The Association of Graph Literacy With Use of and Skills Using an Online Personal Health Record in Outpatient Veterans.

Personal health records (PHRs) are intended to increase patients' access to and ownership over their health care information for self-management purposes. The purpose of this study was to determine the association of graph literacy with adoption of an online PHR and, among adopters with self-reported skills, the frequency of use and intent to return to use the PHR . We conducted a cross-sectional survey of veterans receiving outpatient care. We measured health literacy, numeracy, graph literacy, and Internet and PHR adoption and use. We compared subgroups of veterans using analyses of covariance. We used hierarchical logistic regression models to estimate the effects of the literacy variables on PHR use. A total of 600 veterans (age = 22-94) participated in the survey. After we adjusted for known covariates, we found that adopters of a PHR were more likely to demonstrate higher health and graph literacy than nonadopters. Among PHR adopters, self-reported frequent and skillful users were more likely to have higher graph literacy than lower frequency and less skillful users. Adopters with higher intentions to return to use the PHR were more likely to show lower graph literacy than those less likely to return to use the PHR. Inadequate graph literacy was associated with lower adoption of a PHR and, among users, with lower self-reported frequent use and skills . As PHR use becomes more widespread, stakeholders will need to consider patients' levels of graph literacy when implementing PHRs.

Predicting Older Adults' Perceptions about a Computer System Designed for Seniors.

PURPOSE: Although computer technology may be particularly useful for older adults (e.g., for communication, information access), they have been slower adopters than their younger counterparts. Perceptions about computers such as perceived usefulness and perceived ease of use can pose barriers to acceptance and universal access [1]. Therefore, understanding the precursors to these perceptions for older adult non-computer users may provide insight into the reasons for their non-adoption. METHODS: We examined the relationship between perceived usefulness and perceived ease of use of a computer interface designed for older users and demographic, technology experience, cognitive abilities, personality, and attitudinal variables in a sample of 300 non-computer using adults between the ages of 64 and 98, selected for being at high risk for social isolation. RESULTS: The strongest correlates of perceived usefulness and perceived ease of use were: technology experience, personality dimensions of agreeableness and openness to experience, and attitudes. The emotional stability personality dimension was significantly correlated with perceived ease of use but not perceived usefulness. Hierarchical regression analysis revealed that attitudes (i.e., self-efficacy, comfort, interest) remained predictive of perceptions of usefulness and ease of use when technology experience and personality variables were accounted for. CONCLUSION: Given that attitudes are more malleable than other variables, such as demographic and cognitive abilities, these findings highlight the potential to increase technology acceptance through positive experiences, appropriate training, and educational campaigns about the benefits of computers and other technologies.

The Benefits of Technology for Engaging Aging Adults: Findings From the PRISM 2.0 Trial.

Background and Objectives: Technology has potential for providing support for aging adults. This study evaluated the Personal Reminder Information and Social Management 2.0 (PRISM 2.0) software, in terms of enhancing social engagement and quality of life, and decreasing loneliness among older adults. Research Design and Methods: The randomized field trial conducted in diverse living contexts (rural locations, senior housing, and assisted living communities [ALC]). Two hundred and forty-five adults, aged 64 to 99 years, were randomly assigned to the PRISM 2.0 (integrated software system designed for aging through an iterative design process) or a Standard Tablet (without PRISM) Control condition, where participants received the same amount of contact and training as those in the PRISM 2.0 condition. Primary outcomes included measures of loneliness, social support, social connectedness, and quality of life. Secondary outcomes included measures of social isolation, mobile device proficiency, and technology readiness. Data were collected at baseline and 6 and 9 months postrandomization. This article focuses on the 6-month outcomes due to coronavirus disease 2019-related data challenges at 9 months. Results: Contrary to our hypothesis, participants in rural locations and senior housing in both conditions reported less loneliness and social isolation, and greater social support and quality of life at 6 months, and an increase in mobile device proficiency. Participants in the ALCs in both conditions also evidenced an increase in mobile device proficiency. Improvements in quality of life and health-related quality of life were associated with decreases in loneliness. Discussion and Implications: This study provides compelling evidence about the benefits of technology for older adults in terms of enhancing social outcomes and quality of life. However, the findings also underscore that for technology applications to be successful, they need to be adapted to the abilities and needs of the user group and instructional support needs to be provided. Clinical Trials Registration #: NCT03116399.

Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians.

Studies reveal high levels of inadequate health literacy and numeracy in African Americans and older veterans. The authors aimed to investigate the distribution of health literacy, numeracy, and graph literacy in these populations. They conducted a cross-sectional survey of veterans receiving outpatient care and measured health literacy, numeracy, graph literacy, shared decision making, and trust in physicians. In addition, the authors compared subgroups of veterans using analyses of covariance. Participants were 502 veterans (22-82 years). Low, marginal, and adequate health literacy were found in, respectively, 29%, 26%, and 45% of the veterans. The authors found a significant main effect of race qualified by an age and race interaction. Inadequate health literacy was more common in African Americans than in Whites. Younger African Americans had lower health literacy (p <.001), graph literacy (p <.001), and numeracy (p <.001) than did Whites, even after the authors adjusted for covariates. Older and younger participants did not differ in health literacy, objective numeracy, or graph literacy after adjustment. The authors found no health literacy or age-related differences regarding preferences for shared decision making. African Americans expressed dissatisfaction with their current role in decision making (p =.03). Older participants trusted their physicians more than younger participants (p =.01). In conclusion, African Americans may be at a disadvantage when reviewing patient education materials, potentially affecting health care outcomes.

The Factors Influencing Older Adults' Decisions Surrounding Adoption of Technology: Quantitative Experimental Study.

BACKGROUND: The rapid diffusion of technology apps may support older adults' independence and improve the quality of their lives. Models for predicting technology acceptance in older adults are sparse, based on broad questions related to general technology acceptance, and largely not grounded in theories of aging. OBJECTIVE: This study aimed to use a mixed methods approach involving 5 technologies to comprehensively assess the causal relationships among factors that influence older adults' willingness to adopt the technologies. METHODS: In total, 187 men and women aged 65 to 92 years participated in the study. Participants were given presentations on 5 different technologies spanning domains that included transportation, leisure, health, and new learning and provided ratings of each technology on various measures hypothesized to influence adoption. They were also administered other instruments to collect data on their actual and self-assessed cognitive abilities, rates of discounting of the technologies with respect to willingness to invest time to attain higher skills in the technologies, general technology experience, and attitudes toward technology. We used the machine learning technique of k-fold cross-validated regressions to select variables that predicted participants' willingness to adopt the technologies. RESULTS: Willingness to adopt technologies was most impacted by 3 variables: perceived value of the technologies (ß=.54), perceived improvement in quality of life attainable from the technologies (ß=.24), and confidence in being able to use the technologies (ß=.15). These variables, in turn, were mostly facilitated or inhibited by the perceived effort required to learn to use the technologies, a positive attitude toward technology as reflected in the optimism component of the technology readiness scale, the degree to which technologies were discounted, and the perceived help needed to learn to use the technologies. CONCLUSIONS: Our findings demonstrate that participants' willingness to adopt technologies is mainly determined by perceptions of 3 aspects of the technologies; these aspects possibly mediate many relationships with willingness to adopt. We discuss the implications of these findings for the design and marketing of technology products for older consumers.

Investigating Older Adults' Willingness to Invest Time to Acquire Technology Skills Using a Discounting Approach.

BACKGROUND AND OBJECTIVES: Delay discounting is a common behavioral phenomenon that can influence decision making. A person with a higher discounting rate (DR) will have a stronger preference for smaller, more immediate rewards over larger, delayed rewards than will a person with a lower DR. This study used a novel approach to investigate, among a diverse sample of older adults, discounting of the time people were willing to invest to acquire technology skills across various technologies. RESEARCH DESIGN AND METHODS: One hundred and eighty-seven male and female adults 65-92 years of age participated in the study and were given presentations on 5 different technologies spanning domains that included transportation, leisure, health, and new learning. A measure of discounting was computed based on participants' assessments of how much additional time they would be willing to spend to acquire increased skill levels on each of the technologies and their ratings of importance of attaining those skill levels. Measures of participants' perceived value of the technologies, technology readiness, and self-assessed cognitive abilities were also collected. RESULTS: The findings indicated a significant and robust effect of lower DRs with increasing age. Higher perceived value of the technologies and higher levels of positive technology readiness predicted willingness to invest more time to learn the technologies, whereas self-assessments of cognitive abilities predicted the levels of technology skills that participants desired on the 5 technologies. DISCUSSION AND IMPLICATIONS: Our findings demonstrate that for realistic decision-making scenarios related to the acquisition of technology skills, DRs decrease with increasing age, even within an older adult cohort, and that discounting is related to the perceived value of the technology. The findings also have important implications for the design and marketing of technology products for older consumers.

