Electronic Personal Health Record Use Among ...

CIN: Computers, Informatics, Nursing

& Vol. 33, No. 7, 306–314 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

F E A T U R E A R T I C L E

Electronic Personal Health Record Use Among Nurses in the Nursing Informatics Community KYUNGSOOK GARTRELL, PhD, RN ALISON M. TRINKOFF, ScD, RN, FAAN CARLA L. STORR, ScD MARISA L. WILSON, DNSc, CPHIMS, RN-BC

INTRODUCTION The US health information technology (HIT) action agenda states that effective management of personal health information helps patients collaborate with their healthcare providers to make healthcare decisions, which can ultimately lead to better health outcomes.1 An electronic personal health record (ePHR) is a patient-centric tool that enables patients to securely access, manage, and share their health information with healthcare providers. In addition, an individual ePHR user can choose to allow significant others to access their ePHR.2 Meaningful Use is the federal government’s HIT policy, which requires the use of electronic health records (EHRs). One requirement of Meaningful Use is for healthcare providers to give patient access to their own health inforAuthor Affiliations: National Institutes of Health/National Library Medicine/ Lister Hill National Center for Biomedical Communications (Dr Gartrell); School of Nursing, University of Maryland (Drs Trinkoff and Storr); and School of Nursing, The Johns Hopkins University (Dr Wilson), Baltimore, MD. This work was supported by the American Nursing Informatics Association Scholarship Award and by the University of Maryland School of Nursing. The authors are responsible for the writing and content of this article. The opinions expressed in this article are those of the authors and do not necessarily reflect the policies of the National Institutes of Health. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Kyungsook Gartrell, PhD, RN, National Institutes of Health, Bldg 10, Room 6-2551, 10 Center Dr, MSC 1504, Bethesda, MD 20892 ([email protected]). DOI: 10.1097/CIN.0000000000000163

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An electronic personal health record is a patientcentric tool that enables patients to securely access, manage, and share their health information with healthcare providers. It is presumed the nursing informatics community would be early adopters of electronic personal health record, yet no studies have been identified that examine the personal adoption of electronic personal health record’s for their own healthcare. For this study, we sampled nurse members of the American Medical Informatics Association and the Healthcare Information and Management Systems Society with 183 responding. Multiple logistic regression analysis was used to identify those factors associated with electronic personal health record use. Overall, 72% were electronic personal health record users. Users tended to be older (aged 950 years), be more highly educated (72% master’s or doctoral degrees), and hold positions as clinical informatics specialists or chief nursing informatics officers. Those whose healthcare providers used electronic health records were significantly more likely to use electronic personal health records (odds ratio, 5.99; 95% confidence interval, 1.40–25.61). Electronic personal health record users were significantly less concerned about privacy of health information online than nonusers (odds ratio, 0.32; 95% confidence interval, 0.14–0.70) adjusted for ethnicity, race, and practice region. Informatics nurses, with their patient-centered view of technology, are in prime position to influence development of electronic personal health records. Our findings can inform policy efforts to encourage informatics and other professional nursing groups to become leaders and users of electronic personal health record; such use could help them endorse and engage patients to use electronic personal health records. Having champions with expertise in and enthusiasm for the new technology can promote the adoption of electronic personal health records among healthcare providers as well as their patients. KEY WORDS Electronic health record & Health care provider & Nursing informatics & Personal health record & Privacy

mation through an ePHR.3,4 Meaningful Use stage 2, which began in 2014, sets the ePHR as mandatory, with an adoption rate goal of 5% to start.5 To support continued

