vary and these tools may not be appropriate or preferred by all patients.
The future of digital healthcare rests not only on digital inclusion, but also on extending the policies adopted during the Covid-19 public health emergency that align with care and equity based on the value. Operating community anchor sites will require the permanent removal of geo-restrictions and home-site restrictions, which are dependent on a patient’s location during a telehealth visit. Simplifying interstate licensing laws for clinicians would also allow digital tools to increase access to care for marginalized populations. Additionally, reimbursement parity between various forms of telehealth, including audio-only visits, would ensure that patients without full digital access could still receive remote care, including mental health services. A combination of progressive digital inclusion efforts and digital health policies could lay the foundation for technology-enabled health care equity.
Patients will only benefit from digital tools if health systems advocate digital inclusion policies. As healthcare increasingly adopts a “digital-first” approach, digital inclusion is becoming intertwined with equity in healthcare. Healthcare organizations must therefore engage in digital policy initiatives, including the IIJA, and providers must be prepared to take advantage of the opportunities presented by these policies.