Overcoming Older Adult Barriers to Learning Through an Understanding of Perspectives on Human Information Processing.

The importance to older adults of being able to learn to perform activities related to leisure, work, or daily living for maintaining independence and a good quality of life is unquestionable. An appreciation of the challenges that older adults face during learning, as well as insights into ways to help them overcome these challenges, whether through design or instruction, can be obtained through a basic understanding of human information processing. The purpose of this article is to facilitate this understanding within the context of older adult learning. The article begins with an overview of the human information-processing system and cognitive limitations and capabilities associated with aging. Critical components of the information-processing system are then revisited in greater detail from the perspective of older adult information-processing capabilities. Concepts are illustrated through examples to demonstrate how older adults could make more efficient use of their information-processing resources during learning.

Technology Adoption by Older Adults: Findings From the PRISM Trial.

Background and Objectives: There is growing evidence of the benefits of computers for older adults. Yet, adoption rates are lower compared with younger adults. Extant theoretical models of technology acceptance are limited in their application to older adults-studies on which these models are based included a limited sample of older adults or none at all; none assessed use of a technology specifically designed for older adults; and most only measured intention to use a technology or short-term use, rather than longer-term use (i.e., adoption). We assessed adoption of a computer system specifically designed for older users, for a diverse sample, over an extended period of time. Research Design and Methods: We analyzed archival data from 150 ethnically diverse older adults (65-98 years of age) who participated in the Personal Reminder Information and Social Management (PRISM) randomized controlled trial (Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J, Fisk AD,…Nair SN. The personalized reminder information and social management system (PRISM) trial: Rationale, methods and baseline characteristics. Contemp Clin Trials. 2015;40:35-46; Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: Findings from the PRISM randomized controlled trial. Gerontologist. 2017;58:467-477). We examined the extent to which attitudes, personal characteristics (e.g., age, gender, and personality), and cognitive abilities predicted mid-term and long-term adoption of a computer system designed for older adults. Results: There were individual differences in PRISM use over time. Regression analyses indicated that individual differences in earlier use of the system, executive functioning, and computer efficacy predicted long-term use. Discussion and Implications: These data provide insights for broader-based models of technology acceptance to guide design, instruction, and deployment of products for older adults. Specifically, the provision of opportunities to foster efficacy and gain positive experience with computer technologies may play a critical role in the likelihood that older adults adopt such technologies. Trial Registration: NCT01497613.

Attitudes Toward Computers Across Adulthood From 1994 to 2013.

Background and Objectives: Regardless of the increased deployment of technologies in everyday living domains, barriers remain that hamper technology adoption by older adults. Understanding barriers to adoption such as individual differences in attitudes toward computers is important to the design of strategies to reduce age-related digital disparities. Research Design and Methods: This article reports a time-sequential analysis of data from the Edward R. Roybal Center on Human Factors and Aging Research and the Center for Research and Education on Aging and Technology Enhancement (CREATE) on computer attitudes among a large (N = 3,917), diverse sample of community-dwelling adults aged from 18 to 98 years. The data were gathered from 1994 to 2013. Results: The findings indicated that there are still age disparities in attitudes; older adults report less comfort with and less efficacy about using computers than younger people. We also found a cohort (birth year) effect; attitudes are generally more positive among more recent birth cohorts. Those who have more education and experience with computers also have more positive attitudes. Males generally have more positive attitudes than females; however, the gender difference decreases with increased age. Discussion and Implications: Technology affords potential benefits for older people, but lack of uptake in technology clearly puts older adults at a disadvantage in terms of negotiating today's digital world. This article provides insight into attitudinal barriers that may affect on technology uptake among older adults. The findings have implications for the design of technology training programs, design of technology systems, and policy.

