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1. Attitude and Opinion Research Gulf Coast Initiative Work in support of the Gulf Coast Health Information Task Force Katherine H. Capps Health2 Resources For eHealth Initiative February 7, 2006 Slide 1

2. Survey research company specializing in corporate, public policy and litigation research with office in Washington, Denver and Los Angeles. Established in 1991, more than 7600 research projects, interviewing more than 3 million Americans across the U.S. POS has conducted more than 2400 focus groups Goal of POS is to “Turn Questions into Answers” Clients include Association of American Medical Colleges, CDC, DaimlerChrysler, Robert Wood Johnson Foundation, Verizon, WellPoint and the Markle Foundation. About Public Opinion Strategies

3. Public relations and marketing communications firm based in Washington, DC area- founded 1997 Strategy development, business plan development, customer relationship management, market research Focus only on the health care industry and the relationship between purchasers, providers and payers Integrated approach to marketing communications, media relations and sales communications Clients served: eHealth Initiative, URAC, JCAHO, National Business Coalition on Health, INSPIRIS, Gordian Health Solutions, INSPIRIS, IncentOne, Pharmacia Corporation, Baptist Health System, Intracorp, Schering Plough, Procter &Gamble, Miller Brewing, AHC About Health2 Resources

4. Overall Goals Of This Research: • Understanding public perception and attitudes about secure electronic health information exchange in the Gulf States (AL, MS, LA, TX, FL); • Exploring attitudes, opinions and barriers to the development of secure electronic health information exchange in the Gulf States; and • Determining what language and messaging are most effective in gaining support for secure electronic health information exchange. Slide 4

5. Step 1: Develop Set Initial Key Messages Step 2: Conduct Focus Group Research Step 3: Telephone Survey Research (1000 Adults) +/-3.1% Step 4: Analyze Research Results to Inform Final Set of Key Messages Step 5: Media/ Education Kit - Dissemination Plan Consumers AL Sample Consumers FL Sample FeHI GulfCoast Team Initial Messages Physicians TX Sample Physicians MS MS Sample Employers/ Purchasers ►Media Outreach Tools ►Shared Graphics ►Tools to Support Education ►Tools to Support Partnership Development ►Resources, Research, Real Examples Employers/ Purchasers LA Sample June 2006 July 2006 Aug-Sept 2006 Sept-Dec 2006 May 2006 Source: Health2 Resources, 2006

6. Understanding public perception and attitudes about health information exchange in the Gulf States Slide 6

7. Both telephone and focus group respondents’ initial impression of the term ‘secure electronic health information exchange’ is relatively neutral. Feelings About Secure Electronic Health Information Exchange Mean Scores Total 48 AL 46 FL 49 LA 49 MS 45 TX 49 I am going to read you a phrase you may or may not be familiar with or might not have heard much about. Just based on the words in the phrase, please tell me how you feel about the phrase on a scale of one to one hundred, with one meaning you feel VERY NEGATIVE and one hundred meaning you feel VERY POSITIVE and fifty meaning NEUTRAL. You can use any number from one to one hundred, the higher the number, the more positive your feelings are about the phrase. The phrase is.... Secure electronic health information exchange

8. Defining Health Information Exchange. Language Matters. Where We Started: Where We Are Now: Health information exchange is a way to electronically move a patient’s personal health and medical information through a secure online account between various health care providers. Only with a patient’s permission can their medical information be shared through this service. Health information exchange allows you to make sure a patient’s health information is available when and where you need it while they seek medical care or treatment. Health information exchange is a way to electronically move your personal health and medical information securely between your doctors, hospitals and other health care providers when it is needed for your care. With your consent, your health information will be protected and exchanged under current medical privacy and confidentiality standard procedures. Secure electronic health information exchange allows you to make sure your health information is available when and where you need it while seeking medical care or treatment.

9. Respondents overall impression of health information exchange becomes significantly more positive when presented with a brief definition of the term. Feelings About Secure Electronic Health Information Exchange Mean Score By State 64 48 36% 12% Initial Informed 80-100 Mean Now having heard this description, please tell me how you feel about the secure electronic health information exchange on a scale of one to one hundred, with one meaning you feel VERY NEGATIVE and one hundred meaning you feel VERY POSITIVE and fifty meaning NEUTRAL. You can use any number from one to one hundred, the higher the number, the more positive your feelings are about it.

