Crossing the digital chasm: a narrative review on how technology can improve healthcare access

Introduction

The proverbial term “crossing the chasm” was initially proposed by author and organizational theorist Geoffrey Moore to refer to the need of new, potentially disruptive ideas to transition from early adoption to mainstream acceptance in order to truly make a significant impact in society (1). While generally used in the context of entrepreneurship, particularly in the world of high technology, this phrase also has fundamental implications with respect to the ever-evolving world of healthcare. Given the rapid incorporation of technological advances in healthcare, the importance of effectively integrating digital solutions to address practical problems must be prioritized. Considering that data from the Agency for Healthcare Research and Quality (AHRQ) continues to show that approximately 15% of adults nationwide cannot access healthcare in a reasonably rapid fashion, there is arguably no more pressing issue in healthcare than access (2). Indeed, the right to healthcare extends not only to the timely, appropriate, and high-quality receipt of services but also addresses inclusivity and underlying determinants of health. Consequently, access to care—defined by the National Academy of Medicine as “the timely use of personal health services to achieve the best health outcome”—represents an enormous chasm that must be hurdled so that society become more equitable across all populations (3). In laymen’s terms, access can best be described as the ability of patients to obtain the care and services they expect when they need them. This critical concept spans the entire healthcare continuum, encompassing everything from making an initial appointment to completing treatment and being followed thereafter. Due to the sheer breadth of stakeholders involved in the healthcare marketplace—providers, insurance companies, government regulatory agencies, health systems, industry partners, pharmacies, among others—the coordination required to optimize access is extraordinarily complex. However, given the increasingly broad use of technology to promote a better patient experience, the potential to “cross the chasm” and drive meaningful changes across society is becoming apparent. The potential of technology to ameliorate many of the traditional barriers to healthcare access is just starting to be recognized and forms the crux of this review. With the aim of outlining the core considerations involved in the implementation of digital health, I present this article in accordance with the Narrative Review reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-69/rc).

Methods

A comprehensive literature search of peer-reviewed publications was undertaken to identify original peer-reviewed works pertaining to the implementation of digital health technology using a variety of search terms including “digital health”, “digital technology”, “health information technology”, and “patient technology”. Specific details of the initial search strategy are provided in Table 1. Given the goal of critically evaluating high-level evidence which could enable the preparation of this review, the focus of this work was on specifically identifying original research reporting on the impacts of digital health on patient care. A schematic illustration of the flowchart outlining the results of the search strategy is shown in Figure 1.

Figure 1 Graphical flowchart of search strategy for the narrative review.

Reference lists from included articles were cross-checked to identify additional articles. Review articles and papers presented as conference proceedings were excluded. Articles published from January 2013 to January 2024 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies including those focused exclusively on the waiting time while physically in the office were selectively removed. Where individual patients were included in multiple published series, the most complete or recent article was cited. Core themes focused on healthcare access were subjectively devised based on the review of the relevant peer-reviewed literature. An interpretive synthesis of the available publications was then presented focused on presenting the evidence evaluating the role of access in healthcare.

Results

Search results

The initial search yielded 1,707 original articles. After screening of these articles on title and abstract, a total of 802 studies proceeded to full-text screening. Another 163 articles were excluded because they were review articles (N=99), were designed as subjective narratives or case reports (N=24), were position papers (N=20), used duplicative data (N=11), or were abstracts only or conference proceedings (N=9). A total of 639 peer-reviewed studies thus were included and formed the basis for this narrative review.

Identified themes

The 639 studies that were identified differed significantly in their clinical design, methods, and endpoints. The core themes could broadly be categorized into those related to digital communication or telemedicine (N=101), health outcomes or quality of care (N=100), electronic medical records (N=95), patient education (N=90), wearable technology or internet-of-things (N=88), scheduling and workflow improvement (N=70), social or cultural programs (N=55), and financial transparency (N=40). Artificial intelligence (AI) was a component of 90 of the identified publications. Thirty publications focused at least in part on equity issues, structural racism, and/or implicit bias; and 19 publications addressed disparities in digital and/or technical literacy. Figure 2 outlines the core themes that were identified through this narrative review of the evidence.

Figure 2 Core themes identified related to digital technologies in healthcare.

