The COVID-19 pandemic has spurred a call for change in healthcare, where the economic and racial divides that have existed for decades came into the spotlight as the virus disproportionately affected people of color.
The Centers for Disease Control and Prevention (CDC) reported in November that COVID-19 mortality rates for Native Americans, Alaskan natives, African Americans and Latinos were more than double that of whites. Race and ethnicity are "risk markers" the CDC is surveilling to understand why COVID-19 affects some populations, such as older adults, more than others. And it's become clear that the pandemic is disproportionately affecting people of color and those of a lower socioeconomic status for reasons that are not just about health, but also about healthcare.
Indeed, the coronavirus pandemic has become a flashpoint in healthcare, laying bare the long-standing economic and racial disparities in patient care. The current generation of healthcare CIOs is not sitting idle but is, instead, working to get a deeper understanding of the issues and figuring out how the CIO role can help to make healthcare more accessible to underrepresented communities.
In his role as Penn State Health's CIO, Cletis Earle has felt that call to action. As someone who has been involved with and led diversity initiatives throughout his career, Earle has made himself available to healthcare employees and leaders who want to talk about how they can address economic and racial disparities in healthcare.
Earle tells them a good place to focus is to build trust with underrepresented communities, form community partnerships and provide access to better healthcare education. But eradicating economic and racial disparities in healthcare will also require systemic change -- something that can't be fixed overnight.
Economic, racial disparities in healthcare
COVID-19 has pulled back the curtain on racial and economic disparities in healthcare, an issue that has plagued it for decades, according to Eliseo Pérez-Stable, M.D., director of the National Institute on Minority Health and Health Disparities.
In the 1930s, the U.S. created a "chain reaction of activities and policies" that have perpetuated differences by race, such as residential segregation, that rippled through neighborhoods and schools, causing some areas to deteriorate and economic opportunity to depart, according to Pérez-Stable.
When COVID-19 came to the U.S. in early 2020, people of color were automatically more at risk because of gaps in education and wealth. In "COVID-19 and Racial/Ethnic Disparities," published in May 2020 in the online medical journal JAMA Network, Pérez-Stable, a co-author, assessed early COVID-19 data from residents in Chicago. He found that COVID-19 mortality rates were highest among Latinos and African Americans at 36 per 100,000 residents and 73 per 100,000 residents, respectively. The mortality rate of white residents was 22 per 100,000.
Race, income level, employment, underlying conditions and access to healthcare all play parts in contributing to differences in COVID-19 mortality rates. Underrepresented groups often work more jobs and take front-line roles, rather than quarantine at home and work remotely, thus increasing their risk, Pérez-Stable said.
"If you work in construction, you've got to go out; if you work in the supermarket, you've got to go out," he said. "Those professions are disproportionately represented by African Americans and Latinos to a large extent -- that's what made it so evident."
Indeed, roughly one-fourth of the U.S. adult population is college graduates and has grown in wealth and income, which Pérez-Stable said equates to more resources and better health. The top 20% to 25% have gotten "wealthier and healthier," but income for the bottom 75% to 80% have stagnated, which has affected their access to healthcare, he said.
"What COVID-19 has done, it has shone a light on inequalities that have existed for decades and that have actually worsened since 1980," he said. "If you look at the macro data of income and distribution and inequality, 1980 sort of marks a turning point of when the effort to decrease inequality, somehow those forces went the other way. We created more wealth for 20% of the population, and the rest of the population stood still or improved only slightly."
Forming partnerships and task forces
The issues of economic and racial disparity in healthcare are systemic, but there are things CIOs can do to reach out to underrepresented communities -- namely, building trust, forming partnerships and providing better education.
"We can no longer discard or discount education on health, because we see what that ended up doing to our society as a whole," Earle said of the COVID-19 pandemic's impact. "We're not taking care of these communities who continue to experience loss of unparalleled amounts."
Cletis EarleCIO, Penn State Health
In one example at a former organization, Earle led an initiative to donate the health system's old tablets to local schools after investing in new ones. By funneling those kinds of resources into communities, Earle said healthcare systems can work to make care more accessible through technology, an initiative that has taken on new meaning during the pandemic and the rise of telehealth.
