Dean Schillinger, M.D.
Debra Keller, M.D., M.P.H.
University of California, San Francisco
Most health literacy research, Schillinger said, has focused on characterizing patients’ deficits, on how best to measure a patient’s health literacy, and on clarifying the relationships between limited health literacy and health outcomes. There is now a growing appreciation that health literacy represents a balance between an individual’s health literacy and the health literacy demands and attributes of the health care system. The commissioned paper (see Appendix A) discussed in this presentation is an attempt to advance a conversation about the health care organization side of the health literacy dynamic.
There is increasing interest from multiple stakeholders in addressing the system level factors that contribute to the high literacy demands of the health care system. Implementation of the Patient Protection and Affordable Care Act (ACA)1 provides both opportunities and challenges, especially for individuals with limited literacy, whether it is with respect
1 A summary of the ACA can be found at http://dpc.senate.gov/healthreformbill/healthbill04.pdf (accessed February 6, 2012).
to insurance reform, accessing and taking advantage of Medicaid expansion, maximizing one’s experience in a patient-centered medical home, or benefiting from the diffusion of information technology into health care.
This paper attempts to identify and describe a set of attributes for health care organizations that will enable these organizations to mitigate the negative consequences of limited health literacy and to improve access to and the quality, safety, and value of health care services. The attributes identified in this paper are not intended to describe a specific type of organization; rather it is the case that organizations aspiring to these attributes are those that are committed to implementing improvements. They are organizations committed to reengineering systems in order to better accommodate the communication needs of populations with limited health literacy, that is, to become health literate health care organizations.
The paper is most applicable to organizations that provide direct care to patients. However, the paper also attempts to be relevant to the broader range of organizations and institutions that comprise the very complex and modern U.S. health care system. Organizational investments are needed to maximize patients’ and families’ capacities (see Box 2-1) in a number of areas.
The framework for the attributes of a health literate health care organization can be represented by a pyramid (Figure 2-1). The attributes fall into one or more of the rows of the pyramid. At the base of the pyramid is organizational commitment. The second tier is an accessible educational technology infrastructure. The third row of the pyramid is an augmented workforce. The fourth row is embedded policies and practices, and at the top of the pyramid is effective bidirectional communication.
The structure of this pyramid follows a clear logic. The foundation of becoming a health literate organization is organizational commitment. This is followed by infrastructure, followed by a well-trained workforce, followed by policies and procedures that the workforce and the infrastructure can support so that, in the end, effective bidirectional communication can take place.
This paper presents 18 attributes health care organizations that wish to be health literate should strive for (see Box 2-2). It is important to note that it is not expected that any organization currently possesses all of these attributes. Rather, the paper is an attempt to offer a vision of how organizations should evolve in order to become more responsive to the needs of populations with limited health literacy, thereby improving care for all.
• comprehend and engage in preventive health behaviors and to receive preventive health care services if desired;
• recognize changes in their health states that require attention and then access health care services appropriately;
• develop meaningful ongoing relationships with health care providers that are based on open communication and trust;
• obtain timely and accurate diagnoses for both acute and chronic health conditions; comprehend the meaning of their illness, the options for treatment, and anticipated health outcomes;
• build and refine skills needed to safely and effectively manage these conditions at home and communicate with the health care team when the illness trajectory changes;
• report their communication needs or comprehension gaps;
• make informed health care decisions that reflect their wishes and their values;
• navigate transitions in care; and
• make health care coverage choices based on their families’ health needs, better comprehend the range of benefits and services available to them and how to access those services, and be more aware of the financial implications of health care choices in order to improve decision making.
ATTRIBUTE 1: Health literate health care organizations promote health literacy as an organizational responsibility. This implies that such organizations promote a culture of clear communication and make such communication an organizational priority. They raise organization-wide awareness of the importance of health literacy and take responsibility for effective communication. They build health literacy concerns into their organizational operations, strategic planning, job descriptions, evaluations, and even budgets. And they integrate health literacy into quality-improvement initiatives, patient safety initiatives, and provider competencies.
ATTRIBUTE 2: Health literate health care organizations develop a culture of active inquiry, partner in innovation, and invest in evaluations of operations improvements. Because the science of health literacy is not yet fully developed, health literate organizations need to partner with health literacy researchers from a number of fields to develop and implement interventions, to pilot successful interventions in real-world
FIGURE 2-1 Framework for attributes for health literate health care organizations.
SOURCE: Schillinger and Keller, 2011.
settings, and to evaluate health literacy strategies and programming in real time, applying change as needed.
