Do the nation’s academic medical centers (AMCs) have a role in promoting health equity in the U.S. healthcare system? Absolutely, say the authors of a report published this summer by the Los Angeles-based Manatt legal and consulting firm. “On the Path to Health Justice: How Academic Medicine Can Accelerate an Equitable Health System,” was created by Manatt director Naomi Newman, with fellow contributors Linda Elam, Darrell Kirch, Alice Lam, Alisha Reginal, and Alexandra Singh. On its website, Manatt describes itself as a “multidisciplinary, integrated national professional services firm known for quality and an extraordinary commitment to clients.”
“As the country re-emerges from a pandemic that has had a disproportionate impact on communities of color, academic medical centers (AMCs) are shifting out of crisis-response mode and reflecting on opportunities to intentionally promote equity across their tripartite mission, advance antiracist policies, and bring science to bear on the challenge of eliminating health disparities in access to and outcomes of care. Organizations are at various stages of dialogue and engagement on the topic, with many having a long history of engagement, others renewing their commitment and others just starting the conversation,” the authors write in their introduction to their report. “This paper is intended to support AMCs on that journey by describing strategies in nine areas of focus that can position AMCs to be leaders in eliminating disparities in their organizations and their communities. It is organized around mission-specific strategies (education, research and clinical care), internal strategies (Leadership and Governance, People and Culture, and Data and Analytics) and external strategies (Purchasing Power, Community Partnership, and Policy and Government Relations), and includes an appendix slide pack highlighting successful initiatives around the country. By implementing and resourcing a broad-based health equity action agenda—within their organizations and in partnership with their communities—AMCs can lead the way to a more just and equitable delivery system.”
The report’s authors note that, “As educators of the next generation of clinicians and leaders, AMCs can bring an equity lens to their educational missions to ensure that they are not passively perpetuating systemic biases, but rather proactively shaping a more racially/ethnically representative, culturally humble workforce and a more equitable delivery system.
They cite five key things that health system leaders can do in terms of educating staff and clinicians to promote greater equity:
> “Invest in educational pathways (often referred to as ‘pipeline programs’)”
> “Bring an equity lens to the admissions process”
> “Support underrepresented minorities in funding their training”
> “Bring an equity lens to curriculum”
> “Support the retention and advancement of diverse faculty”
Per the first item, they write that, “As a first step to building a more representative workforce, AMCs can invest in programs that support minoritized populations in building up the foundational science and academic skills required to pursue a higher education in healthcare.”
They also note that, “While great strides have been made in gender equity in the admissions process, the proportion of Black males entering medical school has actually declined over time, with the growth of Black or African American applicants, matriculants and graduates lagging behind that of other groups. As with workforce recruiting efforts,” they note, “the admissions process can be subject to bias and should be reviewed to ensure that eligible diverse candidates are included for consideration. The Ohio State University College of Medicine and Wexner Medical Center is one example of an organization that was able to achieve greater diversity in matriculants.” They also argue that “AMCs should also be deliberate in setting up policies and programs that support diverse candidates in starting and completing their training. This can include enhancing full-tuition scholarship programs, developing or strengthening mentorship programs, and ensuring students from families with low incomes have access to emergency funding to overcome food or housing insecurity that may contribute to their lower rates of completion.”
Recently, Healthcare Innovation Editor-in-Chief Mark Hagland spoke with Naomi Newman about the report and its implications. Below are excerpts from the interview.
Tell me about the context and origins of this report?
I worked as a consultant with academic medical centers for over a decade, and wanted to look at how AMCs are rising to the challenge of addressing inequities, in order to make it a little less daunting for other organizations just embarking on those journeys. I also wanted to address how AMCs can go beyond simply addressing equity as a one-off subject and instead address inequity comprehensively.
AMCs play such a seminal role in shaping the health care landscape. First, they’re educators of the health care workforce of the future. So, the fact that 40 percent of first- and second-year medical students have false beliefs about differences between Black and white patients shows how much work remains. Additionally, clinical decision support tools are race-adjusted and ethnicity-adjusted, and what’s becoming clear is that there’s a need to review those tools with an equity lens. Moreover, some are not based on evidence, and need to be updated. The importance of AMCs in this work can’t be overstated; they’re shaping the future health care workforce, they’re shaping care delivery, and bringing innovations to the healthcare system.
