Access to digital health technologies: personalized framework and global perspectives.

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Published in final edited form as: Nat Rev Cardiol. 2025 Jul 16;23(1):9–22. doi: 10.1038/s41569-025-01184-5 Search in PMC Search in PubMed View in NLM Catalog Add to search Access to digital health technologies: personalized framework and global perspectives Sanjiv M Narayan Sanjiv M Narayan 1 Department of Medicine, Cardiovascular Institute (CVI), Institute for Computational and Mathematical Engineering (ICME), Stanford University, Palo Alto, CA, USA. 2 School of Information Sciences, University of California, Berkeley, CA, USA. Find articles by Sanjiv M Narayan 1, 2 , Mina K Chung Mina K Chung 3 Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. 4 Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA. Find articles by Mina K Chung 3, 4 , Demilade Adedinsewo Demilade Adedinsewo 5 Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA. Find articles by Demilade Adedinsewo 5 , Luisa C C Brant Luisa C C Brant 6 Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. 7 Hospital das Clínicas Telehealth Center, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Find articles by Luisa C C Brant 6, 7 , Leslie L Davis Leslie L Davis 8 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Find articles by Leslie L Davis 8 , David Duncker David Duncker 9 Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany. Find articles by David Duncker 9 , Jennifer L Hall Jennifer L Hall 10 American Heart Association, Data Science and Analytics, Dallas, TX, USA. Find articles by Jennifer L Hall 10 , Janet K Han Janet K Han 11 David Geffen School of Medicine at the University of Los Angeles California, Los Angeles, CA, USA. Find articles by Janet K Han 11 , Carolyn S P Lam Carolyn S P Lam 12 National Heart Centre Singapore, Singapore, Singapore. 13 Duke-National University of Singapore, Singapore, Singapore. Find articles by Carolyn S P Lam 12, 13 , Eldrin Lewis Eldrin Lewis 1 Department of Medicine, Cardiovascular Institute (CVI), Institute for Computational and Mathematical Engineering (ICME), Stanford University, Palo Alto, CA, USA. Find articles by Eldrin Lewis 1 , Joseph Loscalzo Joseph Loscalzo 14 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA. Find articles by Joseph Loscalzo 14 , Manlio F Márquez Manlio F Márquez 15 Department of Electrocardiology, National Institute of Cardiology Ignacio Chávez, Mexico City, Mexico. Find articles by Manlio F Márquez 15 , Vasiliki Rahimzadeh Vasiliki Rahimzadeh 16 Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA. Find articles by Vasiliki Rahimzadeh 16 , Fatima Rodriguez Fatima Rodriguez 1 Department of Medicine, Cardiovascular Institute (CVI), Institute for Computational and Mathematical Engineering (ICME), Stanford University, Palo Alto, CA, USA. Find articles by Fatima Rodriguez 1 , Prashanthan Sanders Prashanthan Sanders 17 Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia. Find articles by Prashanthan Sanders 17 , Emma Svennberg Emma Svennberg 18 Karolinska Institutet, Department of Medicine (MedH), Karolinska University Hospital, Stockholm, Sweden. Find articles by Emma Svennberg 18 , Kenneth Stein Kenneth Stein 19 Boston Scientific, Marlborough, MA, USA. Find articles by Kenneth Stein 19 , Mintu Turakhia Mintu Turakhia 1 Department of Medicine, Cardiovascular Institute (CVI), Institute for Computational and Mathematical Engineering (ICME), Stanford University, Palo Alto, CA, USA. 20 iRhythm Technologies, San Francisco, CA, USA. Find articles by Mintu Turakhia 1, 20 , Clyde Yancy Clyde Yancy 21 Northwestern University Medical Center, Chicago, IL, USA. Find articles by Clyde Yancy 21 , Antonis A Armoundas Antonis A Armoundas 22 Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA. 23 Broad Institute, Massachusetts Institute of Technology, Cambridge, MA, USA. Find articles by Antonis A Armoundas 22, 23 Author information Article notes Copyright and License information 1 Department of Medicine, Cardiovascular Institute (CVI), Institute for Computational and Mathematical Engineering (ICME), Stanford University, Palo Alto, CA, USA. 2 School of Information Sciences, University of California, Berkeley, CA, USA. 3 Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. 4 Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA. 5 Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA. 6 Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. 7 Hospital das Clínicas Telehealth Center, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. 8 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 9 Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany. 10 American Heart Association, Data Science and Analytics, Dallas, TX, USA. 11 David Geffen School of Medicine at the University of Los Angeles California, Los Angeles, CA, USA. 12 National Heart Centre Singapore, Singapore, Singapore. 13 Duke-National University of Singapore, Singapore, Singapore. 14 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA. 15 Department of Electrocardiology, National Institute of Cardiology Ignacio Chávez, Mexico City, Mexico. 16 Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA. 17 Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia. 18 Karolinska Institutet, Department of Medicine (MedH), Karolinska University Hospital, Stockholm, Sweden. 19 Boston Scientific, Marlborough, MA, USA. 20 iRhythm Technologies, San Francisco, CA, USA. 21 Northwestern University Medical Center, Chicago, IL, USA. 22 Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA. 23 Broad Institute, Massachusetts Institute of Technology, Cambridge, MA, USA. Author contributions S.M.N., D.A., L.C.C.B., L.L.D., J.K.H., C.S.P.L., E.L., J.L., M.F.M., V.R., F.R., P.S. and A.A.A. researched data for the article. All the authors contributed to discussions of content, wrote the manuscript and reviewed/edited the article before submission. ✉ [email protected] ; [email protected] Issue date 2026 Jan. PMC Copyright notice PMCID: PMC13064571  NIHMSID: NIHMS2093405  PMID: 40670723 The publisher's version of this article is available at Nat Rev Cardiol Abstract The emergence and rapid adoption of digital health technologies (DHT) present unprecedented opportunities to democratize and reduce disparities in health care by monitoring health and disease at the point of care in all patients. However, limited access to DHT is becoming a major obstacle to realizing these goals. Access to DHT is influenced not only by well-recognized social determinants of health, but also by digital determinants of health, such as digital literacy and the need for broad access to digital infrastructure, as well as commercial and economic factors. Addressing these challenges and designing unbiased systems of care are essential to enable broad access to DHT and to benefit diverse and under-represented communities. Doing so will fill gaps in the clinical evidence base and avoid perpetuating historical biases. In this Review, we propose a personalized framework to improve access to DHT, addressing determinants of access at the individual, interpersonal, community, society, government and industry levels. We frame these issues globally, highlighting how the challenges to DHT access and potential solutions might differ between continents while also emphasizing common themes. We provide perspectives from partners across the spectrum of health care, including clinicians, clinical trialists, and experts from digital health and industry. Introduction Digital health technologies (DHT) offer unprecedented opportunities to democratize and improve health care, patient outcomes and quality of life, and are increasingly central to models of care 1 . DHT can monitor health and disease continuously, uncouple delivery of care from bricks-and-mortar establishments to dynamic mobile platforms, and provide clinical decision support to enable precision medicine for diverse populations, including under-represented communities. DHT vary across the care continuum; therefore, the data they gather can be considered their defining feature and, indeed, a form of technology per se 2 . The promise of DHT as a societal transformation is reminiscent of the general optimism associated with the early introduction of computers 3 . However, inequitable access to DHT, reflecting historical social determinants of health (SDoH) 4 , is becoming a major obstacle to realizing these benefits ( Box 1 ). Novel strategies are required to address these under-recognized challenges. Box 1 |. Benefits and challenges of DHT. Benefits • Improve health outcomes • Address disparities in health care • Fill gaps in the clinical evidence base Challenges: social determinants of health 1 • Educational status • Access to care • Neighbourhood and housing • Income Challenges: digital determinants of health a • Individual: digital literacy, trust, personal access to technologies • Interpersonal: dependence on others, privacy, implicit biases • Community: local infrastructure, local rules and policies • Society and government: societal norms, government