Personal Health Record adoption by healthcare consumer

Effect of Education on PHR use
Imke CaseyGeorgia College and State UniversityJeanne Sewell, MSN, RN-BC, Committee Chair
Rebecca Kitzmiller, PhD, MHR, ADDIN EN.CITE <EndNote><Cite ExcludeAuth=”1″ ExcludeYear=”1″ Hidden=”1″><Author>World Health Organization</Author><Year>2011</Year><RecNum>353</RecNum><record><rec-number>353</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1425831937″>353</key></foreign-keys><ref-type name=”Report”>27</ref-type><contributors><authors><author>World Health Organization,</author></authors></contributors><titles><title>Global status report on noncommunicable diseases 2010. Retrieved from http://apps.who.int/iris/bitstream/10665/44579/1/9789240686458_eng.pdf</title></titles><dates><year>2011</year></dates><urls><related-urls><url>http://apps.who.int/iris/bitstream/10665/44579/1/9789240686458_eng.pdf</url></related-urls></urls></record></Cite></EndNote>RN, BC, Committee Member
Deborah MacMillan, PhD, CNM, Committee Member
Sheila Fusé, B. A. Sc. Committee Member

Abstract
Purpose/Aims: (1) To assess the attitudes towards the use of computers of chronic disease adult primary practice patients, (2) to examine the rate of portal PHR use within a four week time period after an educational session, (3) to evaluate the effectiveness of educational instructions in improving PHR adoption among a group of chronic disease primary care practice patients adults and a matched set, and (4) to identify adult chronic disease primary practice patients’ thoughts about the portal PHR.

Design: Quasi-experimental, pre-test/post-test design with a paired matched set.
Sample: A convenience sample of 50 to 80 chronic disease primary care practice patients.
Methods: Participants will be recruited at the day of their provider appointment. After participants consent’ is obtained, the Background and Computer Questionnaire will be administered (pre-test) and the training session completed, followed by a four-week Computer Questionnaire phone survey (post-test). The treatment group subjects will be pair-matched to enhance the comparability of the two groups. The effectiveness of the educational instructions will be evaluated using the electronic medical record report function and determining the rate of PHR.
Main Research Variables: Rate of PHR use, computer attitude

Table of Contents
Page
Chapter I 4
Introduction4
Problem Statement4
Purpose of the Project5
Specific Aims 6
Chapter II7
Framework7
Synthesis of Literature Review8
Barriers of PHR adoption8
Benefits of PHR adoption9
Technology and Self-Management10
Patient Engagement11
Conclusion11
Chapter III12
PHR Project Planning12
Study Design12
Setting and Electronic Medical Record12
Sample and Inclusion Criteria13
Demographics and Technology Questionnaire13
Procedure14
References15
Appendix18
Effect of Education on PHR use
CHAPTER I
The Personal Health Record (PHR) allows patients to access and edit their medical record either by building their health information on a standalone program or as a portal that is integrated into the provider’s Electronic Health Record (EHR) system ADDIN EN.CITE <EndNote><Cite><Author>Archer</Author><Year>2011</Year><RecNum>5</RecNum><DisplayText>(Archer, Fevrier-Thomas, Lokker, McKibbon, &amp; Straus, 2011)</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1401854907″>5</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Archer, N.</author><author>Fevrier-Thomas, U.</author><author>Lokker, C.</author><author>McKibbon, K. A.</author><author>Straus, S. E.</author></authors></contributors><auth-address>DeGroote School of Business, McMaster University, Ontario, Canada</auth-address><titles><title>Personal health records: a scoping review</title><secondary-title>Journal of the American Medical Informatics Association</secondary-title></titles><periodical><full-title>Journal of the American Medical Informatics Association</full-title></periodical><pages>515-522</pages><volume>18</volume><number>4</number><keywords><keyword>Computerized Patient Record — Utilization</keyword><keyword>Medical Records, Personal</keyword><keyword>Patient Attitudes</keyword><keyword>Practice Patterns</keyword><keyword>Canada</keyword><keyword>Outcomes (Health Care)</keyword><keyword>Patient Satisfaction</keyword><keyword>United States</keyword><keyword>User-Computer Interface</keyword></keywords><dates><year>2011</year></dates><isbn>1067-5027</isbn><accession-num>2011175542. Language: English. Entry Date: 20111111. Revision Date: 20120302. Publication Type: journal article. Journal Subset: Blind Peer Reviewed</accession-num><urls><related-urls><url>http://search.ebscohost.com/login.aspx?direct=true&amp;db=ccm&amp;AN=2011175542&amp;site=ehost-live</url></related-urls></urls><electronic-resource-num>10.1136/amiajnl-2011-000105</electronic-resource-num><remote-database-name>ccm</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote>(Archer, Fevrier-Thomas, Lokker, McKibbon, & Straus, 2011). The portal Personal Health Record (PHR) allows patients to access their personal health information via the internet. It is an online tool that allows people to view and manage their medical record, facilitate self-management and care coordination (Ricciardi, et al., 2013; Sha ADDIN EN.CITE <EndNote><Cite ExcludeAuth=”1″ ExcludeYear=”1″ Hidden=”1″><Author>Shade</Author><Year>2014</Year><RecNum>256</RecNum><record><rec-number>256</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1419189726″>256</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Shade, Starley B.</author><author>Steward, Wayne T.</author><author>Koester, Kimberly A.</author><author>Chakravarty, Deepalika</author><author>Myers, Janet J.</author></authors></contributors><auth-address>Center for AIDS Prevention Studies, University of California at San Francisco, San Francisco, California, USA.</auth-address><titles><title>Health information technology interventions enhance care completion, engagement in HIV care and treatment, and viral suppression among HIV-infected patients in publicly funded settings</title><secondary-title>Journal Of The American Medical Informatics Association: JAMIA</secondary-title></titles><periodical><full-title>Journal Of The American Medical Informatics Association: JAMIA</full-title></periodical><keywords><keyword>HIV care</keyword><keyword>Ryan White Care Program</keyword><keyword>coordination</keyword><keyword>engagement</keyword><keyword>health information technology</keyword><keyword>viral load</keyword></keywords><dates><year>2014</year></dates><publisher>Hanley &amp; Belfus</publisher><isbn>1527-974X</isbn><accession-num>25030033</accession-num><urls><related-urls><url>http://search.ebscohost.com/login.aspx?direct=true&amp;db=cmedm&amp;AN=25030033&amp;site=ehost-live</url></related-urls></urls><remote-database-name>cmedm</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote>de, Stewart, Koester, Chakravarty, & Meyers, 2014). The advantage of integrating EHR data into the patient portal PHRs is that patients gain access to their health information; additionally, providers meet a key requirement for patient engagement in the “Meaningful Use” Stage 2 criteria for EHR technology ADDIN EN.CITE <EndNote><Cite ExcludeAuth=”1″ ExcludeYear=”1″ Hidden=”1″><Author>Griskewicz</Author><Year>2014</Year><RecNum>177</RecNum><record><rec-number>177</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1403910395″>177</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Griskewicz, Mary</author></authors></contributors><titles><title>Technology is improving patients&apos; access to their health information</title><secondary-title>Agency for Healthcare Research and Quality. In: Innovations Exchange</secondary-title></titles><periodical><full-title>Agency for Healthcare Research and Quality. In: Innovations Exchange</full-title></periodical><dates><year>2014</year><pub-dates><date>March 26, 2014</date></pub-dates></dates><urls><related-urls><url>http://www.innovations.ahrq.gov/content.aspx?id=3732</url></related-urls></urls></record></Cite></EndNote>(Griskewicz, 2014).
