The first question on the survey was “I intend to use a personal health record in the future.” Because the physicians planned to provide a PHR, they wanted to know if their patients would use it. As noted above, 74 percent of the participants indicated that they would adopt the PHR. To get an idea of the patients’ ability to use an online PHR and even to understand the content of the PHR, the eHEALS questionnaire was used to assess the patient's level of comfort and skill in using technology for e-health purposes. The eight-question index indicates that 65 percent of patients who intend to adopt the PHR have a high perceived health literacy level. This favorable attitude toward finding and using health information improves the likelihood that patients will adopt and use a PHR, according to the theory of reasoned action.29
Patients at risk for low health literacy included the 52 percent who have a high school education or less, the 7 percent in the category of those 71 years or older, and the 59 percent in the lowest income category of $20,000 or less. In each of these categories, the majority of patients were willing to adopt a PHR. Therefore, patients in this practice at risk for low health literacy, with low education, advanced age, and/or low income, are willing to adopt the PHR, and many perceive their health literacy level to be high.
These seemingly conflicting results do present a challenge in light of the known risk factors for low health literacy. Physicians who plan to provide a PHR for their patients should look beyond the demographic characteristics, which may not represent the patient population in terms of their perceived health literacy. For example, age is not a significant predictor for PHR adoption. Also, patients who are less educated may try to compensate by seeking health information through the PHR format. Low income level was also not found to be a predictor of PHR adoption, which could indicate that these patients are still interested in technology, likely are familiar with it, and have access to the Internet. In this research, a better predictor of eventual PHR usage is how patients perceive their health literacy. With this in mind, careful consideration is warranted to provide tools for interpretation as well as additional staff to assist patients with PHR usage.
Overall, supplying patients with education and other tools, such as access to their medical records, has the potential to decrease healthcare encounters and costs. One tool that was developed to facilitate communication was an “infobutton” used by women to access Pap smear results online.30
This was part of the Patient Clinical Information System (PatCIS) provided by New York Presbyterian Hospital. Definitions for frequently encountered diagnostic terms were made available to aid patients in reading and understanding their reports. Providing patients with such a tool is an important step in allowing patients to take ownership of their healthcare outcomes. Using glossaries and “plain language” at a level the patient can understand enhances understanding and communication.31,
Providers are encouraged to take the time to tell patients the action steps that are needed and use multiple forms of communication to improve understanding.33
Possible limitations included the consistency of the office staff in explaining the purpose and importance of adopting the PHR to the patient, including their attitude (positive or negative). This may have been mitigated in part through the use of written information in addition to the oral instructions. The researcher was present during the majority of the research. Some patients mentioned that they were so pleased with the care they receive that they would do anything the physician requested of them. Therefore, these patients may want to please the physician by providing what they perceive as “good” answers rather than truthful answers.
The use of dichotomized answers for the question regarding intention to adopt and the eHEALS questions might skew the results slightly. However, the majority of the patients did agree with PHR usage and felt they could understand and use the information. The use of the eight-question index to provide an overall ranking of patient perception of e-health literacy allows for a useful summary of the data. However, Norman and Skinner34
did not utilize the data in this manner in their original formulation of the eHEALS questionnaire.
The generalizability of one internal medicine/general practitioner practice is a possible limitation. However, the similarity of general medical office procedures and workflow patterns in comparable practices within the state of Florida may improve this. In the sample used for this research, homogeneity (majority white, majority women, majority with high school education, etc.) detracts from the generalizability of results to minorities and better-educated patients. It should be noted that every effort was made to include all patients who presented for appointments at the practice in an effort to improve generalizability. However, the questionnaire was only available in English, so those patients who could not read English were excluded from participating.
Due to the fact that PHRs are a relatively new technology, further research on potential methods to improve use of the PHR is important. This research used a questionnaire to determine if patients intend to adopt a PHR. If the practice moves forward with offering the technology, future research may include longitudinal data looking for positive correlation between the maintenance of a PHR (with clinical review and follow-up) and the ability of patients to read and understand written health-related materials, including prescription bottles. Lower education levels are well known to be correlated with lower levels of health literacy.35,
However, diabetics with low literacy levels are willing to take action to improve the management of their disease.36
Therefore, a closer look at the patients’ understanding and ability to use information supplied by providers is a worthwhile endeavor. This research could include a closer look at what contributes to the willingness of patients who are at risk for low health literacy to adopt a PHR as well as the inclusion of patients who do not speak and/or read English (by providing the questionnaire in other languages).
This study aimed to determine the relationship between a patient's perceived ability to find and understand e-health information and that patient's willingness to adopt and use a personal health record. Factors known to play a role in health literacy were also investigated to determine if additional relationships existed within this patient population. The theory of reasoned action provided a framework for a patient's willingness to use a PHR based on his or her attitude toward using electronic health information.
Results indicated that 74 percent of the practice's patients do intend to adopt a PHR if it is made available to them. These findings are encouraging in this population of candidates who are socioeconomically unlikely to adopt a PHR (low income, high school education). However, follow-up longitudinal research will be required to determine if the patients (and providers) indeed access the data and use it to improve health status and outcomes.
As the population ages and technology provides enhancements for healthcare, PHRs will become a more common option offered by providers who are implementing electronic health records. Neither patient nor provider can exist in a vacuum, and the ability to communicate in this manner may bridge the gap of missing information needed for improved care management. With improved continuity of care and increased cost savings as the incentives, all third-party payers should see the benefit in improved reimbursements for providers who offer a PHR. The key to ultimate success will be the patients’ willingness to adopt and use the PHR as they participate in improving their own healthcare and well-being.