§1. Health IT’s potential role

Health IT can help reduce or even eliminate disparities in health care among rural and underserved populations. Differences in people’s access to technology (the “digital divide”) have existed for many years. However, recent research reveals that these differences are decreasing. Trends in both Internet access and mobile phones show signs of reducing the digital divide. Another recent report finds that many communities of color are increasingly using mobile technologies and other devices to engage online.

As access to the Internet and web-enhanced tools expands, the federal government is working with communities of color and other underserved populations to enhance use of health IT to improve health.

For example, ONC and other federal agencies are testing various ways to allow providers to “see” patients remotely. Both the Indian Health Services and the Veterans Administration have “telehealth campaigns,” in which videoconferencing allows providers or specialists to hold “virtual” office visits. This use of health IT tools for health care purposes is often referred to as telemedicine. (Learn more about federal telehealth efforts here.)

In addition, health IT can capture information that helps public officials and researchers identify differences in how vulnerable populations access health care.

  • How can government assist people who don’t have Internet access or who may be uncomfortable using eHealth tools?
  • Should the federal government or partner organizations develop training or educational materials, targeted at health care navigators and health coaches who work in underserved communities, to inform them about about health IT, mobile health apps, and other eHealth tools that can help their clients improve health?

For other discussions about developing educational and training materials, see

Current Efforts: Enabling information access

Current Efforts: Empowering consumer action

Patient-generated health data

§2. Focusing on low-tech tools

Efforts are underway to (i) expand broadband Internet access to more rural and underserved areas and (ii) dedicate bandwidth to the high-speed needs of many health IT applications. Meanwhile, ONC and other government agencies are exploring ways to use low-technology tools that enable more people to benefit from home health monitoring and other health IT. In the U.S., 88 percent of adults have mobile phones and 56 percent of all mobile users access the Internet through their phones. Health IT applications can be as simple as text messages to help people stop smoking, to remind them to take medications, or to encourage them to make healthy food choices.

For example, Txt4Health is a text-messaging tool that sends messages that can include assessment of diabetes risks and information customized to the individual’s health status and location.

  • How can the federal government reduce or eliminate health disparities using widely available technology such as mobile phones?

§3. Supporting new tool development

The federal government is challenging technology developers to create new tools that will help people understand and manage their health risks by running innovation competitions.

These competitions have led to the development of mobile apps, such as the Million Hearts Risk Check app challenge and the Office of Minority Health Women of Color app challenge.

Now that Internet access and technologies such as mobile phones are becoming more widespread, ONC is exploring ways to help developers take advantage of this to make low-cost, easy-to-use eHealth tools. ONC can work with communities and developers to ensure that these new tools are easy to use and language- and culture-sensitive, and that the information offered addresses any health needs unique to particular populations. The federal government could provide guidance on the need for developers to consider physical or educational differences among potential users, as well as the tendency for many consumers to access the Internet solely through mobile phones.

  • What types of eHealth tools could best address health disparities?
  • What are some success stories from public or private sources where technology was used to meet traditionally underserved populations’ health needs?
  • What can the federal government do to support the creation of tools that consumers or providers can readily adopt?

For other discussions about the role federal regulation should play, see

Current Efforts: Enabling information access

Current Efforts: Shifting attitudes

Identifying useful health information

Supporting “shared decisionmaking” through health IT

Patient-generated health data

§4. Privacy & security

ONC recognizes that privacy and security concerns may impact the willingness of consumers and providers to use health IT to increase access to health information. Privacy and security are the topic of a separate section of the Strategic Plan (Goal 3), since these concerns cut across all areas of health IT. Although this public comment period is not targeted at updating Goal 3, ONC will be revising that section of the Plan and your discussion of these concerns, and ideas about addressing them, will help the federal government decide on appropriate future steps.

(You can read the current version of Goal 3 by clicking the Background Documents tab at the top of this page, and selecting 2011-2015 Federal Health IT Strategic Plan).

