Elder Law FAX The March 12, 2007, issue of Elder Law FAX, a free newsletter published every other Monday by the Elder Law Practice of Timothy L. Takacs. Improving Health Literacy Improves Health Care "Everything was happening so fast and everybody was so busy," and that is why Mitch Winston, 66 years-old and suffering from atrial fibrillation, did not ask his doctor to clarify the complex and potentially dangerous medication regimen that had been prescribed for him upon leaving the hospital emergency department.   When Mitch returned to the emergency department via ambulance, bleeding internally from an overdose of Coumadin, his doctor was surprised to learn that Mitch had not understood the verbal instructions he had received, and that he had ignored the written instructions and orders for follow-up visits that the doctor had provided. In fact, these had never been retrieved from Mitch's wallet. Despite their importance, they were useless pieces of paper. Mitch cannot read.   (Read about Mitch and the problem of health literacy in Joint Commission on Accreditation of Healthcare Organizations, "What Did the Doctor Say?:" Improving Health Literacy to Protect Patient Safety, 2007.)   Ninety million Americans "have difficulty understanding and acting upon health information," according to an Institute of Medicine report on health literacy. Low literacy may impair functioning in the health care environment, affect patient-physician communication dynamics, and inadvertently lead to substandard medical care, according to a report from the federal Agency for Healthcare Research and Quality. It is associated with poor understanding of written or spoken medical advice, adverse health outcomes, and negative effects on the health of the population.   The problem of health literacy is not just a patient problem--that is, the solution is to improve literacy among Americans. The problem lies in communication between patient and health care provider.   Effective communication is at the heart of the patient-provider encounter. The patient is expected to communicate his or her medical history, symptoms, and concerns. In return, providers are expected to discuss the diagnosis of the patient's illnesses and afflictions, treatments, solutions, and possible outcomes.   In an effort to improve patient-provider communication, the Iowa Health System initiated the Health Literacy Collaborative in 2003 with a series of hands-on workshops. In the workshops, which ran throughout 2004, participants shared information about health literacy and strategies for addressing the issue.   Patients in the Iowa Health System were asked: Did you receive an explanation about tests and treatments you received? Were you informed about medications you received? Did you receive instructions on caring for yourself at home? Did nurses keep you informed? Did physicians keep you informed? The IHS collaborative tested two approaches for improving health literacy--"teach backs" and Ask Me 3. In a teach back, the patient is asked to repeat back to the provider what they heard. Patients and caregivers can assess understanding of diagnoses, treatments, outcomes, and possible negative side effects. Nursing staff working with patients on informed consent forms, for example, will ask them to describe their upcoming surgery. The patients' explanations are recorded on the forms, giving clinicians an opportunity to review information that is not understood.   Ask Me 3, a tool created by the Partnership for Clear Health Communication, recommends that patients ask their doctor, nurse, or pharmacist three questions: 1) What is my main problem? 2) What do I need to do? 3) Why is it important for me to do this? Patients who still don't understand what they need to do are encouraged to ask their caregivers to explain the information again.   Early results of the health literacy intervention initiative show an increase in the percentage of patients reporting that the information, instructions, and explanations provided during the care process were "very good."   For more information on the study, see "Case Study: Iowa's Health Literacy Collaborative Is Transforming Patient-Provider Communication," The Commonwealth Fund, November/December 2006, at  http://www.cmwf.org/publications/publications_show.htm?doc_id=424780#case.