Early Evidence on Personal 

Health Records: A Platform 

for My HealtheVet Research

Susan Woods, MD, MPH

Portland VA Medical Center

susan.woods@va.gov

VIReC Clinical Informatics Cyberseminar

May 19, 2009

Overview

z Consumer Health Information Trends

z An update on My HealtheVet

z Growing evidence on personal health 

records (PHR)

z Explore PHR research domains / agenda

2
3
5

Adults Who Use the Internet

z 74% of adults in U.S.

z 87% ages 18-29; 72% ages 50-64

z 41% age 65 and older

z 64% living in rural areas

z 77% white, 64% black, 58% Hispanic

z 35% if less than High School education

z 57% if < $30,000 per year

Pew Internet & American Life Project http://www.pewinternet.org6
75%

68%

81%

76%

65%

71%

40%

50%

60%

70%

80%

90%

All Men Women Whites Blacks Hispanics

2002

2007

% Ever Looked for Health or Medical 

Information Online, 2002 and 2007

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68%

78%

76%

71%

40%

50%

60%

70%

80%

90%

18‐29 30‐49 50‐64 65+

2002

2007

% Ever Looked for Health or Medical 

Information Online, 2002 and 2007

Age Group 8
% Who Looked for Health or Medical 

Information YESTERDAY, 2002 and 2007

0%

4%

8%

12%

16% 2002

2007

White Black Hispanic 30-49 50-64 65+

S. Fox, Pew Internet & American Life Project

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10

Consumer Access Services

Health Plan

Doctor’s Office

Retail Pharmacy

Millie Using PHR

Consumer Using

a Different PHR 

Blood Pressure 

Device

Hospital

PBM

Mobile Phone

Millie’s Apps

Global Internet Brands 

21st Century Consumer and Others Health Care Institutions

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Personal Health Record (PHR)

Markle Foundation Definition 

...is an Internet-based set of tools allowing people to 

access and coordinate their lifelong health 

information

...people use their PHR as a communications hub: to 

send email to doctors, transfer information to 

specialists, receive test results and access online 

self-help tools

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Personal Health Records

z 1st Generation and Stand-Alone

z Not connected to EHR

z Tethered or Networked

z Push/Pull health information to EHR

z Prescription info, Refills (VA)

z Secure messaging with healthcare team

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Perceived Benefit for Consumers

z Improve understanding of health issues

z Support timely preventive services

z Lower hassle factor – appointments, refills

z Strengthen communication with providers

z Home monitoring - improve chronic care

z Avoid duplicate tests – save money

z Reduce adverse drug interactions

z Verify accuracy of information in health records

z Manage insurance benefits

National Center for Health Statistics, 2006

Connecting Americans to Their Healthcare. Markle Foundation. 2004 13
Authenticated Users Can:

z Refill Prescriptions

z View or Edit Medications

z Research Health Information

z Medical and Veteran-Specific Conditions

z Self-Assessment Tools

z Self-monitor (BP, glucose, weight)

z Health Journals & e-Logs

z Wellness Calendar

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Manage Medications 
Vitals & 

Readings

Labs & Tests

Health History

Family Health 

History

Military History

Allergies

Immunizations

Journals

Personal Health 

Summary 

Track Health Data 

Screening Tools
My HealtheVet Statistics as of 4/30/09 

z 779,799 registered users

z 118,945 Authenticated

z Offers full functionality

z Requires in-person transaction

z 28 million visits

z 9.9 million prescription refills since 8/05

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October 2007 – ongoing

Loyalty factor: 4 pages

Sampling: 4% each add’l page

October 2007 – October 2008

362,379 surveys presented

61,186 respondents

- Recent questions smaller N

Response Comparison:

MyHealtheVet 16.9%

ForeSee average 6.5%

My HealtheVet Website Survey

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Survey Respondents (Oct 2007 – Oct 2008)

My HealtheVet Registrants

N=569,197

Veteran 86 %

Fed. Employee 4%

Vet. Advocate 2%

Provider 3%

General Public <1%

Other 1%

Veteran 93%

Family 4%

Fed employee <1%

Vet Service Org <1%

General Public <1%

Other 1%

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Age: MHV Survey Responders vs. MHV 

Registrants vs. Veteran Population

Age: MHV Survey Responders vs. MHV 

Registrants vs. Veteran Population

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October 2007 – October 2008
Home 96%

Workplace 11%

Others’ home 3%

VA Site 3%

Community 2%

School 1%

Other 1%

Location Accessing My HealtheVet

Oct 2007 – Oct 2008

N = 20645 Choose all that apply

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Advanced: frequent use & search 69 % 

Intermediate: use for a few things 28 % 

Novice: starting or not much 3 % 

Self-Reported Internet Skills

Oct 2007 – Oct 2008

N=18594

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0

20

40

60

80

100

19-30 31-40 41-50 51-60 61-70 71 +

Self-Reported Internet Skill Level, by Age Self-Reported Internet Skill Level, by Age