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ADDIN EN.CITE.DATA (Ricciardi, Mostashari, Murphy, Daniel, & Siminerio, 2013). Self-management is a unique approach for patients to assume greater responsibility in their own healthcare ADDIN EN.CITE <EndNote><Cite><Author>Baumann</Author><Year>2012</Year><RecNum>203</RecNum><DisplayText>(Baumann &amp; Dang, 2012)</DisplayText><record><rec-number>203</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1409512649″>203</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Baumann, Linda C.</author><author>Thanh Tran Ngoc Dang</author></authors></contributors><auth-address>Professor Emerita, University of Wisconsin-Madison School of Nursing, Madison, WI Lecturer, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam</auth-address><titles><title>Helping patients with chronic conditions overcome barriers to self-care</title><secondary-title>Nurse Practitioner</secondary-title></titles><periodical><full-title>Nurse Practitioner</full-title></periodical><pages>32-39</pages><volume>37</volume><number>3</number><keywords><keyword>Self Care</keyword><keyword>Chronic Disease — Prevention and Control</keyword><keyword>Motivational Interviewing — Methods</keyword><keyword>Nursing Role</keyword><keyword>Self-Efficacy</keyword><keyword>Education, Continuing (Credit)</keyword><keyword>Patient Attitudes</keyword><keyword>Nurse Practitioners</keyword><keyword>Health Knowledge</keyword><keyword>Health Beliefs</keyword><keyword>Diabetes Mellitus</keyword><keyword>Communication</keyword><keyword>Support, Psychosocial</keyword></keywords><dates><year>2012</year></dates><isbn>0361-1817</isbn><accession-num>2011480726. Language: English. Entry Date: 20120330. Revision Date: 20120622. Publication Type: journal article</accession-num><urls><related-urls><url>http://search.ebscohost.com/login.aspx?direct=true&amp;db=ccm&amp;AN=2011480726&amp;site=ehost-live</url></related-urls></urls><electronic-resource-num>10.1097/01.NPR.0000411104.12617.64</electronic-resource-num><remote-database-name>ccm</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote>(Baumann & Dang, 2012). The emergence of the PHR is an opportunity to improve patients’ access to health information and an important step towards shared medical decision-making ADDIN EN.CITE <EndNote><Cite ExcludeAuth=”1″ ExcludeYear=”1″ Hidden=”1″><Author>Daniel</Author><Year>2014</Year><RecNum>181</RecNum><record><rec-number>181</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1403929942″>181</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Daniel, J., Deering, M. J., &amp; Murray, M. S. </author></authors></contributors><titles><title>Issue brief: Using Health IT to put the person at the center of their health and care by 2020</title><secondary-title>The Office of the National Coordinator for Health Information Technology. Retrieved from http://www.healthit.gov/sites/default/files/person_at_thecenterissuebrief.pdf</secondary-title></titles><periodical><full-title>The Office of the National Coordinator for Health Information Technology. Retrieved from http://www.healthit.gov/sites/default/files/person_at_thecenterissuebrief.pdf</full-title></periodical><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>(Daniel, Deering, & Murphy, 2014).
Portal PHRs may be of particular value to patients with chronic conditions (Tenforde, Jain, & Hickner, 2011). The WHO defines chronic conditions as those that involve ongoing management over a period of years (WHO, 2011). Treating CD requires care coordination among a wide range of providers and access to medications and monitoring systems (Nolte & Osborne, 2013). Since evidence indicates that self-management may enhance quality of life, the Centers of Medicare and Medicaid (CMS, 2013) established quality metrics that require the provider to enhance CD patient self-care abilities. The researcher is interested to explore the current trend of portal PHR adoption by the chronically ill. She will explore portal PHR benefits and hypothesize that educational activities may improve PHR adoption within the selected patient population. The research project is then introduced and four specific aims of this study are presented.
The adoption of the personal healthcare record is taking a slow motion where people are engaging it in the United States of America. Statistics indicates that the portion which have joined the platform testify the role played by the tool to human health and medication. A personal health record is a tool highly embraced in American states where the approach has been constituted to the medical profession (Archer et al, 2011). It is an approach which intends to influence patient satisfaction, quality medical care, low medical cost and provision of the demanding skill towards a patient’s illness. Sources indicate that the approach extends in the nation where a patient can know his or her status throughout in accordance with the information available on the record. Investigation indicates that it is an approach which endorses the patients to adhere to the respective guidelines given by physicians towards the response to medicine or dictation towards a particular nutrition. Such an aspect cures the situation where the patients tend to be ignorant where the aspect endorses them to a depressed condition of the illness attracting more sophistication. Further, a portion of patients forget the manner in which doctors direct them through the provision of instructions when treating them. Therefore, it provides a source of reference. Statistics indicates that the method is viable and more reliable among patients in extremely bad condition. They entail patients who cannot move where the physicians have a task to grant directives on the illness; thus, providing medical service in a certain platform. Evidence indicates that the medical platform has been introduced in other countries such as European countries and Australia though not effective as it is in America.
Problem Statement
The prevalence of chronic disease (CD) has increased dramatically over the past twenty years, making it the number one cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2014). The World Health Organization also confirms that CD is the leading cause of death and disability globally (World Health Organization [WHO], 2011). To reduce this dramatic development and impact to society, effective chronic disease management and healthcare consumer engagement is essential. Research supports that individuals with chronic conditions have better health outcomes when able to self-manage and collaborate with their provider (Melchior et al., 2014; Nolte et al. 2013).
According to Tenford, Jain, and Hickner (2011), most healthcare consumers feel that a shift from the present paternalistic healthcare system to a more patient-centered care model would be beneficial. In a paternalistic system, the healthcare team is making decisions for the patient; it is assumed the providers are experts who “know best”. However, the effect on the patient is detrimental. It is creating a dependency that is incongruent with modern healthcare. Patients want to be in a partnership with their provider and make decisions about their health in an informed and collaborative manner (Krist et al., 2011). The relationship should be based on mutual respect and shared decision-making. In a collaborative effort the healthcare team would enable patients with self-management tools to encourage decisions that improve health related behaviors and clinical outcomes. PEVuZE5vdGU+PENpdGUgRXhjbHVkZUF1dGg9IjEiIEV4Y2x1ZGVZZWFyPSIxIiBIaWRkZW49IjEi
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ADDIN EN.CITE.DATA (Higgins et al., 2012). One such tool is the portal PHR. Krist ADDIN EN.CITE <EndNote><Cite ExcludeAuth=”1″ ExcludeYear=”1″ Hidden=”1″><Author>Krist</Author><Year>2014</Year><RecNum>351</RecNum><record><rec-number>351</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1425776882″>351</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Krist, Alex H.</author><author>Woolf, Steven H.</author><author>Bello, Ghalib A.</author><author>Sabo, Roy T.</author><author>Longo, Daniel R.</author><author>Kashiri, Paulette</author><author>Etz, Rebecca S.</author><author>Loomis, John</author><author>Rothemich, Stephen F.</author><author>Peele, J. Eric</author><author>Cohn, Jeffrey</author></authors></contributors><titles><title>Engaging primary care patients to use a patient-centered personal health record</title><secondary-title>Annals of Family Medicine</secondary-title></titles><periodical><full-title>Annals of Family Medicine</full-title></periodical><pages>418-426</pages><volume>12</volume><number>5</number><dates><year>2014</year></dates><isbn>1544-1709</isbn><accession-num>2012781759. Language: English. Entry Date: In Process. Revision Date: 20141107. Publication Type: journal article. Journal Subset: Biomedical</accession-num><urls><related-urls><url>http://search.ebscohost.com/login.aspx?direct=true&amp;db=ccm&amp;AN=2012781759&amp;site=ehost-live</url></related-urls></urls><electronic-resource-num>10.1370/afm.1691</electronic-resource-num><remote-database-name>ccm</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote> et al. (2014) found that portal PHR may engage the patient to actively participate in their treatment plan and use information in the portal PHR to better self-manage chronic conditions.
