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Can patient education be more effective by tailoring medical information to individuals and presenting it over the Internet rather than through printed materials?

A new study called MI-HEART (Myocardial Infarct Health Education Aimed at Rapid Therapy) in Columbia's Department of Medical Informatics may answer this question. "MI-HEART tests a system designed to help patients recognize symptoms and to appropriately respond to them," says James Cimino, associate professor of medical informatics and principal investigator of the MI-HEART study.

In a research project made possible by a contract with the National Library of Medicine, about 300 Columbia Presbyterian Medical Center patients at high risk of a heart attack are being enrolled in the study, which examines whether patients provided with information in one of three different ways differ in their levels of individualized knowledge about risks and signs for heart attack.

The project focuses on how people frequently mistake the initial symptoms of a heart attack and, therefore, delay the life-saving care they need. The "rapid therapy" named as the aim of the project can make the difference between life and death for person who has a heart attack. "Many people are looking at how improved electronic medical records can lead to better care after admission to a facility. Rather than focus on improving care after a patient is admitted, we're focusing on reducing the time between a patient's initial pain and dialing 911. The biggest delay is in the patient deciding to call," says Cimino.

The MI-HEART study's 300 subjects are at high risk for any of three reasons: a diagnosis of coronary artery disease, diabetes mellitus or kidney failure requiring dialysis. After filling out questionnaires and having their medical histories entered into a computer, 100 of them will be given access to web pages with personally tailored information about possible symptoms of a heart attack and what to do in case they appear. Another hundred will have access to web pages with similar but generalized information that does not take into account individual patient medical histories. The third group of 100 will receive the same general information in printed format.

For all three groups, the information will be geared to getting the patient to an emergency room and the right kind of treatment as soon as possible in the case of an actual heart attack. While all the subjects will learn that a "Hollywood heart attack"—in which a person is stricken with terrible chest pain and falls to the ground—is not the usual kind, only patients with access to information tailored to individual medical histories will learn how their particular conditions may change the warning signs for heart attack. Cimino gives some examples of instances in which patients might need individualized information in order to decide whether their symptoms warranted a trip to the emergency room. "For instance, if you're a diabetic, you might have different symptoms because the nerves around the heart may not sense pain as well, so you may only have symptoms like dizziness and sweating. If a patient has angina pectoris (chest pains) all the time, the proper response to pain might be to take nitroglycerin a couple of times, spaced five minutes apart, to see if the pain disappears, rather than rush off to the ER immediately. For a patient with angina, more relevant warning signs of a heart attack might be weakness, lightheadedness, fainting, sweating, nausea or shortness of breath, in addition to chest pain."

Rita Kukufka, postdoctoral research fellow in medical informatics and a member of the Mi-Heart team, says "There's a whole cognitive model regarding how information can help patients. This is not limited just to how to recognize signs and what to do, but it's also important that patients are aware of their risks for heart attack." More than one million Americans have heart attacks every year, and too many of them suffer needless damage or die because they do not realize that, for example, a pain radiating down an arm may be a symptom. In addition, many people delay responding to a heart attack because, for example, they attribute its symptoms to something like indigestion or heartburn or they are embarrassed about dialing 911 unnecessarily.

"Patients in the study answer questionnaires about their knowledge. It would be statistically pretty difficult to prove within the scope of our study that improved delivery of information actually increased survival in those patients who actually had heart attacks," says Cimino. "But what we can show is whether access to individualized medical information leads a patient to a better understanding of his or her risk and what symptoms to watch for." The study measures what patients have learned at one or three months after receiving information. Monitoring web site use also may give clues about how a particular patient education strategy might fail or succeed. "Some patients may not click on every page of their web site," says Cimino, "but we will be able to tell which patients click on which pages, so we will be able to tell just how web-based information is or is not getting through."

For more information or to get involved in the MI-HEART study call 212-305-4621.