Health Equity

With increased recognition that the status of an individual’s health is more than just the sum of their clinical encounters, our work is guided by advancements in health equity. Helping our participants support whole-person care practices by connecting the individuals they serve with cross-sector resources is a measure of our mission.

Why Health Equity?

The effort to leverage diverse cross-sector data sets to more effectively and efficiently “tell the story” of an individual’s health, wellness, and wellbeing represents a fundamental shift in the traditional care delivery model.

Understanding that medical care alone cannot account for what makes an individual sick has shifted the diagnostic focus to simultaneously examine the underlying social circumstances and influences impacting their health. According to the Robert Wood Johnson Foundation, only 20% of health outcomes can be attributed to medical care; upstream factors account for the other 80%, including social and economic factors (40%), physical environment (10%), and health behaviors (30%).

The complexity of interpreting an individual’s health-related risks, conditions, outcomes, and drivers casts a light on the many health disparities that exist in our communities, especially within the most vulnerable and underserved populations. Increased information sharing among multidisciplinary providers, who are committed to coordinating access and delivery of care to individuals across clinical and community settings, aims to eliminate these key drivers of health and to move toward health equity — the desired outcome that everyone has a fair and just opportunity to be healthy.

Sometimes the greatest challenge is not in identifying an individual’s social health risk, it’s in how to get that individual connected to the services that can help them – and that is a risk to an individual’s health in itself.

How Do We Define 'Health Equity'?

When it comes to conversations about health equity, semantics matter. One of the most commonly used terms in the study, “social determinants of health,” is a loaded and misused concept that often creates more confusion than it does clarity. Which is why HealthInfoNet employs the following definitions to more pointedly refer to the specific health equity data sets of priority to Maine’s statewide Health Information Exchange.

Expanded Demographics and Personal Characteristics: The various socioeconomic factors that are used to describe populations and their characteristics, such as race, ethnicity, language preferences, veteran status, farmworker status, etc. While “these characteristics are not inherently connected to poor health outcomes… the social and economic conditions affecting patients’ health are deeply rooted in systemic racism, discrimination and inequality” (PRAPARE) that derive from their identities.

Sexual Orientation and Gender Identity: The ways in which individuals identify themselves biologically, emotionally, romantically, and/or sexually, and those identities’ relations to health status. The information is inclusive of preferred names, preferred pronouns, legal sex, sex assigned at birth, sexual orientation, and gender identity.

Social Health: The upstream social, economic, and political circumstances (e.g., food security, transportation access, housing stability/quality, etc.) impacting the downstream health risks, conditions, and outcomes of persons, communities, and societies. The information is inclusive of social risk factors (person-level), social determinants (community-level), and structural determinants (societal-level).

Health Equity Data Action Plan (2022)

In early 2022, HealthInfoNet began having one-on-one conversations with some of our leading participants to understand how to receive their social health and/or SOGI data sets. What became immediately evident was that while each participant was on its own strategic trajectory, each was also curious as to what others in the space were doing to advance their data collection, storage, and use case efforts. And so our Health Equity Data Action Plan convening series was born. Formally known as our Social Health Data Action Plan (since broadened to be inclusive of additional data sets), the effort was designed to create a forum in which healthcare providers across the state could share lessons learned, best practices, and emerging priorities for collecting, storing, and using the information.

How Are We Advancing Health Equity Efforts?

Engagement Opportunities

Expand Participation

Enhance Partnerships

Establish tighter relationships with existing cross-sector information technology systems (e.g., 211 Maine, findHelp, Open Beds, etc.)
Create a directory of participants' homegrown community resource lists identifying key supports in their respective service areas
Partner with health equity subject matter experts to help train/educate participants and other HIE stakeholders on the appropriate uses, best practices, and innovative applications of relevant data sets to inform person-centered care

Support CHIE Efforts

Service Opportunities

Clinical Portal

Carefully incorporate health equity data sets within patients' electronic longitudinal health records to bridge clinical and community care settings
Clearly identify when health equity data sets were last updated within health records to help reduce duplicative screening processes and stigmatic experiences
Expand the system's role-based permissions to provide cross-sector stakeholders with the minimum information necessary within comprehensive health records to meet use case and workflow needs

Notifications

Analytics & Reporting

Build a new report that presents available health equity information for FQHCs' attributed patient populations in support of their Uniform Data System (UDS) reporting requirements
Generate a new report that identifies health equity trends across the state (e.g., food insecurity hotspots, housing shortages, transportation deserts) by incorporating participants' and other third-party data sets
Enable stratifications of clinical reports by key health equity data elements (e.g., Emergency Department utilization among individuals who have been positively screened for food insecurity)