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March 29, 2013 1:20 pm

The deaths and injuries from HIT are extensive. The outages are widespread and go unreported. The disparities in care must first start with assuring that these HIT systems are safe. You, the government, have ignored the scientific method in paying for HIT systems that have failed in the UK. You are wasting taxpayers’ money. Why has not the FDA evaluated these for safety?

Use these buttons to endorse, share, or reply to the preceding comment by sue dementad.
    March 29, 2013 4:28 pm

    Welcome to Planning Room, sue dementad. We wanted to let you know that Planning Room is run by the Cornell eRulemaking Initiative (CeRI). The site is part of an open government project to improve public participation in policymaking by government agencies. The main goal of the site is to provide useful and effective comments to the agency. Our job is to help every person air his or her views in the most effective way – whatever those views are.

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April 1, 2013 8:54 am

People in the communities (health navigators etc) should take the lead in developing training or educational material – not the government, not the MCOs. Why? Because the feds (through MCOs etc) are out of touch. Lets encourage video development etc from the street on up and not the other way. Let’s encourage the use of storytelling from real consumers to consumers (C2C).

Use these buttons to endorse, share, or reply to the preceding comment by broadthinking.
    April 1, 2013 3:25 pm

    Welcome to Planning Room, broadthinking. How could ONC encourage people who work in underserved communities to take the lead in developing training or educational material?

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April 10, 2013 10:05 am

It would be great if the government would work explicitly with organizations trying to ensure that patients have the basic resources, like food & utilities, they need to be healthy. Health IT could be leveraged to connect patients to already existing resources in their own communities, especially if those resources were easily accessible online. Many times patients don’t know what resources they are eligible to access- compensating lay staff to work collaboratively with clinical professionals to connect patients to these resources could go a long way toward raising the basic level of health in our country (and save us all $ in the process).

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    April 11, 2013 8:50 am

    Welcome to Planning Room, health lead-er, and thank you for your comment. What do you think is the best way for ONC to connect the right community groups to the patients in underserved communities who do not know about the resources they are eligible to access?

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      May 1, 2013 2:48 pm

      I work for a NPO called Health Leads which has developed a web-based community resource database. Paired with a structured way to screen for basic resource needs & active follow-up with families, I think we have a model which leverages IT but also helps keep families connected to the clinics where they receive care. The trouble is, because this type of work is not reimbursable with the current fee for service payment structure, it is difficult to justify paying for this service for their patients.

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      May 1, 2013 2:57 pm

      Here is an example of the type of basic resource need I am referring to: a child from a low income family has asthma, which is triggered by the cold weather. In winter-time, the child has more visits to the hospital or primary care clinic. The family is screened for basic resource needs and we learn that the heat has been shut off in their home. The family is referred to a service (such as Health Leads) with a robust database of community resources, and is connected to a resource providing utility shut-off protection services. Health Leads follows up with the family every 10 days until the resource is secured. The basic need for heat in the winter becomes one less factor in keeping this child with asthma healthy during the cold months.

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      May 1, 2013 3:04 pm

      In the example I provide, the effect on the health care system is that the physician does not need to worry about connecting the family with heat & can focus on other reasons (if they exist) that the child’s asthma may be hard to control. If lack of heat was the primary reason, than restoring heat in the home decreases the need to use the emergency dept/primary care clinic, decreases days a parent may have to stay home from work to care for a sick child, and decreases the days a child might miss school. This can be accomplished with a technology backbone which identifies a basic resource need, facilitates referral to a service equipped to both match the patient or family with a resource in the community which can help address their need and follow-up with them until resolution is reached.

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April 12, 2013 5:45 pm

Allowing for across the board access to medical files to any provider you see is going to create barriers for patients that have a bad experience with providers. I have a friend, Elaine, that had a bad experience with a provider. That information was placed in her chart, and afterwords she was unable to find a provider anywhere in New York City. Without stronger privacy protections in Heath IT, we could all end up like Elaine. Perhaps this is Sebelius’s real plan to lower healthcare costs in the US.

