Techquity Series: Cultural Perspectives in Health Tech

[00:00:00] Joy Rios: Hello, and welcome back to the HIT Like a Girl podcast. I'm your host Joy Rios, and today we continue our deep dive into techquity, our five part series focused on digital health equity. Each episode, we'll explore different facets of how technology can bridge gaps in healthcare to ensure equitable outcomes for all.

Joining us again to kick off this interview is Janna Guinen from the HLTH Foundation. Today, Janna will discuss the coalition's current endeavors including drafting vital recommendations and those best practices that can be used in the healthcare industry. Welcome back, Janna. It's wonderful to have you share these initiatives with us.

I'm so grateful for you.

[00:00:47] Janna Guinen: Hi, Joy. Thanks for having me back. For anyone who is just joining us for the first time today, HLTH Foundation is a non profit organization that has an initiative called the Techquity for Health Coalition. And as Joy mentioned, we're working on developing best practices, recommendations, and also metrics for digital health equity or techquity.

We just finished our first Techquity for Health case study competition in February. So in this series, you will hear from five different winners in an interview and here we are joy and I are just giving you some context here about the coalition and about equity to set up these interviews.

So there'll be, you'll have a little more context for the conversation. So now that we've concluded the competition, we have, the coalition has a really fantastic, rich database of information from our close to 200 submissions that we got through this competition. And this is what we're going to use to learn and to check our understanding of perceptions of tech equity, practice of techquity today and where we think it should be.

So we want to provide evidence based information on how to use digital health and data to reduce health disparities and also to avoid or eliminate inequities in health care. And there have been many famous examples of how tech equity could really get in the way of that. But also just as many I think of how technology can be extremely helpful in decreasing barriers in many ways and making healthcare more accessible, potentially more affordable and effective.

So that's what we're working on. And we are only focused on underserved populations. So the people most in need in our country, we just want to influence how every single stakeholder in healthcare, healthcare technology, I shouldn't use the word just because this is such a bold thing to say, but we hope that this happens.

The dream is to influence the way stakeholders and health technology consider health equity from the outset of any project. So whether it's an app or telehealth program or any other tech enabled intervention or use of data or algorithmic analytics, all of it, it just needs, we need to have that consideration.

Using these insights right now, we are preparing a white paper that highlights what we identified as best practices through this case study and our prior work. And we're also planning to publish the individual winning projects. And we want people to see in detail these case studies and to make them visible to a wider audience.

And then the next kind of thing that we're planning, we're launching a Techquity Learning Collaborative. And this will be a chance for our winners, case study winners and our advisors at first, we're treating it like a beta and the goal is to foster this community of mutual support and knowledge exchange integrity. So again, it's going to be beta at the beginning but our winners expressed a strong desire to get to know one another to learn from one another and our advisors are also equally invested.

So we're going to start with them and just, we'll see how it goes, right? After that, if everything goes well, and we think that we have some real value to offer everyone else, then we'll consider opening it up to make a larger industry wide Techquity Learning Collaborative. We'll just see. And then, generally, I will say that this is going to be a huge year of outreach for the Techquity Coalition.

A few of the things we have coming up are a roundtable, which will host HLTH Europe. And the purpose of that is really to just begin to get feedback on our best practices and recommendations that we're putting out shortly and gather information from people in other nations about the conversation the culture of health equity of digital health equity, who are the leaders, what are the projects to just start to understand so that eventually we can build that bridge and adapt our recommendations for other places.

And then I'm working on, I won't go into it all, but I'll just say I'm working on bridging to other organizations, developing partnerships. One important one for me this year is sitting on the digital health collaborative that Peterson Health Technology Institute has rolled out. I'm very thrilled that they are considering Techquity as a really important aspect of the work that they are doing.

And we'll be conducting workshops and out there speaking about techquity this year. Again, just a big year of outreach for us.

[00:05:04] Joy Rios: You guys have so much going on. You've come so far and you have so far to go, but it's just really exciting to see how far you have come and the progress that has already been made, and it's remarkable how many insights you've been able to collect in just this short amount of time.

And so I am so excited to see the progress and how you guys are taking this conversation globally and that the expanse and impact of your work is really impressive. Thank you so much for what you're doing. Now let's turn to the exciting part. Who is joining us today, Janna? Can you tell us a bit about our interviewer and the incredible awardee we'll be hearing from?