ATTRIBUTE 3: Health literate health care organizations measure and assess the health literacy environment and communication climate. They perform institutional assessments focused on the health literacy environment and the variety of communication and support systems in place. At both patient and organization levels, health literate health care organizations identify, track, and monitor health literacy metrics relevant to their organization. These organizations also track provider implementation of best practices in communication.
ATTRIBUTE 4: Health literate health care organizations commission and actively engage a health literacy advisory group that represents their target populations. A health literacy advisory group can have many functions, including
1. development and implementation of health literacy programming and strategies;
2. formulation of organizational policies around health literacy;
3. institutional health literacy reviews and environmental assessments; and
4. development and piloting of health information technology solutions, educational initiatives, and curricular materials.
1. Promote health literacy as an organizational responsibility.
2. Develop a culture of active inquiry, partner in innovation, and invest in rigorous evaluations of operations improvements.
3. Measure and assess the health literacy environment and communication climate.
4. Commission and actively engage a health literacy advisory group that represents the target populations.
5. Provide the infrastructure to avail frontline providers, patients, and families with a package of appropriate, high-quality educational supports and resources.
6. Leverage accessible health information technology (IT) to embed health literacy practices and support providers and patients.
7. Provide patient training and assistance around personal health records and health IT tools.
8. Foster an augmented and prepared workforce to promote health literacy.
9. Distribute resources to better meet the needs of the populations served.
10. Employ a higher standard to ensure understanding of high-risk decisions and high-risk transitions.
11. Prioritize medication safety and medication communication.
12. Make health plan and health insurance products more transparent and comprehensible.
13. Make systems more navigable and support patients and families in navigating the health care system.
14. Recognize social needs as medical concerns and connect people to community resources.
15. Create a climate in which question asking is encouraged and expected.
16. Develop and implement curricula to develop mastery of a threshold-level set of knowledge and skills.
17. Continually assess and track patient comprehension, skills, and ability to problem-solve around health conditions.
18. Recognize and accommodate additional barriers to communication.
a Following the workshop, members of the Workgroup on Attributes of a Health Literate Organization of the Roundtable on Health Literacy, using feedback provided on the paper, collapsed the number of attributes to 10 and published a discussion paper that articulates a rationale for these attributes and identifies the organizations that should use them. There is also a list of resources for organizations interested in taking action. The paper can be found at www.iom.edu/healthlit10attributes.
SOURCE: Schillinger and Keller, 2011.
ATTRIBUTE 5: Health literate health care organizations provide the infrastructure to avail frontline providers, patients, and families with a package of appropriate, high-quality educational supports and resources. Promoting patient comprehension and building skills requires high-quality human, technical, and pedagogical resources that are easily accessible across the organization. In addition to effective interpersonal communication, there is also a need to provide clearly written health information at the right time and place that embodies best practices in written information and applies health literacy principles. Health literate health care organizations ensure that there are multiple opportunities to interface with the health care team, to reinforce health education and self-management goals, and to assist with pre-visit planning and decision support.
The video decision aids developed by Volandes and colleagues for advanced care planning for Alzheimer disease2 are good examples of best practice materials, Schillinger said. Another example can be found in the work of Project RED (Re-Engineered Discharge) at the Boston City Hospital,3 which developed interactive, computer-based teaching tools based on health literacy principles. Health literate health care organizations have an instrumental role in influencing the marketplace of patient communication products by demanding rigorous testing with and adaptation for populations with limited health literacy, and in supporting the development of national certification standards for print and digital material that is accessible to these populations.
ATTRIBUTE 6: Health literate health care organizations leverage accessible health information technology (IT) to embed health literacy practices and support providers and patients. The health IT revolution has great potential to either narrow or widen the health literacy divide. An important role for health literate organizations, Schillinger said, will be to influence the marketplace of patient communication products, first by demanding that patient communication products be rigorously tested with and adapted for populations with limited health literacy and, second, by supporting the development of certification standards for print and digital material that is accessible to these populations.
2 For a description see Alzheimer Video Affects Care Preferences in Clinical Psychiatry News. http://www.clinicalpsychiatrynews.com/search/search-single-view/alzheimer-s-videoaffects-care-preferences/4c4fa54a41.html (accessed December 10, 2011).
