S1E39 Tech Equity (Ft. Dr. Cheryl Clark, Institute for Health Equity Research, Evaluation, and Policy)

Jordan Cooper 0:22
So, by way of background of our listeners, the Institute supports emancipatory research which aims to ensure that science benefits communities who bear the greatest human cost of longstanding health and equities.

Jordan Cooper 0:34
Working alongside 52 community health centers across Massachusetts, more than 1,000,000 patients, they served the construct a new base of research knowledge to better address health disparities.

Jordan Cooper 0:44
And today, Cheryl, the institute's inaugural executive director, will be discussing the need for a data driven approach to help equity and public health, masturbatory research and widespread community collaboration to address health inequities.

Jordan Cooper 0:58
So let's get right into it.

Jordan Cooper 1:00
We're gonna start with a conversation on technology, which is defined as a strategic development and deployment of the technology and healthcare and health to achieve HealthEquity and it's divided into 4 areas, workforce diversity, data trust, equity dashboards and transparent AI.

Jordan Cooper 1:17
So Cheryl, like to turn it on over to you, please.

Jordan Cooper 1:20
What would you?

Jordan Cooper 1:21
What are you working on with tech equity?

Jordan Cooper 1:23
Why is it important?

Jordan Cooper 1:24
What is it?

Jordan Cooper 1:25
Where are we today?

Cheryl Clark 1:26
Fantastic.

Cheryl Clark 1:27
Thank you so much for having me.

Cheryl Clark 1:28
And you know, I would say I'm really excited for this conversation.

Cheryl Clark 1:32
I don't think that equity, I think it's it's more known you know now during the pandemic everyone starting to think a little bit more about fairness and bias in the way that we think about our data.

Cheryl Clark 1:44
But it's kind of an uncommon conversation, and so I'm really looking forward thing.

Cheryl Clark 1:50
The other thing that I would say is I'm so excited to be here.

Cheryl Clark 1:54
I'm at the real beginning of other work that we're doing with the HealthEquity Institute, part of why the Institute was established is this truck to have these conversations which need to happen and into disciplinary circles and another sort of a bit of news, the institute work happens within what are called community health centers.

Cheryl Clark 2:19
As you mentioned, we working for in Massachusetts working alongside 52 Community health centers that are that are serving patients across the state of Massachusetts, sort of almost a million sort of folks who in many cases are have low incomes.

Cheryl Clark 2:41
So 83% are at 200% of the poverty level, or local work.

Cheryl Clark 2:47
And so it's really an opportunity to make sure that as we are thinking about what are the next steps for making sure that we close the gap along the lines of income along the lines of race, ethnicity, other issues, how do we make sure that we're doing that work in partnership with to the Community Health Center movement, which really had its genesis in civil rights movement.

Cheryl Clark 3:13
It was established in places like Mississippi and actually in Boston, not far from where I'm sitting today in a a neighborhood called Dorchester.

Cheryl Clark 3:21
Those were the two initial community health centers that were put in place in many ways to overcome segregation and to provide a place for people to get healthcare, irrespective of their ability to pay.

Cheryl Clark 3:33
And now there are hundreds of community health centers in every state, and there's also an overarching body called the National Association of Community.

Cheryl Clark 3:46
The exciting news is that the news director of Mac, the National Association of Community Health Centers, the CEO, is a physician named Dr Q3, and Doctor Reed has had a storage career on his work in government, has worked in industry.

Cheryl Clark 4:03
IBM.

Cheryl Clark 4:04
Yeah.

Cheryl Clark 4:05
And is now the head of of that and he is the architect.

Jordan Cooper 4:12
And.

Cheryl Clark 4:12
And so the yeah. Uh.

Jordan Cooper 4:15
So so I know that you're working on emancipatory research, and as it relates to structural racism, I was wondering, you know, I think many of our listeners have heard about this, but aren't exactly sure how Germany it is to the operations and their large health systems.

Jordan Cooper 4:30
What are some of the issues that you've been working on to address?

Cheryl Clark 4:34
Absolutely.

Cheryl Clark 4:34
I want to tell you a little bit about equity before, but I had to sort of give you that preamble to to kind of give you a bit of understanding of where we've come with this.

Jordan Cooper 4:47
Umm.

Jordan Cooper 4:56
Umm.

Cheryl Clark 4:43
But I do want it to describe idea of equity, and let's talk about and that's related, you know, so that the equity principles and wanted to give complete and do credit to queue to queue Reid for for sort of defining that and there are really 4 principles and I think this is where the conversation is uncommon.

Cheryl Clark 5:04
You know, as you think about sort of what you need to make sure that the data that we use to make decisions about health, all that needs to have at least a couple of things.

Cheryl Clark 5:15
So one is workforce diversity.

Jordan Cooper 5:18
Umm.

