Barriers and Drivers of Health Information Technology Use for the Elderly, Chronically Ill and Underserved

This project reviewed the evidence on the barriers and drivers to the use of interactive consumer health information technology (IT) by the elderly, those with chronic conditions or disabilities, and the underserved. The project team completed a literature review of the evidence, focusing on literature published in 1990 and beyond. To accomplish this, many databases were searched, including MEDLINE®, CINHAHL®, PsycINFO®, the Cochrane Controlled Trials Register and Database of Systematic Reviews, ERIC, and the American Association of Retired Persons (AARP) AgeLine®. Studies were assessed for their quality, abstracted, and summarized. In particular, the project team summarized data regarding the level of use, usefulness and usability, barriers and drivers of use, and effectiveness of interactive consumer health IT applications.

A total of 563 full-text articles were reviewed and 129 of those articles abstracted. The project team found few studies that compared the elderly, those with chronic conditions, or the underserved to the general population. Data on the level of usage was found to be limited. Comparing studies was challenging as measures varied considerably and had no apparent standardization. Self-management tools and applications which offered peer group support appeared to be used most frequently. Studies which had data on usefulness and usability generally had that data as secondary components of a primary study. Usability was noted to play a key role in the use of applications. Studies generally measured usefulness as part of usability assessments, with user perceptions being high, particularly for self-management systems. Issues around usability included clarity of graphics and simplicity for those users who were older or impaired.

Barriers and drivers to use were most often reported in the literature as secondary outcomes. The most common driver to successful use was the consumer's perceived benefit of using a given system. Other drivers to successful use included non-cumbersome data entry, delivery of information on a device used by the patient on a daily basis for other reasons, convenience, the ability to incorporate the use into the user's daily routine, and fast, frequent involvement from a clinician. Not surprisingly, the primary barrier noted was when consumers did not perceive a benefit to using the system. This barrier became greater when the process of entering data into the system was inconvenient. For those individuals who were doing well with their medications, medication reminding systems were reported as being a nuisance and intrusive. Other barriers noted included technology interventions that did not fit into the consumer's lifestyle, a lack of trust in the system, the technology being cumbersome or malfunctioning, lack of clinician engagement, and cost.

In terms of effectiveness, the review had a consistent finding that there was a positive impact when the health IT application provided a complete feedback loop that included: 1) monitoring of current patient status; 2) interpretation of this data in light of established, often individualized, treatment goals; 3) adjustment of the management plan as needed; 4) communication back to the patient with tailored recommendations or advice; and 5) repetition of this cycle at appropriate intervals. When systems had only some of these functions they were found to be consistently less effective.

Additional research is needed to understand:

1. What the optimal frequency of use of a given consumer health IT application by consumers should be, and whether optimal frequency of use is condition-specific;
2. What the optimal frequency of use of a given consumer health IT application by providers should be; and
3. Whether success depends on repeated modification of the patient's plan or does it depend simply on assisting a patient with a static plan.

The team concluded that it is the consumer's perception of benefit, convenience, and integration into daily activities that will facilitate the successful use of the interactive technologies for the elderly, chronically ill, and underserved.