1. Advancing Health Literacy Ruth M. Parker, M.D. Professor of Medicine, Pediatrics and Public Health; Emory University

2. Health Literacy ….“the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Parker/Ratzan NLM Complete Bibliographies of Medicine, 2000 Healthy People 2010

3. Health Literacy Framework

4. Most people cannot understand health information they need It’s hard to be a patient these days and it’s easy to mess up An issue of quality—essential for self-management, reducing disparities and reducing costs HEALTH LITERACY CHALLENGES

5. Meet Dave.  Husband  Father (2 children)  Employed full time  Commute = 45 min.  Occasional travel  Type 2 diabetes  Hypertension  High Cholesterol  Two prescribers  5 Rx medications daily  Quarterly MD visits  Overweight (BMI = 27)  Variable diet  Variable activity  Frequently misses meds

6. Meet Dave.  Husband  Father (2 children)  Employed full time  Commute = 45 min.  Occasional travel  Type 2 diabetes  Hypertension  High Cholesterol  Two prescribers  5 Rx medications daily  Quarterly MD visits  Overweight (BMI = 27)  Variable diet  Variable activity  Frequently misses meds  Inconsistently controlled.  No plan for improvement.  Not activated, not empowered. -Inadequate knowledge -Inadequate skills = Overwhelmed

7. A $200 Billion Problem The business case for health literacy  Inadequate/inaccurate knowledge of disease, treatment  Poorer self-care skills (medication use, monitoring, device use)  Inappropriate health services use Translates to:  Non-adherence  Costly urgent services (Unscheduled visits, ED, Hospitalizations)  Medication Errors & Adverse Events  Poorer outcomes (HTN, Diabetes, CHF, Asthma/COPD) HL

8. From the ETS report America’s Perfect Storm: Three Forces Changing Our Nation’s Future written by Irwin Kirsch, Henry Braun, Kentaro Yamamoto and Andrew Sum. The full report is available from ETS at www.ets.org/stormreport.www.ets.org/stormreport The Forecast for 2030

9. Health Literacy Framework (Parker) Skills/Ability Demands/Complexity

10. A social determinant of health…and more Essential for reducing costs, improving quality and decreasing disparities Framework for interventions reflects alignment →intervene at system/org. level-examples →What is a “health literate” organization?

11. Closer look…at medication labels Skills/Ability Demands/Complexity

12. A Current, Broken “System” of Patient R x Information Rx Labeling

13. Medication Labels—At the Intersection of Health Literacy and Patient Safety

14. Michael Wolf 04/29/71 Glyburide 5mg Take for Diabetes Take: 2 pills in the morning 2 pills in the evening Noon 11-1 PM Evening 4-6 PM Bedtime 9-11 PM 22 Morning 7-9 AM Do not drink alcoholic beverages while taking this medicine Carry or wear medical identification stating you are taking this medicine You should avoid prolonged or excessive exposure to direct and/or artificial sunlight while taking this medicine Rx #: 1234567 9/8/2009 You have 11 refills 180 pills Discard after 9/8/2010 Provider: RUTH PARKER, MD Emory Medical Center (414) 123-4567 Pharmacy: NoVA ScriptsCentral 11445 Sunset Blvd. Reston, VA (713) 123-4567 NDC # 1234567 Reprogramming the R x Label.

15. Davis et al J Gen Intern Med, 2010; Wolf et al Arch Intern Med 2011; Med Care 2011; Bailey J Gen Intern Med 2012 UMS LabelStandard Label Understanding2.1 (1.1-3.9) 74% --- 59% Adherence (3 months) 1.9 (1.3-2.6) 49% --- 30% Figure 5.

16. William H. Shrank, MD, MSHS, Nov. 2006 What Constitutes the Label? 1) Container Label 2) Consumer Medication Information (CMI) 3) Package Insert 4) Medication Guide

17. A Prescription for Confusion. Mother Master’s degree health educator Father General internist Daughter 6 years old with diagnosis of H1N1 influenza (‘swine flu’)

19. ¾ teaspoon dose: 5 ml (volume of teaspoon) x.75 x 12 mg per ml Tamiflu suspension = 45 mg on syringe September 22, 2009

20. Lessons from the field Patients/consumers are the real experts… partner with them to communicate

25. What Can We Do? Believe the numbers…health literacy is a problem. “Clear and simple” does not offend anyone. Know the public…their needs/ questions. Meet them where they are. --Measure how well we do this. What gets measured gets done.

26. leadership promotes

27. “We envisage a society in which people have the skills they need to obtain, interpret, and use health information effectively…and within which a wide variety of health systems and institutions take responsibility for providing clear communication and adequate support to facilitate health promoting actions ”.

28. A Shared Conversation…4 Questions for Every Provider and Patient What are my choices for health insurance? How do I get it? How do I use it? How much will it cost? REQUIRES understanding: “insurance” options-private, employer-based, public (Medicaid and Medicare) “co-pay” “deductible”

29. From healthcare.gov “Deductible: The amount you must pay for covered care before your health insurance begins to pay. Insurers apply and structure deductibles differently. For example, under one plan, a comprehensive deductible might apply to all services while another plan might have separate deductibles for benefits such as prescription drug coverage.”

30. References Institute of Medicine Health Literacy: A Prescription to End Confusion http://www.iom.edu/CMS/3775/3827/19723.aspx Round Table http://www.iom.edu/CMS/3793/31487/31799/32195.aspx Joint Commission (JCAHO) “What Did the Doctor Say?”: Improving Health Literacy to Protect Patient Safety http://www.jointcommission.org/NewsRoom/NewsReleases/hl_020607.htm Agency for Healthcare Quality and Research (AHRQ) http://www.ahrq.gov/qual/literacy/ AMA Toolkit http://www.ama-assn.org/ama/pub/category/9913.html