Online Health Tools Might Not Help The People Who Need It Most

Tons of money has been poured into digital health technologies, from electronic health records to a smartphone case capable of taking an electrocardiogram. But not everyone may benefit, and e-health interventions may widen, not shrink, health disparities.

Patients who were poor, black, older, unmarried or on Medicare or Medicaid were less likely to use an electronic health record portal to manage their chronic kidney disease, according to a study published Thursday in the Clinical Journal of the American Society of Nephrology.

That's especially worrisome because there are already big differences along race and socioeconomic lines when it comes to chronic kidney disease, says senior author Khaled Abdel-Kader. "When you see these disparities sort of reinforced by new technological disparities, that is a bit worrisome that we may be taking a step back," says Abdel-Kader, who is also an assistant professor of medicine at Vanderbilt University.

The study looked at roughly 2,800 patients at four university-affiliated nephrology offices in western Pennsylvania from 2010 through 2012. The online portal gave patients the ability to look at lab results, communicate with their providers, get prescription refills, review their medical information, schedule or change appointments and more.

Over the three-year period, almost 40 percent of the patients used the portal, but those patients were more likely to be white, married, young, on private insurance and with a higher neighborhood median household income.

The researchers also looked at blood pressure control, a factor that affects kidney disease and the likelihood of needing dialysis, as well as stroke and heart attack risk. They looked at whether patient use of the portal could lead to things like improved use of medication or more communication with providers, perhaps improving blood pressure as a result. While Abdel-Kader says the number of patients in the study wasn't large enough to say if there was a definite effect of use of the portal on blood pressure, there may be a modest benefit.

"Despite the increasing availability of smartphones and other technologies to access the Internet, the adoption of e-health technologies does not appear to be equitable," Abdel-Kader says. "As we feel we are advancing, we may actually perversely be reinforcing disparities that we had been making progress on."

Previous studies, including one looking at patients with diabetes, have found similar results, in that underserved populations are less likely to use patient portals, he says.

The solution, Abdel-Kader says, is to figure out why people aren't using the portals, and make sure they've got tools that work for them before things get worse.

While the barriers from patient to patient will vary, Abdel-Kader says in this case, obstacles might have included patients' confidence and skills in accessing health information on the web; comfort level in communicating with a provider via the portal; and worries about the security of the information and access to the Internet, whether via computer or smartphone.

Patients in the study could learn about the portal through fliers and pamphlets at the clinics, but they weren't given any training on how to sign up or use the portal.

When creating an e-health intervention, providers might consider surveying patients ahead of time to see how they access the Internet, whether they prefer to use a smartphone or a computer, or whether they might like to receive training, says Mallika Mendu, an attending physician and director of quality and process improvement in the renal division at Brigham and Women's Hospital in Boston who co-authored an accompanying editorial. The key, Mendu says, is to better understand the patient population before creating the tools.

"Even with all of the innovation exploding throughout the health care industry, there is a reluctance, a blind spot, to design for diversity in consumer engagement," says Vanessa Mason, founder of Riveted Partners, a digital health consultancy that advises enterprises and startups on consumer engagement and behavior change, in an email interview. "Patient portals often export health care's one-size-fits-all mentality through technology, without considering issues such as lack of broadband internet access in the home and differences in digital literacy."

The potential for making existing health disparities even worse should be "panic inducing," Mason says, given the high burden of chronic disease in vulnerable populations. But that presents an untapped opportunity as well: to design products and services tailored to those people, says Mason, who also serves on the health IT advisory board for the Transdisciplinary Collaborative Center for Health Disparities Research at Morehouse School of Medicine.

Like the researchers, Mason says people from underserved populations need to play a role in designing these interventions. For example, patients may think that text messaging is more convenient, she says, and is something that "doesn't require people to spend their limited income on mobile data plans or broadband Internet at home."

The field of medicine can't afford to be left behind, editorial co-author Mendu says. "Whenever you can empower patients and help patients feel like they're really working with you as opposed to being told what to do I think there's a huge upside there."