Design at Large: Future Prospects in Health Equity and Technological Innovations

Design at Large: Future Prospects in Health Equity and Technological Innovations

Show Video

[MUSIC] Welcome to the students who are in the audience and also our friends and colleagues who are on Zoom and also streaming on YouTube. We have some special remarks from our assemblyman, Chris Ward and I'd like to share those remarks with you. Hello everyone. My name is Chris Ward and I had the honor of representing the 70th assembly district in the California State Legislature. I want to thank you all for joining UC San Diego design labs and California 100 for this important seminar featuring distinguished academic and industry speakers.

Whether you are here in person or attending virtually, you can expect an engaging conversation with an extraordinary group of leaders who reflect the diversity and expertise that California is known for around the world. Again, thank you all for attending and ensuring that your voice is heard on some of California's most pressing issues. Well, he did say that we are here with some esteemed speakers from industry and also academia. We're really excited about this discussion. Today we're going to talk about the factors that make us healthy.

When we think about these things, we often think diet and exercise. People always tell us diet and exercise and maybe sleep, they might throw in sleep there. But what if I told you that your health outcomes, a large portion of your health outcomes are predicted even before you were born. The things that predict your health outcomes are often related to social and structural determinants. What are social and structural determinants? They are your parent's background, they're education, their occupation, they're wealth.

Those are big predictors of your health outcomes. Where they bought a house, the house that they bought, whether it's affordable, what neighborhood they located in, has predictive outcomes for your health. We've talked about affordable housing in this class, and we've talked about its impact on health.

I think I've mentioned that because I'm a housing scholar when I think about health, that housing is health that is a huge part of shaping our health outcomes. How many of you have a cell phone? A smartphone. Everybody has a smartphone. What if I said that this smartphone has the biggest potential to actually address some of these health disparities that we have in our society. It's the most common technology that is equitable at 85 percent of our population has a smartphone, and that's true across race and ethnicity. It has a lot of potential, but whether or not we actually utilize it to bridge the gap between health outcomes to address health disparities. That's something that I think we'll get to today and talk about.

What are some health innovations? What are some technological innovations that will actually help us to address health disparities? About 40 percent of our health outcomes can be predicted on social and structural determinants. That's a pretty big number. We haven't done a good job of addressing these social and structural determinants. I'm going to turn it over to Karthick Ramakrishna an Executive Director of California 100 to talk about California's future and whether or not we're doing a better job than nationally where still 30 million people don't have access to health care. Thank you Mai and thank you all for being here.

We have one of our lead researchers on the future scenarios reports. I'm not going to steal too much of her thunder in terms of what she's going to say. But I'll say on a personal note, not only am I the Executive Director of California 100, I'm also a board member on the California Endowment, which for over a decade has been investing in communities precisely to change some of those structural determinants with the hope that they will lead to more equitable health outcomes. We've seen some progress in San Diego county. City Heights has been one of those 14 building healthy community sites.

What we discovered over time is that even if you can bring the preponderance of evidence to bear and show decision-makers that this is the right thing to do to build more equitable systems that will improve not only health but well-being in many ways, systems have inertia for various reasons. One of our major discovery is not surprising to me, as a political scientist, is that often decision-makers will throw up roadblocks either intentionally or unintentionally, that you need to build power, especially among those most affected or most disadvantaged so that they have the capacity to not only advocate, but to push systems to do the right thing. Now with all that said, I've always found that there is a tale of two worlds when it comes to advancing health. They're the people who are working on health equity with a social determinants lens and a power-building layer if you will, or maybe your power-building lens to that work.

Then there are those that are working on health innovation largely in the technology space and especially post George Floyd, but even prior to that, are attuned to the problems of health disparities and health inequities. But these two worlds rarely intersect with each other. I'm hoping that what we get today is to model the kinds of conversations and especially in a place like San Diego where for more than a decade you've had significant investment in addressing some of those root causes of health disparities and focusing on power-building. But you also have this amazing biotechnology sector. If there is a place in California and I would say in the country that can hopefully bridge these two worlds I think it's San Diego.

I already know that going upstairs at the design lab, some of these conversations are already happening. I just think we just need to increase the volume and intensity of this work. I'm really excited by the conversation today and just as importantly at the ideas that'll spark with all of you in the audience and with the amazing researchers that are affiliated with the design lab.

I agree with you. I think that we're at a moment where the technological advances as well as our understanding that we need to address health disparities and the importance of that have come together at a moment where we can really move the needle on this. We have to be intentional about it. Because what we've seen often is when it comes to early adoption and technology, it actually ends up reinforcing disadvantage before it starts ameliorating disadvantage, and hopefully, we can design better. Well, this is a good segue to turning to our panelists to actually address some of these issues.

