The week of January 25, 2015

How the Affordable Care Act is leaving seniors behind

By Vicki Soloniuk, M.D. and Theodora Ruhs

“I called that new doctor’s office to get my lab results,” my 85-year-old mother told me on the phone. “They said I had to look them up online. Can you help me?”

“Have you tried?” I asked.

“Well, my grandson was here playing video games, and I can’t find the Internet anymore.”

The digital divide is alive and well in the United States, especially among the elderly. As we move into the digital age and are expected to do more and more online, seniors are often left behind. In the U.S., this could cause problems in the area of healthcare, with new online health marketplaces and electronic health records. The combination of the existing digital divide and the drive to shift to electronic medical records and patient portals may be a disaster if it’s not managed carefully.

Some populations in the U.S. do not have enough access to or knowledge of modern communications technologies, creating a considerable gap between them and the rest of America. When educational success and other opportunities—like job postings and career resources—are primarily available through technology, that issue could have lasting consequences. Seniors are especially vulnerable. Pew Research found in 2014 that 41 percent of adults over the age of 65 do not use the Internet. For seniors over 75, the number increases to 53 percent.

Seniors, notably, are also the most likely to need complex medical services and thus need to be able to communicate readily with their physicians about symptoms, prescriptions, questions, and concerns. When that communication is limited to an online patient portal, older patients may have difficulty adjusting to the change—which presents significant implications for seniors who need access to their physicians.

Digital literacy

OTX-West is an Oakland-based nonprofit working to eliminate the digital divide in the community by providing computers and training to students and their families, including elderly members of the community. OTX-West believes that digital access and literacy is critical for students, seniors, and the disability community, all of whom are already challenged by a lack of resources.

The lack of access in their community is not a minor issue. In a recent survey of Oakland public school students, OTX-West found that approximately 40 percent of students did not have access to the Internet at home.

The shift to electronic medical records and patient portals may be a disaster if it’s not managed carefully.

“In rural areas, infrastructure, the infrastructure is not there, and [that] is one of the biggest challenges,” says Domingo Vazquez, the director of curriculum and training. “Even in Oakland, where Internet is pretty much everywhere, reliable 24/7 Internet is a different story.”

Vazquez estimates only about 50 percent of the families OTX works with have reliable Internet at home. The problem is worse for those further below the poverty line. OTX-West is working to provide low-cost Internet access at around $10 a month, but even that is too much for some. An estimated 14 percent of adults over 84 live in poverty, and affording basic Internet services can be beyond their reach. When Americans who do not use the Internet are studied, almost 20 percent state that it is because of cost.

Statistics like this show that the digital divide is persistent and not easily overcome by the introduction of new communications technology, such as smartphones. The image of urban youth with smartphones may conjure up visions of equality, but it’s not the whole picture. Having a smartphone doesn’t provide access to larger computer literacy.

“Ever try to write a résumé or sign up for health insurance on a phone? You can consume and communicate, but you can’t create. Try learning to program on a phone. Same is basically true for tablets,” Bruce Buckelew, founder of OTX-West, told the Kernel. “Most Oakland youth do know how to navigate the Internet, but many equate using Facebook to understanding the Internet.”

The challenges of aging

The same could be said of elders, and there are also a number of other factors involved in their more limited use of Internet technology. Physical challenges such as decreased eyesight and movement that come with aging can create barriers. Smartphones and tablets can be especially challenging to those with contractures—muscle shortening that limits mobility—Parkinson’s, or other movement problems. There are also social, cognitive, and economic factors that impede technology use.

“The learning curve is steep. Cloud computing, for instance, forget about it.”

Vasquez says he sees seniors struggling with new technology for a variety of reasons. Seniors in OTX’s classes often only learn the basics, and even then, retention levels tend to be low. Many also find the belief that the Internet is for youth to be a stumbling block.

“Lot of classes start out with repeating the basics and, if too much time goes by between meetings, it’s like starting over,” Vazquez said. “As technology becomes more advanced and sophisticated, it doesn’t get any easier. The learning curve is steep. Cloud computing, for instance, forget about it.”

A brave new world of healthcare

The digital divide can have implications for health as well, which can be critical for older adults. This is not necessarily taken into account as more medical groups transition to electronics for health records and assume their patients will keep pace.

The Affordable Care Act mandates the computerization of medical care, including patient/provider interfaces often known as patient portals. To meet meaningful-use criteria for 2015 and avoid a drastic cut in reimbursement, a provider must have a patient portal, a way for the patient to communicate online regarding health concerns, to make appointments, and to receive test results. Although ACA states that a group meets the meaningful-use criteria with only a small percentage of patients using the portal, some groups are attempting to have most or all patient interactions occur online.

This means that in order to apply for health insurance or to communicate with your doctor’s office, you need access to a computer, access to the Internet, and the skills and understanding to use them. In addition, you need to feel that your communication is secure—that your health information is not available to the public by virtue of using the Internet.

Seniors who do not have the skills needed to navigate the Internet are relying on third parties to access what they need online.

Providers and medical groups are mandated under HIPAA to protect a patient’s health information. The patient, on the other hand, has no such protection. Those who do not have personal computing access, through home computers or other technologies, are left to use public devices, which pose potential insecurities. When queried, administration at the Mendocino Coast Clinics, Inc., stated that they expected their clients to access the new portal using either the library or the senior center, public spaces with computers shared by many.

Seniors who do not have the skills needed to navigate the Internet are relying on third parties, such as children or neighbors, to access what they need online—and that poses obvious security concerns.

If we are going to bring medical care into the digital age, we need cheap, secure Internet access, as well as education and support around the use of technology. We also need awareness and provision of adaptive devices, not just for seniors but for anyone with physical impairments that make using the Internet a challenge. We also need to include offline support for those who cannot use the Internet.

As for my mother, she gave me the name of her doctor, and I promised to get the labs for her after I, once again, walked her through accessing the Internet and email on her computer.

I consider myself tech-savvy. Setting up a patient portal account and getting mom’s lab results from a geriatric practice, designed for old-timers, should be a breeze, I thought.

I thought wrong. It took eight phone calls and several hours of frustration.

Disclosures: Theodora Ruhs is a former OTX-West instructor. Doctor Soloniuk is a practitioner at Mendocino Coast Clinics, Inc.

Illustration by Max Fleishman