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★ Editor's Choice ★

Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal

Carolyn Turvey, Dawn Klein, Gemmae Fix, Timothy P Hogan, Susan Woods, Steven R Simon, Mary Charlton, Mary Vaughan-Sarrazin, Donna M Zulman, Lilian Dindo, Bonnie Wakefield, Gail Graham, Kim Nazi
DOI: http://dx.doi.org/10.1136/amiajnl-2014-002723 657-663 First published online: 1 July 2014

Abstract

Objective The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs' (VA) personal health record portal, My HealtheVet.

Materials and methods An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers.

Results Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans' self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button.

Conclusions This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.

Keywords
  • Health Record, Personal
  • Veterans
  • Care Coordination

Introduction

The Institute of Medicine identified care coordination as one of 20 national priorities to improve the quality of healthcare.1 Growing specialization and fragmentation of healthcare for patients with complex chronic conditions highlights the need for improved coordination between patients, providers, and both formal and informal caregivers. A key component of care coordination is efficient and accurate sharing of health information. However, timely and accurate communication between patients, their caregivers, and their multiple healthcare providers is often lacking, thereby jeopardizing patient safety and increasing healthcare cost.27 In an international study of the healthcare systems in six countries, the USA fared the worst in care coordination, with 33% of patients reporting that either records did not reach the doctor's office in time for an appointment or doctors ordered an unnecessary medical test that had already been done.8

The US Office of the National Coordinator for Health Information Technology (ONC) promotes the expansion and use of electronic health records (EHRs) to address gaps in communication and care coordination. The ONC has specified core objectives for the meaningful use of EHRs,9 which include providing patients ‘with the ability to view online, download, and transmit their health information within four business days of the information being available to their eligible provider.’ In response, many healthcare organizations have implemented the Blue Button feature as part of online patient portals.10 ,11

Blue Button is a registered service mark of the US Department of Health and Human Services and is most often indicated by a clickable blue circle on the online patient portal home page. The Blue Button allows patients to access components of their EHR, such as past and future appointments, problem lists, allergies, medications, laboratory results, procedures, vitals, and immunizations. With Blue Button access, patients can view, download, or print their information to share with trusted others. The Blue Button feature is currently available in patient portals provided by both public and private organizations such as the Department of Veterans Affairs (VA), the Department of Defense, Centers for Medicare and Medicaid Services, and United Healthcare Insurance. Hundreds of other organizations have also pledged to participate.12

VA deployed the Blue Button on August 29, 2010 as part of its online combined personal health record (PHR) and patient portal, My HealtheVet (MHV). Recent research reveals that a large portion of Veterans also seek care outside of the VA system, making information sharing and care coordination especially critical for them. The 2011 Survey of Veteran Enrollees' Health and Reliance upon VA indicated that 77% had alternative healthcare coverage.13 Results from another recent survey of Medicare-eligible Veterans revealed that, among respondents who reported obtaining medications from non-VA pharmacies, 38.4% reported never discussing those medications with VA physicians.14

There is a small but growing literature exploring which patient, provider, and technology characteristics predict positive attitudes towards online patient portals.1529 Both race and socioeconomic status have been associated with PHR adoption,17 ,24 ,25 although not all studies find minority status to be a barrier.30 The relation between health status and adoption has been mixed, with one study reporting that positive health predicts adoption,28 while another found that high medical comorbidity was positively associated with use.29 Emani et al17 used Rogers' Diffusion of Innovation Model31 and found that concepts such as ease-of-use or perceived value differed significantly between PHR users and non-users. Patients who have full access to the doctors' notes in their medical record report high satisfaction and little resulting distress.3235 Although these studies provide important insights into user characteristics and meaningful use of patient portals, they did not explore patient-initiated sharing of health information.

Prior to the launch of the Blue Button, two online surveys were conducted to examine the use of MHV for information sharing. Veterans reported high interest in using MHV to share information with family caregivers and non-VA providers, yet only a small percentage (4%) had actually done so.36 ,37 The following study is based on this prior work in MHV and in patient portal adoption in general. It used a technology adoption model comparable to the one used by Emani et al17 to inform the development of an online survey of MHV users. This survey aimed to characterize users of the Blue Button, its perceived impact on their health, and its role in information sharing with non-VA providers.

