Don Kemper, CEO,

Healthwise

Mrs Patel had retired and was spending time with her son in the USA. Since her right knee was causing her much discomfort, she visited a doctor who told her that she would require knee-replacement surgery. She had already had her left knee successfully replaced in India. Since there was considerable time before she returned to India, she thought it was best to have the surgery performed in the U.S. itself. Mrs Patel was thoroughly impressed with the manner in which the whole process was done, right from pre-operative visits and counselling to post-operative care and information prescriptions. She felt that such an active involvement of patients was seriously lacking when she was operated in India. How can we emulate the Information Therapy model of the United States? We have all the resources - we just need the intention.

Information Therapy is on the cusp of becoming a mainstream part of American medicine. Since the publication of Information Therapy in 2002, the prescription of patient self- management and decision support tools is becoming embedded within medical practice in America. Healthwise has played a catalytic role in making that happen. As the infrastructure to allow Information Therapy matured, the regulations to require it were written and business plans to support it were developed.

Healthwise (www.healthwise.org) is a not-for-profit organization, founded in 1975 with a mission 'to help people make better health decisions'. Through policy advocacy, program development, and delivery services, Healthwise has been able to advance the basic Information Therapy concept - prescribing the right information to the right person at the right time - as an integral part of the process of care.

The origins of Information Therapy

In the early days, Healthwise used books and workshops to promote its mission. The Healthwise Handbook is a basic self-care guide for families. It covers most common health problems with clear guidance on what can be done at home and when to call for professional help. Healthwise has distributed over 35 million self-care handbooks, primarily in the U.S. and Canada. Since 2009, the Healthwise Handbook has been distributed in India through the Health Education Library for the People (HELP). Healthwise also taught hundreds of nurses and health educators to present workshops in self-care to tens of thousands of people across the United States.

In the early 1990s, Healthwise began development of the Healthwise Knowledgebase with its goal of covering all of medicine, organized around treatment decisions and presented in terms that the general public can easily understand. At first, the information was used by nurses in call centres who gave guidance to patients on when to seek care and how best to prepare for it. Then, with the popularization of the internet in the mid-1990s, the Healthwise Knowledgebase was made available directly to the public. In the years since, the Healthwise Knowledgebase has been licensed to hundreds of hospitals, health insurers, health maintenance organizations, disease management organizations, government agencies, and health portals for distribution on each organization's websites for use by their patients, members, or users.

It seemed at first that reliable, trustworthy information, available freely on health websites, would be enough to inform and engage patients in their care plans and health decisions. Not so. It is true that millions began searching for information on the internet, but when they tried to bring that information into conversations with their doctors, it just didn't work. The physicians could not trust the information without reading it first nor did they have time to read it.Even when consumers found high-quality information, the impact it had on their treatment decisions was quite limited. Information Therapy was born out of the idea that if physicians prescribed information to their patients, they would be more likely to trust it and more likely to listen to their patient's better informed perspectives.

Simply stated, Information Therapy is the prescription of the right information to the right person at the right time in order to make a better health decision or to change a health behaviour. Advances in electronic medical records, government incentive programs, and the increase of patient activation in healthcare have all combined to make information prescriptions an increasingly important aspect of healthcare in America.

Information Therapy in the U.S. today

The growth of Information Therapy is directly linked to the expanded use of electronic health records (EHRs). Prior to 2009, the expansion of EHR use in America was quite slow with less than 20% of doctors using EHRs. In 2009, the Health Information Technology for Economic and Clinical Health Act, or HiTECH Act, was passed by the U.S. Congress. HiTECH promised that the government would reimburse doctors and hospitals for much of the cost of their adoption of EHRs. However, to qualify for reimbursement, professionals and hospitals must demonstrate something that the government calls 'meaningful use'.

These include a number of Information Therapy-related capabilities, such as:

• Patient-specific educationalresources(healthinformation specific to the patient's individual needs) need to be available in the EHR.
• The EHR should be able to automatically send patient reminders for preventive services.
• The EHR should provide discharge summaries for hospital patients.

The HiTECH Act boosted Information Therapy adoption in two dramatic ways. First, as a result of the reimbursement incentives, most hospitals and clinics are now planning to adopt EHR systems. The American Medical Association has reported that 51% of U.S. physicians are now using EHR systems due in significant part to reimbursement incentives.

Some estimates now project that 80% of the nation's hospitals will qualify for the stage 1 meaningful use reimbursements.

Second, along with the growth of EHR is coming a greatly increased use of Information Therapy - and the good news is that it's not only for the forms of Information Therapy mandated by the reimbursement requirements. Since the vendors supplying EHR systems must now provide for the capability to prescribe information to patients, the systems can now easily expand to provide other important information- based services for the patient and the doctor.

The Infobutton standard

The Health Level 7 International Context-Aware Knowledge Retrieval standard has been widely adopted since 2007.

Nicknamed the 'HL7 Infobutton standard', it facilitates the delivery of a set of standardized information about the patient, the provider, and the activity of a specific care encounter or moment in care. An Infobutton manager (or equivalent) accessed by an EHR application can then pull the relevant information needed for improving care at that point. In most cases, the Infobutton has been used to bring up decision support information for the clinician.