CIN: Computers, Informatics, Nursing & July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

growth in ePHR adoption, it is critical for patients and healthcare providers to become educated on ePHR use. Informatics nurses can influence wide adoption of ePHRs by engaging both healthcare providers and patients with their patient-centered view of technology. Potential patient benefits of ePHRs are improved patientprovider communication,6,7 improved adherence to medical intervention and chronic disease management,8–12 and increased use of preventive services (eg, cancer screenings, tobacco counseling, or influenza vaccination).13 Although the potential for ePHRs to improve health management is substantial, there are a number of common barriers to widespread use. Examples are data accuracy, concerns about data privacy and security, inequalities in Internet access, and health literacy issues.14–17 Measuring and understanding the impact of such barriers on ePHR use will be important to understanding how to promote ePHR adoption by patients. Given their HIT leadership role in the nursing profession, members of the nursing informatics community (NIC) are ideal candidates for promoting adoption of ePHR among healthcare providers.18 It is presumed that the NIC would be potential early adopters of ePHR, yet currently no studies have examined the personal adoption of ePHRs for their own healthcare. Therefore, the purpose was to survey nurses in the NIC about ePHR use for their own health and related factors, as we reasoned they could be potential early adopters of such technology.

METHODS Study Design and Sample This study was a descriptive cross-sectional design, with data collected using an anonymous Web survey in the fall of 2013. With a goal of targeting the most informed early adopters of ePHRs, nurses with membership in American Medical Informatics Association (AMIA) and/or Healthcare Information and Management Systems Society (HIMSS) were invited to participate in a 15-minute (37-question) survey. We presumed that NIC nurses in AMIA or HIMSS collaborate and discuss emerging trends and hot topics; therefore, they are more likely to be aware of and adopt cutting edge of HIT, such as ePHRs. The survey was distributed to the AMIA and HIMSS nursing informatics e-mail discussion lists. Qualtrics software (Qualtrics, LLC, Provo, UT) was used to manage the survey. Respondents who were retired, currently unemployed (including students), or not nurses were excluded. In total 183 nurses in NIC participated. Institutional review board approval was provided by the University of Maryland, and authorization from AMIA and HIMSS was obtained.

Measurement The survey domains included demographics, job information, health and healthcare experience, technology experi-

ence and awareness of new technology, and attitudes about privacy of health information. Original questions were modified as necessary and reviewed by informatics experts working in the area of ePHRs. Pilot testing was performed prior to distribution. In terms of the survey, we defined an ePHR as the tool that provides user identification and password—allowing a patient to access and view their own data, update their health information, and manage their healthcare.2,19 The definition of ePHR in the survey was inclusive and did not distinguish between nontethered (Web-based stand alone such as Microsoft Health Vault) or tethered ePHRs (one that is linked directly to a healthcare provider’s EHRs or to health insurance data). A sample ePHR screen image was displayed to the participants. Electronic personal health record use and nonuse were defined based on the yes/no response to the question adapted from the national consumer survey: ‘‘Have you ever used an ePHR to view, update, or manage your health information?’’20 The survey collected demographic and job information using questions adapted from the Web site of the US Census Bureau,21 the Web site of the Hospital of the University of Pennsylvania,22 and the Nurses’ Worklife and Health Study.23 Health and healthcare experience items were adapted from the Web site of the World Health Survey,24 HIT Evaluation Collaborative (HITEC) consumer survey,25 and Nurses’ Worklife and Health Study.23 A global self-health rating had responses from ‘‘poor’’ to ‘‘excellent.’’ Items for chronic medical conditions and prescribed medication use were combined into one variable because of overlap such that 0 = neither, 1 = either one, and 2 = both chronic condition and medication use. Healthcare decision-making preferences for themselves, children, or parents were assessed with yes/no questions. The 5-item technology experience asked about workplace EHR use, their own computer and Internet use, and level of frustration when learning new applications, adapted from the HITEC consumer survey.25 Participants’ awareness of new technology and attitudes about privacy of health information were assessed with question items from the national consumer survey.20 ‘‘Awareness of new technology’’ was assessed by asking if participants had knowledge of Meaningful Use and on their healthcare providers’ EHR use in their practice. ‘‘Attitudes about privacy of health information’’ focused on general concerns with the privacy and security of electronic health information with responses ranging from ‘‘not at all concerned’’ to ‘‘very concerned’’: recoded as concerned versus not concerned. Other questions asked participants about granting permission to specific entities (eg, family member, primary care provider) adapted from the HITEC consumer survey.25 Permissions were granted to adapt questions from the various tools: (1) the Nurses’ Worklife and Health Study23 (A.M.T., e-mail communication, November 17, 2012), (2) the HITEC consumer survey25 (V. N. Patel, e-mail communication, March 18, 2013), and (3) the national consumer survey on HIT by California


