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The influence of health care literacy on the use of PHRs among older adults.

With increasing use of health information technology, a widening gap exists between available information and the older adult's ability to access and utilize that information. Also contributing to this widening gap is health literacy, which consists of an individual's ability to gain access, understand, and use the health information to make appropriate decisions to improve his or her health outcomes (Ball, Douglas, & Hinton Walker, 2011). According to research on health literacy, approximately 80 million Americans lack necessary skills to understand their health information and participate in the management of personal care (Serper et al., 2014). Measures must be integrated into health care settings to assist patients in accessing as well as understanding their health information. Personal health records (PHRs) are now available to most patients; these contain their health information and allow them to enter additional pertinent information as needed (Wagner, Howard, Bentley, Seol, & Sodomka, 2010). However, several barriers exist in the ability to obtain and understand the information. These barriers must be addressed to serve older adults fully as a growing population in the United States.

The Significance of Technology and Health Care

Technology can house and maintain patients' records in one location while creating an atmosphere of patient safety and quality care through coordination of the care (Wagner et al., 2010). It also engages patients and their families as patients become more responsible for their health care. According to Collins, Currie, Bakken, Vawdrey, and Stone (2012), improvement in the consumer's health literacy is absolutely necessary to manage health and chronic illnesses via technology through the use of patient portals. To make this more obtainable, access to health care and health care information must be readily available. Many institutions and provider offices are creating portals for patients to have direct access to their medical information and records including hospital discharge instructions.

According to Ball and associates (2011), patients are to remain informed; thus, health care workers cannot be the only ones privy to their information. This change has encouraged patients to become seekers of health information. Patients trust their providers, and most believe their health information is safe, current, and accurate. The use of technology by health care providers must demonstrate concern for patient health and outcomes. As patients are encouraged to participate in health care decisions, a connection must be established between the care they receive and their ability to access and understand information through technology. Understanding health care information often challenges patients to do more to maintain and improve their overall health. As stated by Wagner and colleagues (2010), the "delivery of personal healthcare information to patients and families via technological systems such as electronic personal health records (ePHRs) provides an opportunity to motivate patients to improve their health and potentially increase the safety and quality of care" (p. 1). Particularly in the case of older adults, measures must be instituted to remove barriers to their access to valuable information.

Barriers to Health Literacy

With technological advances in health care, older adults face more barriers to accessing their PHRs as well as becoming fully knowledgeable about their medical diagnoses (Gonzalez, Ramirez, & Viadel, 2012). Negative attitudes toward technology also can affect their willingness to have a more active role in their health care. However, a study by Kim (as cited by Gonzalez et al., 2012) found older adults are willing to utilize technology if they understand the purpose and function. Many older adults may not have access to computers or the desire to remain informed via technology. Most patients rely on face-to-face interactions with their health care providers for information (Bickmore & Paasche-Orlow, 2012).

Another potential barrier for health care literacy among older adults is the lack of technology support as nurses may be unengaged with the hospitalized patient. Simpson (2010) found nurses who lack engagement on the job are less likely to provide patients with the support needed to use technology. Nurses who are more focused are more likely to educate patients on evidence-based technological advances affecting their health. These nurses also are more likely to incorporate technology into their own patient care.

Additionally, patients may have difficulty understanding available information. Patients fear appearing ignorant and may not ask for clarification regarding something that is not understood. Author Thomas's father was a patient who accepted information provided by his physician just because he was the physician. When her father was asked why he was taking a certain medication or following a certain diet or order from the physician, his response would be "I don't know; just because the doctor said I needed it." In the author's experience, many patients act as her father did, afraid of asking questions that would allow them to become health literate. To compound the concern, "clinicians consistently overestimate patients' health literacy and provide patients with overly complex information" (Collins et al., 2012, p. 599).

Finally, characteristic physical changes of aging adults must be considered in the evaluation of health literacy. Accessibility to health information and use of web-based systems by older adults may be impacted by diminished visual and/or auditory acuity (Taylor et ah, 2014). Use of technology may be affected by loss of fine motor skills necessary for keyboard use and mouse navigation. Chronic joint conditions such as arthritis may restrict finger, hand, or wrist movements and create pain for aging adults during computer use.

According to Serper and co-authors (2014), individuals at risk for limited health literacy may bear a cognitive burden in personal health management. Cognitive function in this age group spans from no or minimal decline to extensive dementia, and is a potential barrier to use of PHRs for health management. Inability to recall passwords and concerns related to privacy and security breaches may discourage use of PHRs among older adults. Competent aging individuals using PHRs may have unrecognized slow loss of cognitive function and begin to interpret health information inaccurately when making important care decisions. If older adults are not able to access and utilize PHRs independently, assistance from family members, friends, or others could impair accuracy of collection and interpretation of medical data (Taylor et ah, 2014).

