Rae Woods: From advisory board, we are bringing you a radio advisory. My name is Rachel Woods. You can call me Rae. We are officially back from our summer vacation and we are ready to dive back into some of the biggest questions the health healthcare industry is grappling with. The COVID-19 crisis has changed so much of our business, and frankly, it's changed our lives. And there's perhaps no better example of this than the dramatic increase in our use of technology. I use it to connect with my family, to order groceries, and now many of us rely on digital solutions to connect with the healthcare system. Most say that this change is long overdue, but if we're not careful, we might actually have a new problem to deal with, the problem of digital inequities. So today I brought digital health researcher, Ty Aderhold to talk about the equity impact of all these digital investments. Hey Ty, welcome to Radio Advisory. Ty Aderhold: Thanks for having me Rae. Rae Woods: We are officially, or I guess almost officially at fall. Are you excited for fall weather or are you going to miss summer? Ty Aderhold: I'm not going to miss summer at all. I feel like the past couple of weeks here in DC, the weather has been just very hot, very humid. I'm just ready for some cooler weather. Rae Woods: Yeah. People call it a swamp because of the politicians. And they don't realize that no, it's actually a swamp. Well Ty today, we're going to be talking about the equity impact that comes with an entire industry's renewed focus on technology in healthcare. When I talked to other leaders, they all kind of call this thing, the digital divide, but I'm not sure that that's the right terminology. And I should acknowledge that you and I have called this problem the digital divide in the past, but we've since changed our tune. Why is that? Ty Aderhold: Digital divide I think, is something that is very common for people to say. It's catchy. The alliteration is powerful, but I don't think it actually captures the real issues that are at stake here. First is it sets up this sort of binary where there's a group of people who are on one side of the divide and a group of people that are on the other. And when we think about the equity impact of technologies, it's much more of a fluid spectrum than just people who do have, and people who do not. Rae Woods: First of all, it's not binary, but also making it binary is kind of problematic in its own right because it sets up this uttering, this your on the other side of the tracks kind of thing that we don't want to put into our conversation about equities. Ty Aderhold: Exactly. And I think it also sets up another classic phrase that you can hear is bridging the digital divide. Rae Woods: Bridging the gap. Yeah. Ty Aderhold: Exactly. And that sets it up to come across as an infrastructure issue. Right. And infrastructure is a small piece of this when we think about broadband and where the broadband wires go and who has access to it. But it's so much more than that. And so by using the term digital divide and getting people to think about bridging it, it immediately puts them in a mindset of this is an infrastructure issue. Rae Woods: So we're not going to be calling this, the digital divide in today's conversation. What terminology should we be using instead? Ty Aderhold: Our team landed on digital inequities after we did this research, just because it's really is able to encompass the full scope of all the potential things that might cause someone not to be able to use a piece of technology. Rae Woods: And you've already started to get to this idea that there are a lot of myths and misconceptions around this topic in general. So I want to run right at that from the beginning. When people talk about digital inequities or when they use maybe some of this incorrect terminology, what are they typically thinking about? What do they focus on and maybe what do they miss? Ty Aderhold: I already hinted at it. The biggest thing is they think about infrastructure and they think about broadband access itself. And that's important. You have to have broadband access, but it is so far from being the only limiting factor here in getting people connected. Because of that focus on broadband and infrastructure, so many other pieces are totally forgotten or just aren't focused on by organizations when they think about this issue. Rae Woods: Like what? Ty Aderhold: The biggest that our team thinks needs to become sort of more top of mind for organizations is digital literacy. So digital literacy is the ability to use a laptop or navigate on a cell phone. But it also is the ability to interpret what you're seeing online and understand what it means, understand if it's a trustworthy source or not. Digital literacy is a huge problem and it's a hard one to solve. Rae Woods: And what you're getting at is the fact that digital inequities is not only a hard problem, it's a huge problem, right? There's all of these different puzzle pieces that impact an individual's ability to use healthcare technology successfully. But it's also part of something even bigger, which is health equity more broadly. How does digital inequities impact this broader theme of equity? Ty Aderhold: Digital inequity is a social determinant of health. Just like any of our other social determinants of health that we think about in general, if it's housing or food insecurity. And it's actually something that can influence and affect some of those other social determinants of health as well. If you think about something like getting a job, most job applications are online. And for most jobs you need to have a resume and to build a resume, you need access to a computer to be able to build a word document. And that's just one small example. It's something that influences really every part of our life these days. When you think about just basic use of technologies and computers, these days, even something like social interaction. We rely on technology so much that if you're not able to use technology, it's another barrier to social interaction. It can lead to isolation. Rae Woods: I think this part is new for most folks, right? We think about social determinants in terms of housing, and education, and access to food. But this pandemic and the pandemic experience more broadly has forced a lot of people to come to terms with the fact that this is a social determinant of health in itself and affects all of the other things that you've been talking about. And frankly, that's the aha moment I want folks to have, rather than the fun alliteration of digital divide. Ty Aderhold: I want to clarify that this is something that's been happening for decades now, Rae Woods: Sure. Ty Aderhold: As society has been investing in technology, but our research team, even we had one or two pieces of research