Let's welcome our panelists. [APPLAUSE] [APPLAUSE] I'm going to start with Chris. Chris Longhurst is the Chief Medical Officer and Chief Digital Officer at UC San Diego Health.

He works alongside leaders at UCSD Health and School of Medicine and UC Health to improve care delivery and oversees UCSD's health reputation for delivering safe, innovative, patient-centered care. Dr. Longhurst is really passionate about implementing innovative digital solutions that help improve the patient experience. Chris, I've read in your bio that you grew up in a rural area and that really shaped how you think about access to medicine and also technology, and I was hoping that you could give us an overview of the advances in technology in health systems. Because I've heard you say, "digital health is not a strategy. It's a tool that is used to help accomplish your goals as a health system."

Maybe you can elaborate on that. Absolutely. First of all, it's a pleasure and a privilege to be here. I really want to thank you for the invitation to have this important conversation. You're right. I grew up on a farm in rural Northern California.

My first introduction to technology was when my father brought home a computer that had a modem. This was before I had a driver's license and so I was able to plug it into the wall and start interacting with people all over the region and the country. That sparked some of my interest in technology that continued throughout my undergraduate career here at UC San Diego where I was a Revelle student, and subsequently at medical school at UC Davis, where I decided to become a pediatrician. My journey has been somewhat circuitous.

I actually returned to the UC system partly because of the mission of the UC is to serve the underserved in the entire community and region. As a pediatrician, this is really near and dear to my heart. Every child deserves an equal chance and I partnered with Dr. Nadine Burke,

who's our California's Surgeon General on the Adverse Childhood Event Prevention and Detection Program, and importantly, we bake that into our electronic health records so that we could become more highly reliable in how we did that. Now, as the Chief Medical Officer overseeing a lot of our inpatient care, we take a careful look at all of our quality and safety dashboards on a very regular basis to make sure that we're delivering not only safe care, but equitable care. Part of that journey is really understanding what is equitable care and how do we define that and is the data trustworthy? Over the last five years, one of our more important journeys has been diving deeper into these data elements that we collect to make sure that they're valid, that they are verifiable, and that they're true.

Because it turns out, for example, that our race and ethnicity data that we collected in an electronic health record, wasn't very good. We went through several cycles of improvement to try to get more integrity around that data. Guess what we found out? We found out things like we weren't offering tobacco cessation counseling at the same rates to people of different races.

Of course nobody is out there consciously thinking, I don't want to offer this individual or that patient the same services, but when you surface this information in a way that's believable, it really changes the conversation. People become more aware of these implicit biases. In fact, we are able to very rapidly address that and make our care more equitable across UC San Diego Health. We found a number of other examples like that, and of course, the latest is during the COVID pandemic, when an unintended digital divide emerged, particularly among people who didn't have bandwidth for telehealth. There was a point in time in April of 2020, when 70 percent of our outpatient care was being delivered via telemedicine because people were nervous about coming in both our patients and our clinicians and some examples.

Today we're still at 20 or 30 percent, but it's a challenge that we continue to face is, how do we ensure that our access from a telemedicine standpoint is equitable? You mentioned the smartphone as a really key tool and we found that it helps to close the digital divide, but it doesn't help to close the whole bandwidth divide. As we serve patients in Imperial County, those of you who've driven East on the 8 know you drop your cell service. There's still continued challenges in ensuring equitable access to the care that we want to offer to everybody in the community, everybody in the region.

Thank you again for opportunity to be here and I look forward to the conversation. I'm going to turn to Ninez Ponce. She's a professor at the Fielding School of Public Health, Department of Health Policy and Management and the Director of its Center for Health Policy Research at UCLA. She leads the California Health Interview Survey, which is the nation's largest state health survey, and is recognized as a national model for data collection on race, ethnicity, sexual orientation, and gender identity, and immigrant health. She has received numerous awards from community organizations recognizing her work in community engaged work.

Ninez, you were instrumental in this California 100 report on health and I wanted to maybe turn a little bit to California and talk about the California Department of Health Care Services and their CalAIM Initiative. This plan really explicitly aims to increase whole-person health access across the state. Building on the existing programs, California is actually pretty innovative in terms of trying to get more and more people access to health insurance, but will CalAIM really get us to universal health coverage in California? We still have an eight percent gap in those who are uninsured.