ATTRIBUTE 7: Health literate health care organizations provide patient training and assistance around personal health records and health IT tools. There are many potential benefits of personal electronic health records (PEHRs). Patients can store and access personal health information, which provides them with additional points of interaction with providers. However, there remain multiple challenges in using PEHRs for populations with limited health literacy. A growing body of research shows that limited-literacy populations use personal electronic health records much less than their counterparts with adequate health literacy. This may partly be a question of access, but individuals with limited health literacy skills often also have low e-health literacy skills which prevent them from benefiting from such initiatives. Health literate organizations
1. involve populations with limited health literacy in the development and selection of electronic health record systems,
2. develop educational initiatives to orient and motivate patients in electronic health record use, and
3. ensure that information and education available on the personal health record can be accessed through interpersonal or alternative means for those who do not access the PEHR.
ATTRIBUTE 8: Health literate health care organizations foster an augmented and prepared workforce to promote health literacy. They develop a diversified workforce with expanded job descriptions for non-physician members which include a variety of educational roles—health educators, health coaches, navigators, medical assistants, peer educators, and expert educators. These are people who deeply understand health education, who help teach others how to teach, and who can tackle a challenging patient who does not appear to be acquiring the skills needed at the pace required to manage his or her condition. In order to ensure that all members of the health care team are prepared to employ best practices in communication during all patient interactions, organizations need to
1. prioritize recruiting health care team members who reflect the socio-demographic and linguistic profiles of the patient populations served;
2. provide health literacy and health communication training for all members of the integrated health team; and
3. provide more sophisticated training for the expert educators.
ATTRIBUTE 9: Health literate health care organizations distribute resources to better meet the needs of the populations served. The inverse care hypothesis, sometimes known as the inverse care law, was
first described in the United Kingdom and states that the availability and quality of health care varies inversely with the needs of the population. Or, put more simply: “The more you need, the less you get.” Health literate health care organizations understand that the inverse care law is especially relevant in the market-driven health care context. Therefore they allocate additional educational and communication resources to populations or to sites that have worse individual or population health outcomes that are attributable to limited health literacy. Furthermore, at the patient level such organizations provide intense and interactive communication proportional to the needs of its patients.
ATTRIBUTE 10: Health literate health care organizations employ a higher standard to ensure understanding of high-risk decisions and high-risk transitions. This involves identifying common high-risk decisions that require greater scrutiny, using standardized and well designed teaching tools for these decisions, and establishing health literacy practices (e.g., the teach-back method4) as part of the education and consent process. High-risk areas include consent for surgery; administration of medications with serious complications or “black box” warnings; and transitions in care, such as discharge from the hospital.
ATTRIBUTE 11: Health literate health care organizations prioritize medication safety and medication communication. They recognize that patients with limited health literacy have great difficulty with medication management and are more likely to misunderstand prescription labels and warning labels (Davis et al., 2006; Wolf et al., 2007) and more likely to make mistakes taking their medications (Lindquist et al., 2011; Sarkar et al., 2010). Systems and interventions are needed to advance medication safety and self management by, for example, efficiently incorporating medication reconciliation into the workflow, establishing guidelines and standards for uniform prescribing practices, and encouraging the use of plain language on the prescription label.
ATTRIBUTE 12: Health literate health care organizations make health plan and health insurance products more transparent and comprehensible. The enactment of the ACA will, Schillinger said, improve access to care through insurance reform, Medicaid expansion, and health insurance exchanges. To assist populations with limited health literacy fully realize the benefits of health care reform, it will be important to establish
4 The teach-back method is a way of confirming patient understanding of what he or she needs to know and do by asking the patient to “teach back” the directions. http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf (accessed December 11, 2011).
methods to ensure that patients and families can access in-person support, that information about health benefit packages is understandable, and that better decision support is provided through such mechanisms as a plain-language summary of benefits, glossaries of terms, and culturally appropriate guides.
ATTRIBUTE 13: Health literate health care organizations make systems more navigable and support patients and families in navigating the health care system. They establish welcoming, shame-free environments where asking questions is encouraged. They offer assistance with literacy-and numeracy-related tasks. They implement system designs that can make the health system more navigable, such as the use of electronic referrals where the referring provider completes a detailed, electronic referral to the specialist that outlines all the information needed; in this way the patient is not responsible for providing all information. As part of making the system more navigable, health literate organizations perform environmental assessments to identify literacy barriers, signage problems, inconsistent labeling, or lack of available personnel for assistance.
ATTRIBUTE 14: Health literate health care organizations recognize social needs as medical concerns and connect people to community resources. They might partner with community resources, develop a clearinghouse of local resources, appoint a team member to be the expert in local resources, or partner with case managers and social workers to embed social services into health care delivery.
