INET Conferences

Bringing Knowledge to the Point of Use: One Company's Experience in Bringing Health and Well-Being Information to End Users

Marcie PARKER <mparker@uhc.com>
R. Edward BERGMARK
Optum
USA

Abstract

This paper provides a brief overview of Optum, a description of Optum Care24, the company's broad health and well-being service (of which the Internet is part), and a detailed description of the Internet portion of the service. This is followed by how end user privacy is addressed. The paper ends with an overview of some of the ongoing challenges to integrating the Internet into a health and well-being service.

Contents

• Introduction
  • The company: Optum
  • The service: Optum Care24
  • The Internet
• Confidentiality and privacy
• Reporting
• Challenges
• Bibliography
• Author

Introduction

The company: Optum

Optum has set out to integrate the Internet into its health and well-being service, known as Optum Care24. The goal is to help individuals and families manage their health and overall well-being. Optum is part of the Specialized Care Services unit of United HealthCare Corporation, a national healthcare management firm serving purchasers, users, managers, and providers of healthcare worldwide since 1974. Optum covers over 13 million lives in 44 major markets and 135,637 employer or public sector groups. It employs 300+ counselors and nurses and has service centers (call centers) in five states. In 1996 (when Optum's enrollee base was 9 million), the company had 28,220,416 contacts with enrollees through the telephone, the audio tape library, the Internet, print media, worksite events and training, critical incident stress management services, and in-person sessions. In the first quarter of 1997, there were 5,361,486 contacts.

The service: Optum Care24

Optum Care24 addresses both health concerns and daily living needs 24 hours a day and 7 days a week. The service includes

• A nurse call-in line staffed by registered nurses offering health and medical information as well as education and support (Optum NurseLine);
• An emotional and mental health call-in line staffed by master's level counselors (Optum Assistance);
• Dependent care information (e.g., child care, elder care, help finding daycare/school/college, adoption services);
• Financial information;
• Legal assessment and information;
• Critical incident stress management services (death of an employee/spouse/customer, robbery, violence in the workplace, illness, accident, downsizing, employee termination, natural disaster, murder, fraud and swindle, organizational conflict, government furlough); and
• Management consulting (for managers dealing with employees who are experiencing problems such as alcoholism, absenteeism, depression, or other work-related issues).

The goal is to address all factors that affect health and well-being such as health concerns, family problems, work stress, financial troubles, legal worries, and substance abuse issues. This is accomplished through multiple access points to help end users access health information when, where, and how they need it. Optum's Care24 approach recognizes that physical, psychological, and social factors are all important and interrelated influences on the individual's, as well as the family's, health.

Optum client self-report results indicate that after using Optum Care24, 89% of end users experienced less stress, 70% had improved family relationships, 50% would have taken time off from work if they had not contacted the service to deal with their issue, and 92% felt better about their employer for offering the service. Twenty-four percent would have accessed the medical system for their issue, 99% felt the service was a valuable part of their benefits, 73% felt an improved sense of physical well-being, and 99% reported that they would use the service again if they needed it.

In this way, Optum Care24 focuses on the overall health of end users. It also provides a variety of information, education, and support services to address any issue that affects the consumer's overall well-being. It gives consumers information on the resources that most appropriately address their needs. It provides access to experienced professionals such as registered nurses, master's level counselors, attorneys, financial consultants, and dependent care advisors. The service supports end users with frequent needs around daily living concerns or helps in crisis situations. It also empowers end users to manage proactively their own health and well-being.

Multiple access points are provided because people have different learning styles and different lifestyles and need to access the information they seek in a variety of ways -- these may change over time or depend upon the topic being researched. These multiple access points include

• Telephone (inbound calls, outbound calls, follow-up calls, satisfaction surveys, and customer service support calls);
• In-person face-to-face interventions (in-person sessions, worksite events and training, and critical incident stress management services);
• Print media (brochures, magnets, postcards, posters, newsletters, product surveys and booklets, self-care books, prenatal program kits, health risk assessments, new customer welcome packets and postcards, affiliate newsletters for affiliates who provide face-to-face services, quarterly/monthly/annual reports, and customer encounter faxes to hospital emergency departments);
• Audio tape (audio tape library calls to listen to a variety of health and wellness topics); and
• The Internet.

