PODCAST/TECH/QUALITY: Don Kemper podcast

Here’s the transcript from the recent podcast with Don Kemper. Interesting stuff from a real pioneer.

Matthew Holt: So welcome to another THCB podcast. Today we're very lucky to have Don Kemper, who is the President, CEO and certainly the joint founder of Healthwise, and also, although he'd be too bashful to say it, probably the main individual in America who has been behind the information therapy movement, which now has its own separate Center for Information Therapy, the one that Don I believe founded. So Don, welcome to The Health Care Blog.

Don Kemper: Thank you, Matthew. I'm pleased to be here. You're very kind.

Matthew: Those of you who've been reading the blog have noticed that over the years I've both been to a couple of information therapy conferences, partly because they're held in Park City, Utah, which is a beautiful and lovely place to go where I have friends (even though I left most of my left knee there in the trees some years ago and am just steadily getting it put back together) but also because I'm pretty convinced and a firm believer that the concept of information therapy is one that is going to be of significant importance no matter what happens in the future health care reform debate. And it's something that, as people are developing new and different forms of information technology to support those patients and physicians, information therapy is going to be an important part of that.

So, with that, Don, why don't you take us back to the early days. Tell us a little about what Healthwise does, how that started, how the Healthwise Handbook got going, and then perhaps just tell us a bit about Information therapy to start off with.

Don: It all started, Matthew, when I was a lieutenant in the U.S. Public Health Service back in 1970, and I heard a talk by the assistant secretary for health education and welfare in those days, Vern Wilson. He said the greatest untapped resource in health care is the consumer. And that was at a time when nobody was thinking about what a patient could do for themselves, and I though, "That's a good idea." I had a little baby at home and somebody had given me a Dr. Spock, and I thought, "Well, what the world needs is a Dr. Spock for the whole family," and began to try to get the federal government to write a basic self-care book that they could give to every family in America.

That idea didn't get very far in my two year tenure with the Public Health Service, but I held onto the idea, and a few years later landed in Boise, Idaho with a pretty open book on what I could do, and we started to develop that idea. And so Healthwise was formed in 1975. We published the first copy of the Healthwise Handbook through Doubleday in 1976. And we have been growing toward the same mission that we established right then, which was to help people make better health decisions.

So over the last 31 years, we have been continually looking for ways to enrich this mission of helping people make better health decisions by giving them books, giving them workshops, giving them good web based information, and now finding ways to prescribe information to meet their specific needs in every moment of care.

Do you want to know more?

Matthew: Sure. Let me ask you some more specific questions. Healthwise is founded as a non-profit, and I guess that perhaps the first time I ran into Healthwise was back in early '90s. Somewhere around that time you convinced the folks at Kaiser Permanente to give that book to every member, I believe. Maybe that was just Northern California. The thing that I as a health care economist policy guy that I sort of sat up and took a notice, was that actually, they showed that emergency room visits declined dramatically amongst people who had these books.

So tell me a little bit about how that evolved, and how, apart from being sort of a worthy organization giving out information to people, Healthwise started evolving into being a place where the health care system realized it could start having a positive impact on savings, as well as outcomes.

Don: In the early days we were grant funded. We had funding from the Kellogg Foundation and a variety of other places, including the National Center for Health Services Research. And we initially had workshops where we would bring mostly women, mothers, family care-givers into workshops. We'd give them a book and we'd give them, say, twenty hours of training in how to do better care at home for their kids. And we had that supported by grants.

And people really responded and said, "Boy these are basic questions that we have, and learning these basic things helps us do a better job, and helps us save money with the doctor." So from that experience, we began to talk with some of the new managed care plans that were evolving in the late '80s and early '90s to say, "You know, this is in line with your mission of helping your members to stay healthy and to avoid high costs. You should begin to do these programs." And so we did quite a few of the workshop programs where we trained trainers at health plans to present that information to their members, but on a pretty small scale.

The first big breakthrough we had was at Health Net, a Southern California based managed care plan, who was planning to deliver some 20, 000 Healthwise Handbooks through workshops to their members, but only to a small percentage of their members. But only to a small percentage of their members. They were going to do this through employers. And we went and talked with them, and they came to realize that every member of their health plan who did not have this book was at a disadvantage. So they said, "Well, can we just give one to every family?" And of course we said, "Sure." And that was the first I think 300, 000 book sale that we came across, and many since.

