Beyond Brochures: Using Tech to Teach Patients

MDNG Psychiatry, August 2008, Volume 8, Issue 8

Cell phone applications and other high-tech tools are changing the way physicians approach patient education.

Cell phone applications, interactive video tutorials, online symptom navigators, and other high-tech tools are changing the way physicians approach patient education and are opening up new possibilities for patients seeking to learn more about their conditions and take control of their health.

In baseball, bats, balls, and gloves are commonly referred to as the “tools of the trade”—the equipment used by players to participate in and determine the outcome of the game. In medicine, tools of the trade have traditionally included a stethoscope and a sphygmomanometer by which physicians obtain information that can help them positively impact a patient’s health outcome. Those tools haven’t gone away, but healthcare providers have begun embracing new tools—technology tools, including cell phones, video, and the Internet—to help educate patients so they can make more informed decisions regarding their own health.

“When I was in training, the focus of medical care was in the hospital,” recalls Alan Greene, MD, chief medical officer at A.D.A.M., a leading provider of high-quality, technology-driven health information solutions. “Th en it was in the outpatient setting. More and more, it’s moving to where people are in their daily lives; the places where they’re making their healthcare decisions.” Enabling that decision-making is the technology that is putting information in healthcare consumers’ hands whenever they need it, wherever they might be.

THE CELL PHONE REVOLUTION

Peter Waegemann is chief executive officer of the Medical Records Institute and founder of the Center for Cell Phone Applications in Healthcare. An international leader in medical informatics, Waegemann believes that in the next 10 years, the cell phone will have the greatest impact on health information and technology. His vision is that in fi ve years time, “a large percentage of people, maybe even 100 million in this country, will have their basic health information on their cell phone.”

Waegemann says the cell phone can serve as the platform for consumer health-related

software, such as wellness-related programs and disease management programs. By off ering consumers health-related Internet access, cell phones can allow patients to quickly and easily look up information about medications or symptoms related to their health status.

Imagine a patient using her cell phone to look up a specifi c medication after it has been prescribed at a clinic visit, noting it interacts with another of her medications that she forgot to mention during the visit, and alerting her physician via the cell phone before the prescription is filled. “And it won’t only be for checking medications,” says Waegemann. “It will be for making decisions. When a consumer has a pain, they may not go to their doctor. Instead, they may look for advice on the Internet using their cell phone.”

Waegemann’s vision is already taking shape. The A.D.A.M. Symptom Navigator for the iPhone and new iPhone 3G is a free application introduced last month that is designed to help consumers match medical symptoms with relevant assessments and appropriate treatments. Adapted from A.D.A.M.’s standard edition of the Symptom Navigator, which is the backbone of many medical websites, including the National Library of Medicine, the tool addresses possible causes of symptoms and medical conditions, how to self-treat, when you should call a doctor, and how to prevent it in the future.

Symptom Navigator resides on the Web. A button on the iPhone’s screen quickly brings up an image of the human body. By touching the part of the body of interest, users are presented with a menu of related symptoms and walked through the possible causes, home care, and when to consult their doctor. “As a physician, it’s wonderful for me to know my patients have access to

this kind of quality data,” says Greene. “It makes patient discussions with physicians richer, deeper, and more efficient.”

WEB-BASED VIDEOS

Patricia Raymond, MD, FACP, FACG, a board-certified physician in gastroenterology and internal medicine in Chesapeake, VA, performs many colonoscopies as direct access, meaning that patients do not actually meet her prior to the procedure. As a result, she needed a way to educate her patients while also promoting some degree of bonding and familiarity. “If you’re going to come in and have me drop a sixfoot-long tube in your bottom, it better feel at least like you know me a little,” Raymond says. She put up a website, from which patients could view videos of her answering questions about colonoscopy.

Developing the script/answers to the questions was easy, says Raymond. She’d always been asked the same questions by patients over and over, so she wrote them down and divided them into pieces, or video clips, that were informative yet short enough that they wouldn’t lock up a patient’s computer during download. Total time for all the video components combined is

between 15 and 18 minutes, says Raymond, and patients “feel like they’ve gotten 15 minutes with me before I’ve even entered the room.”

Why video? Raymond says it’s important to use a level of technology that your patients are most comfortable with. Her patients are age 50 and older, so they’re not going to listen to podcasts. But, they’re savvy enough to use the Internet. And according to Raymond, studies have indicated that if patients are shown a video of the physician explaining something they’ll perceive a much longer contact time with the doctor than if they were limited to a standard office visit.

“[Th e video] is me saying the same thing over and over,” Raymond explains. “If I can have that same conversation with patients at their demand, at their convenience, then maybe they’ll feel more comfortable coming in for a colonoscopy, because they feel like they’ve already met me.”

MAKING VIDEO INTERACTIVE

Interactive Drama, Inc. (IDI), based in Bethesda, MD, has taken the video-based exchange of information one step further. The company has developed a voiceactivated, interactive educational method it calls “virtual dialogue.” Individuals are able to conduct a virtual conversation with a real person, in this case a healthcare expert, whose images are pre-stored on the computer. Using a microphone, the user asks questions, and the expert responds. An intelligent scrolling prompt provides relevant questions for the user to ask, or the user may ask questions on their own.

IDI has conducted extensive scientifi c research to measure the eff ectiveness of the virtual conversation from two perspectives: transfer of knowledge from the expert to the user and the feeling of actually being in the presence of the expert. Testing was conducted both prior to and following users’ conversations. Knowledge gain, says president and CEO William Harless, PhD—who developed the virtual conversation method—has been exceptional.

