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Supplements The Aligning Forces for Quality Initiative: Early Lessons From Efforts to Improve Healthcare Quality
Creating and Sustaining Change: Early Insights From Aligning Forces
Claire B. Gibbons, PhD, MPH; and Anne F. Weiss, MPP
Getting the Structure Right for Communitywide Healthcare Improvement
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Lessons for Reducing Disparities in Regional Quality Improvement Efforts
Scott C. Cook, PhD; Anna P. Goddu, MSc; Amanda R. Clarke, MPH; Robert S. Nocon, MHS; Kevin W. McCullough, MJ; and Marshall H. Chin, MD, MPH
The Imperative to Promote Collaborative Consumer Engagement: Lessons From the Aligning Forces for Quality Initiative
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The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 2012
Dennis P. Scanlon, PhD; Jeff Beich, PhD; Jeffrey A. Alexander, PhD; Jon B. Christianson, PhD; Romana Hasnain-Wynia, PhD; Megan C. McHugh, PhD; and Jessica N. Mittler, PhD
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The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 2012 - eAppendix
Midterm Observations and Recommendations From the Evaluation of the AF4Q Initiative
Jeffrey A. Alexander, PhD; Dennis P. Scanlon, PhD; Megan C. McHugh, PhD; Jon B. Christianson, PhD; Jessica N. Mittler, PhD; Romana Hasnain-Wynia, PhD; and Jeff Beich, PhD
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Jon B. Christianson, PhD; Karen M. Volmar, JD, MPH; Bethany W. Shaw, MHA; and Dennis P. Scanlon, PhD
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Megan C. McHugh, PhD; Jillian B. Harvey, MPH; Dasha Aseyev, BS; Jeffrey A. Alexander, PhD; Jeff Beich, PhD; and Dennis P. Scanlon, PhD
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Dennis P. Scanlon, PhD; Jeffrey A. Alexander, PhD; Jeff Beich, PhD; Jon B. Christianson, PhD; Romana Hasnain-Wynia, PhD; Megan C. McHugh, PhD; Jessica N. Mittler, PhD; Yunfeng Shi, PhD; and Laura J. B
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Using Websites to Engage Consumers in Managing Their Health and Healthcare
Jessica N. Mittler, PhD; Karen M. Volmar, JD, MPH; Bethany W. Shaw, MHA; Jon B. Christianson, PhD; and Dennis P. Scanlon, PhD
Letter From the Guest Editor
David Blumenthal, MD, MPP
Samuel O. Thier Professor of Medicine and Professor of Health Care Policy Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School, Boston

Using Websites to Engage Consumers in Managing Their Health and Healthcare

Jessica N. Mittler, PhD; Karen M. Volmar, JD, MPH; Bethany W. Shaw, MHA; Jon B. Christianson, PhD; and Dennis P. Scanlon, PhD
Objective: This study provides insight into the potential of local community health information websites to cultivate and support consumer engagement through website positioning and content choices.
Study Design: This descriptive study compared health-related websites maintained by 16 multi-stakeholder community alliances charged with improving consumer engagement and public reporting of provider performance data.
Methods: We systematically assessed website messaging, content, and the presence of explicit connections among information and tools related to consumer engagement behaviors for 32 websites maintained by alliances as of November 2011. These findings were triangulated with information about alliances’ public reporting activities from key informant interviews (2007-2011) with stakeholders in 14 alliances.
Results: A total of 25 of the 32 alliance websites contained information for consumers, and 14 of those included information related to at least 3 of 4 consumer engagement behaviors: shopping for high-quality providers or treatments, self-advocacy in healthcare encounters, self-management of illness, and partaking in general healthy behaviors. Positioning strategies and tactics to attract consumers varied widely across alliances. Some targeted specific conditions or behaviors; others took a broader community approach. Two alliances had strong alignment between website messaging and consumer engagement content, 7 had moderate alignment, and 7 had limited alignment.
Conclusions: Although alliances have been experimenting with a wide array of website approaches, their promise as a tool to improve consumer engagement is still uncertain. Further research that addresses the comparative value of different website approaches is needed.