While portal PHRs have been available for more than ten years, they are used only by a fraction of US healthcare consumers; practices struggle to promote patient adoption ADDIN EN.CITE <EndNote><Cite><Author>Krist</Author><Year>2011</Year><RecNum>247</RecNum><DisplayText>(A. H. Krist &amp; Woolf, 2011)</DisplayText><record><rec-number>247</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1417312395″>247</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Krist, A. H.</author><author>Woolf, S. H.</author></authors></contributors><auth-address>Department of Family Medicine, Virginia Commonwealth University, Richmond, VA 23298-0251, USA. [email protected]</auth-address><titles><title>A vision for patient-centered health information systems</title><secondary-title>JAMA: Journal of the American Medical Association</secondary-title></titles><periodical><full-title>JAMA: Journal of the American Medical Association</full-title></periodical><pages>300-301</pages><volume>305</volume><number>3</number><keywords><keyword>Computerized Patient Record</keyword><keyword>Medical Records, Personal</keyword><keyword>Medical Informatics — Trends</keyword><keyword>Patient Centered Care — Trends</keyword><keyword>Access to Information</keyword><keyword>Health Behavior</keyword><keyword>Quality Control (Technology)</keyword></keywords><dates><year>2011</year></dates><isbn>0098-7484</isbn><accession-num>2010918725. Language: English. Entry Date: 20110204. Revision Date: 20120302. Publication Type: journal article. Journal Subset: Biomedical</accession-num><urls><related-urls><url>http://search.ebscohost.com/login.aspx?direct=true&amp;db=ccm&amp;AN=2010918725&amp;site=ehost-live</url></related-urls></urls><electronic-resource-num>10.1001/jama.2010.2011</electronic-resource-num><remote-database-name>ccm</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote>(A. H. Krist & Woolf, 2011). Just making a portal PHR available to patients will not ensure successful use by the patient. Patients are more likely to use a portal PHR if their provider recommends its use and staff is available to explain the portal PHR features ADDIN EN.CITE <EndNote><Cite><Author>Kerns</Author><Year>2013</Year><RecNum>8</RecNum><DisplayText>(Kerns, Krist, Longo, Kuzel, &amp; Woolf, 2013)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1401855209″>8</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Kerns, John William</author><author>Krist, Alexander H.</author><author>Longo, Daniel R.</author><author>Kuzel, Anton J.</author><author>Woolf, Steven H.</author></authors></contributors><auth-address>Shenandoah Valley Family Practice Residency, Front Royal, Virginia, USA.</auth-address><titles><title>How patients want to engage with their personal health record: a qualitative study</title><secondary-title>BMJ Open</secondary-title></titles><periodical><full-title>BMJ Open</full-title></periodical><volume>3</volume><number>7</number><keywords><keyword>Preventive Medicine</keyword><keyword>Primary Care</keyword><keyword>Qualitative Research</keyword></keywords><dates><year>2013</year></dates><pub-location>England</pub-location><publisher>BMJ Publishing Group Ltd</publisher><isbn>2044-6055</isbn><accession-num>23901027</accession-num><urls><related-urls><url>http://search.ebscohost.com/login.aspx?direct=true&amp;db=cmedm&amp;AN=23901027&amp;site=ehost-live</url></related-urls></urls><electronic-resource-num>10.1136/bmjopen-2013-002931</electronic-resource-num><remote-database-name>cmedm</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote>(Kerns, Krist, Longo, Kuzel, & Woolf, 2013). Despite the evidence, many providers do not have a structured program that improves patient portal PHR adoption PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXRsZXI8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Butler et al., 2013).
There is a growing interest to provide persons with chronic conditions with self-management tools, such as the portal PHR ADDIN EN.CITE <EndNote><Cite><Author>Tenforde</Author><Year>2011</Year><RecNum>14</RecNum><DisplayText>(Tenforde, Jain, &amp; Hickner, 2011)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1402777447″>14</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Tenforde, M.</author><author>Jain, A.</author><author>Hickner, J.</author></authors></contributors><auth-address>Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, USA.</auth-address><titles><title>The value of personal health records for chronic disease management: what do we know?</title><secondary-title>Family Medicine</secondary-title><alt-title>Family Medicine</alt-title></titles><periodical><full-title>Fam Med</full-title><abbr-1>Family medicine</abbr-1></periodical><alt-periodical><full-title>Fam Med</full-title><abbr-1>Family medicine</abbr-1></alt-periodical><pages>351-4</pages><volume>43</volume><number>5</number><keywords><keyword>Chronic Disease</keyword><keyword>Communication</keyword><keyword>Databases, Bibliographic</keyword><keyword>*Disease Management</keyword><keyword>Electronic Health Records</keyword><keyword>*Health Records, Personal</keyword><keyword>Humans</keyword><keyword>Medical Record Linkage</keyword><keyword>Patient-Centered Care/*methods/organization &amp; administration</keyword><keyword>*Physician-Patient Relations</keyword><keyword>Self Care</keyword><keyword>United States</keyword></keywords><dates><year>2011</year><pub-dates><date>May</date></pub-dates></dates><isbn>1938-3800 (Electronic) 0742-3225 (Linking)</isbn><accession-num>21557106</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/21557106</url></related-urls></urls></record></Cite></EndNote>(Tenforde, Jain, & Hickner, 2011). In the United States, almost half of all adults are living with chronic illness; 84% of all health spending is allocated to persons with chronic conditions ADDIN EN.CITE <EndNote><Cite ExcludeAuth=”1″ ExcludeYear=”1″ Hidden=”1″><Year>Centers for Disease Control and Prevention 2014</Year><RecNum>249</RecNum><record><rec-number>249</rec-number><foreign-keys><key app=”EN” db-id=”esfx2pe0td0xz1ere07590ftdfa9rx059sze” timestamp=”1417319538″>249</key></foreign-keys><ref-type name=”Web Page”>12</ref-type><contributors></contributors><titles><title>Chronic disease prevention and health promotion.</title></titles><dates><year>Centers for Disease Control and Prevention 2014</year></dates><urls><related-urls><url>http://www.cdc.gov/chronicdisease/overview/index.htm</url></related-urls></urls></record></Cite></EndNote>(Centers for Disease Control and Prevention [CDC], 2014). Evidence-based clinical practice guidelines recommend strategies to support self-management in chronic conditions including patient portal PHR adoption (Registered Nurses’ Association of Ontario [RNAO], 2010).
As the healthcare industry shifts into the digital age, patients now have the ability to more efficiently communicate with their provider and actively engage in their own care. The portal PHR allows the patient to verify and reorder current medication, access and print the medical record, review lab reports, send secure messages, and examine visit summaries. The portal PHR can also be used for interactive monitoring and coaching. It seems only logical to take action to actively promote and facilitate portal PHR adoption.
Pavement of personal health record in medication
Move from paternalistic provider behavior to patient empowerment
Information indicates that the system grew as the society lost interest in the paternalistic scheme. It is a mechanism which upholds the patients’ freedom in a certain capacity (Whetstone & Goldsmith, 2009). Proof indicates that the paternalistic approach extended the scope of the physician where it was believed that he is the only person who should give the directive to the patient on what to do. Studies assert that most of the diseases bear different alternative diagnosis. In a more critical review, the physicians have been taught such approaches, and they absorb the patient’s freedom through certain behavior where they dictate them what to do. It is evident that such an approach is engaged by the private health facilities in their incentive to maximize their level of profitability (Wynia & Dunn, 2010). Further, the public facilities engage it in a certain method where the government is not able to realize (Fetter, 2009). It is an act where the physicians give options on respective diagnosis to the patients whose costs are high in order to merit from the extra charges. Fortunately, the aspect of personal health record has absorbed the character where the patient has power to engage decision towards the action to be taken in regard to his or her condition according to the provided information.

Fig.1 Structure of a personal health record
Evidently, the personal health record maintains a strong relationship between the patient and the provider in that necessary information is maintained in the system. The approach provides a base for understanding and decision- making. It is evident that the paternalistic approach provides a podium over which different patients in different facilities provide distinct view and decisions towards the diagnosis of a particular disease. Such a character provides a profit making phenomenon where they provide remedies which do not solve the illness. It is an investment strategy in the sense that they may overdose patients or under dose them in order to attract more sophistication for them to report back (Kaelber & Pan, 2008). In an additional view, the paternalistic system absorbs trust in the sense that the patients have no individual physician whom they can trust in the provision of true and factual medical service. On the other hand, the aspect of personal health record maintains a pace of trust towards a physician in the sense that the information they disclose towards the cure of a certain disease is enshrined in the records.