Discussion

The results of the present study are notable because they illustrate the overwhelming impetus to utilize technology in healthcare. Regardless of the underlying reasons, a “new normal” has emerged when it comes to the expediency and accessibility of service expected by customers across all industries. Ever since the standards were first raised by innovators such as Amazon, Netflix, and a slew of other corporate titans, increasingly more pressure has been placed on other service-oriented organizations to adapt accordingly regardless of the sector. It is thus particularly instructive to look towards other industries which have leveraged technology to make it a mainstay of driving the consumer experience. For instance, technological giants such as Amazon and Uber have pioneered such user-friendly digital features as same day service, price transparency, and real-time rating systems incorporating reviews from all across the world. For patients in search of healthcare, it is arguable that the stakes are even higher given that there is no commodity that people value more in their lives than their health. Yet, access remains the component of healthcare that is central to the patient experience and to quality of care. After all, what good are advances and innovation in medicine if it is not possible for the general population to benefit from them in a timely manner? While billions of dollars are spent annually on the development of potentially cutting-edge breakthroughs in healthcare, the age-old challenge of ensuring their availability to the masses persists (4). Indeed, the barriers to access are increasingly being acknowledged as obstacles that must be addressed to promote an equitable healthcare system for all (5). However, the rapid adoption of digital tools to empower patients has the potential to fundamentally change the access paradigm as well as the patient-provider relationship for the better. How health systems opt to utilize such strategies could mean the difference between enabling widespread access across society or leaving subpopulations glaring behind.

Through novel solutions, technology offers the potential to improve access to quality care while prioritizing patient well-being, empowering individuals to make customized choices based on what is best for them, and enabling providers to make more informed, evidence-based decisions in real time. However, it must be recognized that how to exactly accomplish this remains uncertain. The World Health Organization (WHO) recently published a framework of “e-Health” for improved health service delivery, describing the potentially powerful contributions of digital platforms to each of the health system attributes (i.e., service quality, efficiency, equity, accountability, sustainability, and resilience) at different levels—the individual, the service provider, the healthcare organization, and the overall health system (6). In order for technology to truly be transformative, all of these levels must be considered as newer platforms for healthcare are increasingly being rolled out.

Digital communication tools, such as mobile health apps, telemedicine, and online health information resources, have gained significant popularity and are increasingly being integrated into healthcare delivery systems. These platforms offer unique opportunities to reach a wide range of demographics, regardless of their geographic location, socioeconomic status, or educational background at a variety of different access points. By offering patients the ability to communicate with their provider teams at their convenience, these digital portals naturally promote a more user-friendly approach to access as information exchanges can be done in the comfort of one’s own home. This solves a key dilemma which has traditionally plagued patients from rural communities in which provider services are often located several hours drive away. Additionally, patients can take their time to gather their thoughts and to thus ask more meaningful questions than in a single in-person encounter at which time they might feel pressured. However, digital communication can become problematic when delays occur in the response time to messaging. Similarly, some patients from underserved backgrounds may not feel particularly comfortable using such technology to communicate personal information, and training protocols might be necessary. Regardless, studies from multiple organizations have demonstrated that digital communication tools improve the patient experience when initiated in an organized fashion (7-9).

By harnessing the power of technology, digital communication tools have the potential to enhance health literacy, improve the patient-provider relationship, and ultimately lead to better health outcomes (10). The availability of virtual educational material and “frequently asked questions” sponsored by provider organizations can also be beneficial for patients who otherwise may not know where to direct questions regarding a condition. Given the massive amount of health-related information available online, the use of cues and provider-endorsed material have the ability to prevent patients the unfortune of being diverted by sources of misinformation. In this sense, the importance of asynchronous education and patient communication through technological solutions can improve the efficiency of healthcare workflow, thus optimizing time and resources for both patient and provider alike. On one hand, these solutions can potentially help save patients from unnecessary trips into physical locations and the accompanying costs related to transportation, parking, and time off work, among others. For the provider, technology can help triage patients such that those most in need of being seen in person actually is scheduled for an in person visit.

In some situations where wait-times might be excessive to see a provider in-person, these digital health tools can even improve access. Indeed, much of the initial work on digital health has focused on mental health, an area where delays in access have been well-described (11). For instance, a muti-institutional prospective study which randomized 63 patients with depression and/or anxiety to the use of an innovative at-home virtual tool which provided voice-guided mental health coaching or to a non-intervention waiting list (12). After 16 weeks, significant improvements were observed in the intervention group with respect to psychological distress and problem-solving ability. Similarly, Canadian investigators conducted a randomized controlled trial of 95 patients with depression who were assigned to either an intervention group that received 12 weeks of web-based therapy guided by a coach who had a background in social work or to a control group that received a physical handout of mental health resources they could access (13). The research showed that patients who used the digital health tool had a better health-related quality of life upon conclusion of the program and showed significantly higher levels of engagement and adherence to subsequent therapy. In another prospective study, investigators from multiple sites randomized 332 caregivers of cancer patients enrolled in home hospice to an automated digital family coaching intervention designed to help with symptom management or to the usual supportive care (14). Again, significant improvements were observed in the intervention arm with respect to caregiver burden, mood, and vitality. These prospective studies, in aggregate, illustrate the power of digital health to potentially transform healthcare, particularly with respect to access and engagement.

