App or Apt: What does the learning patient need?

My 90-year old dad, now two months with a new aortic valve courtesy of Penn Medicine, was puzzled – and perhaps impatient.  “My energy still escapes me,” he asked, wondering when the new valve would make a difference.  The doctors had said give it time, but he still puzzled.  Maybe it’s the meds, some new, others with different dosages.

So, he started reading the fine print, going line by line through the labels, information sheets and other documents accompanying each of nearly a dozen medications.  He also took another look at the materials provided by the Penn team.  He’s keeping track of when he takes each medication and how he feels throughout the day.

His conclusion so far:  Each medication has a purpose despite any side effects, and that he’ll give it time as the doctors advised.  And, he’ll continue with cardiac rehab, walking the block to the sessions and increasing his time on the treadmill with each session.  He’ll also take his research and “charting” with him when he next sees his internist and cardiologist to get their advice.

What he’s done is exceptional, as I’ll explain below, but not unexpected.  You see, he’s a Greatest Generation naval veteran of the 1944 Battle off Samar in the Philippines.  After the war and some time back home in Ohio, he enlisted in the Air Force, where he was a sergeant and a flight engineer.  Reading, following and documenting detailed procedures was part of the job.  Now, he’s surrounded by books.

How he learned about his medications was “apt” for him.  There’s no “app” for it.  In fact, he’ll have nothing to do with new-fangled computers, smartphones or tablets, though he likes emails that emerge on hard copy from a printer at his home.

Here’s the point:  Successfully helping a patient learn doesn’t start with the information or the knowledge.  Neither does it start with the teacher or the tool, be it a website, app or flashcard.  Instead, it begins with and must be apt for, ie. adapted to, the patient.  Unfortunately, this fundamental principle of adult learning – it’s all about the learner, not the teacher – is too often neglected.

Therefore, starting with the patient, here’s what adapting to the patient will need to consider.  It’s sobering.

  • Only a little more than one in ten Americans are considered health literate at the proficient level, according to the National Assessment of Adult Literacy.
  • 90 percent of adults have difficulty following routine medical advice largely because it is often incomprehensible to average people, according to studies cited by Orca Health.
  • Patients at all literacy levels, but particularly those with the lowest literacy skills, have difficulty understanding medication directions and warning labels, according to studies cited by the Institute of Medicine.
  • The National Assessment of Adult Literacy found that only 30 percent of subjects with a bachelor’s degree or higher were considered proficient.
  • According to a study in the Journal of the Royal Society of Medicine, 40 to 80 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate.
  • Patients ask an average of 0 – 2 questions during doctor visits, according to studies cited by Orca Health.
  • Viewing rates for web based educational tools are low.  In a recent study published by the Journal of the American Medical Association Internal Medicine, only 6% of patients in the study viewed the online material.

Clearly, most of the nation is on a steep learning curve.  Successfully helping the learning patient up this curve starts with and requires adaptation to the patient.  Here are some examples:

  • Move away from the discharge data dump, following the example of the University of Nebraska Medical Center (UNMC).  Instead, UNMC focuses on active learning based on patient teach back and teaching sheets.
  • Prepare more extensively for primary care patient visits by adding nurses to counsel and spend more time with patients, ordering labs so discussion of them can be part of the visit and looking patients in the eye to motivate healthier behaviors.  Such team based care has proven quite successful at the Red Cedar Clinic in Menomonie, WI.
  • Pick the right time, being aware of patient readiness, and add a human touch advised Jessie Gruman, president of the Center for Advancing Health, in advice for providers recently shared with the New York Times.  Too much information doesn’t help a patient learn.
  • Speak slowly and plainly, encourage questions, rely on pictures and other visuals, keep information digestible and ask patients to teach back, as suggested CareNovateMag based on information from Plainlanguage.gov and the Federal Health Resources and Services Administration.
  • Initiate face-to-face patient conversations with clinical pharmacists in community health centers to reduce emergency room visits like Health Partners of Western Ohio.
  • Use pharmacists as discharge process leaders like the University of North Carolina does in an initiative to improve anti-coagulant safety.
  • Rely on videos and pictures, engage in conversations and resolve patient issues or concerns when using social media, according to Nucleus Medical Media.
  • Tell stories when blogging for health behavior change, as suggested by a study published in the Journal of Medical Internet Research.  Doing so is the most effective way to engage the reader and establish credibility across a broad spectrum.  Otherwise, the reader wants the blogger to be like him or her to sustain attention, thus making the range for potential engagement much narrower.
  • Look to the Kahn Academy, which has begun producing patient videos.  Rishi Desai, Kahn medical fellow and Robert Wood Johnson Pioneer grantee calls in “flipping the visit.”   They help patients learn before doctor visits, freeing time for doctors to listen to patients.  This is instead of “teaching” during an appointment with a hurried lecture.
  • Prepare patient education materials that reflect knowledge and respect for the audience, feedback during preparation.  Make them simple, interactive and easy to digest, suggests internal medicine physician Erin Marcus in an article posted on KevinMD.

Now, to the question in the title:  App or apt?  Ultimately, it’s not an either or question. There can, should be and likely are apt apps.  A recent report from the Wireless Innovation Council and Mobiquity outlined best practices for creating behavior changing mobile health apps.  The practices, all aptly tailored for the individual user, include individualized solutions, appropriate interventions and outcomes for each user, personalized communications, and low effort data collection.  Suggested as individualized solutions are self-logging, gamification, social feedback, self-measurement, auto-analytics, notifications, alerts and reminders.

In fact, the health self-management app Boston Medical Center is offering its lower income community – about which I wrote in my last post – just might be such an “apt app.”  Take a look at the check in screen to see why Dr. Robert Sokolove says this app, which relies on peer support, is sort of a Facebook for patients.

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