The Second Time Around

Refining iN Touch for a Second Cohort

Holly Logan, M.A., iN Touch Project Coordinator, San Francisco State University

During the first cohort, we came across many challenges; some we had anticipated and others surprised us. These learnings allowed us to refine our design and conduct a second cohort. For the second cohort, each participant started out with health coaching only for two months, then received an iPod Touch, and coaching plus TheCarrot’s customized iN Touch application for two months. The refinements addressed the three major challenges faced by the first cohort: 1) Access to Wi-Fi, 2) Coaching protocol, and 3) Staying in contact with the participants.

Many participants told us that the number one reason they had problems with recording their ODLs was because they did not have Wi-Fi at home and did not know where to access it. Although we had installed a Free Wi-Fi Finder app on their iPods, it still seemed that the participants faced a major obstacle when it came to finding Wi-Fi to record their ODLs. To address this issue, we asked Mission High School for permission to give the participants the Wi-Fi password at school. They agreed, so during the iPod provisioning, we entered the password into each device and informed the participants that they could record their ODLs during lunch and after school. This has been working well for the new cohort.

The second challenge was the initial health coach protocol we had created, which detailed how the health coach should direct participants about what to record, when to record, etc. For the first cohort, we sent reminders to ask participants to record, but we didn’t have a set schedule of what we wanted them to do on a weekly basis. For the second cohort, we developed a Health Coach Guide that the health coach was to follow each week when meeting with the participants. This included setting goals, asking participants to record, checking in through text messages and updating the health coaching logs as well as measurements at each visit. This has helped keep the coach and participants better engaged through each step.

Finally, communicating with the patients and scheduling them to come down during school hours was an issue with the first cohort. We had been using a texting application called Text4Plus, but a lot of the participants were not getting our texts. We had no way to know if they had received our messages or not. For the second cohort, we updated all of the iPods by installing iMessage, and sent and received messages through that application. iMessage allowed us to verify whether a message had been delivered.  If it did not say ‘delivered,’ we knew to send it again until it was delivered. This has helped us stay in better contact with the second cohort, and we have been able to easily let them know when we have sent a pass for them to come see us during school hours.

We are now in the third month of the new cohort, and we may still face challenges in the next two months. However, we’ve had a lot of success with giving the participants the Wi-Fi password, following a detailed protocol and keeping in contact with them through iMessage.

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The iN Touch Approach to Device and Data Security

Holly Logan, iN Touch Project Coordinator, San Francisco State University

When we issued iPod Touch devices to participants, we knew some would be lost or stolen. We installed the Find iPhone application on each device that would allow us to locate a missing device, send messages, lock or wipe it.

The first time a participant came to us to inform us that their iPod Touch had been stolen, we took the necessary precautions: we locked it right away, sent a message to the iPod Touch indicating it was now stolen property and waited for it to hit Wi-Fi so that we’d be able to locate it. That was the catch. In order to be able to locate or wipe the device, it had to connect to Wi-Fi. And to throw in another step, when you choose to remote wipe the device, you can no longer locate it. So you have to take your chances here and work with the participant to see if they think they will be able to ask around and locate it, or think of who could have taken it and from where, etc. That was where it was tricky: Was it really stolen and gone forever, or was it temporarily misplaced?

When our first “situation” arose, the health coach had only spoken with the participant, who had said it was stolen. We decided to lock the device remotely and wait for it to hit Wi-Fi. In the meantime, we met with the participant to see what they thought about the device’s status. We asked “Do you know who stole it? Do you think you will be able to get it back?” When we determined that the participant knew who had stolen it, that they were adamant that they would never be able to retrieve it, and that they did not feel comfortable accusing the person, we decided to remotely wipe all data from the device.

However, we followed another process if we had reason to believe that the iPod Touch was simply lost, because we knew we might be able to recover the device. This happened with one participant who called and told us she had lost her iPod Touch after a day of running errands. She had searched her house high and low and looked in her car. The last place she remembered having seen it was when she was at Target.  I immediately locked the device and sent a message to it, which indicated that it was lost property and needed to be returned. Luckily the iPod Touch was going in and out of Wi-Fi, so I was able to see the location. When I told her the location, it turned out it was at her address. I asked her whether a neighbor could have taken it, or if she could have left it in her car. I had her go into each room and listen as I triggered a sound on her device. She still couldn’t find it. She decided to check her car, and I continued to play the sound. She finally heard it and found it jammed under the passenger seat of the car.  Thankfully, we had decided to search for it before remotely wiping it, otherwise all of her data would have been gone forever. When a device was reported lost, we decided it was important to give it at least a week to try to locate it. After that time, and if it was still lost, we decided it was a good idea to remotely wipe it as a security measure.

