Techquity Series: Transforming Communities Through Data-Driven Efforts

Techquity Episode 5

[00:00:00] Joy Rios: Hello, and welcome back to the HIT Like a Girl podcast. I'm your host, Joy Rios, and you are tuning into the second episode of our five part series on Techquity, digital health equity. Our goal is to explore how technology can be harnessed to create fairer health outcomes for everyone. Today, we continue our conversation with Janna Guinen from the HLTH Foundation.

Janna, it's great to have you with us again to discuss the significant role of the Techquity Case Study Awards in driving forward the agenda of education, research, and advocacy. In our last episode, we delved into the origin story of this initiative, so thank you very much for sharing all of that. Today, let's explore the criteria and selection process that's used to identify the winners of these awards.

What specific metrics and rubrics were implemented to evaluate these award winning initiatives? I'm so eager to hear how these helped distinguish, you know, who became a standout awardee among the submissions.

[00:01:07] Janna Guinen: Thank you, Joy. Good to be back. First and foremost, before we even start, I just want to recognize up front that the Techquity for Health Coalition are not the pioneers in qualifying or quantifying health equity or addressing health disparities.

There are decades of research studies and I don't even know how many thousands of dedicated individuals over the years contributing to this field. I just want to make sure we acknowledge all of them. All of that existing work, but we are still at the emerging stage of understanding how to use data and technology to reduce disparities and mitigate inequities related to health.

And so this is why we run the tech equity for health coalition. We're focusing on that gap in knowledge and the goal is to help the industry sort of standardize approaches to digital health specifically for underserved populations. So it's all about overcoming health disparities and doing it with more consistency and success So about the case study competition, this is a really, um, interesting process to go through with our advisors.

And the conversations that we had had in the, basically for the previous year, helped to inform where we went as well as, as I mentioned before, existing knowledge and health equity, right? But we did have to establish our own criteria for the case study competition that reflects the values of technology, of techquity in healthcare.

All of this typical standard measures that you might use, a clear problem definition, the use of smart goals and achieving defined outcomes, although I will say in this, we also invited works in progress. So we wanted to make it clear that we wanted to award learning and insight and setting yourself up in a project for learning and insight as much as we would award outcomes or if it's not as much as that we would consider and weigh heavily how much a project was set up for learning because of big piece of techquity just has to be collaboration.

So, but there you go. And beyond the traditional kinds of metrics that you would see, I'll just mention a few of the factors that we looked at. So the degree of collaboration with other stakeholders, there's just never one stakeholder group. It seems very clear. Again, from like previous research and, and frankly, from what we know about diversity on any project, that collaboration between stakeholders is really important.

So we weighed that heavily. We also looked at how projects delivered value to the surrounding community. So rather than distracting knowledge from the population intended to benefit, it was what, was there a give back? Was there a consideration to how to extend value beyond the project itself, beyond the technology itself?

We also looked at how projects engaged with the intended beneficiaries of their work, specifically patients. So, did they take the time to challenge assumptions with thorough research into patient needs and perspectives at the beginning of the project? And we also looked at how or whether they built in feedback loops so that patients had a chance to weigh in, and professionals too.

I mean, some of these are patient facing, but there's a maybe a professional usage to the technology as well. So did the users and the attended beneficiaries have a chance to weigh in on their experiences during or after the project, right? That's the only way you can, you can learn about a community or a population upfront, but then how well did it really go?

And the only way to adapt is to ask those questions during and after as well. And then, um, I'll throw in one innovation, you know, innovative criterion that we used as well. And that was around environmental impact measures. And honestly, this, I don't, I don't know if we had anyone report on that yet. We know that the healthcare industry contributes significantly to nationally to greenhouse gas emissions.

I don't know what the number is, but it's a high percentage, maybe 8 percent or so. So we do hope to see more projects as we move forward that we'll consider their environmental footprint just moving forward. It just has to happen. So by introducing it, we hope that at least we generated some awareness.

