2
Overview of Issues

OVERVIEW OF eHEALTH

Janet M. Marchibroda, M.B.A.

Chief Executive Officer, eHealth Initiative and eHealth Foundation


Implementation of eHealth1 and health information technologies is seen by many observers as an effective way to address current concerns about the quality and safety of the U.S. health care system. Among those concerns are the facts that U.S. adults receive only about half of recommended health care services (McGlynn et al., 2003), that less than 50 percent of adults receive the preventive and screening tests called for in guidelines for their age and sex (Commonwealth Fund, 2006), that preventable medical errors in hospitals result in around 100,000 deaths per year (IOM, 2000), and that there are 1.5 million preventable adverse drug events each year (IOM, 2007).

The rising costs of health care are another major concern that eHealth may help address. By 2016, health care spending in the United States is expected to increase from the current 16 percent of the gross domestic

1

There is an ongoing project devoted to determining definitions of various concepts in eHealth and information technology, however, for purposes of this presentation the following definition applies. eHealth “involves simplifying and handling processes relating to information, communication and transactions within and between health care institutions and professionals by utilizing information and telecommunications technologies.” (Deutsche Telekom, 2008).



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2 Overview of Issues OVERVIEW OF eHEALTH Janet M. Marchibroda, M.B.A. Chief executie officer, eHealth initiatie and eHealth Foundation Implementation of eHealth1 and health information technologies is seen by many observers as an effective way to address current concerns about the quality and safety of the U.S. health care system. Among those concerns are the facts that U.S. adults receive only about half of recom- mended health care services (McGlynn et al., 2003), that less than 50 percent of adults receive the preventive and screening tests called for in guidelines for their age and sex (Commonwealth Fund, 2006), that pre- ventable medical errors in hospitals result in around 100,000 deaths per year (IOM, 2000), and that there are 1.5 million preventable adverse drug events each year (IOM, 2007). The rising costs of health care are another major concern that eHealth may help address. By 2016, health care spending in the United States is expected to increase from the current 16 percent of the gross domestic 1 There is an ongoing project devoted to determining definitions of various concepts in eHealth and information technology, however, for purposes of this presentation the fol- lowing definition applies. eHealth “involves simplifying and handling processes relating to information, communication and transactions within and between health care institu- tions and professionals by utilizing information and telecommunications technologies.” (Deutsche Telekom, 2008). 

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion product to 20 percent or $4 trillion (American Academy of Orthope- dic Surgeons, 2007). Health insurance premiums for workers and their employees have increased by 78 percent since 2000, while workers’ earn- ings have risen by only 19 percent over the same time period (Kaiser Family Foundation and Health Research and Educational Trust, 2006). Twenty-one percent of employers report it is “very likely” that they will increase the amount that employees pay for health insurance in the com- ing year, while another 28 percent report it “somewhat likely” that they will do so (Kaiser Family Foundation, 2006). In the year 2000, 12.7 percent of the U.S. population was age 65 or older. That number is expected to grow to 20 percent by the year 2030 (U.S. Bureau of the Census, 2000), a factor that will contribute to the challenges facing the health care system as it strives to address chronic conditions of the population. In 2000 more than 125 million people in the United States had at least one chronic care condition, and it is pre- dicted that the number will reach 157 million by 2020 (Wu and Green, 2000). Seventy-eight percent of all health care spending in 1998 was focused on those with chronic conditions (Partnership for Solutions, 2004). Himmelstein and colleagues (2005) estimate that medical issues are a major cause of bankruptcy in the United States. Furthermore, there are key challenges concerning access to care and the problems of the 47 million uninsured Americans, problems which many states are now trying to address through health care reform. The health care debate that will take place over the coming years will likely include all of these issues. And while health care policymakers are focusing on these issues, consumers are also weighing in. A survey by the Kaiser Family Foundation found that more than half of all those surveyed were dissatisfied with the quality of health care and that almost one-third of those indicated they were “very dissatisfied.” In addition, 81 percent of those surveyed were dissatisfied with the cost of health care in the United States, with more than 50 percent of the respondents describ- ing themselves as being very dissatisfied (Kaiser Family Foundation and Health Research and Educational Trust, 2006). When a recent survey by The Commonwealth Fund asked health care opinion leaders to rate the effectiveness of several key strategies for improving the quality and safety of health care, the highest-rated strategy was to accelerate the development and deployment of health information technology. In particular, 67 percent of respondents thought that acceler- ating adoption of health information technologies would be an effective or highly effective strategy for improving health care, compared with 59 percent for public reporting of provider performance on quality measures, 51 percent for financial incentives for improved quality of care, 50 percent