ATTRIBUTE 15: Health literate health care organizations create a climate in which question asking is encouraged and expected. They activate patients by implementing question-asking campaigns (e.g., the Ask Me 3 campaign5 or Questions Are the Answers6) and encouraging allied staff to reinforce the asking of questions.
ATTRIBUTE 16: Health literate health care organizations develop and implement curricula to develop mastery of a threshold-level set of knowledge and skills. They use the following six principles in the development of these curricula (Baker et al., 2011):
5 The Ask Me 3 campaign of the National Patient Safety Foundation encourages patients to ask such questions as, What is my main problem? What do I need to do? Why is it important for me to do this?
1. Define a limited set of critical learning goals and eliminate all other information that does not directly support the learning goals.
2. Present information in discrete, predetermined chunks.
3. Determine the optimal order for teaching the topics.
4. Develop plain language text to explain essential concepts for each goal and employ appropriate graphics to increase comprehension and recall.
5. Confirm understanding after each unit, perform tailored instruction until mastery is attained, and review previously learned concepts until stable mastery is achieved.
6. Link all instruction to a specific attitude, skill, or behavioral goal.
ATTRIBUTE 17: Health literate health care organizations continually assess and track patient comprehension, skills, and ability to problem-solve around health conditions. They assess and document patient comprehension and basic problem-solving abilities for health conditions that require self-management (e.g., congestive heart failure, diabetes, asthma, or anticoagulation). They put in place systems to connect individuals who have been identified as having continued educational needs with additional educational supports.
ATTRIBUTE 18: Health literate health care organizations recognize and accommodate additional barriers to communication. Patients with limited health literacy often face additional communication challenges. Most common among these are limited English proficiency and cognitive decline. There is compelling research that indicates that as many as one-third of the comprehension difficulties attributable to health literacy may actually be a consequence of subtle and undiagnosed cognitive problems, particularly among the elderly.
Hearing and visual impairment is common, particularly among low-income populations. A provider may think that a patient has limited health literacy when in reality he or she has bilateral wax impaction or a need for glasses. It is also possible that patients with limited health literacy have learning disabilities or learning differences that create specific problems with learning, problems that a teach-back method may not overcome. Or these patients may be burdened with mental health problems that prevented them from completing and succeeding in school. They may also have higher rates of depression that further impair recall and comprehension.
Health literate health care organizations develop many strategies to address additional communication barriers. They establish systems to identify and address communication disabilities. They provide extra support and case management to individuals with cognitive decline,
and, if possible, they identify surrogates and family members to provide assistance. They uphold and implement cultural and linguistic standards, guidelines, and recommendations, recognizing the tremendous overlap between the importance of linguistic concordance and health literacy practice. And they recruit and cultivate a culturally and linguistically diverse staff.
This discussion, Schillinger said, has been a necessarily brief summary of the 21-page, single-spaced, highly referenced commissioned paper (see Appendix A) and, as such, provides only a superficial overview. The paper offers a set of attributes and foci for institutional investment by organizations striving to become more health literate. Many of the attributes apply to direct-service health organizations, but they can also be relevant to the broad range of institutions that now contribute to the health care system. The list, while long, is by no means exhaustive and should be viewed as either the beginning or the continuation of a conversation regarding how health care organizations can address health literacy at the institutional level. These attributes provide a view of how organizations should evolve to be more responsive to the needs of populations with limited health literacy in tangible ways.
Roundtable member Cindy Brach complimented Schillinger on the paper and asked whether one might collapse the 18 attributes to a smaller number and, if so, what the right number would be. Some of the attributes seem full of many kinds of things an organization can do, while others are more focused on a specific topic.
Schillinger replied that he and his coauthor struggled with deciding on the appropriate number. That is why the pyramid was created, he said—to begin to develop a framework. Attributes were then derived for each level of the framework: for organizational commitment, which is the foundation level of the pyramid; for the educational level, which is a very rich level and one in which health information technology can fit nicely; for the workforce level, which includes ways in which the workforce is trained and incentivized; for the embedded policies and practices level, which includes such things as embedding techniques for addressing high-risk situations in ways in which providers routinely interact with patients, whether it is clinically or online; and, finally, for the top level of the pyramid, bidirectional communication, which can be considered an outcome.
