Digitally Disconnected: Qualitative Study of Patient Perspectives on the Digital Divide and Potential Solutions

Background: As telemedicine utilization increased during the COVID-19 pandemic, divergent usage patterns for video and audio-only telephone visits emerged. Older, low-income, minority, and non-English speaking Medicaid patients are at highest risk of experiencing technology access and digital literacy barriers. This raises concern for disparities in health care access and widening of the "digital divide," the separation of those with technological access and knowledge and those without. While studies demonstrate correlation between racial and socioeconomic demographics and technological access and ability, individual patients' perspectives of the divide and its impacts remain unclear. Objective: We aimed to interview patients to understand their perspectives on (1) the definition, causes, and impact of the digital divide; (2) whose responsibility it is to address this divide, and (3) potential solutions to mitigate the digital divide. Methods: Between December 2020 and March 2021, we conducted 54 semistructured telephone interviews with adult patients and parents of pediatric patients who had virtual visits (phone, video, or both) between March and September 2020 at the University of Chicago Medical Center (UCMC) primary care clinics. A grounded theory approach was used to analyze interview data. Results: Patients were keenly aware of the digital divide and described impacts beyond health care, including employment, education, community and social contexts, and personal economic stability. Patients described that individuals, government, libraries, schools, health care organizations, and even private businesses all shared the responsibility to address the divide. Proposed solutions to address the divide included conducting community technology needs assessments and improving technology access, literacy training, and resource awareness. Recognizing that some individuals will never cross the divide, patients also emphasized continued support of low-tech communication methods and health care delivery to prevent widening of the digital divide. Furthermore, patients viewed technology access and literacy as drivers of the social determinants of health (SDOH), profoundly influencing how SDOH function to worsen or improve health disparities. Conclusions: Patient perspectives provide valuable insight into the digital divide and can inform solutions to mitigate health and resulting societal inequities. Future work is needed to understand the digital needs of disconnected individuals and communities. As clinical care and delivery continue to integrate telehealth, studies are needed to explore whether having a video or audio-only phone visit results in different patient outcomes and utilization. Advocacy efforts to disseminate public and private resources can also expand device and broadband internet access, improve technology literacy, and increase funding to support both high- and low-tech forms of health care delivery for the disconnected.