AHCPR1

Using the Electronic Age to Improve Health Outcomes

J. Michael Fitzmaurice, Ph.D.

Agency for Health Care Policy and Research

April 28, 1999

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Overview

Much health information is available – Quality is a concern

How do you judge web site quality– Mitretek/HITI -- Others

Issues AHCPR’s Quality Tools Evaluation

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Where do people get health information?

Recent Rondale Press survey of American of all ages– Television--39 percent– Physicians--37 percent– Newspapers--28 percent– Family or friends--24 percent– Magazines--23 percent– Books--23 percent– The Internet came in lower at 13 percent

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How do people use health information?

To make choices in the market– Health plans– Physician– Nursing homes

To assist choices for treatment to improve quality of care and outcomes – Self-care decisions– Physician-patient decisions

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Desirable characteristics

Accessible, with search capability Seniors like large type--preferrably Arial

rather than Times Roman Health topic interest increases with

age--Healthfinder--Mary Jo Deering, HHS/ODPHP

Low readability levels

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Information Quality

“Good and bad information light up just as brightly”--

C. Everett Koop, MD

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Quality of Information

Coulter, et al., in British Medical Journal (Jan. 1999), evaluated patient materials.– Brochures -- Videos -- Phone helplines

One-third of materials evaluated did not have a publication date

Few materials admitted to any scientific uncertainty

Few were specifically designed to inform treatment choice.

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Criteria for Assessing Quality of Internet Health Information

Developed by Mitretek/Health Information Technology Institute--Helga Rippen, MD, Ph.D., MPH, Director

Convened over 20 experts from national organizations

To develop criteria and test them Targets: public, developers, policymakers WWW.MITRETEK.ORG/HITI

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Criteria

Credibility Content Disclosure Links Design Interactivity Caveats

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Credibility

Source– Credentials, Conflict of interest, Bias

Context Currency Relevance/Utility (validity) Editorial Review Process

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Content

Accuracy Hierarchy of evidence Original source stated Disclaimer Omissions noted

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Disclosure

Purpose of the site Profiling of users

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Links

Selection of forward links Architecture of site Content (accurate, current, credible,

relevant) Back linkages: number & quality

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Design

Accessibility Logical organization Internal search engine

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Interactivity

Mechanism for feedback Chat rooms and bulletin boards Tailoring--based on user characteristics

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Caveats

Alerts to users– Sound-alike names– Impressive sounding names– Puffery in claims--”miracles,” “secret cures,” “amazing

results”

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Top Ten Criteria

Straw test as an example: n=28– Source -- Disclosure– Accuracy -- Currency– Original source stated– Hierarchy of evidence– Relevance/Utility -- Disclaimer– Link-content -- Review process

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Other Site Evaluations

Mary Jo Deering and colleagues (Kim, et al. British Medical Journal, 1999)– Looks at published rating criteria for evaluating

the quality of health sites on the Web.– Found consensus of criteria, including

– Disclosure of authors and sponsors– Currency of information

Health Improvement Institute awards good ratings of sites.

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Issues

Privacy, confidentiality, security– Will people get personal health information

(PHI) about me that I do not release?– Will PHI I release, with conditions, not be

redisclosed without my approval?– By what means will disclosure and redisclosure

of PHI be prevented?– State laws– Federal law: Privacy Act, FOIA– International laws: EU Directive

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Issues

Oversight– FDA--Drugs and medical devices

– Clinical software is a device Competent human intervention

– FTC--misleading advertising and business practices

– False and deceptive claims and practices

Liability– Flawed medical advice– System failure

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Issues

Accreditation and Certification– Ability and capability to deliver– Quality and effectiveness of product– Examples:

– JCAHO– NCQA– State licensing boards

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Issues

Role of government– Investment: time, risk, B>C, access– Regulation– Education– Ensure competition

Payment for web health services– Private pricing– Government activity in payment

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Issues

Health system design and incentives– Web-based information may

– Increase the time physicians take to educate patient

– Reduce the patient seen/physician in 8 hours

– Improve healthiness and reduce the demand for future office visits , evidence of improved health system efficiency

– Physicians do not get paid for this extra time today

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Issues

Access for all– Many are disadvantaged--no access to a

computer or the Net.– African Americans, Hispanics,– Low income and rural families

– Universal Access--at any price? Public Health

– Externalities -- Efficiency– Equity

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Strategies

Strengthen EV and Q of Applications Improve Basic Knowledge Strengthen Capacity of Stakeholders

– Clearinghouses -- Collaborations Ensure Equitable Access Source: Wired for Health and Well-Being

– Science Panel on Interactive Communications and Health, April 1999

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AHCPR Snapshot

AHCPR-- a research agency that studies the U.S. health care system– Outcomes research

– Quality of care measurement

– Cost, Access, and Utilization What works to improve patient health

outcomes in the community?– And what does it cost?

Funds peer-reviewed research grants

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AHCPR’s Health Tools

Medical Expenditures Panel Survey– $30 million/year– 10,000 households/24,000 people– Also surveys employers, physicians, hospitals,

LTC facilities CONQUEST--a data base

– 1200+ clinical performance measures– Validity, availability– HEDIS, FACCT, scientific studies

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AHCPR’s Health Tools Consumer Assessment of Health Plans Survey

(CAHPS)– Will be used by 100 million people in 1999– Medicare, Medicaid, NCQA, OPM, Kaiser

National Guidelines Clearinghouse– www.guidelines.gov -- www.ahcpr.gov– AHCPR, AMA, AAHP partnership

Evidence-based Practice Centers– Compile science findings about specific health

conditions and procedures

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AHCPR’s Health Tools

Scientific Research Findings– Published findings

from AHCPR-funded grants

AHCPR staff expertise and collaboration

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What if we connected!

Personal web-based medical record Provider medical record Health plan enrollment and service

utilization record AHCPR tools

– CONQUEST--aggreg. cpms--provider/plan– CAHPS--patient evaluation in MR– NGC--providers guideline variation

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Evaluating Web Effectiveness

Number of hits is not sufficient for improved outcomes

Should make a difference in health outcomes and improving our lives

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Evaluating the Impact

Does improving access via web sites to critical health information lead to a greater number of– Hits? – Information

retrievals?

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Evaluating the Impact

Does a larger number of hits cause a change in – Provider choice of

treatment?– Patient behavior?

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Evaluating the Impact

Does the change in treatment choice and patient behavior lead to – Improved health

status?– Lower costs?– Both?

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Bottom Line

We need to design and provide information with outcomes in mind--

Dr. John Eisenberg AHCPR Administrator

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Bottom Line

Hits are not enough. We need to show their effects on patient and provider satisfaction and behavior change.

Most important, we need to learn their effects on improving peoples’ health and quality of life.

AHCPR38

Using the Electronic Age to Improve Health Outcomes

J. Michael Fitzmaurice, Ph.D.

Agency for Health Care Policy and Research

April 28, 1999