Opportunities and Challenges to Advance Health Equity Using Digital Health Tools in Underserved Communities in Southeast US: A Mixed Methods Study.

INTRODUCTION: Over the last 30 years, the adoption of health information technology and digital health tools (DHTs) into the US health system has been instrumental to improving access to care, especially for people living in rural, underserved, and underrepresented communities. Despite widespread adoption of DHTs by primary care clinicians, documented challenges have contributed to inequitable use and benefit. The COVID-19 pandemic necessitated rapid adoption of DHTs, accelerated by state and federal policy changes, in order to meet patient needs and ensure access to care. METHODS: The Digital Health Tools Study employed a mixed methods approach to assess adoption and use of DHTs by primary care clinicians in southeastern states and identify individual- and practice-level barriers and facilitators to DHT implementation. A survey was conducted using a multi-modal recruitment strategy: newsletters, meeting/conference presentations, social media, and emails/calls. Focus groups were conducted to assess priorities, barriers, and facilitators and were recorded/transcribed verbatim. Descriptive statistics were calculated for survey results, produced for the whole sample, and stratified by state. Thematic analysis was conducted of focus group transcripts. RESULTS: There were 1215 survey respondents. About 55 participants who had missing demographic information were excluded from the analysis. About 99% of clinicians used DHTs in the last 5 years, modalities included: telehealth (66%), electronic health records (EHRs; 66%), patient portals (49%), health information exchange (HIE; 41%), prescription drug monitoring programs (39%), remote/home monitoring (27%), and wearable devices (22%). Time (53%) and cost (51%) were identified as barriers. About 61% and 75% of clinicians reported being "satisfied" to "very satisfied" with telemedicine and EHRs, respectively. Seven focus groups with 25 clinicians were conducted and indicated COVID-19 and the use of supplemental tools/apps to connect patients to resources as major motivators for adopting DHTs. Challenges included incomplete and difficult-to-utilize HIE interfaces for providers and internet/broadband access and poor connectivity for patients. CONCLUSIONS: This study describes the impact adopting DHTs by primary care clinicians has on expanded access to healthcare and reducing health disparities in regions with longstanding health and social inequities. The findings identify opportunities to leverage DHTs to advance health equity and highlight opportunities for policy improvement.

Variation in Reporting of the Race and Ethnicity of COVID-19 Cases and Deaths Across US States: April 12, 2020, and November 9, 2020.

Despite growing evidence that COVID-19 is disproportionately affecting communities of color, state-reported racial/ethnic data are insufficient to measure the true impact.We found that between April 12, 2020, and November 9, 2020, the number of US states reporting COVID-19 confirmed cases by race and ethnicity increased from 25 to 50 and 15 to 46, respectively. However, the percentage of confirmed cases reported with missing race remained high at both time points (29% on April 12; 23% on November 9). Our analysis demonstrates improvements in reporting race/ethnicity related to COVID-19 cases and deaths and highlights significant problems with the quality and contextualization of the data being reported.We discuss challenges for improving race/ethnicity data collection and reporting, along with opportunities to advance health equity through more robust data collection and contextualization. To mitigate the impact of COVID-19 on racial/ethnic minorities, accurate and high-quality demographic data are needed and should be analyzed in the context of the social and political determinants of health.

Population-Level Disparities in COVID-19: Measuring the Independent Association of the Proportion of Black Population on COVID-19 Cases and Deaths in US Counties.

CONTEXT: There is a need to understand population race and ethnicity disparities in the context of sociodemographic risk factors in the US experience of the COVID-19 pandemic. OBJECTIVE: Determine the association between county-level proportion of non-Hispanic Black (NHB) on county COVID-19 case and death rates and observe how this association was influenced by county sociodemographic and health care infrastructure characteristics. DESIGN AND SETTING: This was an ecologic analysis of US counties as of September 20, 2020, that employed stepwise construction of linear and negative binomial regression models. The primary independent variable was the proportion of NHB population in the county. Covariates included county demographic composition, proportion uninsured, proportion living in crowded households, proportion living in poverty, population density, state testing rate, Primary Care Health Professional Shortage Area status, and hospital beds per 1000 population. MAIN OUTCOME MEASURES: Outcomes were exponentiated COVID-19 cases per 100 000 population and COVID-19 deaths per 100 000 population. We produced county-level maps of the measures of interest. RESULTS: In total, 3044 of 3142 US counties were included. Bivariate relationships between the proportion of NHB in a county and county COVID-19 case (Exp ß = 1.026; 95% confidence interval [CI], 1.024-1.028; P < .001) and death rates (rate ratio [RR] = 1.032; 95% CI, 1.029-1.035; P < .001) were not attenuated in fully adjusted models. The adjusted association between the proportion of NHB population in a county and county COVID-19 case was Exp ß = 1.025 (95% CI, 1.023-1.027; P < .001) and the association with county death rates was RR = 1.034 (95% CI, 1.031-1.038; P < .001). CONCLUSIONS: The proportion of NHB people in a county was positively associated with county COVID-19 case and death rates and did not change in models that accounted for other socioecologic and health care infrastructure characteristics that have been hypothesized to account for the disproportionate impact of COVID-19 on racial and ethnic minority populations. Results can inform efforts to mitigate the impact of structural racism of COVID-19.