The following is a guest post from Arna Ionescu, who is Domain Director, Connected Health for a leading innovation design firm, IDEO, an IxAction Alliance member. This follows up on earlier guest post she wrote, explaining how this innovation test evolved. You can also find more background on the IxCenter’s increasing emphasis on Ix innovation design. 

In our July IxAction Alliance webinar, we interactively brainstormed ways we could leverage curiosity to prompt higher engagement with information therapy. Out of all the ideas generated, participants picked the “High Blood Pressure Club” to explore further. A few weeks ago, I wrote a blog entry about our efforts to better understand the parameters of this club through a “$10, 10 minute prototype.”

Since reducing blood pressure takes a long time, we used the analogous context of gas guzzling to run our experiment. Our three participants self-reported long commutes and minimal awareness of gas consumption. After a week of measuring their baseline gas usage, we inducted them into the “Gas Guzzler Club” and provided a week of information therapy. This involved a short video and daily tips through a channel of their choice (email, text or voice – all three chose email).

So did it work? In terms of the before and after gas consumption one participant did better, one worse and one stayed the same. While the numbers are inconclusive, our follow-up conversations with each participant revealed interesting and sometimes unexpected insights.

1. Our guilt trip was effective only to a degree. Participants juxtaposed words like “pejorative” and “pariah” with “motivational,” and they wanted to take action to get out of the club. However, the guilt only got them so far. One participant said he decided not to remove his roof rack because of the status he associated with that accessory. Name-calling did not outweigh his ego’s need to posture.
2. Feeling that the others are real, living, breathing people is critical. Our participants commented that being asked to participate by a person they knew was critical to keep them going. They commented that receiving the tips from a real person named “Emily” made them feel accountable. They commented that they wished they had more connection with others who do the same drive so they can learn from others’ successes. They commented that they wished they could see the group’s success – how much gas and money had their group of x people saved – since that would feel more significant than just their solitary success. It was clear that the secondary motivation prompted by continuous interaction with real people was as motivational, if not more so, than the primary motivation of reducing gas usage. The design of the club and communications should elevate that human connection and support.
3. The information therapy and the rewards must be personalized. People crave a genuine connection, and if their specific situation and preferences aren’t taken into account, then they’ll tune it all out. Participants commented that both tips and rewards must be personalized; tips must be relevant to their particular drives and rewards must correlate to what matters most to each individual.
4. Getting past the initial skepticism takes effort – so be prepared for it. Participants didn’t buy that small changes would make a difference. The design of this club should include a mechanism that provides constant feedback correlating the output data with a person’s actions. People forget what they did and have trouble relating cause and effect, so we need to help them with that.

This is a sample of the insights we culled from our $10, 10-minute experiment. This experiment wasn’t about statistical significance, but about developing a good sense of what matters to people and where our risk factors lay should we pilot an actual High Blood Pressure Club. Given our experience, we feel the idea holds merit, and we know more about where and how to focus our design efforts.

Who’s interested in taking this further?

The following is a guest post from Arna Ionescu, who is Domain Director, Connected Health for a leading innovation design firm, IDEO, an IxAction Alliance member. You can also find more background on the IxCenter’s increasing emphasis on Ix innovation design.

Thank you to the IxAction Alliance members who participated in our interactive webinar last Tuesday. During the webinar we used IDEO’s design approach to tackle the challenge of providing effective Information Therapy (Ix) to a fictional character named Vernon, who has minimal resources and was recently diagnosed with high blood pressure.

To inspire solutions for this challenge, members of the IxAction Alliance submitted images of unexpected learning moments in their daily lives. These images spanned from public service billboards to Snapple caps and restaurant placemats. In advance of the webinar, the IDEO team synthesized the images into brainstorm questions.

The webinar attendees voted and selected the brainstorm question, “How Might We leverage curiosity to prompt Vernon to engage with Ix?” Following IDEO’s brainstorm rules, attendees submitted ideas using the webinar software.

More than 30 ideas were generated in the ten minute brainstorm, and a second vote allowed the attendees to select which idea to pursue further. Attendees selected the “High Blood Pressure Club.” We discussed “$10, 10 minute prototypes” – an approach that allows us to try out fast and cheap experiments to gain insight before costly design and implementation efforts.

Two members of the Alliance community volunteered to explore the High Blood Pressure Club further. In subsequent discussions, we refined the idea to an online forum that people join when diagnosed with high blood pressure. We hypothesized that members would compete to reach emeritus status. We further hypothesized that people might feel more supported if they were paired with a buddy in the club, making the competition a team sport.

As we refined the idea, a number of questions came up, including: How do we reward people? Is emeritus status enough of a motivation to participate actively? Should buddy pairs be random or selected by club members? What’s the best recruiting mechanism for new members?

We decided to explore our questions around emeritus status using a $10, 10 minute prototype. Because feedback in healthcare takes a long time, we identified an analogous context in which to run the test. Instead of focusing on lowering blood pressure, we would focus on lowering gas usage when driving.