Therefore, such an approach provides trust in accordance with the implications of the directives given by the physician. In a different perspective, shifting from the paternalistic approach to Personal health record associated an aspect of security where it is easy to absorb physicians who engage negligence in their task. Evidently, the different resolutions provided by different physicians create great suspicion that they do not comply with the professional requirement, and some of them will attract more diseases. Therefore, on such a platform, it is difficult to convict the physician. However, the personal health approach upholds a secure patient phenomenon. The approach associates a condition where all details provided by the physician can be retrieved from the system where such an aspect provides a basis for assessment and conviction if suspected. However, the physicians engaging such an approach are very keen and consider every professional requirement to avoid liability in their task. In a different perspective, the advent of personal health record seconds a beneficial implication where patient’s confidential information is confined to the system. Critically, the traditional approach which entails the use of books to record patient’s information discloses it to the society where any person can read it. Therefore, the personal health records maintain it free from the reach of other people. Further, change from the paternalistic system to the personal health record advances patient-provider relationship in a certain capacity where predictive modeling is manipulated. Such a task involves the patients’ inclusion in making predictions of treatment models which would establish a chance for healing.
Additionally, the personal health record has developed a pace of transparency and social networking. Such a condition associates the fact that the provider is willing and anxious to disclose any threat associated with the patient’s condition in order to remain in the secure zone. Information indicates that paternalism embrace a theoretical hypothesis of treatment where the physicians provide the patient with information asserting his or her health condition and the medicine which is necessary for such a condition. Most of the patients fail to buy the drugs strengthening the illness. Fortunately, the personal health record manipulates an actionable medical approach where theoretical information is implemented in reality. It associates the aspect where information is recorded, and liability can accrue the physician if it is not enforced. On the other hand, the information may not be accessed since the book or assessment document can easily be displaced.
Advancement in technology and increased information access
In the second perspective, the aspect of technology has fostered the development of the personal health record where information can easily be obtained. It is an aspect which establishes a remote phenomenon where the physician can access the patient online and anytime. Information indicates that such a platform has been beneficial to patients who engage it because they have low transport costs to the medical centre. In a more critical aspect, the approach provides a unique scheme where medical information provided by the physician to the patient can be reconciled. Evidently, such an approach provides a base over which sophistication in health condition can be analyzed in accordance with the historical information. In a more critical review, personal health record established as a system which would enhance quality in the provision of services ensuring maximum satisfaction among the patients. Evidence indicates that technology established a pace of transparency developing the approach in the sense that the providers of the service engage it in truth. Critically, it is a system which ensures that a patient retains one physician avoiding exposure to the industry where they meet many physicians who provide inadequate information which is exaggerated with errors due to personal interest. Evidently, online personal health record has been incorporated to violate the physician’s psychological perception where they tend to diminish the patient’s opinion in the aspect of knowledge and skill possession. Information indicates that the system has been enhanced with a unique method where the system in which the provider and the patient interact with one another is sophisticated for an outsider to understand. Therefore, such an aspect provides a good system over which confidentiality is enjoyed by the patient. Further confidentiality is enhanced through the differentiation of the personal health record. Additionally, the approach provides increased access to information where the patients can benefit from different regions.
Purpose of the Project
The purpose of this project is to examine the effect of an educational activity to encourage patient portal PHR use in chronic disease adult primary care practice (PCP) patients. Specifically, this research project will assess factors that affect usage of a portal PHR. This project will use evidence-based research and clinical practice guidelines to implement a systemic process to actively promote and facilitate portal PHR use. The goal is to identify factors that impact portal PHR adoption and use.
Specific Aims and Clinical Questions
This translational research study will address the following specific aims and clinical questions.
Specific Aim I
Specific Aim I of this study is to assess the attitudes towards the use of computers of chronic disease adult primary practice patients (participants) in Lake County Florida before and after an educational portal PHR session.
Specific Aim II
Specific Aim II of this study is to examine the rate of portal PHR use by participants within a four week time period after an education session.
Specific Aim III
Specific Aim III of the study is to evaluate the effectiveness of educational instructions in improving PHR adoption among a group of chronic disease primary care practice patients adults and a matched set
Specific Aim IV
Specific Aim IV of this study is to identify individual participants’ thoughts about the portal PHR.
CHAPTER II
Literature Review
Framework
Logue and Effken (2012) have developed a theoretical framework, the Personal Health Record Adoption Model (PHRAM). PHRAM draws concepts from several theories including (a) Social Cognitive Theory, (b) Integrated Model of Behavior Prediction, (c) Unified Theory of Acceptance and Use of Technology, and (d) Individual and Family Self-management Theory. PHRAM explains the interaction between personal, technological, environmental and disease factors and their influence on the person’s behavior. It is the complex interaction between these factors that allow a person to accept or decline the use of technology to improve their health.
The theorists’ “long-term goal is to use the explanatory model to develop and test interventions that will maximize the facilitators and minimize the barriers to PHR adoption” (Logue & Effken, 2012, p. 361). The research question, in chronic-disease adult primary care practice (PCP) patients, how does an educational activity for Personal Health Record (PHR) adoption influence PHR use over a 4 week period compared to non-participants, is built on PHRAM’s concepts.
ADD FIGURE!!
The Chronic Care Model
The chronic care model (CCM) is a framework to improve care for chronic conditions and an excellent tool for improving care at both the individual and population level (Baumann & Dang, 2012). This model encourages patient engagement and more interactions between patients
and health care providers. The CCM identifies the essential elements of a health care system that encourages high-quality chronic care (see Figure 1). These elements include community, the health system, self-management support, delivery system design, decision support, and clinical information system (Wagner, 1998).

Fig.2 The Chronic Care Model
Synthesis of Literature Review
Based on PHRAM, a systematic literature review was performed. CINAHL Complete and PubMed were searched with the key word Personal Health Record, chronic disease, self- management, and technology. There were 642 papers identified, of which 312 records met the 2009 to 2014 publication date restriction. Seventy-four records were screened and a total of 28 articles were reviewed in depth and included into the literature review (see figure 1).

Fig. 3 Literature review process
Barriers of PHR Adoption
There are a number of barriers for patients to using and adopting the PHR as a health management tool. The barriers can be grouped into three categories. The first category is technical barriers including the lack of interoperable networks between the provider and the patient (Archer et al., 2011), the need for encryption (Burke, 2010), and an overall security, privacy, and accuracy concern (Kerns et al. 2013; Yau et al. 2011). The second category include barriers to learning the new technology. Patients may not be computer literate; they report having poor internet skills, feeling too old to understand the PHR, or have a non-compliant attitude (Taha, 2013; Butler, 2013). The final category is socioeconomic barriers. Patients report that they are unable to afford a computer or internet services, some do not trust the computer, and others report being even afraid of it. Butler et al. (2013) found a barrier that lies outside these three listed categories. The study found that patients who are free of chronic illness are less likely to use the PHR.
Benefits of PHR Adoption
The patient perceived PHR benefits seem to have several inter-related components. First, it is necessary for their healthcare provider to offer EHR access through a PHR portal. Kerns et al. (2013) found that patients perceive the PHR as relevant, trustworthy, and functional when offered to them through their PCP (p. 7). Thus provider support is essential for patient PHR adoption.
Secondly, patients report satisfaction with being able to personally control and self-manage their care with features such as easy access to test results, a reminder system, medication refill options, appointment requests, e-consultations, and PHR e-mail. Archer et al. (2011) noted that those patients feel empowered (p. 518). It enhances patient clinician communication and reflects patient centered care. Nevertheless, patients need to be computer literate and must have the financial means to pay for a computer and monthly internet service fees.
