Digital Inclusion as Health Care — Supporting Health Care Equity with Digital-Infrastructure Initiatives | NEJM – nejm.org – DC Initiative on Racial Equity
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Opportunities for Health Care Organizations to Increase Digital Inclusion through Infrastructure Initiatives.

As health care has shifted to increasingly rely on digital tools for patient care, digital inclusion has become critical to promoting health care equity. The recently enacted Infrastructure Investment and Jobs Act (IIJA) makes investments that could foster sustainable digital inclusion. Although the law isn’t focused on health care, it addresses long-standing drivers of digital health disparities, presents new opportunities for community-based digital inclusion, and could be a critical lever for improving access to care. We believe it’s important for health care organizations to understand the opportunities the law presents, to advocate for its effective and equitable implementation, and to take advantage of improvements to digital infrastructure (see table).

With digital health tools such as telehealth and patient portals becoming prominent components of care delivery, the barriers to digital inclusion have grown increasingly apparent.1 For example, more than 100 studies have revealed disparities in portal use based on age, race, socioeconomic status, English-language proficiency, and other factors.2 Digital inclusion refers to “the activities necessary to ensure that all individuals and communities, including the most disadvantaged, have access to and use of [digital tools].”3 Structural barriers to digital inclusion, such as digital redlining, have limited the reach of digital health tools. Digital redlining entails “discrimination by Internet service providers in the deployment, maintenance, or upgrade of infrastructure or delivery of services.”3 Communities affected by digital redlining are generally the same ones that already have poor health outcomes. Health care systems have, by necessity, implemented digital tools in communities affected by digital redlining to reach underserved patients and combat health disparities.

Beyond digital redlining, limited broadband infrastructure, high prices for broadband service, and lack of access to Internet-enabled devices have made deploying digital health tools difficult. At least 21 million people in the United States don’t have broadband access, which has constrained the use of telehealth. People living in areas with low broadband access are less likely to make use of video visits than people in areas with more widespread access. The digital health expansion fueled by the Covid-19 pandemic has also made evident the importance of digital literacy for empowering patients to engage with this new care model. Delivering equitable care to underserved patients requires an inclusive system that ensures access to affordable broadband, Internet-enabled devices, digital-literacy supports, and appropriately designed platforms.

In this new digital care environment, health care organizations are playing an important role in addressing digital divides. Organizations are developing dashboards to better measure digital disparities and guide systemwide solutions. Some


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