Use of the internet and an online personal health record system by US veterans: comparison of Veterans Affairs mental health service users and other veterans nationally
- 1VA New England Mental Illness Research, Education, and Clinical Center, West Haven, Connecticut, USA
- 2Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- 3Yale School of Public Health, New Haven, Connecticut, USA
- Correspondence to Dr Jack Tsai, VACT, 950 Campbell Ave, 151D, West Haven, CT 06516, USA;
- Received 27 March 2012
- Accepted 7 July 2012
- Published Online First 30 July 2012
Objective The Department of Veterans Affairs (VA) operates one of the largest nationwide healthcare systems and is increasing use of internet technology, including development of an online personal health record system called My HealtheVet. This study examined internet use among veterans in general and particularly use of online health information among VA patients and specifically mental health service users.
Methods A nationally representative sample of 7215 veterans from the 2010 National Survey of Veterans was used. Logistic regression was employed to examine background characteristics associated with internet use and My HealtheVet.
Results 71% of veterans reported using the internet and about a fifth reported using My HealtheVet. Veterans who were younger, more educated, white, married, and had higher incomes were more likely to use the internet. There was no association between background characteristics and use of My HealtheVet. Mental health service users were no less likely to use the internet or My HealtheVet than other veterans.
Discussion Most veterans are willing to access VA information online, although many VA service users do not use My HealtheVet, suggesting more education and research is needed to reduce barriers to its use.
Conclusion Although adoption of My HealtheVet has been slow, the majority of veterans, including mental health service users, use the internet and indicate a willingness to receive and interact with health information online.
- mental health
- military medicine
- health services
- electronic medical records
- severe mental illness
Background and significance
The internet offers innovative ways of disseminating health information, enhancing service delivery, and streamlining interactions between individuals and healthcare systems. Over 80% of adults in the USA now use the internet.1 A nationally representative survey found that 40% of American adults with internet access reported using the internet to look for advice or information about health or healthcare in the previous year.2 About a third of those reported that internet use affected a decision about health or healthcare. Patients who use the internet to search for information about their health problems and treatments report that it helps them manage their problems better.3–6
The Department of Veterans Affairs (VA) operates one of the largest integrated healthcare systems in the USA. However, there have been few studies on the use of the internet among veterans in general, and even fewer on their use of the internet for health purposes.7 A 2001 survey of 3408 veterans found that 54% had used the internet and 29% had used the internet for health in the past year, similar to non-veterans.8 However, the study did not use a nationally representative sample and did not examine mental health service users in particular. Veterans who use VA services may have less access to the internet and/or make less use of the internet for health-related information than other patients.5 Thus, additional information on internet use among nationally representative samples of veterans and relevant subgroups are needed to help plan delivery of such services.8
Use of the internet by mental health service users may be particularly important because mental health information, treatment, and prevention are increasingly deliverable online and internet use may markedly improve access.9–11 Patients with stigmatized conditions, such as mental illnesses, may be more willing to use the internet for health information and to communicate with clinicians.12 But no previous study has examined internet use among mental health service users of a large nationwide healthcare system, although a range of internet-based programs for medical and mental health problems have been shown to be effective in randomized controlled trials.13
The VA launched an online personal health record system called My HealtheVet (MHV) in 2003. MHV is free, available to all veterans, and completely accessible through the internet (https://www.myhealth.va.gov/index.html). MHV allows VA patients access not only to their health records, but also to evidence-based health information, patient-directed reminders for preventive health services, secure messaging with healthcare providers, and opportunities to record and track medications and self-entered health data.14–16
Yet despite outreach and promotional efforts, only 15% of veterans who receive VA care registered for MHV in 200817 and <20% registered for MHV up to 2010.18 The slow adoption of MHV by VA users parallels the slow adoption of similar online technologies in non-VA healthcare systems, despite their potential to improve services.15 ,19
To increase understanding about the extent of internet use among veterans, and mental health service users in particular, this study (a) describes the internet use of a nationally representative sample of VA mental health service users and other veterans; (b) describes background characteristics associated with internet use; and (c) examines specific use of the online MHV personal health record system.
