Growth of internet availability and use provides many potential benefits for patients and consumers. The online content is vast and includes highly regarded websites from universities, government agencies and academic hospitals, as well as for profit organizations whose websites are primarily designed to sell profitable products. Websites provide information, tools for health behavior change, and sale of health-related products and services. More health care provider organizations are offering personal health records (PHRs) that give patients access to their electronic health record (EHR), enable electronic communication with the health care team, and facilitate transactions for things like medication refills. Despite the wealth of health information and online tools, many consumers and patients do not have access. This "digital divide" is often related to lack of skills and lack of access to broadband internet. Those with little computer and internet experience may lack the confidence to try, on their own, to explore and use the internet for health-related reasons. And yet those without access are often people who would derive the greatest benefits, i.e. low-income, vulnerable groups with chronic health conditions who tend to underutilize preventive health care services, over-utilize emergency departments, have less information about health conditions, treatments, and prevention, and have poorer health outcomes. Additionally, if they have stigmatized health conditions, they may be reticent to seek out information from traditional person-to-person channels, e.g. asking relatives and friends, picking up brochures at health centers, or purchasing books in book stores.
The objective of this project is to pilot test, among low-income Veterans with stigmatized chronic conditions, a training program in use of internet for health information and in use of the VA's personal health record (PHR) system, My HealtheVet. The goal is to provide veterans with self-management related information and support.
We conducted a 4-part, hands-on training in use of Internet and MHV for health purposes. Session 1 was an introduction to computers, internet, internet searching, and the personal health record system, called My HealtheVet (PHR). Session 2 focused on how to evaluate the quality of health-related information found on the internet. Session 3 covered the VA's PHR (My HealtheVet) in-depth, covering the main features and giving participants practice in using the different features. Session 4 covers how patients can constructively discuss, with their doctor, information they find on the internet.
Evaluation included surveys, interviews, focus groups and ethnographic observation. Measures included frequency of Internet use; self-efficacy; self-reported medication adherence; patient activation; and disease knowledge. Qualitative analysis methods were drawn from grounded theory. We also estimated average cost of the training per Veteran attendee. We created 3 brief videos, designed for Veteran audiences, that summarize the key points from the training.
Fourteen participants completed the intervention program. The training intervention was delivered, separately, to one group of 8 Veterans with hepatitis C and one group of Veterans with HIV. All were 35 years of age or older. The largest age group was 50-64 years old. Only one subject reported health as less than good. Six subjects were homeless or unstably housed. Internet use ranged from about 20% who had never used it, 36% who used it weekly or less often, and 43% who use the internet more often than weekly. All but one subject were male. Incomes were low, with 71% reporting annual household income of less than $12,000. Only 2 (14%) were currently married. Over half (57%) were white, 21% were black, 14% were Hispanic, and 7% were other race/ethnicity. Two (14%) had a doctor outside the VA. Health literacy ranged from 33 to 36, with a mean of 34.8, on a scale of 0 to 36. Every participant exceeded the "adequate" health literacy cutoff score of 23.
On the scale of use of internet for health there was a mean increase from baseline to follow-up 1 (FU1), from 1.57 to 4.07, (p=.0003). At follow-up two (FU2), the difference with baseline was no longer significant, though the p-value was borderline significant (p=.052). Examination of subscales indicated that much of the improvement was due to uses of a patient portal which increased from 0.36 to 2.00 from baseline to FU1 (p<.001), and from baseline to FU2 (0.36 vs. 1.36, p=0.01). General internet use increased from baseline to FU1 (0.71 vs. 1.71, p=0.03). Also significant was the change in self efficacy for information seeking and internet use. It increased from 7.12 to 8.60 (p=0.009) from baseline to FU1, and the change was maintained at FU2 (p=.004). Patient activation showed no change between baseline and FU1 (p=0.66), but there was a modest change from baseline to FU2, 3.43 to 3.61 (p=0.03). There was a borderline statistically significant increase in disease knowledge from baseline to FU1, from 67.9% correct to 72.2% correct (p=.05). There were no statistically significant changes in advanced use of technology sub-scale, nor in the self-reported medication adherence scale.
Qualitative findings were consistent with the quantitative results, for example one veteran described bringing information from MHV to the doctor's appointment, "[It] helped the doctor view me as an informed patient".
Thus average per participant cost of the four session training was $287.
The training intervention helps Veterans from vulnerable populations gain skills and confidence in using the internet and personal health record systems for health related purposes, including transacting with the VA health care system online (e.g. refilling medications). On-site training programs at VA medical centers should be considered in order to increase Veteran access to MHV and the information and services it provides.
- McInnes DK, Solomon JL, Shimada SL, Petrakis BA, Bokhour BG, Asch SM, Nazi KM, Houston TK, Gifford AL. Development and evaluation of an internet and personal health record training program for low-income patients with HIV or hepatitis C. Medical care. 2013 Mar 1; 51(3 Suppl 1):S62-6.
- Nazi KM, Hogan TP, Wagner TH, McInnes DK, Smith BM, Haggstrom D, Chumbler NR, Gifford AL, Charters KG, Saleem JJ, Weingardt KR, Fischetti LF, Weaver FM. Embracing a health services research perspective on personal health records: lessons learned from the VA My HealtheVet system. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:62-7.
- McInnes DK. Internet and My HealtheVet Use for Chronic Disease Self-Management. [Cyberseminar]. 2010 Dec 7.
- Turvey CL, Shimada S, McInnes K, Woods SS, Simon SR, Nazi K. Increasing Veteran Adoption of My HealtheVet: Collaboration between the eHealth QUERI and Operational, Clinical, and Community-based Partners. Presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
- Solomon J, Bulter JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Kan V, Rodrigues-Barradas M, Knapp H, Anaya HD. The challenges and Facilitators of Implementing Nurse-Initiated Rapid HIV Testing in High Prevalence Primary Care Settings with the U.S. Department of Veterans Affairs. Poster session presented at: National HIV Prevention Annual Conference; 2011 Aug 14; Atlanta, GA.
- Solomon J, Bulter JN, Golden JF, Bokhour BG, Hare KA, Kertz BL, Rodrigues-Barradas MC, Kan VL, Knapp H, Anaya HD. The challenges and Facilitators of Implementing Nurse-Initiated Rapid HIV Testing in High Prevalence Primary Care Settings with the U.S. Department of Veterans Affairs. Poster session presented at: International AIDS Society on HIV Pathogenesis, Treatment and Prevention Annual Conference; 2011 Jul 5; Rome, Italy.
- McInnes DK, Solomon J, Shimada SL, Bokhour BG, Houston TK, Nazi KM, Petrakis BA, Gifford AL, Asch SM. Teaching Veterans to Use the Internet and My HealtheVet for Self-Management of Serious Chronic Conditions. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 18; National Harbor, MD.
- McInnes DK, Solomon J, Shimada SL, Bokhour BG, Houston TK, Gifford AL, Asch SM, Samore MH. Intervention to Provide Internet and Personal Health Record (PHR) Skills to Persons with Serious Chronic Conditions. Poster session presented at: American Medical Informatics Association Annual Symposium; 2010 Nov 15; Washington, DC.
Health Systems, Infectious Diseases
Technology Development and Assessment
Adherence, Hepatitis C, HIV/AIDS, QUERI Implementation