Electronic Health Literacy among Linguistically Diverse Patients in the Los Angeles County Safety Net Health System

Digital health literacy and use of patient portals among Spanish-preferred patients in the United States: a cross-sectional assessment

Objective

Individuals with Limited English Proficiency (LEP), including Spanish-preferred patients, face healthcare challenges due to language barriers. Despite the potential of digital health technologies to improve access and outcomes, there is a "digital divide" with underutilization among vulnerable populations, including Spanish-speaking LEP individuals, highlighting a need for increased understanding and equitable digital health solutions.

Materials and methods

A multi-mode, multi-language cross-sectional survey was built based on the Technology Acceptance Model and deployed from a multi-state healthcare practice. Measures included patient-reported comfort level with reading and speaking English, internet and computer access and satisfaction, ability to perform healthcare-related online tasks, and the eHEALS scale of digital health literacy.

Results

A total of 212 Spanish-preferred patients completed the survey (response rate, 212/2,726 = 7.8%), of which 73.6% indicated lack of comfort in reading or writing in English (LEP n = 156). Spanish-speaking individuals with LEP reported higher rates of needing help when learning how to use new technology or devices, reporting difficulty in the evaluation of health information on the internet and being able to differentiate high-quality information from low-quality online health resources, feeling confident in using health information found online to make health decisions, and having lower access to health-related online services than Spanish-speaking individuals without LEP.

Discussion

Improving equitable accessibility to digital tools for individuals with LEP seeking healthcare can help to improve their engagement with their providers and promote self-efficacy in their care. Opportunities exist with emerging technologies to develop language-concordant healthcare resources that will improve outcomes for Spanish-preferred patients.

Lessons learned from a multi-site collaborative working toward a digital health use screening tool

Digital health has the potential to expand health care and improve outcomes for patients-particularly for those with challenges to accessing in-person care. The acceleration of digital health (and particularly telemedicine) prompted by the Coronavirus-19 (COVID-19) pandemic facilitated continuity of care in some settings but left many health systems ill-prepared to address digital uptake among patients from underserved backgrounds, who already experience health disparities. As use of digital health grows and the digital divide threatens to widen, healthcare systems must develop approaches to evaluate patients' needs for digital health inclusion, and consequentially equip patients with the resources needed to access the benefits of digital health. However, this is particularly challenging given the absence of any standardized, validated multilingual screening instrument to assess patients' readiness for digital healthcare that is feasible to administer in already under-resourced health systems. This perspective is structured as follows: (1) the need for digital health exclusion risk screening, (2) our convening as a group of stakeholders, (3) our review of the known digital health screening tools and our assessment, (4) formative work with patients regarding their perceptions on language and concepts in the digital health screening tools, and (5) conclusion with recommendations for digital health advocates generated by this collaborative of digital health researchers and operations leaders. There is a need to develop a brief, effective tool to screen for digital health use that can be widely implemented in diverse populations. We include lessons learned from our experiences in developing and testing risk of digital health exclusion screening questions in our respective health systems (e.g., patient perception of questions and response options). Because we recognize that health systems across the country may be facing similar challenges and questions, this perspective aims to inform ongoing efforts in developing health system digital exclusion screening tools and advocate for their role in advancing digital health equity.

Telemedicine Implementation for Safety Net Populations: A Systematic Review

Background: Telemedicine systems were rapidly implemented in response to COVID-19. However, little is known about their effectiveness, acceptability, and sustainability for safety net populations. This study systematically reviewed primary care telemedicine implementation and effectiveness in safety net settings. Methods: We searched PubMed for peer-reviewed articles on telemedicine implementation from 2013 to 2021. The search was done between June and December 2021. Included articles focused on health care organizations that primarily serve low-income and/or rural populations in the United States. We screened 244 articles from an initial search of 343 articles and extracted and analyzed data from N = 45 articles. Results: Nine (20%) of 45 articles were randomized controlled trials. N = 22 reported findings for at least one marginalized group (i.e., racial/ethnic minority, 65 years+, limited English proficiency). Only n = 19 (42%) included African American/Black patients in demographics descriptions, n = 14 (31%) LatinX/Hispanic patients, n = 4 (9%) Asian patients, n = 4 (9%) patients aged 65+ years, and n = 4 (9%) patients with limited English proficiency. Results show telemedicine can provide high-quality primary care that is more accessible and affordable. Fifteen studies assessed barriers and facilitators to telemedicine implementation. Common barriers were billing/administrative workflow disruption (n = 9, 20%), broadband access/quality (n = 5, 11%), and patient preference for in-person care (n = 4, 9%). Facilitators included efficiency gains (n = 6, 13%), patient acceptance (n = 3, 7%), and enhanced access (n = 3, 7%). Conclusions: Telemedicine is an acceptable care modality to deliver primary care in safety net settings. Future studies should compare telemedicine and in-person care quality and test strategies to improve telemedicine implementation in safety net settings.

The Los Angeles County Department of Health Services Health Technology Navigators: A novel health workforce to digitally empower patient communities in safety net systems

Significant disparities in the uptake of digital health tools have been previously described. Studies have found that low perceived confidence to engage with digital health resources among medically underserved patients partially account for this. To address barriers to digital health engagement (specifically around patient portal enrollment and use), the Los Angeles County Department of Health Services (LAC DHS) introduced the Health Technology Navigators program. To our knowledge, this is the first formal digital health workforce implemented in a safety net system. The objectives of the editorial are to describe the evolution and roles of the health technology navigators and their early effects within LAC DHS, the second largest safety net health system in the United States.

Advancing digital health Equity: Directions for behavioral and social science research

The field of digital health is evolving rapidly and encompasses a wide range of complex and changing technologies used to support individual and population health. The COVID-19 pandemic has augmented digital health expansion and significantly changed how digital health technologies are used. To ensure that these technologies do not create or exacerbate existing health disparities, a multi-pronged and comprehensive research approach is needed. In this commentary, we outline five recommendations for behavioral and social science researchers that are critical to promoting digital health equity. These recommendations include: (i) centering equity in research teams and theoretical approaches, (ii) focusing on issues of digital health literacy and engagement, (iii) using methods that elevate perspectives and needs of underserved populations, (iv) ensuring ethical approaches for collecting and using digital health data, and (v) developing strategies for integrating digital health tools within and across systems and settings. Taken together, these recommendations can help advance the science of digital health equity and justice.