

An Evidence-Based
Approach
Introduction:
Evaluation of IHC
Consumers & IHC
Evaluation
Developers &
IHC Evaluation
Policy Issues Relevant
to IHC
Health Care
Providers, Purchasers & IHC
SciPICH Final
Report

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Health Care Providers and Purchasers and
Evaluation of Interactive Health Communication Applications
Authors: Holly Jimison, Linda Adler, Molly
Joel Coye, Albert Mulley, Jr., and Thomas R. Eng for the Science
Panel on Interactive Communication and Health.
Citation: Health Care Providers and Purchasers and
Evaluation of Interactive Health Communication Applications. American Journal of
Preventive Medicine, January 1999; Vol.16 No.1:16-22
Medical Subject Headings (MeSH): health care
providers, purchasers, computers, health communication, evaluation, computer communication
networks.
[PDF] [References]
Abstract
Health care providers and purchasers of health services
have an opportunity to improve patient care and potentially save costs through the wise
purchase of interactive health communication applications for patients and employees.
Purchasing decisions based on evaluation and evidence should drive the design and
development of new systems. The cycle of evaluation includes a needs assessment before
system development, usability testing during development, and studies of use and outcomes
in natural settings. This type of evidence is critical to our understanding of how best to
provide health information and decision assistance to patients, employees, and others.
Introduction
In recent years there has been increasing interest and
progress in the development, implementation, and research regarding telecommunication and
computer applications designed for consumers to access information on a wide variety of
health care topics. This technology, both hardware and software, is part of a growing
trend toward self-advocacy, empowering consumers to take a more active role in their own
health care and providing the necessary information to enhance their decision making. More
than ever, consumers are using interactive health communication (IHC) applications to
augment the information and support provided by health care professionals in the course of
clinical encounters. Consumers may access databases of health information, educational
tools, and communicate with health care professionals or other patients through e-mail or
online support groups. A variety of IHC applications now exist,[1,2]
with topics on health concerns such as self-care, informed consent,[3]
coping skills,[4,5] and treatment decision-making skills.[4,6]
Health care providers and purchasers have a vested interest
in offering patients and consumers reliable and useful health information.[7]
Providing access to quality consumer health information has the potential to improve the
quality of medical care and lower costs. Interactive health communication technologies are
a promising venue for the effective dissemination of health information, social support,
and skill-building techniques for changing health behaviors or addressing health problems.[8] The challenge for health care providers and purchasers is to identify
systems that are effective and warrant additional investment of resources, time, and an
adaptation of current medical practice. Some IHC applications seem to show clear benefit
for patient care. However, most remain untested, and there is a growing interest about
whether they will provide benefit or result in potential harm. As potential purchasers and
distributors of these systems, it is imperative that physician groups, medical centers,
and health plans make wise and informed selections based on evidence. However, at this
point in time there are few evaluations of commercially available IHC applications. Health
care providers and purchasers need to promote and require meaningful evaluations of these
systems.
From the provider and purchaser point of view, the
importance of supporting the evaluation of IHC applications is based on quality-of-care
and business criteria. Evaluation information can be used to identify more effective
products, and the quality of health care will be improved if patients are using more
effective systems for their health decision-making. Additionally, evaluation feedback on
patients' utilization of health care services and satisfaction provides valuable
information for purchasing decisions based on cost effectiveness and cost savings.
However, there are several barriers to acquiring comparable
evaluation information on IHC applications. Developers are pressed to produce high-quality
applications in an extremely competitive environment with limited resources. The emphasis
is on getting products out the door as quickly as possible, often with fewer features than
originally anticipated and minimal testing. To be competitive, developers cannot afford to
take the time and resources to evaluate a system before bringing it to market. Without
purchaser demand for evidence, there is no incentive for developers to evaluate their
systems. System purchasers must create the demand and promote concern for the quality and
cost of medical care to motivate the evaluation of IHC applications.
Motivation for Evaluating IHC
Applications
There are several practical issues that are important to
health care providers and managed care organizations when considering the purchase or use
of an IHC application. A developer who has integrated evaluation throughout the product
development cycle will be able to provide clear answers to these concerns. Evaluation of a
system is a process that should occur throughout the development cycle. As outlined in the
introduction to this article,[8] it includes a user needs assessment,
a clear definition of the goals and desired outcomes prior to development, pretesting and
quality control of content, iterative usability testing throughout development, the
evaluation of system performance, accuracy, security, pilot testing on potential system
users, and finally, outcome evaluation of actual system use, measuring outcomes of
importance to users and purchasers of the system. Attention to the evaluation process
throughout the product development cycle will prepare developers to respond to the type of
questions a health care provider or organization will have when making a careful purchase.
