In the past couple of months, I’ve attended a couple of forums at which Peter Orzag, Director of the Congressional Budget Office talked about CBO’s expanding emphasis on health care. One of the points he made at both appearances was that (paraphrasing) CBO probably needs less Econ 101 and more Psych 101. Orzag wants CBO to increase its analytic capacity in “behavioral economics,” in part because he realizes that one of the keys to addressing the US federal health care cost problems requires addressing the behavioral psychology of health care actors.

It was a little hard to figure out how much of the behavior he’s talking about is providers vs. consumers (or others for that matter), but I do think both are critically important for addressing health care costs. Ix initiatives, of course, often are built on the foundation of the science of behavioral psychology (maybe a little more advanced than 101).

It will be interesting to see how CBO goes about understanding consumer behavior as the health care reform debate evolves over the next year-plus. It’s clear that Ix initiatives could play an important role in helping to drive behaviors that ultimately lead to more efficient and rational care delivery.

According to new data from Manhattan Research (as reported here by iHealthBeat), 36% of US physicians reported that they communicated online with patients in the first quarter of 2008. That’s up from 31% in 2007 and 25% in 2006.

That 11 percentage-point increase is a 44% jump in adoption over two years–a steady rise. It may signal that we’re nearing a tipping point for adoption of a technology that is a foundation of so many effective Ix applications. Secure messaging and other forms of electronic and asynchronous communication make possible so many enhancements to the traditional clinician-patient relationship.

As online communication takes hold, it will be important that delivery systems, technology companies and other organizations develop creative solutions that facilitate the integration of clinicians’ personalized notes/comments/opinions/recommendations with high-quality health content and navigation to additional resources.

The combination of clinician personalization and accurate, comprehensive, understandable and tailored content will allow for mass personalization of Ix. Paul Wallace (IxCenter Board Chair) and I wrote about strategies for doing this in an IxCenter white paper from a few years back that you can download from our Web site.

Aniruddha Malpani, a physician from India and one of the most active international Ix supporters, posted on his blog today his commandments for remaining healthy. His first commandment is “information therapy,” which which I couldn’t agree more.

It got me thinking…What are the 10 commandments for effective information therapy? Here’s a starting point for this list, which is heavily informed by the work of the IxAction Alliance’s Ix Payer Workgroup that has spent more than a year putting tight definitions around the definition of what constitutes Ix in different contexts. I hesitate to call something that is designed as a starting point for discussion as “commandments,” but there are considerable advantages to not having to (literally) carve your commandments in stone (tablets).

1. Thou shalt not limit consumers’ access to health information.
2. Thou shalt target information to an individual’s moment in care.
3. Thou shalt tailor information to an individual’s particular needs (including, but not limited to: literacy level; learning preferences; cultural differences; language; etc.).
4. Thou shalt proactively deliver information to individuals in accordance with their needs.
5. Thou shalt (to the greatest extent possible) provide high-quality (accurate and comprehensive) information.
6. Thou shalt provide information to consumers that facilitates their navigation of the complex set of choices related to all aspects of health care delivery.
7. Thou shalt provide information that supports people in at least one of three ways: informed decision making; skill building and motivation for healthy behaviors; and/or patient comfort/coping/acceptance.
8. Thou shalt provide information that empowers consumers.
9. Thou shalt build any approach to care delivery, information sharing, and electronic tool development around the needs of consumers/patients/members/employers (people!).
10. [For you to propose–WHAT DO YOU THINK BELONGS HERE?]

I look forward to commandment amendments from all of you.

Last week, I attended the launch of the World Health Organization (WHO) “Safe Surgery Saves Lives” campaign. It’s an impressive international project that has tremendous potential for reducing surgical errors by the simple inclusion of a checklist into the process of surgical care.

As the initiative’s lead, Harvard surgeon and noted mainstream author Atul Gawande said, the idea is to borrow from the processes adopted by the much safer airline industry. Checklists went a long way in reducing flight errors so long ago that they are now fully ingrained in the process.

The Surgical Safety Checklist is brilliant in its simplicity and in the way it directly addresses many problems that arise with surgery, but I also think there’s a big missed opportunity on WHO’s “first edition” of the checklist. The third column–the “Sign Out” process–doesn’t specify any patient engagement. The closest it comes is, “Surgeon, anaesthesia professional and nurse review the key concerns for recovery and management of this patient.”