10. Exploring attitudes, opinions and barriers to the development of health information exchange in the Gulf States Slide 10 Public Opinion Strategies – eHealth Initiative July 2006

11. Support is extremely strong in the Gulf States for the creation of secure electronic health information exchange as described. Support For The Creation Secure Electronic Health Information Exchange +49%+47%+42%+57%+53%+48% 38% 36% 37% 44% 40% 32% Now if you learned that secure electronic health information exchange is being considered made available in the Gulf Coast states, would you favor or oppose the creation of this type of secure electronic health information exchange in the Gulf Coast states?

12. Support for the creation of secure electronic health information exchange is strong across party as described. Support For The Creation Secure Electronic Health Information Exchange By Party +46%+63%+43%+53%+47% 78% 73% 69% 69% 67% 24% 23% 22% 20% 15% 36% 40% 37% 39% 38% Strong Soft Independents Soft Strong Republicans Republicans (19%) Democrats Democrats (22%) (14%) (16%) (23%) Strongly Favor Total Favor Total Oppose Now if you learned that secure electronic health information exchange is being considered made available in the Gulf Coast states, would you favor or oppose the creation of this type of secure electronic health information exchange in the Gulf Coast states?

13. Verbatim Responses Respondents mention the following as benefits of secure electronic health information exchange: • In an emergency, regardless of where you are, doctors/hospitals can immediately get your information; • Speed - very fast access to the information; • Easily available/convenience of availability; • Very helpful when traveling; • Efficient/cost effective; • Ability to access your own information (from anywhere); • Accurate and up-to-date; and, • More clear/legible information than trying to read your doctor’s handwriting. Slide 13 Public Opinion Strategies – eHealth Initiative July 2006

14. Who do respondents trust most to deliver them information about secure electronic health information exchange? This data reinforces how extremely important doctors are to the successful implementation and acceptance of health information exchange among the general public. Doctors. Trust Most To Provide Information About Secure Electronic Health Information Exchange Thinking some more about secure electronic health information exchange, who would you say you would trust the most to provide you with information about health information exchange?

15. As we noted in the focus groups, the greatest barrier to adoption among the general public relates to security and privacy concerns. This echoes as a barrier throughout this data and the open-ends. Extremely/ Very Confident Not Too/ Not At All Confident Total 11% 57% AL 12% 61% FL 10% 57% LA 12% 54% MS 10% 57% TX 9% 57% Now if medical records and personal health information were to be stored electronically and shared through the internet, how confident are you that those records and information would remain confidential?

16. Verbatim Responses Respondents say they have the following hesitations/concerns about secure electronic health information exchange: • Security/privacy/confidentiality; • Fear of people hacking into the records/system; • Fear of records being lost/misplaced (VA incident mentioned); • Accuracy - the information is only as accurate as the human being entering the data; • Possible misinterpretation of information resulting in improper care/mis-diagnosis; and, • Fear of government involvement. Slide 16 Public Opinion Strategies – Health2 Resources - eHealth Initiative July 2006

17. What information is exchanged? How secure is SECURE? How has access to the information? How are healthcare providers defined? Does this include insurers? How does it work? How is it set up? Is it one database or many? How do you know that the information is trustworthy and not fraudulent? Is the system regional, national or global? What is the backup system? Will a patient be able to view their own information? Do providers have access and an open authorization or on a one time basis? Who pays, what does it cost me? What role does HIPAA play? Unanswered Questions

18. What is my liability? Do I have to pay to set this up in my practice? How are we going to learn to use this? Who is going to pay to train my staff? Is this exchange beyond health care services, for instance could the information be used in court? Liability Key barrier for physicians was liability- both their own and the liability for other physician diagnosis or misdiagnosis Cost Key barrier for physicians because of concern of being forced to pay for the technology and the program, as well as staff training while others receive the financial benefit from the HIE initiative Security All groups recognized privacy and security to be a key barrier to use and adoption of health information exchange Unanswered Questions - Barriers Physician Questions Physician Barriers

19. Determining what language and messaging are most effective in gaining support for secure electronic health information exchange Slide 19 Public Opinion Strategies – Health2 Resources - eHealth Initiative July 2006

20. Having access in an emergency medical situation is clearly seen as the most important reason to have secure electronic health information exchange. Having access in an emergency medical situation Having access to your medical record when you are out of state % Having access in an emergency medical situation by state Having access to your medical history when you visit your doctor AL 45% FL 48% LA 42% MS 50% TX 44% Having access during or after natural disasters Transferring lab results, reports or x-rays between health care providers Having access to your medication history when you want to refill your prescriptions And thinking about different situations where and when you might want to have secure electronic health information exchange available, which one of the following situations would be most important to you to have this service available to you, your doctors or health care providers?

