Techquity Series: Transforming Healthcare for Rural and Indigenous Communities

[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 Health 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, Health 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 techquity to set up these interviews.

So there'll be, you'll have a little more context for the conversation. Now that we've concluded the competition, we have, the coalition has a really fantastic, like 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 equity practice of equity 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 healthcare 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 like 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 in 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 in techquity.

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 and to make a larger like industry wide tech equity 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 tech equity coalition A few of the things we have coming up are a roundtable which will host Health 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.

[00:05:03] 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. So thank you so much for what you're doing and transitioning to our interview today, can you talk to us about who we'll be hearing from in today's episode?

Who's our interviewer and who is our awardee?

[00:05:47] Janna Guinen: First, thank you so much for that, Joy. I really appreciate it. And yes, today we will be joined by two distinguished guests Caitlin Lazarus, who is the national project director of Vision Loss Rehab Canada and then Josie McGee vice president of health care and innovation also at Vision Loss Rehab Canada And they will be interviewed by Jay Calhoun who is co founder of the Intertribal Health Innovation Institute And an advisor to the Techquity for Health Coalition.

So I love to do this. I'm going to call out a couple of points of interest for our listeners today. Here's one where, and this is not the only case study where we've learned that they have already expanded their project and or are considering replicating it with new partners or in other populations.

This is the case for Vision Loss Rehab. So listen for that. And then In this episode, we're exploring work done with indigenous and remote populations in Canada around screening for diabetic retinopathy. So Jay comes to this conversation himself very deeply involved in health equity among the indigenous people.

He is of Cherokee descent, and if you listen, he greets us in Cherokee, which is a really special moment not to be missed. And he'll share some insights into his own work as well. So it's a great conversation. And then just a couple of particulars about this case study is that I wanted to call out the use of AI by Vision Loss Rehab Canada was really interesting.

And it was, they deployed it not just in use by experts, actually, at all, really they used community members who they trained on this AI device to conduct screenings in extremely remote areas, and the challenges of implementing such technology as well. They had some serious challenges to do it, but overcame and navigated those challenges with remarkable skill.

[00:07:37] Jay Calhoun: All right. My name is Jay Calhoun and I'm your guest host for today's HIT Like a Girl podcast. I'm the executive director of the Intertribal Health Innovation Institute and a member of the advisory committee for the Health Foundation's Tequity for Health Coalition. I'm also a citizen of the Cherokee Nation, the largest tribal sovereign nation in the U.S.

The Tequity for Health Coalition, much like Intertribal, seeks to leverage technologies to help reduce outcome disparities and systematic inequalities in healthcare. Together, we develop best practices, recommendations, and metrics. We educate the industry, we conduct research, and we tell a story like the one today.

If listeners would like to learn more about the Tech Equity for Health Coalition, contact us at info at healthfoundation.org. That's info at hlthfoundation.org.

On today's podcast, we have special guests, Caitlin Lazarus, the National Director of the Eye Health Screening Initiative at Vision Loss Rehabilitation Canada, and Josie McGee, Vice President of Healthcare Innovation at Vision Loss Rehabilitation Canada.

Welcome, Caitlin and Josie. First off, I want to have a big congratulations for your recent Health Foundation Global Techquity Impact Award announced at VIVE in Los Angeles this year. So congratulations on that award.  

[00:09:00] Josie McGee: Thank you.

[00:09:00] Jay Calhoun: For those who don't know, the Global Techquity Impact Award recognizes a project outside the U.S. that effectively uses technology to overcome geographical, social, cultural or socioeconomic barriers for a population experiencing persistent health disparities. Let's talk about VLRC's diabetic retinopathy or DR screening program for at risk individuals. So Josie, maybe kick us off here. Tell us a little about the origin of BLRC and About the project in general.

[00:09:32] Josie McGee: Absolutely. VLRC decided to develop an innovation program Innovative program utilizing AI handheld cameras and community based screening In order to bring screening into communities and mitigate the barriers teleophthalmology was having. 

[00:09:49] Jay Calhoun: That's awesome. And that brings us to the overall project that we're talking about which is the iHealth screening initiative And specifically in the rural indigenous communities or the First Nations of Canada.

