Digital connectivity and equity are increasingly seen as vital to health

From behind the plexiglass barrier of her improvised help desk in the hall of the Scranton Castle senior apartment complex, Marielee Santiago passed out masks, hand sanitizer, COVID-19 info and asked residents, "How's it going with your laptop?"

In partnership with DigitalC (a nonprofit focused on improving Greater Cleveland's digital literacy and access) and with funds from Dollar Bank, MetroHealth System had helped connect units in the building with laptops, internet service and computer training, though COVID-19 limited the education piece. So, along with representatives from DigitalC and an AmeriCorps member, Santiago, director of transformative knowledge and education at MetroHealth's Institute for H.O.P.E. (Health, Opportunity, Partnership and Empowerment), staffed the temporary desk at the West 25th Street facility, part of the Cuyahoga Metropolitan Housing Authority.

She taught a patient how to connect online with his provider for a prescription, showed another how to send a photo of his rash to his doctor via MyChart and helped a resident follow up with her psychiatric appointment remotely when all behavioral health visits were being done virtually or telephonically. Before her leadership role, Santiago, a social worker and leader within the Hispanic community, connected patients with resources for low-cost internet and educated them on their broadband access.

The pandemic has heightened awareness, buy-in and understanding that digital equity is truly a need for healthcare, Santiago said.

"There may have been providers that didn't think (about it) before, or didn't have that lens before until they came across this pandemic and realized, 'Wow, I have a whole slew of patients that are not able to access virtual care and telehealth appointments,' " she said.

MetroHealth is not alone in supporting digital access in the community. The Cleveland Clinic, DigitalC, TransDigm Group Inc. (NYSE: TDG) and the Lubrizol Foundation announced a partnership last year to provide affordable high-speed internet for Fairfax residents to address disparities in internet coverage.

University Hospitals this summer announced it would team up with PCs for People, a nonprofit providing refurbished computers, to help patients stay connected with laptops, hot spots and three months of broadband service to eligible UH patients. UH is also building WiFi towers on two of its locations and is engaged in a broadband expansion project in East Cleveland.

The Federal Communications Commission selected MetroHealth to participate in the digital equity program, making the system eligible to receive up to $901,000 in federal funds over the next three years for its work at the CMHA facility and in the Clark-Fulton neighborhood.

DigitalC this summer received a $20 million combined commitment from the Jack, Joseph and Morton Mandel Supporting Foundation and the David and Inez Myers Foundation to help it expand capacity and speed up adoption of its broadband infrastructure, which DigitalC CEO Dorothy Baunach said is a call to get people connected and ensure it has the right impact on health, education and economic opportunity.

Amy Sheon, a Cleveland-based digital health equity consultant, said there has been a "groundswell" of recognition to include digital connectivity as a social determinant of health — the economic and social conditions that impact health.

With a greater reliance on digital tools (such as patient portals, health trackers and remote monitoring devices) comes the potential to increase disparities between those who have the skills and access to the tools and those who don't, and therefore, to increase existing health disparities as well, according to a paper, "Digital inclusion as a social determinant of health," published in March.

Hospitals are "highly motivated" to connect with their patients electronically, said Sheon, an author of the paper. Virtual care's benefits were obvious during COVID-19, when, in many cases, it was safer for patients and health systems to connect remotely, and it enabled patients to continue care when, nationally, there was a drop-off of preventive care and chronic illness management.

Even more impactful, she said, is the ability for patients to get connected so they can use the internet for everything it helps people do today.

"We know that income, education and employment are much more important factors in people's health overall than healthcare," said Sheon, who consults for the Clinic, UH and DigitalC through her consulting firm, Public Health Innovators. "And so if healthcare can help people get connected to the internet, so that they can get an education, get jobs, increase their income, their health is going to improve."

Virtually connecting to a provider can help, at least temporarily, break down barriers posed by other social determinants of health. For instance, connecting remotely allows a patient to seek care without having to find transportation, miss work or secure child care — all of which may be difficult for an in-person visit.

Telehealth in and of itself, however, won't change the upstream conditions that have put up those barriers and caused certain populations to face them, Sheon said. Meaningful digital connectivity can help address multiple barriers while also helping patients get access to their doctors, either for virtual visits or through the patient portal.

Stacy Porter, vice president of Consumer Centric Strategy for UH, said she considers digital equity to be a social determinant of health.

"If you would have asked the question five years ago, or maybe even two years ago, I think we would have all had to pause and think about what does that even mean?" she said. "But today, it seems so clear that absolutely, that is a risk point; it's a factor."

Porter expects to see a formalized movement toward digital connectivity being universally considered a social determinant of health, just as tobacco use or physical activity are. The issue will only become more intense and the gap more transparent going forward, she said.

Dr. Akram Boutros, MetroHealth president and CEO, was publicly discussing the importance of digital connectivity and the lack of internet availability in the neighborhoods surrounding the system's main campus well before the pandemic. He called attention to the issue at MetroHealth's 2019 annual meeting, where he committed to connecting neighbors within a 3-mile radius of the campus to affordable, high-speed internet with the help of community partners.

The initial commitment of 100 households with a goal of 1,000 also included providing free training (in English and Spanish) on how to use computers and a free laptop — though other initiatives that connected homes with devices during the pandemic have allowed the system to shift its focus a bit for the device portion of the initiative, Santiago said. So far, they've connected more than 350 households through the initiative.

MetroHealth first began screening patients for social determinants of health with the 2019 launch of its Institute for H.O.P.E., which opted to add digital connectivity to the standard set of screening questions.

Dr. Steven Shook, Cleveland Clinic's lead for virtual health, said the system routinely collects information on a number of social determinants of health, including tobacco and alcohol use, financial resource strains, transportation needs, food insecurity, housing stability, intimate-partner violence, physical activity, stress, depression and social connections.

Information on digital literacy and broadband access is not specifically collected currently, but Shook said the Clinic sees an opportunity to do that, and it's something leaders are discussing.

"What we wanted to do first I think is really get a sense of where our opportunities are to improve first, and that starts with just being able to measure what the digital divide is so that we can target our interventions appropriately," he said.

UH and other providers are understandably excited about the doors telehealth has opened and the new, creative ways they can offer care to patients, Porter said.

"But we can't do that and lose sight of those patients who need and require more traditional types of care, or who need more help, more coaching, more access," Porter said. "We are committed to not leaving any patient behind, and so that has to be part of our focus."

Until every individual in every neighborhood has the ability and knowledge to connect across the digital divide to telehealth and other resources, "we have not succeeded," DigitalC's Baunach said.

"(It's) incumbent on the education system, on the healthcare system and on the economic development and opportunity system to make sure that every person can thrive and has equal access to this fundamental infrastructure," she said. "It's just like water or electricity back in the 20th century. We've shut off these neighborhoods from their basic fundamental access to things that determine social determinants of health."