[00:05:48] Janna Guinen: This is going to be a great conversation. Today's guest is Chrissy Kuahine, who is Director of Clinical and Patient Informatics at the Waianae Coast Comprehensive Health Center in Onoahu in Hawaii. She is being interviewed by Dr. Michael Penn, who is a Physician Advisor for Health Equity and Innovation at the American Medical Association. And I will say this is a giant of a conversation. I know you were there for it. It was, it's just been, it was really interesting and they just brought so much to the table in this conversation. So Chrissy's project addresses digital literacy and connectivity among elderly native Hawaiians.

And I'll just point out a couple of things. One really interesting aspect she mentions is the use of digital navigators and they're people who helped the program participants feel comfortable engaging with technology. This is just she did a lot of work to understand what it would take to get people to really engage.

She also weaves in a few native Hawaiian words, which I just loved hearing, cause that's a fun bit. She's a really good cultural ambassador. And it's something that, you when you meet her you'll just hear, it's just a part of how she lives every day, like knitting together native Hawaiian culture together for the rest of us who may not like really understand the values, the words, et cetera. So that was fun.

Chrissy's an informatics leader and she has a really deep data set, an enviable data set at her fingertips, decades of patient data. And because she serves a large indigenous population, her project was set up to combine a really tight evidence mindset, very experienced group there, the soft skills of valuing community, respecting culture.

And there's also a big piece of this at the beginning that talks about historical context and the meaning of historical context and why it's important in delivering programs around equity. So I'm going to say to anyone who's listening, if you're a little bit skeptic about the importance of soft skills and how those can lead to results, please listen until the end because another really exciting part of the conversation does come at the end.

YNA Coast has developed what they call an impactability score. This is something that they made up. This shows, just because of the data they have, let me just add, it's just because of the depth and the breadth of data, they're able to show what kind of influence they can have on individual patients and their behaviors.

And they can pinpoint the approaches that will influence that patient's behavior and cost. So overall, my takeaways from this conversation are that when you develop programs with collaboration and respect for culture, and then you have appropriate data capture. Eventually, and this is what Chrissy leaves us with, eventually you will be in a place where you can negotiate your own models with payers.

So this is a really good one. Let's turn it over to Michael and Chrissy.

[00:08:39] Michael Penn: Hello. I am Michael Penn, Physician Advisor for Health Equity and Innovation at the American Medical Association and also Advisor to HLTH Foundation's Techquity for Health Coalition. And today I'm here with Chrissy Kuahine, Director of Clinical and Patient Informatics at the  Waianae Coast Comprehensive Health Center.

Welcome, Chrissy.

[00:09:02] Chrissy Kuahine: Aloha. Ka kakia. Michael.

[00:09:04] Michael Penn: Aloha. Ka kakia means morning, right?  

[00:09:08] Chrissy Kuahine: Good morning. Yes.

[00:09:10] Michael Penn: Yay. Tell us about who you are, what you do, and how that helps the community health center that you work at. 

[00:09:18] Chrissy Kuahine: Sure. Mahalo. First of all for having me here. It’s really nice seeing you again By the way, Michael, we were both at Ata.

I work at the  Waianae Coast Comprehensive Health Center, We're a federally qualified community health center in Hawaii on the island of Oahu on the west side of Oahu and I always say the west side is the best. It's interesting. West side is best side for community health centers.

It's interesting folks always ask what do we do? And quite honestly, we do everything. I think the last statistics that I've heard from NAC national association of community health centers, one in four folks in the United States have received or are receiving services from a community health center, sometimes whether they know it or not.

And so really, for our health center, I think we're unique in the fact that we, our patient population is predominantly Native Hawaiian of Native Hawaiian descent. And so with that, we have to address some unique cultural aspects as well as historical. And so I've 34 years when people ask what I do, I wore many hats over that time.

So I have some good clinical insight. I was a medical assistant for many years and then move over to the technology side. When we switched from our paper to an electronic medical record, which is now gosh, 24 years. So I will have to say our health center is really, I think a testament to community driven healthcare.

I think we've done a really good job of blending a tradition and innovation, western medicine and native Hawaiian medicine. And we. Have a native point healing center and so we know the importance of reconnecting or keeping the connection of health care when it comes to there's a place for western medicine, but also tradition, traditional practices.

[00:11:02] Michael Penn: I want to unpack the cultural aspect a bit because I think one of the greatest opportunities, I think in healthcare is to actually tailor and target the delivery of care through the lens of a patient's cultural lived experience. And one, can you give us insight into how that impacts care, right? So how do you make decisions based on insights that you have from a cultural perspective and then I want to ask a broader question.

