This is the opinion of the authors of the comment “Digital inclusion as a social determinant of health” published recently in Nature. The issue was rarely discussed until a few years ago, as hardly anyone had access to patient portals, healthcare applications, wearables, or smartphones.
But much has changed in recent years. Electronic medical records are gaining popularity. Almost everyone has a smartphone and can install one of the 350 000 healthcare apps. However, technological advancement does not equal digital literacy. While some people are quick to tame new tools, others don’t even have access to them.
Therefore, the higher the digital maturity of health systems – measured by the adoption of digital tools – the greater the risk of increasing the health inequalities. An invisible gap is rising between digitally literate people and those excluded from the digital revolution due to financial or social limitations.
No access to the Internet means marginalization in the society
According to the latest Brookings Institution report, 15–24% of Americans have no access to a broadband connection to use mobile healthcare technologies. According to the Eurostat data, 90% of Europeans have Internet access. The differences between EU member states range from 98% in the Netherlands and 96% in Sweden to 75% in Bulgaria. Although the Internet infrastructure has improved in recent years in most countries, the source of the digital gap is predominantly income, irrespective of whether the data relates to urban or rural areas.
Digital skills, Internet connections and access to computers or smartphones have increased in the past few years and are now considered an essential health indicator. The authors of the paper published in Nature refer to them as “super social determinants of health” – they influence other traditional determinants of health. For instance, job advertisements are mostly published through online portals, and employers require the applications to be submitted via the Internet. Furthermore, by accessing the Internet, health-related information can be found, medical appointments can be booked. When citizens have a digital identity, they can then use a series of services, such as e-prescriptions, follow-up examinations, or digital preventive programs.
Infrastructure is only the beginning
The conclusion is clear: investments in infrastructure and digital skills are investments in health. Consequently, the health prevention strategies should implement measures aimed at the digital inclusion of citizens by checking the level of access to technologies, with digital education as a priority, and eliminating the economic barriers.
Responsibility rests with doctors as well. By having direct contact with patients, they can identify barriers precluding the use of healthcare technologies and educate, such as by recommending solutions achievable by a patient, including health apps. This requires empathy and trust similarly when prescribing medicines: Can the patient afford a smartphone to install an app?
As increasingly advanced digital healthcare solutions emerge, a more robust infrastructure is required, including access to 4G networks – an indispensable component of real-time health monitoring or remote surgeries, for example. During the COVID-19 pandemic, anyone who was proficient in these technologies quickly switched to digital medical consultations. Those who did not have such abilities, including many older people, suffered the most when direct contact with the doctors was limited. The new websites that were launched provided such services as e-prescriptions or making appointments for COVID-19 vaccinations, creating the possibility of restoring the service continuity of the healthcare system, including sidelined people having low digital skills.
Who should remove the digital barriers?
Many administration- and healthcare-related services are rendered via mobile applications available on smartphones. The growing “smartphonization” means that this technology is becoming the key to a different form of administration and, more frequently, healthcare services. In Europe, about 85% of the population owns a smartphone; on a global scale, it is about 50%. It means that 15% of Europeans during the pandemic were still unable to use COVID-19 tracking apps or connect with a doctor.
Digital inclusion requires education. Unfortunately, the authors of “Digital inclusion as a social determinant of health” do not suggest who should be responsible for the latter. It is hard to argue that digital support for patients is essential and that technology accompanied by training should be offered to all patients. It would be legitimate to shift the responsibility to the doctors or nurses as having the closest relations with the patient. But how to put it into practice when the average time of an appointment is limited, while medical professionals also lack the competencies in digital technologies. Outreach campaigns, online training, or leaflets can help to some extent. Still, such efforts are insufficient to remove the digital barriers.
Implementation of the recommendations to evaluate the Internet access and digital skills of individual patients on a regular basis may prove to be even more demanding. The authors of the article suggest that patients should be asked about the devices they have access to and how they connect with the Internet. Having these data, a clinician can determine which technologies may be used for treatment support and communication. What is more, a notice regarding the social determinants of health should be included in the patient’s electronic medical records to allow the patients’ level of digital competence to be monitored. But are patients ready to reveal such information to the doctor? This includes sensitive data, such as economic status, level of education, or workplace. Have doctors the right to ask for such information that is not directly associated with treatment or prevention?
If access to digital services is considered an essential element of social life, one can refer not only to economic but also to “digital poverty.” Those affected by “technological poverty” could be included in training programs and qualified for equipment financial support.
When implementing digital innovations, both the potential benefits and the risk of marginalization of neglected groups should be considered. Otherwise, people with better health, not those who really need help, will benefit from digitalization. The aim of technological advances is to allow access to medical services, not to hinder them. Even if digital poverty concerns several or more than a dozen percent of society, it is unacceptable as it contradicts the idea of fairness and equality in health protection.
The introduction of the technology access factor and the ability to use the technologies with respect to social determinants of health is entirely reasonable. This is about awareness, developing the doctors’ digital skills, and smart investment of public funds in digital health solutions. It will be much more difficult to find specific solutions that minimize the digital gaps.