Finally, it was surprising to find that frequent users of healthcare services and people with disabilities and chronic conditions are most interested and likely to use the PHR. Nevertheless, Tenforde (2011) noted that there are only three experimental studies that have evaluated the benefits of PHR use in chronic disease management, all in diabetes care. The studies showed a promising decline in HbA1c levels when patients use the PHR regularly (Tenforde, 2011, p.353).
Enabling Technology
Within the U.S. healthcare system, healthcare consumers are mostly recipients of healthcare rather than active partners of the care team. Health information technology tools, such as the Personal Health Record (PHR), offer the potential to improve this dynamic, enhancing the patient experience and the quality of patient care (Yarmin et al., 2011). Evidence-based research findings indicated that the PHR is an opportunity for positive change towards a more person-centered approach and the possibility to improve healthcare outcomes (Daniel, 2014). The RNAO expert panel (2010) established evidence-based recommendations that address strategies to support self-management in chronic conditions. Motivational interviewing, educational interventions, and the use of portal PHRs are identified as best practice guidelines. The RNAO encourages the use of their toolkit Implementation of Clinical Practice Guidelines to implement the evidence-based strategies.
Taha (2013) conducted a quasi-experimental, pre-test/post-test design study where the participants served as their own control. The study examined the participants’ ability to perform 15 common PHR tasks that were rated as either simple or complex. Scores were generated on several measures to include a (a) Background Questionnaire (Czaja et al., 2006), (b) Heart Disease Fact Questionnaire (HDFQ), (c) Test of Functional Health Literacy in Adults (TOFHLA), (d) subjective and objective numeracy, (e) cognitive battery, and (f) overall performance on PHR tasks. The researchers analyzed the collected data using a t-test to determine the difference between groups. Additionally, a regression model with predictor variables was used as an inferential technique. Major findings indicate that variables such as Education, Internet experience, cognitive ability, numeracy, and age may predict PHR task performance.
Patient Engagement
The Office of the National Coordinator for Health Information Technology (ONC) in the Department of Health and Human Services developed a national action plan to empower people to improve their health and healthcare by giving patients access to their health information, enable consumers to become involved, and enhance patient-provider communication (Ricciardi, et al., 2013). The ONC developed a “Three A’s” strategy: Access, action, and attitudes. It is a program that seeks to increase patients’ access to health information, enable patients to take action based on their electronic health information, and shift attitudes for patients to become engaged partners in their care. Lygeia Ricciardi, director of ONC’s Office of Consumer eHealth, says “a lack of public demand for digital health records is among the greatest obstacles to increase engagement in their own health”. For this reason, the ONC launched a “Blue Button” campaign to boost patients’ use of PHRs (ONC, 2014). The American Nursing Association (ANA) partnered with the ONC and developed a campaign that informs nurses about the importance of using the PHR (American Nurses Association [ANA], 2012)
Patient engagement as a pressing issue in America
Patient engagement in America is one of the pressing issues where it intends to endorse every physician to the full accountability in the discharge of services. It violates the platform where the physicians engage reluctant behavior in their tasks where they expect the patients to seek for them when in need. In a more critical review, the aspect aims at preventing the rate of sickness and mortality rate where it has been manipulated through the personal health record to maintain an adequate relationship between the patient and the provider. In the second perspective, the physician delay in manipulating effective patient engagement intent to witness a large number of the patients in their facilities. Such an aspect is associated with a profit maximization intention where they will earn more from high patient turnover due to the extreme sophistication of diseases. It is evident that they intend to win the patient’s faith. They manipulate a condition where even when the patients are cheated or taken advantage they cannot complain where they will be satisfied with the provider’s guideline since they are desperate.
Critically, most of the physician manipulates cost error in such a platform due to deserve for large profits. They enhance improper assessment in order to sophisticate the diagnosis as a way of inviting the patients again. Further, sources indicate that poor patient engagement aims at living potential gaps in the disclosure of information extending the level of illness. In a more critical review, it involves the duplication of tests where the physicians engage them to confuse the patients. However, the personal health record has taken a standing effect on the character through manipulation of an effective patient engagement ensuring that transparency is a key point in the delivery of medical services. The medical department in United States takes a standing approach ensuring g that the physicians are more involved and motivated towards delivery of services. In such a condition, they take the first position in ensuring that the patients are properly taken care of by making efficient notifications (Wen, Kreps, Zhu & Miller, 2010). It involves sending a notifying message through the personal health record to remind them on critical days when they should report within the medical centre. Further, they have incorporated the technical approach where a notification is sent to their handsets to inform them that they need to report to the hospital. Critically, the approach intends to reduce the patient’s hospitalization rate in United States resulting in congestion and a high mortality rate. Evidence denotes that once they report to the hospital in a large number, they exceed the physician’s capability to handle their challenges where they end up in bad conditions which attract high cost or death.
Engagement steps taken by other countries
Evidently, Europe and Australia are taking certain platforms to ensure that patient engagement is part of physician’s obligation through certain approaches. They entail a situation where the medical departments engage community health. Such an approach provides a platform for keeping the household safe and immediate response to emergencies in the society. Further, the approach makes informed decisions to the patients on when to seek medication from the physicians (Baird, North & Raghu, 2011). In a different perspective, the physicians maintain direct care where an effective direct relationship between the patient and the physician is enhanced. Such a platform creates a social phenomenon where the patient can disclose relevant information about his or her condition. The approach ensures that treatment is enhanced in truth to meet the intended goal with an aim of preventing sophistication or high mortality rate. Further, the medical department embraces a platform where the family share decisions based on any of the member’s health condition. Evidently, when the patient is brought to the physician, he or she will have force of word through provision of suggestions on what should be done. Such a platform violates the paternalistic system of the physicians. It is a system where people believe that the physician knows what should be done and will give directives without any other person’s confrontation. In addition, they embrace self-management through an approach where the patients can manage themselves from their residence (Urowitz et al, 2008). In an additional view, the European and Australia medical department embrace organizational patient care where a group of patients or family engage an advisory council on a respective disease. Such a platform allows the patient to participate when the physician is taking an action to his or her body. Such a condition allows the patient to endorse the physician to full obligation where they are not able to escape respective tasks which they should perform regarding particular illness. Evidence indicates that the nations have not fully embraced persona health record in a wide range.
Engaging primary care patients to use personal health record
Personal health record as a digital tool for ensuring that information is precisely passed has endured a pace of challenges in adoption where a large number in the society have not engaged it. The challenges entail lack of access to the Personal health record system where people from the society cannot access it. The approach associates the rural areas where electrification has not been enhanced; hence, initiating any online task is a problem. Evidently such a condition upholds backwardness where the patients believe that the traditional approach of the paternalistic mode of medication is the best. Such an aspect is an advantage to the providers where they absorb the freedom of such patients in a certain capacity which confines them from their human right (Agarwal, Anderson, Zarate & Ward, 2013). Further, information indicates that most of the people have not established interest in the digital world. They believe that a computer is a secondary good and, therefore, is not necessary for their survival. Such an aspect associates a condition that there are very few homes in the country which possess a laptop or a desktop which can engage them to the internet hence; access, the system. Evidence indicates that the approach associated cognitive and physical disabilities where the patients cannot engage the platform.
The situation encompasses a large number of individuals aged 65 years and above where memory impairment is an outlay to the approach. It is a situation where such people cannot understand how to run it efficiently (Kim et al, 2009). Investigation indicates that those who have engaged it at such an age have indicated clear signs that they are incapable in a certain capacity. It entails a situation where most of them fail to adhere to the information updated by the provider over the personal health record. For instance, they may fail to buy medicinal drugs directed by the physician in time attracting more sophistication of the respective disease. In an additional view, the residents of the nation who posse’s computer knowledge is very low were such an aspect distances them from the system (Druss & Dimitropoulos, 2013). Information indicates that most of them believe in the traditional approach where the physician is supposed to give them directives towards any disease. Such a condition associates inadequacy of health knowledge where the physicians from different health facilities attain an advantage in the provision of the service to maximize their earnings.