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HealthCare Foundation20 (G. Moy, e-mail communication, July 18, 2013). Use questions were tailored to reflect whether the respondent indicated they were an ePHR user or nonuser. For example, ePHR users were asked to whom they granted permission to view their ePHR, and nonusers were asked to whom they would grant permission to view their ePHR if they had one.

Data Analysis Descriptive statistics were used to examine the distribution and frequency of the variables. To compare ePHR users and nonusers by nurses’ characteristics, t tests were used for continuous variables. For categorical variables, Pearson # 2 tests were used with Yates continuity correction or with Fisher exact test, as appropriate. Variables that had bivariate association with ePHR (P e .20) were entered into multiple logistic regression models using forced entry. Four multiple logistic regression models were generated to examine the association with ePHR use. Model 1 included chronic conditions and medication use, Model 2 added healthcare providers’ use of EHR, Model 3 assessed general concern for privacy and security of health information online, and Model 4 included all of these variables. All models were adjusted for ethnicity/race and practice region in the US. No multicolinearity across variables was found, and model adequacies were met (Omnibus tests, P G .05; Hosmer-Lemeshow, P 9 .05). SPSS 21 (IBM, Armonk, NY) was used for all data analyses.

(33%) had a chronic condition or used medications, and 40% of respondents had both (Table 1). A significantly larger portion of ePHR users had a chronic condition and/or used medications than nonusers (P G .05). Almost three-quarters (71%) of respondents reported that they and their primary care providers collaborated on medical decision making. Less than half (44%) were primary caregivers for dependents (eg, children or elderly parents), and about one-third (30%) made medical decisions for their children or elderly parents. Those healthcare experiences did not vary between users and nonusers.

Technology Experience and Awareness of New Technology As seen in Table 2, 68% of respondents reported that they used EHRs for patients as part of their job and for an average of 8 (SD, 5.4) years. In this sample, the use of personal computers for any purpose was very common, averaging 21 (SD, 6.8) years, and only 21% expressed frustration when learning new applications, and the vast majority were familiar with the Meaningful Use initiative. These factors did not vary between ePHR users and nonusers. On the other hand, a larger proportion of ePHR users were frequent (several times daily) Internet users compared with non ePHR users (P G .01). More ePHR users reported that their healthcare providers currently used an EHR for their care than nonusers (P G .05).

Privacy of Electronic Health Information RESULTS Almost three-quarters of the NIC nurses (72%) participating in this survey reported that they used ePHRs (Table 1). Two-thirds were 50 years or older and had master’s or doctoral degrees. The majority were female (91%), currently married or living with a partner (79%), employed full-time (90%), with 25 (SD, 11.3) average years worked. There was no variation between ePHR users and nonusers by age, sex, education, marital status, employment status, or years working as a nurse. A significantly larger proportion of nurses who used ePHR currently held positions as clinical informatics specialists, chief informatics officers, or nursing informatics supervisors and reported specializing in informatics as opposed to nurses who were not using ePHRs (P G .05). While the overall sample was almost equally distributed across the four major regions of the US, a larger proportion of nonusers tended to be from the South (P = .07).