Caitlin, can you tell us a little bit about the project?

[00:10:03] Caitlin Lazarus: Yeah, so we really believe in co design. And so we worked with our indigenous partners at IDHC, the Indigenous Diabetes Health Circle, to really develop the project and what it would look like. We actually do community based screening. As Josie mentioned, traditionally, there would be tele ophthalmology sites, a patient would go and get screened.

With our program, we actually put these handheld cameras in community. So that way screening is done closer to home in a culturally safe way, language of choice, and it's done by the sort of trusted and established staff within that community location. So that's where we started. And because our utilization of AI, we use AI art, anyone can use it.

So you don't need to be an ophthalmic technician. You don't even need to be a healthcare provider. Really anyone can take these images and run screens and it allows us to do point of screen education. So when someone is with us, we take the photos, we dock the camera and get a report in about 60 seconds.

And the technology is highly sensitive, has a high specificity rating, and we can have that conversation directly post screen.

[00:11:31] Jay Calhoun: That's great. And it really highlights the complimentary nature of both the accessible technology and the community partners to use this technology. in those communities. Now, how did you identify and how did you approach the partners in the communities?

[00:11:46] Caitlin Lazarus: It's a great question and it really takes time and a lot of trust. Building relationships with Indigenous Communities and our partners, obviously, our primary relationship with the indigenous diabetes health circle played a large role in that they have 25 years of existing relationships with indigenous communities in Ontario, and we started the engagement process probably a year and a half.

Before our very first screen was completed, when we look at the landscape of health care in Canada with indigenous communities, we identified a lot of barriers as to why people weren't accessing optometry screening, why they weren't going to a teleophthalmology site. And part of that is systemic racism, historical medical trauma, just the distance covered.

A lot of the communities that we support are rural, remote, fly in communities. We were in a community a few weeks ago where we had to take ice highways to get there and even if you live in an urban setting, having to arrange child care or take time away from work. There are so many barriers as to why people don't access screening.

So getting a landscape, spending some time really listening and understanding each community was how we got there and the trust and time that it takes.

[00:13:14] Jay Calhoun: That's great. We can definitely relate to that trust issue and the coordination from the community perspective here in the States. Now from a measurements perspective or KPI, how did you co create those KPIs with the communities in question.

[00:13:29] Caitlin Lazarus: It's a great question. I think what's really important to us is also recognizing indigenous status sovereignty. So really co creating those KPIs and measurements along with our. So we are funded through the Ministry of Health and Ontario Health, and they obviously require some qualitative reporting, but how do we work with each community to decide those measures?

So we looked at individuals screened, the rates of positivity and severity, but then on the flip side, we also looked at patient and provider satisfaction, we really worked on getting data that painted the narrative of the true picture. So our referral pathway, the time intervals, a distance, having to travel and some demographic data as well as diabetes status.

What we know is a lot of individuals don't know that they have diabetes because there's such a mass screening problem. So we've actually screened people who have screened positive for diabetic retinopathy, who didn't know that they had diabetes. So really creating with each community, they get to decide the screening criteria.

So we're in almost 20 First Nations communities in Ontario, and I would say all 20 of them operate completely differently based on need. Following a similar, we have a pathway, but within that high adaptability.

[00:15:00] Jay Calhoun: Thank you. Now, as far as the outcomes, and I would note that reading through the case study, that there was actually one of the providers that was identified and they took the test and got diagnosed themselves.

So that was a great piece of outcome right there. Now, let's talk about those outcomes. When you started collecting the data, anything that surprised you in the data?

[00:15:21] Caitlin Lazarus: I think the biggest piece was specifically in Northern Ontario, almost 50 percent of the people who screened positive hadn't seen an eye doctor in at least five years, if ever.

The clinical standard for screening when you have diabetes is you should be screened every single year. And so when we're at almost 50 percent of people who haven't seen an eye doctor in five years if ever, That was really shocking to me and I think proves why this program should exist.

[00:15:55] Jay Calhoun: And did that affect how you rolled out to different communities as you went?