The Internet

There is an explosion of information currently available to clinicians, patients, and families through many sources. Two recent studies (Miller and Clemente, 1997; Kehoe, Pitkow, and Morton, 1997) illustrate the growing importance of the Internet, especially for consumers looking for health information. By the end of 1997, it was estimated that there were about 40 million American Internet users or about 15% of the population. The user's average age was 33 years and 69% of users were male while 45% were married. Sixty percent accessed the Web from home. The average household income was $58,000. About 54% of Internet users had a college degree and 89% classified themselves as Caucasian/white. More than 85% used the Web daily, between one and four times, for an average of 14 hours per week. These researchers found that the most common Web activities included gathering information (86%), searching (63%), browsing (61%), work (54%), education (52%), communication (47%), and entertainment (45%). Most importantly, over 43% of users retrieved health or medical information from the Internet.

Statistics seem to support that some end users are more comfortable being anonymous when they access health and well-being information (Gustafson et al., 1994; Pingree et al., 1993; McTavish et al., 1994). They are more at ease getting information from a computer program or Internet format, especially if they want to research sensitive questions that cause embarrassment or need information about potentially stigmatizing conditions such as AIDS or sexually transmitted diseases.

As one 60-year old woman recovering from a radical mastectomy said, "With the computer, you can ask questions you'd be too embarrassed to ask a doctor, and it's there every minute of the day and night. You never feel alone." Shirley H.

At the same time, consumers who use the Internet are often faced with online information overload.

Some end users prefer that others take this massive amount of information and make certain it is credible, reliable, and medically accurate. While consumers say they have plenty of information, many acknowledge they need help filtering and prioritizing it according to their particular health interests. They want quality information in the format and at a time and place that is most convenient for them. Their chief online concerns are that information be credible, accurate, timely, understandable, accessible, relevant, unbiased, and applicable to their needs. They would also like the system to have a wide breadth and depth of information and to offer an interactive community environment. Consumers are seeking healthcare information where and when they need and want it, with an assurance of superior quality and low cost (Deering and Harris, 1996).

Optum has developed a single Internet application that provides health and well-being information as well as a member services function. The health and well-being information consists of reference materials which are "pushed" to end users through individual profiles as well as access to online and telephonic nurses and counselors. The member services function allows end users to communicate with their health plans. For instance, they can read about their particular plan benefits, look up a provider and select a map and driving directions to the provider they choose, and e-mail/contact their member services representative if they have a claims question or need a new identification card.

The services included in the newest version of this Internet application are

1. A front section available to individuals covered by Optum services. This front section provides some highlights of what is found in the log-in section described below. It is designed to entice the user to dig further. It is a broad overview of useful information but the end user cannot work with it to the extent that he or she can in the log-in section -- users cannot, for example, save, archive, or search the information to the degree that those in the log-in section can.
   This front section is essentially an online health and wellness newsletter that is updated two to three times a week. Information includes health and wellness articles, summaries of current health journal articles and news, health and wellness tips, postings of user questions and the responses provided by counselors and nurses, live events (or online discussions on important health and wellness topics hosted by counselors and nurses), and e-mail notices specific to the members' concerns.
   
2. A log-in section with a higher level of customization, which the user enters with a password. This section is a secured Web site that allows eligible users full access to the service's database through a variety of features; it allows the user to customize the site to his or her particular needs. Web site features include a personal profile where users can choose topics of interest, and information is delivered behind the selected topics. The information comes from an encyclopedia, a dictionary, recent articles and materials, and resource references including Web sites, books, and national associations.
   There is also information that relates to the chosen profile topics, questions and answers by a nurse/counselor team, a listing of all topics and toll-free numbers for the 900+ topic audio tape library, interactive tools, an e-mail newsletter, folders where the user can create custom archives of selected information, online searches, the ability to send articles to anyone with an Internet e-mail address, and a variety of member service functions including benefits information, the ability to contact member services [for example, to replace a member card], and a provider directory with a mapping feature.

The log-in section also features a Q&A option where users e-mail questions to counselors/nurses on health and wellness topics.

For example, one user of the online service was about to give birth to a disabled child. The counselor and nurse were able to provide the couple with a great deal of information about perinatal issues, how to protect the health of the mother and child, where to find specialized medical care for the child, genetic counseling about possible future pregnancies, information on support groups, spiritual support, and community services as well as financial aid and insurance coverage for the family. They also discussed how to handle any possible feelings of isolation, guilt, depression, anxiety, or grief the family might experience. They then provided the family with lists of specialized hospitals, hotlines, and Web sites and invited them to write back if they had more questions or if their needs changed.