(Am J Manag Care. 2012;18:eS177-eS184)



When the Robert Wood Johnson Foundation (RWJF) launched its Aligning Forces for Quality (AF4Q) initiative in 2006,1 the 16 multi-stakeholder community coalitions (ie, alliances—the generic term used for the multi-stakeholder coalitions/partnerships in each community) were selected largely because of their commitment to publicly report provider performance, support local quality improvement activities, and engage consumers in managing their health and healthcare. Alliances were expected to “align” their efforts across these areas based on the premise that interventions working in concert will be more likely to achieve meaningful, widespread improvements in quality care and health.1,2

One strategy to improve consumer engagement is to increase the availability and use of information that supports health-improving behaviors. Proponents argue that if consumers have access to meaningful information about their health and healthcare when needed, they will use it to make choices that will improve their health, such as selecting high-quality providers or high-value treatments.3 All AF4Q alliances, and multiple national public and private entities,4 have created websites to provide consumers with health-related information, a strategy supported by survey data suggesting that 59% of all adults in the United States search online for health information.5

Overall, the quality of healthcare information available to consumers on the Internet is highly variable6 and may not be consumer friendly.7 Websites can be confusing for the average consumer to navigate and often fail to present technical information in a manner that consumers can easily understand.8 Attracting a wide range of consumers has been a difficult task; evidence to date indicates that awareness of websites and the ability to access public reports on provider performance on websites is relatively low.8,9 As a result, the potential to improve consumer engagement through website provision of health information has remained largely unrealized.

In this paper, we examine how AF4Q alliances are using websites to support their consumer engagement strategies. Specifically, we investigate how alliances are attracting consumers to alliance websites through website positioning and outreach activities, and how alliances are supporting consumer engagement through website content and architecture. While alliances received funding and had access to expert technical assistance in designing, updating, and marketing their websites, they remain a “work in progress” with considerable potential for improvement. Nonetheless, this study of their initial efforts generated some important and specific questions about the realistic role of informational websites in improving consumer engagement moving forward.


AF4Q alliances have addressed 4 types of behaviors in their attempts to improve consumer engagement: choosing care providers or treatments based on quality or value (shopping behaviors), participating in care decisions with their providers (healthcare encounter behaviors), managing their existing health conditions (self-management behaviors), and preventing poor health (healthy behaviors).10-12 Their activities have ranged from sponsoring educational and peer support groups on chronic care self-management, to conducting community-wide campaigns about healthy behaviors, to disseminating information about improving communication with providers (to engage consumers in choosing care providers based on their performance). Harmonizing these different consumer engagement activities and aligning consumer engagement content and messages on alliance websites has been challenging for alliances.

To help alliances develop websites that would effectively serve consumers, the AF4Q initiative provided technical assistance to alliances in the form of consultations with communications firms. Alliances were also given research briefs produced in partnership with the Agency for Healthcare Research and Quality and the American Institutes for Research addressing the presentation of comparative quality data and how to best engage consumers at key decision points.13,14 In practice, alliance website strategies varied, reflecting the preferences of community stakeholders, differences in alliance interpretations of the AF4Q initiative guidelines and technical assistance, and variations in alliances’ strategies to engage consumers. By November 2011, all 16 alliances were maintaining websites that offered comparative provider performance data and other information and/or tools that promoted consumer engagement (Table). It should be noted that prior to joining the AF4Q initiative, 13 of the 16 alliances already had websites that provided general information about the alliance and its activities, and 5 of these alliances offered provider performance information. Most alliances (13 of 16) maintained a home website and a second website dedicated to public reports of provider performance and/or health information related to consumer engagement, with 3 alliances sponsoring more than 2 websites (Table).

Data and Methods

We examined the content of all 32 websites maintained by the 16 alliances as of November 2011, focusing on how the alliances attempted to appeal to consumers through their website messaging, content, and design (Table). Specifically, we collected data about website positioning, content, and architecture (eg, number of distinct websites, clear references, and active links to related information within and across web pages and websites). Positioning was determined by examining each website’s top line message for phrasing, tone, and the specific language used to ascertain the website’s target audience and strategy.