Then Kaiser really came up next, where Kaiser was doing some pilots of the program in Northern California. They were very well received, and they rolled the program out across the country. So I believe every Kaiser member in all of their regions, or at least every Kaiser family, receives a Kaiser version of the Healthwise Handbook.

Matthew: I believe that there were some studies done within Kaiser demonstrating that the initial roll-out, or maybe a test group (I don't know how they did it) was showing not only nice benefits for the members, but also that it was reducing heath care costs for those members. Is that right?

Don: That's true. They've done those internal studies. I don't know how many have been actually published in the medical literature. There have been other studies that have been done as well. For example, in 1996, with funding from the Robert Wood Johnson Foundation, we delivered a Healthwise Handbook to every family in a four county area in Idaho. And incidentally we are in Idaho with our intergalactic headquarters here in Boise. But we delivered those books, and then Blue Cross noted that in the year following the distribution of the books, the per capita use of emergency rooms went down I believe it was 16% during that first year. And that's the most dramatic response that we've seen.

From the Kaiser point of view, all I can say is that they continue to buy books for their members, so the results may have been positive for the organization as well as [dog barking in background] for the individual. Sounds like you've got a dog!

Matthew: That's my dog barking. He hasn't read his handbook about how to not bark during these [laughter] interviews.

Don: I should say, Matthew, that our mission is to make people make better health decisions. We don't limit which people, but we haven't gone to animals yet.

Matthew: Well, he has his own health care issues, which [laughter] get dealt with by serious capitalists called vets.

Let's talk a little bit about how Healthwise as an organization has evolved and started working with different brands. I probably ran into Healthwise as a business entity about seven or eight years ago when I was working at a dot com. We were trying to sell a web based consumer health record to a health plan. We were talking about how do we integrate our web record with the information they're providing, and it turned out they were providing all their information over the web. But it was your information. And there are also different places over the web now that you'll find Healthwise information not just in a book, but also in monographs and consumer friendly forms all over the web. How did that evolve?

Don: The single beacon that we've been guided by is the mission: helping people make better health decisions. How you reach those people... In many cases that means aligning with organizations that have access to those. So we really started with health plans. Health plans have huge numbers of members, and they have a legitimate way to connect with those members at a time that they're having health problems. So it's been a good match for us, and I think if you took the top ten health plans in the U.S., all ten are using our content. So we found a way to ignore the competitive world related to health plans and to just say, "Here is a basic resource that will help your members do a better job of staying healthy and taking care of their problems. And we'll market it to you in a way that really makes a compelling case."

So I think we just naturally found it. That's been a good market for us and a good avenue for our mission. As have things like the disease management world, where many of the big disease management companies now use Healthwise information for their nurses and for their members. And also, of course, many of the big new health portals license our information to deliver to people.

So wherever we can find a channel for getting our information to a consumer at the time they're needing it to make a better health care decision, we want to follow that channel.

Matthew: Let's think a little bit about the state of play. Because this is where, I think, the information therapy movement is coming in. Actually, before we get there, just tell me a bit about the Center for Information Therapy and your role helping to start that, and why you thought it was necessary to create an independent center, given that Healthwise is already a non-profit—albeit one that's competing with for profit companies in the publishing and sort of content world.

Don: When Al Gore invented the Internet...

Matthew: Oh, a cruel hoax.

Don: The Internet came about, we initially thought, "Boy, here's Nirvana. This is utopia for health information, because here now any time 24/7, people can go and get good information about their health problems. This is going to be great!" And then, as we watched it grow out, we saw some problems. Number one, the information on the Internet wasn't all good. Two, people couldn't always tell which information was good and which was not. And three, even if they found great information, there wasn't a good way to use it within their doctor patient relationships, because the docs didn't have time to read it, and the docs didn't necessarily trust it. They didn't know where it was coming from.

So we kind of reached an assessment at one point saying, "Well of course you've got to have good information on the Internet and help people find it. That's number one. But two, you need to find a way to prescribe information to people so that they get it when they really need it, they don't have to go look for it, and what they get has been vetted by their health plan or their doctor." That was kind of the birth of the information therapy idea. Let's prescribe information to people, let's call it therapy, information as therapy, because it's just as important as the test you get or the medication you get, because it can improve your health in just the same way. So that was kind of the birth of the concept.

