Defining the digital determinants of health

What are digital determinants of health?

Unlike SDOH, there is no industry-standard definition for DDOH yet.

Social determinants of health are "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks," according to Healthy People 2030.

While there might be no similarly pithy descriptor defining DDOH, health IT scholars have begun to broach the subject.

"Although factors of digital health have been studied as part of SDOH, there is little formal recognition and exploration of the field," a group of researchers wrote in a literature review in PLOS Digital Medicine. "In fact, to date, there is no widely accepted or recognized definition of DDOH."

But digital determinants can underscore the effects of healthcare's digital transformation on how patients can access and use healthcare, the authors argued.

Take, for example, the adoption of online symptom checkers. Some hospitals and health systems leverage AI to field and assess patients' symptoms and offer medical advice to help triage patient care. The tools might tell a patient with the common cold to ride out their symptoms at home or advise someone displaying signs of a heart attack to get to the emergency department (ED) immediately.

DDOH refer to how such technologies can impact the way individuals access care or manage their own symptoms and well-being.

"DDOH refers to the technological factors that are incorporated to provide affordable, accessible, and quality care to consumers enhancing their healthcare engagement and experience," the PLOS Digital Health researchers said. "Digital determinants refer to factors intrinsic to the technology in question that impact sociodemographic disparities, health inequities, and challenges with care accessibility, affordability, and quality outcomes."

Specific digital determinants of health might include the following:

• Ease of use.
• Usefulness.
• Interactivity.
• Digital literacy.
• Digital accessibility, such as broadband access.
• Digital availability.
• Digital affordability.
• Algorithmic bias.
• Technology personalization.
• Data poverty and information asymmetry.

DDOH are closely linked to super determinants of health, a term many in the health IT academic landscape have used to refer to internet access, digital health equity and the overall digital domain of healthcare.

"Internet access is increasingly recognized as a 'super determinant' of health," Yosselin Turcios, M.P.H., an Office of Behavioral Health Equity fellow at the Substance Abuse and Mental Health Services Administration (SAMHSA), wrote in a SAMHSA article. "It plays a role in healthcare outcomes and influences more traditionally recognized social determinants of health, such as education, employment, and healthcare access."

Similar to the thought behind digital determinants, the digital domain as a super determinant of health acknowledges the role health IT now plays in an individual's journey toward health and well-being.

Exploring the connection between SDOH and DDOH

Although health IT scholars are refining the definition for DDOH, it is clear there is a strong link between SDOH and DDOH. Indeed, access to health IT and broadband have long been considered SDOH. Moreover, certain SDOH, such as income, can influence DDOH.

But the difference between SDOH and DDOH is that DDOH concern the technology itself, the PLOS Digital Medicine authors said.

For example, a patient with limited English proficiency might not be able to use a health system's patient portal if it is only offered in English. Language proficiency is a social construct and a social determinant of health, but the fact that the patient portal is only offered in English is a digital determinant of health.

"The way technology is designed, validated, used, disseminated, and incorporated within healthcare has far-reaching consequences that deserve treatment as a distinct construct," the PLOS Digital Medicine researchers explained.

Health IT developers, plus the hospitals and health systems that purchase their tools, can be mindful of DDOH when assessing tools for their patient populations. In the above example, a hospital might consider a different patient portal vendor that offers the tool in multiple languages to serve a multilingual patient population.

Strategies to address digital determinants

As with social determinants, addressing digital determinants will be integral to the healthcare industry's overall effort toward health equity. After all, DDOH influence how an individual engages with digital and analog healthcare access modalities. Left unaddressed, DDOH can perpetuate existing health disparities.

Health IT scholars have identified a few preliminary strategies that could help promote and address DDOH, including the following:

• Linking DDOH work with SDOH work.
• Implementing better public and payment policy.
• Improving health IT design and development.
• Refining health IT implementation and adoption.

Linking SDOH work to address DDOH

Because SDOH and DDOH are so closely linked, some experts have suggested integrating efforts to address both. Such an approach could avoid redundancies and promote the use of existing, effective strategies.

In a 2022 Digital Health paper, one group of scholars referenced the different layers of the Dahlgren and Whitehead rainbow model for understanding social determinants.

The rainbow model illustrates five key layers to SDOH, working from the outermost layer to the innermost:

• General socioeconomic, cultural, and environmental conditions.
• Living and working conditions.
• Social and community networks.
• Individual lifestyle factors.
• Age, sex and constitutional factors, with the latter being individual-level stable characteristics.

According to the Digital Health authors, DDOH interventions can happen at each level of the Dahlgren-Whitehead rainbow. This is because the digital transformation "has arguably permeated into most aspects of everyday life," the researchers said.

For example, on the general socioeconomic level, experts might focus on broadband, the availability of digital devices and digital health literacy. On the next, living and working conditions level, experts might look at how different technologies can affect living and working conditions, including how some tracking within health apps would affect the user.

The social and community network level would zero in on tech networks in certain traditionally underserved or disadvantaged areas. Finally, the lifestyle factors layer might refer to individual awareness of the benefits of using certain health technologies.

Implementing better public and payment policy

In another paper exploring strategies for addressing DDOH, a group of researchers from the National Institutes of Health (NIH) examined a series of papers focusing on better payment policies. Addressing DDOH will require public policies to make digital health tools accessible in underinvested communities.

Health IT is increasingly being regarded as a human right, considering its role in patient well-being, the NIH researchers added. As such, public policy needs to assess how it can provide or subsidize broadband, actual health IT tools and complementary supports, such as patient navigators or technology training for patients.

Additionally, better standards for cybersecurity will be crucial for addressing DDOH, the NIH researchers recommended. That is because health IT security breaches can be more consequential for patients with disabilities, mental or behavioral health concerns, chronic illnesses or some documented SDOH.

Improving health IT design and development

Addressing DDOH will hinge on health IT vendor participation. That is because many digital determinants can be mitigated on the design level, according to the NIH researchers.

Specifically, health IT vendors should consider how they design their products for users from historically marginalized communities, the cost of the product and the equity of the databases and algorithms that guide the tools.

More intentional IT development should start with user-centered design, the researchers added, meaning collaboration with the underserved populations who might use the tool. This could be in the form of a patient and family advisory council at the health IT developer.

Additionally, health IT developers need to consider user cost. This, in part, means ensuring easy access to low-tech engagement options.

Making sure apps can work on simpler, low-cost smartphones, allowing apps to work in an offline mode and requiring devices to connect to Wi-Fi to avoid battery drain and broadband usage fees will be key.

Refining health IT implementation and adoption

On the health system level, the NIH authors urged leadership to refine their health IT selection criteria.

This means being selective about which health IT systems the hospital or health system adopts for its patient populations. Criteria should consider usability, personalization, language access and the ability to use low-tech devices.

Additionally, healthcare organizations need to set up support services to help patients use the health IT that is being made available to them.

Patient navigators or other non-clinician healthcare workers can help patients -- and, in some cases, staff members -- feel more comfortable with the new technology. These training sessions need to be culturally competent, the researchers stressed, and simulate real-life use of the tool.

And like health IT developers, healthcare organizations should consult their patient and caregiver end-users about adoption and implementation of a new tool, potentially through their own PFACs. This can help engender patient trust in the healthcare organization and the technologies the patients use.

With more judicious policy, product design and health IT adoption, leaders in the healthcare space can work to mitigate digital determinants of health. To that end, they might avoid perpetuating the health disparities that have long plagued medicine.

Sara Heath has covered news related to patient engagement and health equity since 2015.