How does all this play out more broadly in the healthcare system?
This framework and these strategies are applicable not just to AMCs but to the broader healthcare system, including the strategies related to leadership, people and culture, the data and analytics – all applicable to the broader healthcare system.
Typically, AMCs have education, research, and clinical care as their core missions. In education, they’re beginning to bring an anti-racism lens to their approach; they’re diversifying their student body and are providing financial assistance to people of color. In the research mission, we’re seeing more authentic efforts to achieve diversity in clinical trials as well as efforts to increase community involvement in research design. In care delivery, we’re seeing organizations starting to embed equity measures into their quality improvement efforts. In the report’s appendix, you’ll see several examples; (Henry Ford Health System is a great example). Their efforts started in 2008, so this has been ongoing for some time.
How does an equity lens change how analytics is executed?
There are two lenses. There’s basic data analytics, and then there’s AI and machine learning. In terms of the basic data analytics, what we’re seeing is that organizations are recognizing the need to collect “real” data—race, ethnicity, and language. And there are a few issues there. First, there have to be appropriate data collection tools to sufficiently address the diversity of the patient population—so, making sure there are appropriate data fields involved is an important first step. And second, making sure providers are comfortable soliciting the information from patients by clarifying how the data will be used and making sure there are protections. So, there’s a data collection piece that a lot of organizations are working on. On the analytics front, we must look at access and outcomes, followed by the typical data questions on quality then stratify them by race and ethnicity to make sure that care is delivered equitably while addressing patient disparities in experience and outcomes.
Yes, if you could please speak to the AI and machine learning element, that would be great.
This is an area that’s under development in terms of health equity. The goal of AI and machine learning is to train computers to identify emerging diseases and address patients’ specific needs. With respect to health equities, we must consider how you make sure that those underlying data sets are representative. I’ve just read an article referencing that some algorithms are resulting in false negatives and false positives within communities of color. For instance, with regard to kidney function, the eGFR calculation is race-adjusted [the estimated glomerular filtration rate test is a blood test that measures how well a person’s kidneys filter waste from their blood and how well their kidneys are functioning]. If Black people and white people have the same result, the racial adjustment to that score essentially puts the Black person at lower risk and therefore they are likely to be under-treated.
In analytics, the other trend that we’re seeing is health systems looking into tools to screen for SDOH. So there are screening tools being built into the EMR; and then there are tools to connect providers to community-based services. We’re seeing that as another major trend in the IT/analytics space.
What can informatics and clinician leaders do to show leadership and move us forward, around racial and social equity?
There are a few things. One is helping the organization understand the current state of its data collection, review and analysis processes. And another trend I should mention is that we’re starting to see external tools being developed around health equity measures. They’re imperfect, but equity is being added as a measure of quality. In its quality evaluation of hospitals, U.S. News & World Report is now adding equity as a measure. As a result, hospitals need to understand how their organization is doing on health equity, on disparities in access and outcomes--that’s an important role. This process involves bringing an equity lens into developing clinical decision support tools. I think it will be very important to your audience to bring other voices to the table. That might feel uncomfortable or different at first, but it will be important to bring an equity lens to this.
Would you agree that it will be important to bring into the discussion people of color and other people who grew up in marginalized communities, would help?
Yes, I think so. I think having those diverse voices at the table will bring lived experience to the discussion. I think the broader organization also has a responsibility to get training, including around implicit bias, which is probably not something within their immediate wheelhouse.
How do you see the next five years, in terms of the subjects we’ve just zeroed in on?
I would hope that a lot more transparency will come into analytics, especially in terms of outcomes. I also hope that there will be ways to show results around equitable access to care and reduced disparities, as well as more documentation of equitable care delivery as a result of these efforts. I also hope at that time that AI and machine learning will have advanced enough so they’re not reinforcing disparities, but rather advancing healthcare for all.
Is there anything you’d like to add?
Just to reinforce, the healthcare informaticists in your audience play a really important role in this space in terms of shedding light on disparities in access to care and outcomes, and in helping the healthcare system to address those issues. There are a couple of case studies highlighting the important role they play in this process, namely at Northwell Hospital and Vanderbilt, where they have particularly focused on data and analytics. I also want to emphasize that broadband access and telehealth are important, especially as telehealth becomes a more prominent form of care delivery, equitable access to broadband will be so important.