Use these buttons to endorse, share, or reply to the preceding comment by concernedcitizen1952.
    April 14, 2013 2:12 am

    Thank you for your comment, concernedcitizen1952, and welcome to Planning Room. Ensuring that consumers have adequate access to, and control of, their health information is an important goal of the ONC.

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April 26, 2013 1:52 pm

Serving on the National Partnership for Action to End Health Disparities, I have been advocating use of new tools to enable patients to drive the needed changes. Many health care disparities can be eliminated by deploying a new consumer-focused technology platform for the underserved populations. I think the following applications are urgently needed on a single platform:

1. ACA preventive screening application: Any patient can use it at home to self-check risk and understand what preventive services are recommended and covered under ACA specifically for him/her. This app needs to support all minority languages because many patients do not speak English. This tool will increase use of ACA-covered preventive services.

2. Multilingual education website for ACA insurance enrollment. Millions… more »

…of eligible consumers from underserved population don’t speak English. They can use this tool in any language to understand the insurance marketplace, estimate insurance cost, and compare different plans. Currently, education contents and tools on federal and state websites support limited Spanish. A fully-functional website supporting all minority languages will help non-English speaking consumers understand the complex enrollment process and increase enrollment on ACA insurance marketplace.

3. Multilingual After-Visit Summary application. Non-English speaking patients can use this application to view or print AVS in any language they understand. This app will improve patient engagement and compliance, which is tied to Meaningful Use stage 2 and 3 objectives.

In addition, this platform needs to be free for patients, community health workers and community health centers.

HHS has done great job with developer challenges. I hope HHS will also challenge developers and social entrepreneurs to build more comprehensive platforms for the underserved populations. (An example is described above.) Because the business model is not clear in this public health market, HHS would need to figure out ways to attract talents and startups to work in this space, and provide assistance for startups to succeed. For examples, connect startups to existing programs that can potentially test or use the new tools developed by the startups

Coming from IT industry, I understand how critical it is to focus on scalability, adoption, and sustainability in order to win the battle against health disparities. I think ONC understands this very well and hope ONC will continue to partner with industry to achieve the common goals.

AJ Chen « less

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    April 27, 2013 11:42 am

    Welcome to Planning Room, ajchen, and thank you for your comment. Do you have examples of platforms like this that would guide ONC in developing something similar? How could ONC overcome problems like inaccurate translations?

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      April 28, 2013 9:23 pm

      I have not seen anything close to the platform I’m advocating. This platform idea came from the feedback I’ve got from talking with many people as well as my industry experience. It’s also pretty obvious that you have to apply disruptive technology approach to build it and make it adopted across the safety net. Traditional approaches are too costly and can’t be scaled up. To demonstrate this is possible, I’m building prototypes and

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      April 29, 2013 12:14 pm

      continue my thoughts…

      I’m building a prototype to demonstrate it’s feasible to cost-effectively build the comprehensive patient engagement services and provide it for free to patients and the safety net.

      The language barrier is a typical example to illustrate how disruptive thinking is essential. We know we have to have health professionals to translate ACA enrollment education contents and tools to other languages in order to ensure the quality. Everyone will also tell you this is a very very costly and time-consuming process, particularly when you are talking about all common minority languages. In one word, impossible.