Commonly asked questions in this Q&A section are selected and answered for users to read on a weekly basis.

Typical issues addressed online have included such things as "I suspect my daughter is making herself sick after she eats. What do I do?" or "I recently turned 40, my marriage of 16 years has ended, and my job seems to be going nowhere. I also seem to be having lots of headaches and low back pain."

Users can also sign up for e-mail notifications of information; compared to those found in the front section described above, these notices are more robust and have customized content. Optum's proprietary health information topics (such the symptoms of depression, Alzheimer's Disease, or enuresis) are being adapted for layperson's use and made available from a searchable encyclopedia of features. The full list and toll-free phone numbers of the health and wellness audiotape library are also published in this section. Users can access an archive of company-developed interactive tools, such as health and wellness quizzes, symptom guides (taken from Optum's self-care book titled Taking Care), and planners (for planning when to do daily or monthly screenings or get the children to the pediatrician for vaccinations on schedule). In the future, Optum may add calculators to allow end users to monitor their blood sugar or to calculate their blood pressure or other readings for prevention and well-being. Users can also set up folders to create customized archives of selected material. They have the ability to e-mail material to anyone with an Internet address. And finally, users who have access to other Optum services see a display with their specific toll-free phone number for calling a nurse or counselor.

The most recent version of this Internet service works primarily from Optum content, material that is largely not found elsewhere on the Web. Ninety to ninety-five percent of the content is company-produced and assembled in unique ways. The site runs from a content database and content management system; this is cutting-edge Internet technology that offers efficiency, content accuracy, site performance improvement, and greater opportunities for customization for developers, the end user, and the buying customer (usually an employer group, a public sector agency, or health plan). This version is more integrated with other Optum platforms and access points than the earlier version; this integration helps ensure consistent messages and greater service to end users.

There are many sources of information contained in the database. These include

• Company-developed health and wellness articles from 1995 through the present;
• Excerpts on common symptoms and ailments from the company-produced self-care book;
• Health and wellness reference information written by Optum's clinical staff for a lay audience;
• References to national health and support resources from the company's databases;
• References and brief summaries of screened Web sites;
• Over-the-counter and prescription drug information from a leading pharmacology publisher;
• Archives of all past live event transcripts (scheduled one-hour live, real-time Q&A sessions on such topics as depression, caring for elders, planning for retirement, diabetes, smoking cessation, choosing a daycare facility, or fibromyalgia); and
• Archives of screened questions submitted to Optum nurses and counselors as well as their responses.

In addition to these external uses, the Internet also provides advantages to Optum's professional staff. All staff have access to the Internet and are trained to find information that could benefit their clients or assist them in their own work. The Optum intranet allows staff to work from common clinical practice guidelines, to share practice guidelines across disciplines, and to share information for case coordination.

For example, Optum Assistance guidelines for the emotional/mental health call-in line list the biological, psychological, and social/behavioral characteristics of the topic under discussion as well as recommended treatments, client resources [often on the Internet], and references. Also listed are assessment questions about the physical/medical status, the psychological status, and the social impact that the end user is experiencing as a result of his or her concern. Interventions and action plans by level of severity of the call are also included.

Confidentiality and privacy

While absolute privacy can never be guaranteed, Optum uses the most current technology to secure its Web sites. This includes firewall technology and numerous other security measures. Privacy is addressed through the use of SSL (Secure Socket Layers, an encryption protocol). Privacy is further addressed through the use of a personalized Web page, accessible only through the member's user number and a password selected by the user when he or she first signs on to the system. What the individual sees is a personal Web site which becomes his or her own personal health or issues page, accessible only to the user; this includes any future issues or questions generated by the end user. While the identity of users who have accessed specific topics is part of the Optum data system, this is never shared with the client (employer, health plan, or public sector purchaser) except in an aggregated report.

Other security features include the following:

• Web servers are dedicated to their function, are not multipurpose platforms, and are not shared with organizations outside Optum;
• Web servers are not located on shared LAN segments;
• No sensitive data are stored on the Web server (all sensitive data are stored within Optum networks);
• The path between the Internet and Optum Web servers is protected from attack;
• The Internet path between end users and Optum's dynamic-content Web servers is encrypted;
• The network path between Optum Web servers and Optum internal systems is protected by firewalls;
• All identification, authentication, and authorization decisions are made internal to Optum and none are made on Internet Web servers; and
• State-of-the-art security mechanisms are used in the construction of the Web server environment (network infrastructure, the Web server platform operating the system, the Web server software and configuration) as well as interfaces to Optum back-end systems. This results in multiple layers of protection with each layer independent of the others so that the failures of a single layer do not result in the release of confidential information (Optum Internal Document: Internet Content Hosting Architecture, 1998).

