CLEVELAND—Shortly after University Hospitals opened online scheduling for the COVID-19 vaccine, hospital operators were fielding calls from patients without email or internet asking, "How am I supposed to schedule a vaccine?"
UH was able to quickly identify this gap thanks to the manager of hospital operators raising the alarm bell, as well as doctors hearing similar questions from their patients, said Dr. Robyn Strosaker, chief operating officer of UH Cleveland Medical Center.
"We were actually really grateful for those phone calls to the hospital operators, saying, 'Hey, you forgot about (those of) us who can't access the internet and don't have email,' " Strosaker said. "The last thing we wanted to do was create a barrier to access, so we were happy when somebody pointed out and said, 'Hey, we can't access the way you've designed; you need another way.' "
Within 12 hours of launching the preregistration process on its website, UH developed a phone number for patients looking to schedule.
The health care providers, departments and organizations leading the charge to get the community vaccinated don't have expertise or direct experience in mass vaccination. The process has involved a lot of learning and adjusting on the fly to fill gaps when they were recognized.
The digital divide has become a significant gap in the vaccine rollout. It's also a problem others in the community have been pushing to address for years prior to the pandemic, which has exacerbated the disparities in technology access and literacy, as well as given it heightened attention.
Amy Sheon, a digital health equity consultant, has spent eight years urging health systems to be concerned about disparities in their ability to digitally engage with patients. Early last fall, she saw a shift.
"All of the sudden, the health systems that I have been kind of banging on their doors for eight years started calling me," she said.
After almost a decade directing the Case Western Reserve University School of Medicine's Urban Health Initiative, she shifted her focus full time to her consulting firm, Public Health Innovators.
Sheon saw an opportunity to make an impact on digital engagement and the health of underserved populations, after years of difficulty gaining attention and traction on the issue.
"People who have been digitally connected 24/7 for five or 10 years cannot fathom themselves living without 24/7 connectivity, and therefore they cannot even envision that everyone else doesn't have it as well," she said.
Sheon sees three groups of people being impacted by the digital divide: rural populations with an infrastructure barrier to getting the internet; people with cognitive or physical challenges with adopting the internet; and poor people who cannot afford the internet or live in urban underserved areas where affordable high-speed internet isn't available.
"The internet service providers have discriminated and not brought high-speed broadband to core urban areas," Sheon said.
MetroHealth has been doing outreach online, in-person for those walking into the clinic, and via the phone, which has been a huge part of the system's equity efforts, said Dr. Dave Margolius, division director of general internal medicine at MetroHealth.
"From the beginning, we recognized right away that just given Cleveland's legacy with redlining, that there are huge swaths of city, particularly where our patients live, that don't have access to high-speed internet," he said. "And so the phone has been a big part of our approach."
MetroHealth has been doing targeted phone outreach in neighborhoods it knows have the lowest likelihood of reliable internet access, he said. Also to help determine where to focus outreach, the health system monitors a map that tracks the percentage of patients in particular neighborhoods who are vaccinated, as well as other demographics, to see what populations might be falling behind.
The digital divide disproportionately affects communities of color, said Maggie Rivera, a member of the board for the Hispanic Roundtable who chairs the digital divide coalition and has been working on this issue for five years. On top of the digital literacy and access barriers, challenges often are compounded by a language barrier, she said.
The current patchwork of ways patients can schedule their vaccinations is not a good system and involves a lot of community leaders and organizations filling gaps, Rivera said, adding that she applauds the work of the nonprofit organizations helping to Band-Aid the system.
"It really is local community organizations, churches, health departments really just trying to do a grassroots effort and really scraping and clawing to figure out how do we get this information out?" Rivera said.
One of these stop gaps is a duo who's been dubbed the Vaccine Queens. Stacey Bene and Marla Zwinggi began their efforts separately by each helping their family members and friends — and then friends of friends — navigate vaccine scheduling. Eventually the two were connected and have been spending they estimate 10 to 12 hours a day helping strangers get appointments for a COVID-19 vaccine.
Someone reaching them is usually at their wits' end, having tried unsuccessfully for days to get booked.
"I have the privilege of time, for sure," Zwinggi said. "I don't expect people to do this. People who work in the service industry, they work long hours, it's not fair to them. Stacey always says if not us, then who is going to do it? We can do it."
In the initial weeks of the vaccine rollout, Cleveland Clinic sent patients notices through the system's patient portal, MyChart, as well as emails and texts, and then followed up a day later with a phone call to those who didn't respond. It was a campaign that was taxing on the system's resources, said Dr. Michelle Medina, associate chief of clinical operations for Cleveland Clinic community care who is serving as one of the physician leaders for vaccine rollout.
As the eligible population expanded, the Clinic needed to simplify the process, while ensuring there's a doorway for every patient who wanted to get vaccinated, Medina said. People can connect via MyChart, a web portal or via phone to help those who don't have smartphones or access to the internet.
"We will continue to encourage folks to sign up for MyChart — not just because of the vaccine campaign, but really and truly, it's access to your entire interaction with the medical system," Medina said, adding that the Clinic wants to facilitate that in any way it can moving forward.
Sheon identifies several tactics and campaigns that could help reach those not digitally connected. For instance, providers with patient portals could have messaged to systematically ask every patient the provider is connected with whether they have any seniors in their family or that they take care of who need a vaccine. Could that patient be a proxy to setting up a portal and getting the vaccine for that family member?
Another option, Sheon said, could be to partner organizations that already engage with seniors to add vaccine information into any current messaging — for instance, working with utility companies to add messages to bills.
"Everybody should use every mechanism that already exists; we don't need to set up new mechanisms," Sheon said, but she hasn't seen these approaches used systematically.
Rivera believes Cleveland actually had a head start compared to some cities in managing the digital divide, thanks to the work of various community partners and organizations, such as DigitalC's efforts to build the infrastructure to provide internet service to certain Cleveland neighborhoods.
Still, the problem is one that will take a lot of time and effort to solve. And for now, leaders are often left to very old-school, traditional ways of distributing information, Rivera said.
"It's kind of like we're using horse and buggies while the rest of the world is in a Lamborghini," Rivera said.
This story first appeared in our sister publication, Crain's Cleveland Business.