Cheryl Clark 5:18
You know the idea behind that is that the work that we do needs to be multidisciplinary.

Cheryl Clark 5:23
You know it needs to make sure that we have lots of perspectives.

Cheryl Clark 5:27
I will give you an example there.

Cheryl Clark 5:31
There's a sort of a famous paper.

Cheryl Clark 5:32
And many folks who you are in the field may have heard about this, but there's a paper that came out in science a couple years ago and part of what we need to do in population health.

Cheryl Clark 5:44
We're trying to make sure that people get the best care that they get nursing when they need it.

Cheryl Clark 5:49
Is that you have to build algorithms to try to figure out who needs that care in a large sort of hair system.

Cheryl Clark 6:00
The models were trained on cost so that you know people who cost the health system a lot would get referred to care in order to reduce those costs.

Cheryl Clark 6:10
And that makes sense, unless you have the sense that cost and health are really different things.

Cheryl Clark 6:18
What it wound up doing was introducing bias so that people who were African Americans and others who tend to use less care but who are sick weren't getting referred for care.

Cheryl Clark 6:29
And so part of what we need to do if we want to make technology so equity in in sort of technology a reality is making sure that we have plenty of expertise that we get diverse perspectives and that all that's a part of it.

Cheryl Clark 6:44
The other thing that I'll sort of I'll conclude before we start talking a little bit about emancipatory research is this idea of transparent AI.

Cheryl Clark 6:53
I want to make sure that folks have heard about a study, just the preliminary information has been posted online that looks at large language models and when the there's a collaboration between folks at UCSF and Harvard.

Cheryl Clark 7:09
Uh put, um, uh.

Cheryl Clark 7:11
Basically, stories.

Cheryl Clark 7:13
Uh patient narratives and worked with large language models to do that.

Cheryl Clark 7:19
There had already been so much training that a lot of the output had a lot of stereotypes, so that, for example, the majority of cases around a condition, a medical condition called sarcoid, it does tend to disproportionately affect, you know, African American women.

Cheryl Clark 7:38
But all the cases were listed that way.

Cheryl Clark 7:40
So if we want to achieve technically, we really have to do a lot more making sure that we work together and that is why we need emancipatory research.

Jordan Cooper 7:55
Umm.

Cheryl Clark 7:51
Um, the second question that you asked me is sort of, you know, what are we working on and how do we are we about that and you know part of what we mean when we say in math material search is do you think one is that you know we need to give ourselves accountable for actually trying to to solve these problems around an.

Cheryl Clark 8:10
And the second is that we need to create space and community for people who have that lived experience to come together with experts.

Cheryl Clark 8:17
We need to invest in communities and actually do the work where the implementation and I'll give you one last piece around me just to kind of make it clear of a lot of health service does just describe, you know, differences between, umm, part of what, uh, we we talk about a lot.

Cheryl Clark 8:42
It's just the fact that women in the United States and black women in particular, I happen to identify as being African American, not die.

Cheryl Clark 8:50
You know, at greater rates than other people.

Cheryl Clark 8:53
And that our babies are smaller and issues.

Cheryl Clark 8:58
I think the stats are like, you know, three times the risk for African American women than than others, like a thread of like 69400 thousand.

Cheryl Clark 9:08
But that doesn't mean a whole lot when it's you.

Cheryl Clark 9:11
And it was me and I told the story.

Cheryl Clark 9:16
Sometimes it's just kind of cathartic just to kind of get it out there, but it also is instructed umm, in many ways of my I am a an addition to being a DOC and SVP and all those titles.

Cheryl Clark 9:29
I'm also a mom, and both of my kids were born on small and you. Really.

Cheryl Clark 9:35
I got, you know, create healthcare, you know, great.

Cheryl Clark 9:38
You know, attention to detail and we just didn't have a lot on the office.

Cheryl Clark 9:43
I wound up being OK and my kids are running around, so we're very lucky, but they were born early and small and we don't really know why.

Cheryl Clark 9:52
So part of what we mean when we say mandatory research is that we're taking this lived experience.

Cheryl Clark 9:59
You know my experience, experience of folks who you have these outcomes and we're trying to move ourselves, account pushing me off selecting the information that we need to try to understand these issues a bit better and to implement where they are.

Cheryl Clark 10:15
Yeah.

Jordan Cooper 10:14
Umm well, thank thank you for sharing those examples.

Jordan Cooper 10:18
I think we you covered a lot of interesting ground.

Jordan Cooper 10:21
I certainly was unaware of, well, umm, I guess some of the I was unaware about the the uncommon uh equity.

Jordan Cooper 10:34
Well, I wanna.

Jordan Cooper 10:34
I wanna talk actually about your particular example.

Cheryl Clark 10:42
There really you.

Jordan Cooper 10:36
Right now you just mentioned that you gave birth to two to your children who were small.

