Readers Write 6/1/09

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The Psychology of Health Information Technology: What’s Missing?
By Mark Hochhauser

I’m a psychologist whose spouse works in a hospital pharmacy implementing an EMR system. My interest is the missing psychological aspect of the current drive towards electronic medicine.

Behavior change theories

Assumptions about the ability of various electronic health systems to change physician and patient behaviors are not based on an understanding of behavior change principles. Information may help change someone’s knowledge, but changing their attitudes and behaviors is much more difficult.

For example, about 20% of US adults still smoke, down from about 50% in 1964 when the first Surgeon General’s report on smoking was published. That represents about a 60% reduction, but it has taken 45 years to get there. Why does anyone assume that information alone will lead to behavior change when that conclusion not supported by the evidence?

One goal is to give physicians and patients information that will lead to behavior changes by both groups (and healthier patient outcomes), but nowhere have I seen any references to the behavior change literature. For example, relevant behavior change theories such as the 1) Health Belief Model, 2) Stages of Change Model, 3) Consumer Information Processing Model, 4) Theory of Planned Behavior and 5) Implementation Intentions Model are absent from the HIT literature. How can behaviors change when HIT programs are not based on any understanding of behavior change theories? What you’re left with are trial-and-error programs.

Limited patient health literacy

Presumably patients will become more active participants if they get more information via electronic patient records. Missing from that assumption are any insights from health literacy research. The 2006 “Health Literacy of America’s Adults” [http://nces.ed.gov] estimated that 14% of adults had “below basic” health literacy, 22% had “basic” health literacy, 53% had “intermediate” health literacy, and 12% had “proficient” health literacy. What level of health literacy is needed to understand health information and complicated health information tasks such as keeping and updating electronic personal health records? Not everyone is as smart as you.

Lack of an evaluation plan

Years ago, when I reviewed prevention proposals for federal agencies, they recommended that 15% of the budget be spent on program evaluation. Although I’ve read extravagant claims for the future benefits of EHRs, I have yet to see a decent program evaluation plan described in the literature. Unless an appropriate plan has been developed with experimental (EHR, CPOE, etc.) and control groups (no EHR, CPOE, etc.) along with relevant definitions and measurements of physician and patient behavior changes before, during, and after implementation, there will be no way to scientifically determine whether these programs work or do not work. Hype is not an evaluation plan.

Conclusion

Getting physicians and patients to change their behaviors is harder than anyone seems to recognize. The absence of key psychological perspectives in the development and implementation of HIT programs means that they will probably not be very effective. Psychologically, current HIT programs represent the triumph of hope over evidence.

Mark Hochhauser, PhD is a readability consultant in Golden Valley, MN.

Since consumers rely on quality and cost information in many other segments of their lives, I believe it is the consumer who will soon begin to drive improvements in quality and price transparency in healthcare. Further, the American Recovery and Reinvestment Act of 2009 will result in the industry’s increased adoption of technologies that are critical to creating the environment of transparency that consumers will demand.

As consumers become more and more involved in their care, they are coming to realize that better information about cost and quality will allow them to make better, more informed choices. Just as they can book hotel rooms anywhere around the world—and find data on cost and quality that is readily available—they will begin to expect the same in healthcare. Providers operating in a competitive environment will be forced to improve the quality and cost of care if they are to compete effectively. In addition, transparency will encourage these consumers to reward high quality/low cost care. Over time, consumers will not tolerate a healthcare system without quality and cost transparency.

Hotels and healthcare

Already, today’s consumers feel that the current state of information is inadequate. They rarely have cost and quality details about healthcare services, and even physicians rarely have comparative information on the quality of their own care or of the care of physicians to whom they refer patients[1].

Quite unlike decisions about a hotel stay, the unique characteristics of healthcare decision-making includes a high degree of risk and value–both perceived and real. Healthcare decisions therefore necessitate that consumers maintain a high level of involvement in the decision-making process. Unfortunately today, most consumers overall could spend considerable time and effort to uncover a minimal level of information to make their final purchase decision. Further, even though they have researched the service, sometimes the end-user experience differs greatly from what they expected, since the healthcare delivery processes includes many touch points. This variance in the consistency of services and involvement of diverse processes in the system raises additional issues of cost and quality transparency.

