HEALTH INFORMATION RETRIEVAL AND USAGE

AMONG THE ELDERLY

Potential use of the Internet and Personal Health Records in Health

Awareness and Accountability

Dennis Cheung

Department of Health Policy and Management, Faculty of Medicine, University of Toronto

155 College Street, Suite 425, M5T 3M6, Toronto, Ontario, Canada

Keywords: ICT, Aging and Disability, Cognitive Informatics, & e-Health for Public Health.

Abstract: As North America anticipates an increase in the number of individuals expected to retire and fall into the

group of “older adults,” questions are raised regarding Canada’s healthcare system and its ability to deal

with this surge in consumption of resources. As the population ages, so too will the demands placed on the

current medical work force thus creating a shortage of medical practitioners available. By utilizing

information technologies such as personal health records (PHRs) and the internet, it is believed that this can

leverage some of the burden away from Canada’s healthcare system. By creating awareness and

accountability among this aging population through the use of ICT (information communication

technologies), cultural and behavioural changes in how this population consumes healthcare resources may

be altered. Not only are behaviours being changed due to ICT, but the way in which consumers are utilizing

resources and knowledge are also shifting. As the medical community is shifting away from the illness

model to that of a more patient centered one, it is important to understand the value of ICT solutions in the

prevention and continued well being of a patient in an economy where resources are scarce.

1 INTRODUCTION

With the change in Canada’s demographics, more

and more individuals are expected to retire and fall

under the group of “older adults” or the “elderly”.

Yet, contrary to popular belief, the increase in the

“older adult” population need not necessarily

translate into a greater strain on Canada’s Healthcare

system. With the common view that aging is directly

correlated to increased healthcare expenditures, it

was observed by Bevand (2010) that only one-third

to half of these expenditures will happen in the final

years of an individual’s life. In other words, it was

noted by Lee (2007) that the increased consumption

of resources is not entirely due to the population

aging (the cost of living of an aging individual), but

rather because of higher rates of mortality as the

population gets older (cost of dying). Nonetheless,

one significant problem does arise from the aging

population, namely, the lower number of available

healthcare practitioners as the population retires and

begins to work less hours (National Center for

Health Workforce Analysis, 2006).

One solution to this would involve the

integration of technology; in particular the Internet

and personal health records (PHRs), in helping to

leverage the shortage of available healthcare

practitioners providing information and guidance.

Coupled with this generation of older adults having

healthier lifestyles than their predecessors (Wiser,

2005), these individuals may not necessary utilize

public healthcare resources in the traditional sense,

of a patient, but rather as consumers wanting to

improve and be accountable for their own health. By

examining some of the current barriers and issues in

how the elderly access and retrieve information on

the Internet, this paper will strive to identify how the

Internet can be used as a health awareness and

information gathering tool. Together with the

introduction of PHRs, this paper will depict how

greater consumer awareness and accountability can

improve the time required with healthcare

practitioners in gathering health information.

205

Cheung D..

HEALTH INFORMATION RETRIEVAL AND USAGE AMONG THE ELDERLY - Potential use of the Internet and Personal Health Records in Health

Awareness and Accountability.

DOI: 10.5220/0003144702050212

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2011), pages 205-212

ISBN: 978-989-8425-34-8

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

2 BACKGROUND

In a report conducted by the National Center for

Health Workforce Analysis, Bureau of Health

Professions, Health Resources and Services

Administration, five main problems were identified

in relation to future healthcare practitioners and an

aging population:

1) Many health profession are aging rapidly

2) Most healthcare professionals receive limited

training on how to care for the elderly

3) Many health professionals lack diversity

4) Future shortages of health workers to serve

the elderly

5) Future demand for health care professionals

to serve the elderly will be affected by many

factors including health insurance

reimbursement policies, emerging

technologies, new models of care, and

changes in profession-specific scope of

practice (National Center for Health

Workforce Analysis, 2006, p.3).