Jordan Cooper 10:44
They were born early and they're small.

Jordan Cooper 10:46
I'm wondering if you're suggesting that the reason that they're born premature is because of your race.

Jordan Cooper 10:53
Is that what you were suggesting?

Cheryl Clark 10:55
I don't think though, so that is what's really interesting about this is that we know that women who are African American or anything increased risk, right.

Cheryl Clark 11:07
And it's hard to figure out why that might be so.

Cheryl Clark 11:10
There are earlier data that actually look at women who, for example, are immigrants.

Jordan Cooper 11:17
Umm.

Cheryl Clark 11:17
You know who?

Cheryl Clark 11:18
Same sort of label.

Jordan Cooper 11:21
Umm.

Cheryl Clark 11:20
You know the same sort of ethnic label or whatever it is.

Cheryl Clark 11:23
And they don't have that issue.

Cheryl Clark 11:24
It's really women who've grown up and are in the United States.

Jordan Cooper 11:35
Umm.

Jordan Cooper 11:42
Mm-hmm.

Cheryl Clark 11:28
And so I think it's it's uncommon and again you know something that we're all getting more comfortable talking about, but it there is something about the experience we talk about structural racism, this idea that our societies are really are structured on inequity and that there must be something there.

Cheryl Clark 11:50
But it's we have to go further.

Cheryl Clark 11:52
We have to push ourselves to try to understand what is it.

Cheryl Clark 11:55
You know what's going on?

Cheryl Clark 11:57
I'll be honest with you.

Cheryl Clark 11:58
You know, it's a I had really well meaning colleagues and friends while I was pregnant, you know, discussing these issues with me.

Cheryl Clark 12:06
But I want IT solutions you know as I was seeing my, you know, my older, you know little one like the numbers it's not looking as great.

Jordan Cooper 12:15
Uh-huh.

Cheryl Clark 12:14
I wanted I wanted sense.

Cheryl Clark 12:17
I wanted something to do, so I think that we need to have the data.

Cheryl Clark 12:21
That helps helps us to think about prevention, but we also need a community to start thinking about, you know, what the what the solutions are, where we can actually implement those solutions and that's what we mean when we say in master Jordan.

Jordan Cooper 12:35
You you mentioned something interesting when you were talking about workforce diversity, about how there's biases built into algorithms based on payer data.

Jordan Cooper 12:44
For example, African Americans were sick and in need of care but weren't getting it.

Jordan Cooper 12:50
Therefore, they weren't as expensive, and therefore we're not getting the referrals they needed.

Jordan Cooper 12:55
I think that's an interesting example of.

Jordan Cooper 12:58
I guess bias is correlated with race and algorithms, as wondering if you can provide a concrete example, have structural racism in large healthcare delivery systems because many of our listeners are are associated affiliated with large healthcare delivery systems and maybe asking themselves right now.

Jordan Cooper 13:18
Well, what can they do to improve equity in their own institutions?

Cheryl Clark 13:22
Yeah, I have to say.

Cheryl Clark 13:23
And this is where we have to take a hard look at some of our practices.

Cheryl Clark 13:29
I am really enjoying getting a lot more into the history of inequities and really thinking about the history of community health centers and how folks like Aaron Shirley.

Cheryl Clark 13:45
You know, for example, physician who worked with Robert Smith to found the Community Health Center movement along with other physicians and how much they really work to to put policies in place that ended segregation, the ways that we are noticing now that care gets aggregated or really financial instruments.

Cheryl Clark 14:08
We have to have very difficult conversations about prior prior approval processes.

Cheryl Clark 14:14
You know what is it that we need to do to streamline this so that people so that we give the kind of care that people need, we have to have really, you know, hard conversations about how we want to provide uh financial instruments care.

Cheryl Clark 14:33
And there's still a 10 states that happened, expanded Medicaid.

Jordan Cooper 14:52
Umm.

Cheryl Clark 14:36
So as we think about what this looks like, structural racism is a broad term, but has really specific mechanism and a lot of them seem like really routine everyday, you know, natural parts of society, but they have disproportionate impact.

Cheryl Clark 14:54
So if we want to see just our neighbors, our friends just have the kind of healthcare that we need, we have to take a look at things that we think are.

Cheryl Clark 15:04
Yeah.

Cheryl Clark 15:04
And look at their impact and and make those kind of change.

Jordan Cooper 15:09
So I think many of our listeners are listening to this episode right now, maybe familiar with the idea that indigency is inversely correlated with health and a population level.

Jordan Cooper 15:23
I think what maybe worth delving further into is how to improve the health of minority populations who are indigent compared to Caucasian members of the population who are also indigent.

Jordan Cooper 15:40
So kind of controlling for socioeconomic status and trying to get at the structural racism that I believe is the focus of your research.

Cheryl Clark 15:50
Yeah.