Examining links between sign-out reporting during shift changeovers and patient management risks.

This article reports on a qualitative study that investigated how various risk factors associated with the process of sign-out reporting across shifts in critical care hospital environments could lead to flawed communication and thus to increased risk of poor patient outcomes. The study was performed in two critical care hospital units: the pediatric intensive care unit (PICU) and the postanesthesia care unit (PACU). We collected data from observations of eight nurses and four resident physicians in the PICU and four nurses and four resident physicians in the PACU giving sign-out reports during their shift changes. In addition, we conducted semi-structured interviews with a separate sample of medical providers consisting of nurse managers, attending physicians, nurses, and residents from each of these two units. The issues that were addressed in these interviews included how various methods of conducting sign-outs and factors such as personality and experience could impact the effectiveness of communication during sign-out reporting. We also collected data from these medical providers on how failures in communication during sign-out reporting could lead to potentially adverse patient outcomes. The article concludes with the presentation of a modeling framework that demonstrates how the combined influences of risk factors can generate a particularly important type of failure mode in communication and how interventions can be targeted to serve as barriers to such events. A number of recommendations intended for reducing risks associated with the communication of sign-out reports are also presented.

Investigating the Roles of Knowledge and Cognitive Abilities in Older Adult Information Seeking on the Web.

This study investigated the influences of knowledge, particularly Internet, Web browser, and search engine knowledge, as well as cognitive abilities on older adult information seeking on the Internet. The emphasis on aspects of cognition was informed by a modeling framework of search engine information-seeking behavior. Participants from two older age groups were recruited: twenty people in a younger-old group (ages 60-70) and twenty people in an older-old group (ages 71-85). Ten younger adults (ages 18-39) served as a comparison group. All participants had at least some Internet search experience. The experimental task consisted of six realistic search problems, all involving information related to health and well-being and which varied in degree of complexity. The results indicated that though necessary, Internet-related knowledge was not sufficient in explaining information-seeking performance, and suggested that a combination of both knowledge and key cognitive abilities is important for successful information seeking. In addition, the cognitive abilities that were found to be critical for task performance depended on the search problem's complexity. Also, significant differences in task performance between the younger and the two older age groups were found on complex, but not on simple problems. Overall, the results from this study have implications for instructing older adults on Internet information seeking and for the design of Web sites.

Factors Predicting Decisions About Technology Adoption Among Older Adults.

BACKGROUND AND OBJECTIVES: Numerous technology applications are available that have the potential to improve the quality of life (QoL) of older adults. However, older adults are less likely to adopt new and emerging technologies and reap the potential benefits. This study examines factors that influence older adults' decisions about the adoption of new technology. RESEARCH DESIGN AND METHODS: Fifty-two older adults participated in a mixed-method procedure, which entailed: (1) observing presentations detailing nine differing technologies, (2) assessing the technologies using tailored questionnaires, and (3) participating in focus group discussions. Participants were assigned into one of seven groups separated by age (65-74, 75+) and language (English, Spanish). The outcome was willingness to adopt technology. Predictors included self-assessed abilities (e.g., numeric ability), computer/Internet skills and knowledge, technology readiness, age, language, and technology ratings (e.g., perceived value). Analyses included Spearman's ρ, t-tests, and regression analysis. Focus group discussions were examined for supportive examples. RESULTS: Self-assessed abilities and computer/Internet skills were predictive of willingness to adopt technologies although the relationship varied according to the technology examined. Technology readiness, age, and language group showed weak associations with the outcome. Of the technology ratings, perceived value, confidence in ability to learn the technology, and the perceived impact on QoL were the most robust predictors of willingness to adopt technology. DISCUSSION AND IMPLICATIONS: Findings indicate that various stakeholders in technology adoption among older adults must be cognizant of a technology's functionality and complexity as well as the characteristics and abilities of older adults. However, certain factors such as perceptions about the value of the technology and potential impact on QoL are also critically important to decisions regarding technology adoption among older people.

Improving Social Support for Older Adults Through Technology: Findings From the PRISM Randomized Controlled Trial.