The "Evaluation Reporting Template for Interactive
Health Communication Applications" proposed by the Science Panel on Interactive
Communication and Health, which appears in a recent article,[7]
attempts to facilitate the disclosure of information about the evaluation methods used by
developers in a standard format. While the proposed template is not intended to function
as a purchasing guide, per se, many of the questions that health plans, large employers,
and other organizations should consider before buying an IHC application, as presented in Table 1
, are addressed by the reporting elements described in the template. Purchasers should
keep in mind, however, that many individuals are typically interested in outcomes related
to improvements in health, service, convenience, social support, and general ease of use,
rather than cost-effectiveness and market share. Therefore, patient satisfaction, system
use, health status outcomes, and health behaviors should also be important criteria for
organizations purchasing these systems.
Table 1 [refer to PDF file, p.18]
Outcome Measures of Interest to
Providers and Purchasers
From the health care provider or purchaser perspective, it
is important that evaluations of IHC applications address outcomes related to
quality-of-care and cost effectiveness. One outcome to consider may be the potential for
market growth with the use of IHC applications. Use of such systems may be likely to
engender client satisfaction and loyalty, as well as encourage new enrollments. Cost
savings may be expected from systems that facilitate disease management, self-care, and
self-triage. However, as with many medical interventions, it is important to measure
whether the desired effect of a system is actually obtained in routine use. The measured
outcomes should be relevant to a medical care organization's decision on whether or not to
purchase and use such a system. Product evaluations of IHC applications must target the
outcomes of interest to the potential purchasers of these systems and address these
outcomes from a meaningful and coherent perspective.
Targeted outcomes related to cost and quality of care from
the purchaser's perspective include: (1) costall expenditures potentially influenced
by the use of the system; and (2) qualityincluding provider satisfaction, patient
satisfaction, knowledge gains, health behaviors, health outcomes, access, process control,
more appropriate utilization of health care services, and concordance between utilization
and expressed preferences (decision quality).
In addition, potential purchasers must consider the
strength of evidence when interpreting an evaluation of a system.[7]
The results should show internal validity (higher with randomized controlled trials, lower
with observational studies), statistical significance (higher with more samples), and
clinical or system significance (sufficiently large effect). Finally, providers and
medical organizations need to consider how applicable the evidence from an evaluation is
to their own organization. To determine whether findings are generalizable to a different
organization and situation, one should consider the characteristics of the patient
population (demographics) and the characteristics of providers (culture, incentives,
willingness to change or adapt).
When is it Worth Collaborating with
Developers in an Evaluation?
There are many ways that health care providers and
purchasers, as potential purchasers of IHC applications, can promote and participate in
evaluations that will produce relevant information for purchasing decisions. The most
basic way is for the purchaser to demand that the systems under consideration be (or have
been) evaluated. However, the purchaser must understand the added value of evaluation
information and be willing to pay a higher price.
Similarly, for systems that have not yet been evaluated in
their type of organization, a purchaser should consider funding in-house evaluations, on
systems under consideration and those that may be currently in use. It may also be in the
interest of providers and purchasers to collaborate with developers in evaluating new
systems. This may be of particular value to an organization in unusual clinical settings.
The benefits to the purchaser in collaborating with a developer on evaluation include:
- Being perceived as a leader in the field with a new product,
- Reduced system costs (in return for participating in the
evaluation),
- Opportunity to influence the experimental design to obtain
outcomes of interest, and
- Ability to measure effects in the actual population of
interest.
The collaboration can be worthwhile for both parties
because the risks and rewards of the innovation are shared.
How to Judge the Design of an IHC
Application
Providers and purchasers should have some familiarity of
the underlying scientific basis for the methods commonly used by IHC applications to
effect behavior change or improve decision-making. Having this knowledge is especially
important with regards to IHC applications because, in some cases, "showy"
technology may distract and even obscure consideration of the content or methodologies
used in application design. In this section, we briefly review the concepts of empowerment
and self-efficacy, individual preferences, use of the computer as a health information
medium, and influence of individual characteristics on usability of IHC applications.
Potential purchasers of these products need to consider
whether accepted principles have been applied to the product in question. From previous
research, we know that access to health information can enable patients to be more active
participants in their care and lead to better medical outcomes.[9-12]
Patients report that they want to be informed about their medical condition,[13,14] and the process of sharing information enhances the
doctor-patient relationship.