Methods

My HealtheVet

VA's national online patient portal PHR, MHV, was launched in 2003. MHV enables VA patients who have verified their identity and achieved ‘premium account’ status to view information from their VA EHR. MHV has gradually added functionality including current and past medications, refilling VA medications, laboratory results, scheduled appointments, wellness reminders, and secure messaging with healthcare teams. As of January 2014, the MHV PHR portal has more than 2.6 million registrants (37% of the VA patient population), with more than 1.4 million VA patients having authenticated to a premium account (25% of the VA patient population).

At the time of this survey, March through May 2012, the VA Blue Button feature provided Veterans with an electronic file of their self-reported information (eg, self-entered medications and supplements), and VA patients with a premium account could also select EHR data including: VA appointments, laboratory test results, allergies, and prescription medication information. In January 2013, VA significantly expanded the Blue Button to include more types of information from the EHR, and added the VA Continuity Care Document (CCD), which summarizes key clinical data. More than 955 000 Veterans have used the Blue Button and downloaded more than 5.7 million Blue Button files.

Study population

Since October 2007, VA has measured Veterans' satisfaction with MHV using an online survey based on the American Customer Satisfaction Index (ACSI).21 The ACSI survey is an industry standard for evaluating government and private websites. Data presented here originate from custom questions asked during the ACSI survey administered between March 12, 2012 and May 21, 2012. A 4% random sample of the 2 705 131 people who visited four or more pages during the study period was invited to participate. Of the 41 237 who accepted the survey invitation (acceptance rate ∼38%), 25 155 answered the custom questions, resulting in a survey completion rate of 61%. To avoid duplicate respondents, all were asked if they had taken the survey in the previous 3 months, and the 4949 replying ‘yes' were excluded from the analyses. An initial question asked all respondents about whether or not they had used the Blue Button feature of MHV. Respondents who did not answer this question (N=571) or endorsed ‘not sure’ (N=1237) were excluded, yielding a total sample size of 18 398.

Survey design and content

Survey questions were designed in collaboration with the MHV Program Evaluation Workgroup and the VA eHealth Quality Enhancement Research Initiative to address key domains related to: (1) barriers to and facilitators of Blue Button use; (2) impact of the Blue Button on health management; and (3) whether Veterans use the Blue Button for care coordination with non-VA providers. Based on participants' response to a question about Blue Button use, three main groups were segmented for analysis: (1) non-users, ie, MHV users who never used Blue Button; (2) past users, ie, MHV users who used Blue Button once or more, but had no plans to use it again; and (3) current users, ie, MHV users who use Blue Button and plan to continue to use it.

Multiple choice questions were based on the Unified Theory of Adoption and Use of Technology (UTAUT) of Venkatesh et al,38 with response choices corresponding to key theoretical concepts. For example, when past and non-users were asked why they did not use the Blue Button, Veterans could respond that they (1) were not aware of the Blue Button (knowledge/awareness), (2) do not believe the Blue Button is useful (perceived value), (3) prefer to use other methods to keep track of health information (relative value), or (4) do not know how to use the Blue Button (usability). As many of the questions allowed multiple response choices, the total number of endorsements for response choices can exceed the total sample size for these questions.

The online survey also included questions about demographics, self-rated computer ability, whether the Veteran has a system for organizing health information (yes/no), the degree to which the respondent values having a record of personal healthcare on a 5-point scale, and self-rated health on a 5-point Likert scale. Self-rated health was converted into a dichotomous variable indicating ‘good’ to ‘excellent’ vs ‘fair’ or ‘poor’ health status. Age was grouped into five categories: 18–39, 40–49, 50–59, 60–69, 70–79, and 80 or more years. The survey did not include questions about race or income. Respondents could also indicate whether they had been diagnosed with various health conditions: high blood pressure, high cholesterol, pain, arthritis, diabetes, orthopedic problems, mental health problems, heart disease, lung disease/asthma, previous heart attack, cancer, ulcer or stomach disease, spinal cord injury, anemia or other blood disease, or heart failure. The study was reviewed by the local institutional review board and the local VA Research and Development Committee for secondary data analysis.

First, bivariate relationships between patient characteristics and Blue Button use were examined; then multivariate analyses were conducted. Patient demographics, self-rated computer ability, health status, use of a system for organizing health information, and the perceived value of access to health records were compared across the three Blue Button use categories using the χ2 test. Use of the Blue Button by current users, specifically use related to care coordination with non-VA providers, was also examined.