Health and Healthcare Experience The vast majority of nurses (97%) reported they were in excellent, very good, or good health. However, one-third 308

As listed in Table 2, ePHR users were less concerned about privacy and security of online health information than nonusers (P G .01). The majority of ePHR nonusers (90%) said they would grant permission to specific entities to view their ePHRs; however, only half of ePHR users actually granted permission to specific entities to view their ePHRs (Figure 1). Among those who granted or would grant permission (n = 119), fewer ePHR users compared with nonusers granted permission to designated family members or friends (50% vs 77%), other healthcare providers (56% vs 77%), or pharmacists (18% vs 51%) (all P G .05). Primary care providers were given or would be given permission by most respondents, and health insurance companies and employers were the least likely to get permission, with no significant differences between users and nonusers.

Factors Associated With Electronic Personal Health Record Use Among Informatics Nurses In Model 1 (chronic conditions and medication use), ePHR use was significantly associated with chronic conditions or medication use (odds ratio [OR], 2.68; 95% confidence


T a b l e 1 Characteristics of Nurses in Nursing Informatics Community by Personal Use of ePHR n (%)a Characteristics

Total (n = 183),a n (%) ePHR Nonuser (n = 52) ePHR User (n = 131)

Demographics Age, mean (SD), years 25–39 40–49 50–59 Q60 Female White Education Diploma/associate’s/ bachelor’s degree Master’s/doctoral Marital status Never married/divorced/separated/widowed Currently married/living with partner Job information Full-time employed, yesc Years of working as RN, mean (SD) Region for current practice, US Northeast Midwest South West Current position Staff/general/private duty/nurse practitionersd Nurse manager/supervisor/administrator Educator/researcher Clinical informatics specialistse Chief nursing informatics officer/supervisor nursing informatics/otherf Specialty area Direct patient care (noncritical/critical care) Nursing Informatics Health No chronic condition or medication use Either chronic condition or medication use Both chronic condition and medication use Healthcare experience Collaborative medical decision making: PCP and I decide together Primary caregiver for child/elderly Make medical decision for child/elderly

#2

P

(9.7) (15.4) (19.2) (48.5) (16.9) (89.3) (87.8)

t = j0.74 .46 0.68 .88

20 (38.5) 32 (61.5)

37 (28.2) 94 (71.8)

1.37b .24

38 (20.8) 145 (79.2)

8 (15.4) 44 (84.6)

30 (22.9) 101 (77.1)

0.86 .35

164 (89.6) 25.4 (11.3)

46 (88.5) r25.2 (10.2)

118 (90.1) 25.4 (11.7)

G0.01b .96 t = j0.11 .92

51.0 (10.0) 28 (15.4) 37 (20.3) 85 (46.7) 32 (17.6) 167 (91.3) 151 (82.5)

50.1 (10.2) 8 (15.4) 12 (23.1) 22 (42.3) 10 (19.2) 50 (96.2) 36 (69.2)

57 (31.1) 126 (68.9)

51.3 20 25 63 22 117 115

# 2 = 1.41b .24 7.64b .01

41 53 47 39

(22.8) (29.4) (26.1) (21.7)

13 (26.0) 10 (20.0) 19 (38.0) 8 (16.0)

28 43 28 31

(21.5) (33.1) (21.5) (23.8)

7.19 .07

19 21 28 76 39

(10.4) (11.5) (15.3) (41.5) (21.3)

8 (15.4) 8 (15.4) 12 (23.1) 19 (36.5) 5 (9.6)

11 13 16 57 34

(8.4) (9.9) (12.2) (43.5) (26.0)

10.69 .03

62 (33.9) 121 (66.1)

24 (46.2) 28 (53.8)

38 (29.0) 93 (71.0)

4.15b .04

50 (27.3) 60 (32.8) 73 (39.9)

22 (42.3) 13 (25.0) 17 (32.7)

28 (21.4) 47 (35.9) 56 (42.7)

8.26 .02

130 (71.0)

36 (69.2)

94 (71.8)

0.03b .87

80 (43.7) 54 (29.5)

25 (48.1) 13 (25.0)

55 (42.0) 41 (31.3)