And then we began to look around and say, "Well, how do we infect the world with this idea of prescribing information to people?" And we said, "Well, first, let's talk to some of the movers and shakers." So we talked to people like Peggy O'Kane at the National Committee on Quality Assurance (NCQA). We talked to the then CEO of Aetna, Jack Rowe. We talked to the head of internal medicine at Mass General Hospital, Al Mulley. We talked to a variety of people who really are smart and at the front of innovation in health care. And they said, "This is a great idea! You need to find a way to promote this to the world."

So we created the Center for Information Therapy. Initially it was just a part of Healthwise. Healthwise is non-profit, 501(c)(3) organization. Those people I mentioned and others all came onto the board. At that time we called it the Information Therapy Commission. And we began to set policy and promote ideas around Information Therapy even while Healthwise as an organization began to develop information therapy programs.

Then, maybe a couple of years ago, we began to realize that some players in health care, particularly people that provided information on their own, were reluctant to join into the information therapy movement because we had such a dominant role in that movement. And so we decided that for the good of the country, for the good of the field, we would back off from being the direct owner of this information therapy center and make it an independent organization.

So beginning in January of this year the center kind of went off on their own. And they are now a 501(c)(3) completely independent of Healthwise, funded by a membership program where there are some thirty or so organizational members that fund the Ix Action Coalition. And they're on their own. So they're now able to get grants themselves without having to say, "We're tied to a particular content provider." I think that was the main reason it was better for them to be independent.

Now, some of the people that are also developing content are sitting around the table on the board of directors at the Center for Information Therapy and trying to look at how does this idea impact the crises that are going on in health care today.

Matthew: If I was to talk about my sense, having been at a couple of the conferences, that the Information Therapy Center, and the disease management folks to a certain extent, and also probably many of the technology folks (I'm thinking of people like the WebMDs of the world and people like Cleveland Clinic Online and others who have been there demonstrating their tools for getting information to patients, and to physicians by the way) around that, the Information Therapy approach. I think it seems to have done very well getting those folks on board.

If I was to say where it looks like to me that there's still a bridge to be crossed, that there are clearly organizations that do better if they have the ability to get better informed patients and lower health care costs. And obviously Kaiser Permanente, Group Health of Puget Sound, those names always come up when you're having this discussion. Let me add in, of course, that most health plans, although frankly they seem to make more money when health care costs go up hither, but the concept of being a health insurance company is that you are supposed to promote health amongst your members and try to reduce overall costs, and if you can create a better health care quality experience for your members at the same time, that's a great thing as well.

The challenge it seems to me that Information Therapy is having, is how do you sort of integrate the whole concept of Information Therapy into, if you like, the great unwashed of American medicine, which is the 85% of physicians and 80% of hospital systems where most of the care goes on, but really are still in a fee for service world where--let's be frank--the more they do, the more they get, and most of their work is done on acute interventions on sick people. You could argue that if you want people to get healthier, they don't get so much to do and they don't get so much money. That seems to be where the challenge remains. And if I was to look around the room at the Ix conference, some of those folks are the people that are somewhat missing. How do you think we're doing in that respect?

Don: Well, I think the whole provider side of information therapy is just beginning to show interest, just beginning to develop. And I think that you're right, that if you don't develop the side you've really missed the game in the long run.

We also know that it's so darn tough to change this sort of cottage industry delivery side of healthcare that there are going to be some big gaps for a long time in the health plans, and the disease management companies are able to help fill those gaps until the provider world catches up.

But I think you're going to see some significant advances in the provider world. And I can predict the way they're going to come. They're going to come through the EMR plans, the EMR companies that offer electronic medical records to clinics and hospitals that provide a platform for the easy description of information to the patient.

Some of the people you do see at the Information Therapy Conference straddle the worlds of payer and provider. People like Kaiser; people like Group Health of Puget Sound, where they have huge clinical systems that are going. Where they have implemented information therapy, they have received such incredible payoffs, both in terms of improved satisfaction of their members, but also improved workflows and improved results, that it will be impossible to compete with those kinds of plans unless the fee for service system catches on and starts using those as well.

