Identifying Skill and Usability Barriers to Digital Health Tool Use Among Older Adult Patients in US Safety Net Clinics: Mixed Methods Study

Background: Despite their benefits, digital health tools often face adoption barriers because of the digital divide. Identifying the fundamental user skills required to effectively navigate these tools and the usability barriers is essential to addressing disparities in use. Objective: This study aimed to identify the skill and usability barriers to using digital health tools. Methods: This study included English-, Spanish-, or Cantonese-speaking patients, aged ≥50 years, who received care at an urban safety net health system in the United States. Participants completed a survey examining sociodemographic characteristics and digital health tool use and were observed and video recorded as they navigated four digital health care tasks: (1) launch a video visit, (2) visit a health website through a URL, (3) log in to the patient portal, and (4) sign up for a patient portal account. Participants who could not independently perform the tasks received additional support. Tasks were conducted in English, while instructions and additional assistance were provided in each participant's preferred language. Video recordings were thematically coded to identify the fundamental skills needed for effective digital tool use and usability barriers in the design of digital tools. We examined whether task independence was associated with participant demographics and thematic categories using Kruskal-Wallis, χ2, and Fisher exact tests. Results: In total, 74% (34/46), 52% (31/60), 71% (44/62), and 70% (43/61) of participants (N=64) independently completed digital tasks 1, 2, 3, and 4, respectively. Older age, minoritized races and ethnicities, non-English language preference, lower educational attainment, access to cellular data only or no internet access, and lack of a portal account were associated with a higher likelihood of requiring assistance or being unsuccessful at completing each task (P