As consumers are encouraged to take a more active role in their health care, technology is playing a major role in helping them do so. This is of course a positive trend; the problem is that, for a variety of reasons – rooted in systemic flaws in health care, not a lack of interest or effort – providers aren’t always making this easy.
For example, let’s say you’re bothered by some nagging (not urgent) symptoms that you suspect could be related to a certain condition. You probably get on the Internet and wade around medical websites looking for relevant data. Maybe you find something interesting, so you bring it to your physician – if and when you get an appointment. You may or may not find a receptive ear, but there’s a good chance nothing will come of your research.
Almost 20 years ago, John Wasson, MD, a practicing physician, researcher and professor at Dartmouth Medical School and IHI faculty member, acknowledged this growing rift. “We realized that physicians and their patients just weren’t on the same page,” he says. “They weren’t communicating, weren’t interacting with each other effectively.” And as technology advanced, sparking interest among patients for more medical information, physicians had ever-smaller slots of time to offer. The situation, as Wasson and his colleagues observed, threatened to diminish the quality of care their profession could provide.
Envisioning a very different scenario, Wasson started making it real. He began designing and testing a simple survey patients could take that would help them take better care of themselves while at the same time engage patients and physicians in a closer working relationship. Over the years, Wasson and his team at Dartmouth refined the survey based on new technology, developments in health management, and feedback from users in controlled trials. He published results in the Journal of the American Medical Association (JAMA) and other peer-reviewed journals, gaining increasing support for the approach.
Today, the survey has evolved into a robust web-based resource, www.howsyourhealth.org, used by thousands of patients and consumers on their own and through programs sponsored by employers, health care systems and physician groups. It is also the foundation of innovative city- and state-wide health improvement campaigns launched by unusual coalitions – including corporations, state agencies, civic groups, labor unions – in urban and rural communities across the US.
Got 10 minutes? Get a Snapshot of Your Health
The survey, which takes about ten minutes to complete, is a simple series of multiple-choice questions about your overall health, any symptoms bothering you, your medications, diet, tests you may have taken, emotional issues, and health behaviors such as smoking and drinking. How’s Your Health also tries to assess your awareness of health risks and suggested preventive measures. And the survey asks about your experiences with the health care system: how well and how often you connect with your physician, whether you feel he or she is aware of the things bothering you, explains things clearly and gives you enough useful information about your problems.
A key feature of How’s Your Health is that it’s free, with no commercial ties, no advertising, pop-ups or sales gimmicks of any kind. It’s also anonymous unless an individual chooses to share the information with his or her provider. This independence, explains founder John Wasson, is possible with funding from the Commonwealth Fund, the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality and other organizations. And it’s central to the tool’s mission.
When you finish the How’s Your Health questionnaire, you get results right away: a one-page summary of your health, including a brief assessment of relevant clinical issues, that you are encouraged to print and take to your doctor, as well as links to websites specifically related to your health needs. If it’s appropriate given your profile, you’ll also get a Condition Management Form with suggested self-care steps, symptoms to be aware of related to your condition, and guidance in tracking, say, your blood pressure, cholesterol or weight.
Opening the Conversation
On the most basic level, completing the survey can be educational for anyone taking the time to do so. Sharing the survey results with one’s physician can expand the benefits significantly, laying the groundwork for effective communication. For example, Gordon Moore, MD, a family physician in Rochester, NY and clinical assistant professor at the University of Rochester Medical School, uses How’s Your Health to improve his interactions with patients and make sure his practice is meeting their needs.
Moore says he encourages patients with Internet access to take the How’s Your Health survey, even if they choose to do so anonymously. He adds: “For those who feel comfortable putting in their name – and the majority do – it’s a tool that gives me a very simple means of assessing my patients’ needs.”
As he describes: “We go over the results together, literally shoulder-to-shoulder, either at the computer or with the printed summary, and look to see if there are any gaps. I tell them I want to make sure nothing falls through the cracks.” So, adds Moore, “If I see, for example, that they’ve checked off ‘lacks social support,’ I ask them to tell me more about that. Then I can begin to help them work on whatever is lacking.” In other words, Moore says, “It opens the conversation.”
On a broader scale, Moore uses the aggregate data from his patients’ How’s Your Health input to improve his practice. The effects can be substantial. For example, he explains: “From the surveys, I realized that I could segment my population into two groups: those who rated their care as perfect and those who didn’t.”
Moore says when he looked more closely at these two groups, the main difference was that those less satisfied were more likely to have chronic diseases and didn’t feel confident in managing their condition. Based on this data, he says, “I hired a nurse to work with me on chronic disease management – to put in place more supports for this group. I also started offering group visits for patients with chronic conditions, which the literature shows can be a very valuable resource.”
Moore sees the potential for helping patients with self-management as a particularly strong benefit of How’s Your Health: “It’s a terrific vehicle for confidence-building; for helping patients track chronic disease and know what to do about it.”