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 oveRvieW oF iSSUeS for stronger regulatory oversight of providers, and 39 percent for national voluntary quality campaigns (Shea et al., 2007). A variety of data support health information technology (IT) as an effective approach to improve quality, safety, and efficiency. For example, the Center for Information Technology Leadership (CITL) in Boston issued a series of reports examining the value and role of health IT. One study indicated that 100 percent adoption of Computerized Provider Order Entry (CPOE) in the ambulatory care environment could save $44 billion annually in reduced medication, radiology, laboratory, and hospitalization expenditures (Johnston et al., 2003). That same study found that use of IT could prevent more than a million adverse drug events and 190,000 hos- pitalizations per year. A more recent study from CITL indicates standard- ized health care information exchange could, if fully implemented, result in annual savings of $86.8 billion. This would also mean direct financial benefits for providers and other stakeholders (Walker et al., 2005). Additional data support the importance of IT as a strategy for address- ing various challenges of the health care system. Research conducted at the Brigham and Women’s Hospital in Boston concluded that the use of CPOE cut error rates by 55 percent, from 10.7 to 4.9 per 1,000 patient days (Bates et al., 1998). A Kaiser Permanente study of intensive-care patients found that the use of a CPOE system resulted in a 75 percent decrease in incidents of allergic drug reactions and excessive drug dosages. There was also a decrease in the average time spent in the intensive care unit from 4.9 days to 2.7 days. These reductions led to a 25 percent cost savings (Raymond and Dold, 2002). How, then, should the health care industry move forward with infor- mation technology in order to address its various challenges? In 2007, working from a poll of more than 200 organizations across every sector of health care, the eHealth Initiative2 developed a blueprint that provides a common vision for shared action. The purpose of the blueprint is to provide some initial ideas about how to move forward with the imple- mentation of eHealth and information technology as a way of improving health care. Much of the plan is based on work by Ed Wagner who put 2 “The eHealth Initiative and the Foundation for eHealth Initiative are independent, non- profit affiliated organizations whose missions are the same: to drive improvement in the quality, safety, and efficiency of healthcare through information and information technology. Both organizations are focused on engaging multiple and diverse stakeholders—including hospitals and other healthcare organizations, clinician groups, consumer and patient groups, employers and purchasers, health plans, healthcare information technology organizations, manufacturers, public health agencies, academic and research institutions, and public sector stakeholders—to define and then implement specific actions that will address the quality, safety and efficiency challenges of our healthcare system through the use of interoperable information technology” (eHealth Initiative and Foundation for eHealth Initiative, 2008a).

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion forward the chronic care model3 and talked about ways to drive health care improvement, laying out a number of strategies, such as engaging consumers, transforming care delivery, and improving population health. Wagner also examined how eHealth and health information technology can support those key health care improvement strategies. In addition to its ideas for moving forward with eHealth, the blueprint also discusses approaches to aligning incentives and addresses important issues in pri- vacy and confidentiality. The shared vision of the eHealth Initiative blue- print describes a high-performing health care system as one in which • ll those engaged in the care of the patient are linked together in a secure and interoperable environments; and • he decentralized flow of clinical health information directly enables t the most comprehensive, patient-centered, safe, efficient, effective, timely and equitable delivery of care where and when it is needed most—at the point of care (Marchibroda, 2008). Components of eHealth include electronic health records (EHRs)4 and personal health records5 (PHRs). There are also a number of new consumer-facing applications, some of which are not referred to as PHRs but which serve a similar purpose as they provide patients with access to their own health information as they move among providers and health plans. Health information exchange is another major component of eHealth. This refers to the electronic exchange of data across organiza- 3The Chronic Care Model was developed by Ed Wagner, M.D., M.P.H., director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound and colleagues of the Improving Chronic Illness program with support from the Robert Wood Johnson Foundation. 4 An EHR system includes “(1) longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual; (2) immediate electronic access to person- and population-level information by authorized, and only authorized, us- ers; (3) provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and (4) support of efficient processes for health care delivery. Criti- cal building blocks of an EHR system are the electronic health records (EHR) maintained by providers (e.g., hospitals, nursing homes, ambulatory settings) and by individuals (also called personal health records)” (IOM, 2003). 5 “An electronic Personal Health Record (ePHR) is a universally accessible, layperson comprehensible, lifelong tool for managing relevant health information, promoting health maintenance and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools. The ePHR is owned, managed, and shared by the individual or his or her legal proxy(s) and must be secure to protect the privacy and confidentiality of the health information it contains. It is not a legal record unless so defined and is subject to various legal limitations” (Healthcare Information and Management Systems Society, 2005).

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 oveRvieW oF iSSUeS tions and disparate information systems, including data from laboratories, pharmacies, plans, physicians, or hospitals. A major benefit of eHealth is the opportunity it offers doctors and other health care providers to con- nect with the patient through these systems. Neither patients nor the health care system can benefit, however, unless the new health information technology is actually adopted and used. Adoption rates for electronic health records in solo practitioner offices are about 13 percent, while in large medical practices adop- tion rates are somewhere between 19 percent to 57 percent. Overall the adoption rate for EHRs in physician offices is between 17 percent and 25 percent. For hospitals, the adoption rates for EHRs range from 16 per- cent to 59 percent. CPOE system adoption rates for hospitals range from 4 percent to 21 percent. According to a Pew Internet and American Life research study, 79 percent of Internet users, or 95 million American adults, have searched online for information on at least one major health topic (Fox, 2006). A more recent Pew survey indicated that adults living with a disability or chronic disease are less likely than others to go online, but once they are online, they are more likely to look for health information (Fox, 2007). Such consumer use of electronic systems for obtaining health information illustrates the potential value of consumer-facing Health IT applications. According to an October 2005 research report supported by the Markle Foundation, 60 percent of Americans support the creation of a secure online “personal health record” service that would allow con- sumers to • check and refill prescriptions; • get results over the Internet; • check for mistakes in the medical record; and • onduct secure and private e-mail communication with your doctor c or doctors (Markle Foundation, 2005). In a recent Commonwealth Fund survey of consumer views about key health care issues, 94 percent of respondents felt that having easy access to medical records was very or somewhat important and 93 per- cent felt the doctors having access to their medical records was very or somewhat important (Shoen et al., 2006). In June 2006, when the eHealth Initiative Foundation conducted a number of focus groups and a phone survey of individuals in the Gulf Coast area on the topic of electronic health information exchange, it found that 70 percent of those individuals favored secure, electronic health information exchange that is “protected and exchanged under current medical privacy and confidentiality stan- dard procedures” (Shea et al., 2007).

