1. AHCPR 1 Using the Electronic Age to Improve Health Outcomes J. Michael Fitzmaurice, Ph.D. Agency for Health Care Policy and Research April 28, 1999

2. AHCPR 2 Overview # Much health information is available –Quality is a concern # How do you judge web site quality –Mitretek/HITI-- Others # Issues # AHCPRs Quality Tools # Evaluation

3. AHCPR 3 Overview # AHCPR tools and the web –CAHPS –CONQUEST –Evidence-based Practice Reports # What if we connected! # Issues

4. AHCPR 4 Where do people get health information? # Recent Rondale Press survey of American of all ages –Television--39 percent –Physicians--37 percent –Newspapers--28 percent –Family or friends--24 percent –Magazines--23 percent –Books--23 percent –The Internet came in lower at 13 percent

5. AHCPR 5 How do people use health information? # To make choices in the market –Health plans –Physician –Nursing homes # To assist choices for treatment to improve quality of care and outcomes –Self-care decisions –Physician-patient decisions

6. AHCPR 6 Desirable characteristics # Accessible, with search capability # Seniors like large type--preferrably Arial rather than Times Roman # Health topic interest increases with age--Healthfinder--Mary Jo Deering, HHS/ODPHP # Low readability levels

7. AHCPR 7 Information Quality # Good and bad information light up just as brightly-- # C. Everett Koop, MD

8. AHCPR 8 Quality of Information # Coulter, et al., in British Medical Journal (Jan. 1999), evaluated patient materials. –Brochures-- Videos-- Phone helplines # One-third of materials evaluated did not have a publication date # Few materials admitted to any scientific uncertainty # Few were specifically designed to inform treatment choice.

9. AHCPR 9 Criteria for Assessing Quality of Internet Health Information # Developed by Mitretek/Health Information Technology Institute--Helga Rippen, MD, Ph.D., MPH, Director # Convened over 20 experts from national organizations # To develop criteria and test them # Targets: public, developers, policymakers # WWW.MITRETEK.ORG/HITI

10. AHCPR 10 Criteria # Credibility # Content # Disclosure # Links # Design # Interactivity # Caveats

11. AHCPR 11 Credibility # Source –Credentials, Conflict of interest, Bias # Context # Currency # Relevance/Utility (validity) # Editorial Review Process

12. AHCPR 12 Content # Accuracy # Hierarchy of evidence # Original source stated # Disclaimer # Omissions noted

13. AHCPR 13 Disclosure # Purpose of the site # Profiling of users

14. AHCPR 14 Links # Selection of forward links # Architecture of site # Content (accurate, current, credible, relevant) # Back linkages: number & quality

15. AHCPR 15 Design # Accessibility # Logical organization # Internal search engine

16. AHCPR 16 Interactivity # Mechanism for feedback # Chat rooms and bulletin boards # Tailoring--based on user characteristics

17. AHCPR 17 Caveats # Alerts to users –Sound-alike names –Impressive sounding names –Puffery in claims--miracles, secret cures, amazing results

18. AHCPR 18 Top Ten Criteria # Straw test as an example: n=28 –Source-- Disclosure –Accuracy-- Currency –Original source stated –Hierarchy of evidence –Relevance/Utility-- Disclaimer –Link-content-- Review process

19. AHCPR 19 Other Site Evaluations # Mary Jo Deering and colleagues (Kim, et al. British Medical Journal, 1999) –Looks at published rating criteria for evaluating the quality of health sites on the Web. –Found consensus of criteria, including –Disclosure of authors and sponsors –Currency of information # Health Improvement Institute awards good ratings of sites.