So ultimately, by applying our, the values that we have around techquity to these case study awards, we're, we're aiming to paint just a clearer picture of the current landscape in techquity projects and, and then to share their practices. So as listeners hear each episode, I hope they'll appreciate how these values and aspects set our winners apart because they really blew us away.

[00:05:29] Joy Rios: It's so inspiring to hear about the emphasis that's placed both on community involvement and that proactive approach to environmental impact that is so, so, so important. Both of those elements are crucial to making a real difference and achieving genuine equity, I think. So today we continue our exploration of these great projects as we introduce another award winner.

Can you tell us about who we will be hearing from in today's episode.

[00:05:56] Janna Guinen: So today's episode focuses on enterprise data and analytics and this is a project submitted by the Carillon Division of Elevance, I mean, Elevance, the health insurer. So they earned a Techquity for Health case study award for their super comprehensive approach to developing insights around social determinants of health data among their members.

And it was really complex. They had to harmonize data across sources and ensure interoperability of data, develop dashboards and reports for all of their users. And it was just an extensive effort to bring visibility to health related social risks, again, among their members. And a really cool thing they did, so groundbreaking in this, I think, they made new tools available both within Elevance, across their enterprise, but also to their surrounding community. So for the audience, when you hear this interview, listen for the ways that they are supporting the data users and learning from them, they did so much to make this project a reality. interactive, and to make it a learning experience for the project managers, as well as for the people making use of the data.

So here we go. You are going to hear from Tracy Wang, Director of Digital Solutions for Enterprise Data and Analytics at Carillon, who will be interviewed by Luis Belen, the CEO of the National Health IT Collaborative for the Underserved. Luis is also an advisor to the Techquity for Health Coalition.

[00:07:27] Joy Rios: Wonderful. All right, let's dive in.

[00:07:29] Luis Belen: Hi, my name is Luis Belen. I'm the CEO of the National Health IT Collaborative for the underserved and HIT. The organization itself was launched in 2008, uh, funded by the Office of Minority Health at HHS and the National Institute of Minority Health Health Disparities, and our entire focus has been leveraging health information technology to address disparities.

I'm also a proud advisor of the to the Health Foundation's Tech Equity for Health Coalition. I'm here with Tracy Wang, who's the Digital Solutions Director and the Enterprise Data Analytics team at Caroline Digital Platforms within the Elevance Health. Who recently won an award in our Tech Equity for Health case study competition.

Tracy, welcome.

[00:08:22] Tracy Wang: Thank you for having me.

[00:08:23] Luis Belen: We're happy to have you here with us today. Tracy, your initiatives made a remarkable strides in using data visualization, analytics, and interoperability to identify and make visible health related social risks across the enterprise. And in your surrounding communities, can you take a moment to describe your project?

What problems you were trying to resolve? What do you do? And what do you hope to accomplish with this project?

[00:08:55] Tracy Wang: Happy to do so. So I'll just start by framing the why. Why is addressing health equity so important? And just to level set a bit, health equity means everyone has a fair and just opportunity to be as healthy as possible.

And we know that barriers to doing so has to be removed. And that's like discrimination or unmet needs. It definitely is not the same as health equality, which is like a one size fits all approach that suggests we give everyone the same resources, whether they need them or not. So, of course, more equitable healthcare is attainable, but are we there yet?

So let me give you some statistics. One in five people don't have transportation to the doctors, and about 50 percent of Americans can't even find affordable, healthy food. And inequities create 93 billion. dollars in excess medical costs. So how might we overcome these barriers to achieve equity? Well, we know unique life circumstances and experiences impact every individual and their health.

As we look more broadly at what drives health, it's clear that health is driven by social and behavioral factors in addition to the physical factors. We must build partnerships where people are to support health holistically. We also need to imagine the health system, and that's going to start with harnessing the data, which gives a more complete picture of each individual and their health needs.

This can also help make healthcare more personalized and equitable. We also need tools to help us gain data driven insights, and take actions to address whole health. Then we track population health over time. So at LLS Health, we come into something called the Health Equity by Design, which means we create personalized and intentional approach to ensure that all people, regardless of their race or ethnicity, sexual orientation, gender identity, Disability and geographic or financial access can receive individualized care.