Unfortunately for all of the participants whose iPod Touches were stolen, none of them were returned, and we ended up wiping them all once they hit Wi-Fi. In each instance, the Find iPhone app has turned out to be a valuable tool that allows us to take the right steps to ensure the privacy and security of the participant’s health data and to  help the participant locate their device.

Images courtesy of Find iPhone app

If I’d Only Known Then What I Know Now (A Letter to Myself)

Katherine Kim, M.P.H., MBA, iN Touch Principal Investigator, San Francisco State University

Dear Kathy,

Three years from now you are going to be finishing the iN Touch project. You’ll have done some things well, made plenty of mistakes, and learned so much. I’m writing this letter to share some of those lessons.

1. You and Christina made the right decision to apply for the Project HealthDesign grant, even though you were worried because those grants from the Robert Wood Johnson Foundation are so competitive.


2. When you start hitting road bumps, lean on your team. Christina, Hali, Judy, Cam-tu, Holly, Ed, Janelle, and Yulia will amaze you with their creativity, optimism, gumption and all-around smarts.


3. The IRB approval process will take twice as long as you expect. The phased IRB that Barbara Massoudi suggests will be the way to go. Submit the application design and testing IRB right away, then work on the intervention IRB which will probably undergo some changes based on the testing. Just-in-time IRB will not be soon enough.


4. Recruitment will take twice as long as you expect. Prototype your recruitment process with the clinicians and staff. Don’t be discouraged by the disconnected phone numbers and no-shows. Remember that life is complicated and messy for the patients. Start recruiting as early as possible.


5. Over-recruit. I just said life is complicated and messy for patients. Even if they want to finish the study, a third of them won’t be able to. Don’t feel bad, this is typical for health and lifestyle studies and those studies with younger and minority participants have even higher dropout rates. You’ll need to recruit more to compensate.


6. Developing attractive, useful reports of ODL data will be harder than you expect. The clinicians won’t know exactly what they want so you’ll have to start out with a mock-up. Recruit a visualization/design expert next time.  Oh yeah, the hospital, clinic, and school will all be on different browsers and versions and they won’t want to update just for you. So make sure to test the reports on multiple browsers.


7. Use multiple communication modes for reminders and scheduling. Paper notes still work!  Deliver them to the classroom to remind youths to come to their appointments. Some of them will want reminders to record ODLs through their iPod Touches, others via text messages to their phones. Forget about email – they never check email.


8. Be ready to educate and evangelize. Hospital, clinic, and school staff members haven’t heard of observations of daily living (ODLs) before and they’re not sure how they feel about mobile technology. You are not just asking them to partner with you on a project, you are asking them to change how they work and engage with patients.


9. The youths who participate in the study will amaze you. They are motivated and excited to use the technology and new strategies to meet their health goals. They’ll teach you a lot about improving health behaviors.

Have a great time with the iN Touch project.

Kathy

Is Theory-based Design Practical?

Katherine Kim, M.P.H., MBA, iN Touch Principal Investigator, San Francisco State University

A meta-review by Webb, et al.² showed that Internet and mobile health interventions designed based on a behavioral theory resulted in better health outcomes with larger effect sizes than those that were not based on a theory. Of the studies included in the review, those that had used Aizen’s Theory of Planned Behavior were the most successful in improving health outcomes. Aizen’s Theory states that individual attitudes and social norms contribute to motivation. But, motivation alone is not sufficient to yield behavior change. There must also be an adequate level of perceived behavioral control which means the individual must think they possess the ability to make the change (and have the capability to make the change). Sounds good, but how do you actually design based on a theory?

For iN Touch, here’s how we thought about it:

For motivation, we needed to elicit individual attitudes/beliefs/values and reinforce positive social norms. The health coach drew out the participant’s individual attitudes through conversation and reinforced the values of health, well-being, and empowerment to make change. She also facilitated self-reflection about the ODLs and identification of trends and patterns in the combinations of ODLs. Weigh-ins and measurements were also a form of reinforcement by revealing objectively whether behavior changes each person made were effective or not. These contributed to motivation in an ongoing way.

