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Bridging the digital divide among advanced age skin cancer patients

Authors:
David X. Zheng at Massachusetts General Hospital
David X. Zheng
Laura Xiang at Case Western Reserve University School of Medicine
Laura Xiang
Kathleen M. Mulligan at University of California, Los Angeles
Kathleen M. Mulligan
Christopher Cullison at Case Western Reserve University School of Medicine
Christopher Cullison
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ARTICLE IN PRESS
JID: PRAS [m6+; September 15, 2021;14:16 ]
Journal of Plastic, Reconstructive & Aesthetic Surgery xxx (xxxx) xxx
Correspondence and Communications
Bridging the digital divide among
advanced age skin cancer patients
Dear Sir,
The COVID-19 pandemic has ushered in an increasingly
digital age. Innovative technologies (e.g. artificial intelli-
gence for skin cancer screening) and new models of care
(e.g. telemedicine services allowing patients to send im-
ages of suspicious lesions to their clinicians) have been cru-
cial in allowing skin cancer patients to meet pandemic-
related challenges.
1 While health information technology
(HIT) use among skin cancer patients has significantly in-
creased within the past decade, there remains a “digital
divide” in both the access to and utilization of HIT across
various demographics of skin cancer patients.
2
We consider
that the technological advances made during the pandemic,
while potentially beneficial for skin cancer management,
may also have the unintended consequence of exacerbat-
ing this digital divide.
In recent years, there has been increased discussion
surrounding the use of artificial intelligence to diagnose
and monitor potentially malignant skin lesions. While these
technologies have traditionally been designed for clinician
use, researchers and public health advocates have begun to
explore the potential for their use by patients, which may
allow for greater convenience of and access to care. In a
study by Sangers and colleagues exploring the barriers to
and facilitators of use of artificial-intelligence driven mo-
bile health applications for skin cancer screening among the
Dutch general population,
3
the authors concluded that cre-
ation of low-cost, privacy-friendly, and easy-to-use mobile
health applications may encourage adoption of these tech-
nologies for skin cancer screening. Integration of mobile
health technologies into skin cancer care certainly repre-
sents a promising and innovative approach toward facilitat-
ing early skin cancer detection. However, given the afore-
mentioned digital divide, increasing adoption of skin cancer
screening applications alone may be unlikely to reach the
target audience demographic.
Skin cancer tends to occur in patients of advanced age.
1 , 2
In one study, only 17.0% of individuals ages 65–79 currently
owning a smartphone or tablet were interested in using a
health-related application to obtain health information.
4
In
another retrospective analysis of the National Health Inter-
view Survey, an annual survey of United States households,
skin cancer patients age > 65 were the least likely age group
to utilize HIT, which included using a computer to schedule
healthcare appointments, look up health information on-
line, communicate with providers, or fill prescriptions.
2
Fur-
thermore, plastic surgery and dermatology practices have
rapidly invested in and expanded upon their telemedicine
services due to the COVID-19 pandemic.
5
Given the high in-
cidence of skin cancer in the elderly and the likely perpetu-
ation of clinical changes related to telemedicine expansion,
we believe that investing in the infrastructure to bridge
the digital divide among skin cancer patients represents an
equally pressing priority to the continued development of
technological advances aimed at skin cancer management.
As we transition into the post-pandemic clinical land-
scape, plastic surgeons, dermatologists, and other clinicians
involved in the management of skin cancer must actively
encourage eHealth literacy among their older patients.
Simpson and Kovarik present excellent suggestions for
engaging geriatric patients via telemedicine.
5 Helpful
interventions might include creating patient education
materials describing how to perform medical tasks using a
smartphone or computer (e.g. creating an account through
the electronic medical record), engaging advanced age pa-
tients at time of surgery (e.g. iPads in the room loaded with
patient educational videos for post-operative care), and
utilizing telemedicine platforms that allow for multiparity
encounters which permits older patients the opportunity
to attend online visits with a trusted health advocate.
2 , 5
These recommendations would help optimize virtual skin
cancer care across all demographics, and would especially
target the generally lower eHealth literacy of older adults.
The use of artificial intelligence and associated techno-
logical advances to improve early detection of skin cancer is
undoubtedly an important aspect of the ever-changing field
of digital health. While it is necessary to reduce barriers to
use of mobile health screening applications and similar new
technologies for the care of skin cancer patients, we must
first establish a framework allowing for the equitable distri-
bution of practices related to digital health expansion in the
post-pandemic era. Only then can we facilitate optimal uti-
lization of these innovative technologies by their intended
patient population.
Declaration of Competing Interest
The authors report no conflicts of interest relevant to this
work.
