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.

The Center for Information Therapy has been working with the HHS Office of Disease Prevention & Health Promotion to help create more robust e-health and health communication objectives for Healthy People 2020 (see related post for background). There is considerable interest now in the development of a new objective related to information prescribing.

The public input is critically important to advancing these objectives, so please voice your own opinion on the proposed new information prescribing objective. All you need to do is go here, log in, click on the “Discussions” tab on the left nav bar, and click on the “Information therapy and related issues” thread.

Here’s the substance of the argument:

Proposed New Healthy People 2020 Objective

Ensure that each encounter with the delivery system is accompanied by prescribed information that supports an individual’s personalized health needs. 

 Various operational definitions of prescribed health guidance are practical. In order to ensure that the definition incorporates a wide array of strategies, media, and tools to meet the diverse needs of the U.S. population, it is important that the definition balances specificity of purpose with flexibility for varying approaches.

One multi-stakeholder coalition of information prescribing experts developed the following definition, which has subsequently been adopted by various non-profit oversight entities (see “Justification” section).

To be classified as information therapy, information should meet each of the following requirements:

·         Be targeted to one or more of the individual’s current moments in care.

·         Be proactively provided/prescribed to the individual.

·         Support one or more of the following:

o   Informed decision making, and/or

o   Skill building and motivation for effective self-care and healthy behaviors related to the moment in care, and/or

o   Patient comfort/acceptance.

·         Be tailored to an individual’s specific needs and/or characteristics, including their health literacy and numeracy levels.

·         Be accurate, comprehensive, and easy to use.

  Justification for New Objective

Research demonstrates that 40% to 80% of all information communicated orally by a physician during an in-person clinical encounter is forgotten by the patient by the time he or she returns home. Ample peer-reviewed literature exists to support the impact of information prescribing and much of it is summarized in the white paper, “The Ix Evidence Base: Using Information Therapy to Cross the Quality Chasm.” In addition, the Center for Information Therapy has many additional references available.

Some independent, non-profit, private sector oversight groups have begun to build information prescriptions into their expectations for care management.

·         The accreditation organization, URAC, announced in August 2008 that organizations seeking disease management accreditation would be subject to “information therapy” standards.

·         The National Business Coalition on Health (NBCH) revised its eValue8 common RFI for health plans to expand its consumer engagement criteria to include information therapy components.

 Potential Data Source

1) Current assessment of information prescribing relies on structural measures of information prescribing:

a.    URAC began collecting data in 2009 on information prescribing, according to detailed specifications of what constitutes an information therapy intervention.

b.    NBCH will collect data from hundreds of health plans in 2009 (using similar specifications) about their provision of information therapy to their members in order to facilitate better consumer engagement.

2)    Significant interest exists among varied parties in stimulating the development of performance measures that assess information prescribing and related outcomes of it.

a.    The independent, not-for-profit, Center for Information Therapy is exploring measure development in this area.

b.    The National Quality Forum and the associated National Priorities Partnership has identified patient-centered measurement as a critical priority. This work may build on measures of patient activation, behavior change, decision quality, and consumer engagement.

By Matthew Holt,  Joshua Seidman, & Indu Subaiya

On April 22–23 in Boston, two ideas are going to come together. Health 2.0 has been defined in different ways, but is most often considered to be the use of lightweight online technologies which allow consumers to access and exchange health information via the now familiar search, communities and tools. Information therapy (Ix or information prescriptions) involves the proactive delivery of the right information to the right person at the right time, usually as part of the care delivery process.

However, while both Health 2.0 and Ix are focused on improving patients’ participation in care, they tend to come from different backgrounds. Ix tends to be “prescribed” to the patient, often by a clinician (although system-triggered Ix and  consumer-prescribed — either “self-prescribed” or recommended by a peer, caregiver, etc. is also part of the definition). Ix innovations have had the greatest penetration in organized systems of care with robust provider and patient HIT applications like Kaiser Permanente and Group Health Cooperative in Seattle.

Health 2.0 had its start with non-health care organizations delivering content, communities and tools to consumers online—often in the absence of the health care system paying much attention. Thousands of communities about every conceivable health condition exist online, hundreds of sophisticated tools have been developed for consumers and clinicians to use, and now the ability to create and store patient data online is becoming much more prevalent. But in general it’s been savvy consumers, followed by technology and media companies who have been leading the charge.