In Atlanta, Piedmont Healthcare is also addressing economic and racial disparities that the public health crisis brought to the surface, according to CIO Geoffrey Brown.
One of the initial steps the healthcare system took was to form a COVID-19 task force to better understand the disparate impact of the pandemic on its communities of color.
The federal government is taking similar action. President Joe Biden signed an executive order establishing a COVID-19 Health Equity Task Force within the Department of Health and Human Services to provide recommendations on resource allocation, outreach and communication, and better data collection and use for minority communities.
Brown said the task force and tools such as telehealth make it easier to reach patients, providing a greater opportunity to serve the health system's underserved communities.
"With this new world of telehealth, now that we have the ability to connect more effectively with patients where they live and work, I think you're going to see this be a huge part of the future," he said.
Brown said the healthcare system has also developed community partnerships with local health systems and universities to conduct a broader and more thorough data analysis of how COVID-19 is affecting its communities. The partnership includes Georgia-based Grady Hospital, Emory University and WellStar Health System and was possible only because of required public health department submissions and relaxed regulations.
The collaboration has proved valuable for providing insights on effective COVID-19 therapies, according to Brown, but he said he believes it can also help Piedmont uncover social determinants in underrepresented communities that might not be otherwise known.
"We've seen the power of the larger data set, you can convert all that data into actionable activity and get it back to help the quality of life and treatment for patients," Brown said. "With the relaxation of rules, a lot of what I call 'middleware disturbance' and 'regulatory kinds of challenges' were put aside for the benefit of saving people's lives and helping them navigate through COVID-19. I don't think any of these bodies are going to want to see that go away."
Change within a health system
It's not only important to focus on how to bridge the racial and economic divide in healthcare, but it's also important to focus on diversity within the healthcare system itself, according to Pérez-Stable.
The U.S. population is roughly 32% to 34% African American, Latino, Native American and Pacific Islander, but only about 12% of doctors identify as such; women and people of color who become physicians provide more care for poor patients, uninsured patients, Medicaid patients and non-English speaking patients, Pérez-Stable said.
"To me, it's enough evidence to say we should be doing this as an intervention to decrease inequities," he said. "You train more clinicians from these groups because we have empiric evidence that they do more care for the underserved."
Pérez-Stable said the healthcare management structure parallels the wealth gap, meaning there are fewer people of color in healthcare management than whites -- an observation Earle has noticed as well.
"There has been an increase in Caucasian women representation, which is good," said Earle, a member of the College of Healthcare Information Management Executives. "What we haven't seen though, is that same level of increase in other types of diverse pools -- whether it's African Americans, Latinx, Southeast Asian -- there's not been what I would say is an equal distribution of senior leaders being developed."
He said he believes diversity initiatives at healthcare systems could go a long way if they included adoption of polices like the Rooney Rule, which requires at least one woman and one member of a minority community be considered for open positions, and he advocates for CIOs to participate in recruitment.
"We should take an active role in how we're looking at recruiting, take an active role in how we're taking the skills that we have and reaching into these diverse communities, whether it is racial, gender-based, sexual orientation, veterans, or even if you look at some socioeconomic components, looking at rural areas that have a huge disconnect when it comes to technology," he said. "Being able to bring together a collective program with your workforce to go into these communities and show there are different ways of doing things, we can start to cross-train some of our talents in those communities with technology initiatives."
Earle also advised healthcare organizations provide "safe spaces" where employees can discuss sensitive topics such as race and gender and that senior leaders of the organization conduct larger town halls to listen to employees' thoughts and ideas on how to build a diverse organization before taking action -- something Penn State Health has done, he said.
"I've talked a significant amount with different audiences about diversity in healthcare," he said. "I never imagined I would talk about this so much because I wouldn't say I am an expert -- we're all learning this together. What I have noticed though, what's resonating, is the fact that there is a need, there's a want, there is a desire for more people to understand how do we fix this, how do we make a change."