Materials and methods
Data were based on the 2010 National Survey of Veterans (NSV). The 2010 NSV is the sixth in a series of comprehensive nationwide surveys designed to help the VA plan future programs and service for veterans, and the first to ask detailed information about internet use.20
The 2010 NSV was conducted using a mailed, self-administered questionnaire using address-based sampling. The sampling frame was all US postal addresses, and addresses were selected randomly from samples stratified by zip code, carrier route, and walking sequence.20 Of a total of 13 058 veteran surveys distributed, 8710 were completed (66.7% response rate). Survey data were weighted to represent the entire non-institutionalized veteran population; relative weights were created that incorporated the probability of selection and survey non-response, and were post-stratified to known population totals.20 Relative weights maintain the sample size of the original sample, but each individual is weighted in proportion to their representativeness of the population of inference. All analyses were conducted on weighted data. Use of these data was approved by the institutional review boards at the VA Connecticut Healthcare System.
This study focused on the 7215 veterans (82.8%) who provided information about VA enrolment and mental health service use. Those who were missing data on either VA enrolment or mental health service use (n=1495) were excluded from the analyses. Compared to those who were excluded, veterans included in the study were older, better educated, had higher total income, were more likely to be white and married, and reported better general health, but were less likely to have been deployed to Iraq and Afghanistan, and less likely to be working. However, there was no significant difference in internet use or use of MHV.
A dichotomous measure of internet use was used: ‘Do you use the internet, at least occasionally?’ Additional questions regarding internet use concerned frequency of internet use, place(s) where the internet was used, whether email was used, frequency of email use, and place(s) where email was used.
Veterans were asked, on a 5-point Likert scale, how willing they were to use the internet for: obtaining news and information, carrying out research on services, purchasing goods or services, responding to polls or surveys, obtaining information about VA benefits, and applying for VA benefits. Veterans were also asked dichotomously whether they would like to receive VA information through the internet.
A dichotomous measure of use of the MHV site was used: ‘Have you ever used the ‘My HealtheVet’ website to obtain information related to your personal VA healthcare?’
General rating of health was assessed by asking veterans to rate on a 5-point Likert scale their general health from 1 (poor) to 5 (excellent). Further questions about service use allowed identification of mental health service users.
Veterans were divided into three groups: veterans not enrolled in the VA, veterans enrolled in the VA but not reporting mental health service use, and VA mental health service users. Background characteristics and any reported internet use by veterans in these three groups were compared using omnibus χ2 tests and analyses of variance. For significant differences found in omnibus tests, post hoc pairwise group comparisons were then conducted with Fisher's Least Significance Difference test and χ2 tests. Among veterans who reported they used the internet, the three groups were compared on their specific use of the internet, email, and the MHV site using χ2 tests and analyses of variance. Post hoc pairwise group comparisons were again conducted with Fisher's Least Significance Difference test and χ2 tests.
Finally, two series of multivariate logistic regression analyses were conducted to examine first the association between background characteristics, VA enrolment status, mental health service use, and any internet use. A second analysis examined the relationship of these factors with MHV use specifically. A simultaneous entry method was used and all 13 variables measured were included in both sets of analyses. Adjusted ORs were calculated including all other variables as covariates. To adjust for multiple comparisons, the significance level was set at 0.01 for all statistical tests (which is close to a Bonferroni correction for 13 tests 0.05/13=0.004). The statistical software SPSS V.17 was used for analyses.
The majority of veterans were white, male, in their early 60's, had at least some college education, were employed, had a household income of >$30 000, and were married or in a civil union, and 7.2% reported recent service in Iraq or Afghanistan (table 1). Notably, VA mental health service users were significantly younger, less likely to be male, and had lower incomes than other veterans. Among all veterans, 5111 (70.83%) reported that they used the internet.
Veterans who did not enroll in VA services were more likely to use the internet than those who were enrolled in the VA but did not use mental health services. There was no significant difference in internet use between VA mental health service users and other veterans.
