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and Trustees of Dartmouth College.
All Rights Reserved.
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Contents

General Information Privacy and Advertising

For more than a decade, www.HowsYourHealth.org tools and related websites have been developed and tested to serve the needs of children, adolescents, and adults, the very ill and frail, hospital care, problem-solving, care transitions, personal health planning, and quality certification based on patient experience measures.

All of the tools of HowsYourHealth are PUBLICLY, available without charge (for non-commercial purposes). All patients and members of the public can use HowsYourHealth tools at any time. Health professionals may also use the HowsYourHealth tools without charge but if the health professional wishes to test and customize the tools they are required to register. There is a nominal charge for continued use of the tools after testing.

HowsYourHealth accepts no advertising of any type. HowsYourHealth is supported by fees from sponsoring doctor's offices, health systems, and businesses.

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From the point of view of a patient or member of the community, HowsYourHealth tools generally have two parts: 1) the questions asked and 2) the information received after the questions are answered. The diagram illustrates the flow of data for most HowsYourHealth tools. Every patient or member of the community who uses a HowsYourHealth tool controls the data. It is always anonymous unless the patient or member of the community chooses to share it.

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Content Quality

We use Research to make sure the questions and information helps patients and members of the community take better care of themselves and get better health care. For more than thirty years, a cooperative network of physicians, nurses, and researchers affiliated with Dartmouth Medical School has developed approaches to make care truly responsive to the needs of the population. HowsYourHealth.org is derived from this experience and has been shown to be effective and useful in several published research studies. Generous support for this work has been provided by The John A. Hartford Foundation, The Robert Wood Johnson Foundation, The Henry J. Kaiser Foundation, The W.T. Grant Foundation, The Agency for Health Care Research and Quality, and the Commonwealth Fund. In 1992 the World Organization of Primary Care adopted for international use in more than 20 languages the basic methods underlying HowsYourHealth.org.

Research has shown shows that basic information tailored to the needs of the respondent and their doctor or nurses is most likely to make communication better, place everyone "on the same page", and increase confidence with self-care. Therefore, medical information in HowsYourHealth is much less detailed than that provided by MedlinePlus (or other web sites) that are designed to give the latest and best medical information for a specific disease or problem.

Except for the correction of errors that is done immediately, updates of the questions and information are performed annually. John Wasson MD, Professor of Community and Family Medicine, and Medicine at Dartmouth Medical School oversees all updates. The latest update was in January, 2018. For persons aged 13 or older, the sources for updates are:

The Journal of the American Medical Association
The New England Journal of Medicine
The British Medical Journal
The ACP Journal Club (This provides reviews of current publications).
The Journal of the American Geriatric Society

We have the Words Reviewed by non-medical persons. The most recent complete review was in 2012. Language translations of survey items are checked by at least two persons. Elsewhere, Google is now offered for translations.

We have tried to make HowsYourHealth error free. However, those involved in its preparation can not warrant that all of the information is accurate and complete. The information provided on HowsYourHealth is designed to support, not replace the relationship that exists between a patient/site-visitor and his/her physician. When you use HowsYourHealth as a guide for your health and medical care, be sure to discuss any questions about it with your doctor, nurse or other health care worker.

The Trustees of Dartmouth College licensed FNX Corporation to make this approach available to health professionals and others concerned about the health of the population.

Getting the Most Out of HowsYourHealth (For Sponsors)

Fast Easy Implementation

In order to minimize any efforts on the part of busy health professionals and their paid staff, the "Patients as Partners", a program in British Columbia engaged volunteer patients who learned about HowsYourHealth and helped office practices put it into daily routines. This hugely successful approach is strongly recommended to outpatient clinics and hospitals. Learn more about this approach by downloading the PDFs from the section Posters, Newsletters, and Checklists for Implementation.

