A rapidly growing area of competency for effective case management is digital health. To improve proficiency in this area, professional case managers must not only be knowledgeable about the types of digital health technologies available, but also ensure that their patients are able to use and benefit from these technologies as well. How can this be realized? Digital health literacy is the key.
WHAT IS DIGITAL HEALTH LITERACY?
The concept of digital health literacy (DHL) is rooted in the foundation of health literacy but addresses a very specific set of needs relative to the digital age we live in. Digital health literacy (DHL) refers to the specific degree of skills and abilities necessary to use digital health technology and services (Yoon et al, 2022).
Digital health literacy goes far beyond the idea of improving skills to find and evaluate health information on the internet. It encompasses a much broader scope in the context of a multitude of technologies involving mobile devices, remote monitoring, personal health records and chronic condition health management. Just a few examples of activities requiring functional levels of digital health literacy include:
- Participating in telehealth video consultations
- Accessing and navigating patient portals and personal health records
- Using online prescription management refill services
- Completing online registration or admission forms
- Researching anticipated costs of a service or procedure
- Comparing options and enrolling in a health insurance plan
- Completing online booking of appointments
- Setting up mobile apps to interface with wearable devices (such as Bluetooth-enabled glucose monitoring devices and insulin pumps)
- Viewing and interpreting remote monitoring results on a smartphone
- Effectively using medication adherence reminders and alert apps
Given how ubiquitous these and many other digital health tools are in healthcare today, it’s clear that digital health literacy is a critical competency to master.
WHY IS DIGITAL HEALTH LITERACY IMPORTANT?
Access to digital health is increasingly being recognized as a significant determinant of health. In fact, there’s an emerging body of knowledge regarding digital determinants of health and their impact on health equity and outcomes.
Digital determinants of health (DDOH) are conditions within the digital environment that, similar to social determinants of health (SDOH), influence a wide range of health and quality of life outcomes (Richardson et al, 2022). These digital determinants of health include:
- Access to technological equipment and tools (such as smartphones and laptops)
- Availability of and access to broadband internet within one’s community
- Literacy in using and understanding digital information and communication technologies
People who are lacking one or more of these DDOH (a situation termed “digital exclusion“) are more likely to experience health inequities as a result of the digital divide that is created. Digital health equity represents an important step toward overall health equity. Professional case managers can play an important role in addressing this digital divide by assessing digital health literacy and advocating for digital health fluency.
ASSESSING DIGITAL HEALTH LITERACY
Assessing digital health literacy is important to identify patients who may be experiencing issues with accessing, adapting to and confidently using digital health tools and technologies. There has been solid research in this area to test the strength and effectiveness of various digital health technology literacy assessment tools.
One of these evidence-based tools, called the Digital Healthcare Literacy Scale (DHLS), is a brief, three-item scale that measures the basic skills necessary for using digital health technologies (Nelson et al, 2021). The DHLS was developed and tested among a racially and socioeconomically diverse sample, and the three screening items included were determined to be the strongest predictors of digital health literacy. These three items focus on a person’s confidence and ability to use technological programs or services, as well as their ability to independently troubleshoot technical issues.
Case managers can use the DHLS as an evidence-based tool to quickly identify patients who may require additional assistance to use digital health tools or services. The process is simple (see Figure 1):
- The patient is presented with the three DHLS screening items:
- I can use applications/programs (such as Zoom) on my cell phone, computer or another electronic device on my own (without asking for help from someone else)
- I can set up a video chat using my cell phone, computer or another electronic device on my own (without asking for help from someone else)
- I can solve or figure out how to solve basic technical issues on my own (without asking for help from someone else)
- For each item, the patient responds with their level of agreement, using a scale where 0 = equals strong disagreement and 4 = strong agreement
- The response scores are totaled for all three items to arrive at a total score
- The total score provides an overall indicator of digital health literacy, with higher scores indicating higher digital literacy levels
The case manager can then target those patients identified with limited digital health fluency using advocacy-based interventions to help them more effectively engage with and benefit from digital health tools.
