Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases

Abstract

Health information technology (HIT) can enhance optimal health care access and utilization among individuals living with chronic diseases. This study aimed to provide population-level information on racial/ethnic disparities in HIT use and associated trends among those living with chronic diseases. The study sample consisted of adult respondents (≥18 years) of the 2011–2018 National Health Interview Survey living with at least 1 chronic condition. Binomial regression was used to analyze the association between race/ethnicity, year, and 4 measures of HIT use for patient-provider interaction. Regression parameter estimates were used to predict the trends in probability of the outcome variables across race/ethnicity. About 73% of the study sample were non-Hispanic Whites, 15% were non-Hispanic Blacks, and 13% were Hispanics. Compared to non-Hispanic Whites, there were decreased adjusted odds of any HIT use among non-Hispanic Blacks (OR = 0.72; 95% CI = 0.67, 0.76) and Hispanics (OR = 0.78; 95% CI = 0.72, 0.84). The likelihood of any HIT use increased with increasing year (OR: 1.16; 95% CI = 1.15, 1.18). Trends in racial/ethnic disparities were wider for email communication with provider and online prescription refill compared to online scheduling of appointment. The COVID-19 pandemic has led to accelerated adoption or expansion of HIT for patient care. Limited HIT use among non-Hispanic Blacks and Hispanics could worsen the disproportionate chronic disease burden, suboptimal clinical outcomes, and preventable health care costs experienced by this subpopulation. In conclusion, there is a need for intentional and strategic population-level interventions to increase HIT adoption and use among non-Hispanic Blacks and Hispanics living with chronic diseases.

Introduction

Chronic disease prevalence and associated disparities constitute a critical population health burden in the United States. Despite concerted federal and state attempts to address disparities associated with chronic diseases, non-Hispanic Black and Hispanic Americans continue to experience higher rates of chronic diseases compared to their non-Hispanic White counterparts.¹ Geographical barriers to services, lack of health insurance, and low socioeconomic status,² among others, contribute to these disparities. Over the past decade, the use of technology has become more integrated in our daily lives, and health information technology (HIT) is increasingly being recognized as the next frontier in chronic disease management.³

HIT that is integrated into the health care system plays a variety of roles, including but not limited to clinical decision support, computerized provider order entry, electronic medical record systems, electronic prescriptions, personal health records, and telehealth services.⁴ With its diverse options, HIT adoption has the potential to improve access to health care, health care utilization, and potentially could reduce health disparities.⁵ Previous studies have reported the effectiveness of HIT in chronic disease management for diabetes,⁶ chronic kidney disease,⁷ chronic lung disease,⁸ and heart diseases.⁹ There also is evidence that HIT contributes to increased preventive care and has the potential to enhance both the safety and quality of health care.^10,11

Despite the evidence surrounding the use of HIT for chronic disease management, disparities in HIT use persist.^4,12,13 Zhang and colleagues found that adults living with 1 chronic condition were more likely to use HIT compared to those living with no or multiple chronic conditions.⁴ Several clinical studies have shown that racial/ethnic minorities have a reduced likelihood of HIT use.^4,12,14 Population-level studies that have explored disparities in HIT use have included individuals living with and without chronic diseases or used older data.⁴ These studies also have focused on a particular year, older adults, only 1 component of HIT use (eg, email communication), or used an aggregate measure of HIT use (including the use of internet chat rooms for health information or searching for health information online).^4,12,13,15 Therefore, our understanding of population-level racial/ethnic disparities in HIT use for patient-provider interaction and associated trends among individuals living with chronic diseases is limited.

This study aims to fill this gap in literature by: (1) restricting the analyses to HIT measures that capture health care system interaction; (2) analyzing the independent association between race/ethnicity, year, and aggregate HIT use as well as individual measures; and (3) determining trends in the probability of HIT use among individuals living with chronic disease by race/ethnicity. Reducing minority health disparities continues to be a major public health objective; thus, this study provides evidence that can highlight population-level racial/ethnic disparities in HIT adoption by individuals living with chronic diseases and informs interventions to improve HIT use among this subpopulation.