21. As we found in the focus groups, the strongest message focuses on the urgency of care, the need for secure electronic health information exchange in making critical treatment decisions, and being the difference between life and death. 63% Secure electronic health information exchange will allow physicians to access the right medical information at the right time. In an emergency, getting a patient’s medical records quickly could mean the difference between life and death. Very Convincing 91% Total Convincing

22. Verbatim Responses MOVE TO MORE POSITIVE (64%)/FAVOR (12%): • Useful and could save lives in emergency situations - especially out of state; • Would help doctors and pharmacists better manage health care; • Useful when traveling or in another state; • Useful in the event of a natural disaster; • Having access to medical records at any time, from anywhere; and, • May help reduce the death statistics and be useful for the elderly. Slide 22 Public Opinion Strategies – Health2 Resources -eHealth Initiative July 2006

23. 70 64 48 48% 36% 12% Initial Informed Final 80-100 Mean The messages work to give respondents an even more positive impression of secure electronic health information exchange. Feelings About Secure Electronic Health Information Exchange Please tell me how you feel about secure electronic health information exchange on a scale of one to one hundred, with one meaning you feel VERY NEGATIVE and one hundred meaning you feel VERY POSITIVE and fifty meaning NEUTRAL. You can use any number from one to one hundred, the higher the number, the more positive your feelings are about it.

24. The messages also work to strengthen support, particularly the intensity of support, for the creation of secure electronic health information exchange in the Gulf States. Support For the Creation Secure Health Information Exchange 38% Strongly 49% Strongly If you learned that secure electronic health information exchange is being considered made available in the Gulf Coast states, would you favor or oppose the creation of this type of secure electronic health information exchange in the Gulf Coast states?

25. TAKE AWAY POINTS Slide 25

26. It is important to focus on: Security; How it works; Patient permission; Who has access; and The benefit to the patients and physicians Respondents’ questions and concerns after hearing the definition provide helpful guidance in improving how we talk about health information exchange….

27. Health Infomation Exchange • Although the term “health information exchange” was not clearly understood by respondents, their initial opinion is relatively neutral and overall impression of “health information exchange” became more positive when presented with a definition of the term. But even with the definition, unanswered questions remained so it is important to anticipate these questions upfront. • Respondents overwhelmingly say they trust doctors the most to deliver them information about secure electronic health information exchange. • The biggest barriers for adoption and use of health information exchange are cost, security and liability. PCPs present the strongest resistance to adoption. Slide 27

28. MISC SLIDES FOR Q&A- NOT AS PRESENTATION

29. The top three messages across the five states were: 1st 2nd 3rd

30. Looking at what adults in the Gulf States already believe is happening related to their own health information: Question: Answer: How does your doctor keep your medical records? 48% 29% 16% & (Among the 82% who have a personal doctor)

31. Looking at what adults in the Gulf States already believe is happening related to their own health information: Question: Answer: How likely is it that your doctor’s medical records have a back-up copy offsite? 71% Likely 22% Not Likely (Among the 82% who have a personal doctor)

32. Looking at what adults in the Gulf States already believe is happening related to their own health information: Answer: Question: Is the back-up copy kept… 30% 54% 10% & (Among those who believe their doctors have a back-up offsite)

33. Consumers Male and female Registered voters, likely to vote in this year’s election Age 25-74 High school graduate or higher Household income of at least $25,000   Employers Small business owners, 4-50 employees providing at least some portion of health insurance benefits for FTE Age 30-74 with at least some college, personal income of at least $40K women, $60K men Benefit Managers were persons responsible for making decision on health care coverage in business with over 100 employees paying at least some portion of health insurance benefits. In position for at least a year. Same age and income as Small Business. Physicians Mix of internists, general practitioners, OB/GYN's and pediatricians.  Residents and interns were excluded. Focus Group Audiences Defined