0.34b .56 0.44b .51

Abbreviation: PCP, primary care provider. a Percentage may not sum to 100 because of rounding; numbers may not sum to totals because of missing responses. b Yates correction for continuity. c Full-time employed: vs no (part-time, PRN, other). d Nurse practitioners, certified registered nurse anesthetist/clinical nurse specialist/certified nurse midwife. e Clinical analyst/nursing informatics analyst/nurse informaticist/informatician/informatics nurse specialist/informatics specialist. f Other: nursing informatics consultant/ developer.

interval [CI], 1.10-6.53) and significantly associated with having both (OR, 2.58; 95% CI, 1.10-6.06) than nonusers (Table 3). In terms of awareness of new technology (Model 2), the odds of ePHR use for nurses whose healthcare

providers used EHR for their care were six times greater than for nurses whose healthcare providers did not use EHR (OR, 6.07; 95% CI, 1.62–22.69). For attitudes about health information privacy (Model 3), ePHR users were


309

T a b l e 2 Technology Use and Attitudes of Nurses in Nursing Informatics Community by Personal Use of ePHR n (%)a Total (n = 183), n (%)a

Characteristics Technology experience EHRs used for patients as part of job EHRs use for patients, mean (SD), years PC use, mean (SD), years Internet use: several times a dayd Frustrated at learning new applications Awareness of new technology Heard about Meaningful Use My healthcare providers use EHR Attitudes about privacy of health information Concerned about privacy and security of health information onlinee

124 (68.1) 8.3 (5.4) 20.5 (6.8) 176 (96.2) 39 (21.3)

ePHR Nonuser (n = 52) 36 (69.2) 7.3 (4.5) 20.4 (5.2) 46 (88.5) 12 (23.1)

ePHR User (n = 131) 88 (67.7) 8.7 (5.7) 20.6 (7.3) 130 (99.2) 27 (20.6)

#2 G0.01 t = j1.26 t = j0.27 9.00b 0.03c

P .98 .21 .79 G.01 .87

181 (98.9) 171 (93.4)

52 (100.0) 45 (86.5)

129 (98.5) 126 (96.2)

0.01b 4.19c

1.00 .04

98 (53.6)

37 (71.2)

61 (46.6)

8.09c

G.01

a

Percentage may not sum to 100 because of rounding; numbers may not sum to totals because of missing responses. Fisher exact test: cell count less than 5. c Yates correction for continuity. d Frequency of Internet use: several times a day versus once a day or less (about once a day/several times per week/several times per month/rarely or not at all). e Concerned (very concerned/somewhat concerned) versus not concerned (not at all concerned/not very concerned). b

much less concerned about privacy and security of online health information than nonusers (OR, 0.35; 95% CI, 0.17–0.74). Healthcare providers’ use of EHR and privacy and security concerns remained significant in the full model (Model 4) even in the presence of other factors, although chronic conditions and medication use were no longer significant.

DISCUSSION Our study is the first to examine factors associated with ePHR use among nurses in the NIC. Although the vast majority of

respondents rated their health as good to excellent, ePHR users were significantly more likely to have chronic conditions and/or use medications than nonusers. Similar results were found in the national consumer survey, in which individuals who are older and have chronic illness obtain the most benefits from using ePHRs and are therefore more likely to do so.26 Tang et al27 found that chronic disease self-management can be enhanced by using an ePHR, which is an important finding as almost 133 million Americans have at least one chronic illness.28 In the consumer survey, 56% of respondents with chronic illness used the Internet to search for information on their condition or medications.29 Previous studies have also demonstrated the utility of ePHR for diabetes management.30,31

Figure 1. Proportion granting permission to specific entities to view their ePHR among NICa users and nonusers willing to share data (n = 119).

