Our goal is to improve understanding and use of information provided through portals to Electronic Health Record (EHR) systems by older adults with diverse numeracy and literacy abilities. Portals are intended to support patient-centered care, but are underutilized by older adults because they serve more as information repositories than as collaborative tools for patient education. Self-managing health often hinges on comprehension of numeric information, which challenges lower numeracy patients. Older adults, the most frequent consumers of health information, also have lower numeracy. According to health communication theories, patients must interpret numeric information in terms of their goals and knowledge in order to create gist representations organized around evaluative/affective categories that capture the 'bottom-line'for their health. Clinicians are traditionally a key to helping patients create gist representations by using verbal and nonverbal strategies that contextualize the information. With decreasing patient contact time, clinicians are challenged to provide this support. HIT has the potential to support patient comprehension by providing access to information outside the constraints of brief clinical encounters. However, portals may not be effective because they eliminate the clinical context that supports gist comprehension. We will help older adults use numeric information by emulating in portal environments best practices from face-to-face communication. We leverage progress in developing computer-based agents (CA) for human- computer systems. Our team has developed a CA with nonverbal cues (e.g. voice intonation, facial expressions) to convey affective as well as cognitive meaning. We will refine the CA to serve as an expert clinical intermediary that provides succinct commentary on test results reinforced by nonverbal cues to help patients create gist representations that support understanding and engender trust. We address the following aims. 1. Identify portal messages that improve comprehension of clinical test results. We compare standard text/numeric messages to increasingly enhanced formats. 1) Verbal: Standard information is presented and annotated with labels to indicate degree of risk. 2) Graphic: The information is presented graphically as well as numerically and verbally. 3) CA: The same information is spoken by the CA, with nonverbal cues signaling information relevance and guiding affective interpretation. Verbatim and gist comprehension, need for more information, and attitude toward risk information is measured. Enhanced messages should be better understood (especially at the gist level) and meet patient information needs. They (particularly the CA) may especially benefit less numerate participants by reducing need for numeracy and encouraging affective response. 2. Identify messages that make test results more actionable. Self-care recommendations (e.g., about diet) consistent with the test results will be added to the messages. In the CA condition, these recommendations as well as the test results are delivered with nonverbal cues emphasizing key information and supporting affective interpretation. Measures of intention to perform self-care will be added. The CA should increase these intentions by promoting affectively organized gist representations that motivate action. While portals may one day revolutionize patient-centered care by increasing access to information, many older do not use them. We will help make portals more cognitively accessible by making information more easily understood and actionable.

Public Health Relevance

Project findings will help integrate models of health literacy/numeracy with models of risk comprehension and patient/provider communication in order to help develop new formats for presenting numeric information through patient portals to EHR systems. The project will also spur technological innovation: While previous work on computer agents (CA) has not been based on theories of language comprehension and risk evaluation, the proposed CA technology adapts models of emotional prosody (both audible and visual prosody) to communicating the health importance of information in patient-agent sessions. Accomplishing these goals will help realize the potential of portals as collaborative tools for patient education and self-care, especially for older adults with limited numeracy health literacy.

National Institute of Health (NIH)
Exploratory/Developmental Grants (R21)
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Health Care Technology and Decision Science (HTDS)
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Lomotan, Edwin A
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University of Illinois Urbana-Champaign
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United States
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