[00:11:35] Chrissy Kuahine: Sure. Absolutely I think what it comes down to really from a community perspective. So whoever you serve whatever their cultural background is again, we're predominantly native Hawaiian, but we also have other cultures We have our Pacific Islanders in our Asian community and so really it's the connection with community. And I was just talking to some folks who came out here to introduce a particular new technology and they asked the same question and said really it is about going out into the community.

So it helps. I'm born and raised here. I live in my community, work in my community, but going out to our different community summits, to our grassroots different organizations and really hearing what our community's priorities are and what their needs are. And in terms of healthcare there's lots of health inequity.

There are a lot of in terms of digital, there are a lot of digital inequities that we know exist. And so really, my what I feel like my job and the value I bring to my organization, my community is listening to really what folks needs are. I might think that they need something. My executive team might think that the community needs something.

But really, it's about making sure you listen, you communicate being open to what people's lived experiences are, because that's really that's going to shape what we can do best for our community.

[00:12:53] Michael Penn: Thank you for that. So you recently won the Techquity in Action Award for a specific project that addressed some of these barriers that you just alluded to for the indigenous older elderly population.

And this was a special award sponsored by the American Medical Association in conjunction with the HLTH Foundation's Techquity for Health Coalition. So tell us at a high level about this project, right? What problems were you trying to solve and what did you actually accomplish?

[00:13:23] Chrissy Kuahine: Sure thing. First and foremost, it really was a surprise.

I submitted the case study just in hopes of having 10 minutes to share what we experienced and what I really feel like is something that's replicable in other communities. So really honestly, as I go through it, you'll break down and go, wait, there's not really anything special or hard about it.

It's just a matter of understanding the greatest need. And then having in our case, we targeted and focused on a particular population. And so from 2020, we were able to very quickly in our EHR system, create a way that we could collect data. I think I eluded to that as to why our folks were connecting via telephone versus televideo.

And so what we quickly learned is we have two things. We have access issues, right? So whether or not, again, unstable or just no internet access at all. But we also saw that there were some little digital literacy issues. And especially in our patient surveys that we take included in 2020, we started to include telehealth as an experience overall satisfaction. How hard is it to connect?

And we then break it down into age. So maybe not surprisingly, but surprisingly to me, as they got older, the ability to connect. Without having any problems was much higher for our 60 plus, but the other thing is to hear we all live multi generational. A lot of it is cultural, but then some is economics, high cost of living here.

So I think we saw with our own families our kapuna were afraid of going out because they were getting sick. But and at the same time when it comes to the digital literacy part, they may be connected but I don't know about other cases in the U.S. But our folks because of cyber security and people our elders kapuna our elders getting scammed. It was always don't click the link.

Don't click the link and then I remind folks to connect with your provider, you get a text or an email, and how do you connect? You have to connect the link. Connect the link, right? And so it's a matter of educating our kupuna in this case, and we really targeted them because we also have a kupuna council, so an elders council that runs our traditional healing side of our services, and they were giving feedback about my peers, my kupuna friends, they were afraid, and so what was happening is they just weren't seeing their doctor, they weren't following up. And so I talked to my kupuna, my auntie Nalani, and we together said, hey, let's put something together, make sure that we address everything that we need to in terms of creating a tailored computer basics, not 101, 001, and get the right trainer and the right folks involved.

And so we did that. And then I needed access. So I made friends with the for profit, I know we're going to talk about that in a little bit, but we set up a community Wifi, which was eventually for that program, but now has blossomed into a community Wifi initiative.

[00:16:26] Michael Penn: So the access part of it, I guess I want to challenge you a little bit around.

This is easy because I've learned a lot more detail from you since providing the award, you're a pretty unique individual and the things you take for granted in terms of being a connector, being really taking the initiative, being a native Hawaiian, right? All of those things, it seems to me are really critical.

So what is translatable, right? So if you can distill down, because not every place has a Chrissy they may have approximations. But yeah, talk to me about the generalizability.

[00:17:05] Chrissy Kuahine: Sure. So number one, can't do it by yourself. That's not only me. I will say probably one of my strengths is I like to make friends.

And I'm always honestly, I'm always open to what may others may not think is opportunity. And it's not to say that I make friends and somehow we end up with a project. But you don't know unless you are open to the idea. And then really what we call in Hawaii top story, right? And I don't know if it's maybe folks don't have time or think that it's maybe not worth the time to talk story But it's pretty cool how far you can go with just letting folks know what your initiative is, whether it's for you your community organization and then all of a sudden you find there's some common goal. And so that's really I think putting the strategic partnership part together In terms of what's relatable in each community we all have a target population, whether that's going to be a kupuna, your elder, whether that's going to be, if you're looking at the younger generation in Hawaii, we call that our opio our young ones that are coming up.