In addition, Ix has been focused on delivering the “right” information, often implying “evidence-based,” although “right” can have other definitions as well. In Health 2.0 communities, there’s often wild disagreement about what the evidence base actually shows, and what the correct course of action is. Last Tuesday’s post in Well (The NY Times patient blog) about the complexity of understanding the correct course of action in PSA testing for prostate cancer is a typical example.

So can these two movements live together? Better yet, are there synergies that can help them to thrive? Is this a case of the proverbial combination being greater than the sum of their parts?

We are going to find out in Boston on April 22–23 at the Health 2.0 Meets Ix conference, hosted by the Center for Information Therapy and Health 2.0, LLC . We are also going to find out whether the current health care system is ready to adopt Health 2.0, Ix, or some combination. The format will be a series of Great Debates.

Health Affairs is our media partner in this event, and Susan Dentzer will play a large role in helping to moderate these debates. But as a teaser, several of the debaters will reveal some of their cards in this blog, the Health Affairs blog, The Health Care Blog, and several other blogs in the coming weeks. We think you’ll enjoy the debate!

Among the funding in the American Recovery & Reinvestment Act (ARRA) provided to NIH for comparative effectiveness research is an announcement about funds available to evaluate the impact of ‘information prescriptions.” The National Library of Medicine (NLM) is home to this project and the one-paragraph description of what they’re looking for is as follows:

(05) Comparative Effectiveness Research

05-LM-101  Effect of “Information Prescriptions” on Improving Care by Increasing Compliance with Medication Protocol Given to Discharged Emergency Department Patients. A significant fraction of patients who are given a set of prescriptions, such as when they leave a physician office or the Emergency Department, are known to disregard or curtail recommended medications. Individually tailored information about risks, benefits, costs and treatment options are given by some clinicians as “information prescriptions”, but the effectiveness of “information prescriptions” is not known. Studies in this area should determine value of such “information prescriptions” in improving patient compliance as contrasted to current discharge advice systems or standard office practices. Contact: Dr. Valerie Florance, 301-594-4882, florancev@mail.nih.gov.

However, the NLM confirms that the information prescription projects can address topics other than “medication compliance” and in all kinds of settings besides the ED. If information therapy (Ix) implementers out there are looking for a consultant or evaluation partner to collaborate with on a related project, please contact me at jseidman@ixcenter.org.

Several articles published in today’s New England Journal of Medicine are worthwhile reads (all of which, I believe, are free full text).

• News flash (not!): We have a long road ahead. A new study out of Harvard updates the dreary state of electronic health record (EHR) adoption by U.S. hospitals. Just 7.6% of surveyed hospitals have a basic system and a measly 1.5% have a comprehensive EHR system throughout the hospital.
• Incoming HHS National Coordinator for Health Information Technology David Blumenthal, MD, MPP, makes some important points about how the HIT provisions in the stimulus bill were designed to generate “improvements in health and health care” and not just increase EHR adoption. Aside from the financial incentives (and  down the road, penalties) for providers and the important infrastructure created, Blumenthal highlights the critical importance of the “federal government’s skill in defining two critical terms: ‘certified EHR’ and ‘meaningful use.’” He is right that tightening certification criteria and “motivating providers to take full advantage of EHRs” are prerequisites for HIT actually improving quality and efficiency. I’ve described this and the importance of stretching out “meaningful use” to meet the needs of consumers before.
• Paul Tang, MD (Palo Alto Medical Foundation), and Tom Lee, MD (Partners), have an excellent piece comparing the advantages of stand-alone personal health records (PHRs) with what they call “integrated PHRs.” The latter term describes electronic portals that allows patients to gain access to provider EHRs and, perhaps more importantly, communicate directly with their clinicians. One of the big question marks is how fast will the stand-alone version effectively integrate with clinician records to help support the kind of information-supported communication that facilitates participatory medicine.
• An interesting piece from Kenneth Mandl, MD, MPH, and Isaac S. Kohane, MD, PhD, from Children’s Hospital in Boston, makes the argument that HIT “components should be not only interoperable but also substitutable.” Thankfully, they describe in excellent detail the broad range of applications and examples that comprise those “components.” It’s an excellent list, though it could benefit from some more emphasis on content applications.

