Key SDOH Considerations for Remote Patient Monitoring Programs

LANGUAGE

In the US, people with limited English proficiency face numerous barriers to healthcare access. According to KFF, people with limited English proficiency are more likely to have lower incomes and educational attainment levels, be uninsured or covered by Medicaid, and face an increased risk of adverse outcomes and reduced medication adherence.

Limited English proficiency makes engaging in and adhering to RPM program requirements a significant challenge, as language barriers can hinder patient education and engagement.

For instance, a study published in the American Journal of Obstetrics and Gynecology in 2022 revealed that obstetrics patients with Spanish as their primary language were less likely to use RPM for blood pressure (BP) monitoring.

The study included obstetric patients at NYU Langone Health with hypertensive diagnoses who agreed to participate in an RPM-BP program. The RPM-BP patients entered blood pressure readings into the NYU MyChart mobile application, which were directly transmitted to their EHR.

A total of 171 patients were included in the study, of which 118 logged one or more measurements (users), and 53 did not log any measurements (non-users). The researchers found that 28.3 percent of non-users reported that their primary language was Spanish, compared to 6.8 percent of users. Meanwhile, 90 percent of users said their primary language was English.

Another study published last year found that the lack of “culturally and contextually congruent technology, and wrap around services for RPM-enabled health care,” was a major barrier to tailoring these services to diverse patients. As part of the study, researchers interviewed 13 clinicians across nine specialties considered early adopters and supporters of RPM.

One of the clinicians stated, “My main concern is that it’s not all in Spanish. The majority of our patients speak Spanish.”

POOR INTERNET CONNECTIVITY

Access to broadband internet is a widespread challenge in America. The Federal Communications Commission estimates that more than 8.3 million US homes and businesses lack access to high-speed broadband.

A lack of access to stable and fast internet severely limits the ability to adopt and use virtual care modalities. Telehealth and RPM technologies, such as smartphones, tablets, and connected devices, often rely on the internet to function and transmit data to care teams.

According to a study published in the Ochsner Journal, patients and primary care providers (PCPs) “valued remote telemonitoring as adjuncts to care; however, limited service availability and insurance coverage were barriers.”

Researchers conducted qualitative semi-structured interviews for the study between May and July 2021. They interviewed 40 patients and 30 primary care providers in Louisiana within an integrated delivery health system and a rural health center.

The interviews revealed that patients and PCPs uniformly viewed remote monitoring technology as useful but noted that lack of internet/Wi-Fi access could hinder uptake.

A study published in JMIR Mhealth Uhealth in 2021 echoed these qualitative findings. Researchers conducted a review of published research, gathering studies from Embase, MEDLINE, and QxMD published between December 2019 and July 6, 2020.  

They included 48 publications that described 35 distinct remote monitoring technologies in the review. The researchers found that prominent barriers to using RPM technologies include poor internet connectivity.

Specifically, six studies noted that low network quality, internet connectivity, or bandwidth were barriers to RPM technology use. Eight showed that lack of access to RPM technologies in low-resource settings, such as households without internet or devices, was also an equity-related barrier. 

DIGITAL HEALTH LITERACY

According to AHRQ’s Patient Safety Network, digital health literacy includes personal health literacy, which refers to individuals’ ability to find, understand, and use information and services to inform health-related decisions and actions, and digital literacy, which is individuals’ ability to use information and communication technologies to find, evaluate, create, and communicate information.

Lack of digital health literacy can hamper RPM use in several ways, including making it harder for patients to use the connected devices at the center of most RPM programs.

A study published in The Permanente Journal last September, which detailed the perspectives and experiences of healthcare practitioners using RPM tools, showed that technology use issues among patients are a cause for concern. The study reviewed 13 articles that included surveys of 2,351 practitioners.

Among the challenges cited, healthcare practitioners noted that the majority of the patient population involved in RPM is older, and thus, the technology could be “disorienting” for them. Further, the technology may involve diverse equipment from different manufacturers, making them harder to use.

Another study published in JMIR Human Factors last year found that clinicians believe some patients are better suited for RPM than others. The study evaluated the early implementation of RPM initiatives for chronic disease management within the ambulatory network of an academic medical center in New York City. The research included interviews with 13 clinicians and speculative design sessions exploring the future of RPM with 21 patients and patient representatives.

“Tech-savvy persons and high-literacy people are more likely to use [RPM]...[we are] less likely to offer RPM to people who are less likely to use it,” a clinician told researchers.

MINORITY RACE AND ETHNICITY STATUS

Patients who are part of minority racial and ethnic groups often face unique healthcare challenges, including access barriers, underrepresentation in research and among healthcare staff, and non-inclusive treatment modalities.

While RPM can help close care gaps among racial and ethnic minorities, engagement in these programs is influenced by patient demographics, according to a study published in 2021. The study examined data transmission and engagement among 549 patients enrolled in a diabetes RPM program for at least one year as of April 2020.

Researchers found that patients who failed to transmit any data over the course of the program more often identified as Hispanic (46 percent) compared with the overall cohort. Additionally, the study showed that there was a significant difference in engagement through time between Black and non-Black patients, with Black patients initially having a higher rate of engagement but the rate declining more quickly than for non-Black peers.

Research from 2023 further noted various technical, historical and societal, and socioeconomic barriers to RPM for Black patients. These barriers included limitations of photoplethysmographic green light signaling, which make RPM devices using such technology less accessible to people with darker skin tones, distrust in the healthcare industry as a whole, and factors like low annual household income and lack of health insurance.

LOCATION

Location, that is, where a patient resides, can significantly impact their ability to access and engage in RPM programs. While RPM can help improve health outcomes in areas where health inequities abound, these areas are less likely to have hospitals offering RPM.

According to a November 2023 study in Telemedicine and e-Health, rural hospitals near households in the lower middle quartile of socioeconomic status (SES) had 33.5 percent lower odds of having adopted RPM for chronic care management compared with rural hospitals near households in the highest quartile of SES. The research focused on data from hospitals that responded to the American Hospital Association's 2018 Annual Survey and spatially linked census tract-level environmental and SDOH data from the Social Vulnerability Index.

The study also found that urban hospitals near households in the lowest quartile of SES had a 41.9 percent lower likelihood of having adopted RPM for chronic care management than urban hospitals near households in the highest quartile of SES.

Additionally, rural Americans are less likely to be referred to RPM programs.

Research published in Telemedicine and e-Health in September 2023 showed that patients in census tracts with higher social vulnerability were less likely to be referred to RPM programs than those in tracts with lower social vulnerability. The study included 16,739 COVID-19 patients receiving care at an academic health system from March through September 2020. The health system implemented a standardized care pathway that directed healthcare providers to refer patients for RPM services.

Identifying and addressing these SDOH vulnerabilities is critical for the success of RPM programs that aim to improve health outcomes and equity among patient populations.