policies and legislation, data privacy, design of technologies, digital redlining Open in a new tab DHT, digital health technologies. a Solutions that address each of these challenges are required to reduce health inequalities. Telehealth and mobile health devices 5 are the most visible and rapidly developing forms of DHT, building on a rich foundation of innovations 3 , and include electronic health records (EHRs), data networks, novel sensors, digital biomarkers and infrastructures including broadband Internet 3 , 6 – 8 . However, for DHT to address unmet health needs, the focus should not be on technology alone 4 , and should also consider human and material resources, interoperability, ethical implications 9 and data security. Emerging partnerships between health professionals and commercial entities, whose mission might be unrelated to health care, can raise ethical, philosophical and commercial questions 10 , but also present new opportunities. The enormous scope of health care worldwide, and its integral role in society, means that appropriate initiatives for DHT could also broadly shape the landscape of social justice. Importantly, improving access to DHT is not a linear process; it can raise ethical issues 11 and negatively affect health through social and commercial risks, of which patients might be unaware. In turn, this process can inadvertently create fear of data exploitation, hinder the desire to acquire digital skills, reduce the reputation of health-care professionals and erode trust 12 , thereby exacerbating existing disparities caused by inequitable access, misuse or imperfect use of DHT. In this Review, we first explore the central challenges to realizing the benefits of DHT at the individual, interpersonal (or family), community, society (or population), government and industry levels ( Box 1 ). We propose an integrated framework for unbiased access to DHT at each of these levels and across levels. The issues affecting access to DHT are then examined globally, by continent, identifying regional differences and shared elements that could form the basis of generalizable solutions. We frame our discussion through the perspectives of multidisciplinary members of the clinical-care team, clinical trialists and experts from the fields of digital medicine and industry. We provide examples from the field of cardiovascular medicine when relevant. Table 1 provides definitions of terms used throughout this Review. Table 1 |. Digital health terminology and definitions Term Definition Digital health technologies The array of devices, software apps, platforms for remote care and other digital tools designed to improve health and well-being Social determinants of health 18 , 19 A constellation of factors, including access to health care, level of education, economic stability, neighbourhood and environment, social and community context, and other conditions in which individuals work and live that influence health Digital determinants of health 1 A constellation of factors, including literacy in digital technologies and access to broadband Internet, computers and connected devices, across cultural and language barriers Commercial determinants of health 39 Activities of for-profit entities and organizations that influence health systems and outcomes Digital inclusion 141 The appropriate access, digital skills, usability and navigability required in the development of technological solutions 149 Digital infrastructure Internet access (particularly broadband), hardware and software products that enable access and connectivity for digital health technologies Digital literacy 23 The ability to use information and communication technologies to find, evaluate, create and communicate information, requiring both cognitive and technical skills Digital redlining 37 Discriminatory digital practices enacted by commercial entities that result in the provision of limited or poor-quality Internet or digital infrastructure and services for specific areas or communities Intersectionality 31 The way that race/ethnicity, sex, sexual orientation, socioeconomic status and other social identities interact to influence an individual’s health experiences, including access and outcomes Mobile technologies Digital health technologies that include portable sensors, mobile diagnostic devices, wearable devices and, potentially in the future, mobile therapeutic devices Digital health navigators Members of health-care teams dedicated to supporting patient use of digital resources Design thinking A set of cognitive, strategic and practical processes used to understand consumers, challenge assumptions, redefine problems and create innovative solutions in the design and use of products; design thinking typically involves five phases: empathize, define, ideate, prototype and test Open in a new tab Health-care disparities and DHT Disparities in health care and outcomes exist globally and are defined as differences that persist after accounting for patient preference, underlying medical condition and appropriateness of care 13 . Underserved patients are disproportionately affected by disease, less likely to receive evidence-based therapy and have higher hospital readmission rates for several cardiovascular diseases in many parts of the world, as emphasized by cardiovascular societies in Europe 14 , the USA 4 and worldwide 15 – 17 . These disparities must be addressed by system-wide solutions to achieve health-care access that considers SDoH, including access to care, educational level, income, housing, the built environment and other living conditions 18 – 20 . However, reducing health-care disparities is hindered by a lack of data that are broadly generalizable across diverse populations. Prospective registries are needed to analyse changes in patterns of care across racial and ethnic groups over time. Notably, disparities in outpatient and inpatient outcomes persist even after adjusting for socioeconomic and clinical variables 21 . DHT could, in principle, help to address health-care disparities by prospectively linking SDoH, digital determinants of health (DDoH), and diagnostic and therapeutic codes with outcomes across groups 1 , 11 , 22 – 24 . One promising area for artificial intelligence (AI) is to identify novel risk factors in specific cohorts, trained by continuous data. These data could be acquired using tools that foster engagement, including messaging, electronic coaching and reminders in the form of digital ‘nudges’ 25 . DHT could then close the loop by facilitating the implementation of evidence-based practices and policies in specific communities 26 . Digital determinants of health The National Institute on Minority Health and Health Disparities in the USA discusses DDoH along the axes of individual, interpersonal (or family), community and society (or population) levels 27 ( Fig. 1 ). These axes are discussed in detail below and summarized in Box 2 . Fig. 1 |. Equitable access to DHT. Open in a new tab Summary of solutions to address key digital determinants of health (DDoH) at various levels, in which initiatives at each level reinforce the next. These strategies could improve access to digital health technologies (DHT) for all members of society (see also Box 2 ). SDoH, social determinants of health. Box 2 |. Personalized framework for fair access to DHT. Individual • Understand digital skills and literacy as foundational rights • Gain access to digital infrastructure, including devices and broadband • Recognize that digital health technologies (DHT) can be effective • Overcome anxieties about the need for DHT for individual care Interpersonal • Establish care-giver and family support • Establish a private and secure space Community and society • Meet the needs of patients who experience systemic, structural, social and institutional barriers to care • Establish trusted partners (such as community organizations) • Establish digital capacity and infrastructure needs • Broaden dissemination including non-traditional venues (such as libraries and social networks) Health-care and non-profit organizations • Provide sufficient digital training to health-care professionals • Develop crucial digital infrastructure (such as access to devices, video visits, electronic health records) at ‘safety-net’ institutions • Build digital health-care capacity • Recruit and train staff who are linguistically and culturally concordant with the community • Appropriately incentivize clinicians and industry to develop DHT Government • Design digital health systems for the broadest range of end-users • Address the needs of patients requiring health-related ‘safety-net’ services a • Evaluate DHT effectiveness for health systems and populations • Establish widespread, reliable broadband Internet access • Set accessibility standards • Provide sufficient reimbursement via value-based payment systems • Fund research that supports digital health project implementation (such as the National Consortium of Telehealth Resource Centers in the USA) Industry • Focus on populations who need and benefit from DHT to ensure fair