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.

Following up on last week’s post, “Home Is Where the Health Is,” here’s part 2 of my report on the the CHCF Health Care Leadership Network/CCI MD Alumni Session Spring Meeting in San Francisco.

The afternoon panel provides several varied perspectives on the patient-centered medical home (PCMH). Ed O’Neil, PhD, who directs the UCSF Center for the Health Professions talked about the need to create new practice models. In the continuum of prevent-diagnose-treat-manage, most action from health care professionals has been in the middle (diagnosis & treatment). Future emphasis should be placed on prevention — which has great leverage over the long term but little short-term effect — and management, for which we currently and inappropriately deploy a primarily acute-care armamentarium.

Joe Scherger, MD, from UCSD, contrasted traditional care that is episodic and reactive (both of which make it visit-dependent) and provider-controlled with where the medical home should go. Specifically, he pointed to — as I often do (including in my post last week and presentation at this conference) — the Institute of Medicine’s first recommendation for health care delivery redesign: Create continuous healing relationships that is strategically proactive, coordinated, non-visit-based, delivered by a team, and provides a continuous cycle of care. For more, see his BMJ article, “Primary Care Needs a New Model of Office Practice.”

Paul Wallace, MD, the Chair of the IxCenter Board of Directors and from Kaiser Permanente, said that one of the most important aspects of the PCMH debate is that it is one of the first issues to align discussion around both payement reform and delivery system reform. We have serious problems to solve, such as inadequate patient care, and  the field of primary care will no longer exist given the single-digit rates at which medical schools are producing residents for primary care specialties. The PCMH solution needs to focus on population care and engaging patients as care managers. We need to remember that “the medical home is not about a place.”

Betsy Stapleton, FNP (scroll down here), is a consumer engagement consultant, who pointed out that many of the critical elements of a successful medical home identified by the other panelists derive from models developed by nurse practitioners. This profession has made great contributions to advancing the field of patient self-management support.

Arnie Milstein, MD, from the Pacific Business Group on Health, found four practices that effectively demonstrated how PCMH approaches can lower total health care costs. They relied on two re-engineering goals: (Primarily) lowering the frequency of health crises (acute events) and (secondarily) reducing the cost per service. They applied three ingredients to these two goals: Salient caring (tailored to reduced hospital use), team-based production, and tight supplier management. It’s also worth reading Milstein’s Health Affairs piece titled “Medical Homes and Medical Home Runs.”

Natanya Alon, from the National Partnership for Women & Families, focused on what makes a PCMH truly patient-centered — that is a home from the patient’s perspective:

• 24/7 access
• Knowing about me & remembering
• Support of self-management
• Providing the information I want

This requires interdisciplinary teams that support patients and caregivers as partners in care management and foster an environment of trust and respect. She summarized by describing a patient’s comment, “It’s a gift whenever my doctor makes me feel like we’re in this together.” The National Partnershp has some additional useful PCMH materials including patient brochures and consumer advocate guides.

David Shute, MD, talked about the PCMH pilot at Care Oregon.

IxAction Alliance member Kaiser Permanente has launched a national public relations campaign to draw attention to the need to address health care disparities in the context of comprehensive health care reform.

Indeed, the growing ranks of uninsured (nearing 50 million Americans) is more than a huge problem. It’s a national embarrassment (or “national disgrace” as Kaiser puts it). But a lack of insurance is only part of the issue, as a variety of vulnerable populations suffer from both health disparities and health care disparities, even beyond insurance status. Kaiser has also put together a great clearinghouse of resources on the subject.

The Center for Information Therapy has been increasingly tacking the dual questions of:

1. What particular challenges do health & health care disparities mean for implementation of information therapy (Ix)  interventions? and
2. In what ways can Ix initiatives provide leverage in overcoming health & health care disparities?

This two-pronged approach is rooted in two related beliefs. First, it’s imperative that — in our quest to drive Ix advancement — we do it in a way that reduces disparities and a lack of attention to the issues of safety-net populations might result in the opposite. Second, we believe that we need to be innovative in developing solutions to overcome disparities rather than presume that simply by achieving universal coverage or investing money that we’ll solve the problem (not that both aren’t incredibly important).