[00:15:59] Caitlin Lazarus: Yeah, absolutely. I think we took a lot of data. Ontario is a big province. Canada is a massive country. And so what that sort of scale and spread look like, we had to be really thoughtful in how we did that spread. So it certainly informed all of our decisions.

[00:16:19] Jay Calhoun: That’s great. And I noticed that in the case study, one of the challenges was related to staff and staff turnover. Obviously, these small communities have maybe one or two people with multiple priorities. Now, how did you go back and iterate through some of those challenges?

[00:16:32] Caitlin Lazarus: Yeah, that was incredibly challenging.

As we started during COVID, what we found was really high staff turnover. And as you mentioned, Jay, in remote communities, there would be one person who was trained. So when that one person left, it was starting from the beginning. I think the most important piece that we did was we created with the Indigenous Diabetes Health Circle specific refresh training videos.

So step by step, IDHC has a number of elders who participated in the videos. We were able to do sample conversations talking about a positive screen, really making sure that we were producing culturally safe, trauma informed content, and then putting it in video format. So then we're not traveling across the province every time someone leaves. That was critical.

[00:17:26] Jay Calhoun: And some of our listeners, I want to make sure that we expand upon what it means from a trauma informed or historical trauma for these communities. Could you expand upon that a little bit?

[00:17:38] Caitlin Lazarus: Sure. This was actually one of our big lessons learned. So the camera that we use, it's a handheld camera, and it has a long lens and then a handle to take the photos.

And we had been operating for about six months, and then we did some screening with some veterans. And someone asked the question, Oh, this camera looks like a gun. It could look like a gun. We had heard before that it's a gun. Looked like a speeding device, like when police are on the side of the highway.

And that really made us take a step back and look at how from start to finish, we could operate in a trauma informed way. So assuming that going into it, that everyone is traumatized means that we aren't singling people out asking invasive questions, and it changed the entire way that we operate. So the language that we use to the rooms that we do screening in my, I wouldn't have my back to the door sort of blocking the exit.

We no longer turn off all of the lights with retinal photography, the darker the room, the easier it is, but being in a small enclosed space. With all of the lights out can be re traumatizing. So really every single piece from start to finish we worked with a social worker out of the Indigenous Diabetes Health Circle to develop trauma informed practices.

[00:19:09] Jay Calhoun: Caitlin, thank you for that insight and I think this is a good segue. To really talk about beyond the technology where you have a great AI tool that makes it accurate, makes it speedy to diagnose, but really just the surrounding, the wrapper of the process and the insight that you have for the communities.

So maybe Josie, can you talk a little bit about how you go about making this great new technology, this AI enabled technology more accessible to the populations?

[00:19:40] Josie McGee: Thanks, Jay. Really As Caitlin mentioned before, it is really that co design and that community engagement, bringing the care closer to home, meeting the individual where they are, taking into account where they are mentally, socially, physically, looking at adaptability and flexibility with our partners, understanding that each community faces unique challenges.

You said yourself, it's great if we have this technology, but if we can't have the trust of the communities or have them access that technology, then it's a moot point. So I think these are the things that we really focused on in this program to ensure that people felt comfortable with the technology.

They weren't afraid of the technology. They saw the benefits of the technology and. We can't stress enough how much that community engagement and co design really goes a long way in terms of ensuring that goal of bringing these services to communities is achieved.

[00:20:34] Jay Calhoun: That's awesome. And then from a, now that you have the framework, now that you have technology in these communities, Where do you go from here?

Broader geographical, other disease states, other populations? Tell me a little bit about that.

[00:20:48] Josie McGee: Yeah, absolutely. We definitely are wanting to expand the project. We started the project in only a few regions within the province of Ontario. This past year, we expanded that to all across Ontario. This next year, the next upcoming years, we really want to focus on bringing this project to every province and territory in Canada.

Definitely, it is a little bit of movement in a slightly different direction. As I mentioned before, when people come to us, they're already in their vision loss journey. This is really a focus on prevention and population health outcomes. Definitely, we want to look at how we can potentially partner with other types of initiatives around maybe diabetes as a full umbrella, looking at screening for not just diabetic retinopathy, but lower limb preservation, blood sugar levels, really expanding that we found a really good way to bring this screening into communities.

