A multi-level framework for advancing digital health equity in learning health systems: aligning practice and theory...

Achieving digital health equity is essential to realizing the transformative goals of the Quintuple. Aim: optimizing patient experience, improving population health, supporting provider well-being, reducing costs, and advancing health equity. Yet significant disparities persist in access to digital tools, driven by both traditional and digital social determinants of health (SDOH), such as housing instability and limited broadband access. Health system responses often focus on downstream interventions to meet immediate needs, such as referrals for housing assistance or smartphone distribution, while upstream strategies, like partnerships to expand access to affordable housing or advocacy to improve broadband access, remain underutilized. Similarly, targeted tools for specific populations often lack corresponding universal strategies like digital literacy campaigns. The absence of systematic Electronic Health Record (EHR) integration of SDOH data further limits health systems' ability to identify disparities, tailor interventions, and support structural change. This paper introduces a theoretically grounded, multi-level framework for advancing digital health equity within Learning Health Systems (LHS). Drawing on insights from information systems theories, socio-ecological models, organizational learning, implementation science, and systems thinking, the framework supports alignment of equity-centered strategies across micro- (individual), meso- (organizational), and macro- (policy) levels. The framework is organized around three strategic domains: (1) building equity-driven data infrastructure through SDOH-EHR integration, (2) designing scalable, equity-centered interventions that balance targeted and universal approaches, and (3) leveraging strategic starting points to transition from downstream efforts to upstream reforms. Grounded in the U.S. context yet informed by international evidence, this framework offers a roadmap for aligning theory and practice to advance digital health equity in LHS. It is both actionable and adaptable, translating evidence and theory into a structured approach that healthcare systems can use to guide health equity initiatives. It illustrates how SDOH data can inform person-centered care, how targeted tools like multilingual telehealth apps can be integrated with universal strategies such as digital literacy campaigns, and how enabling services, community partnerships, and policy advocacy can catalyze longer-term structural reforms. Emphasizing continuous learning through feedback loops and multi-level alignment, the framework equips stakeholders to embed equity into LHS design and function, ultimately advancing sustainable progress toward the Quintuple Aim.