E-health equality for all: Kaiser Permanente’s efforts to identify and address digital health disparities

Terhilda Garrido, MPH

By Sengyeon Lee

Technology and communications that support health care delivery empower people to take an active role in their care.

“It’s shifting who is in the driver’s seat,” says Terhilda Garrido, Vice President of Health Information Technology Transformation/Analytics at Kaiser Permanente. “Not only are patients going to visit their doctor in person, but they are also using emails and phone calls to connect with their providers.”

Kaiser Permanente’s electronic health record system—KP HealthConnect®—is the largest and one of the most comprehensive non-governmental systems of its kind and is leading edge in the expanding eHealth movement. “We’re increasing access and to some degree reducing the pressure on face-to-face visits. There are more touches with patients,” says Garrido.  More contact has resulted in more effective care.

But not all people have equal access to these technologies and tools.  Some patients have trouble understanding how to use the technology, others face barriers of affordability or language, and for many it comes down to trusting the security of their personal information.  These and other issues cause disparities in eHealth use that can worsen over time: As technology advances, non-users may be left behind in terms of quality of care, service and health outcomes.i Since 2009, Kaiser Permanente researchers have been examining the relationship between members’ demographic and socioeconomic characteristics and their use of the online patient portal, My Health Manager, to identify potential disparities and address them.  Interventions based upon these findings have focused on overcoming privacy concerns, providing tools to address language barriers, and optimizing usability.  This brief examines Kaiser Permanente’s research into the factors that influence digital health equity and offers insights from Terhilda Garrido on how the organization is finding solutions.

How Technology Can Improve Health

Health information technology matters; it can positively affect quality of care and health outcomes.  Kaiser Permanente researchers found that use of secure email by patients to connect with their physicians was associated with a 2.0 to 6.5 percent improvement in Healthcare Effectiveness Data and Information Set (HEDIS) measures of glycemic levels, cholesterol, and blood pressure.ii Another study found that non-Hispanic whites, Latinos, and African Americans who viewed their personal health records had increases in their HEDIS scores ranging from 1.3 to 12.7 percentage points compared to smaller increases or even decreases ranging from -1.1 to 8.1 percentage points among non-users.iii These benefits of eHealth underscore the concern that populations at risk of falling behind may be disadvantaged by technological advancements.  Following are some of the characteristics of low use of eHealth.

Characteristics of Low eHealth Use

Race/Ethnicity

Among Kaiser Permanente patients, members of certain ethnic groups access online tools less often.iv, v One study found that Asian Americans, Hispanics, and African Americans were 23 percent, 55 percent, and 62 percent less likely to register for personal health record access, respectively, compared with non-Hispanic whites. A disparity in use was evident even among those who intended to use the patient portal; African Americans and Hispanics had higher odds of requesting a password but never logging on. For example, only 21 percent of Hispanics who requested a password logged on compared with 38 percent of non-Hispanic Whites.vi

Language barriers may explain some of the disparities in patient portal use; Kaiser Permanente researchers found that individuals who preferred speaking Spanish were less likely to access their health records.

Socioeconomic Status

Another population at risk of eHealth disparities are those of low socioeconomic status (SES)—individuals with lower levels of income and education. Kaiser Permanente members from low SES neighborhoods were less likely to use online tools, and this likelihood persisted even after controlling for those who have Internet access.i  SES has an effect that is independent of race and ethnicity. Therefore, it is important to consider low SES populations separately.

Helping Members Understand Their Health Information

Patients will only find their online health information valuable if they can understand it. Factors such as reading comprehension and education have been tied to seeking out this information using digital tools. Researchers found that lower rates of literacy were associated with higher odds of never signing on to the patient portal.v Literacy is related to educational attainment, and the relationship between education and use of online resources shows a similar pattern: The lower the education level, the lower the likelihood of signing onto the patient portal.vi Less education and low literacy are more prevalent among minority and low SES populations. Addressing literacy issues may be key to minimizing disparities in eHealth use.

Getting Online is Not Enough

Using a patient portal requires having the tools to get online. Low SES populations tend to have less access to the Internet as well as limited opportunities to learn how to use computers.vii However, disparities in eHealth use persisted even after controlling for Internet access among those with low SES and those with low health literacy.i, v Other reasons must explain the emerging disparities and more research is needed to examine factors that lead to these differences.

Kaiser Permanente Strives to Improve

To address potential eHealth disparities, it is important to understand the perspectives of those who are not taking full advantage of online health tools.  Through community benefit grant making, Kaiser Permanente has funded focus groups to explore eHealth access and use.  Other efforts include discussions with African American and Latino members about how to meet their digital health needs.  Garrido has been sponsoring these efforts. “We’re hearing from patients directly. We need to understand what issues they have with the patient portal, so that we can support better access and ultimately empower our members to be involved in their care.” From these focus groups, Ms. Garrido and her colleagues have identified barriers such as privacy concerns, language preference, and the need for a simple log-in.

Kaiser Permanente has already begun to address these issues. For example, Ms. Garrido explained, a lock symbol is visible now on the kp.org website that reassures members they have accessed a secure site with information only available to the patient and his or her care team. Efforts to overcome language barriers are ongoing: a Spanish version of the online portal was launched in Southern California and will soon be available in other regions.  Recently, a kp.org mobile app was released, leveraging the greater use of smart phones than computers among disadvantaged populations. Kaiser Permanente is taking lessons learned from its research and members about barriers to eHealth usage and implementing solutions to ensure that the benefits of health technology can be available to everyone.