Consumer Perspectives on Personal Health Records: A 4-Community Study

Published Online: April 17, 2014
Erika L. Abramson, MD, MS; Vaishali Patel, PhD, MPH; Alison Edwards, MStat; and Rainu Kaushal, MD, MPH
Objectives: To characterize consumer attitudes toward personal health records (PHRs) in 4 diverse communities across New York state (NYS).

Study Design: Combined analysis from four separate cross-sectional studies.

Methods: We analyzed pooled data from surveys separately administered to 4 NYS communities. Results from individual communities have been previously published. However, pooling the data allowed us to conduct multivariable regression analyses that identified key factors associated with potential usage among a broad group of consumers.

Results: We received responses from 701 consumers. A majority (74%) of respondents (n = 494) reported that they would use a PHR and the majority wanted a broad array of functionalities available. We found that potential PHR use was significantly associated with Internet use at least monthly (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 3.3-10.2), a belief that PHRs may improve the security of health information (OR = 2.6, 95% CI = 1.5-4.7), and a belief that PHRs may improve quality of care (OR = 4.1, 95% CI = 2.6-6.6).

Conclusions: As federal initiatives aim to improve healthcare, which includes making care more patient centered, PHRs will likely play an increasing role. Our results provide critical information to inform policy efforts, suggesting that PHRs must offer a broad range of patient-centered functionalities while maintaining high privacy and security standards to narrow the gap between reported interest and actual use. Ensuring widespread access to and frequent use of the internet among consumers will also be critical to avoid creating healthcare disparities through PHR use.

Am J Manag Care. 2014;20(4):287-296
Unprecedented federal initiatives are under way to transform healthcare delivery by promoting health information technology (HIT).1 One key focus of these initiatives is to deliver more patient-centered care. Personal health records (PHRs), which are HIT applications that allow consumers to electronically “access, manage, and share their health information… in a private, secure, and confidential environment” have potential to play a key role in these efforts.2

There are several PHR models. Tethered PHRs are integrated with an electronic health record (EHR) and receive automatically prepopulated information. Untethered PHRs are not linked and generally require users to enter and maintain data. Importantly, there are no specified standards for the content, functionalities, and architecture that should comprise a PHR, resulting in widespread variability.3

Multiple potential benefits exist with PHR use, although literature demonstrating actual benefits is limited.3 Theoretically, PHRs can allow consumers to become more actively engaged in managing their health and can improve patient and provider communication. Certain PHR features such as online appointment scheduling also should improve efficiency by allowing administrative issues to be handled electronically.4

Despite these benefits, PHR usage remains low, even though many nonusers endorse interest in using a PHR.5 Importantly, Stage 2 requirements for the EHR Incentive Program will require that providers give more than 50% of their patients online access to their health information.6 Furthermore, they require providers to demonstrate that 5% of their patients have accessed their health information online and that 5% have engaged in secure messaging. This will likely spur PHR adoption.

Addressing the gap between reported interest and actual usage requires more detailed information on consumer preferences for PHRs and barriers. In this way, PHRs can be better designed and marketed toward consumers broadly. Evidence already suggests that those with less access to and experience using the Internet, as well as people from certain minority groups and of lower socioeconomic status, may be less likely to use PHRs.7-10 Finally, a detailed understanding of consumer preferences can help lead to more uniform standards for PHR products.

We therefore conducted this study to better understand consumer preferences for PHRs and to identify factors associated with potential usage. We used pooled data previously collected and published from individual communities within New York state (NYS) with HIT initiatives already under way to allow us to generate a more broadly representative assessment of consumer preferences and predictors of potential usage.7,9,11,12



We conducted cross-sectional surveys of consumers in 4 NYS communities to assess attitudes toward PHRs. This study was led by researchers from the Health Information Technology Evaluation Collaborative (HITEC), which comprises 4 research institutions across NYS (Weill Cornell Medical College, Columbia University, State University of New York at Albany, and University of Rochester) and is designated to evaluate NYS HIT and health information exchange (HIE) initiatives. The 4 communities, located in Buffalo, Rochester, the Hudson Valley, and Brooklyn, were all recipients of NYS grant funding to promote community-wide HIT adoption and HIE. They are geographically spread across NYS; include rural, urban and suburban areas; and are home to consumers who are socioeconomically, ethnically, and racially diverse.

Survey Design

The novel survey instrument was developed based upon literature review and consultation with experts in clinical informatics, healthcare quality, and survey methodology from Weill Cornell Medical College, Columbia University Medical Center, and the Center for Medical Consumers, a not-for-profit consumer advocacy organization. Wherever possible, survey items were drawn from previously validated questions from other national surveys.13-16 The survey was piloted with 25 outpatients at an adult internal medicine clinic affiliated with an academic, tertiary hospital.

Survey Domains and Measurement

The survey domains included demographic characteristics, health characteristics, healthcare experience, Internet access and use, attitudes toward HIE and EHRs, and attitudes toward and preferences related to PHRs. In the survey, a PHR was described as a tool “primarily used by you to view your health information and manage your healthcare (for example, to make appointments) on the Internet.” We asked consumers about PHR preferences for content and functionalities, and questions regarding health characteristics such as health status, use of medications, treatment for chronic conditions, and caring for someone with a chronic condition. “Healthcare experience” included questions regarding satisfaction with care, interest in collaborative decision making, and problems understanding medical information. We also asked consumers about their access to and use of the Internet, concerns related to privacy and security, and attitudes toward HIE and EHRs.

Most questions were either yes/no, on a 5-point Likert-like scale, or 3-point questions (ie, improve/no effect/ worsen). The initial survey was administered in the Hudson Valley, and tailored slightly for each subsequent community. For example, in Brooklyn, “Russian” was explicitly listed for the question “What is the main language you speak at home?” whereas in the other communities, only “English, Spanish, Chinese, or Other” were answer choices. However, most questions were consistent across communities to allow for cross-community comparisons.

Survey Population and Administration

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Issue: April 2014
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