Multivariate logistic regression models were generated to determine respondent characteristics that were independently associated with past and current Blue Button use. Similarly, a single multivariate logistic regression model was also generated for current users only to determine respondent characteristics that were independently associated with sharing health information generated by the Blue Button with non-VA providers. Preparatory stepwise regression was used to determine which of the 15 medical conditions was independently associated with Blue Button current users, or with sharing of Blue Button data with non-VA providers. Only those illnesses remaining in the preparatory model with a p value of 0.05 or lower were included in the final logistic regression models. All statistical analyses were conducted using SAS statistical software V.9.3.

Results

Blue Button adoption

Table 1 presents the demographic, health and user characteristics for each user group. Of the total sample (n=18 398), 33% (n=5995) were current users, and 63% (n=11 671) had never used Blue Button (non-users). A small minority, 4%, (n=732) had tried the Blue Button at least once, but no longer used it (past users). Self-rated computer ability, a system to organize health information, and user's perception of the high value of having one's own health record showed the strongest bivariate association with Blue Button use.

View this table:
Table 1

Characteristics of Blue Button user groups: non-user, past user, current user (N=18 398)

CharacteristicNon-userPast userCurrent userp Value
N=11 671N=732N=5995
Age range (years), n (%)<0.0001
   18–39300 (2.6)22 (3.0)126 (2.1)
   40–49923 (7.9)64 (8.9)443 (7.5)
   50–592145 (18.6)138 (19.1)1162 (19.6)
   60–695829 (50.5)379 (52.5)3023 (51.0)
   70–791691 (14.6)87 (12.0)934 (15.8)
   80+659 (5.7)32 (4.4)243 (4.1)
Gender (% male)10 108 (90.6)641 (91.6)5244 (91.7)0.05
Self-rated health status (% fair or poor)2695 (23.1)154 (21.0)1375 (22.9)0.44
Number of illnesses range 0–15, mean (SD)3.8 (2.3)4.1 (2.5)3.9 (2.3)<0.0001
Self-rated computer ability, n (%)
   Beginner684 (5.9)40 (5.5)179 (3.0)<0.0001
   Intermediate4469 (38.3)223 (30.5)1701 (28.4)
   Advanced6518 (55.9)4,69 (64.1)4115 (68.6)
Has a system for organizing health information (% yes)5431 (46.5)385 (52.6)3334 (55.6)<0.0001
Values having own record of health (% somewhat, very, or extremely important)94.891.795.5<0.0001

Two separate logistic regression models compared current and past users with the non-user group (table 2). ORs and 95% CIs were calculated to determine how each variable increased the odds of using the Blue Button. Age categories and self-rated computer ability were treated as ordinal variables because each category represented an increase in either age or computer ability. When the 95% CI includes 1.0 within its range, the association is not statistically significant. These regression models revealed that computer ability and having a system for organizing health information yielded the largest ORs in both models. When comparing current users with non-users, the odds of using the Blue Button increased 60% for each incremental increase in self-rated computer ability. The odds of using the Blue Button increased 38% if the veteran reported having a system for organizing his or her health information. Age was not associated with Blue Button use.

View this table:
Table 2

Multivariate analysis of characteristics associated with Blue Button use groups

CharacteristicPredictor variables codingOR (95% CI) current user (n=5995) vs non-user (n=11 671)OR (95% CI) past user (n=732) vs non-user (n=11 671
AgeAge group 18–39-year-olds=0, remaining coded in increments from 1 to 51.00 (0.97 to 1.04)0.96 (0.89 to 1.04)
Female genderFemale=10.82 (0.73 to 0.93)**0.79 (0.60 to 1.05)
Self-rated health statusPoor or fair=10.94 (0.87 to 1.02)0.95 (0.77 to 1.15)
Health conditions
   Pain1.06 (0.99 to 1.14)1.26 (1.07 to 1.51)**
   Diabetes1.02 (0.95 to 1.09)0.84 (0.71 to 0.99)*
   Orthopedic problems1.07 (0.99 to 1.16)1.10 (0.92 to 1.32)
   Mental health0.96 (0.89 to 1.04)1.26 (1.06 to 1.52)**
   Lung disease/asthma1.14 (1.04 to 1.25)**1.31 (1.07 to 1.61)**
Self-rated computer abilityBeginner=0 Intermediate=1 Advanced=21.60 (1.51 to 1.70)***1.29 (1.13 to 1.49)***
Has a system for organizing health informationYes=1, No=01.38 (1.29 to 1.48)***1.37 (1.18 to 1.63)***
Values having own record of health0=Not at all or a little important
1=somewhat, very, or extremely important
1.06 (0.91 to 1.23)0.58 (0.43 to 0.78)**

*p<0.05; **p<0.01; ***p<0.001.