Fig. 4 an overview of online personal heath record adoption rate
The information indicates that the aspect of online personal health record has taken a long period in adoption due to the respective barriers where a significant figure refers the manual approach. Though it is slowly adopted in the United States of America, information indicates that the other regions in the world are yet to engage it (Tang, Ash, Bates, Overhage & Sands, 2006). Evidence indicates that those who have been used to the system have a longer lifespan where their interaction with the providers manipulates an objective system for an adequate medication. However, respective approaches have been enhanced to encourage the society to consider it as the cure for patient-provider engagement and provision of effective information (Kaelber, Jha, Johnston, Middleton & Bates, 2008). It entails a condition where the medical department with the assistance of the government stimulates an online approach to establish awareness regarding the personal health record. Such an idea involves advertisement to the people especially those residing in the rural regions. Statistics indicates that the people living in such regions possess little or no clue of the system.
Such a condition emanates from the perspective where most of them do not attend the highly ranked facilities where they are used to common dispensaries which do not embrace the practice in the society. Research indicates that such small-scale facilities have not availed them in the sense that they cannot afford the respective capital needed to run the system. In addition, the public facilities provide a platform for opening the account (Tom, Mangione-Smith, Solomon & Grossman, 2012). It is an act associated with no charges to embrace a large number of individuals to engage it. Evidence indicates that every patient who attends such facilities is briefly taken through the approach in a practical method (Roblin, Houston, Allison, Joski & Becker, 2009). It is a way of creating interest and requested to engage it if he or she likes it. Further, the account is opened by the physician where they grant the patient details to access the system from their residence or any other region. Critically, education towards the system is enhanced in a different dimension where the public facilities embrace a common training session which entails a theoretical approach. It occurs in a certain platform where a physician provides a lecture to the patients asserting and stressing g the benefits associated with the system. Evidently, the platform has captured 10% of the patients who have realized its importance. Further, educative programs about the approach are stimulated through social media where they are posted on the Facebook and twitter pages to reach a large number in the society.
Critically, the approach aims to destroy the ignorant behavior associated with individuals. Further, educative adverts over televisions and video screel have widely been enhanced to ensure that the society have adequate access to its existence and know the merits associated with the platform. Information indicates that the approach has been enhanced to uphold the respective approach to security and confidentiality. It is a task which involves the creation of different systems to access the record. In the first place, it incorporates the paper approach to personal health record where information is written in the paper or booklet to enhance a relationship between the patient and the provider (Kahn, Aulakh & Bosworth, 2009). Secondly, it incorporates the personal computer system where a patient can use a home machine to access the platform. Evidently, the machine is accessible to every individual in the family. Such a condition sets the scope of confidentiality to the family level where any family member can access it (Nazi et al, 2010). Further, the system is engaged through the internet where patients can seek information from cyber cafes across the region. Critically, such an approach uphold privacy however any person close to the machine can read the information.
Additionally, the system embraces the hybrid personal computer which involves the establishment of a completely private system where a patient can only access the information from the respective machine (Angst, 2008). In a more critical review, the patient upholds the login details to the account, and nobody can access them. It is the most embraced method in America with the intent to retain security and confidentiality. Evidence indicates that the public facilities have taken a standing decision to embrace the practice through an infrastructural approach. It is a system which provides an easy platform to attain the computer and internet among the patients. In a more critical review, most of the hospitals provide the computers to the patients and a billing in which they should respond to. Critically, they are given adequate installments which are affordable where the approach allow them to engage the system. Statistics indicates that the largest group among those who have engaged the platform has been incited by such a provisions since most of the people are in the low class and not able to achieve the machines. In a different perspective, the facilities embrace an effective workflow where convenience is provided (Marchionini, Rimer & Wildemuth, 2007). It is a system which invites the physicians to update information as required. Evidently, the entities have employed adequate personnel where work is fairly shared among the employees to ensure that it is not loaded to a particular person.
Further, it is the approach over which efficiency can be granted. In an additional view, the entities have established respective rules and policies which should guide the employees in the engagement of the platform in order to foster maximum utility to the consumer. It is evident that technology has been advanced in the approach where when they update the information the patient is supposed to read it (Noblin, Wan & Fottler, 2012). Therefore, if it is delivered and read, a response indicating that the information has been delivered informs the provider. Further, if it is not delivered the provider should use a different system to notify the patient of the necessary information. Such an approach involves making a call to speak to the customer. Evidently, the government supports the approach in the sense that it provides financial aid to compensate for their medical charge (Jones, Shipman, Plaut & Selden, 2010). It is a plan excluded from the charges for infrastructure where the patients pay in a simple and affordable approach. It is a step taken by the government to embrace the practice.
Chronic Disease
The WHO defines chronic conditions as those that involve ongoing management over a period of years (WHO, 2011). Treating CD requires care coordination among a wide range of providers and access to medications and monitoring systems (Nolte & Osborne, 2013). Since evidence indicates that self-management may enhance quality of life, the Centers of Medicare and Medicaid (CMS, 2013) established quality metrics that require the provider to enhance CD patient self-care abilities. Chronic disease in United States of America draws attention from every corner in the country. Information indicates that the medical officers and civilians have engaged an effective platform to ensure that respective remedies towards such diseases have been sought. Investigation asserts that the project has taken a large capital base to determine respective conclusions regarding the effects. The diseases entail asthma, diabetes, hypertension, cancer, stroke and heart diseases. Most of them are long lasting where once a person is affected he or she remains with the disease for the rest of the life. It is associated with the implication of diminishing life quality to the entire fraternity (Gibbons, 2011). In the first place, the infected person remains inactive and depressed where such a condition attracts loss of hope and insight early death. Secondly, the disease attracts a negative effect to the entire family where its good lifestyle is absorbed by the disease in the sense that a lot of money should be spent in hospitalization of the respective victim (Police, Foster & Wong, 2010). Additionally, it is a disease which invites the family to invest much of the time in the care of the respective person. Further, the disease withholds the economy in a certain capacity where it affects a large number of people within the nation. In the same way, it attracts high mortality rate leading to loss of brilliant and potential personnel in the society manipulating an economic outlay.
Such a condition is associated with the fact that the victims congest within the medical facilities where the physicians are not able to deliver the demanding skill and expertise since they are overwhelmed (Sunyaev & Chornyi, 2012). Further, the presence of different facilities leads to the provision of distinct information where some physicians mislead them in their profit maximization approach attracting death. Sources assert that the disease is widely attacking the society in that in the ancient period, such diseases were associated with the old generation (Johnston et al, 2007). However, it is now attacking all ages in the society including children, youth, middle-aged and the old. Further, the disease is adverse to all races. Researchers have asserted that such effects emanate from diet inadequacy where the patients take products which stimulate the diseases. For instance, diabetes mellitus is a disease caused by lack of insulin in the body where blood sugar exceeds since glucose is not adequately digested (Tenforde, Nowacki, Jain & Hickner, 2012). Evidence indicates that the aspect of personal health record manages the diseases in a more convenient approach attracting many benefits.
Research on its application indicates that the chronic victims who apply the system in their treatment last longer in a certain platform. In a more critical review, the approach upholds a large number of the victims in the society where the mortality rate is low. Further, its control is essential and simple where people do not have to sacrifice their time for such an individual attracting loss in different sectors (Horan, Botts & Burkhard, 2010). Critically, the use of personal health record plays an intrinsic task among such patients providing a suitable platform to approach the disease. In the first place, the system identifies the patient’s sheet in a more convenient approach in the sense that his or her history is upheld within the record. Such a platform provides an adequate position to provide relevant guidelines to the patient; hence, restore the health condition. In comparison to the traditional mechanism where information is written in a paper or booklet, the personal health records prove to be more secure in the sense that the information cannot be lost. In a more critical approach, the personal health record provides the problem list where the provider can know how to approach the illness (Tenforde, Jain & Hickner, 2011). It is a sequence in which observations are realized by the patient where such a platform allows the provider to apply the required expertise. It is evident that the system provides a suitable mechanism for medication where medicinal drugs are indicated in the record. Such an aspect provides room for implementation of drug taking.
