“Equal Justice Under Law” is a foundational aspiration of the American legal system, a notion so central to our democracy that it is enshrined above the doors of the U.S. Supreme Court. For people of low income, however, simply accessing the legal system requires overcoming a variety of complex burdens. People have difficulty obtaining legal help for many reasons, including concern about the cost of seeking such help, not knowing where to look for help, being afraid to pursue legal action, language barriers, and an underfunded civil legal services system that is regularly forced to turn away more than half of those seeking assistance. Harnessing technology as a means to reduce those barriers is a central focus of the interdisciplinary Access to Justice movement. However, to maximize the contribution that technology can make to ensure “Equal Justice Under Law,” lawyers must not only embrace legal information technology (legal IT) but also look beyond the legal sector for inspiration. This article explores how the legal sector can innovate by leveraging technology from the healthcare sector (health IT).
Like the legal sector, the healthcare sector has faced challenges in serving all patients in need. For a variety of reasons that are beyond the scope of this article, the healthcare sector is using technology in broader and more sophisticated ways than the legal sector to help close gaps in access. Lawyers can and should look to health IT to inspire uses of technology in daily law practice, but they can also use healthcare technology itself to better meet the unmet legal needs of low-income communities.
Throughout the country, innovative legal and healthcare teams have come together and recognized that many health inequities have a legal root and that addressing health-harming legal needs among patients and communities may have a lasting impact on health. These collaborations, known as medical-legal partnerships (MLPs), have been supported by the ABA in a variety of ways, including through its Medical-Legal Partnership Pro Bono Support Project and a 2007 resolution encouraging “lawyers, law firms, legal services agencies, law schools, and bar associations to develop medical-legal partnerships.” Over 10 years later, MLPs are at more than 300 healthcare locations nationwide.
MLP lawyers serve as de facto members of the healthcare team, creating a model for delivering integrated healthcare that addresses the social determinants of health, or the conditions where people “live, learn, work, and play,” particularly for communities that are poor or otherwise vulnerable.
Lawyers who work in MLP are also expanding what it means to practice preventive law. While many MLP attorneys maintain a standard caseload of individual clients, necessity has also forced them to be innovative in thinking about what “legal services” can or should mean in this context. The healthcare industry is larger than the legal industry in the United States in terms of personnel, funding, and reach, with some estimates indicating that healthcare will represent 20% of the GDP by 2025. This imbalance is stark when the focus is on low-income communities. It is not uncommon for a small legal team—often just one lawyer—to partner with a safety-net health center that has 30 employees and serves 25,000 patients or more annually. Because it is impossible to provide individual legal services to every patient with a health-harming legal need, MLPs have incubated new ways of doing business to increase their capacity and impact. Often, innovations within health IT have inspired MLP teams to think creatively yet concretely.
How Are MLPs Currently Using Technology?
The past 20 years have shown us remarkable advances in the way that healthcare is delivered to individual patients, including surgical innovations and sophisticated genetic testing. However, the “nerve center” of healthcare today is located within Electronic Health Record Systems (EHRS). A combination of a database, clinical support tool, communication hub, risk management support, and research engine, the EHRS is also at the center of health IT-inspired MLP innovations. Below we discuss three ways in which MLPs are using EHRS or have been inspired by EHRS to better serve patients.
Identifying and Triaging Health-Harming Legal Needs
A small but increasing number of MLPs are using EHRS to identify and triage health-harming legal needs.
For example, the Legal Services Corporation, the largest funder of legal services for low-income people in the United States, has for many years supported technological advancements through its Technology Innovation Grant program. In 2017, LSC granted a TIG award to the Montana Legal Services Association to improve the ability of MLPs in Montana and Iowa to identify, track, address and evaluate health-harming legal needs. Through the grant, Montana Legal Services Association and Iowa Legal Aid are working with healthcare counterparts at the Montana and Iowa Primary Associations and four Health Resources & Services Administration (HRSA)-funded health centers to add MLP data into EHRS. In Phase I, currently underway, questions that screen patients for health-harming legal needs are being added to the EHRS. When a patient is identified as having an unmet need through that screening process or elsewhere during a healthcare office visit, not only is the need documented, but a referral to the partner legal services nonprofit can be generated quickly and efficiently through the EHRS. In Phase II, an application programming interface (API) will be developed to share information, when a patient consents, between the EHRS and the non-profits’ legal case management systems. That API will allow for direct, real-time referrals. At the end of the legal case, the API will facilitate communication, when the client consents, back to the healthcare team about the legal outcomes achieved.
Several MLPs bring together the legal and healthcare teams to create advocacy documents within the EHRS that are easily accessible to healthcare clinicians who identify health-harming legal needs during a patient’s office visit or hospitalization. For example, MLPs have developed templates requesting repairs from landlords, documenting the need for employment-related reasonable accommodations related to a disability or pregnancy, and asking for an evaluation for special education from a school district on behalf of a student with disabilities.
Still, other MLPs use technology to provide legal support to a variety of healthcare staff as they seek to address a variety of social determinants of health. For example, an MLP that includes the Neighborhood Legal Services of Los Angeles County, along with other legal nonprofits, and the Los Angeles County Department of Health Services Whole Person Care program uses a specially designed online portal to link community health workers with legal experts. The community health workers can refer to Whole Person Care participants directly to the legal nonprofits, and also request “technical assistance” to educate themselves about basic legal rights. For example, a community health worker can quickly refer a patient facing an improper eviction to a lawyer, and also request technical assistance to better understand how housing court operates more generally.
Where Might Health IT Take MLPs in the Near Future?