Yeah, thanks. The four-letter word I love is data. When you were talking about data, so I started reeling over. [OVERLAPPING] By the way, I consider Ninez as the OG when it comes to collecting data on racial and ethnic populations.

I don't think CalAIM will get us to universal coverage, that's the financing piece. But I think it gets as better at health equity because CalAIM is out of the Medi-Cal program. How many people here know what the Medi-Cal program is? Because all of you should be insured by it through your registration, through your enrollment here, but Medi-Cal is the program that covers poor people in California and there's a lot of poor people.

At one point Medi-Cal covered 33 percent of Californians. We're not going to get to the whole entire state, but it's a large part of the state and it's the state that needs the most help. Health equity is giving people what they need and not necessarily giving everybody the same share. What CalAIM tries to do is both from a financing perspective, I'm a health economist. I think you really need to have the incentives to make people give better care, coordinate care, incentives and really trying to get incentives to collect better race ethnicity data. It's also getting at interoperability, which I think we use a lot, at least in my world, but they don't really know how to do it.

So there is at least this financing mechanism, but not like how do you do it? This is why I was very interested to be here, Maya and Cathy, because we have an idea of how to do it or what we need to do, but not exactly how to implement. I do think that the behavioral individual parts, so California could be very individualistic and you can have reforms and innovations at the individual level, which I think there's a place for that, so there's a place for the reminders on your cell phone, there's a place for that. But really what we need some tech thinking and brains on is, how do you make systems behave better? How do you make systems track a patient through the life cycle? Actually CalAIM gets at those who are formerly incarcerated.

How do you get that and really socially complex, clinically complex patients, how do you connect all those systems? Hopefully CalAIM is for the poorest of the poor, the most marginalized people in California. It gets at integrated data, interoperable systems, integrating behavioral health with physical health, healthy aging, aging well in your communities, in your homes. It's very exciting, but it's largely in the Medi-Cal program, not for the commercially insured at this point. But I think we can get there sooner with help from tech and innovations that come from the public sector.

Great, Thank you. Tavae, I'm going to turn to you next. Tavae Samuelu, is the daughter of a pastor and I think that's important for you to put in your bio, from Leulumoega, and you're a daughter of a nurse from Saleimoa. You're currently the Executive Director of the Empowering Pacific Islander Community where you really advocate passionately for your people and you're really committed to liberation for all. I'm going to ask you about the importance of recognizing innovation that can take a number of different forms, including indigenous knowledge.

Oftentimes, indigenous knowledge doesn't get recognized, doesn't get incorporated into our science, our research, our education and often is forgotten and considered to be the past or traditional. What's the important points of incorporating indigenous knowledge into our education and research? How will that actually help us to accelerate human progress? Thank you for that. As Maya said, my name is Tavae Samuelu. My pronouns are she her. I have the honor of being the Executive Director of EPIC.

The reason why my bio very explicitly states that I'm the daughter of a pastor from Leulumoega and a nurse from Saleimoa, because it is indigenous practice to talk about the lands that you're from and the people who have helped to shape all of your notions of power, and privilege, and systems. In addition to being honored to be a guest here at UC San Diego, I'm especially privileged to be a guest here on Coos Bay Islands. I forgot to talk about indigeneity. I need to be really explicit about who the original stewards are, and put forth the question not only about acknowledgment because anywhere you go, you're on indigenous land.

But what is the work that we're collectively doing to return Lilian to indigenous hands? It's deeply tied to what it means to include indigenous knowledge. Now, in preparation for this panel, I actually found myself needing to look up the definitions of innovation and technology, because they're terms that have been used to a point of semantic satiation. They're used so often that they've lost all meaning. At the end of the day, innovation is really marked by this notion of new methods, by novelty.

I approach it with a certain amount of trepidation, especially as someone who comes from colonized people whose cultures and knowledges were erased intentionally. Languages that were suppressed and banned for a very long time until the 1970s, it was illegal for Native Hawaiians to speak Native Hawaiian. The purpose of language is the ways in which all of our knowledge is disseminated through that production, through that retention of language.

The other aspect of why have some reticence around innovation is because how often things are marked as novel to others that have been long part of our genetic memory as a community. Things that we've always known how to do, especially as we think about a specific people who traverse the oceans, reading our environment. Because we had such a deep connection to land and water that we understood and knew just by looking at the sky and the waves exactly where we were supposed to go.

These things that now would be considered innovation, but for us, our reclamation and the ways that we really find ourselves at a precipice of bearing witness to its evolution of the ways that we tailor things in technology, thinking about the practical application of knowledge. For me it's as simple as for someone a tire, there's [inaudible], longhorn for hundreds of years, my mom's innovation was to add pockets. She is tired of carrying prices and so now everything I have has pockets at it.