access • Establish principles of inclusive design • Develop DHT for users of varying educational and social advantage levels • Ensure DHT is available in multiple languages at a reading age of 12–13 years • Provide training and support to help patients to use DHT • Support health-care professionals with training and workflows, especially in under-resourced institutions • Recruit diverse participants to participate in clinical trials of DHT and detail demographics in published reports • Continuously evaluate DHT for population-level health improvements • Minimize costs Open in a new tab See also Fig. 1 . a Institutions that serve low-income, uninsured or underinsured patients. Individual level In addition to digital literacy, positive attitudes and trust towards DHT and access to these technologies influence DDoH at the individual level 27 . Access to DHT requires specific software and hardware tools, as well as infrastructure, including a reliable electricity supply and broadband Internet. Digital literacy comprises the cognitive and technical skills needed to use DHT effectively 23 . For example, in a study in patients who used home blood pressure monitoring after a stroke, individuals from racial and ethnic minorities were less likely than white patients to act on blood pressure data, which might reflect a lower level of health literacy 28 . Trust and positivity towards DHT is required to alleviate anxiety and is increasingly important given concerns about unwanted dissemination of protected health information 29 . Multiple factors such as limited proficiency in the local language, poverty, sexuality and older age can be mutually reinforcing at the individual level, creating singular social experiences that compound and exacerbate digital health disparities 30 , which has been termed intersectionality 31 . Interpersonal level An individual’s access to digital technology is often dependent on friends, family members or care-givers. Key determinants include dependence on others and their implicit biases. These factors, if not adequately addressed, create highly variable patient–clinician–technology relationships. Dependence on others can limit access to DHT if a device is unavailable at a crucial time or if those individuals could be exposed to sensitive data. Implicit bias refers to assumptions made by the health-care professionals (including community and social workers) that exclude individual access 2 , such as assuming that a device is ‘too difficult to use’. Disparities in the digital literacy of health-care professionals themselves can also introduce barriers to DHT use 32 and can be addressed by training them to be ‘digital health navigators’ ( Table 1 ), which reduces digital disparities 33 in diverse racial and ethnic groups 34 . Community level The infrastructure and resources of the community, including rules and policies, surround the individual and interpersonal levels. Broadband access is a foundational community-level infrastructure, and uneven access has created a digital divide between historical ‘haves’ and ‘have-nots’ 27 . Access to DHT can, therefore, be affected by whether local libraries, health centres or other community-based facilities provide devices and broadband Internet and, conditionally, whether these resources are available based on rules of use. Society level Society level factors span technology policy, data standards, design standards and social norms. An expectation exists that industry will develop technologies that are appropriate for societal needs, but several issues have violated these expectations 35 . The digital divide 36 is exacerbated by societal DDoH, such as ‘digital redlining’ ( Table 1 ), in which digital infrastructure is under-provisioned in certain communities, typically those that already have poor health outcomes 37 . In addition, concerns have been raised about how DHT implicitly trade access for privacy 38 , a process that is exacerbated by the mixing of traditional and consumer technologies. Commercial determinants of health Commercial determinants of health (CDoH) involve systems, practices and pathways through which commercial entities drive access to health care 39 , either directly or indirectly, positively or negatively. Societal behaviours and incentives can promote entities that benefit health care and oppose those with a perceived negative influence 40 . Negative CDoH are likely to exacerbate disparities in health-care delivery, because they disproportionately affect individuals who are unlikely to benefit from a product or service. Private sector funding of health education and research also influences practice in favour of commercial interests, for specific sections of society. Although CDoH are largely shaped by market incentives and regulatory policies, they also intersect with product design. For example, the absence of health-care reimbursement often drives direct-to-consumer pricing, including ‘freemium’ models in which the basic service is offered free, but crucial features are locked behind subscription pay-walls. If these premium features have the strongest evidence of efficacy, these designs risk exacerbating disparities. Additional factors include a lack of data interoperability 41 , 42 , user interfaces that do not accommodate diverse literacy levels or languages (owing to limited expected revenue from these populations) and market positioning that targets high-income demographics (such as wellness tools) rather than prioritizing populations with the greatest need. The entry of non-medically focused commercial entities into DHT (a form of ‘sphere transgression’ 10 , in which a dominant product in one sphere allows an entity to command products in a new sphere) risks commercial priorities overshadowing or compromising patient-centred values. Issues of trust, accountability, monopolization of data, transparency and access should therefore be evaluated continuously as digital health care evolves. Product-related determinants of health Differences in evidence-based care attributed to socioeconomic factors or race could reflect upstream differences in consumer devices or diagnostic tools. Studies are needed to understand variations in the access and barriers to the use of low-risk (such as over-the-counter) DHT, moderate-risk DHT (FDA class II in the USA) and high-risk implantable devices (FDA class III in the USA), and their respective effects on health outcomes. For example, in the Multi-Ethnic Study of Atherosclerosis 43 , the prevalence of clinically detected atrial fibrillation (AF) was lower in African American than in white participants, but ambulatory monitoring revealed that race and ethnicity had little effect on the rate of AF detection. Although remote monitoring was initially developed to increase access for patients in rural or remote settings, this technology is currently underused and has substantial disparities according to age, race and ethnicity, income, insurance type and location, as reported in the PREDICT RM study 44 . Disparities in diagnosis can lead to disparities in treatment 45 , 46 . Ethnicity, socioeconomic factors, biological sex, gender and sexuality 47 contribute to differences in care for a variety of conditions 48 , 49 , including AF 50 and aortic valve stenosis 51 , 52 . For guideline-supported, evidence-based diagnostics and therapies, differences in income 53 and in insurance coverage between payers also contribute to inequities in access to DHT. Algorithmic bias is another concern 9 . In a now infamous case, machine learning tools developed for recruitment by a major technology company were revealed to downgrade résumés containing the words “women’s” or “women’s colleges” 54 . The system was abandoned, but this case reveals the insidious effect of biased training data. Algorithmic bias is widespread and has even been reported in a DHT app that drives health-care decisions in more than 70 million Americans 55 . Research is required to understand the real-world use of specific DHT products. For example, although participants in large studies of smartwatches for AF detection were diverse in age, sex and ethnicity 56 , 57 , large-scale and post-market data are scarce, limiting our understanding of how over-the-counter consumer wellness products and FDA-approved pre-diagnostic devices alter the journey from consumer to patient (and back). Factors of interest include variations in accuracy for patients with different demographics, the actions taken in response to notifications (such as a fast, slow or irregular pulse), access to downstream health care and subsequent health outcomes. The proportion of direct-to-consumer devices that are used for medical monitoring is also unknown, because this denominator is not tracked in post-market data sources, such as medical claims or EHRs. Framework for equitable access to DHT The WHO has emphasized that ‘digital inclusion’ ( Table 1 ) should encourage the development of infrastructure for information and communication technologies for health to promote equitable, affordable and universal access 1 . Although general implementation frameworks