Evidently, a large number of patients avoid drugs due to an ignorant perspective. However, the personal health records maintain efficiency in medicinal drugs where the provider insights the patient to seek for them and take as prescribed (Chatterjee & Price, 2009). Further, the approach associates a condition where the provider ensures that the patient is taking a dose after the other where such a task provides the way to healing. The presence of the patient’s historical information about the disease provides an adequate phenomenon where reconciliation and implementations can be done to avoid sophistication of the disease. In a more critical review, the record provides the progress note which allows the provider to assess the patient’s condition and seek respective approaches to attend the condition. Such a situation allows the provider to make alternatives if a certain drug is not performing (Randeree, 2009). Evidently, most of the chronic disorders emanate from lack of sufficient diets where the approach manipulates a condition where the provider indicates the respective foods necessary for the patient to take. Since many patients forget once informed what to take and how, the record acts as a reference centre.

Fig.5 an overview of chronic diseases and causes
Statistics indicates that the number of infected people is the largest in the community where it goes on diminishing due the different approaches of managing the disease. Evidence indicates that it is the only middle class, and the rich who can comply with most of the provider’s guidelines. It is a capability associated with the access of the requirements prescribed for them to remain healthy and strong (Chan, Amer & Aldhaban, 2009). Evidently, most f the low class realizes the disease when it is worsened where such a condition attracts death since they do not have an adequate financial power to manage their condition (Raisinghani & Young, 2008). However, the application of personal health record provides a suitable platform for observation and a successive continuity of life. Evidently, the low class can manage themselves with such system where they will slowly seek medication as provided in the records.

Fig.6 an overview of chronic disease management
Self-Management
Self-management is an individual’s ability to manage the everyday effects of a chronic condition (Novak, Costantini, Schneider, & Beanlands, 2013). It involves a complex and diverse set of skills and activities that are influenced by knowledge and attitudes, such as confidence or self-efficacy (Bagnasco et al., 2014). Individuals are tasked with applying these skills on a daily basis to solve disease-related problems and to set goals (Detaille, Heerkens, Engels, Gulden, & Dijk, 2013). Self-management support is the assistance given to someone with a chronic condition to encourage daily decisions that improve health-related behaviors and clinical outcomes. Self-management support includes techniques and tools that help an individual choose healthy behaviors (Higgins, Murphy, Worcester, & Daffey, 2012)
Barriers to Self-Management
Lu et al. (2014) found that barriers to self-care are a patient’s own perception of how challenging the personal and social obstacles are to achieving and maintaining a specific behavior. Lu’s (2014) study indicates that these barriers have many dimensions, including those related to healthcare providers, healthcare systems, and sociocultural issues. It was found that providers may lack time or appropriate skills, or may incorrectly label patients behavior as “non- adherent” or “non-compliant”. Kennedy et al (2013) evaluated a self-management program and
found that practice nurses were reluctant to utilize recommended motivational interviewing skills to engage the patient in behavior change discussions.
Grady (2013) identified another barrier to self-management: economic challenges.
Resources needed to support optimal self-care, as well as access to continuing care can be very expensive. The adequacy of health insurance for ongoing monitoring and treatment represents a major challenge for those who require life-long monitoring and treatment. Bagnaco et al (2014) completed a systemic review of descriptive and qualitative studies, the researchers found that personal characteristics of the CD patient, such as ethnicity, health literacy, and emotions have an impact on the effectiveness of self-management as well.
Strategies to Overcoming Barriers to Self-Management
Numerous studies found that self-management support programs have a positive effect on CD health outcomes (Dattalo, 2012; Jaglal, et al, 2014; Ory et al. 2013). Clinical best practice guidelines, established by an expert panel of the Registered Nurses’ Association of Ontario in 2010, endorsed self-management programs that utilize interventions and practice considerations based on a behavioral change approach (Registered Nurses’ Association of Ontario, 2010). The approach includes (1) establishing rapport, (2) screening for depression, (3) establishing a written agenda for appointments, (4) assessing client’s readiness for change, (5) combining effective behavioral, psychosocial strategies, and self-management education processes, (6), encouraging monitoring methods and self-management techniques (e.g. diaries, logs, personal health records [PHR]), (7) establishing goals, action plans, and monitor progress, (8) Motivational interviewing, and (9) follow-up.
The University of Stanford (2014) completed a randomized control study with over 1,000 CD patients. The experimental group attended a chronic disease self-management program (CDSMP) and the control group had conventional instructions. Participants who took the program, when compared to those who did not, demonstrated significant improvement in exercise, cognitive symptom management, communication with providers, self-reported general health, health distress, fatigue, disability and leisure activities limitations. Participants also spent fewer days in the hospital, and there was also a trend toward fewer outpatient visits and hospitalizations.
The Stanford CDSMP is a validated program that can be implemented throughout the US. While the program has recognized and excellent results, it has only been implemented in few US organizations and practices. Remarkably, countries such as the Netherlands and Australia have embraced and integrated the Stanford CDSMP into their healthcare system with good results (Detaille et al., 2013; Jaglal et al. 2014).
Knight and Shea (2014) propose a framework that supports technology-enabled self- management interventions. Logue and Effken (2012) established a validated framework that promotes the adoption of the Personal Health Record as a technology tool to engage the CD patient and facilitate self-management. Both frameworks build on the CCM that emphasizes technology as a supporting factor in CD self-management.
Strategies to Improve Self-Management Skills for Individuals with CD
Based on the reviewed literature it is evident that self-management skills in patients with CD should be promoted and facilitated. An area that is of specific interest to the student is the integration of technology to improve CD self-management. Best practice guidelines established by the RNAO (2010) recommend the use of the Personal Health Record as a monitoring method and self-management technique. This information strengthens the need to conduct translational research in PHR use that addresses the educational needs of patients, particularly chronic disease patients. Interventions and educational activities that promote CD self-management should be promoted and encouraged.
Conclusion
Both, expert and research evidence, clearly point to the need to change current practice and integrate the use of PHRs. The evidence relies on expert opinion, qualitative studies, descriptive studies, meta-synthesis of qualitative and descriptive studies, and three randomized control trials. Based on the multiple initiatives to increase patients’ and providers’ awareness about the PHR benefits, it is very likely that a project that seeks to improve patients’ knowledge about health information technology tools, such as the PHR, will be positively received. Expert evidence as well as research evidence supports the need to promote patient PHR adoption. The proposed translational project will attempt to use the presented evidence to improve current nursing practice by empowering patients to personally control and self-manage their care through the PHR.
There are only a limited number of randomized control trial studies with direct clinical outcomes when patients use the PHR (Ralston, 2009; Wagner, et al., 2011; Tenford, 2011); however, the perceived benefits to the patients point to improved patient engagement and better health outcomes. One of the barriers to patient PHR use is a lack of computer literacy. This information strengthens the need to conduct translational research for PHR use that addresses the educational needs of patients, particularly chronic disease patients.
The advent and advancement of personal health records plays an intrinsic task in a significant figure in the United States. It is evident that its main aim is to grant patients their perceived service from medical facilities (Nazi, 2010). It has been implemented to enhance information collection from both sides the provider and the patient. It provides a platform over which the patient and the provider can share the information in order to assist one another (Ball, Smith & Bakalar, 2007). Additionally, the personal health record provides a system in which the patient and the provider can exchange objective information as a significant factor in the provision of medical services. It engages a suitable condition in which the patients can manage themselves. Such an aspect attracts a positive effect to the entire fraternity in that little support and concern is manipulated by the other people close to the patient (Wang, Lau, Matsen III, & Kim, 2004). It is evident that the approach upholds security and confidentiality to the patients where the information access can only occur between the two individuals.