And if anybody that we want to make sure we instill whatever initiative it is whether it's Improving health literacy, whether it's letting them know that they all know technology is here, but how can we use it, whether to shape a career path or in our case, quite honestly, when we set up the kapuna program, we knew that they weren't going to come by themselves, right?

So we said, make sure, bring your caregiver, bring your mo'opuna, right? Your grandchild. And sure enough, there are quite a few kapuna who brought their sixth grade mo'opuna, right? Their grandchild, because if anybody knows. technology. It's going to be them and how wonderful that is right to build that relationship between your kupuna and your mo'opuna.

But then also too they now they have a common bond and really now your kupuna is learning and not just no grandma, I'll do it for you kind of thing. And so that's, I think that's relatable. There's relationships and family. And then at the same time, understanding, I think going back to what your community culture is.

So I understood we understood kapuna not going to come by themselves. We made sure we had digital navigators because kapuna, more likely or they're not going to be willing to raise their hand if they're lost or left behind in that part of the training. So I think just making sure again you and I didn't do it again myself Auntie Nalani, what do we do?

How do we I she was my connector and she had kapuna who like right up until the day before the class called her and said, “I don't know. Do you think I can? Do you think I have? I feel nervous. I've never turned on a laptop”. And so having those folks that can also make the connection because I'm not Kupuna yet. I might be pretty close, but I'm not yet. So having the Kupuna peer so that they can motivate and bring confidence to each other.

[00:19:52] Michael Penn: So the other thing I heard is somebody in the organization needs to have an external lens, strategic partnerships lens, and the personality that would support that and the skills and the gifts that would support that.

I also heard your kapuna council, your healing council. I forget exactly the so that's beautiful, right? The recognizing that there's healing beyond western traditions and that it, so talk to us about that marriage, that blending, because it seems to me that I know that FQHCs tend to have people from the community on their governing boards, but it sounds like what you've put together is even beyond that.

And yeah, talk to us about that…

[00:20:41] Chrissy Kuahine: So you're right. So the real beauty of community health centers is you have a board over 51 over 50 percent of your board have to be patients from your community. So really, community health centers are driven by their community board. On top of that, for us, our native point healing center, which we do have a physical native point healing center that was built here on campus and each of in the component council, each of them are practitioners.

One may specialize in which is use of herbs and medicines, herbs for medicine, and if I say massage. So there's a practitioner for that. So each of those folks have been blessed with that gift, that healing gift. And so they bring that to our community and how that's done. Weaved into western medicine the way that it works is our western practitioners don't refer like you would in a normal referral but our community knows that it's available because that's really part of everyone growing up. And so they know that they can go there at any time and that's for employees as well And use any of those services including hooponopono.

That's one’s a big one. I always like to highlight this one is a way for conflict resolution. So it's a non traditional way of conflict resolution. Very important in native Hawaiian tradition and households. So if you can imagine this, if a family is having conflict, whether it's some pilikia, some conflict that's happening, some, a lot of times that can manifest with, “Oh, you go into your doctor and my stomach hurts all the time, or I have a headache all the time, or I just don't feel well”. A lot of times, western medicine said, “Here, let's take an acid or some kind of pill”. When in reality, if you really break it down, maybe there's some family strife that's happening.

Hooponopono is a way of bringing everyone together, addressing really the root of the issue, which may not be physical, but it's emotional that's now manifesting itself as physical. Yeah, there's, I think that's really the beauty of just bringing those things together because then you're really truly from a traditional Native Hawaiian aspect, you are healing the person.

That's the whole holistic approach. And so I see that. We're so grateful and fortunate we're able to provide that to a community who really just historically that has been, had been lost because of the European occupation and some things that have happened in the past, but that now have brought us to where we're at. So there's definitely a healing aspect that I think is so important for our community.

[00:23:09] Michael Penn: At the risk of opening a can of worms, you mentioned essentially colonialism, right? European occupation. And I had an opportunity recently to travel to Montgomery, Alabama, and there are a series of museums, monuments, and memorials that really unpack the experience of slavery and Jim Crow and reconstruction and racism and mass incarceration.

And I don't think until going through those sites, I appreciated the profound impacts of colonialism and that mindset of domination, essentially, right? And acquisition. And I think the health care community often looks at disparities almost through the lens of why are these people doing this to them?

Why can't they make better choices? And If you actually look at the history like colonialism, racism established many of these patterns long before people. And so talk to me about what in your community, because I think this is something that people in the health care community don't understand enough of. And I think if more people did, it could really shift how they approach care delivery.