From this, it can be expected that as the

population ages, future trends in healthcare workers

will also change. With a lack of interest in the field

of geriatrics from new graduates in the medical

profession, the numbers of individuals replacing

those retiring are few (Häkkinen, 2009). Couple this

with the fact that the aging population will grow

exponentially over next couple of years, this

shortage of available healthcare practitioners is a

huge problem that must be addressed (Robson,

2001). Not only is a shortage of health professionals

an issue, but given the behavioral change in the

elderly today and those entering retirement, a shift in

consumer and patient needs is occurring

simultaneously. With the aging population today

having more access to information (i.e. the Internet),

and being more health conscious, the elderly may

seek out particular services due to their “higher level

of sophistication (National Center for Health

Workforce Analysis, 2006, p.5).” In a study

conducted by Maynard (1991), it was observed that

as individuals aged, favorable health habits

increased within these individuals, and that they

believed that certain diseases could be prevented

with proper-self management.

With technology being so prevalent today, a

transformation is taking place in the way many

individuals process and access information. From

the complexity of online banking to the simplicity of

using parking machines in paying for parking

tickets, technology has shifted many cultural and

behavioural standards assumed in the past.

Healthcare is of course no different. The Internet has

provided a vast array of information at ones

fingertips, the days of healthcare providers being the

sole vessels of healthcare knowledge have long

dissipated (Campbell, 2005). A paradigm shift is

now taking place within many healthcare systems

across the world whereby the medical model is seen

as outdated, and the days of a physician telling the

patient what to do, are long over (Eysenbach &

Jadad, 2001). Instead, a patient centered model has

emerged whereby the patient and physician are

working together for overall patient well-being.

Consequently many new technologies and web-

based applications were developed around this

patient centered model of care; the most promising,

PHRs and consumer portals. PHRs can be described

as information reservoirs where one completes

medical information is stored and accessible by the

patient 24/7 (Shortliffe, & Cimino, 2006). Even

though there are many challenges associated in

properly developing and using a PHR, the potential

of having a complete record of one’s medical

information in the hands of the patient can have

immense benefits (Kim et al., 2007). Accompanied

with the use of consumer health applications such as

patient portals and online health communities,

individuals can share, collaborate, and exchange

information regarding various health concerns and

issues. By utilizing such tools, elderly individuals

can become more proactive in the involvement of

their own health and take into consideration the

various options prior to accessing public health

resources subsequently reducing the frequency of

physician consultation and, in optimal situations,

eliminating utilization of public health resources for

minor concerns completely.

3 THE INTERNET AND PHRs

AS A CONSUMER AWARENESS

AND ACCOUNTABILITY TOOL

In light of the behavioral changes outlined above,

the Internet, together with PHRs can become tools

for individuals to gain greater knowledge and

accountability in understanding and managing their

own health. However, before examining how

technology can improve consumer awareness and

accountability, it is vital that we have a clear

understanding of how elderly individuals seek

information. In a literature review conducted by

Escamilla (2006), it was found that seniors first tend

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206

to turn to their doctors as their primary source of

medical information, and then if all else fails; turn to

the Internet for medical information. Given that on

average, a physician spends only fifteen minutes per

patient, this may not be enough time for seniors to

gather the necessary medical information to make

decisions about their health (Belzer, 1999). Coupled

with findings from the Gladden (2000) study which

reveals that communication between patients and

doctors are often problematic, in that patients often

express dissatisfaction for being labelled as “nosy”

when asking for information.

The Internet can become a great tool in helping

elderly individuals retrieve medical information at a

comfortable pace. Not only does the Internet provide

a timeless space for individuals to retrieve

information, it also provides individuals a place

where they do not feel judged, isolated, or

disempowered (Escamilla, 2006). By empowering

individuals prior to visiting a physician’s office to

ask questions, discuss treatment options, express

opinions, and state preferences during this time, it

has been shown that these individuals have better

health outcomes than those who do not (Campbell &

Nolfi, 2005). In addition, it was noted by Wicks

(2004) that reading was the medium of choice for

many elderly individuals, and that a majority of

individuals use the library to rent books, audio,

videos and participate in library programs. In light of

this, library staff and administrators may be

considered as resources to encourage these same

individuals to try and access information through the

Internet. In a study conducted by Campbell (2005)

on the use of the Internet to gather healthcare

information by the elderly (n = 52), it was found that

86.5% of individuals used the Internet to look up

information. Of this 86.5%, it was further found that

63.5% of these participants who used the Internet for

health information were influenced to change their

current healthcare behaviors (Campbell, 2005). In

another study conducted by Campbell (2003) one

such behavioral change was when individuals were

going to see the doctor, individuals were quoted as

asking “…why I am seeing him in the first place?”

