In 2007, an animated character named Louise was designed to communicate discharge plans to patients with low health literacy in an effort to reduce the number of adverse events experienced after these patients left the hospital. The use of Louise, also known as a Virtual Patient Advocate (VPA), proved to be effective in reducing readmission rates, and now researchers have started using avatars to improve preconception care.

A recent study called "Reaching Women Through Health Information Technology: The Gabby Preconception Care," published in the American Journal of Health Promotion, looked at the use of an online interactive animated character named Gabby in identifying and modifying preconception risks in young minority women. Gabby emulates face-to-face conversational behavior similar to that of an empathetic clinician and can display nonverbal communicative behavior such as gazes, postures and hand gestures.

In an interview with InformationWeek Healthcare, Christina Thielst, vice president at patient experience consulting group Tower Strategies and author of the blog Christina's Considerations, said that since the creation of Louise, she's been waiting to see the use of avatars increase. "They're going to be a huge part of our future in healthcare," she said, "and there are a couple reasons for that."

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The use of avatars, for example, is a form of closed-loop communication -- something video and audio programs can't offer. Tools like avatars allow for this closed-loop, evidence-based communication, in which an organization doesn't simply offer information to patients but also ensures that patients understand what's being told to them. In this case, Gabby takes it one step further by communicating back to patients based on their responses, Thielst said.

According to the study, Gabby had four goals: screen women for their PCC risks, assess their readiness for behavior change in regard to each risk, educate them about their risks, and help develop a "My Health To-Do List." Content differed for each interaction, based on the risks discussed with each patient.

Gabby was tested with two focus groups. One included African American women between the ages of 15-25, each of whom participated in a 90-minute session with Gabby. Then a group of women enrolled in the Office of Minority Health Preconception Peer Educators (OMH PPE) program were given access to the VPA, nine of whom were given unique usernames and password to access the avatar online. These women had access to Gabby for two months and were encouraged to use the system weekly.

According to the report, participants identified an average of 23 health risks and discussed an average of 11 of those risks with the system. Participants added a majority of their risks to their "My Health To-Do List" and took action to partially or fully mitigate 83% of the risks on their list. The women agreed they preferred VPA characters with similar racial and ethnic backgrounds, and they unanimously agreed they would be more comfortable discussing PCC topics with a young female VPA that could be "symbolized" as a health professional through the use of a uniform or stethoscope, for example.

However, they also highlighted the need for VPAs to have "style and layers" -- for example, resembling a friend, wearing makeup and having a stylish haircut and accessories. When participants were asked if they would prefer to speak to Gabby or a clinician, responses were mixed; some preferred the VPA for her anonymity while others viewed her as supplemental to a visit with a doctor.

"The system isn't replacing human staff," Thielst said, explaining that there is still a role for the nurse to follow up with questions or, "based on what Gabby picks up, see if there are things they need to address with the patient specifically. But it can take a big chunk of that education time and put it into the hands of patients, rather than have it guided by staff."

The study's authors concluded that the use of a VPA system like Gabby is promising in its ability to provide care to minority women. "It addresses problems that we identified as barriers to translating PCC best practices to clinical care -- and that might be important in addressing racial disparities." Finally, they added, "VPAs can be used across a range of healthcare, educational, and community settings."

According to Thielst, VPAs are becoming fundamental to making the patient part of the care team. "Sometimes we're not quite sure how to include [the patient] in the process," she said. "But by using these techniques to better communicate with patients, we further the goal not only of patient safety, but also quality of care and patient experience."

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