My understanding from people involved in the process was that the first stage of the campaign specifically decided to focus on the “intra-operative” aspects of safe surgery to the exclusion of patient participation and education. No doubt there are plenty of errors that can be solved by getting the surgical team all on the same page, but failure to engage patients is a major lost opportunity.

As WHO prepares for its “second edition,” I hope that at the very least, they add an additional box to check on the “Sign Out” column of the checklist that would read, “Patient’family provided an information prescription regarding instructions for post-operative management and what signs should trigger contact with providers or other actions.”

With Consumers Advancing Patient Safety President Susan Sheridan advising WHO, I know that they are getting excellent and passionate guidance about consumers’ information needs. I just hope that they listen to it as they go forward to maximize the potential impact of the Safe Surgery Saves Lives campaign.

I have occasionally posed the following riddle: What happens when you breed an information scientists (a librarian) with an information systems engineer (a computer programmer)?

Answer: An information therapy (Ix) crusader… That breeding produced a baby version of Joshua Seidman, who grows up to be considerably less cute but slightly more articulate.

Although my parents are mostly retired, my dad still teaches M programming to IT professionals at the VA (and other places).

More to the point of Ix, however… Not surprisingly, when you go to my mom’s personal Web page, you will find that her interests include:

• Improving communication between information providers and information users
• Integrating traditional with electronic library services
• Fostering core information competencies for students, faculty, researchers
• Developing cooperative activities among different types of libraries
• Family and work issues
• International exchange of information

My mother spent several decades running special libraries–at the Environmental Protection Agency, Hanscom Air Force Base Geophysics Lab, and ultimately the MIT Sciences & Engineering Libraries. The mission of the organizations she ran was basically to figure out how to most effectively deliver the right information to the right person at the right time.

Much like I wrote in my blog post yesterday, the librarian doesn’t necessarily need to prescribe the information to the consumer (whether that be a patient, a research scientist or a library user–which, BTW, are all examples of consumers of Ix that various special librarians encounter). In fact, my mother was a pioneer in both using electronic search techniques decades ago and in trying to figure out how to make such tools more accessible to the library consumer.

The key for the librarian, the clinician, or any other “information therapist” is to provide multiple vehicles to allow the consumer to access the information in the way that works best for him or her at the particular moment in care. Because sometimes I want a precise information prescription and other times I want to go to the stacks myself to rummage around…and other times I want to make a trip to the virtual library with a peer that I trust.

The social networking pioneer Dan Hoch (who co-founded the famous BrainTalk Communities site) posted a provocative commentary on e-patients.net today titled “Information Overload: Problem or Not?”

Hoch notes that the information overload across industries has given rise to the Information Overload Research Group, which is dedicated to “reducing information pollution.” I agree with Hoch that the Internet’s information democratization has been an important driving force behind what he terms the “e-patients movement.” No doubt that is a critically important contribution.

I would never suggest that consumers should be prevented from unfiltered information. But availability of all information on a topic does not equate with real access to meaningful, usable information for everybody. For some people, OD’ing on information may not be possible but many people would like to get guidance from other sources–that could be their personal physician, another health care professional, a community health worker, or another person who shares the condition.

As stated on this blog earlier in the week, Susannah Fox noted that Pew Internet Project data demonstrate that 80% of Internet health information seekers turned to a professional in a time of crisis, and that this figure is much higher than any other information that Pew studies.

Those of us who advocate for information therapy (Ix) never suggest that information should be available “by prescription only.” Information prescriptions are simply another tool, designed to help people navigate the vast information that exists in cyberspace and elsewhere.

(Continuing to follow up with commentaries on insights from the 7th Annual Ix Conference…and the slides are not only available now, but they also are right-side-up!)

The day before the Ix conference, the California HealthCare Foundation released the report (“Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools”) that Ted Eytan and I authored summarizing the Patient-Centered HIT Initiative (funded by CHCF, the United Hospital Fund, Kaiser Permanente, and the Group Health Community Foundation). At the conference, Rachel Block–formerly with UHF and now the Executive Director of the New York eHealth Collaborative–provided an excellent overview of the project with a particular emphasis on our experiences with safety-net populations.