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion In recent years there has been an increasing interest in consumer- facing applications, with very large corporations such as Microsoft and Google developing a number of applications in this area. Most efforts are, however, provider-centric initiatives, increasingly led by hospitals and are designed to exchange data across organizations. There is also some activity with health plans. Of particular value in what is occurring across the field of health information technology is connecting consumer applications with those that exchange clinical data. The eHealth Initiative Foundation conducts an annual survey of Information Exchange Initiatives. The fourth annual survey of health information exchange at the state, regional, and community levels, con- ducted in 2007, found that of the 130 initiatives responding to the survey, 20 were at the beginning stages of effort (stage 1 or 2—see Table 2-1 for TAbLE 2-1 Seven-Stage Framework for Assessing and Tracking the Development of Health Information Exchange Initiatives at the State and Local Levels Stage 1 Recognition of the need for health information exchange among multiple stakeholders in your state, region or community. (Public declaration by a coalition or political leader) Stage 2 Getting organized; defining shared vision, goals, and objectives; identifying funding sources, setting up legal and governance structures. (Multiple, inclusive meetings to address needs and frameworks) Stage 3 Transferring vision, goals and objectives to tactics and business plan; defining your needs and requirements; securing funding. (Funded organizational efforts under sponsorship) Stage 4 Well under way with implementation—technical, financial, and legal. (Pilot project or implementation with multiyear budget identified and tagged for a specific need) Stage 5 Fully operational health information organization; transmitting data that is being used by health care stakeholders. Stage 6 Fully operational health information organization; transmitting data that is being used by health care stakeholders and have a sustainable business model. Stage 7 Demonstration of expansion of organization to encompass a broader coalition of stakeholders than present in the initial operational model. Reprinted with permission from the eHealth Initiative and Foundation for eHealth Initiative, 2008c. Results of 00 Surey on Health information exchange: State of the Field. http://www. ehealthinitiative.org/HIESurvey/2008StateOfTheField.mspx.

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 oveRvieW oF iSSUeS description of stages), 68 were in the process of implementation (stage 3 or 4), 32 were operational (stage 5, 6, or 7), 5 were no longer moving forward, and 5 organizations did not respond to the stage of develop- ment question. Thirty of the initiatives that responded to the 2006 survey reported advances in their stage of development (eHealth Initiative and Foundation for eHealth Initiative, 2008b). While some of these initiatives have not been successful, there are a number that have progressed well. At the same time, there are more efforts directed at consumer-facing applications, which is an entirely different model from the provider- centric initiatives. Congress has introduced bills over the last several years that were intended to address key barriers to health IT adoption. During 2007 more than 19 bills related to health IT were introduced both in the House and Senate, most notably the Wired for Health Care Quality Act of 2007 (S. 1693), approved by the U.S. Senate Committee on Health, Education, Labor, and Pensions in August 2007, and a companion bill introduced in the House in early October 2007, both of which include several provisions related to health IT (Marchibroda, 2008). The Department of Health and Human Services (HHS) has also played a leadership role in moving the health IT agenda forward by emphasizing its four cornerstones of value-driven health care which are to • dopt interoperable health information technology (health IT a standards); • measure and publish quality information (quality standards); • measure and publish price information (price standards); and • promote quality and efficiency of care (incentives) (HHS, 2006). The HHS Office of the National Coordinator for Health Information Technology has made a number of efforts aimed at health IT standards harmonization, standards certification, and trial implantation of health IT prototypes. More work remains to be accomplished, however, particu- larly in the area of modifying payment strategies to reward those health IT initiatives that are accomplishing more rather than just doing more. A number of individual states have also gotten involved, with executive orders and legislative activities at the state level. Marchibroda concluded that, given the momentum of health IT, it is now a time of tremendous opportunity to develop eHealth systems that can address health literacy issues. At the same time, if such issues are not attended to, the creation of eHealth and health information applica- tions may actually exacerbate existing problems, rather than providing a mechanism to help solve them.

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0 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion SkILLS ESSENTIAL FOR eHEALTH Cameron D. norman, Ph.D. Assistant Professor, Department of Public Health Sciences, Uniersity of toronto Since the 1960s and early 1970s there has been a shift from provider- centered care to consumer-centered care, with individuals being encour- aged to search for answers themselves and to take greater responsibility for their own health. This has resulted in the growth of consumer-directed material, such as self-help books and Internet websites. Health information is known to be an essential component of health behavior change. People must have information about the threat, the opportunity, and the ability to make decisions about what actions to take. With the rise of the Internet and the World Wide Web, the public now has access to the greatest information tool ever available, with indi- viduals able to obtain a great deal of medical information on health at a distance, without having to see a practitioner. So far, however, there are no established guidelines for how to use the Internet or how to produce content for it. The Pew Internet and American Life Project (Fox, 2007) found that more than 80 percent of Internet users report seeking health information online; for Internet users with chronic conditions, the rate is 86 percent. And those percentages will most likely increase over the coming years. Unfortunately, few check the sources of information thoroughly and while there is widespread availability of health resources online, a search engine is usually the starting point. Thus, consumers need to have skills to effec- tively seek out the desired information, evaluate it, and then apply the information they find toward solving their health problems. More than half (58 percent) of those who report searching for online health infor- mation also report that the information they found affected their health decisions, and 39 percent say the information they found changed the way that they cope with a chronic condition or manage pain (Fox, 2006, 2007). Given these data, it is clear that it would be valuable to provide individuals with skills essential for eHealth. Robert Logan maintains that the Internet and networked tools for health represent a fundamentally new form of language that requires a new form of literacy (Logan, 2000). A quick search for information on the common cold can be used to illustrate the difficulties in eHealth literacy. A search of WebMD (www.webmd.com) for information on the com- mon cold produces a page with a great deal of text and advertisements for a variety of products, not all of which are related to the health condition described on the page. At the bottom of the text-heavy page is a list of

