Advancing Digital Health Equity in a Safety-Net Health System: Identifying Barriers, Evaluating Training, and Assessing Impact on Diabetes Outcomes

Abstract

Digital health technology, including patient portal use and telehealth visits, has been increasingly utilized across healthcare settings, transforming how individuals access healthcare and contributing to improved quality of care. However, there are differences in which types of patients use digital health technology, stemming from multi-level factors at the structural, contextual, and individual levels. Without better evidence, improved methodology, and proactive interventions to reduce inequity and promote equity, these disparities will persist as the digital divide widens. This dissertation is centered on the experience of individuals at San Francisco Health Network, an urban safety-net health system. Across three papers, I employ novel qualitative and quantitative methods to address critical questions about marginalized populations and digital health technology use, thereby filling gaps in the literature and advancing digital health equity. In the first paper, I employ mixed methods to examine fundamental skill and usability barriers to digital health technology use. Notably, I highlight critical gaps in digital literacy, particularly in device navigation and processing complex tasks, that prevent effective use of these tools, and the need for usability-driven improvements to reduce digital barriers. The second paper uses a zero-inflated negative-binomial generalized linear mixed model to evaluate the impact of person-centered digital training on patient portal uptake and use, considering sociodemographic factors, clinical characteristics, and digital engagement. I identify that patients who participated in tailored training saw a 91% relative increase in average monthly portal users, compared to a 12% relative increase among those who received basic digital support only. More specifically, the basic digital support program especially benefited Spanish-speakers who demonstrated an 80% increase in login counts, although the tailored training significantly benefited participants with low baseline engagement and resulted in a fivefold increase in login frequency compared to pre-intervention rates. The final paper leverages the widespread adoption of digital health technology and remote care engagement in health systems and uses a linear mixed-effects model to examine how combined in-person and remote care utilization patterns impact longitudinal changes in A1c control, and whether these patterns differ across key sociodemographic factors. I found that multiple remote and in-person care utilization patterns were associated with modest but clinically meaningful differences in glycemic control. Specifically, the degree of A1c improvement followed a clear gradient across care patterns, with the least improvement among patients with little or no care and progressively greater gains as remote and in-person modalities were combined, underscoring the value of hybrid engagement for chronic disease management. However, these associations varied by sociodemographic characteristics, revealing disparities in access, adoption, and effectiveness of in-person and remote engagement across patient groups. Together, these papers outline the growing issue of disparities in digital health technology use and pinpoint solutions and evidence to support accessibility and equitable use. These papers highlight the skills needed to use digital health technology effectively, the role of digital skills training in promoting the use of these tools, and the benefits of engaging in care remotely on patient health outcomes. However, a common thread across all these papers is the persistent presence of disparities and barriers among marginalized populations, and how the influence of these barriers extends beyond disengagement with digital health technology but also affects health outcomes. In my concluding chapter, I summarize these findings and suggest areas for future research. As digital health technology becomes more widely adopted in healthcare delivery, and the risk of disproportionate uptake and use of digital health technology becomes more pronounced for marginalized populations, this dissertation provides a strong scientific framework through which new strategies to reduce disparities, and the digital divide can be developed. These results will inform healthcare systems about innovative and equitable interventions and strategies to reduce inequity in digital health technology uptake and use and promote equity.