Next week we will start a two-week experiment about our “Gas Guzzler Club.” Three participants will measure a week-long baseline of their gas usage. At the beginning of the second week, we will “induct” our participants into the Gas Guzzler Club, letting them know they can achieve emeritus status, and provide a short tutorial on how to use less gas. Additionally, we will send daily tips in a medium of their choice (text, email, or voice). At the end of the second week the most successful participant will be granted emeritus status. We will then interview each participant about their experience to gain insight into how well we motivated them.

This plan will take relatively little effort yet should reveal a lot well before we invest significant time and money. We will follow up with another post next week to fill you in on the start of our experiment!

My meeting experience using Cisco’s TelePresence technology brought new meaning to the phrase “just like being there.” I had a lively conversation with some of the UK’s leading information prescribing advocates this morning (or this afternoon if you were sitting on the other side of the table in England).

Two of the participants were from Cisco’s Internet Business Solutions unit — Kevin Dean from the UK side and Danny Sands (who also sits on the IxCenter Board of Directors) — normally in Boston but was down in DC today. Also on the other side of what truly felt like one oval table were John Cain from the UK Department of Health — who has headed up a lot of their patient empowerment work — and Mark Duman, President of the Patient Information Forum.

As I’ve described before, the UK government is way ahead of the US in this area, having already written into their National Health Service Constitution a guaranteed right to information in advance of any treatment. The UK government has taken a leadership role in advancing information prescribing throughout the country.

What I did learn more about today is that converting such good intentions into Ix that is embedded into standard care delivery is still a work in progress. The UK Department of Health currently funds the information prescribing activities, but the National Health Service (NHS) has not yet been able to embed Ix into the care delivery process of NHS providers. The result is that much of the Ix transpiring in the UK is actually from the UK government directly to the people. It’s more of the over-the-counter Ix model.

The UK Department of Health has several Ix initiatives in the works. They are developing tools to make information prescribing easier to use in normal practice settings. They are developing information standards and accreditation processes. They also figuring out how to embed patient experience into the design of Ix services. And, more regionally, other efforts are advancing Ix, such as Scotland’s national health information service that has citizen advice bureaus staffed by health navigators to guide consumers to needed, personalized information.

I shared with my friends across the pond some of the critical opportunities to advance information prescribing now in the US. The IxCenter continues to work closely with several agencies within the U.S. Department of Health & Human Services (HHS) on the development of an information prescribing objective for Healthy People 2020. In addition, legislation to require patient decision aids, a consumer view of “meaningful use” of HIT, more emphasis on consumer needs in the roll-out of comparative effectiveness research, and other legislation could go a long way toward embedding expectations of Ix into everyday care delivery. I also described the IxCenter’s work around advancing more robust models for evaluating the quality of health information.

Our small group had far more to discuss than time available. We’ve agreed to continue our cross-national conversations on information prescribing best practices and strategies for infrastructure development. Hopefully, we’ll continue to learn a lot from our international dialog and truly embed information prescribing into care delivery processes.

I received the following request from NCQA yesterday for the IxCenter to reach out to our collaborators for submissions to Quality Profiles since NCQA recognizes that information therapy (Ix) is a widely used strategy for quality improvement using HIT to address the 6 priority areas below.

Quality Profiles is published annually by NCQA. The overall goal of this series is to provide health care organizations and employers with a rich, up-to-date collection of quality improvement resources, illustrated through best practices, to use as a motivation and foundation for new program development. The seventh edition of Quality Profiles will align with the newly announced national health priorities as defined by the National Priorities Partnership. By highlighting successful ways organizations have incorporated HIT into their patient care processes, this edition of Quality Profiles will help to continue building on the momentum for HIT adoption and implementation.We will include case studies from organizations that will showcase how HIT was used to successfully impact one or more of these 6 areas:

1. Patient & family engagement
2. Population health
3. Safety
4. Care coordination
5. Palliative & end-of life care
6. Overuse

For those organizations that submit applications that involve Ix initiatives to Quality Profiles, we’d appreciate you sharing your best practices with the IxCenter as well. We are in the process of building a methodical library of Ix research, and are collecting as much research as we can both from the peer-reviewed literature and the more organic innovations being developed.

Sometimes our work life and home life collide…or at least it would be good if they did…

The Center for Information Therapy (IxCenter) has just submitted a grant proposal to NIH — part of the stimulus bill funding for comparative effectiveness research included requests for “information prescriptions” evaluations — in collaboration with Ix evangelist Kate Burke (an emergency physician) and some very progressive physical therapy (PT) practices in Massachusetts. The basic premise — and any athlete that has done PT to rehabilitate an orthopedic injury knows — is that physical therapists do great work, but ongoing improvement in orthopedic function often comes from the home exercise that the patient does on his/her own. And, equally importantly, it can be really hard to recreate those exercises at home based on oral instructions received or even text or a single picture.