[00:24:27] Chrissy Kuahine: Oh, absolutely. I'm so glad that you brought that up because I think if you don't know the history of a particular, in our case, Native Hawaiian experience, you might think that they're illiterate in terms of their own health care or their mindset.

It's about this particular point in time. And really it isn't. If you go back to Native Hawaiians, they were the healthiest. And if you look back at old photos, Duke Kohanumoku is a great one. He was a Hawaiian Olympic swimmer, and if you look at his physique and his health that really was representative of Native Hawaiians.

They left off the land, everything that they had, their aina, their land, their vai, their water, they had everything they needed. And then when, with actually the, this Captain Cook discovering the islands that really started off the whole disease, in terms of introducing disease, that Native Hawaiians did not have the immunity for it.

So then you talk about now a decimation of a population from anywhere from there's really hard enough true numbers but some say as much as almost a million native Hawaiians. Once Captain Cook left and other European folks introduced the other diseases like measles. Half the population was, and then you have the U.S. unlawful occupation and overthrow of the monarchy, and literally this is not even an exaggeration, the whole identity of a native fine was stripped. And so I'll give you an example. If you're getting ready to go to high school, and if you're not speaking only English. You weren't allowed to go to high school.

So now what does that do for in terms of education and where you are in terms of level and your knowledge that you didn't have that and then losing your whole your language and how you can care for yourself in a way and then that was all lost. So now we have where we are with health disparities. Our own community, if we look at diabetes prevalence, we're double diabetes just in my community compared to the state. So that's telling right?

And so these are things that we have to keep in mind because it seems like a long time ago, but not really for native Hawaiians. This hasn't been that long and it's just through generation and generation. So i'm trying to be I think first of all understanding it and then you can approach it in a way that diabetes was not part of your family. This is not something that my grandma grandpa has it my mom and dad thus I will have it. No, that's not doesn't have to be the case. And so yeah, thanks for asking that I appreciate it because I don't think most folks know.

[00:26:53] Michael Penn: You're welcome. You had this ambitious goal of empowering your elder community with tech literacy with Wifi, being able to access healthcare providers in a variety of different modalities.

How would you describe sort of the outcomes of this work?

[00:27:11] Chrissy Kuahine: It's actually pretty remarkable. So we started off with some of the partners that we worked with, especially our trainer, and that was really I wanted to make sure that we had someone that was patient, number one, right? And who really understood where our kupuna was coming from in terms of being nervous, not being confident.

A lot of them had cell phones, but really they're either they're ma'opuna or they're adult child set, a set of everything for them. They may have had an email. They don't know how to access it, or they don't know how they're passed. So I had a really great trainer, a native Hawaiian who had been around our state and specifically training kupuna.

The other thing that we made sure to do was we wanted to not only train our kapuna, we wanted them to leave with a device. So we partnered with actually three, one of them was our state library system to have our kupuna walk away with a refurbished laptop once they were done with the training.

So after their first three hour training, they walked away with a free laptop. But one of the things I did want to make sure this is something to that can be incorporated for others. And I'm picking out my list of things that was really important to me for something like really, but if you think from a culture's perspective, we started off every single training session.

So it did blossom from 1 to 3 based on kapuna request, right? We always started off with either a prayer or an oldie, which is the method, or both. And really, that was for from a traditional standpoint, it really is for gratitude for our generations that have come before us. And then also to just asking that we all have all of us involved in this process that we all have strong minds, open hearts to learning new things.

And so we always started off that as a reminder, and I think that honesty can resonate and however that is, even if you're just saying it, let's go in with an open mind and then technology doesn't seem so scary then, right? So some of the outcomes, we started off with a survey, so a baseline, how comfortable are you with technology?

Are you seeing, are you visiting? Or have you thought about using telehealth to visit with your provider? So at the end of our three, three hour sessions, we did a survey on all those things. And so 70%, 76 percent of our kupuna felt more comfortable with using their, in this case, a laptop. Some of them had never turned on a laptop. Ever. So just turning it on was like everyone was cheering. We got on 83 percent said that they felt more comfortable with their computer skills. And then this is what I really love 72%. So most everyone reported that they would be interested and or we're ready to connect with their provider via televideo.

And that's really what it's about when it comes to kapuna having the knowledge and then now the confidence to do it because yeah, what really saddened me was that they just accepted that they wouldn't see their provider until it was over. And look, it was almost four years, right? Three and a half years.