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 oveRvieW oF iSSUeS potential treatments. To one with low literacy, such a page of information can be quite intimidating. Another site with health information was hosted by the Canadian Health Network (www.canadianhealthnetwork.ca), a federation of dif- ferent health resources that does not produce all of the health materials itself.6 If one searched the Canadian Health Network for information on the common cold, one was actually taken to another site—Capital Health, which is located in Edmonton, Canada. While information obtained in this redirected manner might be accurate and appropriate, an automatic switch of sites can be confusing to consumers who expect one site and get another. If one goes to www.healthfinder.gov, a site sponsored by the U.S. Department of Health and Human Services, and types in “cold,” one is presented with a page listing a variety of options to click for information. Clicking on an option then takes the user to a PDF (portable document format) file that provides information about the cold. A PDF file, however, requires the user to have Adobe Acrobat Reader which, if one does not have the software, must be downloaded. A person with minimal eHealth skills may be confused about what to do, and wonder why it is that a piece of software must be downloaded to the computer in order to read the page of information. Such actions can be frightening for those unfa- miliar with health information or working with computers. Finally, if one seeks information about the common cold from NHS Direct (www.nhsdirect.nhs.uk), the website of the National Health Service in the United Kingdom, one finds the design of the site to be fairly pleas- ing to the eye. The page on the common cold is uncluttered, although there is a fair amount of text and there are also some links for basic terms such as sneeze, lungs, and larynx that can be used to look up additional information. Nonetheless, despite its clear design, the site demands more than basic literacy to understand and therefore can be a challenge for those with low literacy skills and involves more than basic literacy. As these examples illustrate, there are challenges to using the Inter- net for obtaining health information. In response to such challenges, the concept of eHealth literacy has been developed. eHealth literacy is “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solv- ing a health problem” (Norman and Skinner, 2006b) Such a definition is consistent with Logan’s contentions that use of the Internet is complex and its use plus the use of other networked tools constitutes a new lan- 6 The Canadian Health Network was operating at the time of this workshop, however it has since ceased operations. Therefore, the example provided during this presentation can no longer be accessed.

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion guage form and requires a new set of skills to fully understand it (Logan, 2000). The eHealth literacy definition is framed in terms of action because if one is looking for information about a health problem, one is looking not just for information but for actions that one can take in order to solve a health problem. Two types of skills are needed for eHealth: general skills and specific skills. General skills apply to a number of different contexts and settings and include traditional literacy (reading, writing, and numeracy), media literacy (media analysis skills), and information literacy (information seek- ing and understanding). Specific skills include such things as computer literacy (IT skills), health literacy (health knowledge comprehension), and science literacy (science process and outcome). Four out of 10 Americans and Canadians have low literacy, making it difficult for them to function in everyday society (Rubenson et al., 2007; Statistics Canada, 2005). Thus in the case of eHealth interventions that are largely text-based, 4 out of every 10 people who might benefit from the intervention will have a great deal of difficulty reading the material. In the case of mathematical literacy (numeracy), one-quarter of U.S. 15-year- olds scored at or below the lowest proficiency level (Miller et al., 2007). To the extent that eHealth involves simple mathematical calculations such as addition or subtraction, or an understanding of numbers, those with low numeracy skills will likely find it difficult to understand the information presented. Such individuals will also have difficulty reading maps or understanding simple charts. Media literacy refers to the skills necessary to think critically and to act based on information from media-based messages. Media literacy places information in a social and political context and considers issues such as the marketplace, audience relations, and the role of the medium in the message. Those with low media literacy lack awareness of bias or perspective in media pronouncements, both in terms of what is presented and what is not presented. They also have difficulty understanding that the media has both explicit and implied messages and they have difficulty deriving meaning from media messages. The third general skill involved in eHealth literacy, information lit- eracy, involves a more general understanding of information. An infor- mation literate person knows “how knowledge is organized, how to find information, and to use information in a way that others can learn from them” (American Library Association Presidential Committee on Informa- tion Literacy, 1989). Those with low information literacy are unable to see connections between information from multiple sources such as books, pamphlets, and websites. They are, therefore, unable to understand that one may have to triangulate pieces of information from various sources to build an entire picture of the subject about which they are seeking