Cheryl Clark 15:51
That's, umm, I.

Cheryl Clark 15:52
That's really, I think an important point and what I would say is that at that's also a part of what we think about when we talk about sort of emancipatory research that we need to establish sort of high priority population.

Cheryl Clark 16:08
So that when we think about people who have been traditionally disadvantaged, you know, how do we think about conducting research that's really centered on those priorities?

Cheryl Clark 16:20
Part of what I find interesting and exciting is the fact that we're now thinking a lot more about this term called social determinants of health or social drivers of health and learning how to connect and collect those data.

Cheryl Clark 16:35
I am excited about a project it's been some years now that we did with uh, a Community health centers that are affiliated with the Brigham and Women's Hospital and my colleagues there helped to drive processes to try to do a full screen.

Cheryl Clark 16:52
So asking patients questions about their social issues or their housing, their transportation, and then creating a scope of work and referring people for sure.

Cheryl Clark 17:04
And we did that as a part of the early phase of account care organization implementation, Medicaid better in our state and we're able to find that so many of our patients.

Cheryl Clark 17:16
And this was in a community Health Center that was really geared to serve high priority patients that have that do have low income, but 75% of them had some sort of social issue and we were able to collect those data and we've been able to sort of track over time how that uh, it's weird with health care.

Cheryl Clark 17:36
You then of care.

Cheryl Clark 17:38
And so part of what we need to do is to minute to collecting data, you know, at point of care that matters to people and then putting services into place and building networks and connections.

Cheryl Clark 17:52
I will say two of the connections that I feel I'm really excited about.

Cheryl Clark 17:57
We worked closely with an agency that has wrapped around services housing security, not to provide a case management and to provide a not to sort of housing rural, but also digging underneath and helping to support that people to figure out what some of those barriers are to being able to to increase their their ability to access housing.

Cheryl Clark 18:23
And also we had our hospital have a a system of care for people who are also victimize victims of who are survivors of intimate.

Cheryl Clark 18:36
So part of what I think what you're saying is what I would recommend is just have to they really dig in to this idea of social determinants and social drivers and and do a lot more around.

Jordan Cooper 18:55
Uh-huh.

Jordan Cooper 18:55
So I think and and by the way for our listeners who aren't aware, I believe Cheryl was just referring to something called the all of US Research program on social determinants of health task force.

Jordan Cooper 19:08
For there were 60,000 surveys that were completed to map, for example, the prevalence of obesity in America, and I think that's interesting insights, which you basically said.

Jordan Cooper 19:18
There's a variety of social determinants of health.

Jordan Cooper 19:20
I think I remember learning that health for an individual is composed of is affected only.

Jordan Cooper 19:28
I think by about 20%, by getting access to health care and the rest were are is affected by genetics, behavior and social economic determinants of health.

Jordan Cooper 19:39
And I think focusing on those non care related issues is what I hear you saying has been improving equity I guess to wrap up this conversation because we're approaching the end of this episode like to ask you a final question.

Jordan Cooper 19:53
So suppose that right now you're speaking to the Chief Information officer of a large healthcare delivery system.

Jordan Cooper 19:59
What sort of information?

Jordan Cooper 20:01
What sort of action is needed in order to address some of these socioeconomic drivers of health, particularly from the perspective of a health care delivery system?

Jordan Cooper 20:12
I know you mentioned a CEO's accountable care.

Jordan Cooper 20:14
We're animations, Medicaid, managed care organizations, some risk sharing, you mentioned payers and providers meeting together.

Jordan Cooper 20:21
Where is there the financial incentive and or perhaps where is there an action that can be taken by provider networks where that would be justified financially that could help address HealthEquity and improve health outcomes for minority populations?

Cheryl Clark 20:35
Absolutely.

Cheryl Clark 20:36
I would say, UM, if there were one action that health systems can take is to invest in the ways that we prioritize primary care, that we invest in, making sure that people can access and get into care, and that while we have our patients and that we're doing this, that we also invest in systems to partner with organizations that can help us to address these broader concerns around social drivers or social.

Cheryl Clark 21:09
It's been interesting to sort of see the field evolved so much.

Cheryl Clark 21:14
There's so many different ways of kind of getting data of using other strategies to to sort of understand social determinants, but I would say that a really important way to invest is also just making sure that we connect with people that we ask about the kinds of questions that are that are important to our population.

Cheryl Clark 21:35
So hopefully I think as this field of all will find the right balance, but making that commitment to addressing social drivers and care is.

Jordan Cooper 21:49
Well, thank you, Cheryl very much for our listeners.

Jordan Cooper 21:51
This has been doctor Cheryl Clark, the executive director and Senior VP of the Massachusetts League of Community Health Centers Institute for HealthEquity Research, evaluation and policy.

Jordan Cooper 22:01
Cheryl, I'd like to thank you very much for joining us today.