Can we give our learnings to other types of screenings that want to go into these communities as well? So definitely looking into expanding from a large scale perspective on bring preventing blindness and looking how we can definitely partner with other organizations to expand screening overall. In terms of other eye conditions, we know that the technology is coming with looking at whether there's someone with macular degeneration or cataracts or other eye disease states. And as the technology improves, then we can start to look at screening other eye conditions as well.

[00:22:23] Jay Calhoun: That's awesome. And so such important work as well, screening and prevention in these communities, because if you can screen to prevent and really build the trust around those things, it prevents other complicated disease states that ultimately can increase the life and increase it.

The community's ability to transmit culture and language and things like that. So we appreciate that. Thank you very much.

A little bit about the ripple effect. Have you seen any other groups inspired by what you're doing to go into these communities and offer new technologies or participate in the collaboration with you?

[00:23:00] Caitlin Lazarus: Yeah, I think where the heart of our project lives is in collaboration and co design. So we've definitely collaborated on a number of other projects, as Josie mentioned, lower limb preservation. So when we look at someone going to foot care, they're already experiencing the impacts of their diabetes. Can we add vision screening to that?

So we've seen the ripple effect in that sense. We're participating in more projects and collaborative efforts. And then in terms of sort of technological ripple effect, what we're seeing is as we find more and more AI projects, the willingness to continue that momentum is enormous. So specifically within our province, we are seeing an increase in AI funded projects, which is really exciting.

[00:23:54] Jay Calhoun: That is exciting. Any advice for other folks that are looking to make changes and use technologies to address some of these health disparities based on your experience, how would you encourage them to go about their mission?

[00:24:07] Josie McGee: Definitely that co design and community engagement is a key piece of looking at how technology can address health disparities.

Making sure that you give yourself the time to really engage with these communities and understand their unique needs and recognizing that it does take time, that it's not an overnight thing. As Caitlin mentioned, I think it took us a year and a half of community engagement before we did our first screen.

And I think being open to change and innovation, as we know, AI and technology is constantly changing, it's changing rapidly and your program really needs to be open to incorporating these changes. So as we move forward, we're going to be constantly looking at the landscape, seeing what improvements there are in technology, what new AI software is out there so that we can improve, continue to improve our program as well.

[00:24:56] Caitlin Lazarus: Yeah, I really echo Josie's thoughts. I know we've said it a lot around community engagement, but when we look at the healthcare system It might be that 90 percent of us are well served within a traditional healthcare model, but how do we address that other 10 percent and bringing care, bringing screening really closer to home is critical for addressing health disparities.

[00:25:23] Jay Calhoun: And then before we wrap up, I know this, the audience on this podcast includes a lot of practitioners. Includes technology, includes investors and philanthropy. Is there any call to action that you would want to make to these, this group of listeners to further your efforts?

[00:25:39] Josie McGee: One call to action. The main call to action is that we want to bring screening to every, as I said, province in Canada and ensure that everybody who needs to be screened can be screened.

[00:25:50] Caitlin Lazarus: And I would say we want every single person who is not regularly getting screened to get screened. So we're open to collaborating with different organizations, different countries, sharing knowledge. We really want to make sure that no one loses their sight because of this preventable disease.

It is so easy to screen and knowledge is power. So having that information can only inform future health decisions.

[00:26:17] Jay Calhoun: And that's the reason why you won the global tech week. I'd like to thank again, our guests, Caitlin and Josie from vision loss rehabilitation, Canada, for being the podcast today. Thank you again to HIT Like a Girl for helping us tell these very important stories and inspiring stories in our communities.

And if listeners would like to learn more, they can contact us at info at healthfoundation. org. That's info at HLTHfoundation.org. And in Cherokee, we say wado is thank you. And dona dago aye. Until we see each other again.

[00:26:54] 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 wherever you listen.

And if you've enjoyed this episode, please share it with a friend who might be interested in digital health. All right. Thanks. See you soon.