Age

Percent

Advanced

Intermediate

Novice

First visit 12 %

More than once/day 2 % 

Daily 4 % 

Once a week 25 %

Once a month 49 % 

Every 6 months 5 % 

< every 6 months 3 % 

MyHealtheVet Visit Frequency

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Oct 2007 – Oct 2008

N=61186
0

20

40

60

80

19-30 31-40 41-50 51-60 61-70 71 +

MyHealth MyHealtheVet Visit Frequency, by Age Group Vet Visit Frequency, by Age Group

Age

Percent

Monthly

Daily-Weekly

6 Months or less

Excludes first-time visitors

Excellent 4 %

Very good 17 % 

Good 39 % 

Fair 30 %

Poor 10 %

Self-Reported Overall Health

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Oct 2007 – Oct 2008

N = 18594
Request Rx refill 76 % 

Rx history from record 24 % 

Seek medication Information 18 % 

Track personal information 14 % 

Track health information 13 % 

Research health condition 6 % 

Information about VA benefits 6 %

Find VA care facility 2 %

Other 9 % 

Goal Using My HealtheVet Today?

Choose all that apply

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Oct 2007 – Oct 2008

N=61186

Released: My HealtheVet Button in CPRS 

z Synchronization of MHV account 

with VA Master Patient Index

z Button for authenticated MHV users

z Button links to MHV website

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Released: MHV Wellness Reminders

VA Electronic

Health Record

(EHR)

My HealtheVet 

Personal Health 

Record (PHR)

VistA Clinical Reminders MHV Wellness Reminders

• 12 basic reminders for preventive care and screening

• Reminders evaluate VistA data (health factors and lab tests) and trigger 

patient-friendly wellness reminders for display in My HealtheVet

• Link to health education resources 

*Veteran must be

In Person Authenticated

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1. Hypertension

2. Influenza Vaccine

3. Pneumococcal Vaccine

4. Colorectal Cancer Screening

5. Lipid Measurement

6. LDL Control

7. Body Mass Index (BMI)>25.0

8. Diabetes Foot Exam

9. Diabetes Hemoglobin A1C

10. Diabetes Retinal Exam

11. Mammography Screening

12. Cervical Cancer Screen

My HealtheVet Wellness Reminders

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Coming Soon

z Secure Messaging

z Triage, team-based

z Veterans Online Applications

z Allergies

z My Recovery Plan

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 Electronic bi-directional, 

asynchronous communication

 For non-urgent questions & 

issues 

 Is not e-mail

 Users must be “staged” into 

program

 Current field testing in 8 sites

Secure Messaging

Response time –

3 business days

35

Secure Messaging Access Through MHV Secure Messaging Access Through MHV

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Veteran Sends a Message (DRAFT Version) Veteran Sends a Message (DRAFT Version)

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Healthcare Team Access SM in CPRS Healthcare Team Access SM in CPRS

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39

Healthcare Member Completes or Triages Message Healthcare Member Completes or Triages Message

SM Note Saved to CPRS SM Note Saved to CPRS

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Where is the real 

opportunity?

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Access

Work

Flow

Usability Usage Value

PHR Utility and Integration into Clinical Care

Access – Internet access, literacy, e-literacy/competence, populations

Usability – Application interface, appropriate and meaningful use

Usage – Measuring use over time, “exposure”, functions used

Workflow – Impact on healthcare team, clinical and other operations

Value – Satisfaction, health/cost outcomes, unintended consequences

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Early Experiences – PHR Use

z Partners (PatientSite, Boston)

z Used: test results > messaging > refill/med request

z Messaging: 28 messages / 100 patients per month

z Messages: clinical > medication > appt > referral

z GroupHealth (MyGroupHealth, Seattle)

z 30% of enrollees authenticated

z Used: test results > refill > visit summary = messaging

z Messaging: about half of those authenticated

z More messaging: higher co-morbidity, 50-65, female

z High variation among provider panels (3% - 52%)

Halamka JD, Mandl KD, Tang KD. J Am Med Inform Assoc 2008; 15:1-7

Ralston JD, Carrell D, Reid R et al. J Am Med Inform Assoc 2007; 14:798-806

Ralston JD, Rutter CM, Carrell D et al. J Gen Intern Med 2009; 24:349-55. 44
z Geisinger Health System (MyChart, PA.)

z Found PHR easy to use

z 33% high school or less educated

z Found errors in medical information (meds)

z University of Colorado (My Doctor’s Office)

z Users reported better communication and care

z 81% said it saved a call, 33% said it saved a visit

Patient Users Are Satisfied

Hassol A. et al. J Am Med Inform Assoc 2004; 11:505-513.

Lin CT et al. J Med Internet Research 2005; 7(4). 45

PHR Interest May Relate to PatientProvider Relationship

z Qualitative study with patients with diabetes (U.Pitt)

z 39 users and nonusers of portal – SM, tests, monitoring

z Those satisfied with relationship – less interest in portal

z Those less satisfied – more interested in portal

z Barriers: difficultly learning to use it, belief it would limit 

communication choices

Zickmund SL, Hess R, Bryce CL et al. J Gen Intern Med 2008; 23(Suppl 1):20-26.

