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Because information on health care quality is often complex, many consumers need help in interpreting the data. They may also need some guidance to combine this information with the other important information (on costs, benefits, provider availability, etc.) they factor into decisions. This can be especially difficult for people who are not comfortable basing decisions on the printed word, let alone electronic information.
This section discusses how you may be able to assist consumers in understanding and using the information you've developed. Select links below to learn about:
Efforts to provide decision support may have any or all of the following objectives:
- Help people understand the nature of their choices (if any), what
factors they need to consider, and the decision they have to make.
Decision support can help people identify and manage their priorities.
Confronted with multiple dimensions, people often focus on just a few, easily
understandable issues, potentially ignoring things they really do care about. By
tracking the information for them, a tool can allow them to consider more
factors than they normally could.
- Help people make tradeoffs.
Decision-support tools can help consumers identify their own interests, needs, and values relative to their decision. By assigning weights to the factors that are most important to a consumer, the tool allows the user to make explicit tradeoffs. For example, the consumer may indicate that the location of a health plan's doctors and clinics is more important than a health plan's score in the area of chronic care, which is more important than the availability of specific providers.
- Help people reduce the information processing burden, possibly by eliminating options.
Decision support can help to structure and simplify the information for users. For example, one approach is to guide consumers through a series of steps and decisions so that they can rule out some of their options. This allows them to focus on a more limited amount of information that is easier to process.
- Help people choose an appropriate strategy for making a decision.
For example, some consumers may be best served by figuring out what they can afford, then picking the organization that offers the best quality for that price range. Others may want to first identify the organizations with the best quality, then pick the one they can afford.
In the context of a health plan performance report, decision support can be directive or non-directive.
Directive support explicitly points people to the choices that seem to be best for them. An example would be a worksheet that uses a consumer's responses to a set of questions to create a ranking of the top three "best" choices for that person. A more sophisticated way to do this is through a computerized tool.
The benefit of a directive approach is that it tells people what to do with the information they have and guides them to a practical conclusion. However, while this has a lot of value, there are several problems with this strategy:
- One major downside is that people may be overwhelmed or annoyed by the detailed questions and, if
they are filling out a worksheet on paper rather than on a computer, by the need to follow specific directions and keep track of every response. They may also be turned off by the time and effort required to find all the information, especially if they have to make a lot of phone calls or consult other documents. Their perception of the
tool—e.g., that it feels like
"homework"—may keep them from using it no matter how well-designed it is.
- Another concern, especially among health plans and
providers, is that a directive approach may imply that there is only one right answer for a consumer. Because they represent only one approach to making a decision, directive tools must strike a balance between being helpful and identifying a single choice of plan (or provider).
- Finally, these tools may ask people to make distinctions that are difficult or not meaningful for them. For instance, a tool may ask consumers to rate the importance of factors on a scale. In many cases, consumers rate everything as equally important, demonstrating an inability (or reluctance) to make tradeoffs.
Unlike the directive approach, non-directive support simply helps consumers identify the issues they need to consider. This approach assumes that people want to find and consider the answers to questions on their own. A typical example of this would be a page that presents a set of questions or issues for the reader to consider.
 Thinking
About Joining A Medicare HMO? (PDF file, 349 KB; HTML) lays out the issues as a series of steps and offers a worksheet for beneficiaries and their counselors to organize their answers.
© Copyright 2000. Baruch College School of Public Affairs. All Rights Reserved. Used with Permission.
In evaluating this approach with Medicare beneficiaries in Kansas, researchers working with the Research Triangle Institute found that people responded positively to this kind of support tool and understood it. People perceived the list of questions as helpful suggestions for organizing their thoughts and an invitation to look for answers; unlike a worksheet, a set of open-ended questions does not place a demand on people to do anything they may not be comfortable with. This approach also opened their eyes to considerations they may not have thought of on their own.