It was definitely something that, and then we left, we have our Wifi. So I told him, “Hey, bring, come to our cafe. We have, it's, we have a cafe on campus”. I forgot to mention my lots of things here. But come back to our cafe where you learned how to get connected and then you bring your laptop and you can meet up with your friends.

One of the things too that I don't think folks realize, we think kapuna, they're retired, they're not busy, but I tell you, our kapuna, they're very much into civic engagement. And so one of the things that I like to, it brings me so much joy that happened. At the end of our third class where we all had done zoom and folks are ready to go out into the go into their digital world, right?

They crossed the bridge over and one kapuna said, “Thank you so much Chrissy”, because all this time I had been in person to our neighborhood board meetings. I had been volunteering for all these grassroots activities, but it was all in person once everything got shut down. He wasn't able to connect and his friends were calling him saying, “Hey, come on. You got to get on Zoom music.” I don't even know how so he said once we got on Zoom. He said now I can get back to my neighborhood board meetings I can do the get sign up for the positions that they want me to take so think about it now people go, “Oh great for him”. I said no, but that think even bigger right?

He's now being able to get back and being active and doing things for our community .See if that's one person but how many people in the community now are going to benefit and are touched by this one class, great. That's big.

[00:31:38] Michael Penn: I think we often overlook the ripples that one intervention can radiate out to the community.

So the other thing that I just thought was amazing when I read your case study is how intentional you were to leverage leading bleeding edge technology, right? So AI measuring sort of the cost savings, the outcomes. So give us a high level view of that.

[00:32:07] Chrissy Kuahine: For a CHC, I like to stay in the middle of the ocean, literally.

We're really a diamond that folks are pretty surprised at how advanced in terms of innovation. But part of our mission statement, believe it or not, is that in order for us to make sure that we provide The best quality of care to our patients is that we will use innovation and emerging technology.

So I think that's pretty telling, right? We're made 52, we'll be 52 years this year. So when you think about our founders and what they were thinking so far ahead, and our CEO who really knew that data was going to be important and that we're talking 30 years ago.

[00:32:44] Michael Penn: We need to pause on that because we're talking decades worth of data.

So when you say AI, you're talking about decades worth of patient information. Very few centers, even health systems, right? Large health systems have them in depth of richness of data. Kudos to your CEO. What's his name? 

[00:33:09] Chrissy Kuahine: His name is Rich Bettini, and I tell you, I used to say, “Hey, Rich, where's your crystal ball?” Because for someone really, and we're talking about care, enabling social services, the kinds of services that we know contribute to health care outcomes from a holistic approach, right? So we're not just talking CPT diagnostic codes. We're talking about if you're in anyone in the health care industry knows it's not just about meeting your provider.

You leave the office. If there's a referral to a specialist or if there's a new medication added to your list of medications or some new health diagnosis If there's time that someone either you the provider your clinical team a case manager sits and explains what's happening with your care or what next what is the next step or with your family?

Now if you don't code that the parents don't know they don't see that complexity, especially in a community that we serve We're underserved marginalized community. So there's so many other things that contribute to a person's well being, and we all know that as social determinants of health. We've been collecting all of that data for 30 years.

No, we didn't use it. We know, we, we knew we would use it at some point, right? And then if another kind of just giving an idea of how I'm going to say technologically advanced for a community health center, we've had our electronic health record for 20 years. We purchased our electronic health record with our own money, not with the grant.

So that's I think that I like to say that because that's even telling about how we knew our data would help to prove our value. That's one thing. I think that all community health centers and even other organizations to the folks that are making the rules in terms of reimbursement in terms of whether or not in this case telehealth really is it going to help with health care comes.

Is it going to cost more money? Is it going to be a cost savings? We have to prove it that's on us because we know what we do is important. Our patients are so in order to do that, you have to have the data for sure.

[00:35:06] Michael Penn: Congratulations, because that is a huge accomplishment. But more importantly, it just positions you to really serve your community and provide the best possible.

My view is that when you look at the annual sort of cost to our country of health disparities based on race and ethnicity. It's nearly a half a trillion dollars, excuse me, 500 billion each year, and it's only going up that if we don't leverage the best of what innovation and technology and data has to offer.

I just don't think we have a real shot. So Thank you. This is part of why I joined the AMA to look at this, why I'm a member of the Techquity Coalition, because we have to lift up this idea. And one, it was just a delight to learn of the work that you guys are doing. To your point around proving value.

But can you give us a sense of the conversations you've had with like health plans as it relates to that? Are you capturing reimbursement for these other pieces? So unpack that for us. 

