Digital health tools for mobile devices can help to advance equity…if designed right

By Connie Ritchey, managing director, and Bobby Powers, manager, Deloitte Consulting LLP

COVID-19 has changed the way we work, the way we interact with each other, and the way we seek care. However, as our colleague Dr. Elizabeth Baca points out in her recent blog, the pandemic has also highlighted a key issue that still needs to change: health inequities. Racial health disparities have gotten worse over the past two decades, and this was highlighted by the pandemic.¹ Many under-represented minorities (URMs) have been adversely affected by tangible issues (e.g., proximity to care and lack of insurance coverage),^2,3 as well as less obvious barriers including implicit bias from providers, health-related stigmas, and trust issues stemming from a history of unethical medical practices in this country.⁴ These and other issues have propagated a gap in the quality of care that is fueling a public health crisis in some communities.

Technology is often seen as a tool that can help reduce health disparities. Mobile phones and other wireless technologies, for example, are increasingly being used to support medical care and public health practices (e.g., treatment support, diagnosis, monitoring, and chronic-condition management). This use of technology is often referred to as mHealth. mHealth solutions could help URM groups overcome barriers that have historically limited their access to quality health care. For example, about 80% of Black and Latinix adults own a smartphone, and they are more likely than white adults to use their phones to search for health information.⁵ This could create an opportunity to overcome issues of trust and access within at-risk populations.

Mobile technologies can also offer a set of tools that could help reduce the implicit bias that has plagued some in-person patient-provider interactions in the past. The technology and health care sectors have been rallying around the idea of using mobile technologies to tackle health disparities.⁶ Nevertheless, the app-store graveyard is littered with unsuccessful attempts to provide health-related tools—particularly to Medicaid populations—over the years. What should the industry do differently this time around? How can product teams make sure they build helpful, sticky, and usable solutions for URM groups?

How can digital health teams get it right?

Rapid proliferation of smartphone ownership, combined with increased use of virtual health during the COVID-19 pandemic, appears to have brought digital health adoption to a tipping point.⁷ But to overcome past challenges of adoption, usability, and utility, we recommend that organizations consider the following strategies to build more inclusive mHealth products: 

1. Expand the scope of customer-experience research and design: When it comes to designing the patient experience, there is a tendency to focus on the point of care. Researchers typically observe patient and provider interactions to identify and address pain points. However, as Dr. Baca noted in her blog, up to 80% of health outcomes are affected by social, economic, and environmental factors. Consequently, focusing on the point of care can only move the needle so far. Design researchers should also explore broader questions. How has health information, consumer attitudes, and beliefs that exist within a patient’s community shaped the patient’s behaviors? How does the patient’s financial situation impact how they manage their condition? Healthfirst, a New York-based health plan, recently asked those questions while designing a mobile app.⁸ Apps developed by health plans typically allow users to search for providers, access telehealth resources, or research benefit details. Healthfirst recognized that access to housing and food security was also important to health outcomes. The new app includes algorithms that create personalized recommendations for services—such as food pantries—available throughout the area. By meeting people where they live or work, product teams can design for financial, cultural, and social factors that impact their users.

2. Design for the most inclusive use-environment: Mobile-app teams often build tools aimed at the largest market-share of customers. A mobile app, for example, might be designed with a middle-aged, middle class white patient in mind. While that persona likely has access to a newer mobile device and has reliable WIFI, the app might not be useful to all patients—especially URMs. This could result in negative experiences for under-resourced members. To drive equitable access, app developers should consider these strategies:

• Develop apps that work offline and with low bandwidth. As our colleague Scott Dillingham discusses in his recent blog, unreliable internet access can make it difficult to access virtual health. mHealth apps that are designed to run on the user’s device without internet access, might be more accessible. Additionally, design teams should consider the size of downloadable assets. Lower-income smartphone owners are more likely to cancel phone service due to the cost,⁹ and might be inclined to stop using the app that requires large amounts of data from their cellular plan. Teams should consider apps that sync information to the cloud after users have reconnected to WIFI. This could help ensure that users can still backup their data, and that product teams can collect valuable data about user behavior.
• Design apps for a wide range of screen sizes, resolutions. App developers should research the types of devices their customers use. For example, apps should be designed to work with small devices and with low resolution. Apps that are built for smaller screens and low-resolution can be scaled up to work with larger and higher-resolution phones.  
• Make sure apps are accessible to everyone. Any genuine commitment to inclusivity and diversity should consider the unique needs of patients who have disabilities. Since mHealth apps often address chronic conditions, designers should anticipate that some users will have physical limitations, disabilities, or other health issues that could impair their vision, hearing, speech, processing, or memory. The Web Content Accessibility Guidelines (WCAG) rate apps by their accessibility to a wide range of user groups. Single A is seen as the minimum, while AAA is considered the “gold standard” for accessibility, according to WCAG. Complying with AA or AAA standards can make solutions more inclusive for all users.¹⁰
• Consider health and tech literacy. It can be challenging to create content that is both easy to understand and provides an elegant user experience (UX). We recommend combining UX writing and health literacy expertise when developing content. This could include answers to common questions (e.g., via chatbots) and support for multiple languages. Apps that incorporate other commonly spoken languages could broaden the possible user base and create a better UX. App designers also should recognize that various operating systems could create challenges for patients who aren’t accustomed to using apps. Consider this: In Colorado, the Governor’s Office of Information designed a chatbot to answer questions from Medicaid recipients.¹¹ The PEAK Chatbot, which Deloitte helped to build, uses conversational prompts and responses to respond to questions about benefits. This means users don’t need to set up an online account, navigate a web portal, or manage a profile. 