ADVOCATING FOR DIGITAL HEALTH FLUENCY
Advocacy is at the heart of professional case management. In fact, advocacy is central to the very definition of case management and is an essential function of the case manager role! The Standards of Practice for Case Management include a specific standard on “Health Information Technology,” which emphasizes the case manager’s advocacy role in helping clients benefit from digital technology (CMSA, 2022). Specifically, this standard of practice encourages the case manager to:
- Take personal responsibility for learning and understanding new technologies
- Assist clients and their support systems with access to available technologies such as applications, patient portals and telehealth services
- Inform, educate, teach and guide clients on how to access technology and monitor outcomes
The barriers to effectively using and benefiting from digital health technologies presents the case manager many opportunities to serve as patient advocate. Consider the variables that have been highly correlated with lower digital health literacy (Nelson et al, 2021, and Richardson et al, 2022). Lower levels of digital health fluency are seen in people who:
- Have less education and lower income
- Identify as a person of color
- Do not own or have access to digital tools such as a smartphone or a laptop computer
- Do not have a stable network connection to use home internet or to use a cell phone data plan
- Have never used a health app
- Have never used video telehealth to obtain care
- Perceive scheduling a telehealth visit as being difficult
- Have not signed into the patient portal available to them
- Have low beliefs about the usefulness of digital health
- Generally lack interest in and familiarity with technology
- Lack a support system (friends/family) who can help with using technology
At first glance, this may seem like an overwhelming list of challenges to overcome. But for many of the examples mentioned above, there is an opportunity to close the gap through case management intervention.
Individualized education can be provided to help patients better understand how technology is used in the care and treatment of their health. This can include building skills in using online tools such as navigating patient portals, downloading and pairing phone-based apps for remote monitoring equipment and wearables and using common videoconferencing platforms. It can also include learning about resources and programs offered by community organizations (such as local libraries) that provide training on using digital tools and apps to offer patients. These types of personalized educational approaches help patients become empowered and engaged in their care, which in turn contributes to improved confidence and self-efficacy.
Case managers can also help patients access new technology and tools that they may be unaware of, or to more effectively use what is already available and accessible to the patient. This requires the case manager to help patients understand the benefits of using various technologies and tools in a way that best supports their unique goals and preferences. Motivational interviewing skills can be used to better understand a patient’s goals in relation to a specific digital health tool or device. This, in turn, enables the case manager to more effectively collaborate with the patient in developing a plan of action that provides the patient with a greater sense of accountability and commitment to using the tool to meet their goals.
Assessing digital health literacy and advocating for digital health fluency are two essential areas of competence for professional case managers to drive patient-centered care and optimal outcomes in the age of digital health. Case managers can use the strategies described in this article to improve digital health literacy, thereby helping patients become more confident in their ability to use the digital technologies, tools and resources that permeate our everyday world of healthcare. In doing so, case managers improve access to equitable and appropriate resources and help reduce digital disparities of care, one patient at a time.
Case Management Society of America (CMSA) (2022). Standards of Practice for Case Management. www.cmsa.org/SOP.
Nelson L, Pennings J, Sommer E, Popescu F, Barkin S (2021). A 3-item measure of digital health care literacy: Development and validation study. JMIR Formative Research 6(4):e36043. https://doi.org/10.2196/36043.
Richardson, S., Lawrence, K., Schoenthaler, A.M. et al. A framework for digital health equity. npj Digit. Med. 5, 119 (2022). https://doi.org/10.1038/s41746-022-00663-0.
Yoon, J., Lee, M., Ahn, J.S. et al. Development and Validation of Digital Health Technology Literacy Assessment Questionnaire. J Med Syst 46, 13 (2022). https://doi.org/10.1007/s10916-022-01800-8.
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