AHRQ Issues Guide To Help Digital Health Developers and Users Advance Equity

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The Agency for Healthcare Research and Quality (AHRQ) has developed the Digital Healthcare Equity Framework: A Practical Guide for Implementation to advance equity via digital healthcare technologies and solutions. AHRQ Director Robert Otto Valdez, Ph.D., M.H.S.A., AHRQ Senior Advisor Kevin Chaney, M.G.S., and NCQA Director of Health Equity Initiatives Bryan O. Buckley, Dr.P.H., M.P.H., M.B.A., introduced the new framework in recent blog post, noting, “The new equity guide provides clear implementation steps to help developers and users implement the framework. For example, developers should ensure that datasets used to train an artificial intelligence (AI)-powered application adequately represent intended patient populations. Providers or health systems seeking to acquire AI technologies and solutions should carefully review them for transparency and fairness.”

Six key principles guided development of the framework. They include:

  1. Ensure digital healthcare solutions that involve digital technologies ameliorate, not exacerbate, inequities.
  2. Represent equity through person-centeredness.
  3. Encourage inclusivity and participatory creation of digital healthcare solutions.
  4. Support effective implementation in diverse settings.
  5. Ensure specific attention to policy/regulatory relevance or impact of the proposed solutions.
  6. Focus on impact and outcomes for patients, health systems, and communities.

Equity Checklist for Planning and Development

The framework includes specific guidance for digital healthcare developers and vendors. AHRQ encourages developers and vendors to:

1. Identify and engage potential users of the digital healthcare solution, particularly those in historically marginalized demographic groups, to ensure it will meet the needs of the intended audience.

Each stage of the technology planning and development process represents an opportunity to intentionally address equity, including developing requirement specifications, design descriptions, and test plans. Developers and vendors are encouraged to employ principles of user-centered design, engaging potential users of the proposed solution.

Equity-related factors to consider in the planning and development phases include age, gender, race, ethnicity, primary language, sexual orientation, gender identity, socioeconomic characteristics, digital access, and digital literacy. For example, technology products should not assume cisgender identifiers and should allow for individuals to identify their gender, as appropriate.

One often-overlooked factor is functional disability status, which could be included as a voluntary self-identified demographic factor, including when/how the disability occurred. Just as other demographic factors impact beliefs and attitudes toward healthcare solutions that involve digital technologies, when someone acquired a disability, how long someone has experienced a disability, and the type of disability can affect those attitudes.

Real-World Example: Assess digital literacy among elderly patients using a survey, such as the eHealth Literacy Scale (eHEALS) tool, for a solution targeting specific patient populations. Having a clear understanding of an audience’s digital literacy levels will help inform the design of a solution.

Real-World Example: Assure the digital healthcare solutions accommodate the needs of patients with disabilities and those who are developing disabilities. Accordingly, consider proper font and color for the interface to accommodate visual impairment and employ voice-activated technology to accommodate hearing impairment.

2. Understand the cultural characteristics and beliefs of the communities for which a digital healthcare solution is proposed to identify potential barriers to using the proposed solution.

Identifying and collaborating with trusted partners in the community helps both to assess the digital capacity and infrastructure needs of the community and to understand the ways cultural beliefs in the community might impact the uptake of a solution.

Real World Example: Find opportunities to sit down with community members to understand their beliefs and lived experiences. For example, in designing a mobile application for African American men to connect with mental health services, you might hold roundtables with African American men to better understand how historical racism and mistreatment influence their trust of the U.S. healthcare system and their willingness to use a healthcare solution that requires the potential disclosure of sensitive information.

Real World Example: Build trust by investing in community partnerships that engage racial and ethnic groups with a disproportionate burden of health disparities. Investments for community engagement could include providing financial incentives for community-based organizations to collaborate with the developers during the planning and development of a digital healthcare solution. Engaging people from minority groups, such as African American adults and bilingual or Spanish-speaking Hispanic adults, in the designing process through community partnerships creates a “chain of trust” that helps potential users feel comfortable with the product.

3. Consider the impact of the proposed solution on digital equity in access, quality, and continuity of care in distinct healthcare settings.

Work with representatives of the health systems for which the solution is planned to be implemented and map the clinical workflows. Digital healthcare solutions rarely follow analog workflows and can disrupt familiar clinical workflows. Thus, it is important to map workflows to identify where a digital solution is relevant and what strategies are needed to support change management for patients and providers.

Real World Example: Enable a new solution for remote patient monitoring to make use of cellular instead of Bluetooth connectivity so that the solution does not require Wi-Fi and assures wide access across different communities.

Real World Example: Design patient-facing digital technologies and software to be used by multiple people/devices under one account to ensure wide access and to create interdependence between users and developers.

4. Assess whether the proposed solution serves as a facilitator (versus a barrier) to accessing and receiving high-quality care.

