A Medical Student-Led Multipronged Initiative to Close the Digital Divide in Outpatient Primary Care

Abstract

Background The coronavirus disease 2019 pandemic accelerated the use of telehealth. However, this also exacerbated health care disparities for vulnerable populations.

Objectives This study aimed to explore the feasibility and effectiveness of a medical student-led initiative to identify and address gaps in patient access to digital health resources in adult primary care clinics at an academic safety-net hospital.

Methods Medical students used an online HIPAA-compliant resource directory to screen for digital needs, connect patients with resources, and track outcome metrics. Through a series of Plan-Do-Study-Act (PDSA) cycles, the program grew to offer services such as information and registration for subsidized internet and phone services via the Affordable Connectivity Program (ACP) and Lifeline, assistance setting up and utilizing MyChart (an online patient portal for access to electronic health records), orientation to telehealth applications, and connection to community-based digital literacy training.

Results Between November 2021 and March 2023, the program received 608 assistance requests. The most successful intervention was MyChart help, resulting in 83% of those seeking assistance successfully signing up for MyChart accounts and 79% feeling comfortable navigating the portal. However, subsidized internet support, digital literacy training, and telehealth orientation had less favorable outcomes. The PDSA cycles highlighted numerous challenges such as inadequate patient outreach, time-consuming training, limited in-person support, and unequal language assistance. To overcome these barriers, the program evolved to utilize clinic space for outreach, increase flier distribution, standardize training, and enhance integration of multilingual resources.

Conclusion This study is, to the best of our knowledge, the first time a medical student-led initiative addresses the digital divide with a multipronged approach. We outline a system that can be implemented in other outpatient settings to increase patients' digital literacy and promote health equity, while also engaging students in important aspects of nonclinical patient care.

Keywords

telehealth and telemedicine - patient portal - social determinants of health - health equity - digital literacy

Background and Significance

The coronavirus disease 2019 (COVID-19) pandemic accelerated the use of digital health tools like telehealth and online patient portals.[1] [2] Telehealth reduces care delays, increases rural health care access, and offers remote support for patients with chronic conditions.[3] [4] Additionally, patient portals facilitate access to health information and communication with health care teams.[5] Despite these advantage, vulnerable populations, such as communities with higher poverty and lower education status, face disparities in access.[6] [7]

Our case report is based at a safety-net academic center, with 72% of the more than 1,000,000 annual ambulatory visits coming from marginalized communities. Our health system conducts social determinants of health (SDOH) screenings every 6 months, providing referrals and resources to patients who screen positive. However, the pandemic underscored a digital divide not covered by the SDOH screener, including internet access, digital literacy, and MyChart (Epic Systems Corporation, Verona, Wisconsin, United States) access. From April 2020 to May 2021, our patient population had fewer video visits completed than scheduled, with 47% completed for White patients and 40% completed for Black and Latinx patients. This highlights unequal telehealth utilization among racial and ethnic groups, emphasizing the importance of digital literacy and accessibility.

As digital health tools become integrated into health care, intentional measures are essential to ensure they reduce, rather than perpetuate, existing health disparities.

Objectives

We explore the feasibility and effectiveness of a medical student-led initiative to bridge digital health gaps in adult primary care clinics at a safety-net academic center. Services include setting up and utilizing MyChart, orientation to telehealth applications, connection to community-based digital literacy training, and enrollment for subsidized internet and phone services via the Affordable Connectivity Program (ACP) and Lifeline.[8]

Methods

The initiative began in June 2021 with the development of workflows to screen patients for digital needs, refer to community and federal programs, and support as requested ([Fig. 1]). The team included medical students, physicians, and a public health graduate student for data analysis. Medical students, acting as “digital navigators,” were paid hourly through a quality improvement grant during this pilot (November 2021–March 2023), with student-leadership passed between cohorts.

