Kevin Wildenhaus, Ph.D., is director of science and innovation at Wellness & Prevention, Inc., a Johnson & Johnson company. Dr. Wildenhaus is a clinical psychologist specializing in health behavior change and practical, effective health intervention programs.

Health risk assessment (HRA) is continually evolving to meet the ever-changing demands of the health care industry. It began humbly as a simple data collection tool, but evolved to become a predictor of an individual’s health perceptions, attitudes and motivations.

The new generation of HRAs is poised to help transform the way we do business. Soon HRAs will not only be delivered more efficiently, but they’ll provide users with fresh, relevant feedback. Sound hard to believe? A brief look at the evolution of HRAs explains why many organizations now view the HRA through a new, more strategic lens, and how today’s innovative companies plan to leverage this powerful tool.

History of Health Risk Assessment

The concept of the HRA dates back to the 1940s, when Dr. Lewis C. Robbins came up with the idea that a patient’s health risks might guide the physician in preventative treatments. In 1980 the Centers for Disease Control and Prevention released a public version, and thus recognized the many benefits that health risk awareness, education and prevention could have on the population. Businesses, employers and health plans took notice of the value too.

The history of the HRA can be summarized in two distinct generations.

• First Generation – Classical Epidemiology (1970 – 1995): HRAs identified health risks in order to reduce the occurrence of illness, injury and premature death. Individual reports focused on a “risk age,” an assigned age for the participant based on his health risks and conditions, which used data all the way back from the 1948 Framingham study.
• Second Generation – Motivation and Self-Efficacy (1995 – 2010): As the HRA and its data became more sophisticated, the ability to create behavior change became a significant challenge. During this generation, behavioral science models like the Transtheoretical Model and Motivational Interviewing helped motivate the individual and build self-confidence.

Today’s HRAs

Today’s HRAs use digital technology to individually tailor health assessments, findings and feedback. And advances in behavioral science are unlocking the secrets to motivation and sustained behavior change.

Research shows that tailoring interventions to the individual’s motivations and readiness to change are the most effective ways to create behavior change (Burbank et al., 2000). Evolving computer algorithms are improving HRA feedback by incorporating various behavior change models. As a result, today’s HRAs focus more on the individual’s motivation, self-efficacy, attitudes and beliefs about health.

Consequently, HRA feedback now incorporates proven clinical strategies to increase the individual’s perceived control over his behavior, provides action plans to address risks, and reinforces the fact that behavior change is ultimately up to the individual. These evolving algorithms prompt interactive or “smart” questionnaires that adapt based on the individual’s previous answers, and thereby create a more personalized, efficient and relevant plan of action.

Online assessment has many benefits, including lower administration cost and an enhanced sense of privacy, confidentiality and anonymity. Evidence shows that online HRAs are associated with greater response honesty and accuracy when compared to face-to-face, telephone or traditional pen-and-paper administration. This medium also allows for a more open evaluation of the individual’s behaviors and permits feedback in a neutral and non-judgmental manner (Pealer et al., 2001).

Online technology also allows for real-time HRA feedback, providing an individual with immediate and personalized support, information and access to tailored online interventions that have been clinically proven to change behavior and lower risk. Further, digital technology allows for greater scalability and improved health access for the broader population.

• Individuals can complete assessments and receive feedback at their convenience, with 24/7 access to information, tools and resources.
• Family members and dependents can also participate, exponentially increasing the reach of the program.
• Individuals can access online resources about a specific condition or behavior, as well as track programs that aid behavior change (e.g. food and pain diaries).
• The web is a natural conduit to online digital health coaching programs that help the participant address lifestyle, behavioral health and/or chronic condition risk factors identified in the HRA.
• Participants can receive reminder or follow-up emails and tailored text messages that encourage and support them to implement or continue behavior change. Ongoing evaluation of the efficacy of a health and wellness solution can be completed conveniently via the web.

The Future of HRAs

In the future, we’ll see increased access to HRAs via the Internet and mobile devices. Next generation HRAs will include:

• Stronger ability to forge a connection between good health and achieving an individual’s life missions.
• Better use of quick, effective sessions or interventions, especially with the increased use of video for today’s YouTube generation.
• Mobile HRA delivery options, especially important for multinational employers and international populations.
• Increased use of health-related mobile applications that conduct real-time assessments, mini interventions and behavioral or habit-based action steps.
• Stronger data integration capabilities with care management systems, including delivery of key psychosocial information to health care providers. Ideally this communication will improve empathy, trust and rapport, as well as improve clinical efficiency.

Where Do We Go from Here?

Today, organizations realize that the HRA itself is more than a simple data collection instrument — it has become a strategic tool to help support employee behavior change. Employers recognize the value of HRA aggregate data, and its ability to provide insights into the specific health issues and risks of employee populations. HRAs help employees make smart choices about how to allocate their limited resources for health and wellness. Health plans will utilize the rich data from HRAs (that traditional claims and lab data can’t provide) to empower nurses, health coaches and clinicians to drive better health outcomes for their members.

Employers today are seeing the value of HRAs, but sometimes are not sure how to evaluate these products. To help, I have listed 10 components necessary for effective health risk assessment.

1. Multi-modal delivery capabilities that augment web-based delivery with print, telephone and IVR administration options to meet the needs of diverse employee populations in multiple locations.
2. The National Committee for Quality Assurance (NCQA) certification to assure the purchaser that the HRA meets industry standards.
3. Individually tailored action plans to aid each unique employee in his pursuit of health and wellness.
4. Biometric uploading and pre-population of data for seamless integration, improved accuracy and employee convenience.
5. Assessment of productivity impairment to help employers determine key health barriers that would lead to absenteeism, and thus, affect the bottom line.
6. Focus on assessing behavioral health issues like insomnia, stress and depression, which are often under the radar, yet cause significant health care costs, disability claims and productivity impairment.
7. Cutting edge participation and engagement strategies to improve employee involvement and help them get the most bang for their buck.
8. Annual population health comparison reports to evaluate the impact of your health and wellness initiatives over time, and to identify key issues for strategic health initiatives.
9. Immediate linkage from HRA to health coaching programs that immediately connect employees to proven interventions for healthy lifestyle, behavioral health and chronic conditions.
10. Strong science with peer-reviewed publications that demonstrates the value and impact to employers that implement these HRAs and associated health and wellness solutions.

In summary, the HRA is in the national spotlight. A new generation of HRAs now offers better technology, science, comprehensiveness and employee access. So, determine whether your organization is ready to take advantages of these advances.

How are you using HRAs today? Do they meet the criteria demanded by today’s competitive business world and health care climate?

Image courtesy of iStockphoto, Lisa-Blue, Flickr, Charles Williams