One could argue that virtually everything one does, and does not do, influences thinking and decisions, so where are the boundaries?
ABSTRACT Veterans represent a unique population in need of accessing health services online. Data from a randomdigit dialed survey conducted by the Pew Research Center's Internet & American Life Project were used to assess differences in online use of health information among Veterans in the Veterans Health Administration (VHA) of the U.S. Department of Veteran Affairs (VA), Veterans not in VA, and non-Veterans. This survey of 3,001 U.S. citizens oversampled lower-income households. Questions assessed Veteran status and use of VA health care services, selfreported Internet use and Internet searching for health-related information, and social engagement related to health online. Overall results suggest Veterans represent an opportune population to utilize personal health records and health services via the Internet. Veterans in VA are more likely to search for health issues related to Alzheimer's disease and memory loss (odds ratio = 3.07; confidence interval = 1.41-8.28) compared to Veterans not in VA. Veterans receiving VA health care also reported higher proportions of social engagement related to health about tracking diet, weight, and exercise than Veterans not in VA, although not statistically significant. Veterans in VA are using the Internet for health information, and there is an opportunity to engage them more.
In Crossing the Quality Chasm, the Institute of Medicine emphasized that health care should not occur just within face-to-face visits, but that "access to care should be provided over the Internet" to foster continuous healing relationships.1 eHealth tools capitalizing on the Internet and providing access in a more centralized and patient-centered manner are regarded for their growing potential to increase patient access, activate patients in their care, and re-engineer patientcentered care.2
Increasingly, health care systems are turning to the Internet to augment health care delivery to address this need. Large health care groups including Kaiser Permanente, Group Health, and Partners Healthcare have implemented and evaluated personal health records (PHRs) for patients, among other online health information tools, to help increase access and use of health care.3-5 PHRs provide great potential to improve patient-centered care with the greatest clinical value in chronic disease management.6 PHRs show a commitment to leverage available technologies to increase patients' access to care and to health information that can improve their disease self-management. Thus, they represent an essential factor that can help with the long-term care and follow-up needed to manage chronic diseases.6
Furthermore, access to the Internet has become critical as a source of more immediate information about health issues to help manage chronic health conditions and improve selfmanagement of diseases. As a result, assessing the use of the Internet as a source of health information has become a way to understand patient's engagement with their own health. In fact, the Pew Research Center's Internet & American Life Project estimates that approximately 75% of Internet users have looked online for health information.7 The same report finds that Internet users with a chronic disease are more likely than other Internet users to be wide-ranging online health researchers and to report significant impacts from those searches.7
Digital Divide and Self-management of Care
Despite these advantages of Internet use for health, the advent of the Internet also created the digital divide phenomenon, especially for health care. As noted in the American Medical Informatics Association (AMIA) 2003 Spring Congress, Internet use varies by age, gender, education, income, and health status; and individuals can become vulnerable because of their lack of access to digital health services.8 Since the AMIA report, many advances have been made to reduce the digital divide and to increase access and use of health information, health care services, and more via Internet technologies. Although the digital divide may be narrowing, disparities still remain.9,10 Specifically, recent evidence suggests that there are disparities in use of PHRs by ethnicity 3,10 and socioeconomic status.10 Furthermore, among Internet users, women are more likely to use the Internet for health-related activities than men.11 Because of these disparities in access and use, patient-centered technologies to augment access and improve delivery of caremay only widen health care disparities for patients who are older, male, minorities, or have lower education, income, or health status.