Fig. 1 General workflow schematic for outreach, screening, interventions, and follow-up. *The Federal Communications Commission (FCC) offers the Lifeline program, providing eligible households with $9.25 per month off phone, internet, or bundled phone and internet services. In response to the COVID-19 pandemic, the FCC expanded its efforts in 2021 by introducing the Affordable Connectivity Program (ACP). This program offers up to $30 per month toward subsidized internet and a one-time discount on the purchase of a laptop, desktop computer, or tablet.[8]

We established partnerships with community-based organizations (CBOs), including digital literacy programs and local internet providers. These programs were incorporated into the THRIVE Directory, our hospital's HIPAA-compliant repository of social service organizations. This directory is integrated with our Epic electronic health record system and hosted on the findhelp.org platform.[9]

Patient screening methods evolved during the study. Initially, we conducted phone outreach to patients with chronic illnesses (diabetes, hypertension, or congestive heart failure) and with upcoming in-person or telehealth appointments within 2 weeks. We also included patients who had incomplete video-based telehealth visits, screened positive for adverse SDOH, or lacked devices for using telehealth. Our team defined these factors as potential indicators of low digital literacy. Due to challenges in assisting patients over the phone, we transitioned to in-person outreach and patient self-referral via fliers.

[Fig. 1] shows how digital navigators assisted patients after conducting the Digital Screener ([Fig. 2]). They placed referrals to CBOs in the THRIVE Directory and completed a data collection form (Appendix A). Two-week postintervention, navigators called patients to assess success and update data. Data collected included patient demographics, type of assistance requested, request status, and method of assistance provided. For MyChart, patients indicated their comfort with key features via a yes/no question. Plan-Do-Study-Act (PDSA) cycles ran quarterly, with adjustments based on the medical student academic calendar. Iterative changes were made based on data review and feedback during monthly meetings.

Fig. 2 Digital needs screener administered by digital student navigators in clinic or filled out by patients through self-referral. If patients have Medicaid, Supplemental Nutrition Assistance Program (SNAP), or other means-tested benefits, they will qualify for Affordable Connectivity Program (ACP) or Lifeline.[8]

Results

The initiative approached 550 patients and received 608 assistance requests during this pilot study. Demographics of participants are included in [Table 1]. After implementing the self-referral program in PDSA cycle 4 (December 2022–March 2023), 11 patients utilized the self-referral process. Of the total patients approached, 496 (90%) received in-person support, 17 (3%) received phone support, and 37 (7%) received both. Most requests (468, 77%) were for MyChart enrollment or navigation ([Table 2]). PDSA cycles revealed challenges that led to changes outlined in [Table 3].

Table 1 Patient demographic report from November 2021 to March 2023, N = 550 (100%)

Demographic characteristics
Sex
Female	281 (39.63%)
Male	269 (48.90%)
Age (y)
Mean	54.38
Ethnicity
Not Hispanic, Latino, Latina, Latinx, or of Spanish or Latin American origin	428 (77.81%)
Hispanic, Latino, Latina, Latinx, or of Spanish or Latin American origin	110 (20%)
Patient chose not to answer	12 (2.18%)
Race
Black or African American	338 (61.45%)
Other/patient chose not to answer/unknown	130(23.63%)
White	69 (12.54%)
Asian	11 (2%)
Native Hawaiian or Other Pacific Islander	2 (0.36%)
Language
English	399 (72.54%)
Spanish	66 (12%)
Haitian Creole	48 (8.72%)
Cape Verdean/Port Creole	10 (1.81%)
Other	27 (4.90%)

Table 2 Digital health equity intervention outcomes: service requests and success rates

Type of service requested	Number of requests	Number of patients helped	% of patients helped out of those requesting the specific intervention
MyChart[a] enrollment + navigation	314	262 (enrolled in MyChart and navigating confidently)	83
MyChart[a] navigation	28	22 (navigating confidently)	79
Telehealth orientation	16	4 (completed tech checks)	25
Digital literacy training	27	9 (connected to training organization)	33
		0 (enrolled in a class)	0
Affordable internet access	97	14 (connected to internet provider)	14
		5 (enrolled in low-cost internet)	5

^a Out of the total 468 MyChart requests, 314 were specifically for enrollment and navigation, and 28 were solely for navigation. Additionally, 126 requests could not be classified as either due to limitations in our data collection form. Since specifying the type of request was not mandatory and patients often selected help with other needs, we were unable to determine the total number of patients helped for MyChart.