Common Questions

Why do doctor's offices, communities, employers, clinics, hospitals, or schools sponsor HowsYourHealth Websites?
A sponsor can customize the HowsYourHealth Family of Web-sites by making "hot links" to their own web-site, adding questions, adding categories, and obtaining real-time summary reports of all responses for quality improvement comparisons. With respondent permission, individual's responses can be emailed and stored in a registry.
Is HowsYourHealth Self-Report Information Reliable and Valid?
The attached PDF review of the Clinimetrics provides much more detail. As an example, several studies compare medical records with patient report for preventive interventions (such as mammograms, bowel cancer screening, immunizations) and generally find 80% or greater agreement and seemed unrelated to patient education level and income.
What should be done when users are asked to email information to a bonafide sponsor such as a doctor's office?
Email address boxes should have access limited to few persons. See the attached PDF review comparing HowsYourHealth privacy concerns vs. typical medical records.
Can sponsors offer special care management programs through HowsYourHealth?
Yes. Once the sponsor has identified a target for improvement or special care the administrative section is needs to be customized. For example, early in our work we recognized that users who have pain AND emotional concerns were more bothered by their pain than those without emotional concerns. We successfully addressed this by inviting persons with pain and emotional problems to register for nurse follow-up and discussion of the exercises in the readings on pain.
How do the HowsYourHealth Family of Websites Improve Health Care?
The behavioral goal of HowsYourHealth tools is to increase the number for respondents who will attest that "I am confident that I can manage and control my health problems and concerns". These tools place clinicians and patients "on the same page" for issues that matter to the patients. They stimulate practice changes that enable more appropriate responses to "what matters" and help patients become better at managing concerns that are important to them.
Measuring Clinical Performance with CAHPS and HowsYourHealth

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is increasing being promoted as a requirement for primary care payment. In academic and government circles it is well-accepted. (see Clinimetrics.pdf for more information) However, the anticipated requirement that CAHPS be mailed to random samples of patients is raising serious concerns because of low response rates and high costs. Furthermore, patients must respond to about 40 items for which they receive no benefit because their results are not linked directly to care.

HowsYourHealth has overcome these problems by offering CAHPS as an option in a way that does not overburden patients. Based on thousands of uses we have published findings that raise serious questions about the cost-effectiveness of the anticipated measures and methods for determining service quality. We strongly suggest that the costs of developing, testing, distributing, analyzing and reporting measures using traditional mail or phone methods will inflate an already unsustainable healthcare budget and burden patients unnecessarily. [The Medium is the (Health) Measure: Patient Engagement Using Personal Technologies. In press. J.Amb.Care.Mgmt. 2012] Our goal and that of the CAHPS investigators is to offer the cost-effective method to serve clinicians and patients while meeting future desires for performance measurement.

Inserting HowsYourHealth Data into an Electronic Health Record
Electronic medical records do not have standard coding for searching the many measures that matter to patients (such as their function, their financial status, their confidence with self-management, etc.) Therefore office staff currently import the action form in either HTML or text format (a choice on customizations) as an image into lab or miscellaneous fields. Some clinicians merely cite that they used HowsYourHealth and note the pertinent positives and negatives in their progress notes. The full survey usually persuades payers to allow this notation.

Signing Up to Use (Registration)

Howsyourhealth tools are provided for free to the public. There is a nominal charge, however, for doctors' offices, health systems, employers, and community sponsors who wish to customize the HowsYourHealth tools. The charges are used to support continued testing and development of the HowsYourHealth tools. After you have tested HowsYourHealth for 50 users on your passcode, you will receive an invoice for annual payment commencing with the date of the invoice. The annual payment is not refundable. Should you decide to discontinue use after free use the names of users stored in the HIPAA secure registry will be returned to you.

The charge for HowsYourHealth Hospital and neonatal versions after 50 sponsored uses is $1000 a year for up to 3000 uses. The charge for the office practice/health system/employer version is $350 a year for up to 3000 uses. (Office practices often use the tool for as many as 10 clinicians per passcode.) There is an additional nominal charge per 1000 uses above 3000 in any year. Note that the personal health plan for patients and specials tools (for frail and decision making and problem solving) are included with any choice.

Once you have received your HowsYourHealth access code and password you can customize the site and review cumulative reports as data accrues. You may also link to the site from your own web site so that users do not have to enter your access code ­ it will be done automatically for them in the link. Go to the section for physicians and businesses and log onto the administrative section to customize your site.

You have undoubtedly heard about the power of "open groups" (such as Linux) and "wikis" (such as Wikipedia) through which users cooperate to enhance a product for the common good. Our hope is that HowsYourHealth participants like you cultivate a cooperative open group to advance high quality and extremely low cost patient-centered tools. The "News" section on the website shares collaborative updates and opportunities.

