With more than two decades of experience and research in telemedicine, the Washington DC-based Children’s National Hospital Telemedicine team has identified a disparity in access to the internet and digital tools that disproportionately impacts low-income and rural communities , creating a digital divide.
THE PROBLEM
Many of these families do not have reliable, unlimited internet access or the necessary devices to provide telemedicine services, which have become a valuable form of healthcare delivery, especially during and after the COVID-19 pandemic.
“The lack of connectivity created several barriers, with families having to travel long distances to reach the hospital, often at significant expense in mileage, parking and time away from work or school,” said Tejal Raichura, director of telemedicine at Children’s National Hospital. . “This was not only inconvenient – it was a significant barrier to timely medical care, especially for chronic conditions that required regular follow-ups.
“The situation was exacerbated for families in rural areas and for families where English was not the primary language,” she continued. “These factors resulted in higher appointment no-show rates, poorer patient compliance with treatment plans and could ultimately impact health outcomes.”
For healthcare providers, these challenges have translated into inefficiencies in care delivery and a growing concern that the most vulnerable patients are slipping through the cracks. Children’s National quickly realized that until broadband access becomes an equitable public good, it will have to try to bridge the gap in technical equity, or “techquity.”
“Most low- and middle-income families with children report having computers, mobile devices and some form of internet access,” Raichura says. “While these numbers of digital ownership and connectivity are high, many families do not have internet access at home. Of all families below the median income, about a quarter have only mobile access, while a fraction have no access.
“Of families living in poverty, about a third have only mobile access and a fraction have no access,” she added. “Among Spanish-speaking immigrants, about four in 10 have only mobile access and about one in 10 have no access. When examined through the lens of race and ethnicity, Hispanic immigrants report significantly less digital technology in their homes than white, black and American parents. -born Spanish parents.”
PROPOSAL
To address the tech equity issue, Children’s National proposed a solution that leveraged cell phone and data subscription technology to bridge the digital divide.
The idea was simple yet impactful: provide low-income families with the necessary tools – subsidized smartphones with unlimited data plans – to access telemedicine services without the burden of connectivity issues. This approach aimed to reduce the physical and financial barriers that previously prevented these families from receiving consistent, high-quality care.
“The proposal included several key components,” Raichura explains. “First, smartphones equipped with a customized mobile application would be distributed to patients who needed them most and who met very strict inclusion criteria, including infants with chronic diseases who lived in neighborhoods with high poverty rates, families where English was not the primary language, and those living 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 that includes patient-reported outcomes, geo-mapping, health outcomes data and e-surveys. This iterative feedback loop was intended to ensure that the program was responsive to the needs of low-income families and could adapt to any challenges that arose during implementation.
MEETING THE CHALLENGE
After the proposal was approved, Children’s National began implementing cell phone technology and data plans to address the tech equity challenge. The first step was to identify and recruit patients who would benefit most from this initiative.
“Outreach efforts focused on underserved families receiving care at Children’s National, as well as referrals from community partners such as DC public school nurses employed by a subsidiary of Children’s National,” Raichura said. “These families were provided with subsidized smartphones with unlimited data plans, along with apps installed to facilitate seamless communication between patients and healthcare providers.
“For the devices, we have engaged service providers who have phones available at no cost or at very low cost with broad coverage of mobile data access,” she continued. “Training was another critical part of the implementation process. Providers and patients were guided through written and video tutorials in using the technology with the assistance of bedside or clinic teams.”
RESULTS
The implementation of cell phone technology and data plans at Children’s National has led to several measurable successes, demonstrating its impact on healthcare equity.
First, greater involvement in telemedicine.
“One of the key results of this initiative is an increase in telemedicine activities among low-income patients,” Raichura said. “By providing the necessary tools and connectivity, Children’s National has made it easier for these families to access care without the need for expensive and time-consuming travel.
“This increase in engagement has not only improved access to care, but has also improved the overall efficiency of regular check-ins and follow-up visits,” she added.
Second, lower no-show rates.
“As barriers to broadband access have decreased, Children’s National has seen a decrease in no-shows for virtual appointments,” Raichura said. “This was clearly evident in patients who lived further away from 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: greater satisfaction of patients and caregivers.
“The feedback from both patients and providers has been overwhelmingly positive,” Raichura noted. “Families appreciate the convenience and lower 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 that the majority of patients and caregivers are satisfied or very satisfied with their connected care experience, underscoring the success of the initiative,” she continued.
ADVICE FOR OTHERS
For healthcare organizations considering implementing similar technology to address tech equity and health equity, several important lessons have emerged from Children’s National’s experience, Raichura said.
“Start first with a clear understanding of the digital divide,” she advised. “It is essential to recognize the specific barriers that low-income and underserved populations face in accessing health care. A thorough assessment of community needs and existing gaps in digital access is crucial before designing an intervention. Understanding these challenges will help tailor technology to meet the unique needs of the population you want to serve.
“Then collaborate across the organization,” she continued. “The success of a telehealth program depends on collaboration between different teams to improve care for our patients and their families. Children’s National’s telemedicine team worked closely with physicians, the information technology and informatics teams, operations 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 caregivers,” she said. “Extensive training and ongoing support are critical to ensure that everyone involved can use the technology at ease. 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 easier it is to use the technology is, higher will be the adoption and engagement rates.
“Also use data to drive continuous improvement,” she added. “Implementing a robust quality improvement framework that includes real-time data collection and analysis is key to the success of any technology-driven healthcare initiative. By continuously monitoring outcomes, gathering patient feedback and making iterative improvements, you can ensure that the technology continues to respond to the needs of the population and adapt to any new challenges.”
In conclusion, while technology alone cannot solve the complex issue of healthcare equity, when used thoughtfully and in combination with a deep understanding of community 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 provide quality health care to the most vulnerable populations,” she said.
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