For me, it was this brilliant addition to making this very traditional attire functional and something more forming for all of the ways that we go around in the world, for making it easier to serve our communities. Because the other things that we learned from scholars like bell hooks, to talk about theory, what use is a tool if it doesn't bring us closer to equity and freedom and liberation? The other aspect about thinking of indigenous knowledge and even protocol is even thinking about being part of the California 100 commission, I pushed back with Karthick. I'm simultaneously too old and not young enough to be on this commission, that so much of our indigenous protocols are about deference to elders. The folks who often holds all of that knowledge that we need to hold onto and remember.

Also knowing that we're in this place of remembering, and also knowing so much of what's been retained has been through a colonial lens. When I look at young people and the things that they're doing, that they're evolving things, that they're making decisions that worked for their generations and knowing that I ultimately want a future that's shaped by buy-in for my four-year-old niece, love and yeah. I love that we're talking to you all as students because I think of the words of folks like Huey P Newton who said that, the revolution is always in the hands of young people. Even as folks are talking about data, the disaggregated data we have now is because Native Hawaiians students at Stanford flagged it, for then Senator a Kafka. They said the data that we see on paper does not match our lived experiences.

In understanding as well that data and other technologies that are often understood to be neutral, actually aren't. That what is understood as objectivity is very often white male subjectivity, and the questions that are at hand, knowing that what you are able to do, the curiosity that you can elevate that actually leads to equitable innovation is actually the things that you are best suited to do, and that young people have always taught me just moving with this urgency of not needing to wait your turn to lead. I'm not needing to wait your turn in this, I think what is often deemed impatience is actually wanting to be really clear, when did we learn to wait for freedom? When did we learn to wait to do the right thing? Really wanting to continue to be pushed by young people, by students like you who are in the best position to hold systems and universities accountable. Camille, I'm going to turn to you. Camille Nebeker, as Associate professor with appointments with the UC San Diego Design Lab, WHO, and the School of Public Health and Human Longevity.

She's also the director of the UC San Diego Research Ethics Program. She applies human-centered design approaches to shape ethical research practices. Camille, you were instrumental in developing the count notify app, that exposure app, when COVID hit. They quickly designed, prototyped, and then created an app. It was a pretty fast process, and one of your goals is really to reach as many people, a diverse population as possible and use human centered design approaches.

Maybe you could tell us about that process and whether you think you are successful at making an app that actually did reach a diverse population, and what you've learned from that process moving forward, if we can create other exposure apps, what would you do differently? Well, thank you and thank you for hosting this important conversation because health equity and technology, we have a long way to go and we're making progress. I have to thank Dr. Longas for inviting me to be a part of the development of CA Notify. In September of 2020, we wanted to do what we could to help people who are in the public know if they had been exposed to COVID. The traditional way that we've done this in the past is through contact notification, which is a manual process that when you are identified as having a positive test, the public health workers will ask you who you have been around, where you were, when were you there? I don't know about you, but I rarely answer my phone. It's not a practice that I think is going to be terribly efficient or effective.

We were invited to pilot the CA Notify system to design and pilot this at UC San Diego. As a research ethicist, I'm really interested in what the person's experience is and what we need to do to make that experience something that is sustainable. Especially for health research, we want our participants to not only join a study because they're informed and they know what they're getting into, but to stay with the study because they were informed and they agreed to participate.

Thinking about what would we need to think about prospectively in order to design a system that people would actually accept and find useful, was to start talking to people. Fortunately, at UC San Diego, our employees including staff and students, and our employees are quite diverse, and represent a nice cross-section of Californians. In San Diego County, we have the second largest Native Hawaiian and Pacific Islander community. We have a majority of Latino residents.

We have a very large refugee population. Here in San Diego, we have access to diversity that is really unusual. The other population that I think is really important to consider, especially with a CA Notify exposure notification system is older adults, people who are using public transportation, people who are essential workers. To get started, we started talking to people.

We, first of all, and this was even before we started with the pilot, we had the opportunity to be a part of a speculative design series of workshops that was hosted by the design labs. In September, before the pilot started, we had a speculative design workshop that's 75 people attended virtually, and we were able to break people up into working groups that represented students, staff, and faculty. What would you be thinking if somebody asked you to activate CA Notify on your phone, what would you be worried about? What would be the barriers to acceptance and the facilitators to its use. People told us what they were worried about. They worried about, is this a government program? While in some cases the government hasn't treated our communities very well, and so I don't know that I could trust it. Well, what could make it trustworthy? We had interactions and the worry about UC San Diego being involved in this, are they trying to take my data? Are they linking my data to my health record? There were a lot of worries about privacy, about data management, about access.

