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Digital Health Equity

Katharine Lawrence1,2
1
NYU Grossman School of Medicine, Department of Population Health; NY, USA:
2
NYU Grossman School of Medicine, Department of General Internal Medicine and
Clinical Innovations; NY, USA
Author for correspondence: Katharine Lawrence MD MPH, 227 E 30th St 6th Fl,
New York NY 10016, USA. Email: katharine.lawrence@nyulangone.org
Cite this chapter as: Lawrence K. Digital Health Equity. In: Linwood SL, editor.
Digital Health. Brisbane (AU): Exon Publications. Online first 2022 Apr 07.
Doi: https://doi.org/10.36255/exon-publications-digital-health-health-equity

Abstract: Digital health technologies have the potential to improve healthcare

access, utilization, and experience for patients; at the same time, their develop-
ment and use can reinforce, exacerbate, and even create health disparities.
Applying a health equity lens to digital health innovations can help inform the
equitable design and development of digital health tools. Specifically, areas of
health equity impact that can be targeted in the development of a digital health
technology include: the tool itself, including its design, technical development,
integration into the healthcare environment, and evaluation; the technology’s
­relationship to various end-users, including individuals, tech proprietors and
developers, and the larger healthcare system; and its impact on identified health
and social determinant outcomes. Targeting one or more of these areas can help
support the design, development, and deployment of digital health tools that
actively work to reduce health disparities and promote health equity for socially
disadvantaged patient populations. More research is needed to understand the
full effect of digital health technology on health disparities, and to develop best
practices for equity-centered digital health implementation and evaluation.

Keywords: digital determinants of health; digital health equity; health disparities;

health equity; the digital divide

In: Linwood SL, editor. Digital Health. Exon Publications, Brisbane, Australia.
ISBN: 978-0-6453320-1-8. Doi: https://doi.org/10.36255/exon-publications-digital-health
Copyright: The Authors.
License: This open access article is licenced under Creative Commons Attribution-
NonCommercial 4.0 International (CC BY-NC 4.0) https://creativecommons.org/
licenses/by-nc/4.0/

121
122 Lawrence K

INTRODUCTION

Despite remarkable progress in medical care over the last century, significant
differences in healthcare access, experience, and outcomes continue to exist
for many communities and individuals. Health disparities (sometimes referred
to as health inequalities) are “differences in the burden of disease, injury,
­violence, or opportunities to achieve optimal health that are experienced by
socially disadvantaged populations,” as defined by race or ethnicity, sex,
­geographic location, socio-economic status, or other social factors (e.g., sexual
orientation, disability, income) (1). Disparities in healthcare access, ­utilization,
and outcomes contribute to significant global morbidity and mortality, and
have profound impacts on quality of life, work, education, and wellbeing.
Studies of health disparities in the United States have repeatedly found
inequalities in morbidity and mortality, chronic disease burden, healthcare
utilization, substance use disorder, and mental health and wellbeing among
racial and ethnic monitories, women, the LGBTQ population, and indigenous
Americans (2). Globally, significant disparities in health have been observed
between high-, middle-, and low-income countries, as well as among
­vulnerable populations within countries (3).
While some health differences are attributable to variations in individual biol-
ogy, physiology, or genetics, health disparities are the result of social and structural
factors that confer a social disadvantage on an individual or population, dis-­
favorably impacting their lived experience with healthcare. Disparities in health
systematically put people who are already disadvantaged at further disadvantage
with respect to their health, resulting in negative downstream effects on their
ability to achieve social, political, and economic gains (4). Health disparities often
stem from health inequities – “systematic differences in the health of groups and
communities occupying unequal positions in society that are avoidable and
unjust” – which are themselves influenced by social determinants of health (SDOH),
or the conditions in which people are born, grow, live, work and age (5). Examples
of SDOH include: safe housing and transportation; education, job opportunities,
and income; food access and security; exposures to pollution and climate change;
language and literacy skills; and racism, discrimination, and structural violence.
These social and structural factors are distributed unevenly among individuals
and communities, often as the result of social policies and practices that intention-
ally withhold or underinvest in them for specific populations, creating an envi-
ronment of inequity that negatively impacts health and healthcare. SDOH are
thought to account for between 30–55% of health outcomes and represent a
major area of focus in health disparities care provision, policy, and research (5).
Health equity is the commitment to reducing and/or eliminating disparities in
health. Ingrained within the various definitions of health equity are the concepts
of human rights, social enfranchisement, distributive justice, and an effort to com-
bat structural violence and institutional discrimination. Increasingly, a focus on
health equity can be found in clinical care, research, health innovations, and com-
mercial health products and services (6); however, challenges remain the prag-
matic implementation of equity in health and to the clear identification and
actualization of health equity-centered goals, processes, outcomes, and
measures.
 Digital Health Equity 123