are available to researchers, few equity-focused models exist 58 . The Equity-Focused Implementation Research for Health Programs (EquIR) model 59 was developed in 2019, and enables researchers and executives to consider unbiased access throughout the implementation process from initial planning to evaluation. EquIR was designed by implementation researchers and health equity experts using data from systematic reviews. The model includes five phases — population assessment, planning, designing, implementing and equity-focused implementation outcomes 59 . Another model, the Consolidated Framework for Implementation Research (CFIR) 60 , could also be focused on unbiased access to DHT, by adopting intervention characteristics that ensure culturally appropriate and accessible solutions. The CFIR is composed of five domains — intervention characteristics, outer setting and inner setting (which can overlap), characteristics of the individuals involved and the process of implementation. In a single implementation, the outer setting can consider the social, political and economic milieu for diverse communities, while the inner setting can achieve an inclusive culture. The characteristics of an individual’s domain addresses bias among those involved in solutions, and the implementation process can itself include diverse groups. Digital inclusion can be considered a personal hub in which multiple SDoH intersect. Appropriate solutions can maintain patient engagement, enable remote monitoring, promote education, and improve diversity and enrolment in participant-centred clinical trials 29 . Below, we propose an integrated framework of recommendations to improve equitable access to DHT by using complementary DDoH solutions at the individual, interpersonal (family), community, society (population), government and industry levels ( Fig. 1 and Box 2 ). Individual-level solutions Individual-level solutions should reinforce the notion that each individual should have the ability to adopt and utilize DHT. Important components include digital access and literacy as well as targeted education to fill knowledge gaps and help individuals to ensure their own data security 61 . Trust can be fostered by monitoring DHT use to ensure data privacy and to enforce safeguards against inappropriate data use by the health-care team 62 . Tailored, frequent training is required from the outset, to demonstrate to individuals who DHT can be effective for them. Training should be contextually appropriate and be delivered in the most accessible language for the individual. Solutions are likely to be enhanced by initiatives that make health care practical and accessible to individuals, such the ‘Home as a Health Care Hub’ 63 in the USA. Interpersonal-level solutions Assessment of whether an individual’s dependence on others determines their ability to access DHT is crucial. Family members should be encouraged to provide support in private and secure spaces that empower individuals to realize the benefits of DHT and accept that barriers to use can be overcome. Family members or friends with high digital literacy can provide invaluable expertise or resources appropriate for an individual’s skill and comfort level. Family counselling should foster positive attitudes, emphasizing how teamwork can empower an individual, improve their health and reduce future dependence. Specific solutions include flexible timetabling that enables several individuals to share resources securely at required times 27 . Technologies could be selected that are supportive of contemporaneous use, such as high bandwidth digital access plans or tools that can migrate from a tablet to a mobile phone. Strategies should include secure access if the data are sensitive and facilitate meaningful discussions between the patient and the health-care team. Community-level solutions The community can be a powerful agent in establishing appropriate and achievable DHT norms. Solutions should include systematic assessment of needs and resources to identify gaps for each community, and engagement with partners to allocate resources and plan training 29 . Communities can help to identify and improve issues such as the suitability of venues for digital health-care delivery, the adequacy of digital education or the balance between digital access and privacy. A crucial step in the process is for communities to understand what they are asked to provide and, in return, what services they can expect 64 through transparent discussions with health-care and industry partners. Such transparency has historically been mixed 62 . For example, although individuals are often not aware that the DHT trade-off between access and data privacy can be controlled 38 , communities of patients and consumers can work with industry and health-care organizations to ensure that digital infrastructures are available to provide and communicate this control. Telehealth-based tools (such as patient portals and EHRs) should accommodate the timing of cultural routines, such as shift work, and reflect technologies available in the community. For example, Android operating system devices have the majority market share in Brazil and India, whereas Apple iOS operating system devices predominate in Japan and the USA 65 . In addition, communities can identify and focus on the most effective communication channels, including digital apps, social networks, libraries, community classes, outreach and non-traditional venues, such as barbershops 66 , all of which can improve the effectiveness of DHT. Society-level solutions Societal organizations should determine their own digital priorities. Health-care institutions should employ staff who are culturally and linguistically concordant with the community, can work with available resources and avoid assumptions about digital literacy. To encourage use, DHT could be offered as an opt-out rather than an opt-in strategy. Recognizing that resources vary across health-care organizations, including sites that serve low-income, uninsured or under-insured patients (so-called ‘safety-net’ institutions) should be encouraged to prioritize access to telehealth devices, video visits and EHR platforms to improve overall outcomes. Societal organizations should also define and implement DHT performance indicators. Examples include digital literacy assessments and surveys on ease of use and patient satisfaction 67 . Acceptability is a key indicator that includes perceived usefulness, intention to use, compatibility, perceived privacy and costs. Adoption can be increased by appropriate education for individuals and communities, as well as integration into daily routines and existing workflows 41 . DHT adoption can be improved by incorporating feedback from patients and care-givers into the DHT design 67 . These programmes might require additional personnel or resources, which should be factored into their design. Government-level solutions Governments should be expected to adopt policies that focus on the goals and challenges specific to their populations. However, international alignment of key policies might help to bring benefits in access, innovation and patient outcomes. Accordingly, governments have an important role in setting regulatory frameworks for industry. In some countries, government legislation has encouraged positive CDoH that democratize access to DHT, such as the Treatment Action Campaign in South Africa, in which pharmaceutical companies were encouraged to improve access to antiretroviral medications 68 . In the USA, government initiatives increased access to DHT through the Affordable Connectivity Program 69 . In 2021, the Infrastructure Investment and Jobs Act legislation was enacted in the USA to enable the development and use of self-sustainable telehealth and online portals 70 . The European Union (EU) ensures strict data privacy via omnibus laws, such as the General Data Protection Regulation (GDPR), that protect data more broadly 71 than the Health Insurance Portability and Accountability Act (HIPAA) in the USA 72 . Government policies could be developed to harmonize DHT with international implications. Examples include policies that prohibit digital redlining 70 , address data acquisition or promote independent regulatory entities and increased public participation. These goals could be achieved by establishing common principles for digital health applications and services 73 focused on transparency, respect for the law, accountability and access. Although technology companies claim that these privacy laws impede innovation 74 , others argue that regulation can spur competition and innovation, enabling the creation of new large digital health markets. These diverging opinions imply that discussions should be focused on the type of regulation rather the need for regulation itself 75 . To ensure success, government solutions to level access to DHT need to balance DDoH and SDoH, while fostering innovation 19 . The danger of adopting either approach alone — focusing on technological advances without considering societal needs, or prescribing solutions