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Secure Messaging and Patient 

Engagement

z Cross sectional cohort w/ diabetes - Group Health

z 5,274 (34% of total) authenticated, 55% used SM

z SM user initiated messages 89% of time

z 32% higher outpatient visits in user vs. nonuser

z More frequent use associated with HgA1c control

z “Chronic but controlled” more engaged? or

z Does engagement lead to better control

Harris LT, Haneuse SJ, Martin DP, Ralston JD. Diabetes Care 2009; April 14. 47

Patient e-Journals Alter Care

z Prepare for Care Study - Patient Gateway, BWH

z RCT patients with diabetes for shared record, online journal

15%

53%

0%

10%

20%

30%

40%

50%

60%

% of Patients With Medication Changes

Courtesy of B. Middleton, MD, Partners Healthcare System

Control (N=41) Intervention (N=82)

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Blood Pressure Control at 1 Year:

PHR with Pharmacist e-Care

z RCT with 778 patients hypertension not controlled

z PHR: e-message, Rx refills, tests, visit summaries

PHR + 

Pharmacist

PHR Only Usual Care

All patients 56% 36% 31%

Subgroup:

SBP >180

54% 26% 20%

% of Patients with BP Control

Green BB, Cook AJ, Ralston JD, Fishman PA et al. JAMA 2008; 299:2857-6749

Interactive, Consumer Health IT for 

Elderly, Chronic Illness & Underserved

z Summary (563 papers reviewed, 129 included)

z Usage measures varied, poorly defined

z Empiric: highest usage with peer support and/or self-management

z Barriers: lack of perceived benefit, usability and technical 

problems, not fitting into usual activities

z Drivers: tailored feedback, clinician involved, convenient

z Effect: bi-directional communication (patient monitoring 

and individual feedback) that is timely and tailored

Jimison H, Gorman P, Woods S, et. al. Barriers and Drivers of Health Information 

Technology Use for the Elderly, Chronically Ill and Underserved. Agency for Healthcare 

Research and Quality. 2009. http://www.ahrq.gov/clinic/tp/hitbartp.htm 50
The Real Digital Divide?

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Physician Views of PHR Use and 

Secure Messaging

z Fewer studies

z Qualitative study of early adopters

z Positives: saves time compared to phone, more patient 

information, better provider access, auto-documentation, 

patients share sensitive information, 1-on-1 relationship

z Negatives: balancing quality/workload, urgent issues 

come up, “scope creep”, overuse, need triage & good 

judgment, unclear impact on time, managing high patient 

expectations, lack of policies

z Also found: providers “choose” patients (disparity?)

Patt MR, Houston TK, Jenckes MW, et al. J Med Internet Res 2003; 5(2):e9 52
Copyright ©2009 by Project HOPE, all rights reserved.

Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa, and Louise Liang, 

The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care, 

Health Affairs, Vol 28, Issue 2, 323-333

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My HealtheVet Research Studies

Examples of current studies:

• Usability/Human Factors Testing (Chumbler, Saleem)

• Patient & Provider Perceptions of e-Messages to Promote Disease 

Screening (McInnes)

• Data Needs and Technical Infrastructure (Weingardt, Wagner)

Examples of proposed studies:

• Identifying Barriers to Reach and Authenticate Patients

• My HealtheVet as a Tool to Support Care Transitions

• Implementation Research with Facilitation

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MHV Infrastructure Development

Clinical

Advisory

Board

Performance 

Evaluation 

Workgroup

PHR Policy 

Workgroup

Research 

Infrastructure 

Workgroup

MHV V/CHIO PMO 

Support Services

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My HealtheVet Performance 

Evaluation Workgroup

z Guide MyHealtheVet program evaluation

z Address research as dimension of program efforts

z Support and expand research agenda

z Identify strategies to support research

z Translate findings into program improvements

Chair: Kim Nazi, FACHE, Veteran/Consumer Informatics Office 

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My HealtheVet Research 

Infrastructure Workgroup

z Standardize process for MHV research requests

z Data transaction logs

z Patient-entered data (e.g. glucose) to link to adherence

z Modifications to MHV content, such as:

z A self-management intervention for a condition

z Address resources needed for research requests

z Within MHV Program Office

z That which researchers can provide

Chair: Fran Weaver, PhD, Hines VAMC

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* An extension of the RE-AIM Framework at www.re-aim.org

MyHealtheVet Performance Evaluation 

Framework

MyHealtheVet Performance Evaluation 

Framework

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RE-AIM Modified to PHR Research

Reach Access, users and usage (nonusers)

Effectiveness Enhance access, quality, outcomes

Adoption Promote clinical integration

Implementation Impact clinical teams, processes, work

Maintenance Monitor impact over time, mitigate 

health IT disparities

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“The laying on of hands will increasingly include the 

pressing of keys. This emerging model will improve 

the practice of medicine but will also bring new 

challenges.”

- JH Stone

Communication between physicians and patients in the era of E-medicine. 

N Eng J Med, 2007

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