on digital inequities, but it was not a focus. And I completely agree that this pandemic has brought it to light in a new way for so many people. Going forward, it should not just be when we're having to stay at home and socially isolate that we think about these issues. It should be something that now is a part of every time we're developing new technology or investing in new technology. We should be thinking about how that can lead to inequities. Rae Woods: And this is where I want to start talking about how big of a problem this is. You are exactly right, that this isn't new. But I do think that it is bigger because of what's happened in the pandemic and what will come in the future. So help me understand how big of a problem is digital inequities. Ty Aderhold: So we think about video visits for example, this is something that in healthcare, so many organizations have had to pivot towards video visits. But right now, one in four Americans either don't have the technology, the access to broadband or the digital literacy in order to participate in a video visit. And so I think that just gives you the scale of how many Americans we're leaving behind, as we assume and pivot to video visits as perhaps a new normal for certain types of care. Rae Woods: Absolutely. I have definitely been in rooms, virtual rooms, I will say where providers are saying, we can't do this unless we get better data from the payers or more reimbursement from the payers. And payers are saying, hey, you're not actually picking the lower cost solution compared to in-person care. So we don't have an incentive here either. And everybody is kind of pointing fingers at each other and looking to the industry to build this magical product that's just going to solve everybody's problems. Ty Aderhold: Right. Rae Woods: So what's your message to all these different constituencies? Why should they care about digital inequities and why should they be working together to solve these problems? Ty Aderhold: We've reached a point where technology and digital health more specifically is the hot thing to be investing in. We see organizations across the healthcare ecosystem, investing in it. If you're investing in these technologies without thinking about how you will address digital inequities and how you'll make sure to somehow meet the needs of patients who may not be able to use these technologies currently, or may not have access to a device or broadband, then you're actually just making the problem worse and exacerbating some of these existing inequities. Rae Woods: And frankly, that will require these different constituencies to be thinking about the downstream impact first. As an example, thinking about what the downstream impact of calling it the digital divide or bridging the gap could have on real people who go wait, I'm not on the other side of the tracks here. How do you recommend that these leaders think 10, 15, 20 steps down the line to make sure that they're appropriately addressing inequities and not to your point, making the problem worse? Ty Aderhold: Step one is considering these issues as you are evaluating new products or changing your current system or evaluating different technologies. And I also want to make sure to highlight that this is not just about video visits or a digital health app. This is as simple as your website and how easy it is for a patient to navigate your website, whether your website is in multiple languages, and also about something like a patient portal or a secure messaging app. So there's so many different technologies that we may not even realize are being used to connect with patients. And we really need to be thinking about all of those and early on in the evaluation and building process of those to make sure that we're at least mitigating any potential negatives impacts. Rae Woods: A running joke on this podcast is that I tend to be a little bit of a pessimist. I would like to believe that that's what makes me a good researcher, but I'm going to put on my pessimists hat for a moment and kind of ask you to peer into your crystal ball and say 10 years into the future. I sort of believe that there's a lot at stake and there's a lot that can go wrong. In your mind, what's the risk 10 years from now if leaders don't actually get this right? Ty Aderhold: I think the biggest risk is that we end up creating a two tiered system where healthcare looks very different for people who do have access to technology and the ability to use it, versus those who do not. Part of the value proposition for investing in digital health and these technologies is the idea that we're improving access, right? That we're- Rae Woods: Yeah. That it would be the major democratization of access. This will bring healthcare to all patients in the simplest way. That's what people have been screaming from the rooftops for the last 18 months. Ty Aderhold: Right. But if we get this wrong, if we don't think about digital inequities, we're just going to improve access for people who already have great access to technology, know how to use it. These are typically going to be people who are getting better healthcare already. And so we're just, making it easier for them, which is great. But on the other end of the spectrum, we're doing nothing for people who maybe don't have great access to healthcare already. Maybe they have transportation issues. Maybe they live in a rural area that's really far away from providers. And if we don't address their digital inequities, their care is going to stay the same while this other groups get so much better. And we'll end up with just a fully two tiered system where care looks very different for those groups. Rae Woods: By the way, it takes me back to health equity. That is the opposite of every organization's mission statement. So let's get ahead of it now. And we'll actually be talking about the impact of technology 10 years into the future in kind of a retrospective in a future episode. So we'll spend a lot more time talking about this. Ty, so far we've been mostly talking about the problem. We've talked about what digital inequities actually mean, why it's a big deal, what folks are getting wrong. And I know that we've been talking about it in the sense that it is a huge problem and it is, but I have to believe that there are some easy things that leaders can do to reduce digital inequities. What are those? Ty Aderhold: The first, I think is that to harken back what I mentioned earlier, is around how you evaluate platforms. But I think beyond that, there's a few other pretty easy steps you can take. The first is, adding it to your risk assessment as you're interacting with patients, just to get better data on, do they have access? If I offer them a video visit for their follow-up care, will they be able to join or not? Those