Objectives: Information and communication technology holds promise in terms of providing support and reducing isolation among older adults. We evaluated the impact of a specially designed computer system for older adults, the Personal Reminder Information and Social Management (PRISM) system. Design, Setting, and Participants: The trial was a multisite randomized field trial conducted at 3 sites. PRISM was compared to a Binder condition wherein participants received a notebook that contained paper content similar to that contained in PRISM. The sample included 300 older adults at risk for social isolation who lived independently in the community (Mage = 76.15 years). Primary outcome measures included indices of social isolation, social support, loneliness, and well-being. Secondary outcome measures included indices of computer proficiency and attitudes toward technology. Data were collected at baseline and at 6 and 12 months post-randomization. Results: The PRISM group reported significantly less loneliness and increased perceived social support and well-being at 6 months. There was a trend indicating a decline in social isolation. Group differences were not maintained at 12 months, but those in the PRISM condition still showed improvements from baseline. There was also an increase in computer self-efficacy, proficiency, and comfort with computers for PRISM participants at 6 and 12 months. Discussion: The findings suggest that access to technology applications such as PRISM may enhance social connectivity and reduce loneliness among older adults and has the potential to change attitudes toward technology and increase technology self-efficacy.

Use of an online personal health record's Track Health function to promote positive lifestyle behaviors in Veterans with prediabetes.

This pilot 3-month clinical trial investigated the feasibility, effectiveness, and acceptability of using the Track Health function of the Veterans Health Administration's personal health record for eliciting a more positive physical activity and dietary intake lifestyle in a sample of 38 overweight and obese Veterans with prediabetes. Comparisons between baseline and 3 months post-intervention indicated significant improvements in weight, physical activity, abdominal circumference, and blood pressure. Use of a personal health record that users can identify with and find usable and useful coupled with instruction targeting critical functionalities could potentially promote healthy behavioral lifestyle changes.

Hospital Discharge and Selecting a Skilled Nursing Facility: A Comparison of Experiences and Perspectives of Patients and Their Families.

PURPOSE OF STUDY: A currently proposed rule by the Centers for Medicare & Medicaid Services would require providers to devote more resources to discharge planning from hospitals to ensure the prioritization of patient preferences and goals in the discharge planning process. Annually, more than 3 million persons enter a nursing home in the United States, with the vast majority of patients coming directly from hospitals. Although early evidence suggests more family involvement than patient involvement in the discharge process, most of this work has relied on retrospective reports of the decision-making process postplacement. This article seeks to examine and compare the experiences and perspectives of patients and others involved in the selection of the nursing home (predominately adult children and spouses). PRIMARY PRACTICE SETTING: Large academic medical hospital with patients being discharged to a skilled nursing facility. METHODOLOGY AND SAMPLE: A total of 225 patients or their family members and involved others who completed an exit survey assessing their experiences and perspectives in selecting a skilled nursing home and in experiencing the discharge process more generally. RESULTS: Patients were the primary decision makers about 23% of the time but were often involved in the decision even when family members/involved others were primarily making decisions in the discharge process. Although patients were involved in the selection of the nursing home to a lesser degree than involved others, their level of satisfaction with the decision to be discharged to a skilled nursing home and their level of satisfaction with their personal level of involvement with the selection of the specific nursing home did not differ from the satisfaction ratings of the involved others. Furthermore, their confidence in the decision and their satisfaction with the decision did not differ from ratings provided by family members/involved others. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Recommendations for case management practice include (1) encouraging patients and their families to take an active role in the discharge process; (2) incorporating technology into the discharge process that promotes this active level of engagement; and (3) facilitating access to data to promote discharge to the highest quality nursing homes available.

Exploring Older Adults' Video Game Use in the PRISM Computer System.

BACKGROUND AND OBJECTIVE: As part of the PRISM (Personal Reminder Information & Social Management) randomized field trial, a large group of older adults (N = 150) received a computer system in their home that presented them with the opportunity to play eleven different video games. While researchers have often assessed older adults' gaming preferences and habits through survey data and focus groups, this trial represented a unique opportunity to study gaming behavior "in the wild" over an entire year. RESEARCH DESIGN AND METHODS: We present an exploration of game usage data, individual differences in game preferences and gaming habits, and individual difference predictors of game use. RESULTS: Although few individual difference variables consistently predicted game use and preferences, there were clear favorites among the different games, and results demonstrate that given the opportunity and training many older adults may become active and long-term gamers. DISCUSSION AND IMPLICATIONS: Findings have implications for designing video games that older adults enjoy, supporting enjoyable and meaningful interactions with video games across the life span, and for designing cognitive, social, and health interventions involving games.

