Melting the iron triangle: health equity in innovative health care landscapes [PODCAST]

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“While the technological boom in the health care field is not a circumstance of the pandemic, the accelerated roll-out and adoption of digital features certainly are. And rapid innovation in the health care technology field is not a bad thing in itself. Health care technology discoveries improve health care access, quality of life, patient safety, and even save lives – for example, remote patient monitoring devices and robotic surgery. Although digital health innovations have significantly impacted patient engagement by empowering individuals’ autonomy over their own health, these modern health tools could yield a much greater impact if they were not primarily utilized by populations already advantaged in terms of cost, access, and quality of care.”

Nina Cloven is a health care administrator.

She shares her story and discusses her KevinMD article, “Melting the iron triangle: Prioritizing health equity in dynamic, innovative health care landscapes.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show, we have Nina Cloven. She is a health care administrator, and her KevinMD article, which we’ll talk about today, is titled “Melting the iron triangle: Prioritizing health equity in dynamic, innovative health care landscapes.” Nina, welcome to the show.

Nina Cloven: Thank you so much for having me, Kevin.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Nina Cloven: My health care journey started at a very young age. I’ve always known that I wanted to help people, and I’ve always known that health care was how I was going to do that. I’m very close with my mother, who’s a gynecologic oncologist, so I was exposed to the clinical side of health care very, very early on. My mom would always talk about how evil hospital administration is, just talk about it all the time. But I really appreciate a challenge, and I was interested in the prospects of being able to help many people at a given time, so I decided that health administration is exactly what I was going to do, even though my mom still asks me every year if I want to go to med school.

From there, I got my bachelor of science in public health at Texas A&M University, and then I went to Johns Hopkins for my master of health administration. During graduate school was when I decided that I was not going to wait 10 years to make a difference in health care. I was just going to try to make a difference now. So while I was in graduate school, I started a student organization at the Bloomberg School of Public Health called Health Administration Leadership Organization, or HALO, which got at my foundational passion in health care, which is clinical and administrative collaboration and shared leadership.

Then in my second year of graduate school, I matched with Elation Health as their first administrative resident, and I really, really liked it. I don’t think there had been any other health technology residencies at the program that I was in, but I was really, really surprised how supportive and empowering all the folks at Elation are, to really empower me to pursue my passions now, regardless of how early I am in my career. So now that I’ve graduated, I am still at Elation, working as their manager of primary care advancement.

Kevin Pho: Now, a lot of us on the clinical side of health care have perspectives not dissimilar to what your mom says about health care administrators. So tell me, from the administrator perspective, how do you positively impact patient health?

Nina Cloven: So I like to think of it as we’re helping people help people, which is a little more far removed from the actual trenches of clinical medicine. But I think that every role in health care is necessary. Even at Elation, I really try to work internally to let even the engineers know that you are saving lives. It seems far removed, but you are. And I really am passionate about uniting everybody in health care under the fact that the large majority just want to help people.

That’s what I love about KevinMD and the community that you’ve built too, because I love how you say, people that are rarely ever heard from in health care. And yeah, like I said, I really do think that if there was a little bit more collaboration, then the health care system wouldn’t be as broken.

Kevin Pho: So what are some ideas that you have to bridge that gap between the clinical side and the administrative side? Because no matter which institution you go to, you’re always going to find a little bit of a chasm there. So what are some ways that we can bridge that chasm?

Nina Cloven: Yeah, so what I tried to do for my student organization was a lot of seminars and education. I noticed that during graduate school, there was a lot of financial management, there was accounting, which I didn’t really like, and there was public health and classes like that, but I was looking for a medical terminology class, because I think that really understanding the clinical perspective as much as you can is really important. And from the other side, if clinicians understood more of the perspectives on the administrative side, that would be a little easier. But practically, in the workplace, I think shadowing and mentoring people who are on different sides of health care than you would really open people’s minds to having different perspectives and recognizing that we all are trying to do the same thing.