Given the increasing backlog of appointments faced by many health systems, resorting to technology to assist with scheduling or to even step in as an adequate substitute for a provider can fill a vast need. The implications are profound, as even when patients can navigate the stream of hurdles to make an appointment, often times, those appointments are not available, or not available in a timely fashion. The utility of having a trained online navigator who is available to answer questions and to help triage patients may be beneficial. For instance, investigators from Switzerland conducted a randomized trial of 198 patients to gauge the effectiveness of a smartphone-based coaching intervention delivered through a virtual chat agent for individuals suffering from frequent headache (15). Remarkably, the patients randomized to the digital intervention arm reported significant improvements in well-being, as well as a reduction in somatic symptoms, perceived stress, and enhanced pain coping skills. As another example, investigators from Memorial Sloan Kettering Cancer Center demonstrated the feasibility of an innovative 10-day, web-based electronic survey that monitored symptoms daily and provided feedback as to whether reported symptoms were expected or required follow-up for patients recovering from outpatient cancer surgery (16). After enrolling 43 patients, the researchers showed that the digital tool was perceived as an extension of the care team, thereby enhancing communication, access, and the overall patient experience.

Furthermore, open access scheduling systems utilizing online self-service applications have also been proposed as a means to streamline the appointment process—so patients can schedule, reschedule, or cancel appointments whenever it is convenient for them, which is often outside provider office hours (17-19) By outlining available appointments in a visible and transparent fashion, these systems empower patients to make user-friendly decisions. These have the added benefit to optimize unused capacity, particularly as machine learning and AI is integrated into pathways. Self-service tools can also reduce administrative overhead, so staff can focus on critical tasks that require a human touch. Similarly, digital pre-registration allows patients to complete paperwork from home, where they have access to their medical records and insurance information. AI-based tools can increasingly pre-fill much of this data, saving time and preventing errors. Health assessments which have traditionally been in the form of paper-and-pencil surveys completed in the waiting room or lobby of the clinic, can increasingly be shifted towards a digital format which can be completed even days prior to an encounter. Once a patient does appear in person, the registration process can thus be streamlined, focusing on critical elements of the moment rather than overwhelming an individual with mounds of paperwork and questionnaires. Making the registration process more seamless has been shown to significantly reduce anxiety and stress for patients as they are waiting to be seen (20). Indeed, the potential of AI to register, triage, and even diagnose patients in the clinical setting is just starting to be explored.

The possibility of expanding clinic hours to offer appointments that might be more convenient for the working population can also be considered to overcome access barriers. This can be facilitated greatly through digital means. For instance, using AI to evaluate peak usage of provider time to ensure that supply and demand matches are optimized can help design scheduling templates based on both historic and real-time data (21). The use of analytics in conjunction with AI can also predict nuances which could be potentially disruptive such as which patients might require more scheduled time than typically needed and/or which patients might be at risk for last-minute cancellations or “no shows”—events which invariably add inefficiency to the workday (22).

Furthermore, urgent care centers and retail clinics are also emerging as access options allowing patients to connect to care outside of a provider’s office hours. The need for such outlets could be predicted based on data acquired through digital means. For instance, in the oncology realm, mini-emergency rooms that are staffed to address cancer-related problems is a practical example of data-driven, specialty-specific customization to improve access. The establishment of mobile clinics in geographical areas traditionally devoid of healthcare services is another way to address issues with transportation that can impede access. The popularity of same day access—which allows patients to be seen within hours from scheduling an appointment—has also been increasingly demonstrated (23). All of these advanced access programs are highly dependent on digital tools to optimize efficiency, particularly as the need to run ‘lean’ in resource-constrained environments are often the norm in healthcare.

To further ameliorate the logistical barriers limiting access, social programs such as housing services and ride share options are increasingly being implemented via technological solutions. Patients who are physically unable to drive, who face financial barriers, or who otherwise cannot obtain transportation to the provider office often go without care. Through collaboration with non-emergency medical transportation providers and emerging rideshare companies like Uber and Lyft, healthcare providers and payers have the ability to design programs to bridge the access gap. One study evaluated the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments and showed significantly improved rates of compliance (24). Partnership opportunities with payers, community organizations, local nursing homes, federally qualified health centers, among other institutions, are actively being explored to align interests with respect to improving access. These collaborative opportunities will be critically dependent on digital solutions to optimize their utilization.