A multilevel modeling approach to examining individual differences in skill acquisition for a computer-based task.

This article explores the role of age, cognitive abilities, prior experience, and knowledge in skill acquisition for a computer-based simulated customer service task. Fifty-two participants aged 50-80 performed the task over 4 consecutive days following training. They also completed a battery that assessed prior computer experience and cognitive abilities. The data indicated that overall quality and efficiency of performance improved with practice. The predictors of initial level of performance and rate of change in performance varied according to the performance parameter assessed. Age and fluid intelligence predicted initial level and rate of improvement in overall quality, whereas crystallized intelligence and age predicted initial e-mail processing time, and crystallized intelligence predicted rate of change in e-mail processing time over days. We discuss the implications of these findings for the design of intervention strategies.

Factors predicting the use of technology: findings from the Center for Research and Education on Aging and Technology Enhancement (CREATE).

The successful adoption of technology is becoming increasingly important to functional independence. The present article reports findings from the Center for Research and Education on Aging and Technology Enhancement (CREATE) on the use of technology among community-dwelling adults. The sample included 1,204 individuals ranging in age from 18-91 years. All participants completed a battery that included measures of demographic characteristics, self-rated health, experience with technology, attitudes toward computers, and component cognitive abilities. Findings indicate that the older adults were less likely than younger adults to use technology in general, computers, and the World Wide Web. The results also indicate that computer anxiety, fluid intelligence, and crystallized intelligence were important predictors of the use of technology. The relationship between age and adoption of technology was mediated by cognitive abilities, computer self-efficacy, and computer anxiety. These findings are discussed in terms of training strategies to promote technology adoption.

Rationale and study protocol for the Nursing Home Compare Plus (NHCPlus) randomized controlled trial: A personalized decision aid for patients transitioning from the hospital to a skilled-nursing facility.

BACKGROUND: Annually more than 3 million people are admitted to one of the 15,965 skilled nursing facilities (SNFs) in the United States, with 90% of admissions occurring from a hospital. Although the Centers for Medicare and Medicaid Services (CMS) publishes several internet-based report cards, including one for nursing homes (Nursing Home Compare, NHC), they are not widely used. This is due, in part, to the complexity of the information available and the fact that the choice of nursing homes is typically made while in the hospital without access to the web-based NHC. We developed Nursing Home Compare Plus (NHCPlus) to address these limitations and to improve the decision-making process. METHODS/DESIGN: This paper describes the design and rationale of a two-arm randomized controlled trial designed to test the effectiveness of NHCPlus compared to usual care only, in a sample of patients being discharged from the hospital to an SNF (N=229). Assessments were conducted within 24h prior to patient discharge and 30-days post discharge. Primary outcomes to be examined included the use of NHC, increased choice of nursing homes with better reported outcomes, and increased distance between patient/family residence and nursing home. Secondary outcomes included satisfaction with the decision to go to a nursing home, confidence in the choice of nursing home, and reduced hospital length of stay. DISCUSSION: NHCPlus is an innovative mobile application designed to allow patients to personalize their choice of nursing homes to meet their medical needs and preferences. The application to other quality report cards is discussed.

The Communication of Global Cardiovascular Risk by Avatars.

Communicating numerical estimates of cardiovascular risk (CVR) to patients encourage risk reduction actions. Avatars may enhance the risk messages ability to improve persuasion to adhere to healthy behaviors. We compared the efficacy of a computer-based aid communicating CVR with and without animated avatars for improving intention to adhere to lifestyle changes. Males with intermediate to high CVR received their risk message in 2 versions: an avatar using voice; voice only. Forty-one participants completed the study. Intent to change lifestyle showed a significant effect favoring the avatar (moderate effect size). Intent to follow medical treatments also showed a significant effect favoring the avatar (moderate effect size). An avatar-based computer aid significantly increased participants' intention to adhere to positive behavioral changes.