However, a non-directive approach does not guide users through the process of using their responses to reach a decision. Once they have answered the questions, they are on their own to determine what to do with the information they have. So far, it is not clear whether consumers are able to use this kind of tool to help make better choices.
Strategies for Providing Support
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While there is a growing consensus regarding the need for decision support, the development of these tools is very much in the early stages. Several sponsors have been experimenting with different approaches, but little is known about how useful these strategies really are to consumers. This section discusses three options you may want to
consider:
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Some Tips for Providing Effective Support
Break down tasks into manageable sections. It's not enough to consider the reading ability of your audience. You have to consider the cognitive capacity that people will bring to this task. How many factors are you telling them to weigh at the same time?
Validate your audience's concerns. Present considerations or questions in an order that will resonate with them. If you emphasize issues that are low on the list of your audience's priorities, they will perceive that you do not understand their concerns. For example, if cost is a significant factor for
the audience, don't do them a disservice by placing it last on the list, implying that cost is not really an important issue.
Recognize that the way you ask for information can influence the response you get. In controlled tests with consumers, researchers found that the method used to elicit preferences from consumers can determine their response. For example, consumers asked to rank a list of factors in order of importance may provide different information if asked to list important factors on their own with no prompting. Another pertinent finding is that people may change their preferences as they get new information. This can complicate the design of a tool intended to collect and use information about people's values and preferences with respect to health care.
For further reading on this subject, refer to the following article:
Booske BC, Sainfort F, Schoofs Hundt, A.
Eliciting Consumer Preferences for Health Plans. Health
Services Research 1999 Oct;34:4.
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Offer Worksheets and Checklists
To date, the most common strategy is to provide consumers with a worksheet or checklist of some kind as part of the performance report. Although worksheets may be too complex for some audiences, they are often useful for coaches and others in an assisting role, since they provide a tool for collecting pertinent data in one place.
Thinking about Joining a Medicare HMO? (PDF file, 501 KB; HTML)
© Copyright 2000. Baruch College School of Public Affairs. All Rights Reserved. Used with Permission.
Medicare: Worksheet for Comparing Medicare Health Plans (PDF file, 574 KB)
Comparing the Quality of Maryland HMO's: A Guide for State Employees 1998 (PDF file, 1 MB; HTML)
© Copyright 1998. Maryland Health Care Commission. All Rights Reserved. Used with Permission.
Comparing
the Quality of Maryland HMO's 2000: Interactive Version (PDF file, 461 KB; HTML)
© Copyright 2000. Maryland Health Care Commission. All Rights Reserved. Used with Permission.
Comparing Texas HMOs 1998 (PDF file, 19 KB; HTML).
For a more recent version, go to the Web site of the Office of Public Insurance Counsel at http://www.opic.state.tx.us/counties2001.html.
© Copyright 1998. Texas Office of Public Insurance Council. All Rights Reserved. Used with Permission.
A computerized tool is essentially a worksheet, but with greater capabilities. Programming can enable the tool to:
- Keep track of more information.
- Give the users access to as little or as much information as they want.
- Interact with the user (e.g., by eliciting information about preferences and interests).
- Format information in a way that is consistent with the user's preferences (e.g., the user may prefer a table of numbers to a bar chart, or vice versa).
- Weight factors to reflect the users' values.
- Hide irrelevant information.
- Help users focus on whatever they indicate is most important to them.
A well-designed program can even provide active support by processing a consumer's responses to questions designed to capture values and needs and helping the person determine which options are most suitable. And a Web-based tool can allow the user to link to other pertinent information (such as comparisons of coverage or lists of the providers associated with each plan).
RAND developed and tested
The Decision
Helper to help people use CAHPS® results. In
a version designed for a commercial audience, the system offered information on types of plans, benefits and coverage, costs, providers and facilities, and CAHPS® results. A summary table keeps track of those survey topics in which a plan performed well. Text on the site then suggests things for the user to think about to make a decision.