Do I have the right phone? Are we leaving people behind? We took every single bit of that information and moved it forward to other design workshops and we did several rapid design workshops. Again, I have to thank Dr. Longhurst and the team for really recognizing how important it was to engage with people to find out what would make this something acceptable. You're only going to have something that's adopted if people find it acceptable and there has to be a value proposition.

What was that value proposition? Well, people wanted to keep their pods happy and safe. If you had created a small group of people that you knew where your social lifelines at that point in time and you wanted to keep them safe, then that might be why you would start using this. Because when you go to the market to pick up something, you're around people who you don't know. Even if a traditional contact tracer were to ask you, you wouldn't know who is at the grocery store or who was in line at the bookstore next to you. This is a tool that Google and Apple created the foundational platform for, with privacy in mind.

They knew that they could work together and that they could build a powerful tool, but it had to have privacy at the forefront. Those of you who have activated it either on an Android phone or an iOS, we have no idea who you are. That limits a lot of what we can know about whether this is useful and effective. But we have taken every precaution to protect people's privacy so that you can receive a notification anonymously and take action and do what you need to do to keep your community safe.

Every time I work on anything to do with whether its technology development or creating curriculum to reach underrepresented populations, I always involve those people in the conversations very early on so that we can understand what the lived experiences are and what the barriers are. Funny story, a health tech company giant contacted me about two years ago through the design lab. They had found a paper that we had published on what technologies would be useful to older adults to help them live independently longer. We spent a lot of time in a retirement community working with people living independently to find out what technologies were they using? Why did they use them? What were they worried about? What would be a game show stopper? We learned all about that. Then health tech company giant said, what made you think to talk to people? We've only really focused on people who are 18-36.

I'm speechless now and I was speechless then I was like, I can't believe that that would be a question at this day and age to not talk to people, to inform the design of anything you're making, and then to continue to iteratively get feedback. A year ago, we continue to do the workshops. We went into Chula Vista local community. We conducted workshops in Spanish with women and men from Chula Vista to find out why might people like you and people in the demographic that you're in not want to use this tool? Well, turned out the word Bluetooth was not understood and it was fearful, and that was the technology that was making this a really safe technology to use.

It was the privacy protection that instead of using GPS, Bluetooth was the privacy key. Well, they didn't know what it meant and they were worried that everything in their phone could be snatched in the shopping mall if their Bluetooth was on. We took that immediately to Google and Apple and said we need a really easy way of explaining how this works.

Then we took it back and we tested that language with the people who were telling us that they were worried about it. That interface with people whether it'd be in Chula Vista or city heights, we have to take the time to do that work. I hope that every single one of you in here will think about when you design anything that's for public consumption, that you take the time to engage with people who might want to use it and benefit from it. Thanks for the question. Thank you.

I'll have the next round of questions but actually, I'm going to go back to Ninez because Ninez, I was hoping they could talk a little bit about the scenarios that was part of your report. Then I want to come back to some best-practices questions when it comes to inclusive tech and equitable tech. But then as we could just say a bit more about the future scenarios work that you and the team worked on. Sure. California 100 was

this really bold project that Carthage is one of the architects, along with Henry Brady on trying to get out of that myopia of term limits for decision-makers two years and then it's like the next, what am I going to run for next? Part of that decision-making myopia then might be one reason that curtails why we don't have universal coverage for all. Why we don't have better care for all, why we don't take care of people who are unhealthy. Why we don't take care of children. It's this community piece on that my said, actually, it's 40 percent. Some theoretical frameworks and some evidence is actually up to 80 percent are non-clinical in terms of social determinants of health.

What we were tasked to do by Carthage California 100 was imagine California 100 years from now and not exactly 100 years, but at least more than two years, at least more than 10 years, maybe 20 years from now for your children, your grandchildren, and I guess most of you here are from California, maybe not, but if you are not, most of you may want to stay here. We looked at these scenarios. We looked at four scenarios with the leavers of do you want a system that's just very siloed or do you want a system that's more integrated? Sorry the extremes.

Do you want a system that's more individualistic or do you want a system that's more community-oriented? We've evolved from the beginnings of the nature of what health insurance is, which is, you're not insuring yourself to get sick because you don't know if you're going to get sick. That's a random event, but you're insuring yourself with the financial risks that you'll incur when you get sick. The beginnings of the insurance system is more like a sickness system. Do you want it to be a sickness system? This is the other part, or do you want it to be a wellness system? We looked at these scenarios and obviously what we wanted were, not obviously as a public health [LAUGHTER] person, we wanted how to make sure that things were integrated.