In addition, the Health Insurance Portability and Accountability Act of 1996 spells out extremely severe penalties (escalating prison sentences and fines) for anyone violating client privacy. Any person who maintains or transmits health information must maintain reasonable and appropriate administrative, technical, and physical safeguards to ensure data integrity and confidentiality and to protect against any reasonably anticipated threats or hazards to security, integrity, unauthorized uses, or disclosures (Optum Internal Document: Internet Content Hosting Architecture, 1998).

Reporting

In order to respect end user privacy, Optum never reports on individual users and their requests for information. Aggregated reports are provided on the numbers of consumers using the Internet as well as all other access points.

If aggregated Optum reports show that female employees in a client company are confused about estrogen replacement therapy [ERT] and their many treatment options, or that men are confused about prostate cancer treatment options, Optum might alert the client and their network of healthcare providers that they need to focus on ERT or prostate screenings in their newsletters, member education efforts, provider training, and other outreach efforts.

Challenges

Integrating Internet technology into healthcare or any other profession is in its infancy. What Optum is trying to do is dynamic, developing, and under constant refinement. In designing Optum's current system, the goal has been to help each end user filter information to make it more conveniently available. It is important to look at each process that is being put online to make sure it is more convenient than what is currently available. One ongoing challenge is to decide if Optum is replicating its telephonic service (the original service, in essence a "human library" involving access to nurses and counselors) on the Internet or providing a service that is unique but as yet undefined while shaped by the capabilities of the medium. In fact, Optum is pursuing both goals in its attempt to embrace the medium and greatly expand what is offered to end users.

Another challenge involves implementing a company-wide paradigm shift so that the service is less passive (e.g., waiting for the caller to call) and more proactive/interactive. For example, Optum hopes to do active community outreach to schools, churches, and support groups in order to give them access to information via the Internet. In addition, Optum has integrated a personal health-risk assessment tool into its Internet application, one which triggers alerts and reminders for the end user at appropriate times.

For example, Optum uses a "push technology" where end users can program an e-mail reminder to themselves to do a monthly breast self-exam or other appropriate screening measures on a regular basis.

Optum also struggles with the idea of putting books and other "flat" materials onto the Internet in a "flat" way. This is not the best use of the Internet and may not be particularly cost-effective. Optum is trying to make everything it does interactive -- this is the real strength of the Internet. In a way, the Internet is suddenly transforming a service organization into a health communications organization, where Optum is reshaping its diverse content to fit the medium. Thus Optum is seeking to bring together, in a coherent and integrated way, all of its resources; at the same time, it is attempting to put whole libraries at the fingertips of end users.

Optum also plans to provide real-time aggregated data on service utilization, including total hits, services used, time of day, and origin of visitors by domain name. In addition, Optum is currently developing ways to track and report its outcomes research -- both qualitative and quantitative -- on its efforts to integrate the Internet into what it offers. Ideally, in the future, Optum researchers would like to evaluate the impact of Optum's Internet interactivity on end user

• Quality of life;
• Healthcare utilization;
• Satisfaction; and
• Knowledge and skills in accessing and using services that improve his or her health and well-being.

Optum is not interested in analyzing or reporting information at the individual level, but if many employees in a client company report high levels of stress or depression, there might be special outreach efforts as well as changes to employer policies to help alleviate employee stress.

A major challenge for American healthcare in general is how to do a better job of meeting the needs of a rapidly diversifying population. As access points and new technologies are developed, the needs of illiterate, functionally illiterate, or marginally literate users should be considered (Minneapolis Star Tribune, 1998). Companies can readily and easily translate their databases and text into any written language, but what is really known about the diverse healthcare paradigms and health-seeking behaviors of culturally diverse end users? Can the United States guarantee plenty of public access points so that poor and homeless Americans can use the system? Failing serious consideration of these issues, some Americans will be at a disadvantage both in accessing the information they need and in knowing how to put it to use once they have accessed it.