How’s Your Health creator, John Wasson, echoes Moore’s view. He notes that the tool mirrors the principles behind the established Chronic Care Model. Wasson explains: “At the heart of the model is an informed, engaged patient who feels confident about self-management and is supported by a prepared practice team. How’s Your Health is right in line with that.”
Health Enhancement at the Population Level
In addition to the physician office level, Wasson describes a tier of applications for How’s Your Health at the population level. He says the tool is used by a growing number of health systems, including employer groups, cities and towns, even the Army. Depending on the age and overall health of the population involved, he explains, organizations modify their use of the survey. “For a relatively young, healthy population,” he says, “we’ll encourage them to send people to the ‘problem solving’ module in the survey that’s helpful for anyone trying to make changes in their life.”
He adds: “Some companies pluck out trends from the aggregate data and highlight them in an internal newsletter that the system can produce for you automatically. So they’ll say ‘Here’s how we’re all doing, here are some areas many people would like to improve…’” The company may decide to start programs reflecting common needs, such as smoking cessation or weight loss classes.
In one ambitious initiative, the state of New Jersey has recently launched How’s Your Health, NJ?, a state-wide public awareness and health improvement campaign based on the survey. According to Dave Knowlton, President and CEO of the lead organization, the New Jersey Health Care Quality Institute (NJHCQI), the impetus for the project was New Jersey’s poor ranking in a comparative assessment of states’ performance in basic care measures provided to Medicare beneficiaries, coming out of the US Department of Health and Human Services in the late-1990s.
Knowlton says: “New Jersey came in near the bottom, which really motivated us to focus on quality improvement.” His group learned of How’s Your Health, says Knowlton, and sought out John Wasson to design a version of the survey customized to target weaknesses cited in the state rankings.
In addition, Knowlton, a former deputy commissioner of Health for New Jersey and current board member of the Leapfrog Group, forged alliances with varied business, government and community organizations to build support for the campaign, with funding from the Robert Wood Johnson Foundation and the Commonwealth Fund.
The resulting public-private partnership behind How’s Your Health, NJ, is unusually broad. The New Jersey Health Benefits Program, which insures some 358,000 municipal workers and retirees and their families, embraced the tool as part of an online wellness initiative. The state’s Healthcare Payers Coalition, an alliance of business, labor and trade association benefit plans, also joined the campaign, motivated by skyrocketing health costs and related employee productivity issues.
“Partnering organizations behind ‘How’s Your Health, NJ?’ at kick-off. From L: Therese Pasqualioni of Tropicana Casino & Resort in Atlantic City, Joan Verplanck of the NJ State Chamber of Commerce, Dave Knowlton of the NJ Health Care Quality Institute, John Wasson, MD, IHI faculty member, Dartmouth Medical School professor and creator of How's Your Health.org, Len Leto of the NJ State Health Benefits Program, and Suzanne Mercure, a consultant to the National Business Coalition on Health.”
The New Jersey Chamber of Commerce and its member organizations also committed to the program. In one creative venture, Tropicana Casino and Resort in Atlantic City is developing a program to encourage seniors who visit the casino to register for How’s Your Health, NJ.
Dubbed “Don’t Gamble with Your Health,” the program is a win-win opportunity, according to Dave Knowlton: “Seniors account for a great deal of the Casino’s business, so we thought, why don’t we partner together to reach out to seniors to help them deal with health issues that prevent them from enjoying themselves.”
Tropicana hopes to enroll 5,000 seniors to take the survey during its promotion, using incentives – a handful of chips or a salad at the buffet, for example. A computer terminal will be set up in the casino, with an on-site health educator to help seniors interpret their results.
Maximizing the Potential: Integration with Physician Systems
Getting employers and the business community to help reinforce the health quality mission and motivate consumers to use How’s Your Health, NJ, is an important first phase, explains Knowlton. The next step, he says, and perhaps the most crucial, is to involve physicians.
Knowlton says that the opportunity to link How’s Your Health data directly with providers in the state was what sold his group on the tool. Wasson’s Dartmouth team designed the program to complement and integrate with technology already used by physician practices, including electronic medical records and patient registries. (It will also create a transportable health record for the patient — a seemingly radical idea, but one passionately advocated by Wasson and leading quality champions.) Knowlton says he is reaching out to “activate the medical community to implement and endorse How’s Your Health, NJ” on several fronts. Representatives from the New Jersey Medical Society and the New Jersey Council of Teaching Hospitals sit on the New Jersey Health Quality Institute’s Leadership Council. His group also has ties to the New Jersey Society of OB-GYNs and other specialty groups.
John Wasson agrees that getting providers on board is the ultimate goal: helping them incorporate the tool in their existing systems once they understand the benefits it can bring, with minimal cost and staff time. He says: “Physicians of course want to offer ‘patient-centered care,’ but convincing them to add something new when they’re already swamped, that’s a hurdle.” He says those that have signed on learn pretty quickly what the research shows: “That if you can help the provider and patient have a good interaction — bring them onto the same page — you’ll start to see the impact on outcomes.”