“We engaged 70 women, 35 of whom were breast cancer patients and 35 of whom were women concerned about breast cancer,” Harless explains. “They each took a pre-test to determine how much they knew about breast cancer, had a virtual dialogue with the oncologists for about an hour, and then took a post-test. Th e average pre-test score was 65, and the average posttest score was 93. That has real implications for medical education.”

Anne Moessner, MSN, RN, CCRN, a clinical nurse specialist with Mayo Clinic in Rochester, MN, has been piloting IDI’s virtual dialogue for several years. She says that she and the families that she has run through the program’s traumatic brain injury series have been amazed by the life-like features of the technology. “[Th e families] feel like they’ve spoken to a person as opposed to passively watching a videotape,” says Moessner. “I think it’s something about the technology that is very engaging.”

To facilitate the conversations, IDI researches and prepares a list of 75—125 questions that patients frequently ask about a particular topic, such as breast or prostate cancer. The questions are reviewed by the healthcare expert, who then answers the questions in front of a camera without a prepared script. Doing so, says Harless, makes the conversation spontaneous, as though the expert were answering the question live. Do individuals ever ask a question for which no answer has been prepared? Quite frequently, it turns out. But IDI executive vice president Marcia Zier says that’s good.

“Ninety-fi ve percent of everything they ask gets a reasonable answer,” she explains. “But if the basic information we provide is triggering new questions or more in-depth questions, we’re delighted, because now their real concerns are starting to surface. And when they talk with their physician, they’re going to have a more substantive conversation. It takes the patient to a diff erent level.”

‘SIGN’ LANGUAGE

From hospital and healthcare system hallways to physician offi ce waiting rooms, digital signage is becoming a popular method for personalizing medical information that not only gains patients’ attention, but educates them as well. For example, at Lancaster General Hospital, in Lancaster, PA, sets of eight, 46-inch, NEC LCD panels form two separate one-by-four matrices that display everything from information on health awareness programs to photo collages showing various hospital departments at work. Th e information is made available, but in a nonintrusive manner.

“With some other technologies, you have to go to a website and pull information; you have to ask for specific information,” explains Jeff Collard, president of Toronto-based Omnivex Corporation, a developer of software for digital signage networks and electronic displays. “Digital signage is very much a visual communication medium where we push information. People don’t come in and ask for it; we make it available to them whether they ask for it or not. But it needs to be supportive of what the patient needs to know, and invite them to get involved.”

In that respect, digital signage is very much an interactive medium, not merely flashing static information. Consider the case of a hospitalized child. The parents inform the hospital that the child’s favorite toy is a stuffed dinosaur. That information is imbedded in the medical bracelet around the child’s wrist. When the child approaches a screen in a common area or the children’s play room, the screen will show a story about a dinosaur. “The bracelet triggers it, so the screen knows who’s in front of it,” says Collard. “Then it goes into this database and pulls out something that relates to that child.”

Collard says the thing to remember about digital signage is that it’s a visual communication medium, and people, he adds, pick up visual cues much better than actual words. And the messages that are communicated are unique and tailored to a specifi c audience. “If I have 20 screens in a hospital, I don’t send the same message to all of them,” he says. “Every location should be a unique message, because where you are in your head and what’s going on in your life in radiology is completely diff erent than in the maternity ward. We’re delivering specifi c messages to specifi c people at specifi c times and places to make them feel more comfortable and help them facilitate a decision.”

Digital signage can also gather information about patients and healthcare consumers when they make choices through a touch screen. That information, says Collard, goes back to the hospital or the doctor’s offi ce and enables the facility to learn how to provide even more effi cient information to the patient. “It’s all data driven,” says Collard, “and that’s where the value is.”

TEACHING WHILE GATHERING DATA

What do patients do in a physician office waiting room? They wait, of course. So, how about putting that waiting time to good use? Patricia Neafsey, RD, PhD, a nursing professor at the University of Connecticut School of Nursing, has developed software that helps counsel patients with their self-medication management through the use of computer touch-screens available to them in the waiting room. With the assistance of a $1 million grant from the National Institutes of Health, Neafsey’s Personal Education Program — Next Generation (often referred to as PEP-NG) is helping older adults with hypertension reduce dangerous self-medication practices.

While patients wait to see their doctor, they can work at a computer screen and respond to various prompts asking what medications they are on—what medication they take for their blood pressure, as well as medication they may take for common health problems, such as pain or stomach ailments. The computer program counsels them, showing them the possible drawbacks of taking multiple medications, and what medications may interact negatively with one another. Upon completion, patients receive a printout they can take with them when they meet with their doctor, allowing for further discussion and maximizing the time available for the appointment.

“Everything is written for a lower health literacy level,” explains Neafsey. “That’s extremely important. And every screen, every word, the size of the buttons, every color, and the speed of the animation has been tested in very structured usability studies, so we know that they are readable and engaging.”

They’re also effective. An initial test of the software showed that 82% of patients with high blood pressure were able to lower their blood pressure using the system over a four-month period. A second, larger study is currently underway with 264 patients at 11 primary care practices in Connecticut.

“These are teachable moments,” explains Neafsey of the time patients spend in physician waiting rooms. “We thought, let’s use the time people spend waiting to gather information, analyze it in real time, and deliver a personal education program that supports the whole regimen for treating hypertension.”

Using technology tools of the trade, A.D.A.M.’s Greene expects healthcare providers to capitalize on those teachable moments going forward. “Th is is really the beginning of a new era,” says Greene. “It’s a new era of tools for patients to be able to track their own health, monitor it, and make changes. It’s an exciting time in medicine. Th ere are some real positive changes happening.”

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.