So I think you'll see, in the relatively near future, any clinic that implements an EMR program, an Electronic Medical Record program, is going to include information therapy in that implementation, so that their patients get patient-facing advantage out of the technology. And it's going to reduce their costs in many ways. It's going to allow them to have more billings because they're able to manage more difficult and more complex patients in a shorter amount of time.

Matthew: Let's dig into that a little bit because I think we're seeing a growth of EMRs. Not as fast as some of us would like, but we are seeing the growth of the EMRs across the nation. Most of the growth is in the larger physician groups but clearly every physician's organization of whatever size is at least thinking of having the internal conversation.

And in particular, if you look at some of the bigger provider groups who are associated with plans or maybe not, but I'm picking here on Kaiser, Group Health Cooperative Puget Sound and Cleveland Clinic, that have active EMR's from Epic. That particular company, they also have the patient-facing view of that, which is, as you say, a venue where there is a lot of information going on. Where people are actually being prescribed: “Go read this piece of information”, or “Here's a link to somewhere interesting”.

Even just the simple things. Here's, as you know, as you've said many times, what's discussed in front of the patient or between the patient and the doctor tends to be forgotten as soon as the people leave the room. That system provides a place where that information can be captured so people remember the basics.

Are you having, either the center or Healthwise, or competitors of Healthwise, having comparable conversations with the other major technology vendors, the Cerners, and the McKessons and the GE IDX's of the world? Do you think everyone's going that route or is it pretty much Epic only at this stage?

Don: No, I wouldn't say it's Epic only. We do have a lot of work with Epic clients and we do have some conversations with Epic themselves, but we're certainly working with other players also. And I think it's our goal to be kind of agnostic related to that and to have our information available to all the major EMR organizations.

We're just getting to the point where we have the products that are compelling for the pure provider market. And what we have done with Kaiser and Group Health has been great because they have a foot in each side. And even then, some of the big clinics like Palo Alto Medical Foundation, they're able to use our knowledge-based content well.

But we have new products that are much more geared toward the provider market called patient instruction, which is a piece of paper or the electronic paper that the doctor gives the patient following a visit or in a visit. And that really is the core platform on which information therapy will be built on the clinical side. It's a little different model than you would use with a health plan or a disease management company. And our products have been a couple of years behind. So we're just now entering those markets and we think that it's going to be something that the clinical world takes note of.

Matthew: That's pretty interesting because we're now discussing how do we replace those pamphlets that you get given with all the discharge instructions or whatever you get given and make sure that the patient can read them and understand them and all the rest of that.

And I think one of the takeaways that I've had from the various information therapy meetings that I've been to in the conferences is that there are many, many different paths to basically the same watering hole. This is a marketing issue of how do you get patients to understand what they should do and what works for the male in his sixties in Boise, Idaho who has some kind of heart condition versus what works for the fifteen year old diabetic living in south-central LA is incredibly different. And just handing out a pamphlet that is not specific to those different people doesn't really work. And I think presumably that's what you're talking about in terms of this...

Don: There's just so many ways to improve what we do now. Before every clinic visit or before every one that's not a walk-in, there's at least some encounter that sets the appointment. And that's an opportunity to send information to the patient so they can prep a little and also do a little assessment so that when they get to the doctor's office, they've already done the base work of thinking about their symptoms, of reporting what they've done at home etc, and the doctor can spend time really helping them solve the problems.

So we heard from the guy at the conference from Geisinger. I'm just blank on his name at the moment but he was talking about why we need $100 an hour resource to do $10 an hour tasks. Why can't we let patients do the things they can do themselves even better than the doctor and then save the doctor's time for things that can really make a difference, really monitoring their co morbidities, for example.

So much of healthcare is around chronic conditions and co morbidities of chronic conditions and yet doctors are pretty much trained to just handle one condition at a time in the visit because there is only time for one. With good information therapy, when the patient comes in prepared and the information they have been presented has been analyzed for the doc in advance, the physician can handle more than one condition at once. So we're moving toward that kind of an intervention. It can really make a difference not just in the cost crisis and the quality crisis, but also in the manpower crisis that the healthcare system is facing.

