via George Timmins
As health disparities continue to widen, an important area of innovation for improving the health system rests in the integration of community-based service providers and educators, such as community health workers (CHW). A CHW acts as a trusted messenger bidirectionally communicating and educating from the provider to the community and vice versa. CHWs have been shown to be both cost-effective and integral towards the goal of addressing racial, ethnic and socioeconomic health disparities (Koniak-Griffin, et al. 2015; Barnett, et al., 2018; Cosgrove, et al., 2014). Electronic Health Records (EHRs) represent a critical backbone of infrastructure for the health system and a driver of potential health systems change as noted by the inclusion of clinical guidance systems, the usage of EHRs for billing and utilization measurement, and the centrality of its use into the fabric of all healthcare encounters. In order to increase the efficacy of CHWs across the healthcare systems, advocates for CHWs have called for CHW access and utilization of EHRs. This type of major health system reform requires collaboration between various stakeholders as the utilization and development of the EHR is shared across multiple levels of power and multiple sectors within the health care ecosystem. To explore early designs and challenges to develop a more equitable and CHW-focused EHR system, I decided to start from the stakeholders involved and map how they currently interact with the systems in place to then consider those most critical to involve for change in the long-run and for the design and implementation of early ideas for such a system. This is critical to view as the healthcare system continues its reforms to become more cost-effective and equitable in the wake of the continued syndemics of COVID-19, structural racism, and substance use.
To begin to understand how this may be operationalized, I undertook a rapid prototyping stakeholder analysis of EHR utilization including metric design, data collection, data pulling and data analysis, as shown in Figure 1. Within this analysis, several key findings emerged that underscored a larger power analysis of the critical players in setting the stage of potential data and those who then become the actual users of these data sources and clinical tools. To complete the stakeholder analysis, I first created a system diagram of the stakeholders utilizing the EHR and the ways in which they input and output data. The system was then translated into a matrix of stakeholders and the type of data they input or output as well as the frequency of those data activities. This was color-coded to be able to best visualize the most important intersections for potential visualization or improvement and the stakeholders most critical for reform efforts. This showed that clinical providers and allied health providers, such as potential CHWs, social workers, care managers, etc. were the most frequent users of EHR data both to input and glean information from. Then, when looking at the stakeholders who are most active in reforming or changing EHRs in the past, one notes that while the input of providers has been utilized, the direction on improvements for the systems come most frequently from those directly supporting the EHR industry such as payers and government agencies.
This apparent conflict of expertise and political power directly impacts the kinds of outcomes and processes that are prioritized for EHR system design and impact the ability of providers to best support their patients. In addition, these conflicts can impact the potential innovations created for example, while many in the health services field have pushed for greater integration of direct patient insight into the health system, uptake of patient portals or direct EHR access has been slow to stagnant. These important innovations could help to improve the quality of care and lead to better health outcomes but until the most knowledgeable experts in utilizing the EHR, the providers and allied providers, are at the forefront of EHR reform, the chances of improvement continue to be limited. This is noted by continual published and anecdotal accounts of provider distrust and frustration with the complex workflows, increasing pop-ups and illogical data systems. Through increased feedback and provider-patient-partnered research and design approaches, EHR reform that prioritizes clarity, safety and high quality data and clinical guidance can allow for universal improvement in patient outcomes and provider well-being.
Figure 1. Rapid Stakeholder Analysis of Potential Data Metrics and Activities by Stakeholder with color coded temporality of needed access for stakeholder to the EHR for said metric/activity
Barnett, M. L., A. Gonzalez, J. Miranda, D. A. Chavira, and A. S. Lau. (2018). Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review. Administration and Policy in Mental Health and Mental Health Services Research, 45(2): pp195-211.
Cosgrove, Shannon, M. Moore-Monroy, C. Jenkins, S. Castillo, C. Williams, E. Parris, J. Tran, M. D. Rivera, and J. N. Brownstein. (2014). Community Health Workers as an Integral Strategy in the Reach U.S. Program to Eliminate Health Inequities, Health Promotion Practice (15) 6: pp795-802, https://doi.org/10.1177/1524839914541442.
Koniak-Griffin, D., M.L. Brecht, S. Takayanagi, J.Villegas, M. Melendrez, and Hector Balcázar. (2015). A Community Health Worker-Led Lifestyle Behavior Intervention for Latina (Hispanic) Women: Feasibility and Outcomes of a Randomized Controlled Trial. International Journal of Nursing Studies, 52(1): pp75-87.