Because it's not just about the symptoms that are presented to doctors offices, but it's all that backstory that occurred. It's childhood adverse experiences that occurred. It's where you live, you may be living in a car because you're unhoused. There's all of this that we thought that you want systems to be interoperable so that we would know about your caregiver. You would know about where you get long-term services and supports if you need those supports because you're disabled or you're becoming frail as you get older.

We want them to look at social services. If you're formerly incarcerated or you have a family member who's just getting out of justice involve systems then want to know do you have the social supports, economic supports, the mental health supports. Even mental and physical health is not well-integrated in our systems here so integrating that. It is about not just computers talking to each other. That's how interoperability is about.

It's not only thing it's about, it's really about people talking to each other. That's how the systems get to work. These scenarios then is what we thought to get there. Then we have to have an interoperable system. SoCal aim is at least it's just a five-year experiment.

We hope it could be more than that. But it's something that we're at least the California Department of Health Care Services, which is a big player here for health care in California for the Medi-Cal program. That at least there are going to invest in more of this connectivity and care coordination. Also then that we also get at this communitarian piece so not individual.

Where we know during COVID that finally, I think people got as an economist, these idea of infectious disease having externalities. There's not just about individual costs, there's external community costs. We're all in this together. Individual behavior has ramifications on community communitarian benefits and harms.

If we get into those values, of being more communitarian, values of connecting and communicating and being more in interoperable. If we can build a better mouse trap that way, then we'll have a better health system. Great, Thank you Ninez. Final coda to that, one of the things I found super fascinating and as when you and I were speaking through this is that some of the biggest innovations that we can see in the next five years will likely come from the public sector, [BACKGROUND] where people typically don't think of as engines of innovation. But in California seems like that there's a lot of promise there. I can tell you, just really insert why. It's cost.

[BACKGROUND] [LAUGHTER] Cost is oftentimes the driver and the systems are built for the most complex patients. Children with special care needs, older populations. Cost is driving the need for innovation, whether we like it or not. [OVERLAPPING] One the state is in a position to do something about it because it is involved in all of these different systems, right? Right. Because you can choose to spend your money in other ways.

What are some of your hopes in terms of building more equitable systems from what we've learned from COVID, as it involves Native Hawaiian and Pacific Islander communities as well as other communities similarly situated? A lot of the work that EPIC does, and our research in particular is grounded in the scholarship of Dr. Linda Tuhiwai Smith who wrote Decolonizing Methodologies. It was this piece that was about listen, I know our people don't trust research because we've been exploited for so long, but I need you to know that we've always been researchers, and we have ways of producing and disseminating knowledge that center our people and understand that our elders are just as much an expert as a PhD student.

In talk about COVID, there are a lot of ways that the dominant narrative really posited our people as inherently unhealthy. That we had COVID because we were obese, because we are diabetic, because we have heart disease. All of these things that are symptomatic of colonization that when you take away people's land, you take away their sovereign foodways, the ways that they have historically taken care of themselves. When you place them in neighborhoods that are food deserts, what options do they have to continue to have care? We have COFA migrants who have been denied healthcare for so long, who have actually not had access to Medicare or MediCal and so how does anybody build healthy wellness habits if for the entirety of their time in this country, they've actually never been able to access health. The inquiry we always placed on systems and not our people.

The other aspect is that people talked about us being inherently unhealthy are cultures as the thing that you had to set aside in order to get healthy, in order to get safe. We reminded them, we actually come from communities of equity and interdependence, who deeply understand in a village setting, in a canoe setting, that everybody has a role to play. There isn't an individualism that any of us actually get to enjoy, how deeply interwoven we are.

In particular, when we talk about data, how frequently our communities are told that we're statistically insignificant. There are more Samoans here than there are in Samoa. There are more native Hawaiians here on the continent than there are in Hawaii. If we are not large enough here, we're not large enough anywhere to matter.

This notion of statistical significance is also really critical to understand that indigenous communities, native communities who've always had these practices of coordinated community care are also the miner's canary of equity. Things that would inconvenience more resourced communities, communities with more power and institutional capital devastate our communities. That you didn't have to look very far, as we were actually taking our lessons , not from California, but actually from Navajo Nation, who when the vaccine was available, chose to vaccinate their Navajo speakers first. They said, we need these people to go first because they're going to carry this on.