We spent a great deal of effort designing perceived behavioral control, using both online and offline tools. The iN Touch application itself was a tool for behavioral control because it allowed the participant to capture the ODLs, review them in real-time, and conduct ad hoc comparisons. We designed the application within a "Five Clicks, Five Minutes" (per day) rule our Youth Advisory Board provided to minimize data entry burden (Sabee, et al.¹). Our post last month provided a detailed overview of the application. The iPod Touch device itself is portable and highly accessible, further contributing to perceived behavioral control.

Offline, we provided participants with a “My Experiment” tool for weekly goal setting and action planning. The key to this coaching tool is it provides the participant a way to make a short-term commitment, prepare for any obstacles, assess their level of confidence, and plan for follow-up. It gives them permission to try out a behavior change and have full control over the conduct of their experiment.  

Finally, our intervention included multi-modal interaction with the health coach in order to provide support when and where the participant needed it, another way of putting control in the participant’s hands. Participants were able to meet with the health coach in person or by phone, during scheduled or drop-in appointments, and communicate via text message. All of these strategies contributed to perceived control by participants.

We used the theory of planned behavior to inform both design of the technology and programmatic elements. The use of health behavior change theory in technological design is still emerging. We are eager to hear about other examples where this has been applied. Please share your experiences with us in the comments.

References:

¹ Sabee CM, Kim KK, Charles J, Logan H, Young E. (October, 2011).  Five Clicks, Five Minutes: Providing a Voice for Youth with Obesity and Depression with a Mobile Health Platform. Manuscript presented at the International Conference on Communication in Healthcare: Chicago, IL.  

² Webb TL, Joseph J, Yardley L, Michie S. (2010). Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. J Med Internet Res,12(1):e4). doi:10.2196/jmir.137.

 

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iN Touch Mobile Application Overview

Holly Logan, iN Touch Project Coordinator, San Francisco State University

We worked with TheCarrot.com team to customize a mobile application for iPod Touch and iPhone. Our participants have been using this personal health application to capture their observations of daily living (ODLs). Here is a sample walk-through of how a participant may interact with the app:

1. Participants in our study first sign in to the application on their iPod Touch devices.
   
   
   
   
2. After they sign in, they come to a homescreen that manages their trackers. Users could choose to manage a variety of trackers,  but for the iNTouch study, participants have been asked to keep track of four trackers: exercise, food, mood and socializing.
   
   
   
   
3. Let’s say this participant, Jim*, just got home for the day and wants to record his activities and observations. First he decides to record what he ate with his friends that day. To do this, he selects “Food” on the “My Trackers” page and comes to the screen below:
   
   
   
   By adding a food and then searching for it, Jim can easily record what he ate with his friends. Let’s say he wants to add strawberries. He can type the whole word or just part of the word into the search box below:
   
   
   
   Once he finds what he wants, he clicks the orange plus button to add the food to his folder. When he's done adding the foods he's eaten, he selects the green save button in the lower right-hand corner. When he hits the save button, he is sent back to the “My Trackers” page.
   
   
4. Jim may then decide he wants to record his mood for the day. When he selects “Mood” on the “My Trackers” page, Jim comes to this page:
   
   
   
   Let’s say Jim is stressed out and sad because he should have been doing his homework instead of hanging out with his friends, and now he has a lot to do and is running out of time. He is also feeling angry and unhappy about this situation. By touching the orange plus button next to each emotion, Jim adds these moods to his folder and comes to this screen:
   
   
   
   The green check next to each emotion means that Jim has added that emotion to his folder. The folder is located in the top left-hand corner, where it shows that he has added four emotions. Once Jim moves the sliding buttons to note how intensely he feels each emotion,  he can hit save in the lower right-hand corner, which takes him back to the main “My Trackers” screen.
   
