By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting
On Call Magazine, June 25, 2008

The U.S. Agency for Healthcare Research and Quality (AHRQ) is charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans. So why is AHRQ producing “Questions Are the Answer” — an upbeat, musical consumer campaign that encourages patients to ask questions?

Getting patients involved

Carolyn M. Clancy, MD, is director of AHRQ. She explains that “Questions Are the Answer” aims to reduce the number of preventable harms happening to patients each year. Data from the Institute of Medicine’s report To Err Is Human show that approximately 120 people each day die from preventable harm. That’s more than 43,000 people each year who die from medical mistakes that do not need to happen.

The “Questions Are the Answer” campaign builds on what patients and providers agree is important — that patients should be involved in their own healthcare. Involved patients tend to have better health outcomes, and asking questions is an important, though admittedly basic, way to be involved. “Yes, it is straight forward. But people don’t do it. This is a huge opportunity,” says Clancy.

Cindy Brach, a Senior Health Policy Researcher at AHRQ, tells a sad story that illustrates the importance of overcoming cultural as well as communication barriers. Spanish-speaking parents brought their teenage son to an emergency room because of some concerning symptoms. Without an interpreter, there was miscommunication about the symptoms and doctors treated the teenager for a drug overdose. The parents knew their son, an anti-drug athlete, had not taken drugs. But they felt it was disrespectful to question the doctor and so stayed silent. The boy was later diagnosed with a brain aneurysm and is now quadriplegic. Brach says that it’s important to make clear that asking questions is neither rude nor insulting. AHRQ has just launched a Spanish-language campaign, “Sea un Superhéroe” (Be a Superhero) that underscores the message that providers want and expect patients to ask questions. Like “Questions Are the Answers,” it includes a list of questions patients can use to know what to ask doctors.

Multiple resources from multiple partners

“Questions Are the Answer” was developed by AHRQ in conjunction with the Ad Council, explains Allan Lazar. Lazar is AHRQ’s director of communications and knowledge transfer. The campaign was launched in March 2007 and is funded largely by donations of time and talent from the advertising industry and media outlets. “Questions Are the Answer” includes several components:

• Web site. The Web site has a plethora of practical consumer information, including “5 Steps to Safer Healthcare,” “20 Tips to Prevent Medical Errors,” and links to both a resource list and a glossary of “How to Speak Health Care.”
• Question builder. On the Web site is a question builder — an extensive listing of important questions plus a way for people to choose which ones they need to ask their healthcare provider. Once people have picked their questions, they can print them. The page they get is already formatted with space to write the answers.
• Video. Honestly, this video is my favorite way to highlight the importance of question-asking. I often show it in health literacy presentations. The video is musical, memorable, and extremely well done. You can access both the 60-second and 30-second versions on the Web site.
• Other formats. “Questions Are the Answer” information is available in formats suitable for television, radio, newspapers, magazines, the Web, and outdoor advertising. Lazar says that media outlets have so far donated more than $27 million worth of free advertising to this campaign. It is also shown on the Patient Channel (satellite television) in 1,700 hospitals and reaches nearly 15 million patients across the country.

Helping patients use questions to better understand health information

Clancy, Brach, and Lazar all have suggestions about how clinicians can use “Questions Are the Answer” to help their patients better understand health information.

Be a voice of encouragement. It almost always feels intimidating to be a patient. One reason is that hospitals, clinics, and other healthcare settings are busy places with many professionals bustling about. “This obviously doesn’t invite patient engagement,” says Clancy. “As a doctor, we send many signals to not interrupt the flow.”

Patients not only can feel intimidated by the environment but also forget what questions they wanted to ask. “In the office, these questions can go out the window,” says Clancy. She recommends that clinicians encourage patients to make a list of questions ahead of time. This way, they have a “roadmap” for what they want to learn more about and discuss with their providers.

Elicit questions in helpful ways. Many patients are reluctant to ask questions of health care providers. Clancy cites an unpublished study showing that men, in particular, ask few questions. From the time they arrive at a healthcare setting until they leave, men ask an average 1.4 questions (and this includes questions about parking!).

Brach recommends providers elicit questions with open-ended phrasing such as “What are your questions?” This lets patients know that questions are expected, as opposed to what happens when you ask almost rhetorically, “Do you have any questions?” Providers can also help patients think of what to ask by referring them to the question builder on the “Questions Are the Answer” Web site. You can learn more about other ways to elicit questions by going to “In other words…Helping Patients Ask Questions.”

Consider “Questions Are the Answer” as a checklist of topics to discuss. Brach cites research showing that over 50% of the time physicians do not give specific dosing directions to patients when prescribing a new medication. She says that the topics on “Questions Are the Answer” cover core information that providers need to communicate and patients must understand.

Create systems to accommodate questions. Question-asking is the responsibility of both patients and providers. “I would love to see more practice settings where patients’ questions and need for information are anticipated and done upfront,” says Clancy. She believes that if basic questions are dealt with first, there will be more time to then focus on each patient’s unique needs.

Of course, time (or lack thereof) is a concern for all providers. Brach recommends that healthcare administrators consider who else, other than doctors, can answer patients’ questions. When she sees one of her doctors, Brach says the doctor is with her for just a short time while the nurse remains to answer questions and review medication instructions. Brach recommends that practices look for efficient ways to answer questions as patients move through the system.

Verify and confirm understanding. Confirming patient understanding is an essential part of all health communication. Clancy, Brach, and Lazar agree that it is one thing for patients to ask questions and another to make sure they understand the answers. One way to confirm understanding is by using the teach-back technique. This happens when clinicians ask patients to state in their own words (teach-back) key points just discussed. Brach finds that many providers are good at explaining information but less skilled at confirming understanding. To learn more about the teach-back technique, go to “In Other Words…Confirming Understanding with the Teach-Back Technique.”

“Questions Are the Answer” is more than just a campaign about asking and answering questions. Lazar says that when patients ask questions of their providers, they clearly communicate the message, “I am interested in my own healthcare and want to take care of my health.”

Ways to learn more:

Questions Are the Answer website

To learn more, contact Allan Lazar at allan.lazar@ahrq.hhs.gov

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. She received two “Gold 2008 Plain Language awards from NIH for her work on the NCI booklets “Radiation and You” and “Chemotherapy and You.”Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.