In other words, it means that we prioritize our efforts and investments that deliver on optimizing health at the individual level for all. So now that we have the chance to kind of frame that the reason for advancing health equity and the why conceptually, I'm going to talk through the what that makes the data and tools so valuable for driving improvements in equitable care.

And so To really address whole health, we need centralized and actionable data. When we look at the factors that drive the health of our communities, we see that only 20 percent of those drivers are connected to clinical care. So it's things like your physical, behavioral, and maternal health, inpatient, emergency, and pharmacy utilization.

The other 80 percent of health is driven by what happens outside of the doctor's office, such as your socioeconomic factor, environmental factor, geographic, and behavioral factors. We need to be able to gain data driven insights into that 80%. So looking at all these factors allows us to address more than medical needs so that we can improve whole health and track population health over time.

So what exactly did we do? We ended up adding social data to our clinical data to create this holistic view of our membership and the communities where they live. We brought in community social risk data like social vulnerability index based on latest information available from reputable public sources such as the American Community Survey, We also ingested member social needs data, things like food insecurity, housing, instability, and transportation insecurity based on member and vendor sources like your claims data, social needs screeners.

And then we summarize all of these public and member data by demographics. So we stratify by age, by gender, race, ethnicity, where they reside, the type of community, and then by geography with a state level, regional county zip code. And then we employ a framework for whole health management analytics. And this framework begins with the identification of health needs through the insights that's given by these data.

And the insights are then used to develop strategic priorities, initiatives, and goals. Next, we deploy the programs and interventions. And after these interventions are launched, we continue to rely on analytics to evaluate the effectiveness of these programs. And our reflection from these evaluations will guide us to return to our strategic development of these initiatives, and then the process continues in this continuous data driven cycle.

So ultimately, success is about decreasing disparities in the outcomes that we're seeing in our populations.

[00:13:46] Luis Belen: Thanks, Aleph. Tracy for giving us that background. I like to say that data for the sake of data is just data. And the fact that you use data to actually look at innovations and engagement is so important.

So thank you for doing this. The type of work that NHIT has been doing with the Data Fusion Center. Tracy, the other part that I think is so crucial in these type of efforts are partners. Making sure that the community relations and the community partners are involved. Can you talk to us and give us some background on how you leverage community relationships, uh, and how important they were, uh, in the aspect of this project, and can you tell us that or any other key partners that you work with to make sure the success of this project and this initiative?

[00:14:35] Tracy Wang: Absolutely. I think we all know that it takes. A village and effective partnership to make lasting impactful changes that will benefit all individuals in their communities. And I'll just tackle this with both internal and external partners that we've engaged with. So within Elevance Health cross functional teams, we work together and share the goals.

And I'll just kind of give you a view of what that looks like. We have the enterprise data and analytics team or EDA in We aggregate disparate data inputs from these public and member sources. We apply interoperable data standards and that with guidance from other teams like advanced analytics and health outcomes organization.

And we also maintain this centralized repository so that our downstream data consumers like care management team can use the information with confidence. So EDA We tag team with government analytics area to create the data analytics reporting capabilities. Then we work together to train the whole health equity and quality team so that they can claim actionable insights that inform their population health management strategies.

Each of the local health plans engage in short term sprints where they use the data to identify health needs. Their implement interventions locally to find those smart goals, and then they measure outcomes to evaluate program success. Internally, we have regular touch points to communicate feedback and best practices, as well as leader update to ensure there's continuous buy in.

And then externally, we engage with industry leaders like the Gravity Project, where I sit on its operating committee. This is where we shape data standardization priorities, and I can bring back Intel so we can align accordingly. Thank you. So secondly, outside of the company, we lean on community based organizations and social service vendors to help support our members physical, behavioral, and social needs.

So for expectant mothers, we implemented DOLA programs and we're seeing positive results, so very exciting. We funded community based organizations to increase access to DOLA services by training new DOLAs. In black and rural communities that needed them the most. And we also offer programs that support our members with chronic conditions.

