NCQA comments on ONC’s Health Equity by Design concept paper

NCQA is encouraged by the ONC’s proposed approach for Health Equity by Design; suggests some guiding principles to inform the framework.

June 10, 2024

Micky Tripathi, PhD, MPP
National Coordinator for Health Information Technology
U.S. Department of Health and Human Services

Re: Advancing Health Equity by Design and Health IT

Dear Dr. Tripathi:

The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Office of the National Coordinator for Health Information Technology’s (ONC) Health Equity by Design white paper.

NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate their journey toward an equitable, digitally enabled health care system. Our mission to improve the quality of health for all Americans, with a focus on health equity and support for meaningful value-based payment models, propels our daily work.

NCQA is pleased to provide the following responses to the questions in the ONC Health Equity by Design white paper.

  1. Do you think this draft identifies the core issues and heads in the right direction? Are there changes you recommend based upon your own experiences with health inequities and health equity by design?

    NCQA is encouraged by the ONC’s proposed approach for Health Equity by Design, and recognition of the need to include health equity in how health IT policies, programs, projects and workflows are designed, built and implemented. Like ONC, we believe equity should be intentionally considered in health care solutions that involve digital technologies, and we are aligned with the goals of Health Equity by Design.

    We recommend ONC add political determinants of health—which encompass voting, government and policy—in health IT system design as a domain that influences health outcomes. Political determinants of health are distinct from social determinants of health (SDOH). They involve community engagement to drive policy changes that can greatly influence adoption and impact of health IT across communities. For example, a local government initiative that requires electronic health record (EHR) systems in all healthcare facilities can improve patient data sharing, enhance care coordination, and ultimately lead to better health outcomes. This kind of policy change, driven by political determinants of health, demonstrates the critical role of the community in sharing healthcare technology use and effectiveness.

  2. What ways do you design and integrate health equity in health information technology, exchange, and use, across your work in health care and delivery? What are the exemplars and lessons you would share with ONC in your comments?

    NCQA is involved in ongoing efforts to advance health equity, and is advancing a digitally enabled health care and quality reporting system. We began implementing race and ethnicity stratification in HEDIS measures in Measurement Year (MY) 2022. As of MY 2024, 22 stratified HEDIS measures align with Office of Budget and Management (OMB) categories. To support stakeholders implementing these stratifications, we deployed a Race and Ethnicity Stratification Learning Network to gain insights on challenges and opportunities. Some identified best practices that could inform ONC’s Health Equity by Design approach include building and maintaining trust with all stakeholders (e.g., members about whom data is being collected as well as providers and quality reporting users), meaningfully collaborating with community partners and maintaining flexibility to adapt to different audiences and needs (e.g., allow for selection of multiple fields; ability to aggregate and look at more granular data).

    We are also advancing digital health equity through research and other partnerships. NCQA recently collaborated on the Agency for Healthcare Research and Quality’s Digital Health Equity Framework—and on the accompanying implementation guide, which is a tool to help stakeholders assess whether their digital health care solutions are equitable at every phase of the digital health care life cycle. The framework specifies that patient and community, health system and health IT characteristics should be intentionally considered for equity in digital health care solutions. The principles used to develop the Digital Health Equity Framework can also inform ONC’s health equity framework, including:

    • Ensuring that solutions ameliorate, rather than exacerbate, inequities.
    • Representing equity through person-centeredness.
    • Encouraging inclusivity and participatory development.
    • Supporting effective implementation in diverse settings.
    • Ensuring policy/regulatory relevance and impact.
    • Focusing on impact and outcomes.
  1. What are the leading barriers to health equity and health equity by design that you experience in your efforts? How do you think ONC can help?

    Through our Race and Ethnicity Stratification Learning Network, we learned that a major barrier to health equity is the difficulty of comparing groups and addressing identified gaps, due to the many ways to define race and ethnicity and capture race/ethnicity data. Health plans emphasized that in order to assess disparities, there must be consistent, reliable identification of members/patients. As noted in our comment letter on USCDI V5, NCQA recommends ONC update the Race and Ethnicity data elements included in the Patient Demographic/Information data class to align with OMB revisions to the Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (SPD 15), published this year. We will update our programs to match these new standards, as well. We also provided recommendations on ways the ONC can support improved collection of equity data elements such as race/ethnicity, sex parameter for clinical use, pronouns and social needs referrals.

    The ONC can help NCQA and health plans by promoting uptake of OMB updates, and by revising other data elements in USCDI to help organizations facilitate collection of these equity-centered data that are valid, up-to-date and aligned with federal standards.

  2. What additional activities, if any, do you think ONC should undertake to implement Health Equity by Design fully and effectively?

    NCQA urges the ONC to include activities that cover cybersecurity and data breach concerns, and how they interact with and inform health equity considerations at all phases of health IT solutions design, build and implementation. Security and privacy concerns may contribute to the public’s mistrust in providing health and other information (e.g., race, ethnicity, SDOH) to providers through health IT platforms. Health Equity by Design should consider the public’s concerns about potential data breaches that might expose sensitive data (e.g., people with substance use disorders or mental health conditions).

We applaud the ONC for its efforts to advance a more equitable, digitally enabled health care system. We strongly urge the ONC—and particularly, technology vendors and infrastructure developers—to enable health IT to be interoperable in a reasonable timeline, so information is easily communicated or transferrable across diverse systems and care settings.

Thank you for the opportunity to comment. We remain committed to working with the ONC and the Department of Health and Human Services to build a more equitable, sustainable and responsible American health care system. We welcome a discussion on our experience and recommendations to strengthen and support the ONC’s efforts to advance Health Equity by Design as regards health IT. If you have any questions, please contact Eric Musser, Vice President of Federal Affairs, at (202) 955-3590 or at



Margaret E. O’Kane
National Committee for Quality Assurance

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