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T a b l e 3 Adjusteda ORs of Factors Associated With ePHR Use by NIC Nurses (n = 180) Model 1 OR (95% CI)

Model 2 P

OR (95% CI)

Model 3 P

OR (95% CI)

Model 4 P

Chronic conditions/medication use None 1.0 Either chronic condition or 2.68 (1.10–6.53) .03 medication use Both 2.58 (1.10–6.06) .03 Awareness of new technology My healthcare providers use EHR 6.07 (1.62–22.69) G.01 (yes vs no) Attitudes about privacy of health information 0.35 (0.17–0.74) G.01 General concern for privacy and security of health information online (concerned vs not concerned) a

OR (95% CI)

P

1.0 2.61 (1.00–6.82) .05 2.00 (0.80–4.96) .14 5.99 (1.40–25.61) .02

0.32 (0.14–0.70) G.01

Adjusted for ethnicity/race and practice regions.

We found nurses were more likely to use ePHRs if their healthcare provider used EHRs. Use of ePHRs has also been found by others to be encouraged by the healthcare provider’s use of electronic record keeping of patient visits.32,33 This is likely because healthcare providers who use EHRs as part of their job are probably more likely to be aware of ePHRs than healthcare providers who do not.34 The use of ePHR along with EHR has many potential benefits. One study found that as more healthcare providers adopted EHRs, the end result was enhanced patient care. For example, more on-formulary medications were ordered, and because laboratory results were available, fewer tests needed to be ordered.35 Furthermore, patients with access to their medical records had a better understanding of their health issues, better communication with their healthcare providers, and greater overall satisfaction with visits36 and made better and more informed healthcare decisions.37 Our study found that ePHR users were less concerned about the privacy and security of electronic health information than nonusers. This might be explained by the fact that the majority of ePHR users (79%) had chronic conditions and used medications that might have resulted in more frequent ePHR use, and based on their experiences, concerns about privacy and security were alleviated.38 The ability of the ePHR to audit users may provide users a sense of control over their privacy and confidentiality.39 In contrast to users, ePHR nonusers have no experience using this feature, and their responses are based on their own perceptions of use. Nurses in our survey were significantly less likely to grant permission to access their ePHRs to family members or friends, other healthcare providers, or pharmacists than nonusers, whereas the vast majority of both ePHR users and nonusers would grant access to their primary care providers, a similar finding found by Patel et al.25 A climate for sharing may partly be attributed to building

alliances with one’s more direct healthcare providers as the majority of nurses in our survey made medical decisions in collaboration with their primary care providers, thus providing an opportunity for nurses to become instrumental in encouraging the use of ePHRs among patients they see. In terms of potential barriers to ePHR use, data privacy and security are critical issues for both patients and healthcare providers.14,26 Privacy concerns were negatively related to the likelihood of adoption of ePHR among the general population.40 Almost two-thirds of consumer ePHR users were concerned about the privacy of their medical records, but they actually worried less about the privacy of their ePHRs.26 This is despite the fact that authentication is required for tethered ePHRs27 and that the Health Insurance Portability and Accountability Act (HIPAA) covers ePHR privacy. However, HIPAA does not apply to nontethered ePHRs, and there are currently no legal protections for these systems (eg, Microsoft HealthVault).41,42 Although not legally binding, the Office of the National Coordinator for Health Information Technology released an ePHR Model Privacy Notice for Web-based ePHR companies to inform users about its privacy and security policies.43

Implications for Informatics Nurses Both the Office of the National Coordinator for Health Information Technology and the American Nurses Association have endorsed the important role that nurses have in supporting ePHR.44 Nursing has a tremendous opportunity to assist and educate patients in establishing and leveraging ePHRs, and nursing informaticists can devise applications for more efficient care and improved clinical outcomes.45,46 Informatics nurses, with their patient-centered view of technology, are in a prime position to influence development


