Digital inclusion as a social determinant of health

The use of digital tools and applications is steadily increasing and can support a range of health information needs 1 – 3 . As tools such as patient portals, health trackers

least moderate income, but important pockets of nonadoption remain.
Most mobile health technology requires a data plan and/or home broadband, yet the American Community Survey shows that 40% of low-income households lack a subscription, requiring them to use limited cell plan data or local public wifi hotspots 12 . These options may appear affordable but they contain important limitations. Using prepaid plans, patients may run out of data or need to prioritize data for specific uses. Even with their lower cost, they may still be unaffordable, particularly for families in need of multiple devices. Open wifi access points are another option but may only be available in public locations in which patients may feel uncomfortable accessing their personal health information.
Prior to the rapid increase in telehealth use due to COVID-19, patient portals to their electronic health record (EHR) were the most common form of mobile health and a gateway to other mobile health applications. However, studies show that lack of Internet access is a leading factor inhibiting use of patient portals 14 . Smartphones may seem to be a logical and ubiquitous substitute for home Internet, but significant gaps still exist for rural, poor, and older adults. Research shows that nearly one-half of older adults and 30% of those earning less than $30,000 own a smartphone and many low-income households share devices, raising both access and privacy issues 15 . Understanding the nuances of access in the communities they serve can help healthcare systems implement more inclusive strategies.
Digitally inclusive strategies of health system adoption also support patients in their use of technology at all levels and should include digital skill training, particularly for recent adopters of technology or those who may have devices with limited features. Patients may also need assistance with setting up email and patient portal accounts. In addition, it is critical to provide ongoing support for patients, reduce medical jargon, and provide interpretive resources, and ensure that technology and training are offered equitably to all patients, not just to those who are confident enough to request help 16 .
Second, we recommend systematically assessing individual patients' access and digital literacies. This became particularly clear since the rapid and pervasive shift to telehealth during the COVID-19 pandemic. Simply asking patients what devices they own and how they access the Internet is not typical in the clinical context, but this information can shape the type of technology a clinician can recommend. The lack of routine assessment prior to COVID-19 meant that some patients fell between the cracks as care shifted to nearly all virtual 17 . Incorporating this and other SDOH into the EHR encourages more consistent documentation and allows assessment of population-level metrics of access 18 . When digital skill and connectivity gaps are assessed systematically and universally, a health system can document overall population-level metrics, examine disparities, and track changes over time.
Third, health systems should partner with community organizations with expertise in training in digital literacy skills and facilitating connectivity. Libraries not only offer the Internet but also provide a spectrum of training services from basic digital literacies to skills required for specific devices and applications. Some communities have leveraged community health workers and patient navigators to screen and refer patients for gaps in basic digital literacies and connectivity 19,20 . They can provide hands-on training in the use of mobile health technologies for patients who do have adequate digital access. Allied health professional education programs leverage a "train the trainer" model to prepare the future healthcare workforce to undertake these tasks [21][22][23] . The National Digital Inclusion Alliance (NDIA) offers a comprehensive list of organizations across the country that provide digital literacy training and national and local resources for free/low-cost Internet and computers 13 .
Mobile health technologies hold significant promise to increase the efficiency of care and improve health outcomes. Yet, we must be cognizant of their potential to increase health disparities. National efforts have been undertaken to promote broadband, such as the Federal Communications Commission's (FCC) Lifeline program that subsidizes the cost of smartphones and Internet service for low-income individuals 24,25 . However, the Lifeline Program's impact is limited by low consumer awareness, and the qualification process varies by state and by the service provider. In addition, Internet service may still be unaffordable even with the monthly subsidy. Another program, the Federal Broadband Opportunities Program, supported over 4 million people to get online for the first time with a $4 billion program but those one-time dollars are long gone, leaving a gap in the need for adult digital literacy support. BTOP has only two remaining operational programs with no new funding on the horizon 25,26 . In response to the current COVID-19 pandemic, the FCC also introduced a variety of programs to increase Internet access for the use of telehealth, including paying for devices and access. However, the future of these programs after the COVID-19 pandemic is unclear 13 . As clinical care incorporates more technology in more contexts, we suggest the recommendations above to facilitate equitable adoption of mobile health technology.