Matthew: Yeah, I think that's certainly true. And I put there are two major battles going in healthcare. One is how do you automate and improve the ten-minute visit, what you're referring to as the ten minute visit or the fifteen-minute visit that the patient gets with the doctor. And the other is how do you actually improve the however many weeks or months it is between those visits, that the patients are basically maintaining themselves.

And that's I think what you're talking about is information therapy is at the nexus of those two pieces. It's how do you make that visit more efficient by getting better information from the patient filling in medical histories in advance or having questions prompted or that kind of stuff versus having better information about happened in the visit and what instructions given, how they should follow up.

And I remember a couple of years back, it might have been Paul Wallace or somebody else at the conference mentioned that (you know these numbers much better than me) even though we know that if you are discharged from the hospital you should be taking beta blockers and an aspirin, in fact, nationally, we're only at 55% or whatever the number is of patients who are actually doing that because somehow or another that information hasn't been properly communicated in the way it should be. That can be simple, there doesn't necessarily have to be an electronic tool to do that. But certainly that's one particular path to making that kind of intervention happen and be more effective.

Don: Right. And we like trying too, if it's so easy to do that. You know we usually think of patient instructions as being sort of the end of an encounter. But what we know now is that you can have instructions before the encounter starts, you can have instructions at the end but then you have instructions that foul up because the day of the discharge you have one set of issues. The next day has a different set, and the following week and the following month there are other things. With the beta blocker issue if you interview people six months later a large number have stopped taking their beta blockers. If you ask them why, they say "I didn't think it was important." They forgot the reason or the reason wasn't explained well enough and nobody refreshed the reason. So they just quit taking them. And boy, computers are great at reminding people of those issues. They're also good, well go ahead with your question.

Matthew: I was just going to say that it's an obvious thing, that an any educational situation you have to tell somebody four or five times the same thing before they learn it in many different ways every time. And at the moment you get one discharge sheet and one quick follow-up with a doctor when you've got a number of other things on your mind and you have to figure all that out. Six months later it's not surprising, although in some ways we know that those numbers of people taking beta blockers should be way higher than they are, we shouldn't be surprised that they're as low as they are because no one has figured out how to get to them at the right time with that sort of follow up reminder.

Don: Right.

Matthew: I think that's a lot of what we are talking about.

Don: It is indeed. Of course we know that even though computers are so great at doing this job there are still a lot of people who don't have access to broadband Internet use and so there are other methods that we have to use as well. I think you probably saw at the conference this year the number of health plans and the number of companies that are now offering telephony phone based information therapy. Which are shorter messages but do a good job of reminding people of things like its time for your immunization or why don't you schedule your mammogram.

Matthew: Right. Now that leads us to an interesting sort of nexus because you've got, if you like, an age spread. I don't want to call this a digital divide because that's not what it is because there's a lot of access across income and class groups. There is certainly still for those over 65 much lower penetration of Internet use and for that matter much lower penetration of mobile phone use other than straight talking over the phone. So there are people developing SMS systems and instant messaging things over the phone for these kind of reminders which are working pretty well on young people in different parts of the world but are not necessarily going to be the solution for the elderly.

But I think the talk that you gave at the conference was looking at how you get this type of information therapy across the spectrum. And we've got that going on. What are the different techniques that you need? Does the telephone work, does the mail work, does even pure person-to-person communication work at conferences for pharmacists or whatever else.

But on the other hand we've got this big development. It's loosely been called the health 2.0 movement or whatever you want to call it where there's a lot of peer to peer communication going on around the web and if I was supposed to make not a criticism but sort of a statement about information therapy at this point, it's been an attempt to sort of verify and put a mark of authority behind information that has been delivered generally from the system to people.

But there's also all this communication going on between people both online and offline. Now that's beginning to become much easier with the advent of Google and search engines and communication devices. Have you thought about how the typical Healthwise monographs are going to fit into that world?

Don: Well clearly you need both. You need good, vetted scientific information that has a good base of medical research behind it and you can track that research, you know it's there. You need that in order to go and work with your doctor so your doctor knows information you're using is vetted. You also need to know what's worked for other patients. The two work together really quite nicely and that's why in our content we always include references to the self-help groups that are relevant to your particular disease.

