The global pandemic has revealed a number of cracks in our current healthcare and public health infrastructure. Care is often fragmented, information is siloed, physicians are burnt out, and existing care models fail many patients, particularly poorer patients and patients of color. COVID-19 laid bare the dire consequences of these structural weaknesses.

At athenahealth, we are focused on creating a thriving healthcare ecosystem, a sustainable healthcare environment that supports all patients with the differentiated care models that are right for them; one in which practices can improve patient and population health while achieving financial success.

In late 2020, athenahealth sat down with Patrice Harris, M.D., past president of the American Medical Association (AMA) to discuss the concept of a successful healthcare ecosystem and how the pandemic has illuminated the path to building it.

What is the healthcare ecosystem?

“Healthcare is about the business of delivering a treatment and intervention,” says Harris. “But health is about feeling right and good.”

And in order to shift to a focus on health, the ecosystem must be defined more broadly than simply providing episodic care. Harris urges that a successful healthcare ecosystem would encompass non-traditional stakeholders — not just patients, providers, and payers. And it would assign and enable accountability amongst them.

She is clear that it begins with doctors, nurses, hospitals, and payers — all the usual stakeholders. “But we need to think about housing partnerships, about jobs contributing to health. The ecosystem needs to include societal solutions, community solutions, and solutions designed around the individual.”

To be successful, everyone in the ecosystem must accept responsibility for health. It begins with holding providers accountable for what they can control, like educating their patients about the importance of colonoscopies (for instance), and then their performance is measured by how many patients actually get them. Harris makes the point that, too often, that is the end of the conversation. She believes the entire ecosystem must take responsibility for understanding why patients who should get the procedure are not.

“Is it because they are afraid and don’t trust the health system? Or maybe they cannot get to the surgery center. Or they don’t have the copay.” Her vision is that insurers would be looking at what they can do to help the patient get the colonoscopy, that they might work with municipal transit systems to make travel to the hospital easier. Or thinking about policy and politics as a determinant of health and holding the system accountable for healthy outcomes. Her vision is an “ecosystem structured to give you the opportunity to live a healthy life — it doesn’t just mean the absence of disease.”

Racial and ethnic health disparities one of many imbalances revealed by COVID-19

When accountability and resources are distributed across all relevant stakeholders, the ecosystem is in balance. The disproportionate impact of COVID-19 on communities of color was the most glaring example of imbalance within healthcare.

Harris lays out the many interconnected factors that create this inequity. First, she cites the chronic underfunding of the public health system upon which so many patients and communities of color rely. And, as is often cited, patients of color often do not have adequate health insurance or live in areas with ready access to healthcare centers.

But she goes further: “A majority of the folks who have died tragically from COVID are black and brown. And that is because they are in these essential jobs, they didn’t have the privilege of working from home. Lack of transportation is an issue. And they often lived in more densely populated communities.”

Providers want to work with patients on their specific health needs and their individual choices, but, at the same time, they need to recognize that patients exist in a larger system that impacts their opportunities for health. Harris notes that something as simple as the recommendation to get more exercise is impacted by whether or not the patient’s neighborhood is safe and well-lit with sidewalks. There are neighborhoods where it might take as long as four hours to reach a grocery store by public transportation, making it difficult to make healthy food choices. As Harris so eloquently states, “the choices you make are based on the choices you have.”

The good news is providers can find out if patients have access to health insurance, are able to afford their prescriptions, and what other issues affect their opportunity to make sustainable choices. According to Harris, this is a perfect opportunity to take advantage of the team-based care model, deploying care team members other than the physician to get the patient’s whole story, to get a real sense of what is going on with them and how best to meet them where they are.

And, she says, “COVID-19 is bringing clarity of purpose” around important conversations about race and health, around the role of policy and norms. “People are, for the first time, in a broader context, talking about structural racism as a determinant of health.”

Accurate and honest data, shared openly, is one of the best public-health tools

The pandemic has made it clear that one of the most important things in an emergency situation is the wide availability of accurate information. Patients have been afraid and unsure of what information to trust, uncertain about when it is worth the risk to come into the practice. The COVID crisis has highlighted the role of credible health and public health organizations like the AMA, their Council on Science and Public Health, the American Hospital Association, and others in distributing accurate health-related information and ongoing updates.

As a longtime public health leader, Harris understands how valuable an open flow of information is in reassuring patients and the public. “One of our key jobs in moments like this is to be honest with our patients and the community, to tell them what we know, tell them what we don’t know, and make sure we are inspiring public confidence and trust that engenders psychological safety, which is just as important as physical safety.”

She also makes clear that it is okay if information changes as the scientific community learns more. “Science does evolve. We know some things today that we didn’t know two months ago.” The most important thing is just to be honest, to tell people when a recommendation is changing, and to tell them why — and Harris stresses that partisan politics have no place in this conversation.

This is especially important for communities of color that have good historical reason not to fully trust the healthcare system. Harris makes it clear that public health officials should go into the community and “share power, demonstrate that you are willing to partner. Ask what they need. Ask what would it take for you to trust me? Because trust is earned.”

Increasing connections will make the ecosystem more resilient

One key question at this moment is how to insulate the healthcare ecosystem against the impact of future health crises, minimizing the negative effects on patients and practices. A balanced system is resilient and can absorb shocks without breaking.

The pandemic has brought to light the fragmentation in the existing healthcare system and negative impact of that fragmentation. According to Harris, healthcare information is siloed and frequently inaccessible across care settings, making the system hard to navigate and access for patients. A more connected ecosystem would “invert the burden,” reducing the care coordination work that falls to patients.

“You have to be intentional about making those connections,” she stresses. “If we want a more resilient ecosystem, we have to be committed to making sure it is an ecosystem, not just connected by a thin thread, but interwoven and interconnected with the patient at the center.” Harris gives the example of integrated mental health care which breaks down siloed information and focuses on caring for the patient holistically.

And her vision goes beyond clinic walls, imagining the important role city planners, education officials, local business leaders, and transportation officials play in creating population health. Building connections with those non-traditional stakeholders will bring balance to the healthcare ecosystem and bring equity as well.

“So many elements need to be connected if we really want our health system to be resilient,” says Harris. “At the societal level, policies and structures, and at the community level, education, the accessibility of good-paying jobs, transportation. I guess I am daring to redefine what a health system is.”

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Click here to read excerpts of Dr. Harris’ recent conversation with Jessica Sweeney-Platt, athenhealth’s vice-president research and editorial strategy