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Readability of Notice of Privacy Forms Used by Major Health Care Institutions
To the Editor: The Health Insurance Portability and Accountability Act (HIPAA) requires that health care institutions inform patients in detail about the use of information obtained during medical care via a notice of privacy form that "must be written in plain language."1 We evaluated the length and readability of notice of privacy practices forms used by top-ranked US health care institutions.
Methods
Using institutional Web sites and electronic mail, we collected a notice of privacy practices from all 185 institutions listed in the 2004 US News & World Report’s "best hospitals" issue.2 Readability indices use formulas combining word and sentence length to quantitate language complexity. Because there is no standard technique for determining readability, we used 3 different scales: SMOG,3 Flesch-Kincaid,4 and Flesch Reading Ease.5 The SMOG and Flesch-Kincaid scales produce an estimated educational level required to read and comprehend a document (reading grade level). Although the Flesch-Kincaid formula has been criticized because it may truncate the reading grade level of complex documents at 12th grade, we included it to allow comparison with previous research on consent form readability.6 The Flesch Reading Ease formula expresses readability in a manner other than reading grade level (scores from 0 [very difficult to read] to 100 [very easy to read]). Font sizes less than 10-point, the minimum required for manuscript submission to JAMA and grant submissions to the National Institutes of Health, were considered inappropriately small for comfortable reading.
We estimated the proportion of the local population who would be able to understand the notice of privacy practices by comparing the reading grade level of individual forms (SMOG scale) to the educational attainment of persons aged 25 years or older living in the 3-digit ZIP code area of the institution.7 Because self-reported educational attainment among adults may overestimate actual literacy by 3 to 5 grades,8 we performed an adjusted analysis in which educational attainment was decreased by 3 grades. We classified persons with educational attainment less than the reading grade level of the notice of privacy practices as unlikely to understand the document.
Results
The median length of the notice of privacy practices was 6 pages, containing 2915 words (Table 1). The median font size was 10-point, and 32 (17.3%) of 185 forms used font sizes less than 10-point. The median reading grade levels were 13 (SMOG) and 11 (Flesch-Kincaid). The Flesch Readability Ease scores were low (median, 42.2), indicating complex language (Table 2). A median of 38.9% of persons in the surrounding 3-digit ZIP code area had unadjusted educational levels below the reading grade level of the forms. After adjustment, a median of 80.0% of persons in the surrounding area would have difficulty understanding the privacy notices.
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Table 1. Document Characteristics, Readability, and Comparison With Educational Levels of the Local Population
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Table 2. Readability of Notice of Privacy Practices by the Flesch Reading Ease Formula, With Standard Interpretation of Scores (N = 185)
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Comment
The privacy practice notifications from these top-ranked US health care institutions were lengthy and often presented in small font sizes. For comparison, these forms shared a number of characteristics with articles in the professional medical literature. For example, JAMA research articles are typically 3000 to 3500 words in length.9 In 1 study, the median Flesch Reading Ease score of articles in the professional medical literature was 29.1,10 indicating language not much more complex than that of the forms we evaluated.
Our study has at least 2 limitations. We evaluated notices of privacy practices from a small proportion of the thousands of health care institutions in the United States. We used census data on the population in the surrounding area rather than directly assessing the patient population of each institution. It is possible that the patient population of some institutions differs from the surrounding population in important ways. Despite these limitations, our study demonstrates that notices of privacy practices are lengthy and contain complex language that is unlikely to be understood by a considerable proportion of the populations served by top-ranked US health care institutions. If the purpose of the HIPAA legislation is to improve communication between patient and clinician, the documents used to do so need to be changed.
Peter Breese, MSPH
peter.breese{at}dhha.org
William Burman, MD
Denver Public Health
Denver, Colo
1. Privacy Rule (2003). 45 CFR  160, 164.
2. US News & World Report Best Hospitals 2004. Available at: http://www.usnews.com/usnews/health/hosptl/tophosp.htm. Accessed March 2, 2005.
3. McLaughlin H. SMOG grading—a new readability formula. J Reading. 1969;12:639-946.
4. Kincaid J, Fishburn R Jr, Rogers R, Chissom B. Derivation of New Readability Formulas for Navy Enlisted Personnel. Millington, Tenn: Memphis Naval Air Station; 1975.
5. Flesch RF. A new readability yardstick. J Appl Psychol. 1948;32:221-224.
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6. Paasche-Orlow MK, Taylor HA, Brancati FL. Readability standards for informed-consent forms as compared with actual readability. N Engl J Med. 2003;348:721-726.
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7. US Census Bureau. Educational attainment by sex, 2000. Available at: http://factfinder.census.gov/servlet/QTTable?_bm=y&-geo_id=01000US&-qr_name=DEC_2000_SF3_U_QTP20&-ds_name=DEC_2000_SF3_U&-_lang=en&-_sse=on. Accessed March 26, 2004.
8. Davis TC, Crouch MA, Wills G, Miller S, Abdehou DM. The gap between patient reading comprehension and the readability of patient education materials. J Fam Pract. 1990;31:533-538.
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9. JAMA Instructions for Authors. Available at: http://jama.com/ifora_current.dtl. Accessed February 14, 2005.
10. Roberts JC, Fletcher RH, Fletcher SW. Effects of peer review and editing on the readability of articles published in Annals of Internal Medicine. JAMA. 1994;272:119-121.
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JAMA. 2005;293:1593-1594.
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