small pieces of information can go a long way to at least understanding the problem in your area. Another really easy one that I would recommend everyone look into is opening up your wifi network at your building. This can make it easy for people to use the wifi at your building, or even in the parking lot. We heard stories during the pandemic of patients driving up to a parking lot and having a video visit from their car. And now obviously that requires a patient to have a car. So this isn't going to work for everyone, but it is a very basic step that your organization can take. Rae Woods: Somebody who sat in a lot of waiting rooms, I love this recommendation. Now let's talk about the hard stuff. And I know there is probably mostly hard stuff because digital inequities and social determinants of health in general are massive problems that I don't think any individual organization can actually tackle alone. What are some examples of partnerships that you've seen form to tackle some of these really big structural, maybe even more expensive aspects of digital inequities? Ty Aderhold: Sure. And I think, to add on to that for some of these issues, the health system is not set up to be the best organization to respond to this. So that's another reason to really think about partnerships here. One area I think is prime for more partnership and more investment is digital literacy. This is an area that is especially challenging to solve because it involves ongoing education. You can think about it. Digital literacy is a moving needle as technology advances. So do people's understanding of how to use technology needs to advance. And so when we think about digital literacy partnering with existing organizations, such as public libraries and community centers that already offer some of these programs is a great way to start having a local impact on digital inequities. Rae Woods: I keep talking about the fact that this is a huge problem, and Ty you've been giving so many good examples of how to start to tackle digital inequities, but I can imagine it might be overwhelming for some folks. So how do you recommend that our listeners actually prioritize their efforts here? Ty Aderhold: It definitely can be overwhelming. I think that's okay to acknowledge. And you do what can hear. I think step one has to be looking at your existing technologies, what you've already invested in, whether it's your video visit platform, whether it's your website, there are certain things you've already invested in and you need to go back and evaluate, are we doing this as best we can to mitigate digital inequities? Are we translating things correctly? Do we have a speech to text option on our video platform? There are small things you can evaluate there. Second, I would say it's adding it into your new investments. As you think about investments you're making in digital health, what is their impact going to be on digital inequities? And then I think the third piece, which is a very important piece is finding those partnerships in local community to help organizations that are providing digital literacy education, or help organizations that provide lower priced broadband, or let individuals come use computers and broadband at their locations. Rae Woods: And if I could add to that, the thread that probably ties all three of those steps together is you need the right team to be doing all of those things. And you need a team that's multidisciplinary that comes from different parts of the organization that represents different backgrounds, whether it's languages or different disabilities. Because the worst thing is that you miss that, hey, our website doesn't have multiple language options. And also what do we do for people who are blind, right? And you need that team to be able to find those problems. Ty Aderhold: Exactly. Rae Woods: Let me ask you the opposite now, are there some mistakes that you want to help our listeners avoid? Ty Aderhold: People think too narrowly about digital inequities, and they don't think about social determinants as a whole. An example of this would be loaner devices. So this is a common solution that organizations employ. They give out device for the patient to connect back for a video visit or the like, but very often those devices are completely locked out. So if the patient isn't using it for a video visit, they can't use it for anything else. But we did talk to one organization, Seattle Children's, who has basically allowed that device to be used for any sort of internet purposes. And it comes with a hotspot and in fact the entire family is able to connect to that hotspot and use that broadband access more broadly for other parts of their life. The example they gave us is letting the kids use it for schoolwork. When you think about that, this one loaner device is having such a bigger impact than it otherwise would be because it's able to impact education and all of these other larger social determinants of health. Rae Woods: Yeah. And it seems silly to give somebody a very expensive brick, 95% of the time. Ty Aderhold: Right. Rae Woods: And to your point to address some of the real root cause in the community, not just in health care or in that particular problem of access. Well Ty, I really appreciate this kind of candid conversation. I want to give you the moment to give our listeners one takeaway or one action item. When it comes to digital inequities, what do you want our listeners to focus on? Ty Aderhold: I would say beyond what we have talked about, that its local scale or organizational scale, we also need to consider sort of the national level and to get there, we have to have advocacy. We need to convince policy makers that digital inequities are a social determinant of health and they need to address them. A key wrinkle to all of that is an issue of affordability. I haven't brought it up yet, but I think it's so important to think, not just the infrastructure of is there broadband access here, but also can people afford broadband access or afford a cellular data plan. And if we don't think about that, we're not going to see the progress that I would certainly hope could be made here. Rae Woods: Well Ty, thanks so much for coming on Radio Advisory. Ty Aderhold: Thanks for having me Rae. Rae Woods: This conversation is such a good example about how we want yours to be thinking about health equity period. We know that there is an equity impact to virtually everything that we do. So like Ty said, we have to start with the investments we've already made and understand where are our gaps and maybe even where have we made the problem worse. And at the same time, we need to continue to make investments to actually make inequities smaller. We've added some links to our show notes, because remember, as always we're here to help.