Things like we deployed a home visiting program and it is staffed by community health workers to engage the black and hispanic families in pediatric asthma management and home remediation. We implemented food as a value added benefit so that we can support our black members with diabetes and targeting body mass index reduction.

So those are just a flavor of the partnership that we engage in, too.

[00:17:24] Luis Belen: I cannot overemphasize how important that is, right? That a lot of the times we're building these efforts from the top down. And we leave the communities out, right? And so the fact that you proactively engage the communities in this project is amazing.

Tracy, a lot of this work comes down to, are we making a difference? Can you talk to us about the measures that you use, both quantitative and qualitative, and also tell us Some of the outcomes that you achieved. It seems like this was an amazing project, but can you share your best practices around this?

Because I think that's crucial for our audience to learn.

[00:18:06] Tracy Wang: Yes, totally agree. I think like measurement and evaluation. of success is super important if we want to continue to work on this initiative. And I'll just talk about I tend to have two groups of goals and metrics. The first one is tied to the analytics and insights tool that we have developed, and it's going to focus on tool adoption, the usage frequency and user experience.

So, First of all, we were giving a chunk of money, and so we have to release a product, right? And then we have to make sure that they're released according to the timing indicated on the product roadmap. And then we had to make sure that there are ongoing enhancements. And then second of all, once the product is released, we want to make sure people are using it and are happy with it.

So we have increased digital tool adoption rate for the associate by greater than 5 percent year over year as a goal. Specifically, that measure looks like the number of cumulative users that are using the tools. How many people are actively using it each month? And how many sessions are active each month, we look at presentations conducted for both internal and external audiences.

And we also look at how many proposals were reports that the tool supported, including, you know, for our regulatory and accrediting bodies. And then, thirdly, in terms of experience, we want to achieve a favorable net promoter score or NPS, and we target achieving above 20 each year. So that's about the tools itself.

The second group of goals and metric really is like the impact, like what did we make a difference. So that's going to be the population health management interventions that have been established by each health plan. And that's going to vary by local circumstances, but typically they would include things like improved clinical outcomes.

So like, Preterm birth, asthma control. Second, reduce unnecessary utilization and things like inpatient admissions, emergency department visits. And third would be increased access to care and services. And that would be looked at by how many prenatal care visits they've had. How many social interventions did we perform?

And then fourthly, we look at controlling overall costs, and that would be looking at the health care spend. Was there some sort of return investment? And then lastly, we're going, we want to be able to improve participant experience and satisfactions, and that can be done through Experience survey that we conducted, and also the qualitative feedback that we're receiving from the participants in the program.

So I know it's a lot, but I feel like it gives us a more comprehensive picture into how successful the program is and make an impact.

[00:20:59] Luis Belen: Tracy, I like to talk and think about health equity and working with underserved communities, and even the last mile, right? The reality is that this is tough work. Right.

And you've got to be committed for the long term outcome to have this success. At the same time, we've got to understand that there are challenges in these type of projects and hence why we need the long term commitment. Can you talk to us about what some of the challenges that you had to overcome implementing this initiative?

[00:21:33] Tracy Wang: Sure. I would say that probably the greatest roadblocks for us was making sure that there is continuous funding for this work, and then that we're prioritizing any new development appropriately. So the Minimum viable product or the MVP of the tools were funded initially with reallocated dollars from Medicaid growth team.

So it's designed with their interest in mind. And I think initially it was tempting to want to try to boil the ocean. So we focus on the 80, 20 rule. What 20 percent of data is going to bring us to the ocean? 80 percent of the value we're looking for, and we know that's not going to satisfy everybody, but it's a start.

As we promoted the tools and obtained additional user feedback, we had to work with Medicaid analytics team to prioritize and the enhancements and the new features that they want enabled. And then there was a time when the initial funding ran out and we have to pause development for a period of time.

Then we work together with existing and new business partners to seek new technology dollars and I'm glad to say that we successfully obtained the funding so that we can expand our work because It is so important for the company and it's a priority.

[00:22:51] Luis Belen: Congrats on that, Tracy. And I do have some questions, uh, later on about the status, but, you know, the reality is that we need to look at beyond the tech, right?

