ADMINISTRATION & OPERATIONS Health Equity Dashboards: A Key Driver Toward Equitable Patient Care

By Marquita S. Norman, MD, MBA, Meagan Hunt, MD, Aaryn Kelli Hammond, MD, and Ryan Tsuchida, MD, on behalf of the SAEM ADIEM Operations Committee and the SAEM ED Administration and Clinical Operations Committee

Health care has made great strides in quality improvement incorporating lessons from industries including manufacturing and aviation. While many cite the 2001 Institute of Medicine (IOM) report as having “groundbreaking” or “practice changing” impact, not all areas of the report have been incorporated similarly. In this report IOM established six aims of health care quality captured in the acronym STEEEP (safe, timely, effective, efficient, equitable, and patientcentered). Institutional interventions and efforts to provide safe, effective, patient-centered, timely, and efficient care are typically both abundant and highly visible. Two decades following this report, more attention is needed toward the aim of equitable care. A recent ACEP workgroup report highlighted the need for integrating and reimagining quality outcomes in care to promote institutional accountability to overcome health care disparities. Here, we report how these quality metrics can be presented and organized using dashboards.

While negative social determinants of health and a variety of structural challenges contribute to the health outcome of patients, so do the practices and policies within a given health system. Disparities in health care delivery have primarily been described using large databases supported by research projects. Less common is the approach for individual hospitals to monitor their own performance on care delivery to detect potential disparities and, in turn, use an equity lens in designing interventions. Institutional process measures designed to address disparities that rely on inpatient resources and interventions may not effectively address disparities experienced by patients solely cared for in the emergency department (ED). To truly assess whether we are providing equitable care at the level of the emergency department, we will have to go deeper.

At least anecdotally, health care systems are increasingly focused on addressing health care disparities experienced by patients. The best practices to address these disparities remains an area of active research; however, many institutions are already deploying tools such as health equity dashboards to define where opportunities to reduce health care disparities exist. With the COVID-19 pandemic came a desire for rapid health care data visualization and public transparency. This led to a surge in the availability of dashboards to provide summary-level data, often with figures and graphs, to aid interpretation. Dashboards have been used for years to track health outcomes, process metrics (wide ranging from timely antibiotics for sepsis, hand washing in patient rooms, and utilization of time outs before invasive procedures), and clinical operations (including hospital capacity, anticipated discharges, and PPE utilization). In this context, it is not surprising that equity dashboards are now being proposed to aid health care leaders in addressing health care disparities.

The greatest argument for a health equity dashboard centers on the principle that problem identification and planned interventions require the availability of data to describe gaps, set aims, and allow for continued evaluation of interventions. The barrier to creating these dashboards is greatly offset by the existing quality infrastructures built within each health care system. For example, the data source (often an EMR), data analytics, and technical support all rely on existing structures. In practicality, the intervention requires the additional stratification of outcomes by various demographic identifiers known locally or regionally to impact health care disparities.

When creating these dashboards, it is important to identify key stakeholders. While a comprehensive list would require individualization to an institution, we highlight the following individuals: quality/ safety officer, data analyst, community members, DEI leaders, physicians, nurses, and registration personnel. Dashboard designers must also thoughtfully consider the benefits of an integrated versus a standalone product.

Integrated dashboards are akin to adding a “column” or “filter” to an existing dashboard. This approach has the shortest startup time. An integrated approach is more likely to catch the attention of key stakeholders such as quality and patient safety officers. It is also reliant on the agreement of those managing these dashboards that the inclusion of this type of stratification is both important and worthy of report, particularly if a health care disparity is identified. Adding complexity to a dashboard can undermine the intent to provide simplified digestible information.

Administrators may find it distracting to have multiple aims for a given dashboard (e.g., highlighting disparities, evaluating individual performance metrics, and meeting operational/capacity demands). This may represent a significant initial barrier to successful implementation.

On the other hand, homegrown versions of dashboards to address department-specific issues have the benefit of truly building in an equity lens from the ground up. This requires a greater initial investment but can be tailored to the needs and health care disparities experienced in a particular community and may include numerous populations. Routine data collection by existing dashboards may not capture these metrics. For example, an ED may decide to focus on disparities in restraint use or hallway bed utilization by varying demographics. For those with the capacity to prioritize ED-specific dashboards, the homegrown equity dashboard may be the way to identify setting-specific health care disparities and interventions to address them.

Regardless of the approach chosen, there will remain challenges in implementing disparities measurement in the ED. Numerous populations are affected by disparities in care and many of them are not identified by traditional demographic collection practices at time of registration. Many institutions have not yet implemented the infrastructure and personnel training to allow for the gold standard of patient self-reporting on a variety of demographic measures. Furthermore, data collection is often aligned with reporting databases such as the CMS RTI Race Code, which has few options and would benefit from additional disaggregation. For example, the current five options (and other/unknown) do not include North African and Middle Eastern descent, nor do they provide necessary granularity to identify disparities that are only experienced by a subgroup. However, this limitation only amplifies the need to pursue change to provide equitable care when even small disparities are noted.

Evaluation of existing data collection and quality efforts to detect and impact disparities in care for minoritized racial and ethnic groups as well as women, immigrants, the elderly, those with cognitive or physical disabilities, children, those living in rural areas, and LGBTQ (Lesbian, Gay, Bisexual, Transgender, and Queer) populations is where we must begin our endeavor to truly provide equitable care. While this list may not even be all-encompassing, its length highlights the amount of work ahead of us to provide equitable care

About The Authors

Dr. Norman is an associate professor and serves as the associate chair of health equity, quality and safety in the Department of Emergency Medicine at UT Southwestern Medical Center. She currently serves as chair of the SAEM Equity and Inclusion Committee and is a past president of SAEM’s Academy for Diversity and Inclusion in Emergency Medicine.

Dr. Hammond is an assistant professor of emergency medicine at Atrium Health Wake Forest Baptist Medical Center where she also serves as the assistant medical director for the Adult Emergency Department.

Dr. Hunt, an assistant professor of emergency medicine at the at the Wake Forest University School of Medicine, serves as medical director for the Adult Emergency Department at Atrium Health Wake Forest Baptist Medical Center.

Dr. Tsuchida is an emergency medicine physician and assistant professor at the University of Wisconsin, Madison. Dr. Tsuchida leads the DEI committee for the BerbeeWalsh Department of Emergency Medicine and collaborates with department and institutional leaders in embedding health equity into clinical practice. @rtsuchida