The dissemination of electronic health records (EHRs) to about 84% of non-federal acute care hospitals as of 2015 has brought clinical care in the United States into the 21st century.1 Uptake in ambulatory care practices is estimated at 86.9% for any system, but 53.9% use a basic system and 73% do not use the EHR technologies to their full capability.2,3 The transition to EHRs was frequently experienced as a painful one by most clinicians and created new challenges as well as opportunities in health care. Incorporating modern information systems into an ambulatory care practice has the potential to guide population-based health care to maximize access, comprehensiveness, coordination, and quality. This opportunity remains the siren call of EHR and health information technology (health IT) overall, as clinicians, patients, and systems reflect on how to adapt and leverage tools in a new world workflow.
Health IT has tremendous potential for promoting health equity for racial and ethnic minorities as well as other disparity populations, although many have feared that disparities could be exacerbated by the new technology.4 Health IT tools such as EHRs, patient portals, patient-monitored health behaviors, and clinical decision support (CDS) systems may yield population health benefits for underserved populations by enhancing patient engagement, improving implementation of clinical guidelines, promoting patient safety, and reducing adverse outcomes. EHRs should provide a platform for improved documentation of social determinants of health using standardized terminology and methods of ascertainment. Availability of real time actionable patient data, clinical care coordination, and decision support enabled by health IT tools may also reduce disparities in quality of care for underserved populations.
The most vulnerable patients with multiple chronic diseases often experience a greater burden of navigating the health system, adhering to multiple medications, and keeping appointments, resulting in signs of poor management. In the context of financial reimbursement for better quality, patients with these characteristics may be perceived as less desirable and lead to an intentional or subconscious effort to “cherry-pick” in order to improve quality within a clinical practice. However, this need not be the reality. Better clinical care coordination via health IT could improve clinician performance and adherence to clinical guidelines, reduce redundant testing due to clinician biases, detect treatment risks, and thus consequently facilitate more equitable treatment for underserved populations. In order to achieve this goal, clinical systems need to approach population health with clear targets for care, coordinate continuously with individual clinicians on their panel, and address the issues that high-risk, nonadherent or otherwise poor outcome patients present.
HEALTH IT AND HEALTH DISPARITIES
Although health IT holds much promise for reducing disparities in underserved populations by facilitating behavior change and improving quality of health care services and health outcomes, few studies have examined the impact of health IT adoption on racial/ethnic disparities in outcomes.5 In fact, the federal health IT strategic plan 2015–20206 calls for research evidence on how health IT can reduce disparities in the quality, accessibility, and safety of health care and long-term support services. Limited studies indicate that health IT investment can reduce disparities in process of care and care standardization.7,8 One consideration is to create a quality measure of health equity by which clinical systems would be evaluated and compared. In other words, how effective is a health system in providing the highest quality of care to its most vulnerable patients defined by demographic, social and/or clinical criteria? This would potentially be incorporated into standard metrics used by professional organizations and included in a clinical system “report card” like rates of cancer screening, childhood immunizations, and medication reconciliation.
Attention to unintended consequences associated with the use of health IT needs to be monitored to ensure health disparities are not inadvertently exacerbated. Uptake of new technology among race and ethnic minorities in comparison to Whites is mixed. Specifically, recent data indicate that African Americans and Latinos have a higher rate of use of mobile technology than their White counterparts.9 However, evidence for uptake of patient portals in the EHRs that use them show a pattern where race and ethnic minorities lag behind Whites in obtaining access. Once access is established, minorities and persons of less privileged socioeconomic status are just as likely to utilize the tools and options within a patient portal EHR.10 Research is needed to investigate the potential unintended consequences of health technologies such as identifying barriers that prevent the uptake and engagement with EHRs by medically underserved patients, develop effective approaches and models to deliver CDS in safety net clinical settings, and implement and evaluate the best models for the inclusion and utility of social determinants of health in order to advance health equity for racial and ethnic populations.