The main Ix intervention in the proposal involves using Flip Video information prescriptions. The physical therapist uses the simple Flip camera to record that patient doing the PT exercise in the clinic and emails the video to the patient that day. I have grown fond of saying about this project: If a picture is worth a thousand words, a video is worth 10,000.

So that brings me home…  We’ve been monitoring my 5-year-old son, Ryan’s, asthma. Last spring (exactly this week), the spring pollen season triggered a reasonably severe asthmatic reaction (see Ix Gets Personal (Again)). He has since had one other bad asthmatic event, and a few consultations and allergy testing with a pediatric allergist. We developed a game plan for trying to prevent another April flare-up.

In many ways, we think our pediatric practice is great, but there are some things that it does not do well. For example, there’s no written (not to mention electronic) asthma action plan, so my wife and I sometimes have slightly different expectations of next steps.

In this case, most importantly, neither of us is a skilled practitioner in the use of an asthma inhaler. As a four-year-old, Ryan used a nebulizer (a clunky device, but one which is fairly straightforward to use), but the allergist trained us once (more than two months ago) in use of the asthma inhaler with spacer. We have no information beyond the package insert. I honestly don’t have a good recollection of the exact steps involved and — when I asked my wife how she did it last week when I was out of town — she confessed to not being too sure herself. And, little Ryan — despite his many talents — isn’t quite ready to teach his parents what to do.

Ryan’s breathing was strained this evening, and we eventually returned to the nebulizer to deliver his albuterol (rescue medication), but it’s not a very good solution. All I could think about was how perfect it would be if my pediatric allergist (or the medical assistant in his office) could have videotaped when he walked us through it step by step a couple of months ago. If he had then sent us this video information prescription via email, I’d be empowered to help my son manage his asthma effectively and efficiently.

It seems so easy, yet so far away…

Over the last decade or two, Kaiser Permanente has done such a good job at managing coronary artery disease (CAD) that it is no longer the number-one cause of mortality for Kaiser members. Last week, a number of media covered a Kaiser CAD management success story that was presented at an Alliance for Health Reform forum in Washington, DC.

This particular intervention, the Collaborative Cardiac Care Service (CCCS), is a multidisciplinary approach developed by KP’s Colorado region and summarized in an article in Summer 2008’s The Permanente Journal. It achieved dramatic improvements in care management, including:

• Improved cholesterol screening (increasing from 55% to 96%)
• Improved LDL control to <100 mg/dL (jumping from 22% to 77%)
• Reduction in all-cause mortality associated with CAD by 76%
• High patient and physician satisfaction

The CCCS intervention was extensive, involved a wide range of clinicians, and integrated existing chronic care management strategies with its new HealthConnect electronic infrastructure. What is also clear is that it relied on a wide range of information therapy (Ix) principles and strategies.

• CCCS made considerable use of information triggers to determine which Kaiser members to target, the particular information needs of each member, and when to prescribe the Ix.
• Critical components of CCCS involved the timely prescription of evidence-based information to Kaiser members — everything from smoking cessation to medication adherence and from testing reminders to diet & exercise education.
• CCCS also integrated different forms of Ix — many data elements collected through HealthConnect produced system-triggered information prescriptions, but they also had clinician-prescribed Ix from physicians, nurses, pharmacists, and counseling/educator experts. (I’m not sure whether the intervention specifically included consumer-prescribed Ix as well — e.g., information prescribing from other members in peer groups such as in group visits, social networks, etc.)

Ix interventions like this likely will not only improve care quality and reduce costs, but will lead to engaged and empowered consumers, like the Kaiser member described in the recent Wall Street Journal article on Ix.

In an information therapy (Ix) world, every data source is a potential information trigger. That is, each piece of information that we have on a particular person tells us something about the information he or she needs at a particular time to make a better health decision or lead a healthier life.

A sophisticated health information technology (HIT) application like an electronic health record (EHR) obviously provides a rich source of Information triggers. But something as simple as demographic information can be a starting point (e.g., your age and sex can be used by a tool like the federal government’s HealthFinder to prescribe prevention plans for you).

The more data sources we have, the better we can pinpoint the information prescription to your moment in care and your individual needs and circumstances. We can build algorithms around the data available and generate a series of system-triggered information prescriptions that meet your needs. Depending on the particular situation, this Ix can be: just sent directly to you (and your support network); sent via your clinicians; or cc’ed to them to facilitate participatory medicine.

Perhaps the most powerful information trigger is data collected directly from the consumer. The best way to guarantee that the Ix is personalized is to collect critical information from that individual. That could be answers to very specific questions that suggest where, for example, someone is along the stages of behavior change.

But valuable information can come from the most basic of questions. IxAction Alliance members like Health Dialog have for years been promoting the idea of patient report of functional status as a key information trigger. Others have suggested similar or even more basic questions about “how are you feeling today?”

All of these consumer-reported data points are so informative in helping us to deliver tailored information at the right time.