Two main findings were observed. Among those patients provided the PHR, utilization of the PHR was quite low with only 26% using it frequently. Additionally, we found minimal differences between patients provided with PHR access and those without PHR access in this effectiveness trial conducted in two busy primary care clinics. Contrary to optimism about PHR impact, PHR access alone failed to activate patients, improve outcomes, increase satisfaction with care, or change the frequency with which patients use medical services. Simply providing patients with a method to access their healthcare information will not ensure changes in patient outcomes. This underscores the necessity to consider the immediate health outcome potential of subsequent stage 2 implementation plans for meaningful use criteria which require that patients are provided with information access after inpatient and clinical encounters with expectations that 20% will use a portal at least once. Our results suggest stage 2 implementation may not produce changes in patient health outcomes. Whether this is due to limited likelihood of patient use or limited impact when used is not yet understood.
The observed infrequent use of PHRs is similar to the findings of others.9
PHR utilization was infrequent, with 54% using it less than twice in 9–12 months, 20% using it 3–5 times, and 26% using it about twice monthly. Only about 10% used the PHR weekly or more. Additionally, only 26% of patients approached to participate in the study actually volunteered, so PHR utilization by the general population of patients similar to our sample may actually be much less than we observed. Future research may clarify the meaningful ‘dose’ of PHR utilization associated with favorable outcomes.
Although patients acknowledged the practical utility of our PHR, many expectations were not met. PHRs operate at increasingly useful levels.29
Our PHR stored information, provided some linkages, and allowed limited tracking and appointment scheduling. Previous inquiry to refine this PHR yielded informative patient recommendations, only some of which were implemented.22
Of note, we did not find that ease of entry of BP data via a USB port produced any additional effect on PHR use or outcomes.
Some optimism about PHRs remains. Patients who were the most frequent PHR users evidenced a reduction of 5.25 points in DBP and 3.97 points in SBP. Although it is not clear that this reduction can be attributed to PHR use, greater motivation to change in general, or other unexamined constructs, considering factors related to frequency of use may clarify practical directions for future research that can produce changed health outcomes.
Access and technology skills
were important. Considering PHR use as a ‘health practice,’ self-efficacy theory suggests that patients need to view themselves as capable of successfully using the PHR
Age, self-rated computer skills, number of ways the internet is used, and baseline perceptions of the utility of HIT predicted PHR use, all indicative of higher computer self-efficacy. Overall, 83% of infrequent users possessed a home computer compared to 91% of frequent users. Mobile technology may reduce technology disparities and could expand potential PHR access.30
Salient clinical need
evidenced in our frequent users as high initial BPs may encourage use. Self-management support trials and studies of increased access to one's health information find similar results.18
The 70% of our patients demonstrating controlled hypertension may not have perceived a need to document or track BP, thus perceptually limiting immediate need for a PHR. Patients perceiving pronounced need, such as those receiving a new critical diagnosis or those challenged to manage conditions such as abnormal BP, may maximize PHR use.
Patients with the lowest PHR use had the lowest baseline activation scores and patients with the highest PHR use had the highest scores suggesting that activation
may be a PHR use mediator. However, our high user group demonstrated reduced activation by visit 4. Our study team is challenged to explain the degradation. For some patients, readiness to engage with the healthcare system may involve ‘surrendering’ decision-making involvement, while for others, readiness may reflect active decision-making preferences. Patients ‘taking care of (their) health problems’ may influence PHR use in contrasting ways.37
Considering the context of the patient-physician relationship
, we found that higher scores on the CAHPS provider communication subscale were associated with greater use of the PHR. Others have found that use of PHRs is most likely when the invitation and interaction of the provider encourages such use.38–40
Thus before we can expect PHRs to change clinical outcomes, we need to understand how both patient and provider engage the PHR and use the information contained within the PHR in the context of collaborative care. In our study, conversations initiated by both patients and physicians about the PHR and the health data contained therein varied greatly.
Perhaps the PHR serves as a ‘cue to action’ as suggested by the health belief model.41
We found that patients with the highest BPs and the highest provider communication ratings exposed themselves to the ‘cue’ most often. Future research should examine how to reinforce use in the clinical context and may improve PHRs' outcome potential.
Examining system level variables, the Family Medicine clinic reported greater PHR use. Discussions with clinic stakeholders suggest patient continuity is highly embedded in their care process, and Family Medicine care teams have used an EMR for 13 years. Both provider and patient comfort with technology and established long-term relationships between patients and providers appear to have stimulated adoption and use of the additional technology of a PHR.
Several limitations were present making the reason for failure to find differences unclear. We tested only one PHR with limited EMR/PHR interoperability. Significant numbers of patients declined to participate in the study, limiting the sample representativeness. Some possible cross-arm contamination may have occurred as intervention patients and control patients received care in the same clinics, and although physicians saw either study patients who had the PHR or study patients who did not, nursing staff saw all patients. PHR use frequency may have been greater if enrollment had been limited to patients with uncontrolled hypertension, maximizing the potential for greater BP change. Finally, we were unable to calculate individual use via PHR data extraction and relied on patient self-report to determine PHR frequency of use.
Health informatics trials are complex interventions, used with great variability by the patient and provider and uniquely implemented within each healthcare system.43
We found infrequent use of a PHR, no increase in patient activation with PHR access or use, and little change in outcomes except in limited areas among those using the PHR frequently. While clinical outcomes such as BP are typically considered the prime objective, process adaptation and intermediary measures are arguably critical to understand PHR use. Expectations of the outcomes produced by patient access to a PHR may need to be tempered until we understand which patients choose to use PHRs and how they use them. It is critical to understand how providers and systems can best incorporate PHRs into the practice settings and individual clinical encounters where the physician and patient join together to use the increased health information. Meaningful use criteria will support the provision of and access to web portals and PHRs. However, additional steps will be necessary before we can conclude that such access will improve patient health outcomes.