The Effects of Age, Cognition, and Health Literacy on Use of a Patient EMR (Florida)

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The Effects of Age, Cognition, and Health Literacy on Use of a Patient EMR - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS06-118: AHRQ Grants for Health Services Research Dissertation (R36)
  • Grant Number: 
    R36 HS 018239
  • Project Period: 
    September 2009 - November 2011
  • AHRQ Funding Amount: 
    $37,800
  • PDF Version: 
    (PDF, 203.29 KB)

Summary: The use of patient portals of electronic medical records (EMRs) is expanding as patient involvement in disease prevention, management, and decisionmaking is increasingly emphasized in the health care system. To date, there has been little usability testing of patient portals, especially with older adult populations. This study, funded through the Health Services Research Dissertation grant program (R36), systematically assessed the ability of middle-aged and older adults to use a simulated patient portal of an EMR to perform common health management tasks. The study also examined the effects of age, Internet experience, and individual characteristics - such as health literacy, numeracy, and cognitive abilities - on the use of such systems.

Participants included people aged 40-to-85 years with a range of health literacy and numeracy abilities. The specific focus was on three common health management tasks associated with patient portals: 1) medication management; 2) interpreting laboratory test results; and 3) health maintenance activities. By assessing the relationship between individual characteristics and the ability to use a patient portal of an EMR system, the study identified the root of a number of usability problems and then proposed a set of empirically-based interventions to help those who are most likely to have problems interacting with these systems. At the same time, this research aimed to increase the general usability of these systems, which will ultimately benefit all patient populations.

Participants completed background and technology experience questionnaires to gather data including gender, age, ethnicity, educational level, income, health information, medication use, and experience with technology such as computers and the Internet. Participants were also given the Test of Functional Health Literacy in Adults (TOFHLA) and subjective and objective numeracy tests. Following the administration of the testing components of the study, participants completed a tutorial on basic computer skills (e.g., using a mouse, scrolling) and were given basic instruction on how to navigate the EMR record and view its information. Each participant then used the simulated portal to perform fifteen tasks encompassing medication management, review/interpretation of laboratory and other test results, and health maintenance activities. Tasks were designed to evaluate basic, computational, analytical, and statistical numeracy ability. Furthermore, each of the tasks was classified in terms of being "simple" or "complex." Following the completion of the tasks, participants were asked to complete a portal usability questionnaire. At the completion of data collection, each participant was interviewed briefly to get additional feedback on use of the patient portal.

Specific Aims:

  • Examine the ability of middle-aged and older adults to use a patient portal of an EMR to perform common health management tasks. (Achieved)
  • Examine the relationships between individual characteristics such as age, cognitive abilities, health literacy, and task performance. (Achieved)
  • Identify usability problems inherent in the use of patient portals and identify design solutions. (Achieved)

2011 Activities: At the suggestion of Ms. Taha's academic advisors at the University of Miami, the sample size increased from 80 to 100. However, Ms. Taha felt there might still be insufficient variability in race and ethnicity and so focused on additional recruitment, bringing the total number of participants to 107. A 3-month no-cost extension enabled the completion of the data collection, analysis, and manuscript development, which were the primary focus of activities during this period. This project was completed in November 2011.

Impact and Findings: Eighty-five of the participants reported varying levels of Internet experience. To create a variable that captured the participants' overall Internet experience, the duration of their Internet use and their frequency of use was combined into a single score ranging from 1-to-16. The 22 participants (11 middle-aged and 11 older) who reported having no Internet experience were given a score of "0".

After accounting for education, Internet experience was found to be a significant predictor of performance on simple and complex tasks and overall task performance. In addition to education and Internet experience, cognitive variables were also found to significantly predict performance, such that those with lower verbal ability, executive functioning, and reasoning skills had lower performance on tasks. Even after accounting for all of these variables, numeracy was determined to significantly predict performance on complex tasks and overall performance. With regard to task performance, age did not significantly predict performance on simple tasks but it was significant in predicting performance on complex tasks and overall performance. Results from this study also indicated that both middle-aged and older adults tended to overestimate their numeracy skills, and that the older participants had less correlation between subjective and objective numeracy measures than middle-aged participants.

Approximately 89 percent of all participants indicated that they would use a patient portal like the simulation if it were available from their doctor. Of those who indicated that they would not be interested in using a portal, five were middle-aged and seven were older. Many of these participants thought that the portal was "confusing" or "difficult" to use. However, among those who said that they would not use a patient portal like the simulation, only one participant thought there was no benefit in using a portal. The other participants who indicated that they would not use a portal acknowledged certain benefits including the ability to get test results or medication information without having to leave the house or call a doctor, to schedule and keep track of appointments, and to find information pertinent to health conditions through portal links.

Both middle-aged and older participants tended to have a positive opinion of patient portals in general. Ninety-four percent of participants either agreed or somewhat agreed that a patient portal would improve their ability to perform health management tasks, and 95 percent either agreed or somewhat agreed that a patient portal would allow them to get information that would help them understand issues related to their health. However, participants did have some difficulty in using the portal simulation: 40 percent of participants indicated that it was difficult to navigate within the portal, and 51 percent thought that it was difficult to locate the information that they needed within the portal.

