My recent request to review health risk assessments (HRAs) brought a number of responses. I’m grading the HRAs I was able to complete, on both advice and readability.

Cerner’s, the first to be reviewed, receives “F” in advice and, as will be shown below, D in readability, for an average of F+. Advice is scored as follows:

• A: Virtually all the advice is up to date and correct
• B: The advice is generally correct
• C: There is good and bad advice in roughly equal amounts
• D: Bad advice outweighs good
• F: Employers using this HRA should caution employees not to take the advice

For each HRA being graded, unless otherwise indicated, I am completing them exactly the same way. I am somewhat understating the quality of my diet and the amount of exercise I do, in order to get “mainstream” advice.

High-risk for alcohol and drug use is incorrect. 10 mg of Ambien, taken as directed by a physician, does not create high risk in the absence of other drug and alcohol risk factors.

Ironically, there is a risk in telling people they are high-risk when they aren’t, which is that they will simply lie, in order to move their score left, out of that red segment, and out of the embarrassing range. As a result, they would not exposed to advice they should be getting if indeed they are at risk for drugs and alcohol.

And then they realize it’s OK to lie in general on HRAs. These lies take place on a massive scale, invalidating the entire HRA instrument.  In an attempt to create a culture of health, companies are creating a culture of deceit.

This blood pressure advice is incorrect. Someone with a “pulse pressure” of 25 (110 – 85) is not at “moderate risk” of anything. This is an emergency situation, likely indicating heart failure fluid overload. (This is not my blood pressure, by the way, or I’d be practically dead.)  

This advice is wrong on five dimensions.

1. People should not be taking blood pressure advice off a computer-generated algorithm, especially one that hasn’t been updated in years. That’s what doctors are for.
2. It’s not at all clear that lowering sodium reduces blood pressure in the large majority of adults. This should not be offered as a fact. In some people it makes a difference. Advising people on their own situation is what doctors are for. 
3. “If you limit your sodium to 1500 mg a day, you can lower your blood pressure even more.” Actually the Framingham Offspring Study says the reverse. It turns out that people who say they consume 4000 mg/day of salt have the lowest blood pressure. (The link is to a lay article that itself links to scholarly material.) Not clear which is right, but advice this controversial should not be passed off as a fact when the evidence conflicts.
4. It is possible that this Cerner-recommended low-sodium diet increases cardiovascular risk. Other studies, largely older ones, say this diet reduces risk. It’s safe to say there is no consensus. But HRAs, which employee are being financially coerced into doing, should not be offering controversial advice as fact.
5. Telling people to avoid salty snacks may encourage people to eat sugary snacks. The HRA is quite deficient in warnings about sugar.

This advice to switch to lowfat dairy is more likely to cause harm than to create benefit. Full-fat dairy is preferable to fat-free for most people. As this summary, with links to the studies, shows, full-fat dairy probably offers protection against diabetes.

And don’t overlook their complete rookie mistake: telling employees to eat “low-fat or nonfat yogurt,” which of course is full of sugar.

The advice regarding saturated fat in meats is controversial but is presented as fact. There is a whole body of research saying the opposite of what Cerner says. Once again, we aren’t taking sides except to note that coercing employees to complete HRAs implies that the HRAs should be accurate.

Omissions

Further, Cerner’s HRA, as Yogi Berra might say, contains a lot of omissions. The following pieces of advice should be included, but aren’t:

• Advice not to text while driving (in lieu of the seat belts question*)
• Health literacy information on finding hidden sugars
• Health literacy information on finding hidden salt (who knows how much “1500 milligrams” is, assuming that advice were good?)
• Eggs are one of nature’s healthiest foods for most people
• Shingles vaccine addresses the most easily avoidable risk for people over 50
• Questions on opioid awareness (not opioid use, which people will just lie about) and information on how addictive they can be

*Not a useful question and speaks to a lack of updating. While decades ago, a few employees might have benefited from the advice to buckle a seat belt, no employee in recent history has ever not buckled their seat belt, taken an HRA on which they admitted not buckling their seat belt, read the printout that said they should buckle their seat belt, realized for the first time that not buckling a seat belt was a bad idea…and then started buckling their seat belt.

Readability

The scale for readability is:

• A: Intuitive — didn’t even think about any readability issues
• B: Readable enough
• C: Readable with exceptions
• D: Not readable in many instances
• F: Exercise in frustration

Cerner earns a “D” only because, as we will see in a future posting, it is better than Optum’s (F) and Interactive Health’s (F). Absent those two HRAs, Cerner would get an “F”.

Cerner says I am “at HIGH risk for chronic health issues.” But on the right it says I am “moderate risk.” That is confusing and decidedly unhelpful in and of itself. But wait. There’s more…now how much risk do I have?

Having sweated bullets while learning I was high risk and moderate risk, I rest easily to learn that I am at “LOW risk for chronic health issues.” 

Eventually I guessed what meaning they were trying to convey, but the typical employee (who, according to Cerner, has to be told to buckle a seat belt) is not going to figure this out.

Why couldn’t they just ask if you are feeling down or depressed? (Not that any employee is going to answer that honestly, in any event.) 

“Has little interest or little pleasure in doing things bothered you?”  Does this mean that if having “little interest or little pleasure in doing things” doesn’t bother you, you write “no”?  I had to read this several times to figure out what they were asking.

It doesn’t help that Cerner’s writing style uses a lettering system for no reason. What do those “a’s” and “b’s” add?  They do that everywhere, to add to the general confusion:

Lots of extra letters, for no reason at all. And “stroke” and “heart attack” are not “conditions.” They are “events.” Heart failure (a serious disease with an average life expectancy of 5 years) should not be lumped in with angina, which can be controlled for many years with diet, exercise and medication.

Summary

There is far too much advice in here – salt, dairy, meat, drugs, blood pressure just for starters – for anyone to internalize and act upon. It is a tenet of human behavior that the more advice is given, the less is taken. Plus, more importantly, a large chunk of the advice is at least arguably wrong, if not definitely wrong.

Further, the two things that are most important for employees to learn about — sugar and opioids — are pretty much ignored. A good HRA will laser-focus on sugar harms. Likewise, opioids, the leading killer of people under 50. While an HRA can’t cure an addict, questions like: “How long does it take for the first signs of opioid addiction to start, when used as directed?” could measure people’s opioid awareness and then provide easily digestible information on what the actual answer is (3 days). Quizzify has placed its pain management-and-opioids quiz in the public domain, which could fill that gap.

The graphics with all the HIGH and LOW risk scores are very confusing.

Virtually everyone with a drinking problem will lie about it. (Just check the national statistics against the results of this HRA.) This will encourage dishonesty in other answers, and in general create the culture that it is OK to lie to one’s employer.

This HRA, and HRAs in general, make the mistake of giving the same advice to everyone who answers a certain question(s) the same way.

This health risk assessment will not provide a net benefit to a population. It is recommended not to use it, or at a very minimum insist that whoever uses it double-check any advice offered with Quizzify or another source that is up to date and accurate.