Kevin Pho: All right, so let’s move on to your KevinMD article that was recently published. It’s titled “Melting the iron triangle: Prioritizing health equity in dynamic, innovative health care landscapes.” Now, for those who didn’t get a chance to read your article, just walk my audience through it and share the story of why you decided to write it.

Nina Cloven: Yeah, so I actually started writing this article in October or November of 2021, during graduate school. My program had a capstone project, and there were three options. One of them was this Stull essay competition, which is a 15-page essay about a relevant health care topic that you submit to the ACHE, and the winner gets published with the ACHE. I was selected to represent Johns Hopkins in this national competition, and although I wasn’t selected as the winner, I still really knew that this is such an important topic that maybe is not as well researched as others, and I really thought it was important that people hear it.

And like I said, Elation has been so supportive, so mission-driven, and so empowering of all of my different passions and of being a leader in health care, everyone. And so when I heard back from you that you were going to publish my paper, I was really, really excited to have the opportunity to share, because I was fascinated by the relationship between innovation and equity.

I really started to think about it: Are the robust, awesome, innovative, accessible new innovations coming out of the pandemic really helping the people that actually needed them the most? So I started diving into the historical context of different pandemics and public health crises and all of the innovation that came from them, even washing your hands, historically, germ theory, all of that. And I started to realize that without accessibility, the people who need it the most are not getting it.

That’s when I started thinking more about the iron triangle, because that is something I learned in undergraduate school, with cost, quality, and access. The theory asserts that if you try to improve two of those things, the other one will worsen. And like I said, I appreciate a challenge, so it’s trying to consider how you can improve all of those things. How could you create an initiative or a new innovation that meets all of those criteria? I really tried to think about it. It is very difficult, but I think the whole thing with equity, especially health equity, especially digital health equity, is that it’s not going to improve unless there’s a true, intentional effort to improve it.

Kevin Pho: So as it relates to the current pandemic, give us an example of a technology that you’re specifically talking about that intersects with that issue of health equity. Which technology in particular would be a good example of that?

Nina Cloven: So for instance, telehealth. Telehealth is great, and it improved access for so many people, particularly rural populations, and especially in the new digital era, accessibility, ease of use, and convenience are all very important things. However, not everyone has a laptop. Most people have a phone, but not everybody has a phone. A lot of people don’t have internet. So what about those populations of people who can’t go in to a clinic or practice during the pandemic and also don’t have access remotely?

So in that case, I did a bunch of research, thinking about, OK, so 80 percent of people have a mobile phone. That’s why I start my recommendations for how to address digital health equity by leveraging the mHealth opportunity. Everything should be accessible on a phone without internet, with different bandwidth styles and different screen styles.

And then patient-facing tools, interestingly enough, are generally less equitable than other equity tools and innovative tools, because it starts going into all of the social determinants of health. And then I learned about digital determinants of health, which include perceptions about technology to help or harm, and societal and cultural norms. So patient-facing tools are a really, really huge opportunity to be able to empower patients to take charge of their own health, have that patient autonomy over their own lives, and be able to have information and access to everything that they need.

Kevin Pho: And when you say patient-facing tools, what exactly do you mean by that?

Nina Cloven: So that would be something that you, as a patient, interact with the health care system with, as opposed to back-end tools for clinicians to, say, gather data about patients and to be able to see patient data visually. So patient-facing tools are definitely the future of health care, I would say, especially as apps and remote patient monitoring devices, all these things, hopefully one day will be connected, so that in this new age of digital information, everybody has access. But to give everybody access, we really, really have to make an effort to make sure that the people who traditionally are undervalued, underserved, and vulnerable have access first.

Kevin Pho: So one example certainly would be those patient-facing portals that a lot of electronic medical records have. So what’s the current situation now, and how far do we have to improve before we get to your ideal?

Nina Cloven: See, I’m an optimist, and one of my weaknesses is that I tend to just believe that anything is possible, and I need to be grounded in reality some more, because I haven’t been, maybe, beaten down enough by the health care system yet. But I think that patient portals for EHRs are an excellent untapped resource for this, because they’re already built, and they already have a lot of the capabilities to be a resource for patients in their lives, not even just at the point of care but beyond.

