Mark V. WilliamsAs consumers take on more responsibility for their own health, health literacy is fast becoming a patient safety issue that is relevant to clinical laboratory services. In this interview, Mark V. Williams, MD, FACP, FHM, a national expert on health literacy, talks about actions labs can take to overcome communication barriers. Dr. Williams is professor and chief of the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Evanston, Ill. He is also the editor-in-chief of the Journal of Hospital Medicine. His primary research interest involves optimizing value in healthcare delivery through evaluating quality of care delivery and costs.

Corinne Fantz, PhD, of the Patient Safety Focus Board conducted this interview.

How do you define health literacy?
In 1999, the American Medical Association's Ad Hoc Committee on Health Literacy defined it as "the constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the healthcare environment." AMA's definition also included "the ability to read and comprehend prescription bottles, appointment slips, and other essential health-related materials." Healthy People 2010 and the Institute of Medicine (IOM) use similar definitions: "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

Are there particular groups of patients who are more likely to have challenges with health literacy compared to others?
Yes, the elderly and those who did not complete high school are more likely to have challenges with health literacy. Research shows, however, that even some high school or college graduates may struggle.

What are some red flags that may indicate low health literacy?
You cannot tell by looking at a person. Some patients who say they "forgot their glasses" may use this as a method to cover up their inability to read.

What are some examples where laboratories fail to adequately communicate important information to our patients?
Inadequate directions or signage to a phlebotomy collection site may prevent access to healthcare, while small print and unnecessarily complex forms can lead to misunderstandings regarding test preparation or interpretation. One group of researchers reported that among patients who have access to their test results, 68% could not interpret a blood glucose value. While labs may feel that this is the provider's role, lab data may be so poorly organized or formatted that patients may easily overlook important findings.

Minimizing the Effect of Health Illiteracy When Communicating with Patients

What are the most commonly misunderstood words/concepts used in communicating lab results or instructions?
Healthcare providers should use "living room" language that patients can understand, but they should also use the proper medical terms. Some of these medical terms may have general connotations that are different than what we intend clinically. For example, when explaining test results, providers should be cautious about using the terms positive and negative. A negative test result is often good, but the patient may perceive this as a bad outcome. Other common words that patients misunderstand are terminal, hyper, and malignant, as well words that refer to concepts such as normal range.

What actions can laboratorians take to reduce the chance of patients misinterpreting lab information?
Labs should develop well-written patient material, such as forms and educational information, that is appropriate for everyone, including people with limited health literacy skills. Important information should be bolded or highlighted. These materials should be assessed for effectiveness, preferably by real patients. For labs that have direct contact with patients, it is important to greet them with a warm, friendly attitude; use plain, non-medical jargon; speak clearly and at a moderate pace; limit instructions to three-to-five key points; repeat the key points; and use illustrations if necessary. Finally, it is always important to provide non-threatening opportunities for patients to have their questions answered.

What safeguards are in place or should be in place to ensure laboratory information is clearly communicated and accurately understood?
I suggest using the "teach back" approach. After providing information to patients, check to ensure they understand. You can do this by stating your desire to ensure that you have done a good job explaining, but want to make sure. Then you ask the patient to "teach back" to you the information you just conveyed.

What is known about the health and economic impact of misunderstood lab results or instructions?
Estimates indicate that inadequate health literacy costs the healthcare system $30–73 billion annually. Researchers have correlated low health literacy with excessive hospitalization, which may suggest decreased knowledge of self-care, reduced compliance, and less ability to negotiate the healthcare system. Although specific data focusing on misinterpreting lab results or instructions are not available, with the amount of lab data generated to make clinical decisions, I imagine it is quite substantial.

There is a new proposal by the Department of Health and Human Services to allow laboratories to directly report results to patients. From everything you've said so far, we have a lot to consider as we begin to build patient portals that will provide access to lab results and instructions for patient testing. Is there anything else clinical lab workers should know about health literacy?
Health literacy affects a patient's ability to access healthcare services, understand health-related information, and follow healthcare instructions. Both clinical and administrative laboratory staff should be concerned with health literacy issues and should use 'universal precautions' that assume everyone may have difficulty understanding lab information. Studies show that compared to those with average or above average literacy skills, patients with marginal or limited literacy and children of caregivers with low literacy skills have poorer control of chronic conditions such as diabetes, HIV, and asthma.


Agency for Healthcare Quality and Research website.

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