5. Let’s say Jim also wants to track the amount he socialized that day. When he selects the socializing tracker, he comes to this screen:
   
   
   
   This screen operates much like the “Moods” screen. Jim  tracks how much he socialized, whether people influenced him negatively or positively and whether people supported him a lot or not much. Let’s say Jim decides he wants to add some personal details about his socializing experience, so he decides to write a note by clicking the “Notes” button on the lower part of the screen. He then comes to the “Notes” screen:
   
   
   
   On this screen, Jim can write a note about what he did with his friends; once he’s done, the green save button takes him back to to the “Socializing” screen:
   
   
   
   When he’s done entering his information, Jim can select the green save button to go back to the main “My Trackers” menu.
   
   
6. Finally, Jim remembers to  record his exercises from the night before in the “Exercise” tracker. When he selects “Exercise” on the main “My Trackers” menu, he comes to this screen:
   
   
   
   On this screen, Jim searches for his exercise and adds what he has done by hitting the orange plus button. When he adds running as an exercise entry, he comes to this screen:
   
   
   
   Because Jim is adding an exercise entry for the previous night, he needs to correct the date and time. When he selects the calendar image at the bottom of the screen above, he is taken to the screen below, where he can change the date and time before selecting the green save button (in the upper right-hand corner), which takes him back to the “Exercise” screen. 
   
   
   
   Once Jim saves his exercise entries and finishes recording his observations for the day, he can take a look at his progress by looking at his “Journal.” To get to the “Journal,” Jim clicks the notebook symbol at the bottom of the screen to review his “Journal,” which displays his progress.
   
   
   
   

Our participants seem to accept our app well, and they report that it is pretty easy to use and takes only a few minutes a day. We are doing exit interviews as participants complete our study, so we’ll be able to share more of their feedback in a future post.

*Jim is not a real participant in the iN Touch study.

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Balancing Patients’ and Clinicians’ Needs [Video]

Libby Dowdall, Communications Coordinator, Project HealthDesign National Program Office

 

iN Touch Co-Principal Investigator Katherine Kim, M.P.H, MBA, talks about some of the challenges her team has faced as they’ve implemented their study. These challenges include:

Balancing patients’ and clinicians’ needs when developing PHR applications and dashboards.
Participants in the iN Touch study say they want to review their ODL data on a daily basis to they can reflect on the patterns and make changes as needed. However, clinicians say they want to see summary reports of the ODL data on a weekly or monthly basis and before their patients come in for visits.

Integrating patient-generated ODL data into clinical electronic health record (EHR) systems.
Clinicians aren’t likely to visit an additional portal or external system to review patient-sourced ODL data; the data must be integrated into existing clinical EHR systems and workflows. However, Meaningful Use requirements have prompted extensive changes to many hospital EHR systems. Because of these changes, hospital IT departments are currently less available to help with ODL data integration.

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Sarah’s Story: Six Months of Determination, Health Coaching and Observations of Daily Living

Katherine Kim, M.P.H., MBA, iN Touch Principal Investigator, San Francisco State University

Sarah* was a 214-pound, pre-diabetic high school student who hated comments her peers made about her appearance. When she first met the iN Touch health coach, Sarah shared that she regularly ate fast food, drank soda and cut class. She wanted to focus on eating healthier and exercising. Sarah and the coach discussed different types of exercises and worked together to create backup plans in case she was unable to do her intended exercise.

Sarah planned to record her observations of daily living (ODLs) about her food, exercise, socializing and mood in TheCarrot.com’s iN Touch application a few times a week. She began recording her ODLs and found it was easy enough to do. She also used the notes section to intensively journal about her path to a healthier life. Sarah texted the health coach and took advantage of in-person coaching visits to talk about her challenges, strategies and progress. She also continued to see her regular physicians and nurses.

By the third month of participation she reported that she was cutting fewer classes. She now regularly power walks with hand weights and started taking dance classes over the summer. She has eliminated fast food, chips and sodas from her diet. Instead, she carries healthy snacks in her purse and drinks only water. At the end of 6 months of participation, Sarah has lost more than 20 pounds.

Sarah is one of the first wave of participants to complete the study this month. While we wait to collect our complete set of evaluation data, we looked at frequency of usage of the technology to see if we could find clues to Sarah’s success. To date, 33 participants have entered 1,794 ODLs, not including notes. (Note: most participants have not yet completed their six months.) Recording frequency varied, and individuals ranged from one ODL recorded to 230 ODLs recorded with an average of 54 ODLs recorded. Sarah recorded 117.