So I think minor adaptations to the patient portal, for instance, just filling in more resources, connecting to community centers and external resources, explaining diagnoses, alerts, having access to clinical opinion, all of these things, as well as accessibility concerns, such as maybe having an audio recording instead of just reading, or having different font sizes, all of these things will help transform patient portals into a tool that people could use. Uptake of these things is a completely different story, but I think we just have to start by at least offering these things, and then from there, we can go into how to spread the word about the potential.

Kevin Pho: So one of the things that you mentioned earlier was that sometimes there’s some cultural hesitancy when incorporating technology in one’s health care. So talk more about some of those cultural issues that come into play when it comes to digital health equity.

Nina Cloven: Yeah, absolutely. I come from a position of privilege, and I do touch on that in my article. I think, realizing that I did all of graduate school fully remote, I’m so lucky to be able to have all the tools necessary to complete my education, and not only my education, remote and fully online, but also to take care of my health and meet with my primary care provider, all online.

So the cultural norms, I think a lot of that comes from traditionally marginalized communities having less trust in the health care system, for good reasons. So it’s not their job to just trust that we as a health care system are doing things to make everybody’s lives easier and to give everybody a better quality of life. It’s our job to go out of our way to prioritize getting vulnerable populations and communities access to the resources that they need to feel comfortable to be able to do that.

Kevin Pho: We’re talking to Nina Cloven. She’s a health care administrator, and we’re talking about our latest KevinMD article, titled “Melting the iron triangle: Prioritizing health equity in dynamic, innovative health care landscapes.” What do you see as the path forward? So what are some immediate things that health care systems can think about or do to really improve those digital health equity issues?

Nina Cloven: The first thing would have to be primary care. Primary care is the source of everything in terms of all the social determinants of health that impact a person’s health. Health care itself only makes up 10 to 20 percent of a person’s health. So I think any digital or any health equity measure or initiative in general has to begin and start at primary care. And that’s become more of a recent passion of mine at Elation, just learning more about how undervalued primary care is in the health care system.

If I could share a personal story, I think a little bit over a year ago, our family’s primary care physician, my mom’s primary care physician, saved my mom’s life, or could have saved my mom’s life. My mom and I both have migraines, and her migraine medicine stopped working. So her primary care physician said, “OK,” and referred her to a neurologist, who found an unruptured brain aneurysm. My mom herself is a gynecologic oncologist, so it’s very strange to experience health care as a patient. Brain aneurysms are rarely ever found unruptured, and when they are found ruptured, it’s a 50 percent chance of mortality.

So my mom was lucky enough to know which physician to go to, which doctor, to go into the hospital and get what is called an endovascular coiling procedure. I spent all day and all night in that hospital, and it really made me think about health care as a patient, and how nobody wants to be in a hospital except for the people who are working there.

And I think primary care is uniquely positioned in that every primary care physician experiences primary care as a patient. My mom’s situation is unique because she actually didn’t like it. They say doctors make the worst patients, and it’s true. She just knows too much. But how fortunate are we that she had the medical literacy, we had the financial resources, and we had access to all the information to be able to get that treated? A lot of people don’t have that.

That’s why I believe that primary care has the ability to kind of address all the social determinants of health and to really empathize with patients, because they are in those situations. So primary care, more than arguably any other specialty, can really understand the patient perspective, give them all the resources, and build a relationship with them to be able to have a better quality of life and kind of, I guess, go through the health care system together.

Kevin Pho: Well, as a primary care physician myself, thank you so much for saying those words, and I completely agree with everything that you said. And my final question: your take-home messages to the KevinMD audience.

Nina Cloven: I think my take-home message would be, I guess for your clinical audience, I would say invest in your relationships with administrative health care workers, because no issue in health care, not digital health equity, not health equity, none of those systemic issues, will get solved without collaboration. We have so far to go, so, so far to go. So I think a strong foundation of collaboration and teamwork is the only way that we’ll be able to fix this broken health care system.

Kevin Pho: Nina, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Nina Cloven: Thanks.

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