Using the Electronic Age to Improve Health Outcomes

1. Using the Electronic Age to Improve Health Outcomes J. Michael Fitzmaurice, Ph.D. Agency for Health Care Policy and Research April 28, 1999

2. Overview • Much health information is available • Quality is a concern • How do you judge web site quality • Mitretek/HITI -- Others • Issues • AHCPR’s Quality Tools • Evaluation

3. Where do people get health information? • Recent Rondale Press survey of American of all ages • Television--39 percent • Physicians--37 percent • Newspapers--28 percent • Family or friends--24 percent • Magazines--23 percent • Books--23 percent • The Internet came in lower at 13 percent

4. How do people use health information? • To make choices in the market • Health plans • Physician • Nursing homes • To assist choices for treatment to improve quality of care and outcomes • Self-care decisions • Physician-patient decisions

5. Desirable characteristics • Accessible, with search capability • Seniors like large type--preferrably Arial rather than Times Roman • Health topic interest increases with age--Healthfinder--Mary Jo Deering, HHS/ODPHP • Low readability levels

6. Information Quality • “Good and bad information light up just as brightly”-- • C. Everett Koop, MD

7. Quality of Information • Coulter, et al., in British Medical Journal (Jan. 1999), evaluated patient materials. • Brochures -- Videos -- Phone helplines • One-third of materials evaluated did not have a publication date • Few materials admitted to any scientific uncertainty • Few were specifically designed to inform treatment choice.

8. Criteria for Assessing Quality of Internet Health Information • Developed by Mitretek/Health Information Technology Institute--Helga Rippen, MD, Ph.D., MPH, Director • Convened over 20 experts from national organizations • To develop criteria and test them • Targets: public, developers, policymakers • WWW.MITRETEK.ORG/HITI

9. Criteria • Credibility • Content • Disclosure • Links • Design • Interactivity • Caveats

10. Credibility • Source • Credentials, Conflict of interest, Bias • Context • Currency • Relevance/Utility (validity) • Editorial Review Process

11. Content • Accuracy • Hierarchy of evidence • Original source stated • Disclaimer • Omissions noted

12. Disclosure • Purpose of the site • Profiling of users

13. Links • Selection of forward links • Architecture of site • Content (accurate, current, credible, relevant) • Back linkages: number & quality

14. Design • Accessibility • Logical organization • Internal search engine

15. Interactivity • Mechanism for feedback • Chat rooms and bulletin boards • Tailoring--based on user characteristics

16. Caveats • Alerts to users • Sound-alike names • Impressive sounding names • Puffery in claims--”miracles,” “secret cures,” “amazing results”

17. Top Ten Criteria • Straw test as an example: n=28 • Source -- Disclosure • Accuracy -- Currency • Original source stated • Hierarchy of evidence • Relevance/Utility -- Disclaimer • Link-content -- Review process

18. Other Site Evaluations • Mary Jo Deering and colleagues (Kim, et al. British Medical Journal, 1999) • Looks at published rating criteria for evaluating the quality of health sites on the Web. • Found consensus of criteria, including • Disclosure of authors and sponsors • Currency of information • Health Improvement Institute awards good ratings of sites.

19. Issues • Privacy, confidentiality, security • Will people get personal health information (PHI) about me that I do not release? • Will PHI I release, with conditions, not be redisclosed without my approval? • By what means will disclosure and redisclosure of PHI be prevented? • State laws • Federal law: Privacy Act, FOIA • International laws: EU Directive

20. Issues • Oversight • FDA--Drugs and medical devices • Clinical software is a device • Competent human intervention • FTC--misleading advertising and business practices • False and deceptive claims and practices • Liability • Flawed medical advice • System failure

21. Issues • Accreditation and Certification • Ability and capability to deliver • Quality and effectiveness of product • Examples: • JCAHO • NCQA • State licensing boards

22. Issues • Role of government • Investment: time, risk, B>C, access • Regulation • Education • Ensure competition • Payment for web health services • Private pricing • Government activity in payment

23. Issues • Health system design and incentives • Web-based information may • Increase the time physicians take to educate patient • Reduce the patient seen/physician in 8 hours • Improve healthiness and reduce the demand for future office visits , evidence of improved health system efficiency • Physicians do not get paid for this extra time today

24. Issues • Access for all • Many are disadvantaged--no access to a computer or the Net. • African Americans, Hispanics, • Low income and rural families • Universal Access--at any price? • Public Health • Externalities -- Efficiency • Equity

25. Strategies • Strengthen EV and Q of Applications • Improve Basic Knowledge • Strengthen Capacity of Stakeholders • Clearinghouses -- Collaborations • Ensure Equitable Access • Source: Wired for Health and Well-Being • Science Panel on Interactive Communications and Health, April 1999

26. AHCPR Snapshot • AHCPR-- a research agency that studies the U.S. health care system • Outcomes research • Quality of care measurement • Cost, Access, and Utilization • What works to improve patient health outcomes in the community? • And what does it cost? • Funds peer-reviewed research grants

27. AHCPR’s Health Tools • Medical Expenditures Panel Survey • $30 million/year • 10,000 households/24,000 people • Also surveys employers, physicians, hospitals, LTC facilities • CONQUEST--a data base • 1200+ clinical performance measures • Validity, availability • HEDIS, FACCT, scientific studies

28. AHCPR’s Health Tools • Consumer Assessment of Health Plans Survey (CAHPS) • Will be used by 100 million people in 1999 • Medicare, Medicaid, NCQA, OPM, Kaiser • National Guidelines Clearinghouse • www.guidelines.gov -- www.ahcpr.gov • AHCPR, AMA, AAHP partnership • Evidence-based Practice Centers • Compile science findings about specific health conditions and procedures

29. AHCPR’s Health Tools • Scientific Research Findings • Published findings from AHCPR-funded grants • AHCPR staff expertise and collaboration

30. What if we connected! • Personal web-based medical record • Provider medical record • Health plan enrollment and service utilization record • AHCPR tools • CONQUEST--aggreg. cpms--provider/plan • CAHPS--patient evaluation in MR • NGC--providers guideline variation

31. Evaluating Web Effectiveness • Number of hits is not sufficient for improved outcomes • Should make a difference in health outcomes and improving our lives

32. Evaluating the Impact • Does improving access via web sites to critical health information lead to a greater number of • Hits? • Information retrievals?

33. Evaluating the Impact • Does a larger number of hits cause a change in • Provider choice of treatment? • Patient behavior?

34. Evaluating the Impact • Does the change in treatment choice and patient behavior lead to • Improved health status? • Lower costs? • Both?

35. Bottom Line • We need to design and provide information with outcomes in mind-- • Dr. John Eisenberg • AHCPR Administrator

36. Bottom Line • Hits are not enough. We need to show their effects on patient and provider satisfaction and behavior change. • Most important, we need to learn their effects on improving peoples’ health and quality of life.

37. Using the Electronic Age to Improve Health Outcomes J. Michael Fitzmaurice, Ph.D. Agency for Health Care Policy and Research April 28, 1999