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

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

Health Literacy Framework

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

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

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

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

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 The Forecast for 2030

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

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?

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

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

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

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 #: /8/2009 You have 11 refills 180 pills Discard after 9/8/2010 Provider: RUTH PARKER, MD Emory Medical Center (414) Pharmacy: NoVA ScriptsCentral Sunset Blvd. Reston, VA (713) NDC # Reprogramming the R x Label.

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 ( ) 74% % Adherence (3 months) 1.9 ( ) 49% % Figure 5.

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

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

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

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

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.

leadership promotes

“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 ”.

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”

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.”

References Institute of Medicine Health Literacy: A Prescription to End Confusion Round Table Joint Commission (JCAHO) “What Did the Doctor Say?”: Improving Health Literacy to Protect Patient Safety Agency for Healthcare Quality and Research (AHRQ) AMA Toolkit