      But, as I talk with people at Palo Alto Medical Foundation’s cultural competency group, Asian & Pacific Islander American Health Forum,… more »

      …Kaiser Family Foundation, I see commitment from public health organizations and care providers to translate ACA enrollment education tools and doctor visit summary to serve their patients better. To me, the question really becomes: How can we provide an information system to engage these health professionals and harness their translations for the benefit of everyone? For example, navigators will explain how insurance marketplaces work in whatever languages their clients understand. Is it possible to give the navigators a tool to make the translation process super-efficient for everyone? I bet it is entirely possible to build a website with ACA enrollment education and tools fully functioning in all common minority languages just in time when the enrollment starts. « less
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May 7, 2013 11:30 am

• Technology allows for the use of off-site resources that can help meet the unique needs of a specific individual – thus removing disparities that otherwise exist due to location or access to specialty providers. While this function is exemplified by the growing use of telemedicine to increase access to medical providers from remote locations, it is also demonstrated through the use of other basic communications tools such as automated video and voice call center systems are used to ensure that a family at a hospital or clinic system has access to medically trained language interpreters, in real time, within seconds.
• In addition, social networking technology can provide patients/families with information that engages and speaks specifically to individuals and their circumstances.… more »

…For example, social networking sites for children with specific conditions, such as the Starlight program for children with cystic fibrosis, allow families to communicate about medication, treatment, and other common experiences, giving them a uniquely useful body of information that they can evaluate and use as they see fit, in addition to connecting the patients with a supportive community. Such resources can be built for any particular community, whether disadvantaged or linked through a health condition.
« less
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May 7, 2013 11:31 am

• eHealth tools have been used to present useful, clear and well-organized information at the appropriate health literacy level for the user and in multiple languages, thus helping address disparities. For instance, migrant agricultural laborers (through the MiVIA program) can access an electronic personal health record (PHR) for themselves and their children that includes insurance details, a photo for identification, a library of targeted resources in Spanish and English, and other information that can be hard to retain in such mobile lives. And, homeless and emancipating foster youth in Sacramento County, California, have access to critical health, education, and life documents and resources through HealthShack, a PHR developed specifically for that population.

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(Q#1) While the adoption of health IT is growing, there is significant risk that populations who lack Internet access will be left behind. To bridge this “digital divide,” the government should capitalize on partnerships with community organizations which have direct access to such populations. For example, consider the partnership between the New York Academy of Medicine Library, the New York Public Library, and Settlement Health in East Harlem, or the partnership between Yale University and Head Start parents in New Haven, Connecticut.

Use these buttons to endorse, share, or reply to the preceding comment by national partnership for women families.

(Q#2) Many of the current training and education materials are not designed with consumers in mind and therefore are not easily digested by patients, families, and caregivers. Once meaningful consumer educational materials have been identified, the federal government could help direct these materials to health care navigators and health coaches. This could be accomplished by creating a singular, central repository and ramping up outreach efforts pointing communities towards the repository.

Use these buttons to endorse, share, or reply to the preceding comment by national partnership for women families.

(Q#1) eHealth tools that improve consumer-provider communication, such as secure messaging through EHR patient portals, mobile apps, texting, gaming, and social networks, could greatly assist in the reduction of health disparities. Research indicates that some underserved populations with the greatest risks have the most difficulty communicating with their providers, mostly due to language barriers (regardless of interpreter services), leading to worse health outcomes. However, secure messaging has been shown to improve health outcomes, treatment adherence, and patient satisfaction. It is critical that these interfaces and tools should be displayed in languages other than English, accessible to those with visual and cognitive impairments, and use plain language, rather than medical jargon… more »

…whenever possible, with links to explanatory materials when not possible.
Additionally, the GPS functions of mobile devices should be leveraged to help people locate services such as HIV testing sites or free clinics in their communities.
« less
Use these buttons to endorse, share, or reply to the preceding comment by national partnership for women families.

(Q#2) There are several examples of partnerships helping to bridge the digital divide. For example, Mt. Sinai Adolescent Health Center (MSAHC) used text messaging to engage their low income, adolescent patient population. Patients were encouraged to submit health-related questions via text message, and received health-related advice and medication reminders.

Use these buttons to endorse, share, or reply to the preceding comment by national partnership for women families.