Veterans who receive health care in the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) represent a unique and complex population whose use and engagement with the Internet for healthrelated content and self-management of care is likely to be affected by the digital divide. Veterans in VA are predominately older men with more chronic health conditions, and are more likely to be homeless.12 In addition, many Veterans also face health issues related to mental health and substance abuse that may influence use of the Internet for specific health information.13 VA has dedicated considerable resources for Veterans who receive care in its health care system, most recently with the design and implementation of My HealtheVet (MHV). The MHV system (www .myhealth .va.gov) is a combination web portal and PHR, the goals of which are to empower Veterans to participate in the management of their health and to promote superior health outcomes through the provision and use of health information. Despite these advances, there is concern that disparities remain for Veterans regarding the use of the Internet to improve health. This presents problems for Veterans for managing chronic health conditions, as access to the Internet and to personal health information that is provided via Web-based PHRs such as MHV can enhance self-management of chronic conditions. Although the digital divide for Veterans may lessen in future years as parts of the general population become increasingly more familiar with access to the Internet, it still remains important to understand whether disparities exist to address Veterans' current health information needs.
To inform implementation of patient-centered Web-based health care resources at VA, we sought to explore differences in the use of the Internet, health-related uses of the Internet, and social engagement with Internet use among Veterans receiving health care in VA, Veterans not receiving health care in VA, and non-Veterans.
The results in this report are based on cross-sectional survey data from telephone interviews conducted by Princeton Survey Research Associates International (PSRAI) on behalf of the Pew Research Center's Internet & American Life Project between August 9 and September 13, 2010, among a sample of 3,001 adults, age 18 and older. Interviews were conducted in English and Spanish.
The method was reported in the September Health Tracking Survey 2010 from PSRAI.14 "A combination of landline and cellular random-digit dialing (RDD) samples was used to represent all adults in the continental United States who have access to either a landline or cellular telephone. Both samples were provided by Survey Sampling International, LLC (SSI) according to PSRAI specifications. The landline sample for this survey was designed to generalize to the U.S. adult population and to oversample African-Americans and Hispanics. To achieve these objectives in a cost-effective manner, the design uses standard list-assisted RDD methodology, but telephone numbers are drawn disproportionately from telephone exchanges with higher than average density of African-American and/or Hispanic households. The cellular sample was not list-assisted, but was drawn through a systematic sampling from dedicated wireless 100-blocks and shared service 100-blocks with no directory-listed landline numbers."14
Furthermore, "disproportionate sampling and non-response in telephone interviews can produce biases in survey-derived estimates. The data set was weighted in two stages. The first stage of weighting corrected for the disproportionate landline sample design and also accounted for the overlapping landline and cellular sample frames as well as different probabilities of selection associated with the number of adults in the household. The second stage of weighting matched overall sample demographics to population parameters. The demographic weighting parameters are derived from a special analysis of the most recently available Census Bureau'sMarch 2009 Annual Social and Economic Supplement. This analysis produces population parameters for the demographic characteristics of adults age 18 or older. These parameters are then compared with the sample characteristics to construct sample weights. The weights are derived using an iterative technique that simultaneously balances the distribution of all weighting parameters."14
Our primary independent variable was assessment of Veteran status and Veteran use of VA health care facilities. We used two questions from the Center for Disease Control Behavioral Risk Factor Surveillance Survey to assess Veteran status. First, respondents were asked "Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War." Then, they were asked "In the past 12 months, have you received some or all of your healthcare from a VA hospital or clinic?" as either "Yes, all of my health care," "Yes, some of my health care," or "No, no VA health care received."
Our primary dependent variable was self-reported Internet use, as measured by "Do you use the Internet, at least occasionally?" and "Do you send or receive e-mail, at least occasionally?" Those who responded yes to either question were considered Internet users.
Secondary dependent variables of interest were 15 questions related to use of the Internet for health-related searching (e.g., searched for specific disease or medical treatment; food safety or recalls; doctors or other health professionals), and six questions on health-related social engagement (e.g., signed up for e-mail alerts about health or medical issues; watched an online video about health or medical issues; tracked weight, diet, or exercise routine online).
The survey also asked participants about demographic characteristics (e.g., gender, ethnicity, age, education, income, rural/urban status) and health status through self-reported measures of chronic health conditions.
Of the 2,991 respondents who reported Veteran status, 92 (3%) were Veterans receiving some or all of their health care in the VA, 261 were Veterans not receiving care in VA (10%), and 2,638 (87%) were not Veterans.
