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Personal health records (PHRs) are an important tool for empowering patients and stimulating health action. To date, the volitional adoption of publicly available PHRs by consumers has been low. This may be partly due to patient concerns about issues such as data security, accuracy of the clinical information stored in the PHR, and challenges with keeping the information updated. One potential solution to mitigate concerns about security, accuracy, and updating of information that may accelerate technology adoption is the provision of PHRs by employers where the PHR is pre-populated with patients’ health data. Increasingly, employers and payers are offering this technology to employees as a mechanism for greater patient engagement in health and well-being.
Little is known about the antecedents of PHR acceptance in the context of an employer sponsored PHR system. Using social cognitive theory as a lens, we theorized and empirically tested how individual factors (patient activation and provider satisfaction) and two environment factors (technology and organization) influence patient intentions to use a PHR among early adopters of the technology. In technology factors, we studied tool empowerment potential and value of tool functionality. In organization factors, we focused on communication tactics deployed by the organization during PHR rollout.
We conducted cross-sectional analysis of field data collected during the first 3 months post go-live of the deployment of a PHR with secure messaging implemented by the Air Force Medical Service at Elmendorf Air Force Base in Alaska in December 2010. A questionnaire with validated measures was designed and completed by 283 participants. The research model was estimated using moderated multiple regression.
Provider satisfaction, interactions between environmental factors (communication tactics and value of the tool functionality), and interactions between patient activation and tool empowerment potential were significantly (
The study demonstrated that individual and environmental factors influence intentions to use the PHR. Patients who were more satisfied with their provider had higher use intentions. For patients who perceived the health care process management support features of the tool to be of significant value, communication tactics served to increase their use intentions. Finally, patients who believed the tool to be empowering demonstrated higher intentions to use, which were further enhanced for highly activated patients. The findings highlight the importance of communication tactics and technology characteristics and have implications for the management of PHR implementations.
Patient-centered care is a core component of the Institute of Medicine’s quality aims and of the Affordable Care Act of 2011. Policy initiatives for health care transformation envision a health care system that is patient-centric [
An alternative to the consumer controlled PHR is one offered by employers as a service to their employees [
The aim of this paper was to understand the factors that influence individuals’ intentions to use a PHR provided by the employer. Our specific focus was on understanding what influences the behavior of early adopters of PHRs, so that PHR adoption can be accelerated. We report findings from the deployment of a PHR implemented by the Air Force Medical Service (AFMS) at Elmendorf Air Force Base in Alaska in December 2010. The PHR tool supported entry and management of health information directly by patients, integrates with the patients’ clinical records, offered access to a wide range of educational materials, and supported secure patient-provider messaging (SM).
Studies of consumer health information technology acceptance have limited their focus to patient demographics and health variables or general perceptions of the technology (eg, ease of use and usefulness) [
SCT describes individual behavior as mutually dependent upon contextual or environmental factors, and individual factors that reflect the individual’s prior history, skills, and innate propensities. SCT is a robust theory that has been successfully applied to explain phenomena across various domains including behavior towards information technology [
The PHR acceptance model is depicted in
PHR acceptance model.
SCT asserts that an individual’s background, expectations, traits, and skills influence their decisions and behavior [
Research on technology acceptance and use and the patient-provider relationship has shown the effect of technology use on various aspects of the relationship and not the reverse [
Studies have shown that patients who demonstrated higher levels of knowledge, skill, and confidence in their ability to self-manage their health (ie, they are “activated”) exhibited healthier behaviors including reading about drug interactions, exercising, and eating right [
According to SCT, perceptions concerning the environment, including available technologies and mass media communications, can promote or inhibit relevant behaviors. In the context of this study, PHRs represent a mechanism through which an individual can gain access to their medical record and securely message their provider. We examined 2 factors associated with perceptions of the tool. First, we studied the influence of perceptions about the value of specific functions provided by the tool on use intentions. Second, we examined the influence of a more affective perceptual measure, which captured patients’ beliefs about how the use of the tool might empower them, on behavioral intentions. We also investigated the influence of communication tactics, an organizational factor, on use intentions.