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 oveRvieW oF iSSUeS information. Those with low information literacy are also unfamiliar with local libraries and other repositories of information, and they are unable to frame search questions in a manner that produces desired results. As described above, the specific skills involved in eHealth include computer literacy, science literacy, and health literacy. Computer literacy is a general awareness of and skill in using computer-based technology to solve problems (Logan, 2000). It relates both to computers and to the kind of technologies that surround the use of computers, such as the use of a keyboard, mouse, or printer. As Skinner and colleagues point out, computer literacy involves more than simply access to this type of tech- nology; it is also about relative access and the comfort with which one accesses computers (Skinner et al., 2003a, 2003b). For example, Canada was the first country in the world to connect each of its public schools to the Internet. One might therefore say that all Canadian students have access to the Internet. But if access is only at certain times of the day, or in one particular room where the teacher is present and overseeing what students are doing, a young person wanting to find information on sexual health may find it difficult to do so. Science literacy, another skill necessary for eHealth, is an understand- ing of the nature, aims, methods, application, limitations and politics of creating knowledge in a systematic manner (Laugksch, 2000). Research on scientific literacy suggests that only 17 percent of Americans are con- sidered able to understand basic science (Gross, 2006). This means that the remaining 83 percent of Americans lack an understanding of the cumulative, dynamic nature of scientific knowledge. They are not aware that science can be understood and used by non-scientists, and they are unfamiliar with simple science terminology, the process of discovery, or how scientific knowledge is translated into practice. Yet 87 percent of online users (128 million adults) use the Internet as a research tool, and 70 percent have used the Internet to look up a scientific term (Horrigan, 2006). Finally, eHealth demands health literacy skills. The Pew Internet and American Life Project found that 64 percent of Americans had searched online for health information in 1 of 17 areas7 identified by the Pew Internet and American Life Project (Fox, 2006). Seventy-three percent of 7 The 17 areas are specific disease or medical problem (64%); certain medical treatment or procedure (51%); diet, nutrition, vitamins, or nutritional supplements (49%); exercise or fitness (44%); prescription or over-the-counter drugs (37%); a particular doctor or hospital (29%); health insurance (28%); alternative treatments or medicines (22%); depression, anxi- ety, stress, or mental health issues (22%); environmental health hazards (22%); experimental treatments or medicines (18%); immunizations or vaccinations (16%); dental health infor- mation (15%); Medicare or Medicaid (13%); sexual health information (11%); how to quit smoking (9%); and problems with drugs or alcohol (8%).

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion system. What AHCCCS is attempting is to integrate the system virtually— to integrate it with information and to integrate more rapid deployment of knowledge—which should result in improved quality and reduced costs. In such a system one would have the same information reference points no matter where one was located—in a community clinic, a physician’s office, or elsewhere. Phase I will include a focus on interactive multimedia product devel- opment that goes beyond static health content. Such products will include e-learning modules, electronic health assessments, Web-based health coaching, Web-logs, streaming video,13 Web-based health awareness cam- paigns, eHealth-connected provider offices for access to downloadable personalized health videos, and podcasts. Multimedia education will focus first on raising the health literacy of those with chronic diseases and, in particular, will be aimed at helping individuals understand their chronic illnesses. Over time the materials will address other important conditions and situations of relevance for the AHCCCS population, for example, how to keep one’s health care cover- age in place and how to use one’s health plan. eHealth education will be personalized. The information that a person retains from an educational program is dependent upon a number of fac- tors including to whom that individual relates well and who is providing the education. In many education efforts the same product is delivered in the same way by the same person. AHCCCS’s goal is to deliver education in a much more personal and culturally sensitive manner, tailoring the important content of that education to the various needs of the population and using messengers who are similar to and can relate to members of various populations. Additionally, these multimedia education programs will be developed in English, Spanish, and in some cases Native American languages. AHCCCS strategies for building eHealth literacy products include knowledge-building programming capability and rapid production of e- learning programs with multiple content sources. The rapid production goal for AHCCCS staff is to produce a new program every day. If it takes 2 months to develop and deliver each audio or video program, that is too long. In a rapid production cycle, content is duplicated but it is delivered by a different person and is aimed at a different population. One can do a great deal with today’s camcorders and digital equipment. One does not need a $100,000 studio; one needs just a couple of creative people with a camera. To establish that the programs actually work, innovation centers, 13 A streaming video is a “one-way video transmission over a data network. It is widely used on the Web as well as company networks to play video clips and video broadcasts” (Techweb, 2008).

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 oveRvieW oF iSSUeS established by AHCCCS at federally qualified health centers with volun- teer physicians, will be test sites for product prototypes. AHCCCS has recently introduced a website. One of the things of interest is who will access the website. Table 2-2 below provides an over- view of utilization trends for 1 month this year. The AHCCCS basic website is called My Arizona Health and Well- ness (www.myazhealthandwellness.com). The mission of the website is “to build health and wellness literacy in AHCCCS members so that they make decisions that improve their health care quality and reduce prevent- able health care care costs through the utilization of interactive, personal- ized health education and health literacy competency” (Rodgers, 2008). This website is the basic mechanism that will be used to deliver many of the eHealth tools AHCCCS will develop. The website also supports the governor’s executive order (Napolitano, 2008) to reduce the escalation of health care costs for Arizona by the following • educing costs through patient-centered care that integrates r wellness, prevention, self-care education and chronic disease management; TAbLE 2-2 Snapshot of Web Utilization Trends/Data January 2008 to February 2008 Website Healthwise Knowledgebase Content Usage Site Usage: Top 10 Search Terms: Top 10 Topic Views: - 1,152 visits Pneumonia Women’s Health - 897 (72%) absolute Asthma Interactive Tools unique visits Dental Health Eating BOOK-n873 Men’s Health Top Traffic Sources: (surgery-carpal Pregnancy - 79% referring site tunnel syndrome) Children’s Health (AHCCCS website) Cancer Diabetes - 18% direct traffic Diabetes Depression COPD Pneumonia Top Content visits: BOOK-d904 Type 2 Diabetes - Health Resources (surgery-varicose - Get Covered, Stay Covered veins) - Wellness in Arizona Immunizations Dairy E-mail signups: 40 (mostly internal/staff) Healthwise Content Usage: 651 visits Hits: 19,722 Visit duration by minutes: Majority (0-1 minute) SOURCE: Rodgers, 2008.