Veterans and Non-Veterans Characteristics
Veteran respondents were more likely to be men, compared to non-Veterans (Table I). The proportion of non-white and non-Hispanic respondents varied from 24% (Veterans not receiving VA care) to 37% (Veterans receiving VA care) to 45% (non-Veterans). Forty-one percent of Veterans in VA were aged 65 and older. Veterans in VA had a significantly higher proportion of less than high school education and lower income compared to those not in VA. A higher proportion of Veterans receiving care in VA reported having a chronic condition, as compared with non-Veterans. Veterans in VA were also more likely to report fair or poor health status (36%) when compared with Veterans outside VA (17%).
Veterans Internet Use
Overall, Veterans did not differ significantly from non- Veterans on Internet use. The proportion of Internet users among Veterans receiving care in VA (59%) was significantly lower than Veterans receiving care outside VA (71%) (odds ratio [OR] = 0.46; confidence interval [CI] = 0.23-0.91). See Table II.
Health-Related Internet Searching
Among Internet users, a higher proportion of Veterans in VA reported health-related searching when compared with Veterans not in VA for 12 of the 15 questions related to searching online for health-related information (Table II). Veterans in VA did significantly differ from Veterans not in VA, with Veterans in VA reporting higher proportions of Internet searching for issues related to memory loss, dementia, and Alzheimer's disease (OR = 3.07; 95% CI = 1.41-8.23). Veterans in VA were also less likely to search for health insurance online compared to Veterans not in VA (OR = 0.37; 95% CI = 0.16-0.84), and less likely to search for other health issues (OR = 0.34; 95% CI = 0.13-0.94).
Health-Related Internet Social Engagement
For questions on health-related Internet social engagement, the three groups (Veterans in VA, Veterans not in VA, and non- Veterans) did not significantly differ. Yet, trends emerged with higher proportions of Veterans in VA health care system reporting having signed up to receive e-mail about health issues, watching online videos about health issues, and going online to find others with similar health issues, compared to Veterans not in VA and non-Veterans. In addition, although not statistically significant, Veterans receiving VA health care exceeded Veterans not receiving VA health care for viewing blogs and online videos about health, going online to find others with similar health concerns, and tracking health indicators other than weight, diet, and exercise (Table III).
We hypothesized that the Veteran population would be vulnerable to the digital divide or differences between Veterans and non-Veterans in the use of and engagement with Internet technologies for health-related purposes. We know from previously reported surveys that older Americans are less likely to use the Internet, and women are more likely to use the Internet for health.10,11 In addition, those with poor health status are less likely to go online; although once online, these users may be more likely to use the Internet for health.11 The VA Veteran population represents a unique population in which comorbid chronic conditions, homelessness, substance abuse, and mental health represent critical issues that may influence use and engagement with Internet technologies. Results from this survey shed light on trends for Internet use and online health searches for Veterans in VA population. Understanding these trends will inform future implementation of patient-centered health information and enhancements to the MHV PHR with the potential to influence future selfmanagement of diseases.
The findings do suggest that Veterans in VA use the Internet differently than those who obtain their care outside VA. Results from this survey show that Veterans in VA use the Internet less frequently than Veterans not in VA and indicates that a digital divide may exist in the current VA Veteran population. Given the focus on improving self-management of care among Veterans in VA, the abundance of health information available, and these findings, it could be inferred that Veterans in VA may have less access to obtaining the necessary information that could help them with their health. It is possible that Veterans in VA are experiencing a deeper digital divide than Veterans receiving health care from other systems. Future research should further examine this issue and how VA may be able to close this gap.
Interestingly, when they are accessing the Internet for health information, Veterans in VA are more likely to search for health information related to Alzheimer's disease, memory loss, or dementia compared to Veterans not in VA health care system. The current older population of Veterans in VA would suggest that memory loss, dementia, and Alzheimer's disease may be a higher health priority compared to other health issues, and perhaps those Veterans in VA are seeking those health services more than Veterans not in VA. VA does have an Office of Geriatrics and Extended Care that provides geriatric and long-term care services to Veterans,15 which may be influencing results. Also, results from this study suggest that enhancements of VA health information online should focus on Alzheimer's disease and dementia, as well as providing guidance and advice about these health issues to further engage Veterans online. Addressing these content needs could help VA better meet goals related to patientcentered care with Veterans.