To sign up for HowsYourHealth, please complete the form.

NOTE: If you intend to have very large numbers of uses or anticipate that you would like to have HowsYourHealth on your own server, please email the webmaster. If you would like a consultant to contact you about HowsYourHealth, also please email the webmaster.

Customizing Your HowsYourHealth Tools

Merely enter sponsor customizations to changes or update your customizations such as adding questions, changing defaults, offering email transmittal for patients and thereby activating the HIPAA secure registry. Viewing the video is strongly recommended to get the most out of the customizations.

View Your Summary Reports

The summary reports contain up-to-the-minute, anonymous total responses for all survey items and your custom queries sorted in the most requested categories (such as by age group, gender, financial status, etc.). When available, summaries of the summary with comparisons to national norms are provided.

Get Your Patients from Registries

List of respondents who have consented to have there information stored in a HIPAA secure registry are currently available for adults and the very sick and frail. The lists in the registries are easily sorted by choosing "and" and "ors" to combine respondent characteristics (such as persons with diabetes AND low confidence for self-management.)

The Personal Health Plan (PHP)

Less than 10% of the US population currently has a PHP. a PHP that is often constrained by the health system and the brand of the Electronic Health Record that created it. The HowsYourHealth PHP is a tool to integrate respondent information from HowsYourHealth tools without dependence on a particular health system or vendor. The PHP is created, updated, and controlled by patients who can choose to store the information on line or place it on a "memory stick", their cell phone, their computer, and on paper. It is anticipated that respondents will also choose to share and update it with their clinicians help.

Uses and Permission

All of the tools of HowsYourHealth are PUBLICLY, available without charge (for non-commercial purposes). All patients and members of the public can use HowsYourHealth tools at any time. Health professionals may also use the HowsYourHealth tools without charge but if the health professional wishes to test and customize the tools they are required to register. There is a nominal charge for continued use of the tools after testing.

HowsYourHealth content is covered by US copyright and HowsYourHealth is a US trademark. If there is a commercial purpose (a use for which there will be either a direct or indirect charge and/or a transfer of revenue) please contact the webmaster with a brief description regarding the use of the tool or tools. We review commercial requests on a case-by-case basis. However, requests for linkages of HowsYourHealth tools to advertise commercial products and services is not allowed under any circumstances.

References

HowsYourHealth tools have a very long history of development, testing, refinement, and dissemination as described below. HowsYourHealth tools have been using the internet for about as long as Google.

Clinical Development and Testing:

[A] Nelson EC, Landgraf JM, Hays RD, Wasson JH, Kirk JW. The functional status of patients: How can it be measured in physicians' offices? Med Care 1990;28(12):1111-1126.
[B] Nelson EC, Wasson JH, Johnson DJ, Hays RD. Dartmouth COOP Functional Health Assessment Charts: Brief Measures for Clinical Practice. In: Spilker B, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. Philadelphia: Lippincott-Raven. 1996:161-168.
[C] Wasson JH, Jette AM, Johnson DJ, Mohr JJ, Nelson EC. A Replicable and Customizable Approach To Improve Ambulatory Care and Research. J Ambulatory Medicine 1997;20(1); 17-27.
[D] Wasson JH, Stukel TA, Weiss JE, et. al. A Randomized Trial of Using Patient Self-Assessment Data to Improve Community Practices. Effective Clinical Practice 1999; 2:1-10.
[E] Bronfort G, and Bouter LM. Responsiveness of general health status in chronic low back pain: a comparison of the COOP Charts and the SF-36. 1999 Pain 83; 201-209
[F] Wasson JH, Jette AM, Anderson J, et.al. Routine, Single-Item Screening to Identify Abusive Relationships in Women. J. Fam. Pract. 2000;49:1017-1022.
[G] Ahles TA, Seville J, Wasson JH, et.al. Panel-Based Pain Management in Primary Care: The Journal of Pain And Symptom Management 2001: 22, 584-590.
[H] Moore LG, Wasson JH. An Introduction to Technology for Patient-centered, Collaborative Care. J Ambulatory Care Manage. 2006; 29(3): 195-198.
[I] Wasson JH, Johnson DJ, Benjamin R, Phillips J, et al. Patients Report Positive Impacts of Collaborative Care. J Ambulatory Care Manage. 2006; 29(3): 199-206.
[J] Wasson JH, Ahles T, Johnson D, Kabcenell A, etal. Resource Planning for Patient-centered Collaborative Care. J Ambulatory Care Manage. 2006; 29(3): 207-214.
[K] Moore LG, Wasson JH, Johnson DJ, Zettek J. The Emergence of Ideal Micro Practices for Patient-centered, Collaborative Care. J Ambulatory Care Manage. 2006; 29(3): 215-221.
[L] Wasson J, Benjamin R. Postscript. Health Disparity and Collaborative Care. J Ambulatory Care Manage. 2006; 29(3): 233-234.
[M] Wasson J. Technical Notes. When All Things Are Not Equal. J Ambulatory Care Manage. 2006; 29(3): 235-237.
[N] Ahles TA, Wasson JW, Seville JL, Johnson DJ, etal. A Controlled Trial of Methods for Managing Pain in Primary Care Patients With or Without Co-Occurring Psychosocial Problems. Ann. of Family Med 2006; 4(3): 341-350
[O] Moore LG and Wasson JH. Ideal Medical Practice: Improving Efficiency, Quality, and the Doctor- Patient Relationship. Family Practice Management. 2007; September: 21-24.
[P] Wasson JH, Mackenzie TA, Hall M. Patients Use an Internet Technology to Report When Things Go Wrong. 2007 Quality and Safety in Health Care; 2007:16:213-217.
[Q] Wasson JH, Johnson DJ, and Macknezie T. The Impact of Primary Care Patients' Pain and Emotional Problems on their Confidence with Self-Management. Jamb CareMngmnt. 2008;31: 120-127.
[R] Wasson JH. Who is in charge? Even affluent patients suffer consequences of fragmented care. JAmb CareMngmnt. 2008;31: 35-36.
[S] Guinn N and Moore LG. Practice Measurement: A new approach for demonstrating the worth of your work. Family Practice Management 2008: Feb. 19-22
[T] Wasson JH, Johnson DJ, and Mackenzie T. The Impact of Primary Care Patients' Pain and Emotional Problems on their Confidence with Self-Management. Jamb Care Mngmnt. 2008;31: 120-127.
[U] Wasson JH, Bartels S. CARE Vital Signs Supports Patient-Centered Collaborative Care. Jamb Care Mngmnt. 2009;32: 56-71.
[V] Wasson JH, Baker NJ. Balanced Measures for Patient-Centered Care. Jamb Care Mngmnt. 2009;32: 44-51
[W] Yasaitis L, Fisher ES, Mackenzie T, and Wasson JH. Health Care Intensity is Associated with Lower HealthCare Quality by Adults. J.AMB.CARE.MGMT. 2009; 32: 226-231
[X] Wasson JH, Benjamin R, Johnson D, Moore LG, and Mackenzie T. Patient Use the Internet to Enter the Medical Home. J.Amb.Care.Mgmt. 2011; 34:38-46 32: 299-302.
[Y] John H. Wasson, MD Helena Hvitfeld Forsberg Staffan Lindblad Garey Mazowita Kelly McQuillen Eugene C. Nelson. The Medium is the (Health) Measure: Patient Engagement Using Personal Technologies. In press. J.Amb.Care.Mgmt. 2012

Community/School Development and Testing:

[A] Wasson JH, Kairys SW, Nelson EC, Kalishman N, Baribeau P. A short survey for assessing health and social problems of adolescents. J Fam Prac 1994; 38(5):489-494.
[B] Bracken AC, Hersh AL, Johnson DJ. A Computerized School-Based Health Assessment with Rapid Feedback to Improve Adolescent Health. Clin. Pediatrics 1998;677-683.
[C] Wasson JH, James C. Implementation of a Web-based Interaction Technology to Improve the Quality of a City's Health Care. J. Amb. Care Managem. 2001;24: 1-12
[D] Luce P, Phillips J, Benjamin R, Wasson JH. Technology to Support CommunityHealth Alliances. J. Amb. Care Managem. 2004;27: 399-407

Sample References:

Additional Helpful Materials (PDFs)