HEALTH (IN)EQUITY IN THE DIGITAL AGE

The digital age has brought about profound transformations in connectivity,

access, and convenience for millions of people. This includes the field of digital
health – “the field of knowledge and practice associated with the development
and use of digital technologies to improve health” (3) including virtual health,
mobile health apps (m-health), wearable devices, the Internet of medical things,
artificial intelligence and machine learning, blockchain, and tools enabling the
storage, exchange, advanced analysis and visualization of data. Prior to the novel
coronavirus (COVID-19) pandemic, digital health represented a global market of
between US $150 and $350 billion across multiple subcategories, with the mar-
kets for technologies in every category expected to grow annually by at least
8  percent (7). During the COVID-19 pandemic, digital health innovations –
­particularly telemedicine and remote patient monitoring (RPM) – were rapidly
implemented and scaled across a variety of healthcare systems in an effort to
address disruptions in in-person care delivery. These novel services provided
ongoing access to healthcare and offered successful test-cases for technologies that
had, prior to the pandemic, been limited in their use due to constraints at the
levels of individual patients, providers, healthcare systems, payors, and regulatory
and policy bodies.
Innovations in digital health technology have shown potential to improve
health outcomes, patient safety, and healthcare quality and experience for patients
(8, 9). However, digital health solutions may have unintended consequences for
socially marginalized and disadvantaged populations, and may contribute to,
exacerbate, or even create health disparities. The digital divide is a term that refers
to gaps between individuals, communities, or larger populations of people that do
or do not have access to critical technologies, including health technology.
Globally, digital divides have been identified among racial/ethnic, gender, geo-
graphic, age, and income demographics, and include things like smart-phone use,
access to broadband, Internet use patterns, affordability of technologies and ser-
vices, and digital literacy and confidence (10).
Unfortunately, to date, very few studies have systematically looked at the rela-
tionship between digital health technology and health equity across the spectrum
of socially disadvantaged populations, and the complexity of its interactions with
SDOH is only beginning to be explored (1). Digital determinants of health (DDOH)
is a term of growing popularity that describes the unique elements of people’s
experiences with the digital health ecosystem that impact their experience of
health and healthcare. Like their SDOH counterparts, DDOH incorporate indi-
vidual, community, and systems level factors (Figure 1). Individual factors describe
an individual’s experiences with digital health technology, including use patterns
and habits (e.g., frequency of Internet use, amount of screen time), as well as digi-
tal skills such as digital health literacy, digital confidence, and digital self-­
efficacy (11). Of note, biological factors are also sometimes included in this level – as
mentioned earlier, however, while biological traits such as genetic race or age may
contribute to small differences in an individual’s health, it is more often the social
constructs around those factors such as racism or ageism that contribute to health
disparities. Social and community factors incorporate the larger representative pop-
ulation’s relationship with technology, including cultural beliefs and communal
124 Lawrence K

SOCIAL DETERMINATS OF HEALTH DIGITAL DETERMINATS OF HEALTH

STRUCTURAL FACTORS STRUCTURAL FACTORS:

public policy, structural inequities institutional racism, tech bias

LIVED CONDITIONS:
LIVED CONDITIONS:
work environment, (un)employment, housing,
digital landscape, infrastructure, and use
education, healthcare services