In addition, the trends for online searches related to disability, drug safety, memory loss, and long-term care by Veterans in VA highlight these important health issues facing Veterans and point to the need to have information and resources available to guide health decisions regarding these issues. This is consistent with Veterans in VA having multiple health concerns, and suggests that Internet is being used as a method to learn more about these conditions. For Veterans, having health information specific to their needs and circumstances remains an important aspect of their selfmanagement of care. Yet, results would seem to indicate that Veterans in VA need to search for this information more than Veterans not in VA. The difference could suggest that information on these health issues may be more readily available for Veterans not in VA, or that in-person interactions in VA are prompting to seek more health information on the Internet. Although results are not conclusive, it does suggest an opportunity for future implementations and enhancement of care for Veterans in VA.
Furthermore, the trends regarding social engagement with health online among Veterans offer hope for the future potential of the MHV PHR to engage Veterans with selfmanagement of chronic health conditions and improve patient-centered care. Veterans in this survey appear to be motivated to engage via online services to track and monitor their health care, and perhaps will be motivated to engage in the MHV PHR available to them. Interestingly, Veterans are using the Internet to track diet, exercise, and weight. These three strategies are often considered a cornerstone of prevention behaviors for many chronic health conditions and a hallmark of self-management of care. VA has invested resources to encourage these self-management behaviors for Veterans in VA, as they can influence health outcomes related to several chronic co-morbid conditions. 16,17 Thus, it is an opportune environment for Veterans to be engaged in improving management of care, and also engaging with their VA health care facility via the Internet. VA should continue its focus and commitment in using Internet technologies and applications to provide health care needs to Veterans as a method of delivering patient-centered care.
The limitations of this study may influence the generalizability of these results. Responses rely on the self-report of participants during a cross-sectional survey, compared to actual Internet use in search of health care information, and thus may not represent long-term use and engagement with the Internet for health information or reflect increases or decreases in use. Although the survey implementation was constructed to elicit a representative sample via landline and cellular phone, those sampled may not be representative of all Veterans because of the proportion of current homeless Veterans without landline or cellular phone. Of note, the number of Veterans receiving VA health care was small, and our power to detect small differences is limited. Thus, the generalizability of this study's findings and possible explanations suggest research topics for the future.
Veterans may be considered a vulnerable population in the context of the digital divide, yet results from this study indicate that there is a potential to engage Veterans with healthrelated services via the Internet. It is important to continue to explore the needs of Veterans regarding health information to help improve patient-centered care and help Veterans better manage their health.
We acknowledge the Pew Research Center's Internet & American Life Project for the incorporation of Veteran status into their survey. We also acknowledge the support provided by the eHealth Quality Enhancement Research Initiative (QUERI) with the U.S. Department of Veterans Affairs to analyze the results.
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Thomas K. Houston, MD, MPH*[dagger]; Julie E. Volkman, PhD*; Hua Feng, MD, MS*[dagger];
Kim M. Nazi, PhD, FACHE[double dagger]; Stephanie L. Shimada, PhD*§; Susannah Fox, BA||
*eHealth Quality Enhancement Research Initiative and Center for Health Quality, Outcomes and Economic Research, Department of Veterans Affairs, 200 Springs Road (152), Bedford,MA 01730.
[dagger]Department of Quantitative Health Sciences, University ofMassachusetts Medical School, 55 Lake Avenue North, Worcester,MA01655.
[double dagger]Veterans and Consumers Health Informatics Office, Office of Informatics and Analytics, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420.
§Department of Health Policy andManagement, Boston University School of Public Health, 715 Albany Street, Talbot Building, Boston,MA 02118.
||Pew Internet & American Life Project, 1615 L Street, NW, Suite 700, Washington, DC 20036.