    Non-users were asked to select the reason(s) they did not use the Blue Button from a list of response choices. The majority (61.3%) indicated that they were not aware of the Blue Button. Those who were aware of the Blue Button stated that they did not use it because they did not know how (34.4%), they only use MHV for prescription renewal (26.0%), they preferred to use other methods to keep track of their health information (11.3%), or they did not know where the Blue Button was located (9.5%). The least commonly selected reason for not using the Blue Button was that the Veteran did not think it would be useful (9.0%).

    Similar follow-up questions were asked of past users. Of these, 40% reported that, when using the Blue Button, they could not find what they were looking for, 22% indicated that the information in the file/printout was not useful, and 17% reported that they did not know how to use it. In addition, 12% reported that the file or printout was too long, and 9% endorsed that they would rather use another way to store their health information.

    Current Blue Button users

    Table 3 presents the responses of current users to a series of questions characterizing their Blue Button use. When asked to rate their satisfaction with the Blue Button on a scale from 1 (‘not at all satisfied’) to 10 (‘extremely satisfied’), 75.1% gave the Blue Button a rating of 7 or higher. The information that respondents were most interested in accessing included their laboratory results (71.4%) and current VA medication list (57.8%). Sharing the Blue Button printout or file was not common, with only 11.8% sharing it with a family member, 9.7% sharing it with a non-VA provider, and 5.7% sharing it with a VA provider. Laboratory results (79.2%) and the VA medication list (54.4%) were the most frequently endorsed type of information shared with care providers.

    View this table:
    Table 3

    Current users' use of the Blue Button

    Questions and response choicesN (%)*
    On a scale from 1 (not at all satisfied) to 10 (extremely satisfied), please rate your overall satisfaction with the Blue Button Feature of My HealtheVet (N=5995)
       1–3313 (5.2)
       4–61182 (19.7)
       7–104500 (75.1)
    How did you use the VA Blue Button? (n=5995)
       I used it to view my health information on the My HealtheVet website4765 (79.5)
       I used it to create an electronic file of my health information (eg, saved a file to my computer)1928 (32.2)
       I printed a paper copy of my health information1537 (25.6)
    What information were you interested in? (n=5950)
       My laboratory results4280 (71.4)
       My current VA medication list3466 (57.8)
       My entire VA medication history2566 (42.8)
       A list of my providers and their contact information (self-entered into My HealtheVet)877 (14.6)
       My list of medications, prescribed outside of the VA (self-entered into My HealtheVet).681 (11.4)
       My list of over-the-counter, supplement, or herbal medications (self-entered into My HealtheVet)391 (6.5)
    What did you do with your Blue Button print out or file? (n=5950)
       I read it3698 (61.7)
       I saved it for my records2796 (46.6)
       I shared it (or plan to share it) with my spouse, child, or other family member707 (11.8)
       I shared it (or plan to share it) with my non-VA healthcare provider579 (9.7)
       I did not keep the information (eg, deleted the file or threw away the print copy)373 (6.2)
       I shared it (or plan to share it) with my VA healthcare provider340 (5.7)
    What information on the Blue Button print out did you want to show your care provider? Check all that apply (n=813)†
       My laboratory results644 (79.2)
       My current VA medication list442 (54.4)
       My entire VA medication history235 (28.9)
       My list of medications prescribed outside of the VA (self-entered into My HealtheVet).136 (16.7)
       My List of over-the-counter, supplement, or herbal medications (self-entered into My HealtheVet)116 (14.3)
    What did your provider do with the Blue Button print out? Check all that apply? (n=813)†
       He or she used it to review recent laboratory results411 (50.5)
       He or she filed it in my medical record304 (37.4)
       He or she used it to review my complete medication list301 (37.0)
       He or she used it to find other health information106 (13.0)
       He or she did not look at it71 (8.7)
    How helpful do you think your care provider found the Blue Button information in making decisions about your care? (n=813)†
       Very helpful425 (52.3)
       Somewhat helpful112 (13.8)
       Not at all helpful15 (1.8)
       Don’t know261 (32.1)

    *Percentages may total more than 100 because respondents could endorse more than one response.

    †Of Veterans endorsing sharing or planning to share their information with non-VA and/or VA provider.

    VA, Department of Veterans Affairs.

      Among current users, self-reported impact of the Blue Button was high (table 4), with 73.3% reporting that it helps them understand their health history better because it is all in one place, 72.2% reporting that it helps them monitor their laboratory results better, and 67.9% reporting that it makes it easier for them to give others important information about their health.