without assessing commercial feasibility — can exacerbate health disparities. Broadband Internet access. Reliable access to broadband Internet is crucial to the equitable use of DHT and can be fostered by government initiatives. Although digital redlining is illegal in many parts of the world 70 , solutions might require partnerships with organizations that have contributed to these practices. Both challenges present opportunities for industry. Creative solutions are needed to enable the widespread provision of broadband Internet. Examples include the identification of alternative economic models, public–private partnerships, tailoring access to local and international laws on data security, and innovation between industry, patient advocacy groups and health-care organizations. Some specific solutions include the creation of open-access hotspots 76 and electrical access and charging stations for mobile devices in public areas. Patient data access and privacy. Several privacy concerns have been raised by the broad scope of data collection and distribution by DHT 38 , 62 . Patients and health-care professionals might not recognize that commercial DHT are often not subject to privacy laws, such as the HIPAA. Therefore, data collected by health-care providers and businesses that are covered by these laws and data gathered using commercial devices might have different privacy stipulations 72 . One strategy is to enact strict data-sharing legislation, which would require novel solutions to protect privacy while maintaining standards of care 38 . Industry-level solutions Addressing CDoH. Balancing the needs of industry with the mandate to address CDoH is vital. This equilibrium can be facilitated by government policy and legislation, such as increased transparency between the US Patent and Trademark Office and the FDA 77 . For example, some sectors of the US Congress have proposed invoking ‘inequitable conduct’, a legal mechanism that invalidates patents acquired by fraud that could be interpreted as intentionally misrepresenting material information. The negative effect of CDoH should be addressed by open discussions between patient advocates, health-care professionals, industry and government. One successful example is the Treatment Action Campaign in South Africa that encouraged pharmaceutical companies to improve access to antiretroviral medications for HIV and AIDS 68 . Product design and use. DHT should be developed for medical conditions that place the greatest burden on society or that are increasing in incidence, which can be identified by societal organizations and potentially prioritized in governmental policies. To be contextually appropriate, DHT products should be designed for consumers and patients at varying reading levels and delivered in various languages. For example, the Digital Care Transformation Program (a digitally enabled, remote hypertension and cholesterol-lowering programme) at the Mass General Brigham health-care system, USA, showed similar enrolment rates and clinical improvement across various races, ethnicities and language groups 78 . Adoption of DHT has been limited by user awareness of the benefits of these technologies and overly complex designs or workflows 79 . Rigorous research on user experience can help to minimize barriers to patient engagement as part of the product design cycle. For example, research into patient mental models can identify points of friction that users might experience, and this knowledge can be used to improve products iteratively. When coupled with ‘design thinking’ ( Table 1 ), this approach keeps the patient at the centre of the product development process. Research into the post-market use of DHT by race, ethnicity, sex, gender, socioeconomic status, geography or other key performance indicators could help to improve designs and develop care models, such as remote electrocardiographic monitoring 80 . Regulatory bodies should prioritize the enrolment of diverse patient populations in DHT studies across the product life cycle, and the FDA has proposed a variety of strategies and solutions to increase trial enrolment in under-represented populations 81 , 82 . Global perspectives Several challenges to accessing DHT share common themes across continents, such as low digital literacy and the need for broadband Internet. However, important regional differences also exist, such as differing infrastructures and government policies, as well as how cultural awareness might affect DHT use. How these factors might change if individuals were to relocate to a different region is unclear 83 . Understanding these geographical and cultural differences can inform solutions that enable communities and entire nations to better address health-care inequalities for their diverse communities and ultimately advance global health. The concept of reciprocal innovation describes bidirectional, mutually beneficial research and translation of information in a framework of long-term global health-related partnerships. The goal is for countries with differing income levels, or health-care partners with varying capabilities, to learn from each other and adapt to their specific context 84 . Low-cost DHT or those that address shared barriers to health care can be developed in low-income to middle-income countries and then be adapted to markets in high-income countries or to low-income communities within those countries. DHT platforms could be co-created by diverse, multinational teams from academia or industry and then be adapted to suit each region or population while maintaining the core elements. For example, a North American app for monitoring cardiac medications, integrated with EHRs and automated prescriptions, might not be suitable for countries such as India, where pharmacist-led care and non-EHR messaging platforms are prevalent. However, the product can be adapted for local use by integrating Indian digital infrastructure and innovations for medication delivery. These innovations could then be reintroduced to the USA with new care models, exemplifying the reciprocal nature of these projects. If products are modified in response to changes in the workflow or population, there should be transparency in reporting such adaptations to generate evidence using well-established frameworks 85 . When these changes are substantial enough to affect generalizability, new clinical evidence might be required. Below, we provide global perspectives on digital health inequalities and summarize recommendations to improve access to DHT worldwide. Given that specific issues in accessing DHT vary by country, or even within countries, we have elected to take a continent-wide approach. The text is supported by Supplementary Tables 1 – 6 . Africa Disparities. Access to high-quality health care and attaining optimal health indices are substantial challenges in Africa 86 , particularly in the sub-Saharan region 87 . Many African countries are attempting to use universal health-care strategies to achieve the United Nations Sustainable Development Goal 3 (to “ensure healthy lives and promote well-being for all at all ages”) by 2030 (ref. 88 ); however, progress is slow 89 . DHT have the potential to accelerate health-care coverage, quality and outcomes, as demonstrated by telehealth services in Rwanda (such as Babyl, a digital primary health-care service, and Mizero Care, a digital health initiative providing psychotherapy to address mental health issues) 90 and South Africa (MomConnect, which supports maternal and child health) 91 . In addition, a randomized clinical trial in Nigeria showed that AI-guided screening using a digital stethoscope improved the diagnosis of cardiomyopathies in pregnant and postpartum women 92 ( Box 3 ). However, several challenges remain, including contextual barriers to adoption and long-term financial sustainability of DHT in Africa 90 . Prioritizing DHT in Africa must also be evaluated in the context of prevailing SDoH, such as sanitation, access to clean water and food security 93 . Box 3 |. Hypothetical case study. Peripartum cardiomyopathy (PPCM) is a life-threatening but treatable condition. Nigeria has the highest reported incidence of PPCM globally 92 . We present a hypothetical female patient aged 26 years from a rural area in Nigeria who is in the third trimester of pregnancy. She participated in a community-based digital health technology (DHT) screening programme, which provides basic health care in remote locations with limited access to specialized obstetric care. Screening using an artificial intelligence (AI)-enabled digital stethoscope is positive for left ventricular systolic dysfunction (LVSD). A subsequent echocardiogram confirms the diagnosis, and health-care providers promptly refer the patient to a specialist hospital to initiate appropriate therapy and planning for the delivery of her baby. In the SPEC-AI Nigeria trial 92 , 1,232 pregnant women in Nigeria were randomly assigned to AI-guided screening for LVSD via a digital stethoscope or usual care between August 2022 and September 2023. LVSD detection was significantly higher