POPULATION HEALTH AS A PATH TO HEALTH EQUITY
To date the US health system has not emphasized the development of population-based health care built upon high-functioning primary care. From our perspective, this transformation is an essential step to address health equity in all patients. For example, it has been shown that elevation of systolic blood pressure ≥140/90 mm Hg in an African American person age 45–64 carries a hazard ratio of 2.38 compared with a White counterpart with identical blood pressure.11 Despite this knowledge, national Medicare data indicate that African Americans (and other race and ethnic minorities) are less likely to have their hypertension controlled compared with Whites.12 Yet, a staff model health maintenance organization system implemented population-based management of its patients with hypertension and demonstrated that over 80% were controlled without disparities with a multilevel intervention including clinicians, patients, and system.13 There is a clear gap between knowledge of what is needed and implementation that can only be addressed by high-quality EHRs and systems coordination.
Research is needed to explore the contributions of health IT in a variety of clinical settings including the patient-centered medical home and safety net clinics. Health IT tools are vital to the success of the patient-centered medical home innovation effort, which holds promise for achieving the triple aim of improved population health, lower costs, and better patient experiences in health care. Clinical data from patient registries can help clinicians identify gaps in care and opportunities for outreach. EHRs should facilitate teamwork to ensure key test results are managed and care gaps of patients are addressed. Evidence-based solutions are also called for in low resource primary care practice settings where the potential benefits of health IT are greater given the challenges to utilize EHR systems for quality improvement of care processes. Health IT tools can also be instrumental in improving the coordination and quality of care of complex chronic diseases especially in primary care settings that serve health disparity populations with a disproportionate burden of chronic diseases and limited access to subspecialty services. For example, early treatment of chronic kidney disease may be suboptimal in primary care, but emerging evidence indicates that the use of electronic registries to enable guideline-concordant care of chronic kidney disease improves quality.14 Future research is needed to explore the potential of decision support tools and new technologies such as artificial intelligence and natural language processing on EHR platforms to improve health outcomes for complex chronic diseases.
HEALTH IT AND PATIENT-CLINICIAN COMMUNICATION
The complexities of patient-clinician communication in the era of EHRs are in need of rigorous research, especially in settings caring for diverse vulnerable populations with chronic disease. The documentation burden faced by clinicians is driven by the need to include multiple components for adequate billing and forces numerous clicks to navigate the system. The consequences are less eye contact with patients, more limited time for patient-initiated conversation, and increased real or perceived communication barriers during the 20-minute medical encounter. This context may further augment health disparities via decreased patient participation in information exchange, developing a therapeutic and trusting relationship, and implementing shared decision making. The availability of accurate and complete past medical records, all test results, visits to other clinicians, and electronic reminders of recommended preventive tests has the potential to become information overload that adds stress to the patient-clinician relationship as opposed to enhancing outstanding care. Patients of safety net clinics often face challenges of limited digital and health literacy, and/or English proficiency, that often impede their ability to efficiently navigate the health system, use patient portals and communicate with staff. This disparity in usability of patient health portals raises the concern that a “digital divide” may exclude the most vulnerable patients from the benefits of portal use in EHRs both in primary care and specialty settings.
HEALTH IT AND SOCIAL DETERMINANTS OF HEALTH
The inclusion of social determinants of health in EHRs is critical for advancing population health equity. Research is needed to explore the optimal approaches of collecting and integrating basic social determinants of health to effectively guide clinical care, promote the development of trust in patient-clinician relationships and increase shared decision making between physicians and patients.15 Selected clinically relevant measures of social determinants of health that are not reliably obtained in clinical care include self-reported race and ethnic identity, country or geographic area of origin, years of formal education, type of employment, income category, family background, health literacy, numeracy, debt, food security, housing security, neighborhood environment, access to transportation, public safety, walkability, access to parks, access to full-service food markets, and residential segregation.