Financial disclosure
The authors report no funding sources relevant to this work.
Please cite this article as: D.X. Zheng, L. Xiang, K.M. Mulligan et al., Bridging the digital divide among advanced age skin cancer patients,
Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2021.08.009
D.X. Zheng, L. Xiang, K.M. Mulligan et al.
ARTICLE IN PRESS
JID: PRAS [m6+; September 15, 2021;14:16 ]
Ethical approval
Not required.
References
1. Zheng DX , Cullison CR , Mulligan KM , Scott JF . COVID-19 and the
surveillance, epidemiology, and end results program: future con-
siderations for skin cancer research. J Plast Reconstr Aesthet
Surg 2021 .
2. Cwalina TB , Jella TK , Zheng DX , et al. Utilization of health infor-
mation technology among skin cancer patients: a cross-sectional
study of the National Health Interview Survey from 2011 to 2018.
J Am Acad Dermatol 2021 .
3. Sangers TE , Wakkee M , Kramer-Noels EC , Nijsten T , Lugten-
berg M . Views on mobile health apps for skin cancer screening
in the general population: an in-depth qualitative exploration of
perceived barriers and facilitators. Br J Dermatol 2021 .
4. Gordon NP , Hornbrook MC . Older adults’ readiness to engage
with eHealth patient education and self-care resources: a cross–
sectional survey. BMC Health Serv Res 2018; 18 (1):220 .
5. Simpson CL , Kovarik CL . Effectively engaging geriatric patients
via teledermatology. J Am Acad Dermatol 2020; 83 (6):e417–18 .
David X. Zheng
1
, Laura Xiang
1
, Kathleen M. Mulligan,
Christopher R. Cullison
Case West ern Reserve University School of Medicine,
Cleveland, OH, United States
E-mail address: dxz281@case.edu
Jeffrey F. Scott
Department of Dermatology, Johns Hopkins University
School of Medicine, Baltimore, MD, United States
1
DXZ and LX share first authorship.
©2021 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2021.08.009
2
... The COVID-19 pandemic has accelerated the rise of online health education tools and telehealth platforms, expanding the reach of providers beyond the constraints of traditional clinical settings. 1 This rapid expansion of digital technology has introduced an unprecedented amount of health information within reach of patients. With convenient access to online health educational materials (HEMs), patients can stay informed about their health conditions and treatment choices. ...
... 2 Merkel cell carcinoma (MCC) is a highly aggressive neuroendocrine tumor with a five-year survival rate of up to 65%. 3 Similar to other cutaneous tumors, MCC typically presents in patients over age 65. 3 Innovative digital health tools have been designed to optimize skin cancer management and treatment. 1 However, advanced age patients utilize these digital health tools the least among all age groups, despite being those who may benefit the most. 1 Prior studies have recommended the need to bridge this "digital divide" by improving readability and accessibility of health information from electronic sources. To facilitate these efforts, the American Medical Association (AMA) has recommended that health information be presented at no higher than a 6th grade reading level; however, HEMs of various high-risk dermatologic patient populations (e.g. ...
... 1 However, advanced age patients utilize these digital health tools the least among all age groups, despite being those who may benefit the most. 1 Prior studies have recommended the need to bridge this "digital divide" by improving readability and accessibility of health information from electronic sources. To facilitate these efforts, the American Medical Association (AMA) has recommended that health information be presented at no higher than a 6th grade reading level; however, HEMs of various high-risk dermatologic patient populations (e.g. ...
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... Dear Editor, We enjoyed reading the recent article in Clinical and Experimental Dermatology by Hussain et al., in which the authors discuss the importance of mentorship for fostering clinical skills of dermatology trainees. 1 In reply, Butt and Butt insightfully explored the complexity of the mentor-mentee relationship, reminding us that mentors not only provide educational supervision, but also help trainees to navigate a diverse realm of adjacent topics, from personal development to systemic racism. 2 In context of the increasingly digital age ushered in by the pandemic, 3 we continue this conversation by critically re-evaluating traditional mentorship paradigms as they pertain to dermatology. ...