in the AI-screening group compared with usual care (4.1% versus 2.0%; OR 2.12, 95% CI 1.05–4.27; P = 0.032) 92 . This finding underscores the profound role that DHT can have in reducing global health inequalities. In the USA, PPCM is often diagnosed later in non-Hispanic Black women than in non-Hispanic white women, resulting in poorer outcomes and higher mortality 150 . The integration of AI-guided screening into routine care could reduce these disparities. See the table for a personalized framework for broad digital health access in relation to this case study. Digital determinants of health domain Actions required Individual Patient education on the need for screening and DHT availability; digital literacy specific to DHT is not required, but health literacy is important Interpersonal Family education on the need for patient screening; health-care professional training to support discussions about screening with the patient and on accurate placement of the digital stethoscope to acquire high-fidelity electrocardiographic and phonocardiographic recordings Community Empowerment of doulas and community health-care professionals through educational programmes to increase digital literacy and promote DHT use for effective identification of high-risk women who require referral to specialized maternity centres Society Communication on the importance of screening to administrative leaders and the need to integrate DHT into clinical care; investment required in device procurement, software licences, health-care professional training, equipment maintenance and incorporation of results into existing health records Government Specific legislation to improve maternal cardiovascular screening and pathways for reimbursement of DHT services; commitment to prioritizing women’s health and reducing disparities can help to ensure that costs remain manageable Industry Post-market surveillance of DHT to ensure stability of key performance metrics and identify barriers to implementation, adaptations and innovative approaches applicable to similar markets Open in a new tab Poverty and the digital divide. Africa has the highest global rates of poverty 94 , and many individuals cannot afford mobile technology. Data collected from 34 African countries between 2016 and 2018 showed that only 43% of adults had access to a basic mobile phone, 20% to a smartphone and computer, and 11% owned neither 95 . Potential solutions include providing devices in shared community spaces for a small fee and increasing the availability of low-cost devices. Broadband Internet access is limited across many African regions and relies mostly on mobile Internet through cellular networks. Although 80% of people in Africa have access to at least 3G mobile Internet, less than 25% use these services because of the cost of data plans and poor service quality 96 . Potential solutions include subsidizing mobile data plans, free Wi-Fi in public spaces or providing high-speed Internet with appropriate cybersecurity at Internet cafes for a small fee. An additional infrastructural challenge in sub-Saharan Africa is the lack of a stable electricity supply 97 . Investing in renewable energy sources, such as solar power, has been identified as a viable solution to address this issue. Health literacy and cultural practices. Low health literacy is a barrier to the adoption of DHT in Africa 98 , as it is worldwide. Strict and pervasive gender-based roles that constrain women to household chores and care-giving, limiting their economic contributions 98 and ability to influence the adoption of DHT, are a specific concern in the region. Potential solutions include: public campaigns on the importance of educating girls, who have a key role in raising future generations; policies against child marriage; providing remote and vocational learning options for women; and targeted media to debunk strict gender-based roles and highlight the benefits of shared decision-making in the home. DHT training. Failure to provide appropriate training to frontline health-care workers is a substantial barrier to the adoption and sustainability of DHT in Africa. Easily accessible, community-level training should be provided at no cost or a minimal fee to promote confidence in and proficiency with DHT 99 . Health-care funding. Public funds for health-care financing are limited in many regions in sub-Saharan Africa where, instead, suboptimal payment models and out-of-pocket expenditures are relied upon that worsen health inequities 93 . In 2022, Nigeria had the highest gross domestic product (GDP) in Africa, but invested only 4% in health care 97 , compared with the 10–17% of GDP allocated to health care in the USA and high-income countries in Europe 93 . A multi-stakeholder approach for health-care financing reforms has been suggested that includes increased government investment, improved utilization of pooling and insurance systems, and leveraging non-governmental organizations, international donors and philanthropy at the outset 93 . Asia Disparities. Asia is home to 60% of the global population, with striking cultural, geographical and socioeconomic diversity. Although Internet connectivity has reached most people in regions such as Brunei Darussalam, Japan, Korea, Malaysia and Singapore, a lack of reliable Internet access remains common in rural regions of Asia. In 2022, the rural populations of Cambodia, Laos and Vietnam were 75%, 62% and 61%, respectively, according to the World Bank. In a study from China, Internet access was found to be lower in rural areas than in urban settings, a digital divide that limits the ability of rural populations to benefit from DHT 100 . Therefore, millions of people across Asia lack Internet connectivity; in 2021, Internet penetration rates were 44% in Myanmar, 53% in the Philippines and 60% in Cambodia, in stark contrast to the 98% in Brunei, 97% in Malaysia and 91% in Singapore 101 . Digital literacy and mistrust. In Asia, older adults and individuals with lower educational levels lack the necessary digital literacy to use DHT effectively 102 . A cross-sectional study of adults aged >65 years from South Korea showed that 67% had low digital health literacy and 81% did not use DHT to access health services 103 . The Itabashi Longitudinal Study on Aging 104 , involving 899 people aged >65 years from Tokyo, Japan, found that only 4.2% owned a smartwatch. A survey in India on the use of mobile phone support to manage tuberculosis found that most respondents preferred mobile phone visits to in-person visits, but <60% could use their phone camera and barely 25% of participants used phones to contact their care providers 101 . In another study from India, the willingness to use mHealth services was associated with younger age, male sex, having a formal education and being in employment 105 . A lack of trust in digital tools, even when they are accessible, can lead to digital health inequalities. A phone survey conducted in Singapore during the COVID-19 pandemic showed that despite nationwide access, 78% of participants were uncomfortable with AI software interpreting medical results and few used digital health services. Independent predictors of reduced use of digital health services were older age (OR 0.71, 95% CI 0.59–0.86 per 5 years) or having lower income (less than Singapore $2,000) 106 . A study from Bangladesh confirmed that trust is an important prerequisite for digital health, and patients who are more trustful are more willing to share their data using DHT 107 . Diversity in culture and language. The Asia Pacific region is one of the most culturally and linguistically diverse areas of the world, with more than 3,000 languages spoken. DHT that are appropriate to the sociocultural milieu might have better acceptability, whereas, conversely, a lack of cultural sensitivity can hinder DHT effectiveness. A systematic review of studies in South Asian adults showed that developing culturally appropriate interventions is important to their acceptability, delivery and uptake 108 . For example, modesty is an important factor, particularly among subpopulations of Asian women, and can limit digital health interventions to increase physical activity in mixed-gender facilities 108 . Digital interventions should also account for sociocultural differences in diet, safety and even the weather, as shown in a study from Bangladesh of a mobile health initiative for type 2 diabetes mellitus 109 . Infrastructure and investment. National governments and policymakers are crucial in setting digital health standards and implementing and regulating DHT strategies. In a World Heart Federation survey, in which 21.3% of the respondents were from South-East Asia, the lack of national guidelines on data privacy and sharing was identified as a crucial roadblock to the use of DHT 110 . This finding also speaks to issues of mistrust. In Bangladesh, the absence of national guidelines on telehealth was reported to be a substantial barrier to its adoption by health-care professionals 111 . Australia Disparities. Australia is geographically vast, spanning >7.6 