By: Chad E. Cook, PT, PhD, FAPTA
Background: As health systems migrate toward hybrid rehabilitation platforms for the management of musculoskeletal issues (see former blogs), there is a standard assumption that patients will simply “log on” and participate. However, over a decade of research has shown that consistent predictors of low digital literacy (older age, socioeconomic disadvantage, rural residence, limited English proficiency, low health literacy, low digital self‑efficacy, limited device access, privacy concerns, low patient activation, poor usability, and lack of social support) are also predictors of poor inclusion in traditional healthcare platforms (Table 1). This is the central paradox of hybrid rehabilitation and digital health equity: the patients who stand to benefit most from digital tools are the ones least likely to be able to use them.
| Consolidated Predictor Category | How it predicts low digital literacy / poor use | Digital behaviors most affected | Key refs\* |
| Age‑related factors (Older age) | Older adults report lower eHealth literacy, less confidence evaluating online information, and less familiarity with devices and portals, leading to lower uptake and sustained use. | Portal registration and log‑ins, telehealth use, online information seeking | 1, 2, 3, 8, 11, 12, 13 |
| Socioeconomic disadvantage (Lower income, lower education) | Lower income and lower educational attainment reduce access to devices/broadband and limit skills needed to navigate digital systems; both constrain opportunities to practice digital tasks and interpret online health information. | Telehealth visits, portal activation, secure messaging, reading results, self‑management tools | 1, 2, 4, 6, 8, 9, 12, 13 |
| Geographic barriers (Rural residence) | Rural patients face poorer broadband, fewer digital support resources, and more structural barriers, amplifying literacy gaps and reducing telehealth feasibility. | Telemedicine visits, AI‑enabled tools, video visits, remote monitoring | 1, 2, 3, 4, 6 |
| Language and cultural barriers (LEP, minoritized racial/ethnic status, lack of language‑concordant interfaces) | LEP and minoritized patients experience linguistic barriers, lower comfort with digital text, and structural inequities that reduce portal and telehealth use; lack of language‑concordant interfaces compounds these barriers. | Portal registration, reading results, messaging, telehealth navigation, follow‑up | 1, 2, 4, 8, 9, 10, 12, 13 |
| Health literacy limitations (Low general health literacy) | Difficulty understanding health information makes digital content harder to interpret, reducing perceived usefulness and confidence in acting on portal or telehealth information. | Interpreting test results, care plans, educational content, self‑management tools | 1, 4, 7, 12, 13 |
| Digital skills & confidence limitations (Low digital/eHealth literacy, low self‑efficacy, low prior internet use) | Low digital literacy, low confidence, and limited prior internet use strongly predict poor portal and telehealth engagement and difficulty evaluating online information. | Portal use, telehealth engagement, online decision‑making, remote self‑management | 1, 2, 3, 4, 7, 10, 11, 12, 13 |
| Technology & connectivity barriers (Limited device access, lack of broadband) | Not owning a smartphone/computer or lacking stable internet directly limits portal access and telehealth feasibility, regardless of motivation. | Portal access, app‑based interventions, video visits, remote monitoring | 3, 4, 6, 10, 11, 12 |
| Engagement & activation barriers (Low patient activation, lack of provider encouragement) | Patients with low activation or who are not encouraged by clinicians are less likely to adopt or sustain portal use, even when technically able. | Portal activation, secure messaging, self‑tracking tools, repeat log‑ins | 1, 7, 8, 12, 13 |
| Usability & workflow barriers (Complex portals, non‑intuitive workflows) | Cumbersome log‑ins, inconsistent features, and poor usability disproportionately burden users with lower literacy, leading to abandonment. | Sustained portal use, advanced features (refills, messaging, scheduling) | 7, 12, 13 |
| Social support limitations (Limited caregiver/technical support) | Lack of family or caregiver support makes it harder for low‑literacy users to overcome initial barriers or troubleshoot issues. | Onboarding to portals, telehealth setup, ongoing use of apps/devices | 3, 6, 11, 13 |
Why Both Platforms (Traditional and Digital) Involve Challenges: Both platforms include access and engagement issues such as transportation challenges, inflexible work schedules, caregiving responsibilities, limited local specialty availability, and difficulty navigating complex health systems. Low health literacy, low self‑efficacy, and limited social support further compound these barriers, making it harder to schedule appointments, follow care plans, or advocate for needed services. Rather than removing barriers, digital platforms often recreate them in different forms: broadband deserts stand in for geographic distance; complicated portal workflows mirror the complexity of clinic workflows; language mismatches remain unresolved; and low digital self‑efficacy becomes a barrier to logging in instead of a barrier to showing up. Digital care does not inherently solve access problems, it simply relocates where the friction occurs.
Toward Inclusive Digital Health: If digital-first MSK care is to reduce disparities rather than widen them, health systems must proactively design for the populations least likely to engage. Evidence increasingly supports the need for simple, systematic screening for digital barriers (Table 2), using brief screening tools that assess device access, broadband stability, digital skills, language needs, health literacy, privacy concerns, and social support.
Table 2. Clinic‑Ready Digital Engagement Risk Score. Each item is scored 1 point if present. Total score: 0–12.
| Demographics and Social Predictors | Score | |
| Age ≥ 65 | 1 | |
| Limited English proficiency | 1 | |
| High school education or less | 1 | |
| Medicaid, uninsured, or financial strain | 1 | |
| Lives alone or lacks someone who can help with technology | 1 | |
| Access Predictors | Score | |
| No smartphone | 1 | |
| No computer/tablet | 1 | |
| No home internet or unstable internet | 1 | |
| Skills and Confidence Predictors | Score | |
| Rates tech comfort as “low” | 1 | |
| Rarely uses the internet | 1 | |
| Needs help using apps or logging into accounts | 1 | |
| Engagement Predictors | Score | |
| Low patient activation (e.g., rarely checks labs, misses appointments) | 1 | |
Risk Interpretation
| Score Range | Risk Level | Meaning | Recommended Action |
| 0–2 | Low | Likely able to use portal/telehealth with minimal support | Standard onboarding |
| 3–5 | Moderate | May struggle with setup or sustained use | Provide guided setup + follow‑up |
| 6–8 | High | Significant barriers to digital engagement | Offer assisted telehealth, simplified tools, or in‑person alternatives |
| 9–12 | Very High | Digital tools unlikely to succeed without intensive support | Consider non‑digital pathways or dedicated digital navigator |
Screening alone is insufficient unless paired with targeted interventions. Assigning digital health navigators or health coaches to patients with identified barriers can meaningfully improve onboarding, portal activation, telehealth setup, and sustained engagement. Community-based digital literacy training, language‑concordant interfaces, simplified authentication workflows (i.e., the steps used when logging in to access a secure system), and low‑bandwidth telehealth options help level the technological playing field.
Summary: To tackle this complex issue, the following needs to be considered:
- Digital literacy must be treated as a core social determinant of health, not an optional add‑on.
- A concerted effort to target the populations least likely to engage is imperative, not the ones already digitally fluent.
- Design must prioritize simplicity, language concordance, and low‑burden workflows.
- Health systems must invest in digital navigators, caregiver support, and community‑based training.
Digital health will not become equitable by accident. As much effort that goes into the healthcare planning should go into ensuring that patients with digital barriers receive the access adaptations they need.
Artificial intelligence tools were used to assist with editing and improving the clarity of the manuscript. All intellectual content, analysis, and conclusions are the authors’ own.
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Nice blog. I ponder as time passes and more individuals exposed to digital ie phones, tablets, iPads throughout their lives age, this will hopefully become a moot point.