Why CMS' Health Tech Ecosystem needs a health equity mindset

Health tech ecosystems need to work for all patients

For as much promise as a Health Tech Ecosystem might have, there's a risk for deepening an already glaring digital divide.

"This is a CMS initiative, which is really important to remember because that means that this has to work for all people, especially for people who are Medicaid recipients, who are often left behind in these kinds of situations," Pollak said in an interview.

The digital divide has been a growing concern for healthcare's technology experts, as they lament the possibility of digital haves and have-nots. In some cases, the digital divide is regarded as a key social determinant of health. Certain factors like race, age, income and geographic location can drive the digital divide.

The CMS Health Tech Ecosystem can't be another wedge in the nation's exiting digital health disparities, Pollak said. Although there are promising guardrails in place, he still stressed the importance of considering the most vulnerable when designing the digital ecosystem of the future.

"CMS was explicit that this is all opt-in, that nobody is being forced to do this, but this is the future of healthcare, and I think that we want to design it for all people, not just the wealthier among the smartphone users and high-tech folks," Pollak remarked.

This will require the private sector partners involved in the project to carry their weight.

"I definitely agree with the position that the government has taken that they can't do this alone and this has to be a collaboration with the private sector, but we also know that the private sector doesn't have the greatest track record of doing things to benefit those underserved communities," Pollak noted. "So, I think there's a lot of work to do there."

The technologies available to patients must be affordable, usable and protect all patients, he added. And, in most cases, that starts with better digital health literacy.

Bolstering health literacy to prevent digital health disparities

The digital divide is in large part driven by income and geography. If you can't pay for digital devices or have access to the broadband that powers them, most digital health tools don't serve you.

But perhaps more pressing is limited health literacy that also gets in the way of patient tech adoption. Indeed, a 2023 Ohio State University report found that factors like English language proficiency and low health literacy are bigger drivers of the digital divide than access to devices or broadband.

That notion has to be front and center as healthcare moves forward with CMS' idea of a Health Tech Ecosystem, Pollak explained.

Part of the responsibility for better digital health literacy will be on app developers themselves.

"It's about developing applications that are very obvious and intentional about informing patients about their rights, about what is happening with their data, about who data might be shared with and making it really clear to them where they have choices to do those things and where they don't," Pollak noted.

Crafting language at the appropriate reading level, accounting for cultural competence where possible and providing explanations in multiple languages will be key.

"We don't need to be insulting or condescending to people, but at the same time, we also don't need to be writing end user agreements that are written by lawyers and only for lawyers," Pollak added.

There's also the possibility that conversational AI could help patients navigate a growing and complex health IT landscape. Admittedly more skeptical of AI than the average tech expert, Pollak posited that AI agents could answer patients' questions and fill in informational gaps at the appropriate health literacy level.

"When we get to the point where we're confident that the dialogue, results and information that AI are providing is, in fact, safe and good, that's going to be an area of huge advancement in terms of being able to meet people where they are and provide them with information that they can understand outside of the AI," Pollak noted.

But creating systems in which more patients can easily understand and utilize health information and IT might open another can of worms in terms of privacy and security. With more folks logging onto consumer health apps and moving their medical records between systems, Pollak cautioned that some populations might be taken advantage of.

Ensuring the poorest, sickest patients have secure IT tools

CMS said it wants an ecosystem of patient-facing apps to drive more patient empowerment and complement the health information patients have from their providers. The agency is starting with the obesity and diabetes spaces.

But free flow of information from the HIPAA-protected EHR and patient portal to a consumer-facing nutrition or fitness app can sometimes be cause for concern about patient privacy and data security. While there is some good work happening on the healthcare and consumer side of technology, the worries about patient privacy are very real, Pollak said.

Ensuring patient data is safe and protected -- and patients fully understand how their data's being used -- is a key area for exploration, Pollak stated, but the Health Tech Ecosystem needs guardrails to ensure the sickest users don't get exploited.

"We've heard from so many people that even today they're willing to upload their entire dataset to ChatGPT to get good results," he said, referencing folks with complex chronic illness or rare diseases.

"They're willing to trust third-party applications that they wouldn't otherwise because they're just so desperate to receive the best information that they can. And that is 100% understandable, but I also really hope we're not setting up a system that takes advantage of those situations."

There's also the question of wealth and income.

Many of apps have free and paid versions. According to Pollak, paid versions can have added privacy protections, which can benefit the rich and disadvantage the poor. He called on his peers to ensure all patients have the highest level of data protection, regardless of their ability to pay for advanced versions of an app.

For its part, The Commons Project will be working on free and privacy-protecting options for users, he added. But being that the Health Tech Ecosystem and Interoperability Framework that undergirds it rest on an industry pledge, Pollak said time can only tell how things will roll out, although he is optimistic.

Sara Heath has reported news related to patient engagement and health equity since 2015.