Access to online medical information has transformed how patients and doctors approach treatment and care. Other new technologies, such as electronic health records, are beginning to transition into our lives and are poised to revolutionize health care. With medical care being increasingly mediated by information technology (IT) we are faced with an alarming prospect: the emergence of a digital health divide where access will become critically dependent not only on ability to pay, but also tech-savvy. Given the many well publicized failings of our health care system, addressing this divide may seem like a low priority. Yet, there are important reasons why we cannot afford to be so complacent. First, the digital divide – already evident in the inequitable access to online resources, and the migration of only the larger and more successful medical practices to electronic health records – is likely to widen. Second, the technologies and standards of tomorrow’s health care system are being developed today – so the time to influence their shape is now.
It has become fashionable to suggest that IT can help fix our beleaguered health care system. Policy makers from both parties frequently emphasize ITs potential for turning a disparate health sector into a coherent system. Industry giants such as Microsoft, Intel, and Google have invested heavily in health IT and are busy staking their claims (witness the recent release by Microsoft of its health record system HealthVault). Policymakers see in health IT the potential to reduce paperwork, medical errors, and costs. Private companies realize that a centralized database of the nation’s health records would be a gold mine – with fortunes to be made. The digitization of health records is not just “the next big thing” – it is the critical technology that will enable a transition in the way medicine is practiced.
The vision of health IT is enticing. In a world with electronic medical records, care providers in emergency rooms at the other end of the planet would be able to access our medical history instantly. This information would be stored in secure locations with appropriate privacy protections and de-identified data would drive new medical discoveries. We could view and update the information on our phones and PDAs, which would come with in-built reminders prompting us to take our medication. Glucose readings at home would be wirelessly transmitted to call centers that monitor the data and sends alerts as necessary. Increasingly rich content on the Internet would enable us to make more informed decisions and empower us to ask our care providers probing questions. We would connect to and receive social support from others struggling with similar conditions or challenges like quitting smoking. Electronic prescribing systems would automatically transmit our prescription to the local pharmacy to be filled with cost-effective drugs that pose no risk of interaction, and telemedicine would give us access to the best specialists. In short, we are promised a safe and hassle free world where as health care consumers we are empowered to take control of our own health conditions and have the knowledge and information necessary to make considered choices.
There is a fundamental flaw with this vision. It is built around a concept of a future patient who is affluent, well educated, and – most of all – tech savvy. It is predicated on the ability to access and use complicated technologies and neglects groups that lag behind in this – racial and ethnic minorities, the elderly, and the less-educated. Will these individuals, who could benefit a lot from the right health IT applications, get further distanced from the movement to transform health care? This would certainly be the case if, in the zeal for cutting costs, technologies are used to shift the responsibility for managing disease on to patients. Or if the target customer of the new technologies – e.g. those built around digital health records – are only the affluent.
We need to address this digital health divide. The provision of broadband infrastructure to rural and under-served areas at affordable rates, and training in the use of digital technologies, takes on some urgency. We already have a model for this in the universal and lifeline service programs for telephones. It is high time to extend these to broadband. As we invest resources in developing technologies for the future, government has a crucial role to play in the choice of standards for the database of health records. We need to ensure that we do not neglect the needs of the disadvantaged – whose voices are not part of the current negotiations about the future health system. If we don’t pay attention to such issues proactively, and allow vested interests to lead the innovation in health IT, we may end with an even wider schism between the haves and have-nots. That is not a promising vision for the future.
(Jointly authored with Kislaya Prasad)