million square kilometres, which presents unique challenges in delivering equitable digital health services. Although a substantial proportion of the population resides in urban centres, remote and rural areas account for the majority the landmass, and infrastructural barriers limit access to DHT for residents of these areas. Australia has widespread Internet availability in urban areas, but coverage is less reliable in remote and rural regions. Although individuals who reside in remote areas are likely to benefit the most from digital health care, digital inclusion is low in these populations, which limits the use of telehealth, online health resources and other DHT tools 112 . The high cost of technology and Internet services coupled with low digital literacy in socioeconomically disadvantaged populations, including First Nations people, also hampers widespread adoption of DHT. Digital health services in Australia have advanced over the past decade, particularly with initiatives such as My Health Record, a national digital health record system aimed at improving the accessibility and continuity of health information 113 . Despite these efforts, the uptake of digital health services has been variable. Health inequalities and First Nations people. The issue of health inequalities is especially important when considering the First Nations people of Australia, who have a worse health status than the non-Indigenous population. For example, a study of nearly 20,000 patients with AF showed that anticoagulation was frequently not prescribed in accordance with guideline recommendations and that this deficit was substantially more common in Indigenous than in non-Indigenous patients 114 . First Nations Australians, particularly those in remote communities, face multiple barriers to accessing health services, including geographical isolation, cultural differences and a lack of trust in mainstream health systems. DHT promise to address some of these barriers by offering accessible and personalized health-care solutions. However, the uptake of digital technologies among Indigenous communities has been slow, primarily due to limited Internet access, a lack of culturally appropriate digital health tools and the need for greater community engagement and trust-building 114 . To improve digital health access in Australia, efforts should be directed towards expanding digital infrastructure in rural and remote areas, increasing digital literacy and co-designing health technologies with Indigenous communities to ensure that they are culturally relevant and trusted. Europe Disparities. Despite high overall levels of Internet connectivity, high digital literacy and strong data protection standards, considerable variation exists in access to the Internet and DHT across regions and socioeconomic groups. Underserved groups benefit less from telemedicine, e-health services and health information than those in well-provisioned communities 26 . Attempts have been made to harmonize spheres of the digital space in the EU, but differences remain between member states in terms of the uptake of DHT (such as wearable devices for heart rhythm analysis 115 ) and reimbursement (such as for the remote monitoring of cardiac implantable electrical devices 116 ), with northern and western regions leading adoption. However, ongoing trials could alter practice. For instance, implementation of the TeleCheck-AF infrastructure in the Netherlands led to a change in digital health-care utilization and directly created the basis for a new reimbursement code 117 . Challenges in health care. Health care in Europe faces several challenges, driven in part by the ageing population, with a high proportion of complex, chronic health conditions that increases pressure on health-care systems 118 , 119 . Workforces are strained by shortages of health-care professionals, leading to disparities in access, particularly in rural areas. In 2011, a European Society of Hypertension Working Group reported that 80% of cardiovascular deaths occurred in underserved communities 14 . In addition, a need exists to provide care that is culturally sensitive and integrates the diverse populations of Europe. The European Commission’s digital health strategy could help to harmonize these efforts by interoperability and cross-border health care between member states 120 , 121 . Integration of DHT into health-care models. Health-care systems vary across Europe, with differences in structure and methods of reimbursement 122 . In some regions, advances have been made in integrating digital solutions into health-care systems. Initiatives include EHRs that are accessible to patients, e-prescriptions, digital disease management programmes (such as the TeleCheck-AF project in the Netherlands 117 ) and access to health care through electronic booking systems 123 . The adoption of remote technologies increased during the COVID-19 pandemic but has since plateaued or even decreased 124 , making it important to identify and address the factors underlying this shift. Strict data privacy laws, such the GDPR, protect all personal data in the EU, including health data 71 . The implications of this approach to data sharing in other legal systems outside the EU is yet to be determined. Latin America and the Caribbean Disparities. Digital communication has also been widely adopted in Latin America, which includes Mexico, Central America and South America, and the Caribbean (LAC). For example, 95–98% of individuals with Internet access use messaging apps 125 . Nevertheless, gaps in digital connectivity do exist 126 , 127 . Smartphone ownership varies between c ountries, from 90% in Brazil and Chile to 60% in lower-income countries 125 . Latin America is the most urbanized region in the world, with 81% of the population living in urban areas 15 , where Internet access is more reliable than in rural areas. However, heterogeneity between countries exists, and precise measurements are lacking in some countries. Internet penetration in rural areas is approximately 37%, almost half that in urban areas where 71% of the population have connectivity options 128 . Confronting the connectivity gap will require a multisector approach to improve infrastructure, including public and private investment in expanding broadband and mobile networks, establishing community access in places where digital educational programmes could take place, and enhancing regional cooperation for digital inclusion through governments and global organizations 127 . Adoption of DHT in LAC could increase contact with health-care systems and facilitate education 15 , given the ageing population, growing burden of chronic diseases and anticipated shortages of health-care workers 15 . Affordability. The distribution of wealth in LAC is highly disparate, and 27% of the population of this region live in poverty 129 . Smartphones are the main source of access to the Internet, and ownership is growing due to the availability of low-cost devices. However, the cost of Internet access and data packages present an important barrier to access 130 . In LAC, Android operating systems account for 80–95% of mobile devices 65 , and DHT should be designed to be used accordingly, which will enable reciprocal innovation in other lower-cost markets. Digital literacy. DHT should be designed with the low digital literacy of most of the LAC population in mind. A human-centred approach to build DHT for local communities, taking the cultural diversity of the region into account, could increase patient trust and acceptance of these technologies 130 . In addition, the use of videos, audio messages and short messaging apps could facilitate DHT use. Health-care providers in LAC might also lack digital literacy and, as elsewhere, digital training could increase the adoption of DHT 131 . Regulation and integration. Although digital health regulations, led by telemedicine, increased in Latin American countries after the COVID-19 pandemic, legislation varies between countries, and regional frameworks are lacking. However, several LAC countries such as Brazil have made notable progress in regulating DHT approval, telemedicine use and data protection 132 . Although many countries in LAC have universal health-care systems, the lack of EHRs and of their integration into workflows are barriers to comprehensive use of DHT, because they hamper coordinated collaboration 15 . Accordingly, a governmental priority should be to integrate DHT with EHRs, and scale broadband Internet and other infrastructure accordingly. Health-care reimbursement models are key to advancing DHT use, as seen in a study conducted in Europe and Israel 133 . Such models for DHT in LAC are evolving. North America Disparities. Substantial health disparities exist in Canada and the USA. In 2011, the Centers for Disease Control and Prevention in the USA reported that life expectancy for Black men and women was 3–4 years shorter than for white men and women 134 . To better document such disparities, the American Heart Association (AHA) created the Get With The Guidelines (GWTG) database as a