Methods

Study sample

The 2011–2018 National Health Interview Survey (NHIS) was used for this study. NHIS monitors the health of the US population and is the primary source of information on the health of the civilian noninstitutionalized population residents of the 50 states and the District of Columbia. NHIS data are based on a multistage probability sampling design and, therefore, are nationally representative. The data contain information on health care access/utilization, health behavior, and demographic characteristics.¹⁶ This study was restricted to adults (≥18 years) who identified as non-Hispanic Whites, non-Hispanic Blacks, or Hispanics living with at least 1 chronic disease. Chronic diseases assessed by the NHIS survey include hypertension, congestive heart failure, coronary artery disease, high cholesterol level, stroke, arthritis, asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, hepatitis, schizophrenia, and substance abuse (drug and alcohol) disorders. These conditions also are part of the chronic disease definition by the Department of Health and Human Services Interagency Workgroup on Multiple Chronic Conditions and the Office of the Assistant Secretary of Health.¹⁷

Measures

There were 4 outcomes of interest: (1) communicating with a provider by email in the past 12 months; (2) scheduling an appointment online in the past 12 months; (3) filling a prescription online in the past 12 months; and (4) use of at least 1 type of the 3 modalities (referred to as any HIT use hereafter). These outcomes are common functionalities of a personal health record but will be referred to as HIT use in line with the survey question framing.

The independent variables of interest were race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) and year of survey. Covariates include sex, poverty ratio, marital status, educational attainment, nativity, insurance status, age, and number of chronic conditions.

Statistical analysis

Summary statistics of the study sample were computed. Bivariate and multivariable binomial logistic regression were used to analyze the association between the dependent and independent variables. All analyses were adjusted for NHIS complex survey design. All statistical tests were 2-sided, and findings were considered statistically significant at P ≤ .05. Exponentiated coefficients (odds ratios [ORs]) and 95% confidence intervals (CIs) are reported. Predicted probabilities of outcomes by race/ethnic categories across all years were computed using regression parameter estimates. All analyses were conducted using Stata Statistical Software: Release 15 (StataCorp LLC, College Station, TX).¹⁸ This study was approved by the Arizona State University Institutional Review Board.

Results

Descriptive analyses

Table 1 shows summary statistics of the study sample. About 73% of the study sample were non-Hispanic Whites, 15% were non-Hispanic Blacks, and 13% were Hispanics. A greater proportion of the study sample were members of households at federal poverty level (FPL) >350% compared to members of households at <100% FPL, 100%–199%, or 200%–349%. The majority of the study sample were privately insured compared to those insured through Medicaid, Medicare, or the uninsured (9.77%).

Table 1.

Descriptive Statistics of Study Sample (n = 111,138)

Race/ethnicity		Freq.	Percent
	Non-Hispanic White	80,674	72.59
	Non-Hispanic Black	16,149	14.53
	Hispanic	14,315	12.88
Sex
	Male	47,672	42.89
	Female	63,466	57.11
Poverty Ratio
	<1	17,619	15.85
	1–1.99	22,771	20.49
	2–3.49	25,501	22.95
	≥3.50	45,247	40.71
Marital Status
	Married	49,078	44.16
	Not married	62,060	55.84
Educational Attainment
	Less than High School	16,891	15.2
	High School	29,438	26.49
	More than High School	64,809	58.31
Insurance Status
	Private	49,260	44.32
	Medicaid	9241	8.31
	Medicare	41,781	37.59
	Uninsured	10,856	9.77
Nativity
	US born	98,321	88.47
	Not US born	12,817	11.53

		Mean	Std. Deviation
Age (years)		55.99	16.60

Regression analyses

Table 2 shows regression analyses.

Table 2.

Regression Analyses of Health Information Technology Use (n = 111,138)

	Bivariate	Multivariable^a	Bivariate	Multivariable^a
	Any HIT use		Online appointment scheduling
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Race/Ethnicity
Non-Hispanic White	Ref.	Ref.	Ref.	Ref.
Non-Hispanic Black	0.55(0.52, 0.59)^***	0.72(0.67, 0.76)^***	0.73(0.67, 0.80)^***	0.91(0.84, 1.00)^*
Hispanic	0.51(0.47, 0.54)^***	0.78(0.72, 0.84)^***	0.71(0.65, 0.78)^***	0.96 (0.86, 1.06)
Year of survey	1.17(1.15, 1.18)^***	1.16(1.15, 1.18)^***	1.25(1.24, 1.27)^***	1.25(1.24, 1.27)^***
	Online prescription refill		Email communication with provider
Race/Ethnicity
Non-Hispanic White	Ref.	Ref.	Ref.	Ref.
Non-Hispanic Black	0.49(0.45, 0.53)^***	0.66(0.61, 0.72)^***	0.55(0.50, 0.59)^***	0.72(0.66, 0.78)^***
Hispanic	0.50(0.46, 0.54)^***	0.84(0.76, 0.93)^***	0.50(0.46, 0.55)^***	0.78(0.70, 0.86)^***
Year of survey	1.09(1.08, 1.11)^***	1.08(1.07, 1.09)^***	1.22(1.20, 1.24)^***	1.21(1.20, 1.23)^***

Note: ^*indicates P ≤ 0.05; ^**indicates P < 0.01; ^***indicates P < 0.001.