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0 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion • mplementing new incentives and policy changes for providers to i adopt e-health technologies and evidence-based standards; and • mproving accountability by empowering consumers with quality, i cost and health information. It is important that each beneficiary have an e-mail address and access to the internet so that each person can obtain needed information and also so that eHealth tools can be used effectively. One of AHCCCS’s require- ments will be that each beneficiary have an e-mail address and, eventu- ally, that each individual document how he or she will access the Internet. If an individual does not have a way to access the internet, then AHCCCS will take responsibility for devising a way to provide access. Such options could include using cell phones, text messaging, or an iPod or MP3 player on which information can be downloaded. One new tool that can be used for patient Internet access in a pro- vider’s office is the “Tablet,” a handheld personal computer with an 8.4 inch screen that runs Microsoft Windows XP. AHCCCS envisions a time when each patient who enters a physician’s office will be handed a device that provides access to the Internet. The patient will then be asked to update his or her health history (AHCCCS is developing a Web-based health history), and each patient will also access his or her personal health account which will contain a personalized audio/video file of e-learning programs. In this future vision, once a patient accesses his or her personal health account, the physician will be able to view the information and make sure that the patient understood the individual e-learning programs, since patient responses will be automatically uploaded to the electronic health record (EHR). If misunderstandings occur, the physician will then be able to correct the information and discuss the problems further. This is the vision of “medical home” that each AHCCCS beneficiary will eventually have. To become a medical home, primary and specialty sites will be required to have EHRs, Internet connectivity, an AHCCCS Health Education Kiosk or Wi-Fi14-enabled touch-screen tablet, and a high-definition television with speakers in the examination room so that patients can access the e-learning tools. These e-learning programs will not be something that the patient obtains from the Web, but rather will be pro- grams developed specifically for the chronic conditions or other problems 14 “Wi-Fi (short for ‘wireless fidelity’) is a term for certain types of wireless local area network (WLAN) that use specifications in the 802.11 family. The term Wi-Fi was created by an organization called the Wi-Fi Alliance, which oversees tests that certify product inter- operability. A product that passes the alliance tests is given the label ‘Wi-Fi certified’ (a registered trademark)” (SearchMobileComputing.com, 2008).

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 oveRvieW oF iSSUeS the patient has. Physicians will be familiar with the programs and so will be able to engage in a dialogue with each patient about his or her specific conditions, using the e-learning programs as a basis for discussion. In one AHCCCS video on diabetes, the main character is a white adult male talking about diabetes while standing next to his vehicle in a parking lot. The video presentation was made by Knowledge Builders, the name that members of the AHCCCS staff gave themselves. The next charac- ter featured in a video with the same content might be an adult female Hispanic who is Spanish-speaking or perhaps an adult male Spanish- speaking individual or a Native American–speaking individual. In the AHCCCS approach, Rodgers stated, the same content is used for every- one, but the content is delivered by different characters depending on the audience. The purpose is to see if this engages the various beneficiary populations. Rapid production of these materials allows change in the material. AHCCCS evaluates its e-learning programs to determine exactly who is learning what and where most of the problems are. Material is then edited to address identified problems. Rodgers concluded by predicting that AHCCCS eHealth, properly configured, will help address one of the major obstacles to achieving better outcomes, that is, eHealth literacy. DISCuSSION George isham, M.D., M.S. HealthPartners Moderator One questioner asked Rodgers to provide more detail about the infra- structure that AHCCCS is building. Rodgers replied that the first effort is being directed at EHRs so that providers will be able to exchange health information. This is not an EHR in the fullest sense, he said, but it will include the problem list, information regarding medications, lab results, x-ray views, and clinical notes. Further down the road the idea is to be able to embed files and other information into the EHR. The e-learning pro- gramming for patient-focused education will be available through the Web, as will be provider-focused education, the clinical support tools, and the patient decision-support tools. These will be configured with the EHR. Another audience member asked whether AHCCCS is educating con- sumers about the system as it is being developed. Are they learning what eHealth means, what an electronic medical system can do, and how to use the specific hardware (e.g., the tablet discussed earlier)? Rodgers replied that the system is not currently in the market and available. What does exist is a prototype that is being tested. Once this is validated and addi-