This statement in itself is significant as it points

towards a cultural and behavioral change in how

individuals access healthcare resources. Moreover, it

was further noticed that because participants have

more knowledge and awareness of specific medical

conditions and treatment options, these individuals

had measurably better health outcomes than those

who did not use the Internet (Mahler & Kulik,

1990). In being able to ask specific questions,

treatment options, and having an overall higher

understanding of the different illness and their

ramifications, individuals today play a more

collaborative role with their doctor and allied health

professionals in making important decisions

regarding treatment options (Campbell, 2003). With

75% of respondents from Campbell’s study

(Consumer Informatics: Elderly persons and the

Internet, 2005) reporting playing a collaborative role

in decision making with their physicians. It is hard

to deny that the Internet has significant influence in

creating greater consumer awareness and

accountability with regards to their own health

(Campbell, 2005). As health wellness and other

related material are becoming increasingly

accessible and available on the Internet, older adults

will also become more familiar with using this

medium to retrieve information in self-diagnosis and

remote consultation. In a study conducted by Chou

& Wister (2005), it was observed that lay

information-seeking behaviour could positively

influence health promotion activities for the elderly

population. It was found that elderly participants

(n = 827, age 50+) within this study who would

retrieve and look up information regarding chronic

illness, seek assistance from health professionals,

gain knowledge of community services, and consult

with friends about their own illnesses were more

likely to take action in self-care activities (Chou &

Wister, 2005). Findings from such studies

(Campbell, 2005; Mahler & Kulik, 1990; Campbell,

2003; & Chou & Wister, 2005) help to build on the

empirical evidence that information retrieval can

translate into significant self-care action by those

exposed to ICT. In addition, not only do health

promotion activities increase with the individual,

health outcomes can also improve as elderly patients

remind medical practitioners regarding best practices

and proper treatment methods (Campbell & Nolfi,

2005).

Another popular tool emerging in healthcare

today is the idea and concept of a PHR. PHRs may

be defined as a person’s entire medical history at his

or her access 24/7. PHRs can house different

elements which can include doctor visits, notes,

laboratory results, pharmacy information, diagnostic

images, and other medical information (Sprague,

2006). In an online survey conducted in 2003 by the

Markle Foundation’s Connecting for Health Project,

it was found that those with chronic illnesses

(usually those in the higher age groups) and those

caring for elderly parents reported the highest and

most urgent interest in PHRs. Given such existing

interest in PHRs, the shift in the way individuals

manage and account for their health is already in the

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Personal Health Records in Health Awareness and Accountability

207

midst of a paradigm shift. In a study conducted by

Kim et al. (2007), it was observed that participants

who used PHRs regularly filled in information in the

following elements: 1) medication, 2) health

problems, 3) surgeries, 4) lab tests, 5) allergies, & 6)

immunizations. Of these elements, the most

frequently updated was medication (updated 96% of

the time), which suggests that elderly individuals

recognize the value in recording their medication in

preventing adverse effects. Moreover, the active

updating and use of filling in medication history also

suggests that the elderly know their medication

information reasonably well (Kim et al., 2007).

From this, it can be deduced that individuals, when

given the opportunity will try and manage their own

care, thus displaying accountability in regards to

personal well being. As individuals are becoming

more active in managing their own care, it is no

surprise that these same individuals will also start to

become more aware of their own health condition. In

a study conducted by Jerden & Weinehall (2004), it

was reported that individuals who had access to

patient-held health records did change their

behaviours. Highlighted below in Figure 1 are the

findings from this study.