In the future, Optum foresees an era of "digital convergence," when the computer will be as easy to use as the television set and consumers will be able to get health and well-being information when and how they want it. This will come with the Internet's emergence and maturation as an integrating medium for the access points of voice, audio, face-to-face communication, and print media. The information infrastructure of the 21st century will enable all Americans to access information and communicate with each other easily, reliably, securely, and cost-effectively in any medium -- voice, data, image, or video -- anytime, anyplace. Future access points, platforms, and delivery systems are limited only by the world's collective imagination.

Optum is seeking to ensure that end users are empowered to cope with new disease diagnoses and to manage chronic conditions more effectively. The goal is to simplify and enhance access to information and at the same time to provide support and education to families and caregivers. Optum wants to provide help with the problems of daily living, enhance the continuity of care, and alleviate feelings of isolation experienced by families in the community. In short, Optum wants to respond to the changing work and lifestyle trends of end users.

Some Americans feel overwhelmed by their complex roles and responsibilities. Many Americans now have older family members as well as young children for whom they care. They are experiencing increasing levels of stress and are struggling financially. A health and well-being service that is truly end-user-focused can go a long way toward helping Americans deal with these issues quickly and effectively, before they affect quality of life.

Bibliography

Deering, M.J., and J. Harris. Consumer health information demand and delivery: implications for libraries. Bull Med Libr Assoc 1996 April; 84(2): 209-216.

Gustafson, D.H. 1993 Personal communication from Shirley H., a participant in the CHESS study.

Gustafson, D.H., R.P. Hawkins, E.W. Boberg, E. Bricker, S. Pingree, C.L. Chan. The use and impact of a computer-based support system for people living with AIDS and HIV infection. Proc Annu Symp Comput Appl Med Care. 1994: 604-608.

Kehoe, C., J. Pitkow, K. Morten. GVU's 8th WWW User Survey. December 1997. http://www.gvu.gatech.edu/user_surveys/survey-1997-10

McTavish, F.M., D.H. Gustafson, B.H. Owens, M. Wise, J.O. Taylor, F.M. Apantaku, H. Berhe and B. Thorson. CHESS: An interactive computer system for women with breast cancer piloted with an under-served population. Proc Annu Symp Comput Appl Med Care 1994: 599-603.

Miller, T.E., and P.C. Clemente. The 1997 American Internet User Survey: Realities Beyond the Hype. FIND/SVP Emerging Technologies Research Group (phone: 800-539-7126). http://etrg.findsvp.com/internet/findf.html

Minneapolis Star Tribune. "Illiteracy and ill health in chronically ill patients." Variety section, page E1, February 10, 1998.

Optum Assistance Clinical Guidelines, 1997 and 1998.

Optum Internal Document: Internet Content Hosting Architecture, 1998.

Optum Internal Reports, 1997

Optum Internal Reports on Satisfaction and Utilization 1995-1997

Pingree, S., R.P. Hawkins, D.H. Gustafson, E.W. Boberg, E. Bricker, M. Wise, T. Tillotson. Will HIV-positive people use an interactive computer system for information and support? A study of CHESS in two communities. Proc Annu Symp Comput Appl Med Care 1993: 22-26.

Author

Marcie Parker, PhD, CFLE, is Senior Qualitative Researcher and Manager of Senior Programs and R. Edward Bergmark, PhD, is President, both with Optum, part of the Specialized Care Services unit of United HealthCare Corporation, a national leader in healthcare management and health and well-being services that serves customers and clients worldwide. Dr. Parker is an anthropologist, a gerontologist, a Certified Family Life Educator, and a strong family and consumer advocate within managed care. Dr. Bergmark envisioned and has implemented the health and well-being concept as a broader definition of healthcare for more than a decade. His PhD, from the University of Minnesota, is in Clinical Psychology. Dr. Parker may be reached by phone at (612) 797-2718 in the United States or via e-mail at mparker@uhc.com. Interested parties may wish to visit http://www.optumcare.com or http://www.unitedhealthcare.com.

This paper was prepared and submitted for the INET'98 Conference July 21-24, 1998 in Geneva, Switzerland, under the Health Track, for a Panel chaired by Mary Jo Deering, PhD on "Health informatics for consumers and patients: innovations to extend and enhance health care." Dr. Deering is Director of Health Communication and Telehealth, Office of Public Health and Science, U.S. Department of Health and Human Sciences, in Washington, DC.