3. Create solutions that overcome implicit bias: Technology has the potential to exacerbate discrimination, from facial recognition¹² to mobile advertising.¹³ In health care, implicit bias can lead to less equitable care.¹⁴ Given these dynamics, app designers and product managers should be trained to recognize bias across economic and racial groups so that they can use creative design to reduce it. Hospital systems often have data on doctors’ personal biases from testing and training efforts. mHealth tools, for example, could tap into this information to nudge doctors toward different behaviors.¹⁵

4. Get started with more inclusive product teams: Product teams that have depth and diversity are more likely to examine multiple perspectives and create a broader range of hypotheses that lead to more meaningful solutions. Case in point: A Black woman and a half-Japanese woman founded the wellness app, Shine. They drew on their personal experiences to create a product that spoke to the unique stressors experienced by women of color. The app has more than 4 million users and was selected as a Best of 2020¹⁶ winner. Product teams can employ other strategies to make their teams more inclusive. Patient communities are often evaluated when apps are designed for patients. Instead, designers could work with patient groups during their creation sessions. Platforms like Wego Health¹⁷ can be used to find more diverse patient advocates and experts. Designers such as Antoinette Carroll argue for an equity designer¹⁸ to become a dedicated product team role. Regardless of the approach, teams should be cognizant of their own biases while designing. Teams can build a culture of inclusivity through training, awareness, and accountability within the larger organization.

2020 has seen the rise of several powerful forces for change. We have seen a dramatic shift to virtual health, rising levels of social consciousness, and advances in mobile technology and adoption. We are in the midst of a once-in-a-generation opportunity for health care technologists to make a real difference. To capitalize on the opportunity, we should recognize that this decades-old problem requires a new, more collaborative, and more inclusive approach. 

Endnotes

^{1.        Racial health disparities worsened over 20-year period, Patient Care Access News, xtelligent Healthcare Media, November 18, 2020}

^{2.        Rural Health Care: Big Challenges Require Big Solutions: AHA News, January 28, 2020,}

^{3.        States that do not expand Medicaid, Kaiser Health News, January 14, 2020}

^{4.        Amid coronavirus pandemic, black mistrust of medicine looms, Associated Press, April 5, 2020}

^{5.        Smartphones help Blacks, Hispanics bridge some—but not all—digital gaps, Pew Research Center, August 20, 2019}

^{6.        New coalition plans to apply mHealth to tackling health disparities, mHealth Intelligence, xtelligent Healthcare Medi, September 30, 2020}

^{7.        Mobile fact sheet, Pew Research Center, June 12, 2019}

^{8.        Healthfirst Continues to Advance Digital Tools with Launch of Mobile App.” PR Newswire: News Distribution, Targeting and Monitoring, July, 9 2020}

^{9.        A portrait of smartphone ownership, Pew Research Center, April 1, 2015}

^{10.     Web Content Accessibility Guidelines (WCAG) 2.1, W3C, 5 June 2018}

^{11.     Colorado PEAK Chatbot, State of Colorado, 2019} 

^{12.     Housing Department slaps Facebook with discrimination charge, National Public Radio, March 28, 2019}

^{13.     Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review, American Journal of Public Health, American Public Health Association}

^{14.     Orchestrating impartiality: The impact of ‘blind’ auditions on female musicians, American Economic Review, September 2000}

^{15.     Project Implicit, About the IAT, 2011, implicit.harvard.edu/implicit/iatdetails.html.}

^{16.     Apple Presents App Store Best of 2020 Winners, Apple Newsroom, December 2, 2020}

^{17.     www.wegohealth.com}

^{18.     Designing for a More Equitable World, performance by Antionette Carroll, YouTube, January 17, 2019}

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