We need them to survive. They are the critical piece of when I needed to figure out how to take care of our communities, systemically, we went to our own people. I think of my mom and my sister, who are both nurses, who after working 16-hour shifts, would come home and then explain in Samoan to church members this is what your doctor meant, this is what they said.

I really appreciate what Camille had lifted up, this notion of what it means to start in language first and then translate into English. Because when we start from Samoan, there's an oratory protocol that dictates and starts from a place of equity. Because that's actually already embedded in our language and our oral tradition. Wanting to make sure that we're the starting place and not an afterthought. Because we know that's going to be the best way to get to equity. Thank you, Tavae.

Final question for the remaining speakers. Just want to ask, are there things that you're exploring from an institutional perspective that could design better from a human and community-centered design approach moving forward? As we look at how we're going to evolve as an institution, it starts from within, and that means our workforce and our labor force and the equity of the people delivering care as well as the patients that are receiving it. Lots of credit to our CEO, Patty Mason, who recently appointed Associate Chief Medical Officer and VP of Health Equity, Dr. Crystal Cene. One of the things that Crystal is really bringing is that our true north as an organization is delivering high-quality, equitable healthcare to our community. We can't do that if we don't have people who speak natively, who resonate with community, who understand the cultural values.

We're really recruiting and developing with intention to address these areas of disparity. That includes things like bringing undergraduates into positions that we might not have hired into previously. It still includes a lot of data.

There's a notion that's been coined called tequity or technology equity. It's a concept that I think we're reaching for, but have a ways to go. When we launched the state's first vaccine superstition, we launched it in five days, that we could get to our goal of delivering 5,000 vaccines a day, back in January of 2021.

We accomplished it very quickly, and at the same time, because we had real-time data on who was getting vaccinated, we found out that, number 1, we were vaccinating people coming from higher socioeconomic areas. Number 2, when we slice and dice the data by race, ethnicity, and language real, it wasn't actually race or ethnicity that was the biggest disparity. Language. It was really about how are we communicating and getting the information out in native languages. Then number 3, with our CTO support, we immediately launched what we call MVUs, or mobile vaccine units. The MVUs got out in the community to deliver vaccines not in a way where it was UC San Diego Health communicating, but in partnership with the local community organizations, the CBOs, who they were getting the word out.

We weren't advertising. It was so incredibly effective, and the Navajo Nation did a tremendous job vaccinating their populations. Imperial County did a tremendous job of vaccinating the LatinX population there. We had gaps and we took those strategies to really help to deliver healthcare in our region.

Longer-term, there's a whole lot of labor and workforce implications that we've learned as well. I just want to add to that. I think it's really important that we're thinking about our pipeline of next-generation. But existing right now in our systems are people that are being impacted by the use of predictive analytics to start improving the healthcare system. That influences not only the decision-makers but there's a connection to patients and to workflows. All of these different stakeholders are influenced by these new technologies.

When there was a decision to use predictive analytics to improve the scheduling of patients in clinics, they ran a model to see who was likely to no-show. Guess what happens? The model picks up people of color as not likely to show up, double books them, and doesn't deal with the reason that they can't make their appointment. If you can get people at the table who can foresee the social downstream implications of these decisions, and then test the model and see how it works. Then try to figure out what were the social determinants that are causing this? Try to figure out how do we solve for that root cause and really think through these problems carefully.

We actually have 12 AI models in production to help with health care at UC San Diego. It's overseen by an AI committee that takes an ethics and just approach. I know Dr. Neuberger is a participant and it's explicitly because we want to ensure that we're aware of potential biases that are developed by these models. Every large dataset has biases inherent in the data set.

If you don't acknowledge those, then you can end up with these unintended consequences that you're talking about. Getting back to Tech, oftentimes we create new technologies and it's used for efficiency rather than equity because equity is much harder to do. How do we know we're addressing equity and not using our technology to do other things. Like what are some measurable ways that you're going to tell me, we're dismantling this inequitable system with technology.

Well, you go back to when I said, we have one of the highest child poverty rates in the nation. You go back into looking at measures of structural determinants. When I go to different rooms where I read the room and it's really not about equity. I actually talk about efficiency and quality. That better data that really reflects the experience, the pain, the joys of people, and the intersections that they live in, that that actually is more efficient in getting the types of services that people need so that it's not an either or dichotomous like, oh, I'm going to just deal with efficiency.

The problem is that we were dealing with efficiency for the average consumer. That's part of the problem. Hi, my name is Glen Wing I'm a medical student here and I've had the privilege of working at UCSD student run free clinic who when we work with a lot of undocumented immigrants. I know that on May 1st, there was a rule change that now anyone over the age of 50, you will get full Medicare coverage. We are transitioning a lot of our patients over to family health clinics or whatever system that we'll use them.

