Stephanie L. Shimada

Internet health information seeking is a team sport: Analysis of the Pew Internet Survey

BACKGROUND Previous studies examining characteristics of Internet health information seekers do not distinguish between those who only seek for themselves, and surrogate seekers who look for health information for family or friends. Identifying the unique characteristics of surrogate seekers would help in developing Internet interventions that better support these information seekers. OBJECTIVE To assess differences between self seekers versus those that act also as surrogate seekers. METHODS We analyzed data from the cross-sectional Pew Internet and American Life Project November/December 2008 health survey. Our dependent variable was self-report of type of health information seeking (surrogate versus self seeking). Independent variables included demographics, health status, and caregiving. After bivariate comparisons, we then developed multivariable models using logistic regression to assess characteristics associated with surrogate seeking. RESULTS Out of 1250 respondents who reported seeking health information online, 56% (N=705) reported being surrogate seekers. In multivariable models, compared with those who sought information for themselves only, surrogate seekers were more likely both married and a parent (OR=1.57, CI=1.08, 2.28), having good (OR=2.05, CI=1.34, 3.12) or excellent (OR=2.72, CI=1.70, 4.33) health status, being caregiver of an adult relative (OR=1.76, CI=1.34, 2.30), having someone close with a serious medical condition (OR=1.62, CI=1.21, 2.17) and having someone close to them facing a chronic illness (OR=1.55, CI=1.17, 2.04). CONCLUSIONS Our findings provide evidence that information needs of surrogate seekers are not being met, specifically of caregivers. Additional research is needed to develop new functions that support surrogate seekers.

Evaluating user experiences of the secure messaging tool on the Veterans Affairs' patient portal system.

Background The United States Department of Veterans Affairs has implemented an electronic asynchronous “Secure Messaging” tool within a Web-based patient portal (ie, My HealtheVet) to support patient-provider communication. This electronic resource promotes continuous and coordinated patient-centered care, but to date little research has evaluated patients’ experiences and preferences for using Secure Messaging. Objective The objectives of this mixed-methods study were to (1) characterize veterans’ experiences using Secure Messaging in the My HealtheVet portal over a 3-month period, including system usability, (2) identify barriers to and facilitators of use, and (3) describe strategies to support veterans’ use of Secure Messaging. Methods We recruited 33 veterans who had access to and had previously used the portal’s Secure Messaging tool. We used a combination of in-depth interviews, face-to-face user-testing, review of transmitted secure messages between veterans and staff, and telephone interviews three months following initial contact. We assessed participants’ computer and health literacy during initial and follow-up interviews. We used a content-analysis approach to identify dominant themes in the qualitative data. We compared inferences from each of the data sources (interviews, user-testing, and message review) to identify convergent and divergent data trends. Results The majority of veterans (27/33, 82%) reported being satisfied with Secure Messaging at initial interview; satisfaction ratings increased to 97% (31/32, 1 missing) during follow-up interviews. Veterans noted Secure Messaging to be useful for communicating with their primary care team to manage health care needs (eg, health-related questions, test requests and results, medication refills and questions, managing appointments). Four domains emerged from interviews: (1) perceived benefits of using Secure Messaging, (2) barriers to using Secure Messaging, (3) facilitators for using Secure Messaging, and (4) suggestions for improving Secure Messaging. Veterans identified and demonstrated impediments to successful system usage that can be addressed with education, skill building, and system modifications. Analysis of secure message content data provided insights to reasons for use that were not disclosed by participants during interviews, specifically sensitive health topics such as erectile dysfunction and sexually transmitted disease inquiries. Conclusions Veterans perceive Secure Messaging in the My HealtheVet patient portal as a useful tool for communicating with health care teams. However, to maximize sustained utilization of Secure Messaging, marketing, education, skill building, and system modifications are needed. Data from this study can inform a large-scale quantitative assessment of Secure Messaging users’ experiences in a representative sample to validate qualitative findings.

Market and beneficiary characteristics associated with enrollment in Medicare managed care plans and fee-for-service.

Background:Risk selection in the Medicare managed care program (“Medicare Advantage”) is an important policy concern. Past research has shown that Medicare managed care plans tend to attract healthier beneficiaries and that market characteristics such as managed care penetration may also affect risk selection. Objectives:To assess whether patient enrollment in Medicare managed care (MMC) or traditional fee-for-service (FFS) Medicare is related to beneficiary and market characteristics and provide a baseline for understanding how changes in Medicare policy affect MMC enrollment over time. Research Design:Data sources were the 2004 Medicare MMC and FFS CAHPS surveys, the Social Security Administrations Master Beneficiary Record, MMC Market Penetration Files, and 2000 Census data. We estimated logistic regression models to assess what beneficiary characteristics predict enrollment in MMC and the moderating effects of market characteristics. Results:Enrollees in MMC plans tend to have better health than those in FFS. This effect is weaker in areas with more competition. Latinos and beneficiaries with less education and lower income, as indicated by earnings history or local-area median income, are more likely to enroll in MMC. Conclusions:Enrollment in MMC is related to beneficiary characteristics, including health status and socioeconomic status, and is modified by MMC presence in the local market. Because vulnerable subgroups are more likely to enroll in MMC plans, the Centers for Medicare & Medicaid Services should monitor how changes to Medicare Advantage policies and payment methods may affect beneficiaries in those groups.