Initiatives to improve data usability by centralizing information into integrated servers can also make the healthcare system more efficient, thus optimizing downstream services such as patient scheduling. Electronic health record databases are increasingly being recognized as not just keepers of patient encounters and transcriptions but are rapidly being deployed to function as a dynamic entity—to serve as a hub for patient communication and to convey information to patients including test results, prescriptions, and even treatment recommendations (25). While the implementation and adoption of electronic health record databases have varied across institutions and providers, there is no question that they have changed practice patterns. However, it must be recognized that significant drawbacks have been recognized regarding the limitations of these electronic databases (26-28). For instance, they can introduce new inefficiencies in workflow and create potential problems with respect to confidentiality and patient protection. Furthermore, questions have also arisen regarding the usability of the information populated in these systems particularly with regard to the fidelity of data analysis (29). In the United States, the continued lack of a national data registry can likely be traced to the variabilities with regard to standardization, usability, and acceptance, among others (30). While electronic health record databases were once touted as a panacea for health information technology, it is clear that additional work is needed from a practical standpoint.

The adoption of specialized software which can automatically drive real-time analysis of access data and performance can also modernize care delivery. As wearable devices become popularized and touted for their ability to generate continuous data that can be fed into electronic records, understanding how to utilize and maintain this information will be critical. Given the vast amount of patient-related data associated with encounters, the establishment of a nationalized database of health records could also revolutionize access, allowing the sharing of information among providers instantaneously (31). Due to the episodic nature of most patient encounters, the healthcare system is notorious for a high degree of fragmentation and inefficiency as a result of siloed data. The digital health revolution has the potential to change this pattern by adding a level of transparency to patient medical records which could fundamentally alter care. Moreover, leveraging the foundation of electronic medical records databases to facilitate virtual healthcare visits (i.e., telemedicine encounters) continues to prove successful and has been shown to expedite care (32). Lastly, the potential of digital health platforms to enable big data collection and analysis for population-level based analysis is beginning to be recognized. This will entail the passive and active acquisition of patient data acquired in various settings to help make clinically relevant decisions based on analytics. Indeed, technological innovation of increased sophistication using AI-based algorithms to facilitate data mining from digital databases is growing rapidly.

An increasing amount of research is also focused on harnessing technology to enhance the collection of patient-reported outcome data (33-36). By introducing new avenues for patients to input information related to their health, electronic platforms have the ability to provide a degree of empowerment that promotes engagement. For instance, patient symptoms can readily be inputted into technological devices which can be transmitted to centralized servers or to providers in real-time (37). The utility of these platforms to collect information related to psychosocial distress and well-being have also been shown. It must be recognized that levels of patient comfort in utilizing such tools vary. Paudel et al. surveyed over 3,000 individuals and showed that approximately one-third lacked readiness with potentially using electronic patient-reported outcome platforms, specifically as they related to confidence in technology, ease of asking clinicians questions, and symptom management (38).

Moreover, efforts to thoughtfully promote cost transparency are needed to make the healthcare system more open and friendly for all (39,40). While nearly all other goods and services available for purchase can be done online by comparing prices thus enabling consumers to shop for the most effective, lowest-cost product, healthcare continues to lag behind other industries. Furthermore, digital rating scores based on patient-reported evaluations still are difficult to find and/or lack utility in making decisions regarding healthcare. The advent of digital tools could drastically enhance the current healthcare landscape in this regard and improve patient centricity. Indeed, the financial barriers to access are well-documented. Data from West Health and Gallup poll found that 29% of adults in the United States reported putting off medical treatment because of out-of-pocket costs between 2001 and 2021 (41). While 34% of Americans with an annual household income of less than $40,000 were likely to skip or delay healthcare for a serious medical condition, a considerable proportion of higher earners (18%), defined as those with household income greater than $100,000, also stated the same.