SOCIAL & COMMUNITY FACTORS: SOCIAL & COMMUNITY FACTORS:

social networks and support relationship with technology

INDIVIDUAL FACTORS: INDIVIDUAL FACTORS:

individual behaviors experience/relationship
and attributes with technology

BIOLOGICAL BIOLOGICAL
FACTORS FACTORS

Figure 1.  Social and Digital Determinants of Health.

attitudes; these include perceptions of usability and usefulness, as well as trust,

privacy and security, surveillance, and experiences with tech bias or discrimina-
tion. Lived conditions are the digital environments a person or community experi-
ences, including infrastructure and services; geographic areas that lack access to
affordable quality technologies such as Internet broadband, known as “digital des-
erts” is one example. Finally, structural factors are the larger policies, practices, and
beliefs of a society that influence and (re)inforce a socially disadvantaged group’s
interactions with technology and include things like structural racism and
tech bias.
Each of these determinants impacts the ability of a digital health technology to
improve health outcomes and contributes to a technology’s effects on health dis-
parities. DDOH are often multi-factorial and can be complexly inter-related, in
addition to interacting with SDOH at multiple levels.

APPROACHING AND ADVANCING DIGITAL HEALTH EQUITY

While the concept of digital health equity is still emerging, at its center is the
acknowledgement that digital health technology has the potential to both amelio-
rate and exacerbate health disparities. As stated by the World Health Organization
(WHO) in their global strategy on digital health 2020–2025 “Digital health should
be an integral part of health priorities and benefit people in a way that is ethical,
safe, secure, reliable, equitable and sustainable” (12). This includes emphasizing
key principles such as transparency, accessibility, scalability, privacy, security, and
confidentiality­­­­– all factors that can contribute to the equitable design, develop-
ment, use, and impact of digital health tools. At the same time, there is growing
 Digital Health Equity 125

recognition that industries supporting digital health innovation –­ such as bio- and
med-tech startups, big pharma, and Silicon Valley – must themselves be more
diverse, equitable, and inclusive (DEI) in order for their products to be both effec-
tive and valid as tools to reduce disparities. As such, digital health tools must
strive to: (i) improve health outcomes, equitably; (ii) mitigate or actively reduce
general digital inequity; and  ​(iii) be themselves equitably designed, developed,
and implemented​.
To attain this goal, target areas for equity considerations in the digital health
technology ecosystem and pipeline include: the digital health tool itself, including
its design, technical development, deployment into the healthcare environment,
and evaluation; the technology’s relationship at various levels to the individual
end-user, its proprietors (e.g., a digital health startup or corporation, the design
team, developers), and the larger healthcare system; and its effects on target health
and health determinant outcomes (Figure 2). At each of these points are opportu-
nities for and challenges to promoting equity; these can either be selectively tar-
geted for intervention or incorporated into larger strategies of equity promotion or
inequity mitigation.
This model presents one of many ways of conceptualizing digital health equity,
in a field that is continuing to grow and expand. Other models include the Digital
Health Equity Framework (DHEF) and the Framework for Digital Health Equity,
adapted from the U.S. National Institute on Minority Health and Health Disparities
Research Framework (13, 14).

Building equitable digital health tools

Equitable digital health product design and technical development can benefit from
the complementary strategies of human-centered design (HCD) and Agile soft-
ware development, two processes that are well-established in the tech industry

Digital Product
Determinants Design

Health
Technical
Outcomes
Development

Digital
Health Tool Release/
Implementation
Healthcare
System
Evaluation
Team
End-user

Figure 2.  Target areas for equity considerations in the digital health technology development.
126 Lawrence K