Hold roundtable discussions with different stakeholders and perform a root cause analysis of potential factors that could contribute to inequitable health outcomes that the proposed solution seeks to solve. Be proactive in thinking about what barriers the proposed solution might create for some subgroups of patients to access and receive high-quality care.

Real World Example: In developing a website that allows patients to sign up for vaccinations, hold discussions with patients, policymakers, and clinical providers to determine which patient subpopulations would experience improved access to high-quality care from the solution and which populations would experience additional barriers to quality healthcare.

Real World Example: To prevent implicit bias in the healthcare system affecting access to and use of a new solution, develop opt-out enrollment processes for eligible patients to remove dependence on clinician referral.

Real World Example: Data transparency can improve the quality of care. For a more transparent process, incorporate data analysis and interpretation tools in the patient-user interface of digital technologies to empower patients and caregivers to be more active in managing their personal health and healthcare.

Real World Example: To ensure widespread access, develop products and business models that target both safety net health systems and academic early adopters. An example of this is how OCHIN, a national network of community health organizations, has tailored electronic health record-based tools to help streamline digital and clinical workflows for community health centers.

Real World Example: To ensure risk-prediction models are not biased toward people with disabilities, be cautious about ableism inherent in many standardized measures of health.

Real World Example: Test medical devices on different subpopulations of patients to ensure that racial and ethnic variations do not result in the malfunction of medical devices and subsequently alter the medical care provided to those patients. For instance, pulse oximeters are racially biased and work less accurately on dark-skinned populations because melanin interferes with light-based pulse oxygen measurements. This bias may result in the provider missing hypoxemia events for dark-skinned patients.

5. Assess the technical characteristics of the proposed solution and whether those meet the current needs of potential users.

Implement proper methodologies, such as agile methodology, to ensure cycles of planning/development are accompanied by seeking feedback from potential users of the proposed solution. Such approaches result in incremental deliverables and dynamic flexibility as the solution matures, helping ensure the solution’s technical characteristics consider the needs of the users.

Real World Example: The developer of patient-facing healthcare solutions may design multilingual interfaces to address the needs of diverse patient populations.

Real World Example: The developers may ensure that a new digital healthcare solution is compatible with other devices, offer translation extensions and plugins for digital health information and services, and offer multilingual and multimodal support that considers different levels of digital literacy.

6. Ensure that data are used equitably and transparently during the creation of a proposed solution and when a solution is capturing, generating, or transmitting data.

It is important to ensure datasets used to create, train, or test a proposed solution adequately represent the characteristics of the patient population (e.g., race, sexual orientation, gender) for which it was developed. Being transparent with users that are implementing or using a solution about what and how data were used to develop, train, or test a solution is equally important.

Develop policies, procedures, and controls that take patient privacy into account by ensuring data captured, generated, or transmitted by a solution are accurate, transparent, secure, and interoperable. Regular review of privacy protocols and content in close collaboration with are presentative sample of users will help developers to iterate the policies and protocols as needed to maximize privacy and control by all users.

Real World Example: To build interest and trust among patients, a technology vendor planning and developing a remote patient monitoring solution may allow patients to actively approve all data transmitted to clinicians.

Real World Example: Technology vendors may engage in Health Level Seven (HL7 community forums; a set of international standards for the transfer of clinical and administrative data between software applications used by various healthcare providers) to: 1) lobby for the inclusion of data on social needs and social determinants of health in Fast Healthcare Interoperability Resources standards (FHIR; a standard used to access and exchange healthcare data) and 2) participate and keep up to date with those standards.

Set up regular roundtable discussions with policymakers to share challenges related to the structural barriers in providing healthcare solutions involving digital technologies and suggest potential policies that could address those barriers.

General Recommendations

AHRQ offers the following general recommendations to aid in implementation of the framework:

1. Assess Your Organizational Readiness

Perform an organization self-assessment of your readiness to start implementing the framework. The assessment should focus on 1) change management capabilities, 2) economic assessments, including costs and the potential return on investment related to equity intentionality, 3) health IT and data capabilities, and 4) leadership commitment to improving health equity.

2. Identify an Equity Champion

Identify an equity champion to help bring an equity lens to ongoing efforts to plan, develop, acquire, implement/maintain, and monitor/improve/perform equity assessment for healthcare solutions that involve digital technologies. The equity champion can help develop a business model and assess the economic sustainability and impact of the equity intentionality approach, which will help leadership systematically consider equity in long-term planning and resource allocation.

3. Develop a Diverse Workforce

Develop a diverse workforce capable of offering their lived experiences to ensure equity intentionality at an organizational level and for specific projects.

4. Build in Equity Assessments and Feedback Loops

Ensure that equity assessments and feedback loops are built in to processes related to healthcare solutions that involve digital technologies. The feedback loops should continuously assess and improve equity intentionality in healthcare solutions to achieve predefined success.

5. Track Whether Equity is Achieved

Track equity as part of your organizational metrics. For example, develop an equity dashboard to measure equity intentionality in key healthcare solutions that involve digital technologies during key phases of the digital healthcare lifecycle.

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