This same HL7 standard can also be used to trigger relevant, education orders or 'information prescriptions' for the patient. While the knowledge request can be triggered by the click of a button, the button click is not always necessary. The information prescriptions can be automatically generated by the system as well, based on the context of the patient's particular moment in care, for presentation in a handout or a secure message, or on the personal health record (PHR).

The adoption of the Infobutton standard has made it easier for many diverse EHR systems to deliver patient-specific information and tools from many different health education and Information Therapy providers. Such increasingly wide adoption is speeding the movement of Information Therapy into the mainstream.

Information Therapy by health plans and health insurers

Health Information Technology (HIT) has also advanced the mainstreaming of Information Therapy within health insurance companies and health plans. While health insurers have long had the economic incentives to help their subscribers make smart health decisions, two things have blocked their progress: timely information and the trust of their members. Progress is being made in both areas.

Improving timeliness: U.S. health plans now get almost continuous data streams about patient medications from the pharmacy-management companies. A new medication prescription can be enough to trigger an information prescription that guides the patient toward improved self- management for a newly diagnosed chronic condition or an indication of a change in patient status. Similarly, the absence of a predicted medication prescription refill can provide a trigger for information to help the patient learn about the importance of medication compliance (for example, when a hypertensive patient does not refill his prescription for antihypertensives within a defined time period).

Hospitals and doctors are also providing patient billing information much more quickly, although most data is still far from current. The data is coming in with more information and in a higher quality than ever before. All this is allowing health plans to use predictive modelling and analytics to identify patient needs earlier and with more accuracy than they could in the past. The better they know the patient's needs, the more effectively they can deliver information prescriptions.

Overcoming mistrust: Health insurers have never been considered to be a trustworthy source of information, because patients suspect that their information is biased in favour of reducing costs. While that perception is not likely to change soon, health plans are drawing patients into their websites and self-management programs through the use of incentives and value-based benefits.

'Value-based insurance design' describes an approach for adjusting insurance benefits to remove barriers to essential, high-value health services for a particular individual. Value-based insurance design lowers the cost to the patient for services likely to reduce long-term costs and discourages unproven or cost-ineffective services through less favourable pricing policies. The same technology platforms are also being used to adjust individual benefits based on the patient's commitment to completing prescribed learning programs that promote self-management of the patient's condition. These incentives are often effective in getting patients to engage in more education and to accept more accountability for personal health management.

Crossing the payment chasm

In 2001, the (U.S.) Institute of Medicine's report on 'Crossing the Quality Chasm' created an urgent call for fundamental change to close the quality gaps in American healthcare. Ten years later, many (though not all) of the quality gaps have been narrowed. Today, there is the realization that the high cost of care, even more than the quality gap, is threatening the sustainability of our healthcare system.

In response, the Accountable Care Act passed in 2010 laid out a myriad of payment reform experiments to test how best to bend downward the healthcare cost curve. The experiments include:

• Pay-for-performance incentives;
• Accountable care organizations;
• Patient-centered medical homes; and
• Bundled payments.

In each case, the objective is to moderate fee-for-service economics by other forms of payments that more readily support prevention, self-management, and value-based purchasing. It's worth pointing out that in all these cases, a shift in payment structure would encourage an increased use of Information Therapy.

However, today in America, the physician that does the very best job of encouraging prevention and health promotion gets paid the same (or often less) than the physician who does very little, if any at all. Today, hospitals are driven by competition to add more technology, more modern facilities, and more aggressive marketing with little regard for the value-based impact on health. As these new payment reforms change incentives for doctors and hospitals, the use of Information Therapy to engage, inform, and motivate patients will become essential.

Opportunities for an Information Therapy explosion in India

The concept of Information Therapy has evolved over the past decade in the United States. It is only now entering the mainstream of American medicine. The basic idea of prescribing the right information to the right person at the right time is a universal one that can improve healthcare and health in every nation of the world. However, each nation will have to develop the idea within its culture and infrastructure and with the resources available. For India, the opportunity for an Information Therapy explosion is enormous.

To thrive, Information Therapy requires three things:

• An infrastructure of information technology that can deliver patient-specific information prescriptions in real- time response to patient needs;
• A source of trusted consumer health information to support shared medical decision making and guided self- management for long-term conditions; and
• A medical culture that respects the role of the patient.

India is known, worldwide, as an IT powerhouse. Indian software engineers are among the best in the world. Internet access to the population is expanding quickly and at low cost -particularly through the nearly ubiquitous presence of mobile phones. The infrastructure is in place to leapfrog Information Therapy development in much of the developed world.

India also has substantial resources for educating its people to better manage their own health problems. Organizations like Health Education Library of the People (HELP), which have provided health education resources to the people of Mumbai for over a decade, are now serving the nation's population through their websites and outreach programs.

Is the Indian medical culture ready to embrace an informed and activated patient? The answer will depend entirely on the Indian champions of Information Therapy - their creativity, sensitivity to culture, and openness to ideas. With the right leadership, India could quickly become a world leader in Information Therapy. The time is ripe.