Closing Digital Divide Requires More Than Patient Access to Health IT

It’ll take more than improving patient access to health IT to close the digital divide, according to a new assessment from the VA’s Office of Inspector General.

The OIG report found that a program aiming to close the digital divide successfully distributed health IT to veterans in need, but actual patient utilization was low. Despite expanding patient access to the health IT needed for things like video consults, the digital divide remains, the OIG report concluded.

The digital divide is an emerging social determinant of health that got a lot of time in the spotlight during the first period of the COVID-19 pandemic. As healthcare organizations shuttered their door to in-person medical care, patient access to telehealth increased.

But not everybody saw the same telehealth access; income-based and racial health disparities in telehealth utilization and access plagued health equity efforts and underscored a digital divide nationwide.

The Department of Veterans Affairs set out to close that digital divide in 2021 with a program that would deliver video-enabled devices, iPads, to veterans obtaining a referral and completing a social determinants of health screening. The VA posited that giving these patients the actual devices needed to carry out virtual healthcare would eliminate disparities in utilization.

OIG found that VA successfully issued iPads to 41,000 patients within 14 days of consult.

That said, the program wasn’t exactly successful at closing the digital divide. Only around half (49 percent) of patients getting a digital health device actually used it to have a virtual care encounter. The report indicated that VA needed a more comprehensive approach to closing the digital divide and connecting patients to care.

For one thing, the process did not close the loop for patients, OIG found. Particularly, VA did not schedule video visits for patients once they received the iPad, leaving that onus on the patient and opening the door for that patient to fall through the cracks.

In total, 10,700 patients never had a video consult scheduled. And although 10,000 patients did have a video visit scheduled, that visit never actually happened, potentially due to digital health literacy problems or scheduling conflicts.

There were also some oversight issues, with OIG finding that Veterans Integrated Service Networks (VISNs) weren’t entirely clear on their roles and responsibilities for the program. There were also no requirements for staff to schedule video appointments for patients with a loaned iPad. OIG did note that staff members were instructed to retrieve an iPad if no video appointment was scheduled within 90 days of iPad receipt.

There were also hiccups with distributing iPads, and those hiccups were costly. VA ended up sending out 8,300 unused iPads, totaling to $6.3 million and about $78,000 in additional cellular data fees during the review period. In addition to the cost inefficiencies, OIG pointed out that not retrieving unused devices means other veterans may not loan the technologies.

And even when VA did get the devices back, there were some inefficiencies hampering the agency’s ability to get the iPads out to other veterans in need. OIG found a backlog of around 14,800 returned devices that needed to be refurbished, mostly because of some technical issues at the refurbishment center. VA was aware of the backlog, OIG added, but did not suspend purchasing of new iPads, totaling a cost of $8.1 million for some 9,720 devices.

OIG offered several oversight recommendations to streamline the device lending program, ideally making the program more cost-efficient.

But notably, promoting cost efficiency will not close the digital divide. The OIG report demonstrated that simply connecting patients with the devices needed for digital patient engagement is not enough to address the digital divide.

OIG specifically said VA needs to set up a system for scheduling virtual care appointments to close the gap between veterans receiving a device and veterans accessing care.

This program does hold some promise, but healthcare organizations looking to replicate it will want to heed OIG’s advice about closing the care access loop for patients. Supplementing access to patient engagement technology with patient education will help shore up some of the digital health literacy problems that hamper engagement efforts.

Some healthcare providers have tapped support staff and students to offer up that education.

At Jefferson Health, the health system of Thomas Jefferson University Hospital, MPH students supported the organization’s virtual care access efforts by educating folks with low digital health literacy on how to use technology.

“People vary significantly in their degree of ‘digital readiness’ for using technology,” Kristin Rising, MD, MS, director of acute care transitions at Jefferson University Hospital, said of the program. “It didn’t feel right to provide patients with these devices without offering support to help them learn to use the devices to engage with telehealth services.”

The program made sure MPH students were prepared for a wide variety of patient challenges. While someone might struggle connecting to WiFi, others may need to be oriented within their devices.