Figure 1: Percentage and Type of Change in Health

Behaviour (Jerden & Weinehall, 2004).

As seen in Figure 1, there were significant

changes after the implementation of individuals

using patient-held health records. However, due to

the limitations of the study, the most significant

portion, being “any change” could not be further

explored. Overall, physical exercise and diet were

the most common of the health behaviour changes

with fifteen and fourteen percent of participants

reporting a change in their health behaviour. As an

enabling technology, PHRs can aid individuals to

become more actively involved in their own health.

In a national survey conducted by The California

Healthcare Foundation, it was found that 90 percent

of individuals in the United States wanted to be

active partners with physicians, 52 percent wanted to

make final treatment decisions for themselves and

family members, and 38 percent wanted to make

decisions together with their physician (Ball, Smith,

& Bakalar, 2007). Given these statistics, a shift in

consumer behavior has begun as consumers are

taking a more accountable and active role in their

own health. In two studies conducted in the fall of

2005 (McInturff; & Markle Foundation), it was

found that 60 percent of Americans favored the

creation of PHRs and believed that PHRs could

improve safety and convenience. Of this same

group, 69 percent of respondents said that they

would “use it to check for mistakes” in their medical

records and medical prescriptions. Additionally,

another 58 percent said that they would use PHRs to

get lab results over the Internet with 57 percent

stating that they would turn to PHRs to contact and

communicate with their family physicians. As such,

a new trend is emerging in the way people,

especially elderly individuals, manage their own

health. As stated above, with 90 percent of

individuals wanting to be active partners with their

medical practitioners and only 9 percent wanting

physicians to manage their health for them (Ball,

Smith, & Bakalar, 2007). Technologies, in particular

PHRs, have enabled individuals to take affirmative

action in the delivery of care. With the economy as it

is today, the ability for older adults to manage their

own health can translate into savings of hundreds of

dollars on prescription drugs and other health related

expenses through access to information in guiding

them in making healthier lifestyle changes.

Through the use of the two technologies as

highlighted in this section. Elderly individuals today

now have the tools that past generations have long

sought after in assisting to make informed healthcare

decisions. Through awareness and accountability of

their own health conditions and treatment options,

elderly individuals can change their health behaviors

accordingly in order to live longer, and healthier.

4 BARRIERS TO THE INTERNET

AND PHR USE AMONG

THE ELDERLY

Given that the Internet and PHRs have just arrived in

the healthcare field during the last decade or so,

there are of course challenges associated with its

adoption and usage among the elderly. Some

barriers include, though not exclusively: 1) access to

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a computer and the Internet, 2) computer literacy, 3)

individuals that have the ability to understand and

interpret health information, and 4) that users have

the ability to assess the health information available

to them (Donahue, personal communications, June

07, 2010). In another article by Tang et al. (2006),

two wider range of barriers were discussed which

were characterized as “environmental” and

“individual-level” barriers. Environmental barriers

included organizational, economic, legal, and

privacy concerns while “individual-level” barriers

included items such as workflow models, challenges

to provider autonomy, recognition of value by the

patient, and behavioural changes.

Moreover, from the literature, it was found that

cognitive functionality and physical limitations

among the elderly also played a big part in the

adoption of information technology (IT) and

information communication technology (ICT). In a

study by Lober et al. (2006), it was observed that for

many individuals over the age of 65, cognitive

barriers were prevalent. With 11% of women and

15% of men over the age of 65 having moderate to

severe memory impairment, the ability to navigate

and keep track of what information was inputted and

retrieved would prove to be daunting (Federal

Interagency Forum on Aging Related Statistics,

2008). Furthermore in Lober’s study, it was

observed that as the population ages, physical

limitations begin to limit certain activities. With

21% of the elderly population having visual

impairment, 24% (ages 64-74) and 40% (age 75)

with hearing impairments, and 60% having arthritis

and other rheumatic conditions; this portrays a pretty

clear image in how physical limitations can create

barriers to IT and ICT adoption when individuals

cannot see, hear, or navigate a computer properly

(Lober et al., 2006).