It is evident that the system has effectively attracted a positive implication in the cure of chronic diseases among other health defects. In the first place, it provides a condition in where its management is simple. It is a disease known to cause a high mortality rate in the society where many people lose life. Statistics indicates that such an approach associate every human demographic United States where an approximate of 4000 people lose their life within a year due to chronic disease. The study indicates that the adoption rate in America is slow in the sense that there are several barriers which accrue the citizens where many of them cannot access it. Such an aspect has outlay it (Fuji, Galt & Serocca, 2008). Evidently, the other nations have not extended to such advancement in the medical facilities where they engage different approaches to avoid the implications associated with poor disclosure of medical information. However, to the third world countries where corruption is highly exaggerated, such an aspect is not even recognized and is difficult to introduce it.

CHAPTER III
PHR Project Planning
Study Design
The portal PHR project will use a quasi-experimental, pre-test/post-test design with a paired matched set. The study will evaluate the portal’s effectiveness through the aid of questionnaires where the participants will seek adequate information about its performance from the facility and a sample of the respective health consumers. A set of questions about the provider’s response to the consumers will be enhanced in a comparative approach highlighting the change in their performance with the incorporation of the platform. It will involve a randomized approach where few health consumers will be selected (Kerns et al, 2013). The findings retrieved from their PHR will help to draw a conclusion on effectiveness associated with the entire system. The investigation will assert the respective validity associated with the portal where the health consumers will provide a sample of information provided by the physicians.
Such a platform will provide an opportunity to determine how it is effectively transmitted to the consumer. Further, the participants will seek information on the manner in which the consumers respond to guidelines provided by the physicians in order to spur adequate medication. Such an approach will involve investigation of the time taken by the consumers to take action on measures given by the physicians (Chan, Amer & Aldhaban, 2009). In a different perspective, it will determine the integrity engaged by the physicians in the provision of their services. It is a task which will involve determination of information granted by the physicians to health consumers suffering the same disease.
Permission was obtained by Czaja (2006) to use the Background and Computer Questionnaire for the PHR project (see Appendix B). This study will evaluate portal PHR use of middle-aged adults (40-62 years) and older adults (63-85 years) after an educational intervention with instructions how to (1) log-in, (2) view a current medication list, (3) print the Personal Health Record, (4) view lab reports, (5) send a secure message, (6) view the visit summary, and (7) sign-out. Evidence indicates that the institutional review board provided an approval for the approach on the basis of certain ethical tools which spur sufficient medical quality in health facilities with the aid of PHR. The institutional review board observed the character enhanced by the providers to the patients (Lustria, Smith & Hinnant, 2011). They realized that the benefits of the system would absorb the behavior. It is the unethical behavior associated with the paternalistic system of medication where the providers seek for respective approaches in which they can make profits from the consumer. Logically, they practice such behavior in an unethical mechanism where they benefit large amounts paid by the patients and grant a service which is not worth and sufficient to the patient’s illness. In the first step, the institutional review board aimed at stopping such a platform embracing non- maleficence where the providers harm the patients.
The personal heath record ensures that the patient is not harmed in the mechanism where information given by the provider can be retrieved from the system and engage liability if it is misleading (Andry et al, 2009). In an additional view, the institutional review board aimed at ensuring that the service providers’ associate quality, where information granted, will attract a positive outcome to the patient. It is evident that such a platform seconds existence of several medical facilities in United States where they provide distinct information about a disease. Further, the institution embraced autonomy inviting the providers to grant maximum respect to the patients where services can be offered in truth and faith. It is evident that the urgency of the patients is highly considered by the personal record where information about their health condition is updated as it is prescribed. Evidently such a condition provides a platform in which healing can easily be reached by the patients. Further, the institution approved the system on the basis of seeking justice to the patients from the providers (Parry, Min, Chugh, Chalmers & Coleman, 2009). It is critical that the providers gave unfair information which would sophisticate the condition in a certain condition where they could establish a way in which they extended their income. Analyses indicate that such a character attracted injustice to the consumer. Finally, the institution aimed at establishing a system which would uphold fidelity in the profession where the providers would exercise integrity as they offer their services (Segall et al, 2011). Investigation indicates that they violated all the ethical requirements of the profession at the expense that it is difficult to retrieve such information. However, the personal health record provides a standing remedy to the situation where information is ever available.
Setting and Electronic Medical Record
The selected clinic for the PHR project is a moderately sized, physician owned, group primary care practice located in a Central Florida town, with a population of approximately 30,033 (U.S. Census Bureau, 2010). The practice setting transitioned from paper-based medical records to using an electronic medical record in 2011. To support the coordinated care management approach the practice joined an Accountable Care Organization and put eClinicalWorks electronic medical record system in operation. The practice uses the eClinicalWorks patient portal PHR and has been in the process of meeting Meaningful Use “Stage 2” by enrolling 5% of their patient population. number of patients seen/day
The practice site services approximately 3,500 patients. A memorandum of understanding was signed between the Medical Director and Georgia College and State University on November 11, 2014 (see Appendix A).]
An investigation from Florida health facility asserts that the personal health adoption is based on several aspects. They entail age, income, health literacy and education. Evidently, the portion of the population which has engaged the platform is approximately 15% where among them the youth is the largest participating demographic. It is an aspect associated with income, knowledge and desire to engage the digital world (Daniel, Deering & Murray, 2014). The old struggle to venture he system since most of them are not literate and their ability to engage it is minimized. Therefore the youth is the largest group. In an additional view, the youth are incorporating the children to the platform in a wide capacity in the sense that they receive their child’s information from the physicians. It is a platform which allows the children to get involved in the system in a certain mechanism.
Sample and Inclusion Criteria
Patients that are scheduled from May 18 to May 29, 2015 at the primary care practice setting will be recruited for the study. The patient list will be screened for inclusion in the study the day before they are scheduled. Will include all patients seen in the practice setting that day! Participants have to be 40 to 85 years old, been diagnosed with a chronic condition, and must speak English as a primary language. The goal is to recruit up to eight participants a day; with an anticipated 50-80 total enrollment. For the purpose of this study, the chronic disease operational definition by the World Health Organization (WHO) is adopted. It is an operation which will provide a platform to realize the physician’s effectiveness in educating the patients. Evidently, the questionnaires will seek the respective topics stressed by the physicians to the patients about the importance of incorporating the personal health record. Further, it will allow the participants to determine the patients’ interest to engage it and the manner in which they respond to the teachings. In a different perspective, the approach will allow the participants realize the level of teamwork enhanced by the physicians in handling chronic diseases among other health hazards through the incorporation of the personal health record.
Demographics and Technology Questionnaire
Czaja’s (2006; Appendix B) Background and Computer Questionnaire is a validated tool that gathers information on participants’ demographic data, perceptions of their health, medical conditions, and medications taken. Another part includes a 20 item depression screening. The last two parts of the questionnaire assess the degree to which participants’ agree with 15 statements concerning their attitudes towards computers, titled Computer Questionnaire 1. Those who report having experience with computers will respond to questions concerning the extent of their typical computer use; it is the final part and is titled Computer Questionnaire 2.
Procedure
Participation in the study will take place on the day of recruitment. Eligible participants will be approached after they check-in at the front desk. If subjects agree, they will sign the informed consent and complete the Background Questionnaire (Czaja, 2006) after they have seen their primary care provider for their scheduled appointment. Once the Background Questionnaire is completed, participants will receive a portal PHR demonstration with instructions to (1) log-in (2) verify their current medication list, (3) print the Personal Health Record, (4) view their lab results, (5) send a message to their provider, (6) review the visit summary, and (7) sign-out.
Participants will receive a refrigerator calendar magnet as a “thank-you” token. They are reminded to use their PHR during the following four weeks and that there will be a follow-up phone call. The follow-up phone call will gather information from Computer Questionnaire 1 and Computer Questionnaire 2 (Czaja, 2006) four weeks following the intervention. Upon completion of the study, participants will have the option to select one of three five USD gift card option.
A paired matched set will then be selected from the setting’s electronic medical record data base. The matched study design is used to evaluate the effect of the intervention by comparing the matched set to the study sample. Matching will enable the comparison of PHR use among the intervention group and non-participants. It will also enable to estimate the effect of the educational session.

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Appendix A

Appendix B

Appendix C