      View this table:
      Table 4

      Veteran-reported impact of Blue Button on quality of healthcare

      Question and response choicesN (% somewhat or completely agree)
      Please indicate whether or not you agree with the following statements (n=5995)
         The Blue Button feature helps me understand my health history better because all the information is in one place4393 (73.3)
         The Blue Button feature makes it easier to monitor laboratory results4330 (72.2)
         The Blue Button feature makes it easier for me to give others, such as healthcare providers or family members, important medical information4071 (67.9)
         The Blue Button feature has helped me better manage my health in general3878 (64.7)
         The Blue Button feature has helped me to go to my medical appointments at the appropriate time3382 (56.4)
         The Blue Button feature helps me understand better which medications I need to be taking.3237 (54.0)

      Sharing of Blue Button printout with non-VA providers

      Table 5 addresses current users' Blue Button use in sharing health information with non-VA providers, with 43.9% reporting having a provider not affiliated with the VA. When asked how their VA and non-VA providers communicate, 52.4% reported ‘I share information between them’. Options indicating that the providers are responsible for information sharing were endorsed far less frequently. One out of five (20.9%) current users who reported having a non-VA provider stated that they share Blue Button information with these providers. Of these, 68.2% thought their non-VA provider found it ‘very helpful’, and 19.2% found it ‘somewhat helpful’. In a multivariate logistic regression analysis (table 6), the dichotomous outcome was use of the Blue Button for care coordination (=1) or not (=0), and the predictor variables were the demographic and computer use variables found in the first column. Use of the Blue Button for care coordination was most likely in patients with diabetes or lung disease, individuals who rated their computer ability higher, and those who had a system for organizing their health information. The odds of using the Blue Button for care coordination increased 68% for Veterans who had a system for organizing their health information.

      View this table:
      Table 5

      Current users and the Blue Button printout for care coordination with non-VA providers

      Questions and response choicesN (%)
      Do you see any healthcare providers who are not affiliated with the VA? (n=5995)
         Yes2633 (43.9)
         No3362 (56.1)
      How do your VA providers and non-VA providers communicate about your healthcare? (n=2633)
         I share information between them1381 (52.4)
         I do not know how they communicate 390 (14.8)
         They do not communicate 389 (14.8)
         They exchange medical records via mail or fax 344 (13.1)
         They speak by phone 48 (1.8)
      How satisfied are you with the communication about your medications and healthcare between your VA providers and the providers outside of the VA? (n=2633)
         Not at all satisfied 325 (12.3)
         A little satisfied 251 (9.5)
         Somewhat satisfied 718 (27.3)
         Very satisfied 912 (34.6)
         Completely satisfied 428 (16.2)
      Have you ever shared the Blue Button printout with your non-VA providers? (n=2633)
         Yes550 (20.9)
         No2083 (79.1)
      How helpful do you think your non-VA care provider found the Blue Button information in making decisions about your care? (n=550)
         Don’t know 68 (12.3)
         Not at all helpful1 (0.2)
         Somewhat helpful106 (19.2)
         Very helpful376 (68.2)

      *Percentages may not add to 100 because of rounding. Some percentages may exceed 100 because multiple responses were possible.

      VA, Department of Veterans Affairs.

        View this table:
        Table 6

        Multivariate logistic regression testing the associations between demographic, health, self-rated computer ability, health information management, and sharing of Blue Button with non-VA providers (N=2633)

        Comparison groupsOR (95% CI)p Value
        Age0.99 (0.90 to 1.11)0.89
        Gender1.10 (0.74 to 1.56)0.63
        Self rated healthFair or poor=1
        All other choices=0;
        1.04 (0.92 to 1.1)0.74
        Health problems*
        DiabetesYes=1, No=01.38 (1.1 to 1.7)0.002
        Lung diseaseYes=1, No=01.53 (1.2 to 1.9)0.0007
        Self-rated Computer abilityBeginner,=0; Intermediate=1, Advanced=21.40 (1.14 to 1.71)0.0013
        System for organizing health informationYes=1, No=01.68 (1.36 to 2.08)0.0001
        Values own record of health information0=Not at all or a little important
        1=somewhat, very, or extremely important
        2.01 (0.99 to 4.07)0.052

        *Prior to conducting the final model, a stepwise multiple regression including all health variables was conducted to determine which had an independent association with sharing of the Blue Button. Variables with p<0.05 in the stepwise regression model where then included in the final model above with other demographic and health variables.

        VA, Department of Veterans Affairs.