Advances in big data, geospatial technology, and public access to large data sets that provide contextual information also make it feasible to embed community level geocoded data into EHRs as an alternative to or complementary to patient derived data. Having this geocoded data readily available would allow health care teams to see, for example, if patients live in a high poverty area and have access to healthy food sources and walkable streets, and how these resources (or lack thereof) predict increased risks for adverse health outcomes and impact treatment adherence. CDS tools could provide alerts to health care teams of patients who would benefit from targeted preventive or therapeutic interventions based on a community level predictor (eg, high unemployment) or public health concern. In addition, individual perception of community level metrics such as perceived safety, access to healthy food and community cohesion, may be utilized in a similar manner.
FUTURE DIRECTIONS OF HEALTH IT TO ADDRESS MINORITY HEALTH AND HEALTH DISPARITIES
Clinicians and systems need to redesign work flows to overcome the burdens and barriers that have surfaced in the implementation of EHRs in health care settings. The potential for leveraging the tools inherent in EHRs to improve minority health, decrease disparities and promote health equity exists now. System adaptation to enhance use of patient proxies to engage portals, touch screen technology to enter data, or educational videos with text and sound, for example, would be applicable to patients who are cognitively impaired or have limited English proficiency or limited health literacy. Scripted video doctor communication for specific clinical situations in the patient’s preferred language can be developed, archived and updated as needed.
Expansion of patient derived data from what we obtain in an office visit or through diagnostic tests is also feasible. Wearable devices to monitor blood pressure, mood, and glucose are being used now, but how this technology can be leveraged to promote health equity has not been a priority. Access to specialists within the same urban center or to remote rural areas can be a special barrier for patients with no or limited insurance or because of other factors that make navigation of systems a challenge. Tele-medicine consults and electronic consultations from clinician to clinician can be implemented to decrease these barriers and improve quality of care. Technology has already facilitated access to interpreters through videoconferencing and health systems have also used electronic consults to improve care.
The goal of the National Institute on Minority Health and Health Disparities is to promote scientific discovery in an America where all persons have the same opportunity to live a long and healthy life. The routine clinical encounter is an excellent setting to conduct research to improve minority health and decrease health disparities. The EHR has changed the processes of clinical care, and the opportunity to leverage these technological changes to promote health equity is here for the taking.
3. Rumball-Smith J, Shekelle P, Damberg CL. Electronic health record “super-users” and under-users” in ambulatory care practices. Am J Managed Care. 2018;24:26–31.
4. Weiss D, Rydland HT, Øversveen E, et al. Innovative technologies and social inequalities in health: a scoping review of the literature. PLoS One. 2018;13:4.
5. Lee J. The impact of health information technology on disparity of process of care. Int J Equity Health. 2015;14:34.
7. Blumenthal D. Stimulating the adoption of health information technology. New Engl J Med. 2009;9:1477–1479.
8. Jha A, DesRoches C, Campbell E, et al. Use of electronic health records in US Hospitals. N Engl J Med. 2009;360:1628–1638.
10. Graetz I, Gordon N, Fung V, et al. The digital divide and patient portals: internet access explained differences in patient portal use for secure messaging by age, race, and income. Med Care. 2016;54:772–779.
11. Howard G, Lackland DT, Kleindorfer DO, et al. Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med. 2013;173:46–51.
12. Ayanian JZ, Landon BE, Newhouse JP, et al. Racial and ethnic disparities among enrollees in Medicare Advantage plans. N Engl J Med. 2014;371:2288–2297.
13. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699–705.
14. McBride D, Dohan D, Handley MA, et al. Developing a CKD registry in primary care: provider attitudes and input. Am J Kidney Dis. 2013;63:577–583.
15. Daniel H, Bornstein SS, Kane GC, for the Health and Public Policy Committee of the American College of Physicians. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians Position Paper. Ann Intern Med. 2018;168:577–578.