HIV-infected individuals face many challenges and need to be proactive in self-management of their HIV and comorbid conditions to live a healthy life. One promising solution is the use of personal health records (PHRs), which have the potential to facilitate disease self-management, improve health outcomes, and reduce unnecessary health care utilization. The VA has one of the nation's largest PHR systems - My HealtheVet (MHV). There has not yet been an examination of use of MHV features and their relationship to health outcomes in any chronic disease group. HIV-infected Veterans are of utmost importance to focus on not just because they face several challenges in self-management as they age, but because Veterans with HIV have been the largest group proportionally of any chronic disease group to adopt MHV (i.e., 26%).
The objective of this project is to conduct an in-depth analysis of MHV use by HIV-infected Veterans and their providers and develop an intervention based on our findings. The quantitative analysis will allow linkage of MHV self-management tool use to care processes and outcomes, while the qualitative analysis will help discern why Veterans adopt or fail to adopt MHV and what benefit they derive from using specific MHV tools. The role providers have in facilitating (or discouraging) Veteran use of MHV will be explored.
To achieve these objectives, we utilize mixed methods that integrate quantitative and qualitative data using a multiphase design, comprised of sequential and convergent elements. The design is sequential in that Aim 1 (quantitative aim) findings provide not only assistance with recruitment but will inform some of the data collected in Aim 2 (qualitative aim). For example, findings related to MHV tool use frequency could shape the types of questions asked during Aim 2 and provide greater clarity for why there is a difference in tool use. This study also relies on convergent elements of a mixed methods design in that Aim 3 involves the integration and comparing and contrasting of quantitative and qualitative findings to inform development of an intervention. Our Aim 1 cohort includes HIV-infected Veterans who used VA care from FY11 to FY17 regardless of MHV registration status.
Preliminary findings show demographic differences in use of MHV tools. HIV-infected Veterans who registered for MHV are slightly younger than their unregistered counterparts, with an average age of 50 (SD 11.5) compared to 55 (SD 10.5). Our cohort is primarily made up of black/African American and white Veterans. Preliminary, unadjusted measures suggest that the black/African American members of our cohort are less likely to register for MHV than white members or our cohort, with only 42% of black/African American members registered compared to 51% of white members. Unadjusted measures also show that among those registered for MHV, black/African American users show less utilization of MHV tools than white users. Among white and among black/African American MHV users respectively, 47% and 34% used Blue Button, 40% and 24% used Secure Messaging, 55% and 38% used Rx Refill, and 57% and 43% viewed appointments.
In addition, our Aim 1 work revealed that 34% (N=11,859) of our cohort utilized non-VA care for which a claim was submitted to the VA; 16% (N=5,394) of Veterans in our cohort live in rural or highly rural locations; and 29% (N=10,159) of Veterans in our cohort experienced housing instability or homelessness at some point in FY11-FY17. Among Veterans in our cohort who have experienced housing instability or homelessness, 9% (N=931) have been at risk of homelessness, 36% (N=3,684) have experienced some period of homelessness, and 55% (N=5,544) have experienced chronic homelessness and were placed in long-term supportive housing.
The study's great value lies in the linkage, at the individual Veteran level, of highly detailed PHR activity data with VA medical record data. Understanding how MHV can facilitate improved self-management of chronic conditions would have tremendous benefits for most Veterans in VHA who have chronic conditions. The findings from this study will be used to develop a PHR-supported intervention that optimizes health outcomes by targeting patients and providers, which will improve health care processes for Veterans.
- Javier SJ, Troszak LK, Shimada SL, McInnes DK, Ohl ME, Avoundjian T, Erhardt TA, Midboe AM. Racial and ethnic disparities in use of a personal health record by veterans living with HIV. Journal of the American Medical Informatics Association : JAMIA. 2019 Aug 1; 26(8-9):696-702.