Multivariable model is adjusted for age, sex, poverty ratio, insurance coverage, marital status, nativity, educational attainment, and number of chronic diseases.

CI, confidence interval; HIT, health information technology; OR, odds ratio; Ref, reference.

Any HIT use

On bivariate analyses, non-Hispanic Blacks (OR = 0.55; 95% CI = 0.52–0.59) and Hispanics (OR = 0.51; 95% CI = 0.47, 0.54) were less likely to report any use of HIT compared to non-Hispanic Whites. There was increasing likelihood of any use of HIT with increasing year.

On multivariable analyses, there continued to be a significantly decreased likelihood of any HT use among non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites. The relationship between year and any HIT use also remained statistically significant (Table 2).

Scheduling appointment online

On bivariate analyses, non-Hispanic Blacks and Hispanics were less likely to report scheduling an appointment online compared to non-Hispanic Whites. The likelihood of scheduling an appointment online increased with increasing year (Table 2).

On multivariable analyses, there continued to be a significantly decreased likelihood of scheduling an appointment online among non-Hispanic Blacks compared to non-Hispanic Whites. There was no significant association between Hispanic ethnicity and online scheduling of appointment. There continued to be an increased likelihood of scheduling an appointment online with increasing time (Table 2).

Online prescription refill

On bivariate analyses, non-Hispanic Blacks and Hispanics were less likely to report online prescription refill compared to non-Hispanic Whites. There was an increased likelihood of online prescription refill with increasing year (Table 2).

On multivariable analyses, there continued to be a significantly decreased likelihood of online prescription refill among non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites. There also continued to be a statistically increased likelihood of online prescription refill over time (Table 2).

Email communication with health care provider

On bivariate analyses, non-Hispanic Blacks and Hispanics were less likely to report email communication with their provider compared to non-Hispanic Whites. The relationship between year and email communication with a provider also was statistically significant.

The significantly decreased likelihood of email communication with their provider among non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites persisted on multivariable analyses. There also continued to be an increased likelihood of email communication with the provider with increasing time (Table 2).

Predicted probability trends

Figure 1 shows trends in probability of HIT use among the study sample by race/ethnicity between 2011 and 2018. There was an increase in HIT use across all years and racial/ethnic groups analyzed; however, non-Hispanic Blacks and Hispanics lagged behind non-Hispanic Whites. Non-Hispanic Blacks had the lowest probability of using any of the HIT outcome measures across all years. Racial/ethnic disparities were wider for email communication with provider and online prescription refill compared to online scheduling of appointment. Online prescription refill had the least predicted probability across all 3 racial/ethnic groups and across all years compared to the other outcome measures.

FIG. 1.

Predicted probability of HIT use by race and year. HIT, health information technology; NHB, non-Hispanic Black; NHW, non-Hispanic White.

Discussion

This multiyear evaluation of racial disparities in HIT use and associated trends among people with chronic diseases found a significantly decreased likelihood of HIT use among non-Hispanic Blacks and Hispanics, compared to non-Hispanic Whites. This pattern was strong across all 4 measures examined – email communication with health care provider, scheduling appointments online, online prescription refill, and any HIT use – indicative of persistent HIT adoption or translation barriers that non-Hispanic Blacks and Hispanics living with chronic conditions continue to face. Overall, study results show that non-Hispanic Black patients had the lowest probability of any of the outcomes measured across all years, and interestingly, racial/ethnic disparities were widest for online appointment scheduling and prescription refill. The trend results also show that HIT use for prescription refill lags behind the other HIT measures analyzed. The increasing use of technology for patient care – including chronic disease management – makes these findings concerning.