Strategies to Eliminate the Lack of Health Literacy

Awareness of the existence of multifaceted barriers to health literacy and the advantageous use of PHRs among older adults and their caregivers may be the first steps in narrowing the gap between accessibility and the communication of available health information. A lack of validated tools to assess health literacy and technological literacy necessary for web navigation complicates identification of at-risk older adults (Collins et ah, 2012). Significant influences on assessment and determination of health literacy and identification of barriers in access and use of PHRs include not only reading and numerical skills, but also cognitive abilities to process information and make informed health decisions (Serper et ah, 2014).

Increasing information technology (IT) can empower health-literate individuals to access and utilize information and applications for informed medical care decisions, condition management, and healthy lifestyle promotion. As IT becomes more prominent in diverse aspects of health care (e.g., such as computer-based assessments, medical provider communication, ePHRs), aging consumers may experience increased disparities because of lack of necessary skills to obtain and understand available information. Successful navigation of IT requires reading literacy, knowledge of some medical terminology, computer/Internet access, and technological dexterity (Bickmore & Paasche-Orlow, 2012). Exposure to technology and development of computer skills often happen in the workplace, phenomena that may not occur for older adult consumers. They may lack self-confidence in personal technological abilities due to inadequate exposure and experience. Access to computers may be cost-prohibitive for retired individuals on limited incomes. Health care providers may not utilize health literacy identification and education on use of PHRs, and patients may not have resources or self-motivation to seek guidance or training.

One measure to decrease or eliminate these challenges involves assessing learning needs of patients and families to begin educating them during hospitalization and clinic visits. Although some patients may not own a computer, most have some type of hand-held device such as a smart phone. Mobile devices not only make health information available, but also can present data based on the patient's literacy level. Elders also can be encouraged to use their local libraries for computer access. Of critical importance is providing older adults with effective teaching about proper use of technology (Bickmore & Paasche-Orlow, 2012). They must be informed concerning their right to access personal health information and urged to exercise their right to participate in health care decision making (Wagner et al., 2010).

Clinicians also must ensure customized health information systems are managed easily by disadvantaged older adults to prevent progression of disparities. Health care providers must understand the importance of identifying and assessing health literacy barriers for patients so successful, individualized, evidence-based interventions may be developed and utilized in educating older adults and their caregivers on use of PHRs in quality health management. The design of educational strategies for use of PHRs is challenging but pivotal in empowering older adults to become informed, active participants in personal health management (Wagner et al., 2010).


Information technology is becoming increasingly valuable in health care. However, vigilance is needed to assure all patients have the necessary tools to address this change. This includes older adults who may or may not have access to tools that help them manage their health and improve outcomes. Implemented technology systems must be user-friendly and patients must be taught at a level they are able to understand. Vulnerable populations such as older adults should remain a point of focus in these efforts.

Laurie Harris, MSN, RN, is Assistant Clinical Professor, School of Nursing, Auburn University, Auburn, AL

Valarie Thomas, MSN, RN, is Assistant Clinical Professor, School of Nursing, Auburn University, Auburn, AL.

Margot Fox, MSN, RN, is Assistant Clinical Professor, School of Nursing, Auburn University, Auburn, AL.


Ball, M.J., Douglas, J.V., Hinton Walker, P. (2011). Nursing informatics: Where technology and caring meet (4th ed.). London, England: Springer-Verlag.

Bickmore, T.W., & Paasche-Orlow, M.K. (2012). The role of information technology in health literacy research. Journal of Health Communication, 17, 23-29. doi:10.1080/10810730.2012.712626

Collins, S.A., Currie, L.M., Bakken, S. Vawdrey, D.K., & Stone, P. (2012). Health literacy screening instruments for ehealth applications: A systematic review. Journal of Biomedical Informatics, 45(3), 598-607.

Gonzalez, A., Ramirez, M.P., & Viadel, V. (2012). Attitudes of the elderly toward information and communications technologies. Educational Gerontology, 38, 585-594. doi:10.1080/03601277.2011.595314

Serper, M., Palzer, R.E., Curtis, L.M., Smith, S.G., O'Conor, R., Baker, D.W., & Wolf, M.S. (2014). Health literacy, cognitive ability, and functional health status among older adults. Health Sen/ices Research, 49(4), 1249-1267. doi: 10.1111/1575-6773.12154

Simpson, R. (2010). Engaged nurses lead way to improved outcomes via technology. Nursing Administration Quarterly, 34(3), 268-273. doi:10.1097/NAQ.0b013e3181e702a6

Taylor, M.J., Stables, R., Matata, B., Lisboa, P.J., Laws, A., & Almond, P. (2014). Website design: Technical, social, and medical issues for self-reporting by elderly patients. Health Informatics Journal, 20(2), 136-150. doi:10.1177/1460458213488382

Wagner, P.J., Howard, S.M., Bentley, D.R., Seol, Y., & Sodomka, P. (2010). Incorporating patient perspectives into the personal health record: Implications for care and caring. Perspectives in Health Information Management, 7, 1-12.
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Title Annotation:Professional Issues; personal health records
Author:Harris, Laurie; Thomas, Valarie; Fox, Margot
Publication:MedSurg Nursing
Article Type:Report
Date:Jul 1, 2015
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