(Q#3) ONC should encourage the development of robust standards and continue to fund advanced research projects that leverage the standards of EHRs, such as the SMART platform, which is an open way that individual patients, physicians, small software vendors and others can design innovative health IT applications at a lower cost.

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May 8, 2013 8:13 pm

Health IT has the potential of decreasing disparities if appropriately leveraged. For example, data demonstrates that African Americans and Latinos access the internet through their mobile phones at higher rates than other populations. Accordingly, health IT directed at, or for use by, African Americans and Latinos should use text messaging and mobile applications as much as websites and email. Similarly, there are online and mobile applications that are readily available and used in many languages other than English. If these online and mobile communications and information technologies are not used for heath IT, then the digital divide and disparities will only INCREASE rather than decrease.

If health information can be accessed and used by diverse and underserved populations who experience… more »

…the greatest health disparities, then they can be more informed, engaged, and empowered health consumers that become activated and more proactive partners in their own health care plan, and maintenance or improvement of their own health status.

Finally, at a population and public/community health level, having more data and health information about a population can identify specific local disparities and prioritize interventions to reduce those disparities. However, it is essential that demographic information about patient race, ethnicity, language and other factors such as disability status, sexual orientation, and gender identity continue to be collected AND all quality data be stratified by each of those demographic characteristics to identify and reduce disparities. In terms of race and ethnicity, further granular disaggregation, as recommended by the Office of Minority Health under its Affordable Care Act section 4302 standards, and further recommended by the Institute of Medicine in its 2009 report “Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement” should be implemented through health IT, including all ONC-certified EHRs and all health information exchanges.
-California Pan-Ethnic Health Network « less

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May 9, 2013 4:15 pm

To: Office of the National Coordinator of Health Information Technology
From: The Fenway Institute at Fenway Health
Re: Comments on Federal HIT Strategic Plan submitted at http://www.planningroom.org
Date: May 9, 2013
Topic 7: Decreasing health disparities through health
§1. Health IT’s potential role
• Should the federal government or partner organizations develop training or educational materials, targeted at health care navigators and health coaches who work in underserved communities, to inform them about about health IT, mobile health apps, and other eHealth tools that can help their clients improve health?

Yes, the federal government should mandate the collection of data on sexual orientation and gender identity (SO/GI) in Electronic… more »

…Health Records (EHR) as part of Stage 3 meaningful use guidelines, and train health care providers and clinical staff in how to gather these data and talk with patients about SO/GI in a culturally competent way. The National LGBT Health Education Center at The Fenway Institute as well as groups like the Center of Excellence in Transgender Health at UC San Francisco could assist in developing these trainings and materials.
–Sean Cahill, Ph.D.; Harvey Makadon, M.D. « less
Use these buttons to endorse, share, or reply to the preceding comment by sean cahill.
    May 9, 2013 6:20 pm

    Thank you for your comment and welcome to Planning Room, sean cahill. It looks like you are already familiar with the commenting process. However, commenting on our site is a little different. The issue posts and sections on Planning Room are designed for targeted commenting, which encourages discussion on specific issues. You can visit our about section for more information. It may be helpful to remove the headings from your comments to give yourself some more room while also making them easier for other commenters to read.

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May 9, 2013 4:16 pm

To: Office of the National Coordinator of Health Information Technology
From: The Fenway Institute at Fenway Health
Re: Comments on Federal HIT Strategic Plan submitted at http://www.planningroom.org
Date: May 9, 2013
Topic 7: Decreasing health disparities through health
§2. Focusing on low-tech tools.
• How can the federal government reduce or eliminate health disparities using widely available technology such as mobile phones?
The federal government should encourage all patients to disclose their sexual orientation and gender identity to providers and assure them of measures in place to protect privacy and confidentiality. This would allow widespread data collection on lesbian, gay, bisexual and transgender (LGBT) identity, a critical first… more »

…step toward better understanding and reducing LGBT health disparities.
– Sean Cahill, Ph.D.; Harvey Makadon, M.D. « less
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