Development of trigger tools for surveillance of adverse events in ambulatory surgery

Background The trigger tool methodology uses clinical algorithms applied electronically to ‘flag’ medical records where adverse events (AEs) have most likely occurred. The authors sought to create surgical triggers to detect AEs in the ambulatory care setting. Methods Four consecutive steps were used to develop ambulatory surgery triggers. First, the authors conducted a comprehensive literature review for surgical triggers. Second, a series of multidisciplinary focus groups (physicians, nurses, pharmacists and information technology specialists) provided user input on trigger selection. Third, a clinical advisory panel designed an initial set of 10 triggers. Finally, a three-phase Delphi process (surgical and trigger tool experts) evaluated and rated the suggested triggers. Results The authors designed an initial set of 10 surgical triggers including five global triggers (flagging medical records for the suspicion of any AE) and five AE-specific triggers (flagging medical records for the suspicion of specific AEs). Based on the Delphi rating of the triggers utility for system-level interventions, the final triggers were: (1) emergency room visit(s) within 21 days from surgery; (2) unscheduled readmission within 30 days from surgery; (3) unscheduled procedure (interventional radiological, urological, dental, cardiac or gastroenterological) or reoperation within 30 days from surgery; (4) unplanned initial hospital length of stay more than 24 h; and (5) lower-extremity Doppler ultrasound order entry and ICD code for deep vein thrombosis or pulmonary embolus within 30 days from surgery. Conclusion The authors therefore propose a systematic methodology to develop trigger tools that takes into consideration previously published work, end-user preferences and expert opinion.

The National Cancer Institute’s Health Information National Trends Survey [HINTS]: a national cross-sectional analysis of talking to your doctor and other healthcare providers for health information

BackgroundThe need to understand preferred sources of health information remains important to providing patient-centered care. The Internet remains a popular resource for health information, but more traditional sources may still be valid for patients during a recent health need. This study sought to understand the characteristics of patients that turn to their doctor or healthcare provider first for a recent health or medical information need.MethodsUsing the national cross-sectional survey, Health Information National Trend Study [HINTS], characteristics of those who sought a doctor or healthcare provider for a recent health information need were compared to other sources. Weighted survey responses from Cycle 1 and Cycle 2 of the HINTS survey were used for multivariable logistic regression.ResultsA total 5,307 patient responses were analyzed. Overall, those who seek a doctor or healthcare provider first for a health need are female, 46–64 years, White non-Hispanic, educated, in good health and users of the Internet. Yet, adjusted logistic regressions showed that those who sought a doctor or healthcare provider first during a recent health information need compared to other sources were most likely to be 65+ years, in poor health, less educated and have health insurance.ConclusionsPatients who seek their doctor or healthcare provider first for health information rather than other sources of information represent a unique population. Doctors or healthcare providers remain an important resource for these patients during recent needs, despite the wide use of the Internet as a source of health information.

Patient-provider secure messaging in VA: variations in adoption and association with urgent care utilization.

Background: The Veterans Health Administration has implemented patient to clinical team electronic asynchronous secure messaging (SM). This disruptive technology has the potential to support continuous, coordinated quality care, but limited evidence supports this connection. Objectives: The objective of this paper is to (1) measure SM implementation and identify facility characteristics associated with higher rates of adoption and (2) understand the association of SM use and noncontinuity care [ie, urgent care (UC)] utilization rates. Measures: We conducted a retrospective cohort study of 132 VA facilities implementing SM in primary care. We used a combination of cross-sectional survey data on predictors of SM implementation and longitudinal data (July 2010–June 2012) on use of SM and UC. Results: Human resources (coordinator and staff/volunteer availability to directly assist Veterans), computer resources (computers and computer rooms for Veterans), and leadership support for coordinators were associated with increased SM adoption rates. Higher SM use was associated with lower UC rates; early adopters of SM achieved a greater decrease in UC utilization over time than later adopters. Conclusions: In this exploratory analysis of early SM implementation in VA, we found a path of associations linking SM and reductions in UC utilization. These results suggest a need for further examination of the relationship between SM and its effects on health care utilization patterns.