Roundtable chair George Isham said the framework that Schillinger presented, which begins with the organizational perspective of what it takes to succeed as an organization, has similarities to the Kaplan and Norton balanced scorecard approach7 in which organizations consider four perspectives: financial, customer, business processes, and learning and growth. The idea is that the organization must be financially viable, relentlessly focused on the needs of the customer, with internal business processes that serve the organization’s needs, and with a culture that continually learns from its experience and its contact with customers.
HealthPartners takes this approach and for health care translates the four perspectives into people, health, experience, and affordability. If one relentlessly focuses on improving the health and experiences of the people one serves, Isham said, one is inevitably led to think about health disparities and health literacy. Another framework that resonates with the attributes presented at the workshop is the one presented in the IOM report Crossing the Quality Chasm (2001). That report lists six aims for care provided by health care organizations: Care should be safe, timely, effective, efficient, equitable, and patient-centered. In the 10 years since that report was published, there has been insufficient progress on making care equitable or patient-centered, Isham said, but nonetheless the report is extremely valuable in helping one think about how to move forward in these areas.
The attributes paper presented at the workshop also helps one think critically and thoughtfully about the relationship of health literacy and health disparities, Isham said, and such thinking can contribute to obtaining equitable and patient-centered care. The paper also provides ideas about how one might make progress in reducing disparities by addressing issues of poor health literacy.
Roundtable member Paul Schyve said that one needs to think about the pyramid and attributes as conceptual: What story do they tell that will stimulate changes in the health care system and in policymakers understanding? The story is that the system is far behind on achieving the six aims of quality care, particularly the ones dealing with equity and patient-centeredness. How do the attributes relate to improvements in these areas?
Roundtable member Benard Dreyer agreed that the paper is a critical contribution to thinking about health literacy and quality improvement.
7 The balanced scorecard approach “is a strategic approach and performance management system that enables organizer’s to translate a company’s vision and strategy into implementation, working from 4 perspectives”: financial, customer, business process, and learning and growth. http://www.valuebasedmanagement.net/methods_balancedscorecard.html (accessed December 13, 2011).
As the pyramid shows, organizational commitment is the basis for a health literate organization. The lack of that commitment is the reason so little progress has been made, he said. Dreyer’s concern is that organizations will decide to pick one or two attributes rather than trying to do something with each. Is the pyramid a stepladder? he asked Schillinger. Does an organization have to go from one to the next? Are there critical things that need to be done at one level before going to the next step?
Schillinger said that there is overlap among the levels of the pyramid. Furthermore, it is not feasible to attempt to address all 18 attributes simultaneously. As for where one should focus first, he said it is likely that finances will drive many of the decisions about how to proceed with the attributes. An organization may try to first address those attributes that it believes will have the greatest return on investment. If one takes the risk-management perspective, then high-risk decision moments may be the place to start. High-risk decision moments are also very palpable places to intervene at the level of the provider and would demonstrate that the organization has committed to doing things differently. Or the organization might decide to focus on high-risk conditions such as congestive heart failure or on transitions in care.
The key question is from what perspective the organization will approach the attributes: a clinical, financial, population health, or public health perspective? From the public health perspective, for example, one would want to embed practices and use a universal-precautions approach in order to have incremental improvements applicable to the greatest number of patients and, thereby, improve population health. What an organization chooses to do will depend on decision making at the executive level in terms of what that organization wants to achieve.
Roundtable member Leonard Epstein said that the paper neatly puts together in one place what needs to be accomplished at an organizational level in order to achieve effective health care communication. It would also be helpful, he said, to articulate the major components of effective health communication. Health literacy is obviously one component, as are effective cross cultural communication, use of trained interpreters and translators, and use of plain language. These need to be emphasized more, Epstein said.
Roundtable member Winston Wong said that the attributes presented resonated with what Kaiser has been exploring, particularly in terms of using the electronic health record to capture utilization information and track demographic profiles of users. Another aspect of the attributes that Kaiser has been examining relates to health equity or health disparities.
The organization is looking at specific ways it can intervene in situations with measurable clinical disparities and is incorporating aspects of health literacy into the strategies for approaching different population groups. Finally, he said that the attribute concerning assessing and tracking patient comprehension for conditions requiring self-management captures some of the work Kaiser is doing with different chronic disease management strategies.
Roundtable member Yolanda Partida said that the paper seemed to address health care organizations only and asked where the public health or community level fits. What about health organizations that do community-based work?
Schillinger replied that there is no question that public health has a critical role to play, particularly in integrated systems that are public delivery systems such as the New York Health and Hospitals Corporation. There are a range of issues that need to be addressed around public health communication and public health in clinical connectivity. However, the charge from the roundtable for preparing this paper specified that the focus was to be health care organizations, not public health entities.