Empowerment and Self-Efficacy
Involvement in one's own medical care also involves the
closely linked concepts of patient empowerment and self-efficacy. In general, empowerment
can be thought of as the process that enables people to exert control over their lives and
their destiny.[15,16] It is closely related to health outcomes in
that powerlessness has been shown to be a broad-based risk factor for disease. Studies
demonstrate that people who feel "in control" in a health situation have better
outcomes than those who feel "powerless."[17,18]
Similarly, self-efficacy is a person's level of confidence
that they can perform a specific task or health behavior in the future.[19-21]
Clinical studies show that self-efficacy can be most predictive of improvements in
patients' functional status.[22,23] Perceived self-efficacy was shown
to play a significant role in smoking cessation relapse rate, pain management, control of
eating and weight, success of recovery from myocardial infarction, and adherence to
preventive health programs.[24-28]
An important measure of success for many IHC applications
is how well they promote empowerment and self-efficacy for patients. Empowerment can be
enhanced, for instance, by online support groups that allow patients to feel
"connected" to others with a similar medical problem. This has been demonstrated
in women with breast cancer and patients with AIDS.[4,5,29]
Individual Preferences
The concept of individual preferences is important for IHC
applications that focus on health decision-making.[30] While patients
need information about the quality of life associated with the medical outcomes of
possible decisions, reliable assessment of individual preferences and risk attitudes for
clinical outcomes are probably the weakest links in clinical decision-making. Recent
efforts to explore the use of computers in communication about health outcomes and in
assessing patients' preferences for various health outcomes have started to address these
issues.[31-33] Information on patient preferences is important for
tailoring information to patients and for providing decision support.[34]
Tailored information has been found to be more effective in providing consumer information[35-38] and is preferred by patients.[39] In
addition to differences in preferences for health outcomes, patients differ in the degree
to which they choose to be involved in decision-making. Research confirms that age
(younger), gender (females more than males), and education level (better educated) are
strong predictors of the desire to be involved in medical decisions. There is also a
greater desire to be involved in medical decisions that appear to require less medical
expertise, such as knee injury as opposed to medical decisions for cancer.[40]
The Computer as a Health Information Medium
There has been an increase in research devoted to testing
the effectiveness of various formats and types of media for conveying health information
to consumers.[41-44] These studies generally show that video and
slides are educationally more effective than books and audiotapes. Computer-based
approaches offer interactivity, provide feedback in the learning process, and can tailor
information to the individual, but more research is needed on the effectiveness of
computer-based approaches. Developers will need to be sensitive to human-computer
interface issues and implement specifications that meet the needs of a wide variety of
users.
Influence of Individual Characteristics on Usability
Factors that influence the health-information-seeking
behavior of people include age, gender, disability, race and ethnicity, and socioeconomic
status.[45] Research indicates that these variables can predict
differences in the amount and type of health-related information that individuals want.
While some do not seek much information, others encounter serious barriers to the use of
IHC applications.[46]
A lack of reading ability is a functional barrier affecting
use of these systems. Numerous studies on literacy and readability confirm the widespread
problem of low literacy skills.[47-49] Approximately 1 out of 5
Americans is functionally illiterate, reading at or below the fifth-grade level. Studies
show that only one half of people examined are able to comprehend written health education
materials and that people's reading levels were well below what is required to understand
standard health brochures.[47,50-52] In developing health
information, one cannot assume that a person who has completed a certain grade level can
read at that level. Health materials should be written at least three grade levels lower
than the average educational level of the target population.[53] Text
characteristics and organization and clarity also play important roles in comprehension
and retention of material.[48] Multimedia techniques can be used to
facilitate comprehension by conveying information through video, audio, and graphics, in
lieu of text. Additionally, computer approaches that represent material in multiple
languages allow efficient tailoring to the user's language of choice, thereby increasing
comprehension. Developers should also consider cultural issues associated with
health-information-seeking behavior and willingness to use health information technology
when designing IHC applications.
Issues Related to Access
As the demand for more health information and decision
support grows, the need for wider availability of these systems becomes even more
important. Today, these systems can be found in a variety of settings and forms. The most
common locations to access these systems are physician waiting rooms, hospitals, health
resource libraries, public libraries, worksites, schools, community centers, and of course
on personal home computers. Different systems may require quite different physical
locations. For instance, many people are uncomfortable exploring sensitive health
information in a public space.
Finally, the question of who will pay for the access and
use of technologies for consumer health information is still unresolved. Educational and
socioeconomic factors still determine access to computers and information technologies.