and are emerging as effective tools for product development in healthcare delivery
and research. HCD utilizes repeat cycles of ideation, prototyping, testing, and
refinement to develop digital health interventions that incorporate the needs and
preferences of end-users (e.g., patients, clinicians, caregivers). Agile is an iterative
process first used in software development that involves reviewing the software or
product requirements at every stage of development and generating partial deliv-
erables for stakeholders and end users. Both strategies allow for rapid, iterative
development of technology products, and for stakeholders to be actively involved
in the development process from inception to implementation. Both are also
increasingly informed by equity-centered perspectives; equity-centered design
approaches (in particular, equity-orient human computer interaction design
[HCI]), critical design, and liberatory design are some examples from the world of
product, HCI, and experience design (15–17). It is important to recognize, how-
ever, that while HCD and Agile offer blueprints for equitable design and develop-
ment of digital health tools, the strategies themselves are not inherently equitable;
explicit commitment is needed on the part of those using these strategies to priori-
tize equity, inclusion, and representativeness, and to ensure that the perspectives
of socially disadvantage and underrepresented parties are included.
Once digital health tools have been developed, their release into the live envi-
ronment of the healthcare system offers critical moments for evaluating and
addressing any impacts on health inequity; this is the case for all digital health
technologies, not only those expressly designed to address health disparities.
Unfortunately, systematic long-term assessments of the impact of digital health
technologies on health disparities are lacking, and requirements for ongoing eval-
uation, validation, and/or remediation of adverse effects of a technology on health
disparities have been largely absent. Approaches to evaluating a digital health
technology’s impact on health disparities and/or equity can be effectively adapted
from existing clinical, research, or industry models. For example, implementation
science (sometimes known as knowledge translation science) frameworks such as
“RE-AIM” (Reach, Effectiveness, Adoption, Implementation, and Maintenance)
and Proctor’s Implementation Outcomes Framework (IOF) offer means to under-
stand how evidence-based interventions are taken up in real-world contexts, and
to optimize specific intervention goals such as adoption, sustainability, or cost
(18); these frameworks can be applied to digital health technologies, and can be
adapted to incorporate equity goals more explicitly (19–21). Similarly, business
development approaches to product metrics such as the Pirate Metrics (acquisi-
tion, activation, retention, referral, and revenue) (22) can be repurposed to high-
light equity-centered goals for digital health products –­ for example, redefining
acquisition (how a company attains customers) to focus on the recruitment of
diverse patient end-users and retention (how a company keeps customers) to focus
on empowerment, representativeness, or enfranchisement. Whatever the
approach, having a plan in place that incorporates equity into the implementation
and evaluation of digital health tools can help ensure these technologies do not
contribute to health disparities.

Incorporating stakeholders in equitable digital health innovations

Key stakeholders in the development of a digital health technology include: indi-
vidual end-users, or those who are the intended customers or recipients of a digital
 Digital Health Equity 127

health tool; the technology team, including proprietors (e.g., startup founders,
intellectual property owners, patent holders), technologists, and designers and
developers; and players in the larger healthcare system.
At the individual level, participatory design frameworks from research and
consumer insights fields that serve to actively identify, incorporate, and enfran-
chise disadvantaged stakeholders in the process of building health interventions
can be leveraged to ensure that digital health tools are effective, appropriate, and
equitable across a diversity of users. Care should be taken to ensure that represen-
tatives of disadvantaged communities are appropriately acknowledged, incorpo-
rated, and supported at each step of the technology development pipeline, that
feedback is regularly and actively solicited, and that changes to digital health
products are reflective of this feedback.
Increasingly, the global technology industry (particularly Silicon Valley) has
been criticized for its lack of diversity and equity, where people of color and
women are grossly underrepresented and are unable to make professional
advances at the same rate as their white and male colleagues (23). To address
equity at the level of a digital health technology team – such as a startup, corpora-
tion, or non-profit organization – requires meaningful investment in diversity,
equity, and inclusion (DEI) efforts that promote representativeness and enfran-
chisement of its diverse employees, members, or contributors. It also means criti-
cally evaluating the processes used by teams to develop digital health technologies
(including corporate culture), and putting into place procedures that explicitly
center equity, address bias, and mitigate potential harms.
A final key stakeholder in digital health is the larger healthcare system, which
drives specific use-cases for digital health technologies (e.g., artificial intelligence
for radiology practices) and can support or hinder the effective wide-spread adop-
tion and use of digital health tools. Priorities areas for healthcare systems to sup-
port digital health equity include the development of infrastructure for data
integration, interoperability, and analysis in a way that promotes “data s­ olidarity” –
an approach to health data that emphasizes data justice and equity and centers
those potentially disadvantaged by health data and technology use (24).
Additionally, beyond individual healthcare systems is the network of health poli-
cies, payor environments, and regulatory practices that interact with digital health
tools to create healthcare experiences and may inadvertently (or explicitly) drive
health inequities – health technologists committed to advancing digital health
equity should have an understanding of these players and be able to identify key
priorities for equity promotion and disparity reduction.