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of ePHRs. Patient-centered care has been a rising topic in healthcare, along with use of technology. For example, Dr Eric Topol emphasized that ‘‘digital health tools can help the patient come alive.’’47 The Web site supports patients to take an active role in their healthcare, assisted by technology, therefore enhancing the partnership with their healthcare providers. Working with patients and healthcare providers at various levels of health literacy will enable informatics nurses to establish interface and data-view designs that will meet the needs of both patients and healthcare providers.46 For example, ePHR functions, such as reviewing laboratory results and communicating via secure messaging, can help healthcare providers and patients make decisions related to treatment together. A study found that highly health-literate patients with diabetes are more likely to correctly identify the out-of-range hemoglobin A1c level than patients with lower level of literacy.31 As a result, patient self-care can be improved when educational materials and explaining current clinical practice guidelines on specific diseases are added to ePHRs.48 Nurses also were involved in implementing a personal health information management system (PHIMS) that was deployed at a federally funded housing authority for low-income, elderly, and disabled patients.49 With education and support from graduate nursing students, residents showed improvement in updating medications and health problems in the PHIMS. Programs such as these may foster a health-promoting role for nurses in use of ePHRs. Nurses can also help to decide what information is needed at a level the patient can comprehend.46 A study tested the feasibility of using a tool (Infobutton) to explain medical diagnoses to patients, which helped patients understand their medical conditions listed in an ePHR.50 For instance, to promote understanding of laboratory results, clinical guidelines for chronic diseases or age-appropriate preventive care recommendations can be embedded in ePHRs via an Infobutton. Informatics nurses can also contribute to these design decisions based on their experience and knowledge. Such an effort can help transition patients into active participation their own health management via ePHRs.

Limitations While the data support the notion that nurse members of AMIA and HIMSS are among the early adopters and users of ePHRs considering their higher ePHR use rate (72%) compared with hospital nurses (41%)51 and consumers (10%),52 the narrow focus of the sample population and the voluntary participation limit the generalizability of the findings. Nurses who belong to these organizations are predominantly nursing informatics specialists and represent only a small fraction of practicing nurses. Inaddition, the majority of respondents were aged 50 to 59 years, and not many respondents were younger than 39 to 40 years. The younger generation of nurses who have grown up in the digital age 312

might have responded differently to our survey questions. The majority of management/upper levels of the nursing informatics world have a very different experience with technology than do those new to the nursing workforce. Self-administered Web surveys may have response biases; for example, nurses who were interested in the topic of ePHRs may have been more likely to respond. Furthermore, the cross-sectional design can only establish associations, and findings do not reflect causal relationships. We did not ask ePHR users what type of ePHR (tethered or nontethered) they used. Therefore, we cannot explain whether the quality or complexity of the ePHR affects ePHR use. Reliability and validity of the measures are a concern. Many of the factors studied are based on simple categorized responses to single-item questions; however, these questions were used in previous surveys and allowed us to compare some of the findings. Future research can address many of the limitations noted. New measurement tools that accurately assess the various dimensions important to adopting new technology such as the ePHR are needed to improve data quality. Further assessment of different types of ePHRs (tethered or nontethered) might suggest important gaps in their usefulness and security. In addition, greater representation of the nursing workforce is also needed, including samples with a wider variety of nursing specialties and job-related factors.

CONCLUSIONS Nurses’ use of ePHRs was associated with their healthcare providers’ use of EHR and trust in privacy of health information online. Therefore, healthcare providers who use EHRs in their practice may be more likely to be aware of ePHRs, and consequently nurses may be more aware of ePHRs as well. It is vital that the NIC be involved in ePHR development, because it is an untapped reservoir of experience and information. Designing systems that are user-friendly that also have stringent security and privacy protection can be achieved with input from nursing informatics specialists who have personal experience with ePHR. A nurse’s patient-centered focus puts them in an excellent position to understand and champion ePHRs. Our findings can inform policy efforts to encourage informatics and other professional nursing groups to become leaders and users of ePHR; such use could help them endorse and engage patients to use ePHRs. Having champions with expertise in and enthusiasm for the new technology can promote the adoption of ePHRs among healthcare providers as well as their patients.18

Acknowledgments The authors thank the nurses who participated in the survey. The authors also thank Douglas Joubert, National Institutes of Health Library, for manuscript editing assistance.


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