There's a national self-help clearinghouse that has hundreds of these self-help groups that allow self-helpers to get in and say "I was in your shoes and this is what you have to watch out for and this is how I did it." That just gives you the context to use the more evidence-based information to your benefit. So I think the two don't fight against each other at all, they really work hand in hand. You really need both in order to do the best job.

Matthew: Yeah, and I would speculate that maybe Healthwise itself there are sort of two things going on. One is the issue of things that we know we ought to do but don't do. How do we get the patients after they're discharged to take their beta blockers? How do we get the diabetics to check their blood sugar and regulate their insulin levels? Then there are the sort of things that we know how to do it but we don't know how to get everyone to do it.

Don: Yeah.

Matthew: There's a lot around there, which is true. The other is what's increasingly starting to be called the long tail, which has been borrowed, from this book by the guy from Wired magazine, Chris Anderson. The concept is there's a lot of information, that there's always new information being developed in health care and there's stuff that we don't know clearly what the answer is. If we generate more and more information online we have the capacity to search that information more and more and we can start judging that and evaluating that.

There's a couple of interesting physician based websites that just opened starting to do that work where physicians are asking each other questions and putting in queries about new things they are seeing. Sermo is one, MyMedNetworks is another. I think you are going to start seeing an explosion of this on the patient side.

I think there's a role for the Center for Information Therapy or other sort of bodies is to start helping with the process of validating, either on the physician's side or on the patient's side, again, what's good information and what's not good information and who are the people you can trust. I think it's not just anymore the American Diabetes Association or whatever but who are the patients that are useful people to add to this discussion and who are the people who are selling Alfalfa beans from Mexican clinics as a cure for cancer.

You've gone referring people to the peer-to-peer discussions as self help. Are you thinking of getting involved in the validation of that side?

Don: I think that kind of defeats the purpose. I think you need to know where to go to get the good evidence based information. We've tried to establish ourselves as a source for that. Then you need to be able to take other people's opinions and make your own judgment about whether that's going to be particularly useful and helpful. For so much of health problems the medical piece is not the only piece that you've got to solve. It's the family piece, it's the social piece, it's what do I do at work or what do I do at school or what do I do with my child not related to the medicine and tests they are getting but related to how do I nurture them through this episode? There's not a good way to validate that. I think that you've got to give people at least one good source of evidence-based information and let them rely on that. And you need to let them open up to whatever sources peer-to-peer might, they might find valuable. It's kind of like you can get the ratings, you can go to the movies and get a rating for whether a movie is PG or R-rated, or whatever, and you can also read the reviews of the experts and see whether this is a good movie, or see who wins the Academy Award, but you also often want to ask your buddy well, what did you think of the movie? And that's what makes up your mind whether you go or not. The combination of all these things, what we're committed to doing is giving people at least a source or the evidence base, vetted information, written in a form they can understand and presented in a way that's truly structured around the decisions they have to make. We think that is one of the pieces they need, and they need other pieces as well.

Matthew: That makes a lot of sense. I think that the wave of the person asking their buddy what happened in the movie, whether they liked the movie, the word-of-mouth piece is actually going to become much bigger in health care, especially in the next five years. I think that's going to be an interesting contrast. But I think the obvious thing as people become more aware of this stuff, they're going to be using all kinds of, all that as a source, but also you'll see an explosion in the trusted sources like the Healthwise and other content providers like that.

Don: One of the kings of health care blogging but I suppose they're now I don't know if there's a 100, 000 health blogs or if they're more than that but,..

Matthew: Actually, probably the most interesting stuff is not the blogs like mine on changes and trends in the health care system, but actually the ones written directly by patients.

Don: That's right, that's what I was referring...

Matthew: There are some, especially in the diabetes world, I'm thinking about Diabetes Mine, Amy Tenderich's blog, which is really got an extraordinary information about somebody going through life as a diabetic, and now people are sending her new diabetes blood-glucose measuring tools and pumps and talking about her experiences, and there are a lot of people writing about that experience, and there's a huge amount of information sort of coming peer-to-peer, as that develops. And you're going to see, like in any kind of social market, knowledge and opinion leaders emerge and she clearly is one in that very specific area. And I think that how that plays out is going to be interesting, but it's going to be there. Certainly much more information is better, so long as there is some validation.