Susannah Fox–Associate Director of the Pew Internet Project and also a member of the PCHIT Advisory Group–responded with a presentation highlighting the digital thermometers she has created with Pew data. They provide a great snapshot of consumer use of Internet/email, cell phones and broadband, broken down by a wide range of demographic characteristics. Susannah has explained that access to electronic technologies is not a matter of a “digital divide” because access is not an “on-off switch” but more of a “dimmer switch.”

A few of her comments beyond the thermometers are worthy of considerable thought as we figure out how to maximize the potential of Ix and patient-centered HIT.

• Susannah notes that 80% of Internet health information seekers turned to a professional in a time of crisis–far greater than any other industry that Pew studies.
• It’s clear that low access does not equate with low interest–a finding that matches exactly what the PCHIT Initiative found.
• To better understand the Internet’s potential for health care, it’s critically important that we talk to those people who are not online as well.
• The world is changing rapidly, so it’s important to (as Susannah paraphrased Diana Forsythe) “design for what could be.”

What do all these findings from Pew and the PCHIT Initiative report mean for next-generation patient-centered care?

(Continuing to post on some of the session from our 7th Annual Ix Conference from June 12-13. Note that the PowerPoint presentations are now available. We had a minor glitch in our transfer to PDFs, so you need to rotate them sideways. We’ll get that fixed tomorrow.)

One of the most innovative Ix leaders in the safety-net provider community is Neil Calman, MD, the CEO of the Institute for Family Health (IFH), a network of federally qualified community health centers in New York. He presented in our Ix & Health Disparities Track in a session on “Engaging Safety-Net Providers in HIT” with Kyu Rhee, MD, MPP, Director of Innovation & Program Coordination, NIH Center for Minority Health & Health Disparities. IFH was one of the sites we visited during our Patient-Centered HIT Initiative.

Neil has a direct way of putting things and his presentation probably set a PowerPoint font size record. He started off by telling the audience that, “For the past 6 years we have done everything we could to help bring information to our patients to help them improve their health.”

He then frames this in terms of what it means for the clinicians at IFH: “We have worked really hard to be a model for how electronic health records could be used to help us become…Information Therapists!!”

Neil explained what they learned from their patients when they studied what the health care experience was like for people with chronic conditions in the southwest Bronx. What they found out was that–for many of them–going to the doctor’s office was often “traumatic.” They found two really important things. First, there was great distrust of, and disrespect by, health care providers serving racial an d ethnic minorities. Second, there was bad communication resulting in major misunderstandings.

So when IFH decided to invest $2 million in its EHR deployment, they did it with these two lessons from their patients in mind. Neil said, “We deployed our EHR in a way that would build trust wit our patients. And give them the tools to help them find their way through the health care system.”

That’s why they designed their exam rooms so there were flat-panel monitors that clinicians and patients could look at together and put printers in there so clinicians could print out Ix for their patients and hand it right to them.

It’s amazing what clinicians can do for their patients in EHR implementation if they start by asking them what they need and then bake that into their implementation plans. It’s too bad that’s not a requirement for every EHR deployment in the country.

Paul Wallace (now Medical Director for Health & Productivity Programs at Kaiser Permanente and Chair of the IxCenter Board of Directors) closed out the first day of last week’s 7th Annual Ix Conference with some insights on how we can modernize health care effectively.

He noted that he came of age as a physician during what he termed “Health 0.0.” Although much of health care is now being practiced in a “Health 1.0″ mindset as information flows more freely, there is still a long way to go until we’ve reached the Health 2.0 goals of on-demand, 24/7 access to information that can be democratically created.

Paul pointed out that we need to figure out how to hold onto the close in-person relationships from 0.0, and build the information flow from 1.0 as we create the social networks and real-time information access of 2.0. The goal they all have in common is building trust–one of the most important elements in an ideal health care delivery system.

Ideally, the new tools of Health 2.0 will actually help us do a better job of meeting the demands of 0.0 by creating more efficient ways to allow for personalized health care. How can new technologies enhance our ability to take care of people one patient at a time?

The American College of Cardiology’s Cardiosource Video Network has posted a new four-minute video segment on “Next-Generation Patient Care.” The segment provides an excellent summary of the issues addressed at last week’s 7th Annual Ix Conference.