For more on what we’re doing in this area, look at the Safety-Net Populations and Ix & Health Disparities categories down the right nav bar of this blog. Also, we’ve written an issue brief on innovative HIT solutions for the Medicaid population for the Georgetown Health Policy Institute’s Center on Children & Families.

There’s a Letter to the Editor, “Don’t Polarize Health Care,” in today’s New York Times from David Kahn, a psychiatrist at Columbia University, suggesting that the term “perverse incentives” will polarize the health care reform debate. Kahn suggests that a variety of prospective reimbursement arrangements could be described as perverse by others, and such language will only “polarize the difficult discussions ahead.”

I have to admit to having used the term “perverse incentives” from time to time. For example, I do believe that it is perverse at some level that our current reimbursement system, in effect, penalizes clinicians for extra effort invested in patient education, well-structured information therapy (Ix) initiatives, and providing assistance to their patients outside of reimbursable encounters.

Investing resources — perhaps the most valuable clinician resource being their own time — for non-reimbursed care clearly draws resources from those activities for which they can get paid, despite the demonstrated value of tailored health information tools and asynchronous communication. I do see perversion at work there.

Whether eradicating inflammatory phrases from our vocabulary will lead to a less polarized debate environment or merely reduce the urgency for delivery system reform remains to be seen. If the former were true, I’d take an immediate pledge to swear off use of such phrases. Until then, I worry more that the pull of inertia remains strong enough to maintain the status quo — which includes a somewhat perverted payment structure.

Bristish IxAction Alliance member, the Patient Information Forum (PiF), has just released a report, “Information: First Line Therapy?” (overview available here). Among PiF’s main conclusions:

1. Whenever possible, information should be the first therapy prescribed.
2. Information therapy (Ix) needs to be personalized and targeted to the “correct stage of the patient journey.”
3. Because of the vast information available and that the fact that much of it is “incorrect or misleading…there is a definite need for a more stringent monitoring system, condensing information and/or signposting information to direct professionals and patients to the most suitable resource.” They’re not sure how to operationalize this recommendation.

Based on these findings, PiF has identified a series of next steps — some of which are:

1. PiF wants to develop a bigger research base in three areas: a) “how information can be integrated into routine theerapuetic management;” b) “measure the impact of health information;” and c) assess the current state of “health information provision.”
2. PiF plans to become a more forceful public policy advocate in this arena in the UK.
3. PiF recognizes that it needs to “find ways to help the consumer health information workforce develop in their roles, increase their skills and share their knowledge and experiences more widely and effectively.”

The Center for Information Therapy (IxCenter) has answered some of the research questions in our white papers.

• “The Mysterious Maze of the World Wide Web: What Makes Internet Health Information High Quality?” evaluates the quality of diabetes content on the Web and — based on empirical research and scientifically validated tool development — provides a series of policy and operational recommendations for advancing more robust measurement of information quality.
• “The Ix Evidence Base: Using Information Therapy to Cross the Quality Chasm” synthesizes the empirical evidence in support of Ix interventions and organizes them around the Institute of Medicine’s 10 health care delivery redesign recommendations from its “Crossing the Quality Chasm” report.

The IxCenter also has conducted other relevant research to answer these questions that fall into two categories (both of which are accessible to IxAction Alliance members through our member portal):

1. Ongoing review of the peer-reviewed literature. Through our bimonthly IxResearch Briefings, we have added about 40 more studies to the original “Ix Evidence Base” white paper, each of which describes implications for implementation of initiatives focused on proactive and targeted delivery of information to consumers/patients.
2. We have also collected more than 40 IxInsights reports and associated archived webinars on a wide array of innovations or best practices in the field. Although many of these interventions were implemented without a prospective study design, they still offer critical learnings about the best Ix implementation strategies.

As I have alluded to before, Ix Pioneer Sponsor Group Health Cooperative has provided a seed grant to help us develop a database that rigorously and methodically integrates these two types of evidence. By doing so, we will be able to answer the questions posed by PiF (and others) more robustly.