So let me ask you, two quick final questions, Don. The first one is, you talked about the evolution of the next ground of information therapy being very connected to the development of electronic medical records, we've seen in a couple of countries I'm thinking the UK, Norway, New Zealand, actually pretty widespread use of primary-care electronic records at this stage. Has there been much impact that you've seen internationally of information therapy.

Don: There has been a little. Not a whole lot, but Molly Mettler and I wrote a white paper in which we, we wrote it for the Department of Health in the UK, about this time last year. Some of the elements of that, of our paper, showed up in their big white paper, which was called "Our Health, Our Care, Our Say," I believe. It was signed by Tony Blair and released at the end of January last year, and in just this month there has been an announcement of some I think they called them information prescription pilots, in the UK, using Cancer Backup, which is one of the nonprofits there that does a lot of cancer education and a few other organizations. So, it's being picked up in the UK. Of course they have the National Health Service, so they have more of a organized way of getting across the whole system I guess. But they also are struggling with their EMR side, so it's there's still a long way to go there. And there has been interesting in information therapy really across Europe, so others and I have done presentations on information therapy in Luxembourg, in Prague, in the Hague, in the Netherlands. And everywhere there is an acceptance that this has got to be the way it's done in the future. It takes a while, so they're having to pull their infrastructure together and of course in many cases they don't have the consumer health information that we have in order to deliver the content within the information prescription.

Matthew: Well, in some ways that's good, that's a whole new market, right? But what you're saying is that even though they have a lot of primary care EMR used in some of these countries, they haven't mastered the information therapy to the extent that some of the more advanced places here that have got primary care EMR, even though they may be exceptions.

Don: I think that's right. I think in some ways they may be ahead. I think they're ahead in infrastructure, not necessarily in the delivery of content. Partly because the culture isn't quite there yet in many of these countries. There is a good book called The European Patient of the Future by Angela Colter, who interviewed patients and doctors in I think eight different EU countries and you can just see from one to the next to the next the variance in the cultural readiness for empowering patients. It's nothing you'd want to try in Spain right now, for example. Theirs is a very paternalistic system, not ready to empower the patient. But in some of the countries you mentioned there's a much greater openness.

Matthew: That's pretty interesting. And finally the last question is what are you most excited about — maybe you were already asked it — in terms of the adoption of the technology behind information therapy. Where do you think the biggest movement in the next two to the three to four years will be around the whole information therapy movement?

Don: The thing I'm most excited about in that period of time is what health plans will be able to do for their members with chronic conditions. These are people generally that have multiple chronic conditions. The RAND study showed that about half of them don't really get the care that they should be getting. There's a big gap between what we know we should and what we do. And information therapy campaigns that can be easy for patients are that are identified by their health plan and sent to each person on a periodic basis can give a very personalized guide, sort of their own personal care management plan that will in a very exciting way help them get better health outcomes, help them avoid emergency room visits, help them avoid hospitalization, help them get more money's worth for the drug money, for the drugs they spend, for the drugs they buy. And I think that's the most exciting thing right now is these campaigns for chronic disease that for really the first time give a patient a sense of mastery over their condition or over their multiple conditions.

Matthew: That's great. Because I wrote an article a while back called "The Yin and the Yang of Health Insurance Plans," and there are plenty of things health insurers are doing that many of us find pretty uncomfortable and pretty discouraging. But, on the other hand, there are those beavering away within these medical management groups within the health plans who really have been trying to figure out how to do disease management better and it's great that they're now getting to promote some of these programs, both with health coaching, and also with advocacy programs but also with these disease-management programs which communicate better how to use these disease-management tools and techniques and companies or whatever, to the chronically ill. I think you're right. The patient is a scarce resource, but also the organizations that are reaching out to the patients have to figure out how it is that they can make the best of that resource because self-management is a great thing, but if people aren't informed how to do it, it won't happen, so...I'm with you on that.

So with that I want to say thank you very much, Don, it's been great chatting with you and I'll looking forward to seeing you at the next information therapy conference or the next time I end up in Boise, Idaho, whichever is sooner, and thanks very much for being a guest on The Health Care Blog podcast today!

Don: It was my pleasure, Matthew. Thank you!