Sarah’s size is not the only change. “I have confidence,” she says,  “I feel this is my year. Now if people want to come at me with drama, I’m just like, ‘I don’t care.’ I’m going across that stage. I’m going to a 4-year college. Twelfth grade is my serious year.”  She says she plans to continue using her iPod Touch and free TheCarrot.com application to improve her health.

*Not her real name.

My Summer with iN Touch

Uba Backonja, Project HealthDesign Ph.D. in Nursing Student, University of Wisconsin-Madison

I could not have asked for a better summer. I repeated this often during the six weeks I spent in San Francisco with the iN Touch team. I meant it wholeheartedly then, and I still feel the energy and excitement now that I am back in Wisconsin.

Having worked with the National Program Office at the University of Wisconsin-Madison for nearly three years, I’ve been able to experience Project HealthDesign from the macro level. When I was given the opportunity to spend my summer with Kathy Kim and the iN Touch team at San Francisco State University, I jumped on the opportunity to get an intimate, first hand, micro-level experience with one of the project teams. I knew about the amazing work they were doing, using iPod Touches to facilitate health coaching for overweight and depressed adolescents in San Francisco. But that knowledge was gained from a distance and from reading about the project. Needless to say, I was ecstatic to spend my summer in San Francisco.

Almost as soon as I arrived to the San Francisco State University Health Equity Institute, I met the inspirational Kathy Kim, iN Touch principal investigator. She gave me the rundown of what I would be doing, after which I had the opportunity to see iN Touch in action. I shadowed three amazing project team members in action at a San Francisco high school — Health Coach Kehinde Apara, Project Manager Holly Logan and Research Assistant Janelle Charles.

Seeing them working so well with the students, school administrators and each other left a lasting impression. What was even more powerful was the opportunity to witness the health coaching setting. Watching Kehinde work diligently with each of the students to address their tailored goals, while taking into account their needs, abilities and limitations, was transformative not only for me but also for the students.

Teens who were initially quiet opened up during the sessions, their excitement building as they worked more with Kehinde on their personalized goals. Teens who were energetic and open were bursting with pride when they told Kehinde that they had met and exceeded their weekly goal. Each participant was motivated and driven to take on a challenge for the next week, with smiles on their faces and springs in their steps.

I’m excited to see how the project continues to positively impact the lives of these teens in San Francisco, and how the program can be applied in the future elsewhere. I learned so much from the teens and from Kehinde, Holly and Janelle. The one thing I can say for sure right now is that I could not have asked for a better summer.

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Incentives for Research Participants in Personal Health Information Technology Studies

Katherine Kim, M.P.H., MBA, iN Touch Principal Investigator, San Francisco State University
Holly Logan, iN Touch Project Coordinator, San Francisco State University

I was recently asked whether we were using incentives to motivate our participants to use iN Touch. In designing our incentive strategy we combined our team’s experience with youth and the advice of the Project HealthDesign National Advisory Committee. We wanted to promote participation in research but we didn’t want incentives to be an external motivator for health goal attainment. We also wanted to minimize participants’ disappointment if they were selected for the control group.

Our strategy is to provide iPod Touches to all intervention group participants, which they will keep upon completion of the project. Control group participants are randomly selected to receive either an iPod Touch or an iPod Shuffle, but are guaranteed to receive one of these items. In addition, we offer a $10 gift card from Target or iTunes for each focus group or interview. The 13- to 18-year-olds prefer iTunes and the 18- to 24-year-olds usually select Target. We do not provide any incentives for use of the application, collection of observations of daily living (ODLs) or visits with a health coach or clinician.

We wondered how other research projects were approaching the use of incentives so we did a little research. AHRQ recently published an excellent report on the impact of consumer health informatics applications.¹ That was a good starting point. We conducted a quick review of 12 randomized clinical trials that showed a positive relationship between the use of personal health information technology and either health outcomes or intermediate outcomes. This is what we found:

Three papers didn’t report on incentives, four reported giving no incentives, and five gave incentives. Here is a summary of the five papers that reported on incentives:

• An Internet self-help application for test anxiety for college students provided a $5-10 incentive for filling out pre and post surveys.²
• An Internet weight loss intervention for African-American adolescent girls provided a subsidy for the purchase of a computer and compensation for time for completing each of four assessments (adolescents received a gift valued at ~$10, parents received $30).³
• A computer-aided behavioral weight loss program for adult women offered a pedometer and $9 per appointment.⁴
• A computer-based health information support system for HIV/AIDS patients offered an incentive for each of three surveys (no amount stated).⁵
• A comparison of computer-tailored counseling and email counseling for overweight/obese adults offered $25 for first visit, $50 for second visit and discounts on meal replacement drinks.⁶

This mini-review showed that detailed incentive strategies were inconsistently described in clinical trials of personal health information technology. We’d love to know more about what others in the field are doing and what the impact of incentives are on behavior or adoption of technology.

