This study conducted a mixed methods evaluation of the early use of and satisfaction with the Blue Button feature of My HealtheVet (MHV). This feature simplifies the process for Veterans to integrate self-entered and VA medical record data to create a single health history summary presented in a user friendly and professional format. The goal is for Veterans to use the print out created to improve 1) self-management of their health, 2) communication with health care providers, and 3) coordination of care between VA and non-VA providers.
The main objective was to determine the factors contributing to the adoption and meaningful use of the Blue Button feature.
There were two phases to this study. In the first phase, an online survey was administered to 25,155 MHV users. Of these, there were 18,219 unique veteran respondents who answered the question about Blue Button use. Online survey questions were designed to determine which factors (lack of awareness, low perceived value, low usability, or preference for another way to organize health information) were most strongly associated with Blue Button adoption. The second phase consisted of qualitative interviews with 34 Veterans, 10 VA providers, and 8 non-VA providers about their experience with care coordination, personal health records, the Blue Button feature, and their critique of the design, content, and usefulness of the Blue Button print out.
Adoption of the Blue Button: Of 18,219 veterans, 11,541 (63.3%) had never used the Blue Button, 5,950 (32.7%) were current users, and 728 (4%) had used the Blue Button in the past, but were not current users. There were no large differences between these groups on age, gender, number of medical illnesses, use of the VA in the past year, or service cohort. The largest difference between users and non-users was in self-rated computer ability: 68.7% of Blue Button users rated their computer ability as advanced, while 55.9% of the non-users and 64.1% of past users rated themselves as advanced.
The most common reason for not using the Blue Button was lack of awareness (61.2%), not knowing how to use it (34.4%), or not knowing where it is (9.5%). Very few (9.1%) endorsed that they did not think the Blue Button was useful. Past users endorsed that they could not find what they were looking for (39.8%) as the main reason for not using the Blue Button again. The two types of information they most desired were their complete medical record (58.4%) and lab results (54.8%). Lab results are currently available.
Blue Button users were asked how they used their Blue Button file. The most highly endorsed use was for simply viewing their health information (79.4%), while 32.2% saved an electronic copy, and 25.7% printed it. Of all the information available, current users endorsed looking at lab results most highly (71.4%).
Qualitative Results: Ten VA providers and 8 non-VA providers were interviewed. Overall, for all providers there was little experience with patients bringing them a Blue Button print out, although some providers had experience with patient portals/personal health records (PHRs) tethered to other medical records systems.
Thirty-four veterans ages 36-78 (x= 61, SD 10.2) completed the qualitive interview and also a brief quantitative questionnaire. This included 24 Veterans who previously used the Blue Button feature and 22 with non-VA providers. Most veterans found MHV to be useful (79%); however, 24% also reported that it was difficult to learn how to use MHV. Of the participants who reported not using the Blue Button feature, several had made previous attempts, but were unsuccessful. The most common technical problem reported was related to the "Your information is being updated...:" message with instructions to refresh or return at a later time. At this point, they considered their attempt at downloading their data as failed, not realizing they could look further down the page and continue to generate their report.
Both provider and Veteran interviews indicate that communication between VA and non-VA providers is unsystematic, highly variable, and relies primarily on the patient to provide information. When asked if his care providers communicated with each other, one Veteran replied: "I don't think so. No, they um, uh, it's-it's up to me to uh, uh, move the information back and forth."
Non-VA providers expressed more dissatisfaction with care coordination than VA providers, but there were problems going both ways. VA providers often thought the Blue Button print out provided redundant information due to their access to CPRS. Veteran self-entered information was more valued, but some providers indicated this information should be available in CPRS. One VA provider stated "it doesn't make any sense to me. If they could put in the HealtheVet, which is electronic, why can't we just access that information and copy it into CPRS?" Veterans often agreed with their VA providers accessing their MHV information or limited access suggesting a mechanism in MHV to 'tag' what they wanted to be accessible to their VA provider to view.
There was concern on the length of the print out; however, regardless of the length there was value in using PHRs and the Blue Button print out as a way to engage and empower Veterans in their care. One provider discussed the print out as a tool that could help identify gaps in understanding that could be addressed. A Veteran noted ".the first time I used it, I was really happy because, I, was participating in my health care. I mean, you can actually see real time what's going on...which is really good. So it makes-make you part of the process." Providers also noted that effective sharing of information would improve care and be beneficial for the overall healthcare system, ". it would increase our accuracy, and, and decrease our duplication of, uh, tests. Um, it would make it.more economical sense for the patient insurance system as well."
When asked about the most important information available to include in the Blue Button document, providers wanted a current medication list, recent laboratories, wellness reminders, immunizations, allergies, and adverse reactions. Of information not available on the print out reviewed, they endorsed wanting to view a problem list, recent notes or hospitalizations, and results from procedures or pathology. Veterans interviewed also expressed interest in accessing their visit notes to facilitate care, but also to assist with applying for benefits so that they did not have to rely on medical record requests. The recent release of the Blue Button in January 2013 provides greater access to medical record data.
The main impact of this study will be recommendations to the My HealtheVet program office of strategies to increase adoption and meaningful use of the Blue Button.
- Klein DM, Fix GM, Hogan TP, Simon SR, Nazi KM, Turvey CL. Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews With Patients and Providers. Journal of medical Internet research. 2015 Aug 18; 17(8):e199.
- Nazi KM, Turvey CL, Klein DM, Hogan TP, Woods SS. VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. Journal of the American Medical Informatics Association : JAMIA. 2015 Mar 1; 22(2):380-9.
- Turvey C, Klein D, Fix G, Hogan TP, Woods S, Simon SR, Charlton M, Vaughan-Sarrazin M, Zulman DM, Dindo L, Wakefield B, Graham G, Nazi K. Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal. Journal of the American Medical Informatics Association : JAMIA. 2014 Jul 1; 21(4):657-63.
- Woods SS, Schwartz E, Tuepker A, Press NA, Nazi KM, Turvey CL, Nichol WP. Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study. Journal of medical Internet research. 2013 Mar 27; 15(3):e65.
HSR&D or QUERI Articles
- Woods SS, Nazi K, Turvey CL. E-health records lead to better patient-doctor communication. ORD VA Research Currents. 2014 Mar 12;(Spring).
- Turvey CL. Veteran Engagement and Access to Health Information: Collaboration in the Evaluation of the Blue Button Feature of My HealtheVet. Using Data and Information Systems in Partnered Research [Cyberseminar]. HSR&D Cyberseminars. 2017 Feb 28.
- Turvey CL. Use to Access and Share Health Record Information. [Cyberseminar]. 2014 Nov 4.
- Charlton ME, Rosenthal GE, Turvey CL. Dual Use of VA and Non-VA Services by Veterans in PACT. [Cyberseminar]. 2013 May 15.
- Turvey CL. Patient Engagement Using the Blue Button for Care Coordination. Presented at: Iowa eHealth Summit; 2015 Jun 24; Des Moines, IA.
- Woods SS, Nazi K, Turvey CL, Klein DM, Hogan TP. VA OpenNotes: A first look at the experience of Veteran users of the My HealtheVet Blue Button to access clinical notes. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2014 Apr 25; Philadelphia, PA.