          Discussion

          In this survey of individuals who use the VA online patient portal, MHV, approximately one in three currently use the Blue Button to access, store, or share their health information. Of Blue Button users with a non-VA provider, one in five has specifically used this tool to share their information. Blue Button users reported that this feature yields a range of health benefits, including a better understanding of their health history because all information is in one place, greater ease of monitoring laboratory results, and improved understanding of medications.

          Use of the Blue Button for care coordination was most common among individuals with diabetes or chronic lung disease, and for patients who indicated that they had a system for organizing their health information. Laboratory results generated through the Blue Button was the information most likely to be shared with providers.

          Non-use of the Blue Button is a function of patient lack of knowledge about the feature rather than patients not valuing it. Within the concepts explored from Venkatesh et al's38 UTAUT, low knowledge appears to be the biggest barrier, but users also indicated usability as a significant obstacle. Even among respondents with the computer ability to use a patient portal and to respond to an online survey, 34% reported that they did not use the Blue Button because they did not know how, and 9% endorsed that they did not know where the Blue Button was on the site. Therefore, the Blue Button feature was even challenging to respondents with considerable computer ability. Notably, almost half of the non-users have a system for organizing their health information. This group may be more motivated than those without a system to adopt the Blue Button in the future if the VA clearly demonstrates the advantage of the Blue Button relative to the Veterans' current system.

          Of current users who reported having a non-VA provider, 21% reported sharing the Blue Button printout with their provider. Although 21% is promising, it is hoped that a greater proportion of Veterans with non-VA providers will harness this tool's ability to improve care coordination. Given these results and prior usability research with the MHV site,39 a redesign of the MHV website is in progress.

          Reports from other patient portals and PHRs agree that usability and patient comfort navigating the site limits patient portal adoption.16 ,17 ,1921 ,4045 Compared with other forms of successful consumer technology, such as smart phones or online banking, patient portals may require more concerted awareness-raising and educational efforts. Although people have had prior experience with phones and banking, it cannot be assumed that patients have had comparable prior experience reviewing and managing their medical records. Therefore, patients may need greater education about potential benefits and efficiencies of patient portals to promote meaningful use.

          When asked how their providers communicate, respondents endorsed that they themselves were primarily responsible for sharing health information. Although several health information technology initiatives promote provider-to-provider communication,2 ,46 ,47 patients are reporting that they are often the most important means of sharing information. This underscores the importance of the Meaningful Use Stage 2 Core Objective of providing patients with the ability to download and share their health information. Currently, VA and other healthcare systems are developing functionality that allows patients to transmit electronically a comprehensive health summary.

          This study has several limitations. This was a voluntary online survey of MHV site visitors. Survey completion rates may have biased the sample in unknown ways. Race and income were not assessed, so the effect of these important variables is unknown. Another study limitation is that many of the outcomes were self-reported with no independent verification.

          Conclusions

          This study contributes to our understanding of the early use of the Blue Button and patient portals in patient health management and sharing of health information. Blue Button users value having all their health history in one place and the greater ability to monitor and share information, particularly laboratory results. Those who use the Blue Button value it and endorse high rates of satisfaction. The barriers to Blue Button use reveal that addressing usability issues and taking into account patient experience in interface design will be critical to continued adoption of this feature.48 Finally, future work on the demonstrable impact of the Blue Button on health behavior and outcomes, both self-report and independently assessed, is needed to better quantify the value of patient-facing health information technology.

          Correction notice

          This article has been corrected since it was published Online First. The author ‘Tim Hogan’ has been changed to ‘'Timothy P Hogan’.

          Contributions

          CT was the principal investigator of the study and had primary responsibility for writing the manuscript. CT, DK, GF, SW, SRS, MC, MV-S, DMZ, LD, BW, and KN contributed to the study design. CT, DK, GG, and KN were involved with the study implementation and data collection. CT, DK, TH, MV-S, and KN were involved in the analysis and interpretation of the data. All authors contributed to drafting the article or revising it critically for intellectual content.

          Funding

          This work was supported by the Department of Veterans Affairs, Health Services Research & Development, eHealth Quality Enhancement Research Initiative (RRP 11–407). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

          Competing interests

          None.

          Ethics approval

          University of Iowa Institutional Review Board.

          Provenance and peer review

          Not commissioned; externally peer reviewed.

          Acknowledgements

          We acknowledge the assistance of Carrie Franciscus at the Iowa City VA Health Care Center for her work preparing data for analysis.

          References

          View Abstract