While some sponsors merely replicate their paper-based worksheets, possibly with a few enhancements, others are starting to take advantage of a computer's capabilities. The challenge is to offer this kind of sophistication without making the system so complicated that it becomes a "black box" to the user. The problem is that consumers may not be willing to use a tool (or its results) if they cannot see how the computer reached its conclusions. In particular, consumers may worry that the tool has implicit biases, perhaps towards managed care options. This perception is especially likely with commercial Web-based products that could carry advertising or links to health plan sites.
Some Guidance for Using the Web
What's true for print documents—that people do not read them word for
word—is even more true for computerized documents. One problem is that, in contrast to paper, a screen has less space for text. Also, because of the poor resolution of computer screens and the need to scroll, big blocks of text can be very hard to read. Here are some things to remember when you design a Web-based tool:
- Limit the amount of text you use.
- Write the text to be appropriate for the Web; don't simply repeat a printed document. If you cannot rewrite the text, at least look for ways to "chunk" it differently. For example, you may be able to provide the same information as a set of bullets, or add headers that will allow people to skim.
- Test to make sure people are picking up the information you want them to see (e.g., headers in a table, a link to a drill-down option).
- Avoid putting important information at the bottom of a screen, because many people will not scroll.
- Keep the formatting straightforward. Remember that the look of a page is affected by the user's browser, so it is not necessarily under your control.
- Keep the organization scheme clear and simple. Offer simple navigation tools and make links available where people would expect to see them and in ways that they can't miss.
- Don't provide too many options or decisions (e.g., ways to see the information, ways to navigate). The risk of information overload is tremendous.
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Many Americans do not like to make decisions based on what they see in writing from someone they don't know; rather, they want recommendations from someone they know and trust. Surveys sponsored by the Kaiser Family Foundation and the U.S. Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research, or
AHCPR) in 1996 and 2000 found that consumers were most likely to rely on the advice of their doctors, friends, and family when choosing health plans.
For specifics, select Some Results from the 2000 National Survey.
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Other surveys have also found a reliance on and confidence in information provided by personal providers, family, friends and neighbors, and leaders of faith-based organizations and community groups.
Thus, for many consumers, one of the most critical resources you can provide is access to someone who can answer their questions, address their concerns, and help them apply information on health care quality to their personal situations, whether face-to-face or over the telephone. In addition to providing a more personal interpretation, this "information intermediary" can reinforce and supplement the information your audience has.
The best coaches tend to be the organizations and people that your audience already knows and trusts, such as faith-based organizations, caregivers, family advisors, benefits specialists, and advocates for consumer segments (such as the staff of senior centers). Ideally, these intermediaries should be available wherever the materials are distributed, but this is not always feasible (for example, you probably can't offer support at a public library). Peer-to-peer support is also useful. As illustrated by the success of Internet bulletin boards, people appreciate the advice and support they can get from each other. Also, the information on quality may seem more relevant when consumers can hear about each other's problems and experiences.
Select for
information about the State
Health Insurance Assistance Program (SHIP).
If you go into the community to find sources of decision support, make sure they are equipped with the resources they will need to do the job. If they aren't associated with health care organizations, many
intermediaries, especially volunteers, may be no more familiar with health care and quality issues than the people they serve. It's critical to help them understand the meaning and value of the data and feel positive about how they can use the information to help their constituents.
- Train them how to talk about the issue of quality, interpret the data, and guide consumers through the decision-making process.
- Provide them with scripts or talking points that focus on common issues, as well as consumer-oriented brochures and other documents they can pass on to their "clients."
- Teach them to recognize the "trigger events" that can help them identify people who may want to reconsider their choice of health plan.
- Make sure they know where to get information on related questions and concerns that consumers may raise, such as procedures for filing grievances, benefits information, and coverage issues.
- Recognize that community organizations tend to have other priorities and scarce resources. Particularly in poor communities, you may not be able to rely on volunteers to do the work, so consider ways of compensating people for providing support.
Select to learn about a program for Training Information Intermediaries in New York.
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