Greetings from the National Library of Medicine and MedlinePlus.gov

I’m Rob Logan, PhD. Senior Staff, US. National Library of Medicine substituting this week for Donald Lindberg, M.D, the Director of the U.S. National Library of Medicine.

Here is what’s new in MedlinePlus this week.

The Joint Commission recently reported serious communication breakdowns between health care providers, patients and the public -- and made new recommendations for health care organizations to improve what they call the nation's health literacy.

In a report based on an expert roundtable, the Joint Commission found that not addressing health literacy problems undermines the ability of health care organizations to meet accreditation standards and patient safety goals. The acknowledgement is important because the Joint Commission is the independent organization that accredits hospitals, clinics, laboratories, nursing homes and other health care organizations in the U.S. The 'Joint Commission' is the new, shorter name of the former 'Joint Commission on Accreditation of Health Care Organizations.' It used to be fondly referred to as "Jay- Co". They changed their name in January.

The Joint Commission enforces the standards of care and safety that are the foundation of institutional medical care for most Americans. The work of the Joint Commission is vital to any major  improvements in public health and medical care in the U.S.

Meanwhile, how about "health literacy"? This is a term and an idea that is gaining familiarity among physicians, nurses and other medical professionals, but it is unknown to the public.

In a pioneering report in 2004, the Institute of Medicine of the National Academy of Science defined health literacy as in the following way. Quote “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (unquote).

Interestingly, the World Health Organization defines this idea even more broadly. WHO says (quote) Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health." (unquote)

To explain it a different way, health literacy includes helping everyone understand: a doctor’s instructions, health care forms, the signs in hospitals and clinics, and consumer health information. Health literacy includes the goal that patients, caregivers and the public  understand medical instructions and health information, if necessary overcoming cultural, educational or language barriers. So, health literacy focuses on improving routine encounters in patient care.  It includes the situation when someone cannot understand a provider’s instructions or basic health information because English is not his or her primary language.

The Institute of Medicine noted three years ago that about 90 million, or about one in three Americans, cannot understand basic medical instructions. This was also confirmed by several studies. Naturally part of the problem can be attributed to poor educational level of some patients. This is the part of the problem that is often addressed by saying, "the message should be confined to vocabulary at such a grade level". But of course this solution ignores the host of quite well educated persons who have ample vocabularies but who lack much school background in biology, anatomy, and basic medical science. Thus the Joint Commission and the Institute of Medicine both acknowledge that even well-educated, highly literate Americans frequently experience frustration in understanding medical concepts when these are expressed in medical professional jargon. Think of the inadvertent use of medical abbreviations! "CT" or "CAT Scan", both of which refer to a radiological examination, or  "MI" standing for "myocardial infarction" rather than the more easily understood "heart attack". In the medical chart itself one also sees funny jargon still, especially abbreviations, such as "SOB" still. There it is not an insult; it means "Shortness of Breath".

Of course, even if a person were pretty familiar with these medical concepts, he or she will still frequently be left frustrated in attempting to complete insurance claims forms or medical consent forms.

There's no doubt that lack of health literacy can be a pervading problem. Likewise there's no doubt that both the patient groups and the medical staffs could help by trying a little harder. As patients, each of us can prepare for a medical encounter by reading up a bit on our health problem. Use a dictionary if need be. If a medical dictionary seems like a better bet, please try MedlinePlus. This Internet service from the National Library of Medicine is designed precisely to help persons in reading up before and after a medical appointment.

So, both the Institute of Medicine’s and the Joint Commission’s reports underscore a compelling need to improve health communication for everyone. But the Joint Commission added some new ideas and strategies to foster improvements.

The Joint Commission’s recommends that  health care organizations do the following:

• Use clear communications in all patient interactions from the reception desk to discharge planning
• Use easier to understand signs in hospitals and clinics and better materials to help patients and caregivers find their way around the building
• Use well-trained medical interpreters for patients with low English language proficiency
• Providing reimbursement to cover the costs for providing trained interpreters
• Train the entire hospital or clinic staff to recognize and respond appropriately to patients with literacy and language needs
• Establish medical liability insurance discounts for physicians with good communication practices.