Personal Health Record Reach in the Veterans Health Administration: A Cross-Sectional Analysis

Background My HealtheVet (MHV) is the personal health record and patient portal developed by the United States Veterans Health Administration (VA). While millions of American veterans have registered for MHV, little is known about how a patient’s health status may affect adoption and use of the personal health record. Objective Our aim was to characterize the reach of the VA personal health record by clinical condition. Methods This was a cross-sectional analysis of all veterans nationwide with at least one inpatient admission or two outpatient visits between April 2010 and March 2012. We compared adoption (registration, authentication, opt-in to use secure messaging) and use (prescription refill and secure messaging) of MHV in April 2012 across 18 specific clinical conditions prevalent in and of high priority to the VA. We calculated predicted probabilities of adoption by condition using multivariable logistic regression models adjusting for sociodemographics, comorbidities, and clustering of patients within facilities. Results Among 6,012,875 veterans, 6.20% were women, 61.45% were Caucasian, and 26.31% resided in rural areas. The mean age was 63.3 years. Nationwide, 18.64% had registered for MHV, 11.06% refilled prescriptions via MHV, and 1.91% used secure messaging with their clinical providers. Results from the multivariable regression suggest that patients with HIV, hyperlipidemia, and spinal cord injury had the highest predicted probabilities of adoption, whereas those with schizophrenia/schizoaffective disorder, alcohol or drug abuse, and stroke had the lowest. Variation was observed across diagnoses in actual (unadjusted) adoption and use, with registration rates ranging from 29.19% of patients with traumatic brain injury to 14.18% of those with schizophrenia/schizoaffective disorder. Some of the variation in actual reach can be explained by facility-level differences in MHV adoption and by differences in patients’ sociodemographic characteristics (eg, age, race, income) by diagnosis. Conclusions In this phase of early adoption, opportunities are being missed for those with specific medical conditions that require intensive treatment and self-management, which could be greatly supported by functions of a tethered personal health record.

Veteran Internet Use and Engagement With Health Information Online

Veterans represent a unique population in need of accessing health services online. Data from a random-digit dialed survey conducted by the Pew Research Centers Internet & American Life Project were used to assess differences in online use of health information among Veterans in the Veterans Health Administration (VHA) of the U.S. Department of Veteran Affairs (VA), Veterans not in VA, and non-Veterans. This survey of 3,001 U.S. citizens oversampled lower-income households. Questions assessed Veteran status and use of VA health care services, self-reported Internet use and Internet searching for health-related information, and social engagement related to health online. Overall results suggest Veterans represent an opportune population to utilize personal health records and health services via the Internet. Veterans in VA are more likely to search for health issues related to Alzheimers disease and memory loss (odds ratio = 3.07; confidence interval = 1.41-8.28) compared to Veterans not in VA. Veterans receiving VA health care also reported higher proportions of social engagement related to health about tracking diet, weight, and exercise than Veterans not in VA, although not statistically significant. Veterans in VA are using the Internet for health information, and there is an opportunity to engage them more.

Development and Evaluation of an Internet and Personal Health Record Training Program for Low-income Patients With HIV or Hepatitis C

Background: Vulnerable populations face difficulties accessing and using the internet and personal health record (PHR) systems for health-related purposes. Populations disconnected from the internet also tend to be disconnected from health care services. Objectives: To develop and evaluate an intervention to increase skills in health-related internet and PHR use for vulnerable populations with limited computer and internet experience. Research Design: Preevaluation and postevaluation using quantitative surveys, semistructured interviews, focus groups, and ethnographic observation. Subjects: Fourteen low-income Veterans receiving care at Veterans Affairs medical centers for human immunodeficiency virus or hepatitis C. Measures: Internet and PHR use, self-efficacy, patient activation, disease knowledge, predictors of medication adherence. Results: At follow-up one (FU1), mean number of internet for health features used increased from 1.57 to 4.07 (P<0.001) as did number of PHR features, from 0.36 to 2.00 (P<0.001). Mean self-efficacy increased at FU1, from 7.12 to 8.60, (P=0.009) and was maintained at follow-up two (FU2). Patient activation increased only at FU2, from 3.42 to 3.61 (P=0.03). Disease specific knowledge showed borderline increase at FU1, from 67.9% to 72.2% (P=0.05), whereas there were no changes in predictors of medication adherence. Qualitative findings underscored the interest in using internet and PHRs and their contribution to increased engagement in care. Training cost per participant was

Sustained Use of Patient Portal Features and Improvements in Diabetes Physiological Measures

287. Conclusions: Group training of vulnerable patients represents a cost-effective method to increase internet and PHR skills, and improve patient confidence in finding health-related information, making online health-related transactions, and interacting with health care providers.