Target Population: Adults, Elderly*, Low Literacy

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

 Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

The Effects of Age, Cognition, and Health Literacy on Use of a Patient EMR - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS06-118: AHRQ Grants for Health Services Research Dissertation (R36)
  • Grant Number: 
    R36 HS 018239
  • Project Period: 
    September 2009 – November 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $37,800
  • PDF Version: 
    (PDF, 774 KB)


Target Population: Adults, Elderly*, Low Literacy

Summary: The use of patient portals of electronic medical records (EMRs) is expanding as patient involvement in disease prevention, management, and decisionmaking is emphasized in the health care system. To date, there has been little usability testing of patient portals, especially with older adult populations. This study will systematically assess the ability of older adults to use the patient portal of an EMR to perform health management tasks and examine how individual characteristics, such as health literacy and cognitive abilities, impact the use of such systems.

Participants will include individuals aged 40-to-85 years with low and high health-literacy levels, as measured by the Test of Functional Health Literacy in Adults (TOFHLA). The specific focus will be on three common health management tasks associated with patient portals: 1) medication management; 2) interpreting laboratory test results; and 3) health maintenance activities. By systematically assessing the relationship between individual characteristics and the ability to use a patient portal of an EMR system, the study will identify the root of usability problems and develop empirically-based interventions to help those who are most likely to face problems interacting with these systems. At the same time, this research should increase the general usability of these systems, which will ultimately benefit all patient populations.

Participants will be given a background questionnaire to gather data including gender, age, ethnicity, educational level, income, health information, medication use, experience with technology, and cognitive battery tests. Participants will also be given the TOFHLA and subjective and objective numeracy tests. Basic information will be provided on how to navigate the EMR record and view its information. Each participant will then use the portal to perform the three aforementioned types of health-related tasks. Following the completion of the tasks, participants will be asked to complete a portal usability questionnaire. At the completion of data collection, brief interviews will be conducted with each participant to get additional feedback on use of the patient portal.

Specific Aims:
  • Examine the ability of middle-aged and older adults to use a patient portal of an EMR to perform common health management tasks. (Ongoing)
  • Examine the relationships between individual characteristics such as age, cognitive abilities, health literacy, and task performance. (Ongoing)
  • Identify usability problems inherent in the use of patient portals and identify design solutions. (Ongoing)

2010 Activities: All tool development was completed and all forms were tested and revised. Cognitive tests were identified and modified. The Web site, which mimics a patient portal, was created and tested. Recruitment was initiated and 95 people had been recruited by the end of the year. Sixty-one people have come in for the required two days. Of the 61, only one participant has been lost to followup.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The project is meeting most of its aims on time. Budget spending is roughly on target.

Preliminary Impact and Findings: The project does not have any findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

The Effects of Age, Cognition, and Health Literacy on Use of a Patient EMR - Final Report

Citation:
Taha J. The Effects of Age, Cognition, and Health Literacy on Use of a Patient EMR - Final Report. (Prepared by the University of Miami under Grant No. R36 HS018239). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 701.59 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
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Project Details - Ended

Summary:

Unless individuals are comfortable and able to use technology, the full potential of personal health records (PHRs) cannot be realized. This Health Services Research Dissertation (R36)-funded project looked at adults aged 40-85 and their ability to conduct health management tasks within a simulated patient portal of an electronic medical record (EMR), also known as a "tethered" PHR. The principal investigator evaluated how individual characteristics, such as health literacy and cognitive abilities, impacted the use of these systems in an effort to understand the extent to which adults can effectively use patient portals of EMRs. In particular, the project looked at the health numeracy aspect of health literacy in their evaluation. Health numeracy refers to the quantitative aspect of health information. Common PHR tasks that rely on numeracy include managing appointment dates and times; understanding medication dosage instructions; reviewing lab results; and interpreting health information from charts, tables, and graphs.

The main objectives of this project were to:

  • Examine the ability of middle-aged and older adults to use a patient portal of an EMR to perform common health management tasks.
  • Examine the relationships between individual characteristics such as age, cognitive abilities, health literacy, and task performance.
  • Identify usability problems inherent in the use of patient portals and identify design solutions.

The study team developed a simulation portal that contained a fictitious medical record. Participants were asked to perform 15 tasks around medication management, interpretation of lab results, and health maintenance activities in order to evaluate their cognition, health literacy, and numeracy capability.

Participants who were older had lower mean scores on complex tasks and overall performance than middle aged adults. The project team found that age, cognitive variables, health numeracy, and experience with the Internet impacted participant’s performance. Those individuals with lower verbal ability, executive functioning, reasoning skills, and health numeracy performed less well than others. The team concluded that older adults may well encounter difficulties when using these portals. The results of the study strongly suggest that the numeracy aspect of health literacy is critical to consider when developing PHRs targeted to the needs of older adults.