The Joint Commission suggests that individual health care providers do the following:

• Always use plain language
• Use ‘teach back’ and ‘show back’ techniques to ensure patient understanding
• Limit the information provided to two or three important points at a time
• Redesign the informed consent process to include forms written in easy-to-understand sentences and use ‘teach back’ methods during the informed consent process
• Broaden reimbursement policies to encourage patient education within hospitals, clinics and physician’s offices. 

Incidentally, the idea of "teach back", that is to ask the other persons to explain what has just been said, while certainly excellent technique DOES take extra time for both the doctor and the patient.

MedlinePlus attempts to do much the same kind of thing in an automated and anonymous fashion. To see this, try any of the tutorials in the Senior Health section. All have pauses for multiple choice questions asked by the system and answering by the patient or family member.

All studies of teaching have concluded such techniques are valuable - virtually essential for understanding and learning. But imagine if you will how big a change - even in scheduling the time involved - the 'teach back' recommendations will require in most clinical settings we know about now! I definitely wish for the doctor to spend the extra ten minutes explaining to ME what I need to know, but I shudder to think about waiting for the twelve patients ahead of me while each gets his or her extra ten  minutes. That's TWO HOURS! Maybe I should invest the two hours at my own convenience reading up on my questions through MedlinePlus!

While we wait for the additional hospital and doctor's office time to become available, I invite you to try out the same good ideas by bringing your health questions to MedlinePlus, especially the MedlinePlus interactive tutorials. There are about 165 Tutorials all together. I'm especially proud of those in the Senior Health section. Please try for example, topics such as "Arthritis", "Alzheimer's Disease", "Cataract". "Depression". "High Blood Pressure", or "Shingles".

Of course, one of the ultimate goals of the Joint Commission’s report is to help each of us when we are patients to make more informed choices and decisions about our health care. That is exactly why the National Library of Medicine started MedlinePlus.gov and other health information services for the public a decade ago.    

But besides its comprehensive information about more than 700 diseases and conditions, MedlinePlus additionally addresses some of the specific concerns raised in the Joint Commission report.

For instance, there is a section within MedlinePlus called ‘Talking with your doctor’ that addresses how to improve provider-patient communication.

This section explores how to talk to physicians about some specific health problems:

• Eye problems
• Heart disease and heart health
• Testicular cancer
• Bladder control problems
• Orthopedic problems
• Obtaining a second medical opinion before surgery
• Plus a key topic within the Joint Commission report, how to discuss and give informed consent before a medical procedure occurs.

The same section also provides tips for a child who is about to experience medical treatment as well as information to assist teenagers and seniors.

To find this section, simply type ‘talking with your doctor’ on the search box on MedlinePlus’ home page. Actually you can just type "talking". That will get you to this section. In either case, click to choose ‘talking with your doctor (National Library of Medicine).’

Similarly, there is a section within MedlinePlus that is a gateway to information about personal health issues. Some of the issues raised by the Joint Commission report that are discussed here include:

• your rights as a patient
• the use, availability and privacy of your medical records
• your safety as a patient
• counsel on considering a do-not-resuscitate order
• handling end of life issues
• understanding medical research information
• how to evaluate the quality of health information that is provided by websites and other resources.    

To find this, simply click on the ‘health topics’ link on the left side of MedlinePlus’ home page. Then, click on the ‘personal health issues’ link on the right side of the page.

Overall, we hope you will think of MedlinePlus as a premier resource in English and Spanish that helps you talk to a doctor, decipher medical terms and assists you to care for yourself and others. Although about two million people access MedlinePlus.gov daily, we always have room for more visitors and look forward to helping you.

I should add that we welcome your comments to improve MedlinePlus and the National Library of Medicine’s consumer services. To provide feedback about MedlinePlus, just click on ‘contact us’ in the upper right hand corner of the front page.

To find MedlinePlus.gov, just type in “MedlinePlus.gov’ in any web browser, such as Firefox, Safari, Netscape, or Explorer.

Before I go, your comments about this or any of our podcasts are always welcome. Please email me anytime at: NLMDirector@nlm.nih.gov    That’s NLMDirector (one word) @nlm.nih.gov

A written transcript of recent podcasts is available. Just click on the ‘Director’s comments’ link on MedlinePlus’ home page.

The National Library of Medicine is part of the National Institutes of Health. The National Institutes of Health is part of the U.S. Department of Health and Human Services.

It was a pleasure to be with you….

Please join me here next week.