With more than two decades of telemedicine experience and research, the Washington, D.C.-based Children’s National Hospital Telemedicine team identified a disparity in access to the internet and digital tools that disproportionately affects low-income and rural communities, causing a digital divide.
THE PROBLEM
Many of these families lack reliable, unlimited internet access or the necessary devices to engage in telemedicine services, which has become a valuable mode of care delivery, especially during and after the COVID-19 pandemic.
“The lack of connectivity led to several barriers: families had to travel long distances to reach the hospital, often facing considerable costs in mileage, parking, and time away from work or school,” said Tejal Raichura, director of telemedicine at Children’s National Hospital. “This was not just inconvenient – it was a significant impediment to timely medical care, particularly for chronic conditions requiring regular follow-ups.
“The situation was exacerbated for families in rural areas and those where English was not the primary language,” she continued. “These factors resulted in higher no-show rates for appointments, poorer patient compliance with treatment plans, and, ultimately, could impact health outcomes.”
For providers, these challenges translated into inefficiencies in care delivery and a growing concern that the most vulnerable patients were slipping through the cracks. Children’s National quickly realized that until broadband access becomes an equitable public commodity, it will need to try to bridge the gap in technical equity, or “techquity.”
“Most low- and moderate-income families with children report having computers, mobile devices and some form of Internet access,” Raichura said. “While these rates of digital ownership and connectivity are high, many families do not have home Internet access. Among all families below the median income, about a quarter have mobile-only access, while a fraction have no access.
“Among families living in poverty, about one third have mobile-only access and a fraction have no access,” she added. “Among immigrant Hispanics, about four in 10 have mobile-only access and about one in 10 have no access. When explored through the lens of race and ethnicity, immigrant Hispanic parents report markedly less digital technology in their homes than white, Black and U.S.-born Hispanic parents.”
PROPOSAL
To chip away at the “techquity” issue, Children’s National proposed a solution that leveraged cell phone and data plan technology to bridge the digital divide.
The idea was simple but impactful: provide low-income families with the necessary tools – subsidized smartphones with unlimited data plans – to gain access to telemedicine services without the burden of connectivity issues. This approach aimed to reduce the physical and financial barriers previously preventing these families from receiving consistent, high-quality care.
“The proposal included several key components,” Raichura explained. “First, smartphones equipped with a custom mobile application would be distributed to patients who needed them most and met very strict inclusion criteria, including infants with chronic diseases living in neighborhoods with high poverty rates, families where English was not the primary language, and those residing far from the hospital.
“This would allow parents and guardians to conduct video visits with their care teams, upload home monitoring data, and receive real-time feedback on their child’s health status,” she continued.
The proposal also included a robust quality improvement framework, incorporating patient-reported outcomes, geo-mapping, health outcomes data and e-surveys. This iterative feedback loop was designed to ensure the program was responsive to the needs of low-income families and could adapt to any challenges that arose during implementation.
MEETING THE CHALLENGE
Once the proposal was approved, Children’s National set about implementing the cell phone and data plan technology to start tackling the techquity challenge. The first step was to identify and recruit patients who would benefit the most from this initiative.
“Outreach efforts targeted underserved families receiving care at Children’s National, as well as referrals from community partners like D.C. public school nurses employed by an affiliate of Children’s National,” Raichura said. “Subsidized smartphones with unlimited data plans were provided to these families, along with apps installed to facilitate seamless communication between patients and healthcare providers.
“For the devices, we engaged service providers that have phones available at no cost or very low cost with broad coverage of cellular data access,” she continued. “Training was another critical component of the implementation process. Providers and patients were guided through the use of the technology with the help of bedside or clinic teams through written and video tutorials.”
RESULTS
The implementation of cell phone and data plan technology at Children’s National has led to several measurable successes, demonstrating its impact on health equity.
First, increased telemedicine engagement.
“One of the most significant outcomes of this initiative has been an increase in telemedicine engagements among low-income patients,” Raichura reported. “By providing the necessary tools and connectivity, Children’s National has made it easier for these families to access care without the need for costly and time-consuming travel.
“This increase in engagement has not only improved access to care but has also enhanced the overall efficiency of regular check-ins and follow-up visits,” she added.
Second, reduced no-show rates.
“With the barriers to broadband access reduced, Children’s National observed a decrease in no-show rates for virtual appointments,” Raichura said. “This was evident among patients who lived further away from the campus or required regular follow-ups. The convenience of being able to connect with a provider from home made it easier for families to keep their appointments, leading to better continuity of care and improved health outcomes.”
Third, enhanced patient and provider satisfaction.
“The feedback from both patients and providers has been overwhelmingly positive,” Raichura noted. “Families appreciate the convenience and reduced costs associated with virtual visits, while providers have noted the ease of use and the ability to deliver care more efficiently.
“Satisfaction surveys have shown the majority of patients and providers are either satisfied or highly satisfied with their connected care experience, underscoring the success of the initiative,” she continued.
ADVICE FOR OTHERS
For healthcare organizations considering the implementation of similar technology to address technical and health equity, several key lessons have emerged from Children’s National’s experience, Raichura reported.
“First, start with a clear understanding of the digital divide,” she advised. “It’s essential to recognize the specific barriers that low-income and underserved populations face in accessing healthcare. A thorough assessment of the community’s needs and the existing gaps in digital access is crucial before designing any intervention. Understanding these challenges will help tailor the technology to meet the unique needs of the population you aim to serve.
“Next, collaborate across the organization,” she continued. “The success of a telehealth program depends on various teams working together to enhance the care of our patients and their families. Children’s National’s telemedicine team worked closely with clinicians, the information technology and informatics teams, operational teams, grants teams, and legal and compliance teams. Members from each area played a key role in the success and implementation of this initiative.”
On another front, invest in training and support, she added.
“While the technology itself is a powerful tool, its success depends on how well it is integrated into the lives of both patients and providers,” she said. “Comprehensive training and ongoing support are critical to ensure that everyone involved is comfortable using the technology. This can include inline prompts, video guides and written materials, as well as hands-on training sessions. The more user-friendly the technology is, the higher the adoption and engagement rates will be.
“Also, use data to drive continuous improvement,” she added. “Implementing a robust quality improvement framework that incorporates real-time data collection and analysis is key to the success of any tech-driven health equity initiative. By continuously monitoring outcomes, gathering patient feedback, and making iterative improvements, you can ensure that the technology remains responsive to the needs of the population and adapts to any emerging challenges.”
In conclusion, while technology alone cannot solve the complex issue of health equity, when used thoughtfully and in conjunction with a deep understanding of the community’s needs, it can be a powerful catalyst for change, Raichura said.
“Children’s National’s experience demonstrates the potential of cell phone and data plan technology to bridge the digital divide and bring high-quality healthcare to the most vulnerable populations,” she said.
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