References

1. Gibbons MC, W. R., Samal L, Lehmann CU, Dickersin K, Lehmann HP, Aboumatar H, Finkelstein J, Shelton E, Sharma R, Bass EB. (2009). Impact of Consumer Health Informatics Applications. Evidence Report/Technology Assessment No. 188. (Prepared by Johns Hopkins University Evidence-based Practice Center under contract No. HHSA 290-2007-10061-I). Rockville, MD: Agency for Healthcare Research and Quality.

2. Orbach G, Lindsay S, Grey S. A randomized placebo-controlled trial of a self-help Internet-based intervention for test anxiety. Behav Res Ther 2007; 45(3):483-96. 134. March S, Spence SH, Donovan CL. The Efficacy of an Internet-Based Cognitive-Behavioral Therapy Intervention for Child Anxiety Disorders. Journal of Pediatric Psychology 2008.

3. Williamson DA, Walden HM, White MA et al. Two-year internet-based randomized controlled trial for weight loss in African- American girls. Obesity (Silver Spring) 2006; 14(7):1231-43.

4. Adachi Y, Sato C, Yamatsu K, Ito S, Adachi K, Yamagami T. A randomized controlled trial on the long-term effects of a 1-month behavioral weight control program assisted by computer tailored advice. Behaviour Research and Therapy 2007; 45(3):459-70.

5. Gustafson DH, Hawkins R, Boberg E et al. Impact of a patient-centered, computerbased health information/support system. American Journal of Preventitive Medicine 1999; 16(1):1-9.

6. Tate DF, Jackvony EH, Wing RR. A randomized trial comparing human e-mail counseling, computer-automated tailored counseling, and no counseling in an Internet weight loss program. Archives of Internal Medicine 2006; 166(15):1620-5

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Does Good Health Care Mean Satisfied Patients?

Christina M. Sabee, iN Touch Co-Principal Investigator, San Francisco State University

As an academic interested in ways that we can improve health care, I find myself reading a lot about the different practices that can help improve communication between patients and their health care providers. Specifically, practitioners and scholars have focused on “patient-centered” communication as a concept worth promoting. In fact, the promotion of patient-centeredness has worked its way into federal government regulations (e.g., the meaningful use requirements for electronic health records). Throughout these policies, the actions of our health care providers must be meaningful and centered on their patients.

So how do we know when health care is patient-centered? Scholars have asked patients whether they believe their health care providers are patient-centered, and they’ve tracked actual communication while identifying the areas of conversation where health care providers do what patients say is centered on them (for a critical review, see Epstein, et al., 2005). Many times, they seem to know that these things are patient-centered because they are associated with patient satisfaction. Patient-centeredness is highly correlated with patient satisfaction (e.g. Venetis, Robinson, Turkiewicz & Allen, 2010). In some cases, reported correlations are so high as to make a statistician wonder whether the two concepts are really one and the same.

I think we need to be careful about what we are measuring and reporting when it comes to patient-centeredness. It’s easy for health care providers to increase their patient satisfaction rates — they can provide free parking, address patients by name and start appointments on time. These things are nice, but not necessarily related to improved health care; glancing at the name on the chart and rushing through appointments to stay on schedule are more attempts to appear patient-centered than they are actually centered on the patient.

I worry that a continued focus on the satisfaction that patients might feel with their communication with their health care providers shifts our focus away from what really might be meaningful for patients. Sometimes, health care providers need to talk about things that patients don’t like to hear, and sometimes patients might not like their recommendations. I believe that health care providers can have these challenging conversations in ways that are patient centered, but that doing so might not satisfy a patient as much as just forgoing those conversations in order to comply with patient requests. So let’s be careful to measure what is meaningful and necessary for improving health care, rather than marketing toward a satisfied patient population.

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