The basic form of PHRs typically store medical information and allow users to access, add to, or modify this information [
PHR tools in general can incorporate a wide range of functions that support different tasks and activities, each of which has distinctive instrumental value for patients [
An important aspect of the environment that influences behavior is the information received through mass communication [
To test the research hypotheses, we collected data during the first 3 months post go-live of the deployment of the PHR with secure messaging tool implemented at Elmendorf Air Force Base in Alaska in December 2010. Approximately 26,000 individuals over the age of 18 were enrolled for receipt of health care at the Elmendorf military treatment facility (MTF) provided by a medical group staff of approximately 150. Initial goals associated with the PHR project included improving the quality of health care patients received, increasing staff productivity, decreasing staff workload, and enabling patients to have more control over their own health information. The tool was named “MiCare” to signal to patients that it would afford them greater control over their care.
Several weeks in advance of system go-live, patient registration cards were provided to the MTF. To register, patients visited the MTF and showed their military ID to the registration staff located at enrollment desks in the lobby. Once their information was entered into the system, the system automatically generated an email with a link to complete the registration process. Registered users’ data was extracted from existing Air Force medical databases to populate the PHR. Periodic updates kept the data current and consistent with the clinical “database of record”. Once the registration process was completed, the user could access the PHR tool from any Web-enabled computer (a screenshot of the Home tab is provided in
After initial registration, users received an email requesting their participation in an electronic survey to measure baseline expectations about the system and other individual characteristics. If the user chose not to participate in the survey at the initial request by selecting the “not now” option, 2 reminder emails were sent, one week apart. If the user agreed to complete the survey, the system assigned a unique identifier to the respondent to de-identify them for study purposes while also facilitating the matching of survey responses with existing data from military databases. We obtained patient demographics and health condition variables from existing Air Force databases to serve as control variables.
We used multi-item scales for all variables, relying on prior research for scales wherever possible. Because the data collection occurred prior to hands-on use of the tool, items were worded to reflect the respondent’s
To gain a more granular understanding of the types of functionality that would be most valuable for patients, the survey included a list of 17 PHR features (eg, link to information about potential drug interactions, store and manage medical images, record and manage health care expenses) that respondents scored on a 1-7 Likert Scale anchored with “not at all useful” (1), “neutral” (4), and “very useful” (7). These features were selected based on the specific requirements that had been identified during the extensive requirements analysis performed by the research team and the software contractor who developed the PHR system for the Air Force. Requirements analysis included interviews with 20 patients and 3 patient focus groups. For tool empowerment potential, we developed a 5-item scale that tapped into the patients’ beliefs about whether the use of the tool would make the individual feel more empowered, more in control, more informed, better prepared, and more organized.
Baseline patient activation (the knowledge, skill, and confidence for self-management) was assessed using the 13-item patient activation scale from Hibbard et al [
Because computer skills have been previously linked to PHR adoption behavior [
Prior to conducting the full study, we did extensive pre-testing of the survey instrument to ensure that the scales were valid and reliable, and that respondents interpreted each question the way it was intended. The final survey contained a total of 81 items, together with 1 open-ended response. We performed cognitive testing with 6 subjects who completed the survey while 2 researchers were present, and provide feedback on the format and wording of the questions. This was followed by a field pre-test where we solicited patients in a military treatment facility that was different from the main study site. We obtained responses from 38 patients. Analysis of the pre-test data supported the validity and reliability of the measurement scales. We also confirmed that the survey could be completed by the respondent in less than 10 minutes.
The adoption trajectory of the system over the first 3 months post go-live is shown in
Demographic profile of early adopters.