Table 3 Challenges and solutions from Plan-Do-Study-Act cycles

Plan-Do-Study-Act cycle	Challenges encountered	Interventions
1st (October 2021–December 2021)	Inability to reach patients over the phone and to solve complex issues (mostly due to technical difficulties and limited patient digital literacy)	Shifted focus from phone outreach to in-person outreach
	Difficulty activating MyChart without Epic access, which required calling MyChart Help Desk, then waiting for activation code in patient's email inbox	Obtained Epic access for all outreach staff to obtain activation code instantly. This shortened the process and allowed digital navigators to communicate with clinic staff on patients needing assistance
	Limited opportunities for in-person outreach during clinic times	Utilized waiting rooms and exam rooms for in-person outreach Increased patient awareness with (1) posters displayed in clinic with date, time, and location of in-person support, (2) paper version of digital needs screener form offered where patients can select their needs and leave contact information for future outreach if they prefer to be reached privately or at a different time Increased provider awareness of the program by posting fliers on clinic bulletin boards
2nd (January 2022–April 2022)	Due to COVID-19, clinics were closed for students to do in-person outreach from January to February	As in-person outreach was limited, new digital navigators were hired and trained Obtained equipment (laptops and scanner) for future outreach Medical student leadership transition
	“Tech checks” do not simulate the experience of an actual telehealth appointment, which uses different user interface and platform	Telehealth orientation discontinued to brainstorm a new approach to help patients with telehealth orientation that provides a more realistic experience
3rd (May 2022–September 2022)	Volume of outreach less than anticipated due to COVID-19 pandemic	Focused time on onboarding new digital navigators and improving workflow, increased total staff to 17 total members 3 staff members attended the Affordable Connectivity Program (ACP) Webinar to learn about ACP, which replaced the Federal Communications Commission's Emergency Broadband Benefit (EBB) program, borne out of the COVID-19 pandemic for low-cost internet services Reinforced communication with clinic staff to encourage more referrals to our program and increase visibility
	Time-consuming training process for digital navigators	Created training videos to supplement and standardize the onboarding process Simplified the training slide deck to be used as an easy reference while on shift
	Unequal support for patients of non-English speaking languages	Integrated interpreter services to assist patients in clinic with variable language needs Ordered ACP pamphlets and posters in English, Spanish, Haitian Creole, Portuguese, Vietnamese, and Arabic for patient viewing in waiting rooms and patient navigator rooms
	In-person help limited by navigator availability, leading to inconsistent hours	Required each digital navigator to contribute a minimum of 4 hours per month Established an online scheduling program for more efficient shift sign-up Provided schedule of in-person support availability to clinic staff on the first of every month, allowing patients and providers to know when help would be in clinic
4th (October 2022–March 2023)	Limited outreach to non-English speakers	Created a new self-referral process, allowing patients to input contact information directly into our program for callback Posters with instructions and a QR code for self-referral were placed in all 40+ primary care patient exam rooms and translated into multiple languages Trained multilingual clinical staff in directing patients with digital needs to the program posters
	Difficulty completing ACP applications in one sitting. Issues including uploading documentation such as IDs, social security numbers, or documents to verify their residence	Provided more in-person assistance times and started hiring process for a full-time digital navigator to help with completing ACP applications
	Patients who were approved for the ACP program were unable to be connected to a local internet provider	Established a new partnership with a local internet provider (Comcast) that provides service to our patients and ensured a closed-loop referral between us and the local internet provider
	Incomplete data due to digital navigator variability in filling out data collection forms and difficulties reaching patient for 2-wk phone follow-up	Reinforced the importance of filling out the data collection form completely and following up with all requests during team meetings

Abbreviation: PDSA, Plan-Do-Study-Act.

During this pilot, the number of patients assisted monthly consistently increased, peaking in November 2022 ([Fig. 3]). This growth can be attributed to the doubling of digital navigators from 8 to 16 between November 2021 and November 2022, allowing expansion to six adult primary care clinics. However, in February 2023, outreach volume decreased due to fewer available digital navigators.

Fig. 3 Number of patients helped per month from November 2021 to March 2023.

Regarding assistance outcomes, 83% of those seeking MyChart enrollment help signed up for MyChart accounts, and 79% of those needing navigation assistance felt confident using MyChart. Twenty-seven individuals requested digital literacy training, with 9 referred to programs and 0 enrolled in a class. For subsidized internet support, 97 expressed interest in applying for ACP, with 14 connected to internet access providers and 5 successfully enrolled in low-cost internet services. Telehealth orientation had 16 requests with 4 completing the tech checks ([Table 2]). Additionally, 65 patients had an initial screener form without successful follow-up.