Deconstructing traditional dermatology mentorship paradigms in the digital age
Article
Full-text available
  • Feb 2022
Dear Editor, We enjoyed reading the recent article in Clinical and Experimental Dermatology by Hussain et al., in which the authors discuss the importance of mentorship for fostering clinical skills of dermatology trainees.¹ In reply, Butt and Butt insightfully explored the complexity of the mentor–mentee relationship, reminding us that mentors not only provide educational supervision, but also help trainees to navigate a diverse realm of adjacent topics, from personal development to systemic racism.² In context of the increasingly digital age ushered in by the pandemic,³ we continue this conversation by critically re‐evaluating traditional mentorship paradigms as they pertain to dermatology. Society's collective adjustment to remote and hybrid workflows due to COVID‐19 has upended typical face‐to‐face (F2F) arrangements between mentors and mentees. Instead, a new model of ‘digital mentorship’ has formed, characterized by mentor–mentee relationships developed via cold emails and direct messages, and strengthened by Zoom calls and social media interactions.⁴ For example, early career trainees have begun to capitalize on the potential of the microblogging platform Twitter to connect with dermatology mentors, often leading to opportunities to conduct research and optimizing identification of mentors with similar backgrounds and interests (e.g. for students underrepresented in dermatology or without home dermatology programmes).⁴ Given the likely continued disruption to and virtualization of in‐person engagements (e.g. annual society meetings) normally facilitating mentor–mentee pairing, dermatology trainees would greatly benefit from seeking out and building upon virtual connections with mentors of interest.
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... 1 With digital health becoming increasingly relevant, it is important for online patient educational materials (PEMs) for transgender individuals to be written at a level easily understood by the average patient. 2 Although the American Medical Association recommends that health information be presented at no higher than the sixth grade reading level, PEM readability has failed to meet this mark for various high-risk dermatologic patient populations (eg, acral lentiginous melanoma and pyoderma gangrenosum). 3,4 Yet, the readability of online PEMs for transgender dermatologic care remains unknown. ...
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Views on Mobile Health Apps for Skin Cancer Screening in the General Population: An In-Depth Qualitative Exploration of Perceived Barriers and Facilitators
Article
Full-text available
  • May 2021
  • BRIT J DERMATOL
Background: Mobile health (mHealth) applications (apps) integrated with artificial Intelligence (AI) for skin cancer screening are increasingly reimbursed by health insurers. However, an in-depth exploration of the general public's views towards these apps is lacking. Objectives: To explore the perceived barriers and facilitators towards mHealth apps for skin cancer screening among the Dutch general population. Methods: A qualitative study consisting of four focus groups with 27 participants was conducted. A two-stage purposive sampling was used to include information-rich participants with varying experience with mHealth from the Dutch general population. A topic guide was used to structure the sessions. All focus groups were transcribed verbatim and analyzed in a thematic content analysis by two researchers using several coding phases, resulting in an overview of themes and subthemes, categorized as (sub-)barriers and (sub-)facilitators. Results: Main barriers to using mHealth apps included a perceived lack of value, perception of untrustworthiness, the preference for a doctor, privacy concerns, a complex user-interface, and high costs. The main factors facilitating the use of mHealth among the general population were a high perceived value, a transparent and trustworthy identity of app developers, endorsement by healthcare providers and government regulating bodies, and ease and low costs of use. Conclusions: To increase successful adoption in skin cancer screening apps, developers should create a transparent identity and build trustworthy apps. Collaboration between app developers, GPs and dermatologists is advocated to improve mHealth integration in skin cancer care. Special attention should be given to the development of low-cost, privacy-friendly, easy-to-use apps.
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Older adults' readiness to engage with eHealth patient education and self-care resources: A cross-sectional survey
Article
Full-text available
  • Mar 2018
  • BMC HEALTH SERV RES
Background This study examined access to digital technologies, skills and experience, and preferences for using web-based and other digital technologies to obtain health information and advice among older adults in a large health plan. A primary aim was to assess the extent to which digital divides by race/ethnicity and age group might affect the ability of a large percentage of seniors, and especially those in vulnerable groups, to engage with online health information and advice modalities (eHIA) and mobile health (mHealth) monitoring tools. Methods A mailed survey was conducted with age-sex stratified random samples of English-speaking non-Hispanic white, African-American/black (black), Hispanic/Latino (Latino), Filipino-American (Filipino), and Chinese-American (Chinese) Kaiser Permanente Northern California members who were aged 65–79 years. Respondent data were weighted to the study population for the cross-sectional analyses. Results Older seniors and black, Latino, and Filipino seniors have less access to digital tools, less experience performing a variety of online tasks, and are less likely to believe that they would be capable of going online for health information and advice compared to younger and white Non-Hispanic seniors. Consequently, they are also less likely to be interested in using eHIA modalities. Conclusions The same subgroups of seniors that have previously been shown to have higher prevalence of chronic conditions and greater difficulties with healthcare access are also less likely to adopt use of eHIA and mHealth monitoring technologies. At the patient population level, this digital divide is important to take into account when planning health information and chronic disease management programs. At the individual patient level, to provide good patient-centered care, it is important for providers to assess rather than assume digital access, eHealth skills, and preferences prior to recommending use of web-based resources and mHealth tools.
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