So can you talk to us about what factors beyond the technology do you believe are crucial to addressing social determinants of health?

[00:23:11] Tracy Wang: Absolutely. So actually quite a few factors come to mind as I think about how to bring people along in this journey. I'll just start with aligning with industry standard requirements.

So we start by looking at, well, what is the demand of us? What's CMS asking? What's the Medicaid state asking? What is our accrediting body like National Committee for Quality Assurance is asking? They want to make sure that there's leadership buy in and adoption for resources. And who is at the table and is willing to sponsor this work?

What's the value we're bringing to them? And then I think about streamlining stakeholder interests so we can scale this appropriately. I want to know what is on their mind, what is their agenda, is there a way to create efficiency. Then we want to make sure we collaborate and have a team across enterprise focus on this work so that we can leverage collective expertise.

And then there's sharing out the knowledge and making sure we bring new people along. So how do you make sure we have forums to ensure everyone stays on the same page? And then lastly, we kind of like enabling the analytics and insights that have been derived from these tools. And how do we scale best practices so that everyone benefits at the end?

[00:24:31] Luis Belen: Both the community and the partners engage in these type of initiatives. One of the things with these type of projects is that sometimes they just go away. Can you talk to us about where the project is today? What are your plans to expand and replicate this project and keep the momentum? Because it's this is such an amazing initiative that I believe a lot of folks should know about and that it should be replicated.

Can you just give us a where we stand right now with the project?

[00:25:01] Tracy Wang: Sure. I'm super happy to say that it is still going on and I know i've seen a lot of projects And then go right as leaders change, but because there's such an invested interest in addressing health equity, and it comes from top down. And then the greatest is that we, I mentioned earlier that Alvin's Health invested additional technology dollars so that we can continue this work.

And not just continue, but really to expand the data foundation. And that's Focus on maybe collecting more self attested data to understand stratifications by demographics and then also additional social screening data. So this is really a priority. And we've also developed a suite of complementary analytics and insights tools, which have been incredible resources to our associates because they can use the self service data.

Features and empowers them to do their own data analysis. Then they can use these data driven insights to inform intervention efforts and really saves them a lot of time trying to hunt down information from multiple sources. So we're in the process of consolidating like the vast, many numbers of analytics tool and to simplify it for our users.

So it's a streamlined experience for them. We continue to keep our user interest high and consistent by training and having office hours to answer questions from the users so that they can share about their use cases and then expand it into additional use cases that was not initially implemented. So on all this benefit, not just the group of people who are using it, but it's being taken across the enterprise and making a difference by making things a little easier and more simplified for

[00:26:52] Luis Belen: them.

Thanks a lot for that update on Tracy. Tracy, one of the big concerns in underserved communities and health equity is Trust and keeping that trust and the fact of that trust in those in communities and, and one of our concerns at NHIT is that we understand the rising pressures on health equity and de and I efforts, right, especially in industry.

And how do you keep people engage and focus. On its importance, including the impact on health equity efforts, and what's the ROI? Can you talk to us about that? How do you keep folks engaged, address the trust factor issues, but also if you could share some of your best practices, right? Because I think it's so crucial for industries to understand how important this type of work is and why we should continue to focus on health equity efforts.

And that there is an ROI, can you talk to us about that?

[00:27:53] Tracy Wang: Sure. So, I agree with you that trust is such a crucial factor, especially when we're trying to build something new with a, a huge group of people and working toward common goals, especially I think within Elevance Health is a matrix environment. And so, to me, like building trust is going to entail Well, do the right thing, right?

We're going to make sure that we're doing this because it is the right thing to do. And we're considering users feedback and solutioning and we're aligning where we can to minimize duplicative efforts within the organization. And then we have to deliver on our commitments, right? We have to hold stakeholders accountable.

We're going to release information as we promised. Making sure that we have the right people doing the work. And then we address conflicts as they come up, that's definitely there, and that's going to take communicating effectively. We negotiate, compromise when needed to, in order to have these win situations or solutions.