Opportunities and solutions

Cost and quality transparency would help patients to make informed choices about their care, encourage private insurers and public programs to reward quality and efficiency, and compel providers to improve services by benchmarking their performance against others[2]. To develop and implement a national strategy for health care quality measurement and reporting, for example, the National Quality Forum (NQF), a private not-for-profit membership organization, was incorporated in 1999. NQF is also involved in standardizing health care performance measurement and reporting. Some of the selected projects include cancer care quality measures, mammography standards for consumers, cardiac surgery performance measures and nursing care performance measures. Some effective state-driven transparency efforts[3] in the US include various programs such as the Pennsylvania Health Care Cost Containment Council, California health care reform, Florida Compare Care and the Massachusetts Health Care Quality and Cost Council.

The demand for details and quality in the form of report cards and rating systems for hospitals has also provided business opportunities for private companies. Some of these report card providers are:

• “Consumers’ CHECKBOOK,” which provides “desirability” ratings for hospitals based on surveys of physicians, risk-adjusted mortality figures, and adverse outcome rates for several surgical procedures
• “Leapfrog Group,” which surveys hospitals on about 30 safety practices and then combines them to provide an overall safety score
• “HealthGrades,” which rates hospitals by individual procedures and conditions[4].

These report card providers may differ in the methodology of their rating systems, so it’s become important for consumers to have a broad perspective in order simply to evaluate these ratings.

Key conclusions

Going forward, the cost and quality transparency and standardization of services will act as key purchase drivers and contribute to the success of a healthcare system.

Therefore, if stakeholders in the health sector wish to look forward to assured profits from this industry, they have to execute activities such as in-depth planning, deployment, execution, and monitoring of various parameters which can equip them to deal with customer sensitiveness for quality and cost transparency. What might the role of technology play in this arena?

[1] Collins SR and Davis K. Ibid

[2] Collins SR and Davis K. Transparency in Health Care: The Time Has Come, The Commonwealth Fund.2006 Available at:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=361215. Accessed February 6, 2009

[3] Health care price transparency: A strategic perspective for state government Leaders, Ibid

[4] Hospital report cards: Making the grade. The Harvard Medical School Family health guide Available at: https://www.health.harvard.edu/fhg/reportcards.shtml . Accessed February 6, 2009.

Colin Konschak is a managing partner at Divurgent.

EMRs are more than Electronic Filing Cabinets with Advanced Health IT – Improving Care and Lowering Costs
By Rich Noffsinger

The act of digitizing patient information won’t lower costs or improve care on its own. Improvements cannot be accomplished without aligning patient, provider and payer interests. Health IT contributes to this alignment by integrating critical patient, clinical and insurance data – enabling stakeholders to leverage multiple sources of information at once to personalize care, improve quality and lower costs.

Similar to how the Internet reformed the investing and travel industries by opening up access to information that was once siloed or guarded, health IT will enable a level of information sharing that simply does not exist today – between doctors and patients, laboratory and other health care providers, health care facilities, insurance companies and providers, etc. It will also allow us to apply computing power throughout the health care supply chain.

Once we unleash these kinds of processing capabilities such as modern analytics, we will see rapid advances in closing gaps in care, revealing wasteful spending, the application of evidence-based treatments, and even broadening medical research. However capitalizing on this data and computing power requires a Herculean level of interoperability and participation.

The value is not simply in digitizing health information; rather, the ROI comes from what you can actually do with the data electronically – through advanced tools and IT strategies like clinical decision support, predictive modeling, comprehensive risk stratification and evidence-based medicine.

By ignoring sophisticated health IT tools and technologies, patients, payers and providers miss opportunities to leverage the volumes of medical guidelines, insurance rules, treatment comparisons and best practices – that can improve health care and lower costs.

Rich Noffsinger is CEO of Anvita Health.