Variable | Elmendorf Population (1) |
PHR Early Adopters (2) |
Survey Respondents (3) |
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Gender, (Male=1, Female=0) | 0.46 | 0.37, (1)a | 0.36, (1)a |
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Age, years | 40.0 | 32.1, (1)a | 47.2, (1)a,(2)a |
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Sponsor pay grade, numeric scale 1-9 | 5.48 | 5.40, (1) a | 5.69, (1)a,(2)a |
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Number of dependents, sum | 0.72 | 0.63 | 0.60 |
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Dependents vs active duty, (Dependent = 1, active duty = 0) | 0.52 | 0.64, (1)a | 0.55, (2)a |
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Average total chronic diseases, sum | 0.39 | 0.49, (1)a | 0.63, (1)a,(2)a |
*This variable is significantly different from the same variable in columns (1) or (2), as labeled in the heading.
Baseline patient enrollment.
We first performed factor analysis to confirm the psychometric properties of the measurement scales. Principal components factor analysis of the 17 items used to assess the importance of various features of the PHR tool yielded a two-factor solution. The first factor consisted of 9 items related to the tool’s capability to store and track patient historical information, and therefore, we labeled it the “record keeping” feature of the tool. The second factor consisted of 8 items related to the tool’s potential to provide the patient “health care process management support” (eg, exchanging information between providers, reminders about appointments). All constructs and the corresponding items used for the statistical analysis are presented in
The patient activation items loaded on 2 factors that represent different stages of patient activation [
We estimated the research model using moderated multiple regression in SPSS. Intention to use was regressed on all the independent variables shown in
Descriptive statistics: reliability, means, SDs, and correlations (N=283).
Construct | Reliability |
Mean |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |
Intentions | .91(3) | 5.98 |
1 |
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PA-knowledge/ beliefs | .90(7) | 6.40 |
.48** | 1 |
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PA-actions/ maintenance | .89(6) | 5.62 |
.31** | .58** | 1 |
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Provider satisfaction | .96(3) | 6.05 |
.44** | .50** | .40** | 1 |
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Tool empowerment potential | .95(5) | 5.97 |
.67** | .48** | .29** | .40** | 1 |
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Record keeping functions | .94(9) | 6.26 |
.51** | .41** | .31** | .34** | .53** | 1 |
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Health care process management support functions | .95(8) | 6.29 |
.57** | .41** | .26** | .35** | .64** | .84** | 1 |
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Communication tactics (impersonal) | .83(7) | 2.10 |
-.03 | -.01 | .16* | -.05 | .10 | -.01 | .04 | 1 |
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Communication tactics (personal) | .72(2) | 3.03 |
.16* | .07 | .10 | .07 | .24** | .11 | .16* | .37** | 1 |
*
**
Both personal and impersonal communication tactics interacted with perceived value of the health care process management support features of the tool to increase use intentions. Intentions to use were highest for patients who perceived the health care process management support feature to be very useful and who also heard a lot about the tool through either personal or impersonal communication channels. Contrary to what was hypothesized, communication tactics that were more personal in nature had a negative interactive effect on the relationship between value of the record keeping function of the PHR and intentions to use. Hearing a lot about the tool through personal communications tended to decrease a patient’s intentions to use the tool when their perceptions of the usefulness of the record keeping functions of the tool were high. If the patient’s perceptions of the usefulness of the record keeping functions of the tool were low, hearing a lot about the tool through personal communication tactics had no influence on intentions.
Interaction effects for personal communication tactics and perceived value of the PHR tool on use intentions are depicted in
In summary, hypothesis 1, predicting a significant relationship between satisfaction with health care provider and intentions to use the PHR tool, was supported. The results also partially support hypothesis 2, which proposed a significant positive interaction between the perceived value of the PHR tool and patient activation in their effects on intentions to use (the interaction was significant for PA-actions/maintenance but not for PA-knowledge/beliefs). Finally, we found partial support for hypothesis 3, which proposed that communication tactics conditioned the effects of perceived value of record keeping and health care management process support functions on intentions to use. Collectively the hypothesized predictors explained 42% of the variance in behavioral intentions to use the PHR tool.