At Elevance Health, health equity really is a high priority. We, internally, we know that it is the right thing to do. It is good for the business. So, in fact, I'm going to share, uh, 21 of our Medicaid plans were the first in the nation of 28 to receive Health Equity Accreditation Plus from the National Committee for Quality Assurance, or NCQA.

And the tools that we developed support the NCQA accreditation right. So that's a firm commitment of the organization to have health equity at the forefront of our strategy. And then last year, 75 associates, including myself, were selected to participate in Harvard T. H. Chen School of Public Health's Health Equity by Design Certificate Program.

And with that, we worked together to create solutions to decrease health inequities for specific populations. We've even set up several forms to talk about social and health equity data to bring everyone up to speed. Again, this kind of minimizes duplication, drives alignment across the enterprise and creates some sort of efficiency.

And this is where we're seeing dollar savings because we can just piggyback and leverage what's been built already. So these forms could be. Things like a learning collaborative where you have broad representation of functional units across enterprise. We come together to share information, onboard people, ask and answer questions.

The second group is more like a smaller work group where folks discuss in depth those social and health equity data model. How do we secure access? How to make decisions based on what's coming from the industry, from ONC, US CDI, and then we have a office hours for users to continue to share best practice and use cases and plans can come and show us the data, show us what they've implemented and was successful and both in their outcomes and also any cost savings that may have been estimated.

So I think advanced hanging health equities definitely is everyone's business and at Elevance Health Associates are part of that solution so we can move in the same direction.

[00:31:12] Luis Belen: Wow, Tracy, along these lines, can you share some of the successes Elevance has achieved, for example, with the close to home project or the project whole health.

And specifically, can you talk about the community's health outcomes achieved?

[00:31:31] Tracy Wang: Sure. As we're using tools like close the home project, whole health and act on the data insights to make informed use of the limited resources. We see that there's success in improving outcomes and health disparities. And I'll just share one example with our annual population health.

analysis, we've identified maternal health as a consistent of priorities across our health plans and particularly improving birth outcomes for black individuals. There are a few initiatives that are in flight, but today I'm going to highlight doula care. So doula is, for those of you who don't know, it's, uh, provides person centered care to pregnant and postpartum individuals through information, education, and physical, social, and emotional support.

The dollars help birthing people achieve a healthy and satisfying experience. Dollar care is evidence based and addresses the specific needs of the people in their own community. Um, so what did we do, where, who, and how? So with the data insights claimed from the tools, members with high risk factors in pregnancy, for example, diabetes, hypertension, and depression were prioritized for referral into this program.

We then partner with local community based organizations or CBOs who made visits during pregnancy period. They provided ongoing birth support during labor and delivery. They also made home visits in the postpartum period. They screened these individuals for behavioral and social needs and then connected them to community resources that would address needs like transportation to the doctors, making sure there's enough diapers and then clothing.

We observed a pretty fundamental difference in members who use services and the outcomes for the women who received DOLA care compared to women who did not. The women who received DOLA services had superior outcomes and that includes quantitative things like they have significantly greater odds of having a childbirth.

As opposed to preterm. And then they're less likely to have babies of low birth weight or requiring NICU admission. And they also have significantly lower odds of cesarean delivery, significantly greater odds of prenatal and postpartum care. And women using DOLAR also had 1, 675 lower prenatal and birth costs.

We also observed that more black women are using dollar care compared to Hispanics and Asians. So in conclusion, the use of dollars appears to be an effective strategy for improving maternal health, especially among the socially economically vulnerable and marginalized minority populations. It's no surprise that DOLA Care became a key priority area for expansion into different markets we operate in.

Each help plan can use data driven insights from the analytics and insights tool to inform the where and who and how of implementing DOLA Care.

[00:34:45] Luis Belen: I have a couple of friends that are DOLAs and wholeheartedly believe that what you're doing is so right. How has the availability of enterprise and community Level social determines data, guiding elements on decisions about new interventions.

And in your opinion, how do you, how do these two specifically enable health plans to address the needs of diverse populations? Great

[00:35:12] Tracy Wang: question. And I'll describe how we're using So the three tools that together to understand our population and strategize intervention, I'm going to sort of picture this in your mind.

