Response to Feds

The following is my response to a request for comments on Federal Strategic Plan to Reduce Health IT Disparities. My response can also be found at http://www.healthit.gov/buzz-blog/from-the-onc-desk/federal-strategic-plan-disparities/#ixzz1XIGFDBt6

To the Office of the National Coordinator for Health IT(ONC)

I think it is commendable that ONC is working to address the issues of Healthcare disparities. I find much to like in this strategy and offer the following comments as suggestions to further enhance your work.

While there may not be consensus as to the causes of health, Healthcare or Health IT disparities, it is increasingly clear that disparities are a complex phenomenon resulting from the interactions of many factors. Also, with almost a decade’s worth of the National Healthcare Disparities Reports behind us, it is clear that addressing disparities defies simplistic solutions. As we all believe that the complexity of cancer, cardiovascular diseases and HIV/AIDS will not stop us from one day finding a cure, I firmly believe that this same tenacity of spirit is needed to successfully surmount the challenges of disparities. Rather than seeking a “magic pill” or single set of policies/practices/programs that can “solve” the problem for all, we need people, policies and programs that educate, encourage and support every provider, healthcare professional, hospital , patient and caregiver to consider their role in the generation or elimination of disparities. When this tipping point is reached, momentum will inevitably propel the policy, practice, regulatory and IT innovation that will be needed to successfully achieve the vision of an equitable healthcare system and health outcomes.

So, my first comment is, as you can see above, more philosophical than programmatic or policy oriented. Yet I think it is very practical. Strive to develop a strategy that at its core galvanizes the populace to become involved in this issue, to see it as “our” issue rather than “their” issue and to recognize that “inequities among some inevitably threaten equity for all”.
Secondly and even more specifically, it is not clear what disparities or target audience is being envisioned as the focal point of this strategy. Goals must have a clear target. Without this they are unlikely to be successfully achieved.

Thirdly, the metrics that will be used to evaluate achievement of these goals are not specified. Without a plan to measure progress or clear methods of doing so, it will not be possible to convincingly document success.

Fourth, the overwhelming focus of this strategy appears focused on medical providers and the healthcare system. While there is some inclusion of patient engagement and consumer health informatics there seems to be little appreciation that all patients will not be able to, of themselves, become engaged. Thus the role of formal and informal caregivers and Health IT must be integrated in to any systems oriented strategy. Incidentally, research has shown that reliance on formal and informal caregivers and care giving burden is higher among many disparity populations. The extent to which we are able to improve outcomes in general and improve disparities in particular will in part be related to the ability of formal and informal caregivers to provide needed “care” and to receive the supports they will need to adequately do so. Similarly this strategy does not seem to speak to the potential role of Health IT in enhancing chronic disease self management. In that the major causes of morbidity and mortality today are chronic diseases, patients and caregivers alike are struggling with these illnesses for protracted periods of time, yet are in the personal or virtual presence of a medical provider, for relatively short periods of time, over the lifespan. If all we do is use Health IT to improve what occurs in the traditional clinical encounter, without addressing patient/caregiver interaction between encounters through Health IT, we are unlikely to sustain patient engagement efforts, improve provider-patient communication or reduce disparities, particularly over the long term.

Finally, this strategy does not appear to speak to the fact that providers and patients alike live in dynamic and changing environments with changing needs and issues. Even a perfect plan will not remain perfect forever. A sound strategy must be iterative in nature and intentionally evolve over time, as our nation evolves. Managing expectations along these lines will be critical to the long term success of the strategy and should start from the very beginning.

I hope you find these comments and suggestions helpful.
I wish you much success!

M. Chris Gibbons, MD, MPH
Associate Director, Johns Hopkins Urban Health Institute
Baltimore, MD