Discussion

Assessment of Interventions

MyChart support was the most requested and successful intervention due to seamless enrollment facilitated by in-person support.

ACP application assistance was the second most requested. However, we faced multiple barriers, as only 14 out of 97 patients were confirmed to have internet connectivity. While we could start the online ACP application with patients in clinic, patients had trouble completing the multistep process outside of clinic due to inadequate internet connection or digital literacy (e.g., uploading eligibility documentation). Patients approved for the ACP program had challenges connecting to an internet provider. The internet provider we originally partnered with did not service many areas in which our patients lived. In that event, the onus of connecting with an internet provider was on the patient, who may have varying levels of motivation and ability to navigate phone calls and paperwork necessary to do so. Sometimes, despite patients' efforts, they received no response. We have since partnered with a different internet provider, Comcast (Comcast Corporation, Philadelphia, Pennsylvania, United States), to establish a closed-loop referral system.

For patients ineligible for ACP, Lifeline serves as an alternative, although with fewer benefits. Many may transition to Lifeline once ACP funding is exhausted in May 2024.[8] Given the importance of affordable internet access, our team is advocating to renew ACP funding. Losing this support would have detrimental consequences for our patients.

With the COVID-19 restrictions, CBOs lacked adequate resources to meet the demand for digital literacy training. Thus, when screening for digital needs, digital navigators tended to emphasize MyChart and ACP interventions. However, the lifting of the Public Health Emergency[10] may increase class availability. We plan to partner with additional community organizations, including Boston Public Library, and develop a hospital-based digital literacy training program.

The telehealth orientation required patients to complete a tech check by accessing a Web site that tested their device cameras and microphones. However, this process did not simulate an actual telehealth appointment, which utilizes a different user interface. Additionally, the orientation did not mimic the process of receiving the appointment link via text or email. Due to these inconsistencies and the low volume of requests, the intervention was discontinued. Our next PDSA cycle will focus on simulating a demo call on the actual appointment platform before telehealth visits.

One major limitation was incomplete data follow-up; digital navigators often focused on providing support but sometimes didn't complete the data collection form or couldn't reach patients for follow-up. To address this, the leadership team emphasized the importance of patient follow-up and completing the data collection form during PDSA Cycle 4. Despite this, the 2-week postintervention follow-up does not capture long-term programmatic effects. Future assessments should consider metrics like completed telemedicine visits or recent MyChart logins for longitudinal evaluation.

Digital Navigator Recruitment and Training

Most digital navigators are first- and second-year medical students seeking hands-on patient experiences; however, the volume of outreach fluctuates with students' schedules. This limitation was present despite students being paid during this study. With the grant funding ended and students now volunteering, we plan to hire dedicated staff and expand recruitment to other university programs (e.g., public health and social work) to offer interdisciplinary service-learning opportunities and assist with shift coverage.

Initially, onboarding posed a bottleneck due to individualized training, requiring multiple sessions for new digital navigators to feel confident. Guided by the importance of streamlining the onboarding process as highlighted by Pereira et al,[11] we developed standardized training videos followed by in-person shadowing sessions.

Integration into Clinic Workflow

The first PDSA cycle highlighted the necessity for hands-on support due to low digital literacy levels. In-person support proved more effective, leading to increased patient engagement. Digital navigators assisted patients before and after visits in waiting rooms, exam rooms, and checkout areas. Each navigator committed at least 4 hours monthly, ensuring consistent coverage and facilitating warm handoffs from front desk staff, medical assistants, and patient navigators.

Language Barriers

Language barriers presented challenges. The use of phone interpreters, which increases time spent with each patient, often led to patients being called to see their provider before their needs were fully addressed. Non-English-speaking patients faced inconsistent language support: ACP enrollment instructions were offered in multiple languages, but MyChart was only available in English and Spanish. These limited language options perpetuated the lack of access to care, with patients enrolling in ACP independently but struggling to use MyChart without guidance. Currently, we are advocating for the inclusion of more languages in MyChart.