So imagine that I work for a whole health and health equity team and we have a task of managing populations with coexisting clinical condition and social need in let's say California. So, Where do we begin? We're going to start with kind of understanding the community then the individuals impacted.

We're going to go to the first tool, which is called Close to Home, and we can select any state, county, or zip code to see community level attributes populated. And we're going to compare a one county, for example, Los Angeles County, to its neighbor, Orange. And we're going to see that Los Angeles is less affluent and has more social needs, including food insecurity.

So, as a intervention, we can advocate that our Elevance Health Foundation fund a food as medicine program in Los Angeles to work with programs like Feeding America and then Essential Hospital. And then now that we understand the factors influencing the health of the community, we use the program. The second tool, the project Whole Health to identify prevalence of clinical conditions combined with social needs for our members.

So sticking with a California example, we see that diabetes prevalence by county and prevalence. We see LA or Los Angeles County has the greatest membership and a higher diabetes prevalence than California plan average. Where some of our members are food insecure, we can then as an intervention screen all members with diabetes for social needs, and then we prioritize those with food insecurity for programs like medically tatered meal to help them control sugar level.

We can also use this tool to slice and dice by racial ethnic disparities and then help our members accordingly, prioritizing particular population for outreach. Now that we understand the historical prevalence disparities by geography, race, ethnicity, we can use our third tool, Project INFORM, to glean additional insights about members who are active.

So we are able to drill through to see members who have top conditions and a large member, membership for intervention and track their outcomes over time. As an intervention strategy, we can develop culturally tailored messaging as well as the information or materials within certain literacy level to educate them about managing their conditions.

And then we can screen them for social needs and provide help from the community. So this really demonstrates how we're sort of using or data driven insights to inform our intervention efforts, and then placing limited resources into places where it makes sense.

[00:38:09] Luis Belen: Yeah, talking about using the data for action, right?

You're doing it. Uh oh. And so thank you for that. Sincerely, thank you for that. Do you have any closing remarks or recommendations for other innovators and community members doing this type of work? And what do you think others could learn from your experience? This heavy lifting experience that has meaningful impact.

[00:38:33] Tracy Wang: Sure, and I'll just share that to me, like lack of data, perpetuous lack of understanding, which perpetuous lack of action. There's definitely no lack of data at Avalanche Health or in the public space and the challenge is really how do we package or connect them in a way that is meaningful for people so we don't go on a scavenger hunt every time we need information.

Understanding the population's need will enable us to do something to make a difference. We have And I'll just share that we have seen the value of building the centralized data to make sure we understand disparities and deploy interventions to ensure success. And a key aspect of success really is in working collaboratively with multifunctional teams and aligning our priorities with the community as well.

And then engage strategies to maximize our investments to improve health equity. This way we can leverage the power of many. to scale programs and impact. Um, so in closing, I want to express my thanks to Health Foundation and Tequity for Health Coalition for this amazing opportunity to share Alavan's health journey in using our data and technology to impact health disparities and inequities.

Hopefully our work inspires others. In the same engage in the same space to do their own innovations and make a positive change to improve the health of humanity. And Louis, thank you for hosting this conversation. It's been a pleasure to talk to

[00:40:09] Luis Belen: you. Thanks a lot, Tracy from an NHIT perspective, the work that we've been doing the last 15 years and the NHIT data fusion center around this work.

And it's so important to us. So thank you for the work that you've done and for taking on the challenge. And I just want to thank you for taking the time to talk to me today and for setting the bar high for tech equity in healthcare, you're leading the way. Thank you for doing that. And on behalf of myself and the tech equity for health coalition, Congratulations again on your award.

We can't wait to see what you do next and please reach out if we could be of any help. Thank you so much, Tracy.

[00:40:48] Joy Rios: Thank you. Thanks for joining us as we've explored this winning Tequity case study. To learn more about the amazing work being recognized by the Tequity 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 wherever you listen. And if you've enjoyed this episode, please share it with a friend who might be interested in digital health equity. Alright, thanks! See you soon!