Mark Savage on the disparity factor

Inequalities occur in all areas of healthcare, and health information technology is no exception
By Bernie Monegain
10:00 AM
Mark Savage, National Partnership for Women and Families

As director of health information technology policy and programs for the National Partnership for Women and Families, Mark Savage keeps a close watch on healthcare information technology, along with all other aspects of patient care. The idea, of course, is to even the playing field.

Savage, a lawyer, has a long record of advocating for consumers and multi-cultural communities, with landmark achievements in his work against insurance redlining and ending auto insurers' practice of basing premiums primarily on drivers' ZIP code and basing them instead primarily on driving safety record. 

Before joining the National Partnership, Savage was senior attorney at Consumers Union, the policy and advocacy arm of Consumer Reports. Savage currently serves on the Consumer Empowerment Workgroup of the federal HIT Policy Committee, eHealth Initiative's Leadership Council, and the California Health eQuality Program's Advisory Committee at U.C. Davis Medical Center's Institute for Population Health Improvement.

Landmark wins for the National Partnership, which speaks on behalf of women and families, include the Lilly Ledbetter Fair Pay Restoration Act (2009), California Family Leave Act (2002), Family & Medical Leave Act (1993), Civil Rights Act (1991), Pregnancy Discrimination Act (1978), as well as paid sick days wins in San Francisco, Washington, D.C., Seattle and Connecticut.

Healthcare IT News recently caught up with Savage to talk with him about his work on the health IT front.

Where do the disparities in healthcare mostly occur?

In my experience, I'd say it's all over. Here we are focused on it from the perspective of using health information technology to try to address it. But, before I came here, I worked in California. It took different forms, but across the state, we saw health disparities – the need for linguistic and culturally competent care. It could be all different kinds of communities. This is not just along race or ethnicity lines. It could be along disability. It could be along language. It could have to do with access to resources, whether you had providers who were willing to serve a community. It took many different forms, and I saw it all over. 

Has your organization's emphasis changed to focus more on one aspect or another over the years?

I started here a year ago. I would say we've been working on disparities across the board. So, the HIT team is focused on leveraging health IT. We have a program here that is focused on quality measurement, which has paid some attention to the differences in quality measurement for different communities. We have folks who work on healthcare reform that are acutely aware of the differences in access to coverage and insurance in different communities. We have a program that focuses on patient engagement and is attuned to the ways it can be more – or less – possible for people to be engaged. I think the attention to disparity has persisted for quite some time. And, the solutions we try to bring may vary depending on which program within the National Partnership is looking at it. 

It sounds like the partnership is taking a broad approach – and also focused – with different groups working on different aspects.

Yes, broad and deep. It's one of the exciting things about the National Partnership. One of the things that brought me here was the ability to coordinate and talk across different programs, and sort of learn from some things that people have found in other programs and to try to maximize what we can get out of,  for example, in health information technology.

How did you get involved in this work?

I started as a Civil Rights litigator in California. I became the president/managing attorney of public advocates. We did class action/impact litigation on issues of discrimination and poverty. I went there because that was my passion, and I was there quite a number of years bringing a variety of different cases – some in healthcare. For example, we brought a case against Gov. Pete Wilson when he tried to take away pre-natal care from undocumented women. Some of it was in other areas, like insurance. Insurance companies were increasing premiums in underserved communities. We filed some litigation against this redlining and were actually successful. Fast-forward, I went from public advocate to Consumers Union, where, sort of halfway through, when the HITECH Act was passed, I was asked to try to figure out how get the consumer voice into California's planning activities for health information technology. So worked on that and found out that it was quite lonely. There were not many consumers asked to sit around the table and work on these activities. We worked pretty hard and were able to do a pretty good job of bringing consumer organizations that understood the importance of health IT and were willing to take some positions on it. 

You have a long list of partners.

Everybody is affected; everybody cares. And, there's a whole mess of work that needs to be done. So, partnership is the only way you can get it done.

On the healthcare IT front, what concerns you the most?

I'm not sure if there's only one overarching concern. The needs of different communities can vary. So, we are trying to get them all met. So, maybe the way to say it is my overarching concern is we have an opportunity here to build it right the first time, and I worry that we might not do that – that we may continue to look at it from partial perspectives and not recognize the entire population that needs to be served by health information technology.

Let me peel that away a little bit. In some ways we start off with this work. And, by the "we," I mean the nation starts off with this work, and looks at it largely from a provider perspective. What does the doctor need here; what does the doctor need there? But the National Partnership's vision is to have a fully engaged patient and consumer at the center of that. We focus on patient- and family-centered healthcare. So, we would be concerned about building health IT so it only looks at care coordination or transitions of care from one doctor to another, but doesn't remember that the patient needs access to that information. The patient is actually the one at the center of the care. The patient might actually have a different way of articulating what the health goal is here. 

It seems that on the flip side, technology can hold a lot of promise. I'm wondering what you think the biggest promise healthcare IT offers. 

This may not be the typical answer. But, I think actually the biggest promise is we're transforming from a paper record system to an electronic system. So, if you have all the information in a paper file in the doctor's office, you make it pretty hard for the patient to get access to it and to make contributions to it. Just the overall enterprise of trying to get healthcare into the 21st century, the way we've done things with so many other systems – like banking, for example – I'd say that's the biggest upside. And, that presents some of the more specific opportunities that we're talking about. One of the things I haven't mentioned is accessibility for people with disabilities. When you are doing this electronically, you have the ability to incorporate Web-based accessibility guidelines that make it more possible for people with disabilities to see information they need to see in order to be engaged, in order to take care of themselves. 

What about the meaningful use program? How do you see that? I wonder if you see it as an opportunity as well as something you have to watch in terms of disparity.

I think both. It's definitely an opportunity. I am thankful that Congress set a national goal that every American should be in an EHR by the year 2014. I will acknowledge that it's proven to be somewhat of an ambitious goal, but if that important and ambitious goal had not been set, we wouldn't be moving as quickly as we are right now. So that program focuses on the places where the United States is the payer in Medicare and Medicaid. It focuses on setting minimums for EHRs, but if it had not done that, we would not be moving as quickly as we need to be moving. There are more particular things about the meaningful use program, but if your question is about the program overall, I would say it has actually helped the nation to move. You see dramatic increases in adoption rate. You're starting to see some really different kinds of uses like patient online access, which is just beginning to emerge with Stage 2. This is really helping to transform the culture of healthcare.

Why is it important to provide a list of patients by disparity variables?

It's important for the doctor to be able to differentiate inequalities of care and to understand why those are occurring, and you can't do that unless you start stratifying by the different important demographic of variables. So, if you don't do that – at least at a population or at a practice level – everybody looks average. It's when you start stratifying that you notice that perhaps there are higher rates of diabetes in one population than another, and yet you, as a doctor, may think, "well, I'm providing the same care to all of them. Why should the outcomes be different?" If you can't identify the disparity, you're not really well positioned to start to address it and to tease it out. The answers might be different for different populations, and it's very important to note them in the first place.