Roundtable member Scott Ratzan asked Schillinger to think about the idea of integrating a checklist into Attribute 17 (“Continually assess and track patient comprehension, skills, and ability to problem-solve around health conditions.”). A simple checklist for congestive heart failure, diabetes, asthma and other chronic diseases could be used to assess whether patients are, for example, practicing the most important behaviors for their conditions. The safe surgery checklist developed by the World Health Organization8 is an example of such a checklist. Or, he asked, are the chronic conditions too complex for such an approach?
Schillinger said that he believes developing such checklists would indeed be complicated and would require significant work to define the crucial pieces that need to be included, but that such checklists would be a major contribution.
Linda Harris, another roundtable member, suggested that in thinking about attributes of a health literate organization it might be useful to use such language and concepts as productive interactions in the Chronic Care Model,9 patient-centered care, the medical home, and accountable
9 The model can be found at http://www.improvingchroniccare.org/index.php?p=the_chronic_care_model&s=2 (accessed December 13, 2011).
care organizations (ACOs).10 Organizations and individuals may not relate to the term “health literate organization,” but they do relate to the other terms. It would be useful to create a conceptual map that shows how these concepts correlate with the attributes.
Roundtable member Ruth Parker said there is an opportunity to frame the discussion more broadly in order to help those who provide health care see that a health literate organization is one that values health and values sharing that with populations and individuals. This means not wasting money and resources as well as being accountable. Accountable care organizations were mentioned earlier, but no one yet understands what that means. We have an opportunity to advance the national conversation about ACOs; that is, a necessary element of an ACO is to be a health literate organization. There is nothing more patient-centered than health literacy, Parker said.
Roundtable member Sharon Barrett said that the paper provides a comprehensive view of what the attributes of a health literate organization look like. What is the next step? Can one pull out from these the “how to”? This will be important, she said, because a number of organizations are going to begin to look at what they can do to become health literate organizations. Perhaps there is some way to look at this as a continuum, since it is unlikely that an organization can accomplish everything mentioned in the paper.
Schillinger said that the paper authors explicitly tried not to create the perception that each of the attributes has to be accomplished immediately. The paper is focused on goals and recognizes that a great deal of work needs to be done between where things stand now and where things will stand in the future. Becoming a health literate organization is a process and achieving each attribute moves the organization along the continuum closer to becoming a health literate organization.
Isham concluded by saying that the tangible suggestions offered in the paper provide a clear way to think about how to align incentives for organizations so that they do the right thing and succeed as an organization.
10 “An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. In the new law, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.” http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx (accessed December 13, 2011).
Baker, D. W., D. A. Dewalt, D. Schillinger, V. Hawk, B. Ruo, K. Bibbins-Domingo, M. Weinberger, A. Macabasco-O’Connell, and M. Pignone. 2011. “Teach to goal”: Theory and design principles of an intervention to improve heart failure self-management skills of patients with low health literacy. Journal of Health Communication 16(Suppl 3):73–88.
Davis, T. C., M. S. Wolf, P. F. Bass, 3rd, M. Middlebrooks, E. Kennen, D. W. Baker, C. L. Bennett, R. Durazo-Arvizu, A. Bocchini, S. Savory, and R. M. Parker. 2006. Low literacy impairs comprehension of prescription drug warning labels. Journal of General Internal Medicine 21(8):847–851.
IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.
Lindquist, L. A., L. Go, J. Fleisher, N. Jain, E. Friesema, and D. W. Baker. 2011. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. Journal of General Internal Medicine 27(2):173–178.
Sarkar, U., A. J. Karter, J. Y. Liu, N. E. Adler, R. Nguyen, A. Lopez, and D. Schillinger. 2010. The literacy divide: Health literacy and the use of an Internet-based patient portal in an integrated health system—results from the Diabetes Study of Northern California (DISTANCE). Journal of Health Communications 15(Suppl 2):183–196.
Schillinger, D., and D. Keller. 2011. The Other Side of the Coin: Attributes of a Health Literate Health Care Organization. PowerPoint presentation at the Institute of Medicine Workshop on Attributes of a Health Literate Organization. Washington, DC. November 16.
Wolf, M. S., T. C. Davis, W. Shrank, D. N. Rapp, P. F. Bass, U. M. Connor, M. Clayman, and R. M. Parker. 2007. To err is human: Patient misinterpretations of prescription drug label instructions. Patient Education and Counseling 67(3):293–300.