After all, when patients are faced with not knowing what they will owe for their care until they receive a bill weeks later, encounters are frequently delayed or skipped altogether. Indeed, data has been published showing that most patients have no idea of what their out-of-pocket costs will be prior to receiving their bill—and even their best estimates at the time of presentation are far off from the reality of the situation. It is thus no surprise that price transparency is supported by over 90% of Americans (42). While the Affordable Cara Act required individual hospitals to make prices transparent by publishing their “chargemasters”, or list prices, for all the services they provide, the resultant effect has arguably increased confusion. This is because the unwieldy labyrinth of information published, listing thousands of goods and services posted on thousands of websites is of little practical benefit for patients, who are more interested in out-of-pocket costs. What is needed instead are efforts to provide patients an accurate, personalized breakdown of their estimated financial responsibility prior to being seen. This should be accompanied by initiatives to increase patient engagement, provide real-time assistance with interpreting both outcomes and cost information, compare available treatment and provider alternatives, review ratings and assessments, and couple price information with quality metrics of specific relevance to enable making fully informed decisions. Provider organizations can also leverage this data to address inequities on a community and population-based level. Only through standardization of these efforts will consumer empowerment truly be optimized. Digital health tools are well-positioned to serve as a foundation for price transparency. After all, if one can shop for a pair of running shoes on Amazon or E-Bay and know exactly what will be delivered (and the cost), the same should ultimately be expected in healthcare. However, it must be recognized that due to the variabilities and unpredictable elements inherent in healthcare, price transparency can be an elusive concept.

While the digitization of healthcare has empowered some people, it is important to recognize that others are at risk for being left behind. Due to the pace at which technological innovation is changing healthcare, the lack of technical literacy for many patients, particularly those on the lower end of the socioeconomic spectrum, can also hinder activities such as scheduling appointments, checking results, and/or communicating with providers—tasks that are increasingly digitized in modern healthcare (43). Indeed, underrepresented minorities have been shown to have more difficult accessing their medical records online (44). More recently, the term “digital redlining” was introduced to describe racialized inequities in access to technology infrastructure, including access to health care, education, employment, and social services (45). Efforts to help promote awareness among those at risk for falling behind with respect to technical literacy are urgently needed as digital health becomes more mainstream.

Lastly there are a growing number of initiatives to address social determinants to promote health equity (46). Models under the Center for Medicare and Medicaid delivery system are increasingly screening for and/or providing referrals for social needs; and a recent survey found that nearly all responding plans reported activities to address social determinants of health (47,48). Digital tools can vastly help take the lead in these efforts. By standardizing methods with respect to health screening, preventive awareness, and education, the use of technology can serve as the foundation for driving social change to improve health. Furthermore, digital tools have already been shown to be beneficial in the development of survivorship care planning—that is once, patients are finished with episodic care and transition into modes of health living, recommendations regarding follow-up care, the ordering of tests, and preventive care can be optimized using digital tools which can be accessible by hand-held devices (49). In this sense, the potential of digital tools to help with care coordination in the sub-acute setting for health maintenance purposes is just being recognized.

To improve cultural literacy, the use of professional medical interpretation services and multilingual patient education materials can improve cultural responsiveness in healthcare. Digital tools have the ability to make this process seamless and could reach millions of patients who are underserved just by the fact they do not speak English. One study showed that digitally based educational material available in non-English languages has the immense potential to reduce health disparities (50). With regard to access, digital initiatives focused on education are being explored to help patients understand the options for care delivery and the varying caliber of services available at different care facilities (51). To reduce implicit bias in healthcare, digital programs to offer a higher degree of cultural competency and to create policies that are inclusive and sensitive to the needs of all have the potential to address longstanding disparities faced by disadvantaged groups (52).

The digital revolution in healthcare is just beginning and still fraught with imperfection. While the allure of technology to help improve access and engagement for patients has been shown in multiple areas of healthcare, numerous uncertainties persist. Effectively “crossing the chasm” will require the commitment of all stakeholders to refine, standardize, and evaluate digital platforms with the goal of making them available to the masses at large. Given the expense of many of these innovations, the need for well-designed prospective studies to explore the utility of such technologies is also becoming recognized so that the costs and benefits can be vetted. Ultimately, technology should be promoted with the goal of enhancing the patient experience with respect to quality, efficiency, and accessibility.

Conclusions

The potential of technology to fundamentally alter the provider-patient paradigm in healthcare is exciting yet daunting at the same time. As discussed in the review, the impetus to harness technology is rooted in the desire to improve quality of care in accordance with published guidelines as such (53,54). Given the breathtaking pace at which innovations are being introduced into clinical practice, understanding the objectives of digital health are imperative to drive pragmatic and widespread adoption. While the transformation of healthcare access through digital means is already taking place, continued thoughtfulness will be required to ensure that the primary focus remains on consumer (i.e., patient) centricity akin to what is happening across other service-oriented industries. Effectively “crossing the chasm” to make healthcare accessible for all will be dependent on successfully integrating technological gains into the patient experience.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The author has completed the Narrative Review reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-69/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-69/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-69/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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