Lastly, another common theme found among the

literature with regards to barriers to the Internet and

PHR adoption, were the terms digital and social

divide. The digital divide being defined as the gap

between individuals owing or knowing how to use

technology, i.e., ICT infrastructure, hardware, and

software, has always been a barrier to adoption (Kim

et al, 2009). Given that low income families or

elderly individuals may not necessarily have the

resources to purchase a computer or accessories to

optimize these online tools, many individuals are left

in the dark. Moreover, accompanied with this notion

of low income, is the idea of a social divide whereby

the skills required to manipulate and utilize these

technical tools are split between the low and high

income individuals (Kim et al., 2009). Provided that

those with higher incomes usually have higher levels

of education and continued access and training on

up-to-date technologies, those on the lower income

spectrum are usually the opposite. That is, low

income earning individuals on average will never

have a chance to learn the skills to use such

technologies, and in many instances, may not even

be exposed to them.

From listing the number of barriers associated

with the adoption and usage of the Internet and

PHR, it is hard to believe that these technologies can

be used to increase health awareness and

accountability. However, given the speed to which

technology has advanced, and is continuing to

advance, many barriers related to technology and its

usage among the elderly are slowly dissipating. As

the population ages and technology (computers and

the Internet) becomes more common and prevalent

in daily lives, the number of elderly individuals who

don’t have access or don’t know how to use a

computer will also decrease, thus increasing

adoption and usage of the Internet and PHR as a

health awareness and accountability tool.

5 DISCUSSION

In light of the number of barriers associated with the

implementation, adoption, and usage of the Internet

and PHR among the elderly; how then, can such

tools be used in the creation of greater consumer

awareness and accountability in overcoming the

shortage of healthcare professionals in the foreseen

future? As it was discussed above, the Internet and

PHRs have the capabilities to change not only an

individual’s health behavior, but it can also place

greater emphasis on the individual themselves to be

more aware and responsible for the type of treatment

they are to receive (Campbell, 2005). Provided that

this generation of elderly individuals thrived and

worked during the age of the computer, many

elderly individuals today are at least aware of the

Internet and computer as information gathering

tools. Knowing this, the concept of using the

Internet or a computer to retrieve or document

information is not a new idea. However, even with

familiarity and awareness of the computer and the

Internet, many websites and computer applications

are not user friendly. Due to the fact that not enough

consideration has been given to the usability of

many of these websites and PHR applications, the

implications of usability features can play a big role

in the adoption of these technologies (Squire &

Preece, 1996). In the article by Lober et al., one of

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209

the main reasons provided to account for the poor

adoption rates of elderly individuals with computers

was that “they were scared.” Given that most

websites today and applications are jumbled with

many features and options, it is no wonder this is the

case. One solution to this would be to gather

stakeholder input prior to launching a site or

application (or the proper term, usability testing), to

ensure it matches the needs of those using it. In

addition, another problem with this idea of

technology as a social awareness and accountability

tool, is the fact that physical ability plays a role in

the success of such a strategy. As mentioned earlier,

with old age being accompanied usually with some

form of physical deterioration, the ability to use

tools that are tailored towards able bodied

individuals may not be adoptable to this older age

group. Even though some tools and/ or applications

are geared specifically towards the elderly, the costs

associated to these pieces of technology are usually

higher. With the knowledge that elderly individuals

may not have high incomes, this can become an

issue in terms of accessibility.

As elderly individuals become increasingly

engulfed in technology, the natural shift towards

using computers and the Internet for healthcare

needs will become ever apparent. With 5 million

adults aged 65 and over who use the Internet to

access and search for health related information, this

trend will surely continue to grow. Indeed as

technology advances, mankind becomes ever more

reliant upon it (Campbell & Nolfi, 2005). With

elderly individuals (or consumers) using these tools

in preparing themselves prior to seeing a family

physician, i.e., looking for health information,

individuals then can better maximize and utilize the

limited amount of time they have with their

physicians (Belzer, 1999). By changing the

relationship between physician and patient, in that

both parties arrive informed, patient outcomes can

also be improved as adverse events are more

noticeable, mistakes are flagged, and physicians are

kept up-to-date with current best practices.