Results of model estimation.
Interactions between perceived value of tool functionality and personal communication tactics.
In this study, we used SCT as the basis for building and testing a model to predict patient acceptance of a PHR tool sponsored by the employer. Our findings supported a mutual and reciprocal relationship among the individual and environmental determinants of behavioral intentions to use the PHR. We found evidence that patients who were more satisfied with their providers were more likely to accept the PHR tool. In addition, perceptions of the 2 factors present in the environment, the technology, and organizational communication tactics, interacted to influence behavioral intentions. Finally, patient activation, reflecting the extent to which individuals felt confident in health self-management, interacted with perceptions of the tool’s ability to empower the individual, a technology environmental factor.
It is widely known that a strong patient/provider relationship can result in better patient outcomes [
We found that use intentions were significantly affected by the perceived value of the various features offered in the PHR, but this relationship was contingent on the communication tactics deployed by the employer. For patients who did not perceive PHR functionality as valuable, communication efforts had no significant influence on intentions. However, for patients who perceived the health care process management support features of the tool to be of significant value, communication efforts served to increase their intentions to use the tool. This was true for both impersonal and personal forms of communication. Intriguingly, for patients who perceived the record keeping functions to be particularly important, personal communication had a negative influence on intentions to use the PHR while impersonal change management efforts had no influence on the relationship.
One possible explanation for the findings related to the communication tactics and the two types of functionality and intentions is in the specific capabilities and benefits stressed in the materials used by the implementation team throughout the project, that is, the content of the communication.
MiCare allows you to take command of your health care:
request your next appointment
request medication renewals
receive your test and lab results
maintain a PHR to manage your health
communicate online with your health care team about non-urgent symptoms
avoid unnecessary office visits and telephone calls
request a copy of your immunization record
access a large library of patient education materials
Because the content of communication materials focused on health care process management support functions, it may be that the record-keeping functionality available within the tool was inadvertently downplayed. Perhaps, in personal exchanges with providers and staff or at registration desks (ie, personal communication), the emphasis may have been even more on the health care process management functions. As a result, patients may have walked away from these interactions with the impression that record keeping functions were minimally provided in the tool or not at all provided. For patients who perceive functionality to be very useful, if they were given the impression it was not available in the tool during these personal communications, it would likely lower their intentions to use it. An important implication of this finding is that communications from providers, staff, and other volunteers working at information/registration desks must convey balanced messages about the functionality of the tool.
We also found evidence of a positive interaction between the tool’s empowerment potential and patient activation on intentions to use the PHR. Patients who indicated the tool would make them feel more organized and in control of their health information demonstrated higher intentions to use, which was enhanced for highly activated patients. Thus, patients who were beginning to take actions to manage their own health and felt confident they could maintain these activities going forward were more likely to use the tool when they believed it would further enhance their capabilities to self-manage their health condition.
Our study has some limitations that also represent useful opportunities for future work. First, we examined overall provider satisfaction. Future research could investigate patient satisfaction with their provider at a more granular level (eg, competence, thoroughness, respectful attitude, active listening skills, responsiveness to questions) to determine if specific dimensions of provider satisfaction influence technology acceptance [
Despite significant policy interest in promoting patient empowerment and the use of consumer health IT and mounting evidence suggesting that PHR use can reduce medical errors [
Our study reinforces findings in other areas of health, which stress the importance of an involved patient. Just as it is less realistic to expect a hypertensive patient to consistently test blood pressure levels at home, exercise to lose weight, and follow other health-management behaviors in the absence of understanding about the health condition or a lack of confidence in his/her capability of self-management [
PHR/SM home tab.
Measures used in study.
Air Force Medical Service
military treatment facility
personal health record
social cognitive theory
secure patient-provider messaging
None declared.