July 28, 2017; New America Media
Despite GOP insistence that the Affordable Care Act (ACA) has been a disaster for the American people, the reality is quite different. Far from perfect, the ACA has delivered health coverage to 20 million more Americans, many of them low-income people of color. Further, efforts were made to reduce health disparities. A critical tool intended to reduce disparities has been the widespread implementation of digital patient portals and electronic medical records (EMRs). But new data suggests that the digitization of medical access may in fact increase health disparities rather than reduce them.
In 2015, the Kaiser Family Foundation reported, eight percent of nonelderly whites were uninsured, compared to 12 percent of Blacks and 17 percent of [email protected] Overall, people of color accounted for more than half of the total 32 million nonelderly uninsured. Lack of access to care leads to disparities of outcomes. For example, Blacks have persistently higher rates of HIV, asthma, and diabetes, diseases that are also correlated with higher rates of poverty.
In addition to digital patient portals and EMRs, a number of other provisions of the ACA were intended to address health disparities. For example, establishing Offices of Minority Health within HHS agencies, promoting cultural competence, and strengthening data collection. The ACA also appropriated $11 billion over a five-year period to enhance community health centers, where many low-income people access care.
In a recent article by reporter Viji Sundaram, Suneel Ratan, chief strategy officer of Community Health Center Network and the Alameda Health Consortium, discussed her recent research on patient portals used by Bay Area community health centers. She said, “You could argue they increase disparities.”
Patient portals did not arise under the Affordable Care Act, but they have become more widespread. Portals generally allow patients to make appointments online, pay bills, renew prescriptions, and review lab results. In some cases, patients can review their entire medical record.
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Kelvin Quan, Executive Director of MayView Community Health Center, noted that many of the health centers’ patients can’t afford computers. Moreover, they may not have a high degree of English language or technology literacy. Sundaram cites a recent California study that found an increasing number of low-income Californians access internet service only through their cell phones. The patient portal, however, is not mobile friendly.
The MayView Community Health Center, with clinics in the Silicon Valley communities of Mountain View, Palo Alto, and Sunnyvale, launched a patient portal last year to meet “meaningful use” requirements of the Electronic Health Records Incentive Program and qualify for incentive payments. In addition, said Quan, MayView invested $30,000 in building the portal and connecting it the electronic health records system in order to meet the standard of a “Patient-Centered Health Home,” a coordinated care model also promoted by the Affordable Care Act.
What MayView has found, however, is that only about 10 percent of its 6600 patients enrolled with the online patient gateway. Of those, only about 200 patients are active users. MayView’s clinic attracts patients with low incomes and from [email protected], Asian, and Pacific Islander communities. A similar clinic in East Palo Alto, Ravenswood Family Health Center, found that only 10 to 15 percent of their patients used the patient portal. By contrast, Kaiser Permanente did a study two years ago showing that 70 percent of its 5.2 million patients used their patient portal. The difference: Kaiser’s portal is geared toward users who are white and middle class. Kaiser finds that patients without a high school degree are much less likely to use their portal.
Patient portals are intended to create health care consumers who are informed and empowered. But, Dr. Vikas Saini, president of the Lown Institute, pointed out that electronic medical records (EMRs) were not designed to improve patient care, but rather to improve administration and billing. As a result, he said, “It’s no surprise that patient portals, which must be tightly integrated with EMRs, are not user friendly and available to poor and working-class people.”
Among the most significant issues facing the American health care system is how to resolve issues of health care access and disparate outcomes. It may be time to rethink how technology can support that project.—Karen Kahn