However, as consumers are using the Internet to

look for health information, the lack of proper

training or level of knowledge required to interpret

this information, could also have potential harm for

individuals retrieving this information (Cline &

Haynes, 2001). Although the Internet can never

replace the information received and given from

physicians, it can, if used and interpreted correctly,

can provide useful insight into treatment options and

barriers against adverse events. In one survey

conducted by Neff (1999), it was found that 67% of

physicians reported having patients who discussed

internet retrieved information with them. Given that

this survey is a little outdated, one would expect the

number of individuals today who discuss

information with their physicians should be

increasing as more individuals use the Internet to

search for information.

In general, if the technologies used by the elderly

are tailored towards their individual needs, it is

believed that the adoption rates will greatly improve.

Due to the fact that old age hinders many physical

abilities that many others take for granted,

technology may not always be the best fit. However,

given the growing body of literature and

advancement in technology, the use of the Internet,

PHRs have shown to be quite useful in providing

individuals with health information which have

positively changed their health behaviours.

Consequently individuals are more likely to take a

greater interest in the control of their health

information by being more accountable for it.

However, many of these studies and findings are

based on able bodied elderly individuals. Thus, this

leads to the question those who cannot use these

technologies. Will the results be the same? Is this

really representative of the elderly population?

Nonetheless, as physicians and patients begin to

work side by side in sharing and exchanging

information, patients will in all likelihood live

healthier lifestyles because of this. Moreover, due to

the large amounts of health information available on

the internet 24/7 with personal health information

stored within PHRs, accessible 24/7, the utilization

and need to see healthcare practitioners (especially

physicians) should also decrease. Individuals will

search the internet for minor illnesses and utilize

information available from their PHR to share with

other health professionals in remote consultation.

This subsequently should help move some of the

burden away from the healthcare systems since

individuals will not need to see physicians as often

for minor items, allowing relief for the already small

number of health practitioners available.

6 CONCLUSIONS

Technology has grown leaps and bounds over the

last century. The internet has opened many new

doors for individuals to gather and share

information. This in itself is changing the ways

many individuals do things. Provided that humans

are becoming ever reliant on technologies to perform

daily activities, it is only a matter of time until

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looking up information on the internet becomes

second nature (Givens, 2008). Of course, given the

vast amount of information available on the Internet,

perhaps having websites meet certain standards in

health information would be beneficial in preventing

harm (Cline & Haynes, 2001). One example of this

is HON which stands for Health On the Net

Foundation which aims to promote and guide the

deployment of useful and reliable online health

information and its appropriate and efficient use

(HON, 2010). Even though this accreditation and

standard is relatively new, it allows the individuals

searching for online health information instant

access and protection from inaccurate or false

information. By providing consumers or the elderly

the proper tools and information about health

information and their own personal health records,

many of these same individuals will change their

health behaviors to that of a more positive one, or a

health promotion and wellness model. Even though

there are barriers associated with using technology

in changing ones health behaviors as shown above;

by working with stakeholders and application/ web

developers, many of these hurdles can be overcome

(Squire & Preece, 1996). Moreover, with technology

advancing faster than anything else currently in

development, the costs of owning a personal

computer are decreasing while having access to the

internet is increasing rapidly. Through the use of

technology, particularly the Internet and PHRs, the

number of individuals going to visit family

physicians will decline. As more elderly individuals

become healthier and act healthier from changing

their lifestyles; many elderly individuals will think

twice (or check twice) prior to seeing a physician. In

doing so, this will ultimately decrease the number of

individuals having to see a physician for all their

information needs, thus allowing physicians more

time in seeing more severely injured or ill

individuals.

ACKNOWLEDGEMENTS

I would like to thank my friends and mentors, in

particular Kamran Ahmed and Jimmy Wang in

encouraging me to actualize my academic pursuits.

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