title: The personal health record paradox: health care professionals' perspectives and the information ecology of personal health record systems in organizational and clinical settings.
abstract: BACKGROUND
  Despite significant consumer interest and anticipated benefits, overall adoption of personal health records (PHRs) remains relatively low. Understanding the consumer perspective is necessary, but insufficient by itself. Consumer PHR use also has broad implications for health care professionals and organizational delivery systems; however, these have received less attention. An exclusive focus on the PHR as a tool for consumer empowerment does not adequately take into account the social and organizational context of health care delivery, and the reciprocal nature of patient engagement.
  
  
  OBJECTIVE
  The purpose of this study was to examine the experiences of physicians, nurses, and pharmacists at the Department of Veterans Affairs (VA) using an organizationally sponsored PHR to develop insights into the interaction of technology and processes of health care delivery. The conceptual framework for the study draws on an information ecology perspective, which recognizes that a vibrant dynamic exists among technologies, people, practices, and values, accounting for both the values and norms of the participants and the practices of the local setting. The study explores the experiences and perspectives of VA health care professionals related to patient use of the My HealtheVet PHR portal and secure messaging systems.
  
  
  METHODS
  In-depth interviews were conducted with 30 VA health care professionals engaged in providing direct patient care who self-reported that they had experiences with at least 1 of 4 PHR features. Interviews were transcribed, coded, and analyzed to identify inductive themes. Organizational documents and artifacts were reviewed and analyzed to trace the trajectory of secure messaging implementation as part of the VA Patient Aligned Care Team (PACT) model.
  
  
  RESULTS
  Study findings revealed a variety of factors that have facilitated or inhibited PHR adoption, use, and endorsement of patient use by health care professionals. Health care professionals' accounts and analysis of organizational documents revealed a multidimensional dynamic between the trajectory of secure messaging implementation and its impact on organizational actors and their use of technology, influencing workflow, practices, and the flow of information. In effect, secure messaging was the missing element of complex information ecology and its implementation acted as a catalyst for change. Secure messaging was found to have important consequences for access, communication, patient self-report, and patient/provider relationships.
  