prospective observational registry and a quality improvement initiative to track adherence to evidence-based cardiovascular care across groups 135 . A report by the Canadian government concluded that, although its population is one of the healthiest in the world, good health is not shared equally across communities 136 . Health inequities disproportionately affect disadvantaged populations, including Indigenous communities, the Black population, sexual and racial minorities, and low-income populations, all of which experience poorer health outcomes and higher rates of chronic diseases 136 . Digital determinants of health. Broadband access is suboptimal in nearly half of the USA, particularly in rural areas. Although 85% of adults in the USA own a smartphone, many low-income households do not have the data plans required for DHT use 137 . Counties with poor broadband access have substantially fewer primary care physicians and specialists in cardiovascular medicine than areas with high Internet connectivity 138 . Moreover, the American Community Survey showed a strong inverse association between access to high-speed broadband and cardiovascular mortality 139 . Disparities can be exacerbated by income; for example, 35% of users of Apple products in the USA have household incomes above $100,000 (ref. 53 ). Some of these issues have been addressed by initiatives such as the Federal Affordable Connectivity Program 140 , a successor to the (now discontinued) COVID-era Emergency Broadband Benefit programme 69 . Limitations of this programme included a lack of awareness of its existence and bandwidth constraints 29 . In the USA, several non-profit organizations advocate for digital health access. The National Digital Inclusion Alliance promotes unbiased broadband deployment 141 . The AHA has been a proponent of improving digital literacy 142 , and hospitals participating in the GWTG programme are within reach of 80% of people in the USA. Many are designated by the Centers for Medicare and Medicaid Services to provide care for low-income and uninsured patients. In addition, the AHA has pioneered the cloud-based Precision Medicine Platform that has funded research on structural racism 143 , rural health, air pollutants, smoking and diet 144 . In Canada, a government task force report 145 highlighted several limitations in their use of DHT, echoed elsewhere in the world, including a lack of integration between different record-keeping platforms, lack of health information interoperability between providers, inadequate clinician training, limited digital health literacy, cultural and systemic barriers, and inadequate Internet connectivity in rural areas. Canada’s federal government has attempted to address some of these challenges with Bill C-72, which requires companies providing digital health services in Canada to adopt common standards and allow for secure information sharing. Reimbursement. Coverage for (and therefore access to) DHT in the USA differs between government (Medicaid and Medicare) and private health insurance 59 . In Canada, some insurance providers are leveraging technology to promote healthier behaviours, such as offering discounts or rewards to individuals who use wearable devices to track their fitness, heart rate or sleep patterns 146 , 147 . Standardizing core coverage across insurers might also be a useful step towards expanding access. Even if some DHT costs are not reimbursed directly, their implementation and maintenance could be offset by long-term cost savings and improved efficiency, such as avoiding emergency department visits and decreasing readmissions to hospital 41 . As health-care coverage has historically been connected to specific outcomes, reimbursement for DHT could be linked to diverse outcome measures across health systems. Metrics should be defined and could include acceptance and inclusivity, outcomes tied to community-specific targets, repeated use (engagement) and health-related costs. Data privacy and access. In the USA, the HIPAA regulates the disclosure of protected health information, a predetermined set of 18 personal identifiers, by covered entities 148 . However, several commercial providers of DHT are not classified as covered entities and are, therefore, not bound by this privacy legislation. Additional national legal frameworks exist via the Federal Trade Commission, and some states, such as California, have their own data privacy laws. Conclusions The rapid development of DHT has created unprecedented opportunities to improve individual patient outcomes and advance evidence-based clinical practice, thereby promoting unbiased access to health care for all. However, if implemented suboptimally, DHT can have unwanted consequences, including exacerbating disparities and undermining ethics and privacy. By identifying gaps in clinical evidence, and the role of DHT in filling these gaps, we have identified digital, social, commercial and product-related determinants of health, detailed across continents. Addressing these factors offers a unique opportunity to develop a pragmatic and personalized framework to improve DHT implementations to enable access for all communities worldwide. Supplementary Material Supplementary Material NIHMS2093405-supplement-Supplementary_Material.pdf (381.6KB, pdf) Additional information Supplementary information The online version contains supplementary material available at https://doi.org/10.1038/s41569-025-01184-5 . Key points. Digital health technologies have created unprecedented opportunities to democratize the delivery of health care. Inequitable access to digital health technologies is a major obstacle to realizing their potential. Social, digital and commercial factors are well-recognized determinants of access to digital health technologies. Addressing these determinants of health is essential to fill gaps in the evidence base and enable broad access to digital health technologies. We propose a framework to improve access to digital health technologies, describing determinants of health at the individual, interpersonal, community, society, government and industry levels. We provide global perspectives from practitioners across the health-care spectrum, to identify determinants of access to digital health technologies that are shared or differ between systems and continents. Acknowledgements S.M.N. is funded, in part, by the Laurie C. McGrath Foundation, through the National Institutes of Health by grants R01 HL83359, R01 HL149134, R01 HL162260 and T32 HL166155 (‘Computational Medicine in the Heart’). D.A. is supported by the Mayo Clinic Women’s Health Research Center and the Mayo Clinic Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Program funded by the National Institutes of Health (K12 AR084222). L.C.C.B. is supported in part by CNPq (307329/2022–4 and RED 00192–23). J.L. is funded, in part, by National Institutes of Health grants U01HG007691, R01HL155107, R01HL155096 and R01HL166137; and by AHA grants AHA957759 and 24MERIT1185447. M.F.M. has received financial support by CONAHCYT (Frontier Science Sector Fund), through project number 845144. E.S. is supported by CIMED (Centrum för Innovativ Medicin), Stockholm County Council (Clinical researcher appointment), the Swedish Heart and Lung Foundation and the Swedish Research Council (DNR 2022–01466). M.T. has received research grants from the AHA, Bayer, Bristol Myers Squibb, the FDA and Gilead Sciences. A.A.A. is funded by the Institute of Precision Medicine (17UNPG33840017) of the AHA, National Institutes of Health grants 1 R01 HL135335–01, 1 R01 HL161008–01, 1 R21 HL137870–01, 1 R21EB026164–01 and 3R21EB026164–02S1, and the RICBAC Foundation. Competing interests S.M.N. has equity in Lifesignals.ai and PhysCade, and is co-inventor of patents owned by the Regents of the University of California and by Stanford University, USA. D.D. has received modest lecture honoraria, travel grants and/or a fellowship grant from Abbott, AstraZeneca, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, CVRx, Medtronic, Microport, Pfizer, Sanofi and Zoll. J.K.H. has received modest lecture and medical advisory board honoraria from Abbott CRM, iRhythm Technologies, Medtronic and Vector. C.S.P.L. has received research support from NovoNordisk and Roche Diagnostics; has served as a consultant or on the Advisory Board, Steering Committee or Executive Committee for Alnylam Pharma, AnaCardio, Applied Therapeutics, AstraZeneca, Bayer, Biopeutics, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Corteria, CPC Clinical Research, Cytokinetics, Eli Lilly, Impulse Dynamics, Intellia Therapeutics, Ionis Pharmaceutical, Janssen Research & Development, Medscape/WebMD Global, Merck, Novartis, Novo Nordisk, Quidel Corporation, Radcliffe Group, Roche and Us2.ai; and serves as a cofounder and non-executive director of Us2.ai. M.F.M. has received modest lecture honoraria and travel grants from Boston Scientific and Pfizer. E.S. has received lecture fees from Abbott, AstraZeneca, Bristol-Myers Squibb–Pfizer and Johnson & Johnson. 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