[00:36:14] Chrissy Kuahine: It’s done with our AI advanced analytics. And we work with a company for state healthcare solutions. And actually, we've been using AI for a long time.

For gosh, almost five years now. So yeah, so for some it's that's the new buzzword. It's been our buzzword for quite a while, but again, you can't do it without the data. So just very quickly, we've been able to capture not only so those HCC codes in our peers, if you're not, if any, for those not familiar peers, look at patient risk based off of really one, one form of data, and that's the HCC codes that Medicare then assigns a risk, right?

So if you have diabetes, high blood pressure we are a comprehensive risk model is way more than that, right? So it's besides that we have our S2H survey data. We have been able to, I'm going to say, make friends with our peers, or at least have negotiation where they send their claims data to us every month.

So having that is really, truly invaluable. And then, of course, our EHR data, and then we also have our, we use natural language processing. That's another, it's not a buzzword, it's been around for a while, but we use it to look at our community health worker notes. And for those in that field, that's going to be narrative, it's not going to be discrete data. So if you're picking up those particular words, that can really illustrate the comprehensive nature of the kind of patients you're seeing.

And now imagine being able to use that analytics to give you really, truly a comprehensive illustration of the risk score of an individual. Now that's your predictive analytics, right? What their cost is going to be in terms of accessing resources, hospitalizations, and then the overall cost. Now imagine if you can have, with all of that data, calculate an impactability score. I think we made that up, by the way, I don't know if there is such a thing as impactability score. Sounds good. It says what, it is what it says, right?

That you, so you may identify these patients at high risk for costs and poor healthcare outcomes, but what kind of impact as an organization can we have based on, sometimes peers attribute you a patient that maybe doesn't even live in your area anymore, or maybe a patient really just doesn't want to engage, and we have ways to measure that.

So then you make sure you focus on those that you can have a great greatest impact. That's predictive stuff. Now you get into prescriptive. Once you've identified those, wouldn't it be great if you knew as an individual patient, out of all these 10 things, these services that we provide, Social services, enabling services, care services.

If we could identify the top three things that would help improve your healthcare outcome the best and have a cost savings, that's like a cheat sheet for helping someone to achieve and realize their best health outcome. We've been able to do that with all of our data, all of our analytics partner.

So just to give you an idea, we piloted with a two of our local peers and because that gives you negotiating power, right? So my COO says it's the grand bargain is that if we say we're able to do what I just explained and whatever is in that risk pool. Whatever is left over we're going to have it here you get back what the savings is and then the 50 we get goes back into our same programs. And to being able to, it goes back into our community so that we're able to provide, because food programs like food our food is medicine, our community health records, those are not typically reimbursed, that service by a peer.

And so that's really the grand bargain. There's a lot you can do. It really gives you that negotiating power for sure.

[00:39:45] Michael Penn: I suspect that'll resonate with a lot of listeners, right? Because everyone's searching.

[00:39:50] Chrissy Kuahine: That’s our value based care by the way, right? So you don't have to go with the model that's being served to you.

That's I think that's probably the takeaway. You can as a community health center. Look, we've been able to i'm going to say create the roles that others now can go “Oh, okay”, we can and there's no downside risk for us I mean, we're doing it all preventive care as well as addressing really truly what the needs are now. 

[00:40:15] Michael Penn: Your data actually serves, I mean provides true information, right? And insight. Act upon and tweak and obviously greater level of confidence. So I love that clearly Government and policy are important stakeholders in this game.

So what have you been able to bring to them and perhaps maybe get from them as a result of this effort? 

[00:40:42] Chrissy Kuahine: I'm sure I'm in the digital front when it comes to telehealth and then also you Just digital inclusion as a super social determinants of health and I did not make that up. I would like to remind folks that our FCC back in 2015 they did their own study and I would love for folks to read up on it because if our federal government can identify that they've done all the studies.

I don't think we need to do any more. I think we just need to know that really truly exists and we need to start addressing it. And in terms of policy, each state's Medicaid system works differently. And with the study that we've done in terms of the, impact that or really maybe a paradigm shift to really truly looking at a hybrid virtual care model in primary care.

So I think behavioral health there's a lot of great information on that and we see that there's really truly benefit for both telephonic and televideo. And primary care, not so much, but we've done a study and that's actually what I recently presented at the ATA, as well as a *unitelligible*conference, just a few weeks ago. And I'm hoping you, what we're hoping for that is that'll impact at least our state medicaid director and seeing really the value of telephonic care in primary care because it helps so many. But honestly during Covid, and the fact that now it's been rolled back in terms of, we still provide it, because it's a community health center. We want to break down any barrier to health care. But in terms of reimbursement, it makes it really difficult not only for us as a big chc, but for smaller chcs in terms of financial feasibility to offer that as a service, but you're not being reimbursed.