  
  CONCLUSIONS
  Study findings have direct implications for the development and implementation of PHR systems to ensure adequate training and support for health care professionals, alignment with clinical workflow, and features that enable information sharing and communication. Study findings highlight the importance of clinician endorsement and engagement, and the need to further examine both intended and unintended consequences of use. This research provides an integral step toward better understanding the social and organizational context and impact of PHR and secure messaging use in clinical practice settings.
authors.affiliation: Veterans and Consumers Health Informatics Office, Veterans Health Administration, Department of Veterans Affairs, Albany NY 12208, USA. kim.nazi@va.gov
authors.forename: Kim M
authors.initials: KM
authors.lastname: Nazi
mesh_terms: D001291:Attitude of Health Personnel; D003695:Delivery of Health Care; D006282:Health Personnel; D055991:Health Records, Personal; D006801:Humans; D010358:Patient Participation; D017216:Telemedicine / Q000706:statistics & numerical data*; D014481:United States; D014493:United States Department of Veterans Affairs
references.citation: Perspect Health Inf Manag. 2012;9:1f
references.pmid: 22783154
references.citation: N Engl J Med. 2007 Jun 14;356(24):2451-4
references.pmid: 17568026
references.citation: Int J Med Inform. 1999 Aug;55(2):87-101
references.pmid: 10530825
references.citation: Stud Health Technol Inform. 2007;127:77-90
references.pmid: 17901601
references.citation: J Am Med Inform Assoc. 2010 Mar-Apr;17(2):224-8
references.pmid: 20190069
references.citation: J Gen Intern Med. 2011 Nov;26 Suppl 2:628-35
references.pmid: 21989614
references.citation: J Am Med Inform Assoc. 2006 Mar-Apr;13(2):121-6
references.pmid: 16357345
references.citation: Hosp Health Netw. 2008 Aug;82(8):36-9, 1
references.pmid: 19062435
references.citation: J AHIMA. 2005 Nov-Dec;76(10):38-40
references.pmid: 16333942
references.citation: Manag Care. 2007 Jan;16(1):40-2
references.pmid: 17285811
references.citation: J Am Med Inform Assoc. 2005 Nov-Dec;12(6):614-7
references.pmid: 16049224
references.citation: Int J Med Inform. 2010 Jul;79(7):469-77
references.pmid: 20472495
references.citation: Int J Med Inform. 2003 Mar;69(2-3):191-6
references.pmid: 12810123
references.citation: BMJ. 2007 Aug 18;335(7615):330-3
references.pmid: 17703042
references.citation: Inform Prim Care. 2004;12(3):129-38
references.pmid: 15606985
references.citation: Health Commun. 2000;12(3):239-59
references.pmid: 10938915
references.citation: Ann Fam Med. 2008 Jul-Aug;6(4):331-9
references.pmid: 18626033
references.citation: J Gen Intern Med. 2010 Jan;25 Suppl 1:62-7
references.pmid: 20077154
references.citation: Perspect Health Inf Manag. 2010 Jan 01;7:1d
references.pmid: 20697465
references.citation: Implement Sci. 2008 Jan 07;3:1
references.pmid: 18179688
references.citation: AMIA Annu Symp Proc. 2006;:764-8
references.pmid: 17238444
references.citation: Int J Med Inform. 2003 Mar;69(2-3):135-56
references.pmid: 12810119
references.citation: JAMA. 2002 Oct 16;288(15):1909-14
references.pmid: 12377092
references.citation: J Healthc Inf Manag. 2007 Winter;21(1):76-86
references.pmid: 17299929
references.citation: J Med Internet Res. 2011 Sep 30;13(3):e71
references.pmid: 21959968
references.citation: N Engl J Med. 2008 Apr 17;358(16):1732-7
references.pmid: 18420506
references.citation: BMC Med Inform Decis Mak. 2008 Oct 06;8:45
references.pmid: 18837999
references.citation: J Gen Intern Med. 2011 Nov;26 Suppl 2:639-47
references.pmid: 21989616
references.citation: J Am Med Inform Assoc. 2002 Mar-Apr;9(2):171-80
references.pmid: 11861632
references.citation: J Am Med Inform Assoc. 2012 Nov-Dec;19(6):1089-94
references.pmid: 22847305
references.citation: Annu Rev Public Health. 2009;30:313-39
references.pmid: 19296778
references.citation: J Med Internet Res. 2011 Dec 05;13(4):e111
references.pmid: 22155738
references.citation: Int J Med Inform. 2001 Apr;61(1):1-10
references.pmid: 11248599
references.citation: N Engl J Med. 2008 Apr 17;358(16):1653-6
references.pmid: 18420496
references.citation: J Gen Intern Med. 2004 Sep;19(9):978-83
references.pmid: 15333064
references.citation: Med Care. 2013 Mar;51(3 Suppl 1):S52-6
references.pmid: 23407012
references.citation: AMIA Annu Symp Proc. 2008 Nov 06;:343-7
references.pmid: 18999276
references.citation: J AHIMA. 2007 Apr;78(4):71-5
references.pmid: 17455852
references.citation: J Law Med Ethics. 2010 Spring;38(1):64-73
references.pmid: 20446985
references.citation: J Am Med Inform Assoc. 2003 May-Jun;10(3):260-70
references.pmid: 12626378
references.citation: Evid Rep Technol Assess (Full Rep). 2008 Nov;(175):1-1422
references.pmid: 19408968
references.citation: J Am Med Inform Assoc. 2007 Sep-Oct;14(5):542-9
references.pmid: 17600093
references.citation: Milbank Q. 2004;82(4):581-629
references.pmid: 15595944
references.citation: J Med Internet Res. 2003 Apr-Jun;5(2):e9
references.pmid: 12857665
references.citation: Int J Med Inform. 2001 Dec;64(2-3):143-56
references.pmid: 11734382
references.citation: Am J Manag Care. 2007 Jul;13(7):418-24
references.pmid: 17620037
references.citation: JAMA. 2008 Jun 25;299(24):2857-67
references.pmid: 18577730
references.citation: Fam Med. 2009 Apr;41(4):285-8
references.pmid: 19343560
references.citation: J Am Med Inform Assoc. 2011 Jul-Aug;18(4):515-22
references.pmid: 21672914
references.citation: J Am Med Inform Assoc. 2008 Jan-Feb;15(1):1-7
references.pmid: 17947615
references.citation: J Am Med Inform Assoc. 2008 Nov-Dec;15(6):729-36
references.pmid: 18756002
references.citation: Arch Intern Med. 2006 Sep 25;166(17):1822-8
references.pmid: 17000937
references.citation: Telemed J E Health. 2008 May;14(4):330-2
references.pmid: 18584775
references.citation: Perspect Health Inf Manag. 2012;9:1-13
references.pmid: 23209454
references.citation: J Am Med Inform Assoc. 2010 Mar-Apr;17(2):192-5
references.pmid: 20190063
references.citation: J Biomed Inform. 2010 Oct;43(5 Suppl):S51-S55
references.pmid: 20937485
references.citation: Health Aff (Millwood). 2011 Feb;30(2):266-73
references.pmid: 21289348
references.citation: J Am Med Inform Assoc. 2004 Jul-Aug;11(4):260-7
references.pmid: 15064295
references.citation: Fam Pract Manag. 2006 May;13(5):57-62
references.pmid: 16736906
references.citation: J Am Med Inform Assoc. 2010 Mar-Apr;17(2):203-11
references.pmid: 20190065
references.citation: Health Aff (Millwood). 2010 Jul;29(7):1370-5
references.pmid: 20606190
references.citation: BMC Med. 2011 Apr 27;9:45
references.pmid: 21521535