We'll use this medical service. It's great for these patients because there'll be able to be seen faster get these services. Were also getting a lot of hesitancy from our patients who come to free clinic because they know they will get services that it has a health equity in mind where they will be working with students and doctors who speak their language.

It worries me as someone who has been following patients who are now transitioning to the system. I'm wondering what you all thought or thinking about how this change will affect the shift in more people go into family health centers. Then also how we can encourage our patients to trust the system that may not have necessarily, as you said, been very kind to them in the past.

Well, first of all, thank you for volunteering the student-run clinic. We loved the clinic. Secondly, I'm going to take a circuitous but brief approach to responding to your question. You've mentioned Medi-Cal and the importance in our state. We also talked about the likelihood of the public systems contributing to innovation. I just can't stress that enough.

In the state of California where Medi-Cal is a significant insurer or we get a lot of our money from the federal government. The federal government gave us a waiver called the 1115 Waiver. Through that, the prime program was born in the state of California. The prime program helped us to fund and drive a bunch of these equity efforts. In fact, UC San Diego, among 35 safety net institutions in the state, ranks Number 1 in the prime program.

I will say that we're more proud as a leadership team of that than we are of our US News rankings. The federally qualified health centers that you're talking about, they do a tremendous job taking care of the medical covered patients and they're reimbursed for acts as much. They have resources that we don't have to care for those patients. That's a really important piece of data as well. I'm a trustee and also my background is data and analytics.

I was very intrigued by your point about an opportunity around how large datasets have inherent bias. Well, that's true, but that's an opportunity. Given there's so many datasets, what can we do to collaborate and also what's missing and how can we actually add to it? It's easy.

It just as long as we know what we need to look forward to augment them so that the predictive analytics can actually deal with the root cause versus come up with these things that are like double booking. People who are not white because they can make it. It's about measures, and it's about having truth through community voices. There's direct measurements, and indirect measurements and know a little bit of this because I also worked for Nielsen where their insights company, and they had to use big data. But they also had a panel. They thought that their comparative advantage was they had the direct survey work than with the big data work.

What I would suggest is, first of all, talk to people, get communities get to via [LAUGHTER] a lot of commissions. It can pay communities too when you're talking to them? Yes. But you still should use surveys because you still need direct estimates are truth from people. Because if it's all about they're spending patterns are, or the big AI story was that showing that blacks didn't have access to care problems because they weren't spending that much when they looked at expenses is because they weren't giving care.

But again, the doors, that's part of the bias. What's your measure? The first thing is what's the measure? Then making sure that all of these auxiliary datasets like your credit card statement, your finance statement, how you shop. Because mostly lot banking, that's also big data. That that's augmented by some truth of direct estimates.

I'm talking from a survey data producer point of view. Karthick, just wrap up. I'll just say a couple of words to wrap up and then turn to Mai to close today's session. We've talked a lot about data and the power of data.

Very good point if we have choices of different types of data that let's not get stuck to one thing. there are couple of other things that have come up as threads in this conversation and then prior conversations too, which is, what are our values? I've really found that interesting exchange in terms of we're Number 1 in what? Often when it comes to higher ed institutions, when it comes to health systems, there are these rankings that are so misaligned with the values we purport to care about. How can we then change it so that the things that we, not only that we measure, but that we value that gives prestige, that get people promoted, that get people into CEO positions are not.

The bottom line things that are totally at odds with our values of equity and inclusion and all these other values. That's so important. I remember Larry, I forgot his last name.

Larry Frank. Larry Frank. In terms of the walkability score and the power of that, and how it change the way you would think about urban design. But there are values that are underlying it that we have to keep in mind. We also need to think about power and disparities and power. Of course, as someone who believes in the power of data, it's data and research are not value-free.

They are not free from power either. Is not just to acknowledge it, but to actually change the way we design these things so that we can get to equity. After this, we are actually having a health tech demo upstairs in the design lab. I encourage you all to come up and check it out because just as you said, we're really thinking about how we design the future so that it is more equitable that through technology and the design lab, I'm so proud of my design lab faculty and students who could go out and work in tech and design things that make a lot of money. But what they're trying to do is actually democratize access to health care and make it accessible and available to everybody regardless of their income and their ability to pay. I encourage you to come up and take a look at some of the cool innovations and advances that we have here.

Thank you [MUSIC].

2022-08-26 22:19

Show Video

Other news