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion tional models are developed, AHCCCS plans to hold focus sessions with various groups to determine if different populations engage the system differently and if individuals can relate to the system. The assumption is that the system will work, but that needs to be vali- dated. Once validated, the idea is to use the innovation centers discussed earlier as the first beta sites. There are several options that one might use in these sites, including a workstation-type kiosk or provision of the tab- lets. One could also create an education room, but since AHCCCS plans to ultimately offer these services in provider offices where space tends to be limited, creating a separate education room may not be the best option to pursue. The hope is that access will eventually be available in the homes. The most logical access point, however, is the physician offices where patients can use the system at the time of their appointment. This is probably also the time at which the patients will be most motivated to seek information, and it will be a good way to use waiting time. Norman was asked to comment on what is involved in teaching indi- viduals to be computer literate. Norman responded that there is a com- plex and a simple way to teach computer literacy. The simple approach is usually constructed around a particular piece of technology, such as e-mail. In this case, one works with the individual to find the simplest route to e-mail and puts an icon on the desktop computer so that it is a simple matter to call up the e-mail. The idea is to have a familiar entry screen so that use is simple. eHealth is a place, although most do not think of it that way, Norman continued. It is a place to go in the system. A system needs benchmarks or landmarks that are easily associated with where the individual using the system needs to go. One should have a set of screens with a consistent style throughout the application, and people must be trained to under- stand the screens in order to use the system. The more complex problem arises when one is attempting to teach people to search for information, that is when the people will need to use multiple platforms. Just as is the case with learning to speak another language, it is not something one can pick up in a weekend course; it is a much more complex task. A constant dialogue is needed, with markers for learning the language of computers and information searching. The key is to find where individuals are in terms of their knowledge and comfort levels. That is what eHEALS is designed to do. Rodgers added that individuals must also have a reason to want to use the technology. If they are not interested, if they do not perceive the value of using the system, they will not use it. By grabbing individuals’ attention with what one might think of as medical entertainment or with something that is fun and real to them, it becomes much easier to get them to want to use the technology.

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 oveRvieW oF iSSUeS Another questioner asked Rodgers, what happens when one is dealing with multiple chronic conditions since people seem to be able to under- stand only three concepts at any one time? Individuals need to be able to do many things, not just three, both in terms of navigating technology and in terms of self-management. Clinical professionals may identify specific things that they think are most important for such individuals to know. Conversely, those from the technological or navigational side might iden- tify another set of skills. How can one deliver the right information at the right time to the right person so that that person is doing the right thing? Rodgers responded that AHCCCS is ready to learn from its benefi- ciaries what works best for them and what does not work. The system must be modular, and it must be engaging, interesting, and real-world rel- evant to those using it. When one is working with Native Americans, for example, the programs and the person delivering them must understand the conditions (e.g., nutrition, daily life, etc.) in which that population operates and what strategies they might be willing to employ. The key to being able to make such an approach work is technology, as technology is very forgiving and flexible, and it allows one to make relatively inexpensive changes as conditions change. With technology there is a great deal of flexibility, much more so than with the static pam- phlet approach. One questioner stated that quite a bit of research has been conducted that is relevant to AHCCCS’s idea of delivering health information to people in a kiosk environment—for example, on such things as where the kiosks are located and whether people enjoy using them. A number of studies have shown that, for reasons that may or may not apply to Arizona’s plan, using kiosks generally does not work well. Despite that, the questioner continued, what Rodgers describes appears to be a promising approach, and she said that she is particularly interested in the idea of focus groups and what individuals actually learn from the e-learning programs. The National Library of Medicine has illus- trative tutorials on its Medline Plus in both Spanish and English. These are very popular with those with low health literacy and with those who work with such populations. It would be interesting to see whether these could be made even more effective if they were delivered, as AHCCCS intends to do, by individuals who look or appear to be like those for whom the tutorials are designed, although in the case of some of the inter- active materials illustrations rather than live individuals are used. Rodgers responded that with the technology AHCCCS uses, change can be made relatively inexpensively. One does not need to reinvent things, just to present the material differently. The innovation centers, federally qualified health centers that have multiple and different types of populations, will serve as the laboratory for testing to determine how

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion various populations respond to the various programs. It will be possible to determine whether individuals learn better from people like them- selves. It will even be possible to measure variables over time because each time the system is accessed there is a time stamp and information on what modules are being accessed. One participant suggested that the public library is a good place for people to learn to use technology as well as to learn basic information about health. In the United States, public libraries are accessible to almost everyone. Furthermore, Arizona has a fantastic Arizona Health Informa- tion Network. Another participant suggested that non-English-speaking popula- tions may not generally begin their searches on home computers. She asked Rodgers whether anyone has looked at the health information searching behavior of this population, including how they use the public library. Are there community intermediaries that can help? Rodgers responded that AHCCCS has looked at this issue and that there are a number of community organizations that are willing to coop- erate with them, such as libraries and schools that are willing to give computer access to parents. To date, however, AHCCCS has not had any product to provide access to. Eventually access will be provided not only in the physicians’ offices, the clinics, and the hospitals, but also in a num- ber of other places as well. The key is for individuals to know when and for what they should access the internet. AHCCCS wants to have its beneficiaries fill out a health assessment as soon as they become eligible for services. Ultimately, the idea is to put the application online so that as they apply, they also fill out a health assessment form which will immediately provide informa- tion to the health plan that has never before been available. One participant said that she sees health literacy as patient-centric. Most eHealth initiatives, however, appear to be provider-centric and motivated by costs. The main reason for increasing the efficiency of those systems appears to be recouping costs. At the Medicaid level, a very dif- ferent system is driving eHealth. Here the issue is population health and how it can be improved, which is a more patient-centric approach. How can those motivated by costs be convinced to care about a patient-centric approach to eHealth? Marchibroda responded that Rodgers’ description of what is happen- ing in Arizona makes her wish this was the case across the country. The reality is, however, that most current initiatives do not connect with the consumer. When one examines community-based initiatives, for example, only 4 percent are connecting with consumers. There are many barriers to connecting with consumers, including lack of a business case and con- cerns about liability, privacy, and confidentiality.