The other thing that I found, at least in our community, when it comes to the accessibility with our community Wifi infrastructure, we have been able to influence up actually a recent bill that just went through that's creating the framework for all of the grant money that's coming in from the internet for all millions of dollars into each of the states.

Billions of dollars that have been set aside for getting our communities connected, especially rural, but we've been able to influence it in a way that we can hopefully fund better fund the accessibility part, right? So the community Wifi infrastructure part, because without that there's digital literacy, but if you're not connected, you can't use any of those things. And so it starts with access for sure.

[00:43:02] Michael Penn: I'm just so grateful for you joining us today. Tell us where the project is now, what your sort of vision is for the next 10 years, maybe, and then any parting words for our audience.

[00:43:14] Chrissy Kuahine: Sure thing. First of all as you get older, when I was younger, 10 years seems so far away. As you get older, 10 years is I don't have enough time to do everything I want to do. I'm actually really excited.

I've partnered with University of Mississippi Medical Center. So again, getting back to really, you can't do any of this alone. There's collaboration and strategic partnerships. But UMMC is one of two in the nation who are HRSA designated entities for telehealth. And so we have gotten together to do a data scarcity project. And so what that's going to entail, we're working with T Mobile. We have 150 iPhone devices with unlimited cell plans that we're going to deploy out to patient participants who have uncontrolled or poorly controlled diabetes.

We want to see if connection without limitations to their provider will help to improve. Their diabetes, so their hemoglobin A1c, that's going to be our indicator. And that's going to be through not only the access to healthcare when they need it, but also a health literacy part. So we as a community health center have created a mobile app and it's a community health network app where you have all your social services connection to your provider in one mobile app connection.

And so that's going to be deployed onto the phones. And so really, we're looking to see whether or not what kind of impact on you will go in a A1c. And then we also have a national health literacy survey that will do a baseline. And then after the project, it'll be a 12 month project, really directly having the patients use whatever resources they need. And then we'll also continue that on hopefully for another 12 months after that to see, really a longer time frame and impact the great thing about that is I was able to work with our T- Mobile partners And so during the summer before we deploy those phones out to the patient participants I'm going to have a computer For community specifically on iPhones.

And so because a lot of the work that we all know, a lot of the work we do our own cell phones, including applying for jobs, including you can upload resumes. Now, if you know how to use Microsoft 360. So I want to be able the whole part of digital inclusion is access, digital literacy and then the last part that people we all need to remember is the adoption and usability.

And for me, usability means making sure my community not only knows how to use it, but they're now they have the opportunity like everyone else that takes technology for granted great access to the same opportunities. Beyond healthcare, there's education, there's workforce development. And so I'm e-commerce.

We have lots of entrepreneurial spirits out here in one line. I want to make sure that they have the same opportunity. So that's what I'm working with leaving. I'll leave you with this working at our last community summit. Our own community came up with a leads. Initiative. So literacy, education, development, sustainability, accessibility.

And that's from our community. They came up with a *unintelligible*. So there's lots of not only what that what each of those letters stand for, but really, we want to be the leaders. Not in not being the best at having the highest diabetes prevalence not being the best at having the highest obedient obesity prevalence. We want to be the best at being innovative and having the same or if not better opportunities. We want to be the innovation hub where folks come to us, right? And want to learn from us and we can uplift our community. So i'm going to leave it at that because there's lots of work to be done, but I know that if we all work together, that's what I found.

We're gonna, we're making good things happen.

[00:46:49] Michael Penn: I love that. Thank you, Chrissy. Thank you so much for joining me today. Congratulations again on your award and for anyone interested in learning more about the work of the Techquity for Health Coalition, please email info at hlthfoundation.org. That's info at H L T H Foundation.

Thank you for joining us.

[00:47:14] Chrissy Kuahine: Mahalo, Michael. Mahalo, everyone. Appreciate it.

[00:47:20] Joy Rios: Thanks for joining us as we've explored this winning Techquity case study. To learn more about the amazing work being recognized by the Techquity for Health Coalition and see all the incredible winners we've featured throughout this series, head over to the dedicated Techquity landing page on the HIT Like a Girl website.

You'll find it linked in the show notes. Before you go, remember to like, follow, and subscribe to the HIT Like a Girl podcast And if you've enjoyed this episode, please share it with a friend who might be interested in digital health equity. All right. Thanks. See you soon.