Of veterans who used the internet, most used the internet at least once a day (table 2). Veterans who were not enrolled in the VA were more likely to use the internet at home and at work, while veterans who were enrolled in the VA were more likely to use the internet at somebody else's home or a public location. Not surprisingly, veterans enrolled in the VA indicated greater willingness to obtain information about VA benefits, apply for VA benefits through the internet, and use MHV for their personal VA healthcare. There were no significant differences between VA mental health service users and other VA service users on any internet use, although they were less likely to use the internet in their own homes than non-VA service users. Of all VA service users, 21.51% reported using MHV.
Multivariate logistic regression showed no less internet use or MHV use among VA mental health services users than among other groups of veterans (table 3). Veterans who were more likely to use the internet were younger, better educated, white (compared to black), had higher incomes, were married, and served in ‘Other’ military branches (figure 1). Among veterans who were enrolled in the VA, there were no significant predictors of use of the MHV website at the p<0.01 level (figure 2). However, examination of the magnitude of ORs indicated a trend that veterans who entered active duty later (OR 1.06), were more educated (some college education or higher vs below high school education, OR 6.93–9.45), had higher household income ($30 000–49 999 vs <$10 000, OR 2.95), and served in Iraq or Afghanistan (OR 2.48) were more likely to use MHV (all 0.01<p<0.05).
To our knowledge, this is the first study to examine internet use among a nationally representative sample of veterans. The majority of veterans (71%) used the internet and had access to the internet at home. Veterans who were younger, better educated, white, married, and had higher incomes were more likely to use the internet, which is consistent with a previous study on the general population2 and suggests sociodemographic factors related to internet use are similar among veterans and non-veterans.
VA mental health services users were no less likely to use the internet than other veterans enrolled or not enrolled in the VA; the majority of VA mental health service users had home internet access, but a quarter also accessed the internet in other locations (work, school, library, etc). This finding is important because it establishes that VA mental health service users have ready access to the internet, and because more than half (63%) use the internet daily, there may be great potential for internet-based mental health interventions. Several studies have shown that internet-based mental health interventions for post-traumatic stress disorder, depression, substance abuse, and other psychological problems can be effective.9–11 ,13
Almost all veterans who used the internet used email and were receptive to receiving information about the VA and their healthcare online. On average, veterans who used the internet indicated they were ‘somewhat willing’ to ‘very willing’ to use the internet to research services, obtain information about VA benefits, and apply for VA benefits. The majority of veterans who used the internet reported they would like to receive VA information online.
Despite this reported willingness to use the internet for information, only about a quarter of VA mental health service users and a fifth of other VA service users reported using the MHV website for their personal healthcare. Use of MHV was not significantly associated with sociodemographic characteristics or use of mental health services, suggesting these factors are no different from other barriers to general internet access. However, more research is needed on particular patient populations, such as those with severe mental illness or other chronic disabilities. Nonetheless, some have argued that adoption of technologies by healthcare systems have traditionally been slow despite potential benefits.21 ,22 In the case of the VA where personal health record systems have been made available electronically, it seems patients have been the ones who have been slow to adopt this new technology.
There may be other factors not measured in this study that may be related to use of MHV. For example, previous studies on other populations have found that use of the internet for health-related purposes was related to chronic illness, lack of health insurance, and longer travel times for healthcare,2 ,23 which may be applicable to the use of MHV. There may also be concerns about privacy and confidentiality, and issues with information-sharing both on the part of patients and their healthcare providers.24–26
Two mechanisms for breaking down these barriers may be education and research.7 ,27 Veterans should be taught how to use online tools available to them to help them manage their health, including use of MHV. Efforts to promote MHV17 should be continued. More research is needed on the workflow of patients and providers as personal health record systems are only useful when the maintenance and coordination of health-related documentation and activities is facilitated by both parties.27
The majority of veterans, including those who do and do not use VA services, have access to and use the internet. Although most veterans reported they are willing to receive and interact with health information online, only about a fifth of veterans use the MHV personal health record system. Veterans who use VA mental health services are no less likely to use the internet or the MHV system compared to other veterans.
Competing interests None.
Ethics approval Ethics approval was provided by the VA Connecticut Healthcare System.
Provenance and peer review Not commissioned; externally peer reviewed.