Despite these limitations, we recognized the importance of capturing non-English-speaking patients who face more digital barriers. During PDSA Cycle 4, we modified our protocol to allow patients to self-refer into our program when digital navigators or interpreters are unavailable. We placed posters with program information in English and Spanish in over 40 primary care rooms. These posters featured QR codes allowing patients to leave contact information and specify digital needs in the THRIVE Directory digital needs screener. A digital navigator would then follow up by phone or in person. Additionally, language-concordant clinic staff were trained to guide patients with digital needs to our posters. Only 11 patients utilized this process, likely due to inadequate digital literacy (necessary for utilizing the QR code and online screener) and limited reading and writing abilities.

Comparison to Other Initiatives

Our initiative addresses various aspects of digital health equity, unlike prior interventions focused solely on MyChart or video visits.[12] [13] [14] [15] The COVID-19 pandemic highlighted the feasibility of medical student involvement in bridging care gaps, such as contacting patients affected by appointment cancellations or no-shows.[16] [17] Several programs have demonstrated the utility of enlisting medical students to conduct social needs assessments via phone, allowing preclinical exposure to address patients' social concerns and the development of quality improvement skills.[18] [19] [20] However, what sets our initiative apart is its inclusion of in-person digital needs screening, providing hands-on experience for students while aiding patients with substantial needs.

Small-scale technology training programs have been started within hospitals or in research settings to increase digital literacy.[21] [22] Distinct to our intervention are partnerships with not only CBOs that offer digital literacy courses but also local internet providers participating in ACP. Despite challenges encountered with digital literacy and subsidized internet referrals, community partners remain interested in collaboration. With CBO buy-in and a HIPAA-compliant referral process, we aim to increase the likelihood that patients receive help. Through in-person support and referrals to community resources, our program has enhanced digital access, improved digital literacy, and empowered patients to take charge of their health care.

Conclusion

The COVID-19 pandemic accelerated technology integration in health care and exacerbated the digital divide due to low digital literacy, limited access to affordable internet and devices, and inadequate awareness of community resources. We outline an initiative to address these digital needs, applicable to various health care settings. Our results highlight implementation challenges and interventions to overcome them, offering insights to navigate similar hurdles. As telehealth and technology reshape health care, equitable access must be a priority for the medical community.

Clinical Relevance Statement

As telehealth gains prevalence, digital literacy is increasingly intertwined with health literacy, impacting access to care. Involving students in the initiative not only alleviates burden on clinic staff and expands outreach but also offers crucial hands-on service-learning opportunities for future providers. We outline a team-based framework that other health care settings can adopt to bridge the digital divide and enhance health equity.

Multiple-Choice Questions

1. What type of iterative, problem-solving model was used to assess and adjust the initiative?

   • LAMDA: Look, Ask, Model, Discuss, Act

   • PDSA: Plan, Do, Study, Act

   • SDCA: Standardize, Do, Check, Act

   • DMAIC: Define, Measure, Analyze, Improve, Control

   Correct Answer: The correct answer is option b. The PDSA problem-solving model was used to assess the initiative.

2. To improve patient outreach, which of the following solutions were implemented?

   • Pivoting from phone outreach to in-person outreach in the clinic

   • Distribute pamphlets and posters about the initiative in multiple languages

   • Collaborating with clinic staff to encourage more referrals to the program and increase the visibility of posters

   • All of the above

   Correct Answer: The correct answer is option d. We implemented all the above changes in an attempt to increase outreach. Please see the Discussion section and [Table 3] for further description.

Conflict of Interest

None declared.

Acknowledgments

We gratefully acknowledge the support of the FindHelp team for their assistance in creating the closed-loop referral system essential for tracking our data. We also extend our appreciation to the primary care operations managers for their valuable input in discussing and developing improved patient outreach strategies.

Protection of Human and Animal Subjects

A qualified member of our Institutional Review Board staff reviewed and determined that our initiative qualifies for an exemption determination under the policies and procedures of the Human Research Protection Program under the category of Quality Improvement.

^* These authors contributed equally to this work.

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Publication History

Received: 06 March 2024

Accepted: 20 July 2024

Accepted Manuscript online:
22 July 2024

Article published online:
09 October 2024