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 oveRvieW oF iSSUeS Out in the field, talking with leaders at the state, local, and national level about eHealth and health technology, people find that there is little awareness of the problems associated with low health literacy. The first step, then, must be an educational effort to raise awareness. Once aware- ness has been raised, efforts must focus on figuring out how to tackle the remaining issues. Looking at the drivers of health IT, one might be able to make a busi- ness case for health literacy. In 2008, for example, analysts expect that $1.8 billion will be spent on chronic care management, most of which will be paid for by health plans or employers. Connecting consumers who have chronic conditions to e-learning systems built to address low health lit- eracy issues—systems such as the one described by Rodgers—could offer a compelling business case for health literacy. Another participant asked Rodgers how AHCCCS made the business case for developing its eHealth system and how it addressed issues of lia- bility, privacy, and confidentiality. Rodgers responded that AHCCCS ana- lyzed the potential return on investment and found that it is about $144 million a year. This is achieved on the provider side primarily through reduction of lab duplication, reduction in emergency room visits by pro- viding patients with alternative sources of care, and reduction in x-rays by deploying images to where patients go for care. On the consumer side the key element is compliance. There is signifi- cant variation in how well patients comply with physicians’ instructions. It is difficult to see beyond the basic compliance issue because more data are needed—for example, data on whether patients are taking their medi- cations. It is expected that the system will allow providers to track various kinds of compliance (e.g., whether patients pick up their medications or keep their health care appointments). Once data are available, personal- ized interventions can be developed—it will not work to implement the same intervention for everyone because the reasons for noncompliance are not uniform. A participant asked if the speakers could elaborate on what Web 2.0 is. Norman responded that it reflects a shift in technology to more consumer- driven content. When the World Wide Web was first introduced, for exam- ple, in order to create a Web page, one had to know some programming language and HTML (HyperText Markup Language). With Web 2.0 tech- nologies anyone, even those with no technical skill, can post on the Web with, for example a wiki (essentially an editable Web page) or a social net- working Web page like Facebook. One does not need to understand any of the technology. Rodgers said that the great potential for health care is that patients with special health care needs can communicate with others who have the same needs, so that they can learn from each other. This is an entirely new way of providing coaching and obtaining support.

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 HeALtH LiteRACY, eHeALtH, AnD CoMMUniCAtion One participant pointed out that there is a movement called Health 2.0 which is focused on health. One Health 2.0 site, called Patients Like Me, allows patients to identify themselves, either anonymously or not, and then interact with others, describe their conditions, describe their experience with drugs, and so on. Patients Like Me also contains a variety of sites dedicated to particular health issues. For example, there is an ALS (amyotrophic lateral sclerosis) site within Patients Like Me. One questioner referred to the study of CITL mentioned by Marchibroda which suggested that if standardized health care infor- mation were exchanged among health care IT systems, there would be a national savings of $86.8 billion. Is this a reasonable figure and how would that happen? Marchibroda responded that those conducting the study examined data flow across different organizations. The estimated savings come from a variety of things, such as reductions in duplicate lab tests and reductions in transactional costs related to messaging. In order to achieve the savings, one must provide multiple services to multiple parties in the system, which is not how things happen in the real health care system, in order to realize a return on the capital investment. One participant stated that when she thinks of populations with low health literacy she thinks of recent immigrants, the elderly, and those with limited English proficiency. Would the tools that are being developed for eHealth actually disenfranchise these groups even more? How can these populations learn to use Health 2.0 or other eHealth tools? Won’t these tools be of benefit only for other populations, those who do not have the health literacy problems faced by these disadvantaged populations? Rodgers responded that, for AHCCCS efforts, the strategy is to keep eHealth tools really simple (e.g., point and click on pictures, not words) and to provide an easy set of audio/video instructions for those experi- encing difficulty. To ensure that these tools are effective, one must start at the point of those being served and provide help, whether that is in the library or the physicians’ offices. Even as more and more of the popula- tion becomes comfortable with using eHealth tools, there will still be a group for which using the tools will be a challenge. For these individuals, new strategies will need to be developed. The idea is to try something, evaluate what has been tried, learn from that evaluation about what works and what doesn’t, and have a system that is flexible enough so that necessary changes can be made. One participant observed that the role of individuals is going to be important in the realization of cost savings. Individuals will have to be literate enough to interact with the technology in order to harvest savings. How much of the projected $144 million for Arizona or the $86.6 billion estimate savings will depend upon computer literacy?

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 oveRvieW oF iSSUeS Norman responded that the eHealth system is dependent upon indi- viduals with some type of literacy. The system must be structured in such a way that it meets the needs of those using it, that is, it must be user friendly for those with low health literacy or cultural needs. It cannot just repackage the same old information in a digital format. The design of the system must consider who is using it, how those using the system inter- act with technology, what their needs are generally (such as literacy and cultural needs), as well as what their needs are at a given time. Rodgers said that one of the tools that will be important in the future is an iPod or iPod-like device that enables the user to download informa- tion. With such a tool individuals will not have to use a computer. Rather, they will need to understand how to record and then play back infor- mation. While such a mechanism is less interactive, it will still provide important health information to users. One participant said that the focus in developing eHealth systems should not be just on the package of technological or system tools. Rather, it will be critical to recognize the importance of the skills that individu- als bring to the table and to understand what it is one is asking people to do. With the market driving development, competition is the name of the game: How can one do this a little cheaper, a little better? Medicaid in Arizona is doing it one way—and it seems to be a good way. Other health care organizations are developing different approaches. People using eHealth systems are confronted with 25 different ways of doing one thing. How can they possibly navigate through these options? What is needed is a system that people can navigate, one in which a set of skills can be taught and used throughout health care. While cost may be the driver, the real bottom-line quest is, Do these systems actually improve the health of the population?

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