Using digital health tools to improve health outcomes

Measurement of health disparities and health equity continues to evolve as our
understanding of their contexts and complexities improves. In general, the most
common measurements of health disparities look at “preventable” differences in
health outcomes across specific demographics (e.g., race, income, zipcode);
interventions that reduce the difference in these outcomes are considered to be
effectively addressing health disparities and/or promoting health equity. But the
clinical effectiveness of an intervention is only one way to measure its impact –
as discussed, equity can be defined and evaluated in a number of ways across a
variety of metrics, priorities, and goals, as well as at multiple points in time.
128 Lawrence K

If achieving health equity is the goal, the outcome may not always be tied to a
specific disease; rather, it may focus on specific SDOH or DDOH such as
healthcare delivery outcomes (e.g. access, utilization, or experience), or
­
­structural outcomes (e.g., broadband access, algorithmic bias, or DEI in the
healthcare workforce).
Currently, concrete measurement tools that assess the impact of digital health
technologies on health disparities beyond health outcomes are lacking. However,
concrete examples of measures that can be adapted to digital health in the United
States include Medicare’s value-based purchasing (VBP) programs, which target
quality improvement outcomes through service enhancements, patient engage-
ment activities, and adoption of best practices; the Measurement Framework for
Evaluating How Well an Organization Meets National CLAS Standards; the
National Quality Forum (NQF) Disparities-Sensitive Measure Assessment, which
operationalizes existing quality metrics for specific use in health disparities efforts
in the ambulatory care setting; and CAHPS and HEDIS data for Medicare
Beneficiaries (25). These measures capture important healthcare metrics beyond
health outcomes, and can be used to assess disparities and prioritize digital health
interventions among socially disadvantaged populations. More work is needed,
however, to rigorously define, capture, and analyze health equity outcomes; doing
so will help guide more effective and targeted development of equity-focused
digital health innovations.

CONCLUSION

Digital health is a growing area of healthcare delivery that increasingly impacts the
healthcare experiences of patients, providers, and others across the industry.
Digital health technologies have the opportunity to significantly improve care for
individuals and populations; at the same time, however, digital health tools can
contribute to and even create health disparities for socially disadvantaged groups.
Approaches to digital health that focus on health equity – the active commitment
to reducing health disparities and improving the experience of healthcare for
diverse, marginalized, and underrepresented patient populations – can help
ensure that digital technologies in healthcare are designed, developed, and
deployed in an effective and equitable manner. Solutions for building and imple-
menting equitable digital health tools can be found along multiple places in the
development pipeline and within the digital health ecosystem; these include the
design, technical development, release, and evaluation of a digital technology into
the healthcare system, as well as its relationship to a variety of stakeholders, health
outcomes, and social and digital determinants. Ongoing work in industry,
research, and clinical practice continues to identify strategies for the prioritization
of health equity, as well as to diversity, equity, and inclusion within the industry
itself. More research is needed to develop validated processes and measures to
identify, prevent, and mitigate inequity in digital health. The active participation
of digital health corporate interests, advocacy groups, regulatory and policy bod-
ies, and patients themselves is critical to creating a future of digital health that
supports those who most stand to benefit from a more equitable, fair, and just
healthcare system.
 Digital Health Equity 129

Acknowledgement: Dr. Lawrence acknowledges the contributions of her col-

leagues in the Center for Digital Health Equity, as well as the clinicians, communi-
ties, patients and partners working to reduce disparities and promote equity in
health.

Conflict of Interest: The author declares no potential conflicts of interest with

respect to research, authorship and/or publication of this chapter.

Copyright and Permission Statement: The author confirms that the materials
included in this chapter do not violate copyright laws. Where relevant, appropri-
ate permissions have been obtained from the original copyright holder(s), and all
original sources have been appropriately acknowledged or referenced.

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