Although the findings show an increase in HIT use across all racial/ethnic groups examined, this study found that between 2011 and 2018, HIT use by non-Hispanic Blacks and Hispanics increased at much slower rates compared to non-Hispanic Whites. This finding aligns with a previous study that reported that Black and Hispanic respondents to the 2014 Health and Retirement Study had a decreased likelihood of using technology for health-related purposes, including making or receiving phone calls, using health management sites, and searching the internet for health information.¹² Several clinical studies also have reported that African American and Hispanic patients use HIT at a lower rate compared to White patients.^19,20 The present study adds to the science by demonstrating the persistence of these disparities at the population level across all years examined. These findings highlight a need to identify factors that limit HIT use among this subpopulation. It also is crucial to identify factors that influence disparities in the type of HIT used by this subpopulation. Although several studies continue to explore interventions to increase HIT use for patient-provider interactions such as personal health records, few of these studies focus on interventions to reduce associated racial/ethnic disparities,²¹ especially among those living with chronic diseases.

According to the Centers for Disease Control and Prevention, the United States spends an estimated $3.8 trillion on health care annually, and chronic and mental health conditions account for 90% of this expenditure.²² Suboptimal chronic disease management and health care use contribute to this economic burden.²³ Black and Hispanic individuals living with chronic diseases are at risk for inadequate health care access and disease management, which often leads to preventable health care utilization.^17,24 The reported positive effect of HIT use on various aspects of health care use, chronic disease management, and clinical outcomes among individuals living with chronic diseases could improve disease outcomes and reduce associated racial/ethnic disparities.⁵ Therefore, limited HIT use among non-Hispanic Blacks and Hispanics could worsen the disproportionate chronic disease burden, suboptimal clinical outcomes, and health care costs experienced by this subpopulation. This is particularly relevant during the COVID-19 pandemic that has necessitated increased dependence on HIT for patient care,^25

–28 especially given that studies have reported decreased likelihood of telemedicine use or specific telemedicine modalities among non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites during the pandemic.^29,30

Mackert et al reported that low health literacy levels are associated with a lower likelihood of using HIT or perceiving HIT to be easy to use.³¹ Evidence also suggests that health literacy is lower among Black and Hispanic patients compared to non-Hispanic White patients.^32,33 Further, low health literacy is associated with poorer health outcomes as well as decreased use of health care services.³⁴ Thus, interventions that target health literacy among non-Hispanic Blacks and Hispanics living with chronic diseases could improve HIT use, and potentially optimize health care use among this subpopulation.

Another potential solution that could reduce the gap in HIT utilization among racial/ethnic groups is implementation of patient navigators to facilitate HIT adoption and use by patients of minority race/ethnic populations. Several studies have demonstrated success in improving health care use and health outcomes with the use of patient navigators.^35,36 It has been suggested that consistent integration of patient navigators into health care could potentially eliminate health disparities because they advocate for the patient, facilitate care coordination, and address matters related to distrust in the health care system.³⁶ A previous study explored the impact of the use of personal health record and/or patient navigators to improve chronic kidney disease outcomes.³⁷ Other studies have explored the use of patient portals for patient navigation.^38
–40 However, interventions using patient navigators to increase HIT use are lacking. Considering the previously demonstrated positive impact of patient navigators on health care use and health outcomes, patient navigator interventions could improve HIT use among non-Hispanic Blacks and Hispanics and should be explored.

Limitations

This study has some limitations. First, NHIS data are cross-sectional, which limits the ability to explore person-level changes in HIT use over time. Second, NHIS data do not include other critical measures that could influence HIT use, such as provider recommendation; therefore such factors could not be controlled for. Third, the data rely on respondents' recall; therefore, there is the risk of recall bias.

This study does have several strengths. First, it provides critical population-level information on racial/ethnic disparities in HIT use for provider communication, and associated trends. Second, study findings are generalizable to the entire US population because NHIS data are national and based on multistage probability sampling. Third, restriction of the outcome variables to HIT measures that capture patient-provider interaction provides clarity on the importance of population-level interventions to improve HIT use among patients with chronic diseases.

Conclusion

In conclusion, non-Hispanic Blacks and Hispanics living with chronic diseases continue to lag behind in use of HIT. The increased adoption of HIT for health care-related purposes during the COVID-19 pandemic could worsen these disparities. There is a need for intentional and strategic population-level interventions to increase HIT use among non-Hispanic Blacks and Hispanics living with chronic diseases.

Footnotes

Authors' Contributions

Dr. Ojinnaka: Conceptualization, methodology, data analysis, and writing - review and editing. Dr. Adepoju: Data interpretation and writing - review and editing.

Author Disclosure Statement

The authors declare that there are no conflicts of interest.

Funding Information

No funding was received for this article.

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