Quantifying Digital Health Inequality Across a National Healthcare System
Joe Zhang1,2Institute of Global Health Innovation, Imperial College London, London, UK; Department of Critical Care, Guy's and St. Thomas' Hospital, London, UK, Jack Gallifant2,3Department of Critical Care, Guy's and St. Thomas' Hospital, London, UK; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA, Robin L Pierce4University of Exeter Law School, University of Exeter, Exeter, UK, Aoife Fordham5Transformation Directorate, NHS England, London, UK, James Teo6,7Department of Neurology, Kings College Hospital NHS Foundation Trust, London, UK; London Medical Imaging & AI Centre, Guy's and St. Thomas' Hospital, London, UK, Leo Celi3,8Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA, Hutan Ashrafian1,9Institute of Global Health Innovation, Imperial College London, London, UK; Leeds Business School, University of Leeds, Leeds, UK
Digital Health Inequality in the National Health Service
This study quantifies digital health inequality within England's National Health Service (NHS). It focuses on the differential utilization of digital tools across population groups, examining the deployment of universal digital health interventions like a national smartphone app and online primary care services.
The results reveal a significant association between increased population deprivation and reduced digital tool usage. Specifically, the most deprived quintiles correlate to lower activation rates of the NHS App, affecting approximately 4.27 million patients. The findings raise concerns about the potential widening of healthcare inequalities driven by technology. The study underscores the need for targeted incentives to address digital disparities, thus preventing them from translating into broader health outcome disparities.
Quantifying Digital Health Inequality
The past decade's rapid digital transformation in healthcare has highlighted the importance of digital access as a key health determinant. This study focuses on observationally quantifying digital health inequalities in England, particularly in the context of the NHS 'Digital First' strategy. We analyzed two NHS digital interventions: the 'NHS App' for accessing services and records, and online portals for primary care interactions, to measure the adjusted association of socioeconomic and demographic factors with digital utilization. Our methods incorporated multivariable analyses at the practice level, considering variables like socioeconomic deprivation, ethnicity, age, geography, disease and medication burden, and provider characteristics. This approach provides a unique observational analysis of digital product activation, reflecting broader trends in digital health utilization across the population.
Three-dimensional choropleth maps showing (A) percentage of population with activated accounts on the NHS App at the level of middle layer super output (MSOA) geographical units; (B) estimated percentage of population where NHS App non-usage is associated with presence in lowest two deprivation quintiles at MSOA level, derived from regression coefficients in multivariable model and per-practice activation metadata. Values are represented by both colour and height of each unit. NHS, National Health Service.
Digital Equality: A Crucial Element in Modern Healthcare
Our study reveals a significant digital divide in healthcare, with lower socioeconomic strata showing substantially reduced digital engagement, particularly in the usage of the NHS app. This translates to an estimated 4.27 million patients in England being disadvantaged due to digital inequity. While ethnicity did not show a direct correlation, it is likely influenced by other factors in our model.
The crux of our findings is the real-world impact of digital inequality in a health system increasingly reliant on digital solutions. Despite limitations in measuring the extent of usage and factors like digital literacy, our results raise important concerns as the NHS moves towards app-based healthcare access. The risk is clear: without careful consideration, digital transformation could inadvertently widen healthcare access disparities.
To address this, we propose three key recommendations. First, digital transformation should be context-specific, with a focus on local needs and strong community links. Second, while achieving complete digital equality may be challenging, the efficiencies gained from digital pathways should be reinvested in supporting vulnerable groups. Lastly, embedding equity considerations in the assessment of digital technologies is vital. Monitoring disparities in digital health utilization and outcomes should be an ongoing process, not just a one-time evaluation. In conclusion, our study underscores the urgent need for targeted strategies to bridge the digital divide in healthcare. As the NHS and other health systems worldwide continue to embrace digital transformation, it is crucial to ensure that this shift does not exacerbate existing inequalities but rather serves as a tool for promoting equitable access to healthcare for all.
Related Work
Our work builds upon insights into how technology can impact outcomes across subgroups:
Gallifant, J., Celi, L.A. & Pierce, R.L. Digital determinants of health: opportunities and risks amidst health inequities. 2023.
Notes: While digital transformation offers unprecedented opportunities for advancing healthcare, it also raises complex ethical and legal challenges. Emerging drivers of health disparity termed digital determinants of health (DDOH) are explored in this piece.
How To Cite
This article can be cited as follows:
Bibliography
Joe Zhang, Jack Gallifant, Robin L Pierce, et al. "Quantifying digital health inequality across a national healthcare system." BMJ Health & Care Informatics 2023;30:e100809. doi: 10.1136/bmjhci-2023-100809.
BibTeX
@article{zhang2023quantifying,
title={Quantifying digital health inequality across a national healthcare system},
author={Zhang, Joe and Gallifant, Jack and Pierce, Robin L and Fordham, Aoife and Teo, James and Celi, Leo and Ashrafian, Hutan},
journal={BMJ Health & Care Informatics},
volume={30},
pages={e100809},
year={2023},
publisher={BMJ Publishing Group},
doi={10.1136/bmjhci-2023-100809}
}