To characterize the types of consumer engagement content, we mapped alliances’ website content to the 4 consumer engagement behavior types mentioned earlier, using the following definitions: (1) shopping behaviors are activities individuals perform to become more effective purchasers of healthcare; (2) healthcare encounter behaviors are activities individuals perform to become more effective self-advocates with their healthcare providers; (3) self-management behaviors are daily tasks that individuals with acute or chronic illnesses perform to control or reduce the impact of illness on their health and well-being; and (4) healthy behaviors are activities undertaken by individuals to maintain health and well-being and to prevent the development of illness.10 We used the results of this mapping to describe the overall consumer engagement content of alliance websites.

To assess alignment among alliances’ website consumer engagement resources, we identified specific directions aimed at consumers that attempted to connect the different dimensions of consumer engagement, classifying alliances into 1 of 3 categories. Websites with strong alignment had explicit links (ie, information was plainly connected by verbiage or website architecture like hyperlinks) across consumer engagement content related to all 4 different behaviors (eg, consumers were reciprocally directed to provider performance measures on diabetes care and self-management of diabetes through text and hyperlinks). Websites with moderate alignment connected consumer engagement content, but consumers sometimes had to make more of an effort to access the information (ie, it requires multiple clicks or page jumps to locate). Websites with limited alignment linked consumer engagement content, but not across all consumer engagement areas and/or not very explicitly (ie, descriptions or directions such as “use this to do this” were lacking).

In addition to website content analysis, we reviewed strategies that alliances used to facilitate consumer awareness of the websites, and identified community characteristics that appeared to have influenced alliances’ web-based consumer engagement efforts, based on a review of existing descriptions of 14 alliances’ public reporting programs. These descriptions were developed from a systematic review of key informant interview data collected regularly between 2007 and 2011 and AF4Q initiative documents, and are described in the article by Scanlon et al in this supplement.15


Attracting Consumers to Websites Through Website Positioning and Outreach Activities

Alliances used different positioning strategies to attract consumers to their websites (Table). Some alliances chose to orient their websites toward particular types of consumer behaviors, while others geared their websites directly to consumers, as a group. Core messages including terms such as “learn,” “compare,” “act,” and “make informed decisions” suggested particular behavior types, and audience scope was indicated by the use of terms such as “everyone,” “you/your,” “family,” and “doctor.” Six alliances emphasized using their web-based performance reports to choose providers (ie, shopping behavior) and named their websites accordingly; for example, the Wisconsin Health Reports website states “Doctors. Hospitals. Clinics. Some offer better care than others” while the MyCareCompare website states: “Make informed decisions about your health care.” In total, 8 alliances used branding aimed at educating consumers about the existence of variations in quality across providers and the value of using quality data when choosing providers. Three alliances that hosted multiple websites had 1 website specifically targeting consumers. These sites encouraged consumers to take a more active role in their health and healthcare, primarily through better self-management, with taglines such as “I CAN! Challenge,” “Our Pathways to Health,” and “My Health Counts!”

Some alliances positioned their websites more broadly. Six alliances had taglines emphasizing that all stakeholders—consumers, providers, and payers—need to work together for healthcare improvements in their communities, indicated by phrases such as “working/joining together,” “improving health/healthcare across the community/(geographic area name),” “alliance for improved health,” and “healthcare is everyone’s issue.” For example, “Better Health Greater Cleveland: an alliance for improved health” and “Working together for a healthy community.” Of these 6 alliances, 5 positioned their public reporting websites as trusted sources of information regarding the performance of the overall community healthcare system using the brand “Community Checkup.” The Puget Sound alliance initiated the Community Check-up brand, presenting its public report and website as a community educational tool that “…identifies what patients, physicians, employers, and other purchasers and health plans can do to achieve better health at a cost that more people can afford.” This brand was subsequently adopted by 4 other alliances for their public reports.

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