The opportunities for technology-driven advancements in the ability of MLPs to address health-harming legal needs are diverse and exciting. In many cases, these potential advances need only harness existing technologies that are already widely in use in health IT. Once again, the EHRS is at the center of areas ripe for innovation. For example, MLPs could use EHRS to:
- analyze which unmet legal needs are most prevalent among which patient populations;
- identify which unmet legal needs are associated with which health outcomes;
- evaluate which types of legal interventions impact which key health indicators;
- spot trends and identify issues appropriate for policy advocacy and impact litigation; and
- use artificial intelligence to analyze notes from healthcare clinicians and key health indicators to proactively identify health-harming legal needs among patients.
Harnessing the power of EHRS in these ways could be crucial in determining how to prioritize limited resources. For example, such tools could be used to identify and triage patients at highest risk for poor health outcomes and the highest need for referral for individual legal representation. Furthermore, they also could, in real time, direct healthcare clinicians and support staff to online legal resources inside and outside the EHRS to help address health-harming legal needs without meeting with a lawyer directly.
Outside the EHRS, MLPs can consider using existing telehealth infrastructures to expand the capacity of understaffed, underfunded legal non-profits and pro bono projects to reach populations that are isolated by geography or other factors. HRSA defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, public health and health administration. Telehealth is generally divided into three modalities: real-time (live video or phone); remote patient monitoring (asynchronous monitoring); and store-and-forward (sending images via secure messaging). Telehealth is often used to link patients in rural areas experiencing a clinician shortage to healthcare specialists in more urban areas, but even in urban areas, the use of telehealth is growing to reach underserved communities.
Common examples of telehealth include securely linking patients and their test results with a cardiologist or providing secure video sessions between a patient and a psychiatrist. Telehealth is in wide use in the United States. (To give a sense of the wide-scale and breadth of telehealth, more than 200 health IT and telehealth vendors were at the American Telemedicine Conference in 2018.) MLPs, legal services programs, and pro bono programs could all use existing telehealth infrastructure to expand their own options for providing legal advice, counsel, and representation to underserved communities.
Finally, legal and healthcare teams should continue to work together to train the next generation of the healthcare workforce so that they understand the basic principles of how legal interventions can address or disrupt social determinants of health. In formulating future training, MLPs must add existing legal technology resources already in play or currently being developed through the Access to Justice movement to the curriculum. This interprofessional education of the healthcare workforce must:
- include a broad range of healthcare workforce members and students/trainees, including community health workers, caseworkers, resources specialists, social workers, health aides, as well as nurses, physicians’ assistants, advanced practice nurses and, and physicians.
- include concrete information on what existing legal technology available to assist communities of low income and how to access it, for example by sharing high-quality online resources and providing training on how best to use them.
Lessons from MLPs & Healthcare Technology
The experience of MLPs that are leveraging health IT to better address the health-harming legal needs of low income and other vulnerable patient populations can be applied more broadly to those interested in legal technology overall. Key lessons include:
Nurture relationships, then explore technology
When developing technology-based solutions for stakeholders that come from disparate backgrounds, such as the legal and healthcare sectors, nurture relationships, and then explore technology. Nikole Nelson, executive director of Alaska Legal Services and a founder of the MLPs in Alaska, says that “Success is based on the taking the time to build the relationship between the legal and healthcare sides. We are natural allies [in serving vulnerable communities], but we need to build trust to weather the bumps that inevitably will come along the way. It’s worth the effort.” When complex questions arise where law, health, and technology intersect, the ability to create workable solutions is greatly expanded when the parties already know and trust one another.
Look to rural areas for innovation
As Robert Onders, medical director of Community and Health Systems Improvement at the Alaska Native Tribal Health Consortium and medical champion of the MLPs in Alaska has experienced, “Innovation occurs where there is stress and strain on the system.” In both the healthcare and legal sectors, rural states and regions have grappled for decades with the challenges distance and isolation can play on access to healthcare and access to justice. These rural areas often lead the way in designing and implementing technology to mitigate those challenges, identifying solutions that ultimately work in frontier, rural, suburban, and urban settings alike. Dr. Onders adds, “The healthcare sector is much further advanced than the legal sector in its ability to reach isolated communities, and it has much better infrastructure. Sometimes the best innovation is to leverage existing technologies and adapt them to a new use.”
Collaborate with the healthcare workforce to disseminate tools
Many effective technology-driven tools have already been developed to address Access to Justice, but getting those tools into the hands of those who really need them remains a challenge. Alexander Rabanal, associate director of The Law Lab at Chicago-Kent College of Law, emphasizes that “The importance of placing access to justice technology at sites with maximum use potential cannot be understated.” Legal IT innovators should not overlook the healthcare workforce as a key resource in the effort to connect technology with its intended audience.
The Future of Innovation for Health and Legal
These are just a few examples of how health IT can inspire the legal sector to move closer to our goal of ensuring “Equal Justice Under Law.” The future holds many opportunities for the legal sector to partner with other sectors in ways that maximize resources, bridge access to justice gaps, and help lawyers be more efficient and effective in their delivery of legal services. So, what can you do? Remain curious, get serious about multi-sector collaboration, and adopt technologies that make sense. The newest technology is not always better, and revolutionary innovations are closer than you might think.
About the Authors
Sara Agate (left) is a third-year law student at Chicago-Kent College of Law and has a master’s degree in public health policy and administration. She was an Access to Justice in Technology Fellow this past summer. Connect with her LinkedIn or follow her on Twitter @sara_agate.
Mallory Curran (right) was a legal services lawyer for 13 years and now works as a consultant, including with Montana Legal Services Association and Neighborhood Legal Services of Los Angeles County. Connect with her on Twitter @CurranMallory.