Younger, more affluent, and well-educated patients are more likely to have access to home
computers, diagnostic software, and the Internet than disadvantaged populations. Special
effort is required to ensure universal access to health information and support.[46] Overcoming these barriers will go a long way toward ensuring access
for the people who have the greatest need for these resources.
Elements of a Good Evaluation
Ideally, evaluation should be designed at the conception of
a system. Consumer needs and the desired effects of a system should be clearly specified
prior to system implementation, so purchasers should ask to see this information. These
desired effects should help define the outcomes of interest and evaluation design to
carefully measure those outcomes. As presented elsewhere, initial stages of evaluation
include specifying a problem or need of a particular target audience through needs
assessment.[8] The results of this analysis are used to define the
specifications for a product to address those needs.
Evaluations during product development include iterative
usability testing to ensure that the product meets the needs of potential users with
regard to usability and the facilitation of workflow or tasks. Component testing ensures
that all aspects of the system perform accurately and meet design specifications. The
final stage of evaluation is to actually measure outcomes during system use. However, a
preliminary first step usually involves a pilot evaluation to work out the implementation
details of the evaluation and assessment tools. Quite often there are obvious
misunderstandings of terms or unanticipated barriers that can be corrected before
beginning the larger, more complete study. A more detailed description of evaluation
methods and additional references can be found in Rossi and Freeman's book on evaluation.[54]
Role of Evaluation in Driving
Quality of Care
Developers of commercial systems have pushed the field of
interactive health communication forward with many innovative systems. However, to achieve
significant improvements in quality-of-care and health outcomes, we need to acquire
evidence on the effectiveness of these systems. Additionally, researchers and system
developers must focus on integrating the knowledge gained from these evaluations into the
design of new systems. This is a new and emerging field with significant innovations in
the commercial sector. Research in several areas is needed to move the field forward in
providing real benefits to individual's health outcomes and in showing the effectiveness
of the systems to purchasers of health care. Careful needs assessment before system
development, usability testing during development, controlled clinical trials, and studies
of use and outcomes in natural settings are all critical to our understanding of how best
to provide health information and decision assistance to patients.
Advances in communications and information technology will
change the way in which medicine is practiced, and it will also change the way in which
patients receive information and interact with the health care system.[7]
The future holds great promise for consumers becoming empowered and active participants in
their medical care decisions. Because the vast majority of health-related decisions are
made by the people outside of the formal medical setting,[55] the
input of health care providers and purchasers into the IHC application development and
evaluation processes is critical.
Acknowledgements
Panel members and staff: Farrokh Alemi, PhD,
Cleveland State University, Cleveland, OH; David Ansley, Consumer Reports, Yonkers, NY;
Patricia Flatley Brennan, RN, PhD, FAAN, University of Wisconsin-Madison, Madison, WI;
Mary Jo Deering, PhD, Office of Disease Prevention and Health Promotion, U.S. Department
of Health and Human Services, Washington, DC; David Gustafson, University of Wisconsin,
Madison, WI; Joseph Henderson, MD, Dartmouth Medical School, Dartmouth, NH; John Noell,
PhD, Oregon Center for Applied Science and Oregon Research Institute, Eugene, OR; Kevin
Patrick, MD, San Diego State University and University of California San Diego, San Diego,
CA; Thomas Reeves, University of Georgia, Athens, GA; Thomas N. Robinson, MD, MPH,
Stanford University School of Medicine, Palo Alto, CA; and Victor Strecher, PhD, MPH,
University of Michigan Comprehensive Cancer Center, Ann Arbor, MI.
The authors are grateful to Paul Kim; Andy Maxfield, PhD;
Anne Restino, MA; and John Studach, MA, for their contributions to the panel's work, and
to Linda Friedman for assistance with copyediting. In addition, the authors thank the
liaisons to the Science Panel on Interactive Communication and Health, especially the
following persons who offered valuable suggestions for improving this manuscript: Loren
Buhle, PhD; David Cochran, MD; Connie Dresser, RDPH, LN; Alex Jadad, MD; Craig Locatis,
PhD; Ed Madara; Georgia Moore; Kent Murphy, MD; Scott Ratzan, MD, MPA, MA; Helga Rippen,
MD, PhD; and Christobel Selecky.
Address correspondence to: Thomas R. Eng, Office of
Disease Prevention and Health Promotion, HHS, 200 Independence Avenue, SW, Room 738G,
Washington, DC 20201.
Address reprint requests to: Mary Jo Deering, PhD,
Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human
Services, 200 Independence Avenue, SW, Room 738G, Washington, DC 20201.
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