20. AHCPR 20 Issues # Privacy, confidentiality, security –Will people get personal health information (PHI) about me that I do not release? –Will PHI I release, with conditions, not be redisclosed without my approval? –By what means will disclosure and redisclosure of PHI be prevented? –State laws –Federal law: Privacy Act, FOIA –International laws: EU Directive

21. AHCPR 21 Issues # Oversight –FDA--Drugs and medical devices –Clinical software is a device u Competent human intervention –FTC--misleading advertising and business practices –False and deceptive claims and practices # Liability –Flawed medical advice –System failure

22. AHCPR 22 Issues # Accreditation and Certification –Ability and capability to deliver –Quality and effectiveness of product –Examples: –JCAHO –NCQA –State licensing boards

23. AHCPR 23 Issues # Role of government –Investment: time, risk, B>C, access –Regulation –Education –Ensure competition # Payment for web health services –Private pricing –Government activity in payment

24. AHCPR 24 Issues # Health system design and incentives –Web-based information may –Increase the time physicians take to educate patient –Reduce the patient seen/physician in 8 hours –Improve healthiness and reduce the demand for future office visits, evidence of improved health system efficiency –Physicians do not get paid for this extra time today

25. AHCPR 25 Issues # Access for all –Many are disadvantaged--no access to a computer or the Net. –African Americans, Hispanics, –Low income and rural families –Universal Access--at any price? # Public Health –Externalities-- Efficiency –Equity

26. AHCPR 26 Strategies # Strengthen EV and Q of Applications # Improve Basic Knowledge # Strengthen Capacity of Stakeholders –Clearinghouses-- Collaborations # Ensure Equitable Access # Source: Wired for Health and Well-Being –Science Panel on Interactive Communications and Health, April 1999

27. AHCPR 27 AHCPR Snapshot # AHCPR-- a research agency that studies the U.S. health care system – Outcomes research – Quality of care measurement – Cost, Access, and Utilization # What works to improve patient health outcomes in the community? – And what does it cost? # Funds peer-reviewed research grants

28. AHCPR 28 AHCPRs Health Tools # Medical Expenditures Panel Survey – $30 million/year – 10,000 households/24,000 people – Also surveys employers, physicians, hospitals, LTC facilities # CONQUEST--a data base – 1200+ clinical performance measures – Validity, availability – HEDIS, FACCT, scientific studies

29. AHCPR 29 AHCPRs Health Tools # Consumer Assessment of Health Plans Survey (CAHPS) – Will be used by 100 million people in 1999 – Medicare, Medicaid, NCQA, OPM, Kaiser # National Guidelines Clearinghouse – www.guidelines.gov -- www.ahcpr.gov – AHCPR, AMA, AAHP partnership # Evidence-based Practice Centers – Compile science findings about specific health conditions and procedures

30. AHCPR 30 AHCPRs Health Tools # Scientific Research Findings – Published findings from AHCPR-funded grants # AHCPR staff expertise and collaboration

31. AHCPR 31 What if we connected! # Personal web-based medical record # Provider medical record # Health plan enrollment and service utilization record # AHCPR tools –CONQUEST--aggreg. cpms--provider/plan –CAHPS--patient evaluation in MR –NGC--providers guideline variation

32. AHCPR 32 Evaluating Web Effectiveness # Number of hits is not sufficient for improved outcomes # Should make a difference in health outcomes and improving our lives

33. AHCPR 33 Evaluating the Impact # Does improving access via web sites to critical health information lead to a greater number of –Hits? –Information retrievals?

34. AHCPR 34 Evaluating the Impact # Does a larger number of hits cause a change in –Provider choice of treatment? –Patient behavior?

35. AHCPR 35 Evaluating the Impact # Does the change in treatment choice and patient behavior lead to –Improved health status? –Lower costs? –Both?

36. AHCPR 36 Bottom Line # We need to design and provide information with outcomes in mind-- # Dr. John Eisenberg # AHCPR Administrator

37. AHCPR 37 Bottom Line # Hits are not enough. We need to show their effects on patient and provider satisfaction and behavior change. # Most important, we need to learn their effects on improving peoples health and quality of life.

38. AHCPR 38 Using the Electronic Age to Improve Health Outcomes J. Michael Fitzmaurice, Ph.D. Agency for Health Care Policy and Research April 28, 1999