While demographic changes like increased longevity are putting pressure on healthcare systems, with more complex, expensive care needs, empowering patients through digital tools like electronic Personal Health Records (ePHRs) can help enable better management of care across sectors (1). As people age, they tend to utilize healthcare services more through increased medication use and doctor visits (2). ePHRs empower patients to take control of their health data. Generally, ePHRs are defined as electronic records that contain a patient’s health information, which can be accessed and managed by the patient (3). Due to this patient-centered approach, ePHRs are considered a paradigm shift, highlighting the sovereignty and autonomy of the patient (4). ePHRs allow individuals to manage their own health information, including medical history, medication, allergy data, family information and laboratory test results (3). Furthermore, ePHRs enable patients to access their health information from anywhere, at any time, using secure digital private environments, and the rights of access are managed by the patient (3, 4). The utilization of the ePHR is associated with several benefits. ePHRs can help to reduce medical errors through greater access to health information (3, 4), improve communication between patients and healthcare providers (5) as well as quality of care (4, 6) and increase patient engagement and empowerment as regards their own care (3, 5, 7). Considering the overall quality of care, ePHRs improve the availability of medical data, leading to better personal, medical treatment outcomes. Additionally, ePHRs can reduce the time spent on information retrieval, allowing clinicians to spend more time on treatment-related tasks (3, 4, 8). Furthermore, double examinations or treatments can be avoided, which benefits both patients and healthcare providers (9).
In Germany, the electronic patient file (elektronische Patientenakte; ePA) was introduced as a national ePHR system. Since 2021, statutory health insurance providers must offer the ePA to their insured members free of charge (9). Similar to the previous definition of ePHRs, the ePA enables comprehensive storage of medical findings, past examinations, diagnoses and treatments across practices and hospitals. Crucially, the ePA prioritizes patient decision-making authority and empowerment by allowing individuals to control if and how their data are uploaded, stored, deleted and shared with healthcare providers (9, 10). However, adoption of ePHRs, including the ePA, remains startlingly low, despite the potential benefits for both clinicians and patients (11–14). In Germany, less than 1% of insured individuals had registered an ePA as of early 2023, and usage actually halved over the course of 2022, with 170,000 individuals creating an ePA file in the first half of the year and only 84,000 in the second half (15). There are currently just under one million registered ePHRs in Germany (16).
Several barriers hinder adoption, such as concerns over privacy and security, limited accessibility and digital competence, insufficient technical and social support, perceived complexity, lack of perceived value and general unawareness of novel eHealth technologies, as well as personal and socioeconomic factors (3, 6, 17, 18). These hurdles disproportionately impact older adults (OA) with less technological experience and self-efficacy (18, 19). Indeed, feeling inadequate or not regarding technologies as useful can undermine their usage. At a basic level, many are simply unaware ePHRs even exists (20).
To overcome these barriers, conceptual technology training programs that target specific groups such as OA offer a promising solution for those with basic smartphone/computer knowledge (20–22). Such training programs provide opportunities for users to build familiarity and confidence with complex technological systems through hands-on practice. Digital training strengthens self-efficacy, knowledge and competence, factors that are vital for the sustained use of eHealth technologies long-term (18, 22). In this domain, digital literacy education, in particular, aims to cultivate perceptions of self-efficacy and competence, core determinants of both initial and continued engagement with eHealth solutions (4, 20, 23) as well as ePHR systems over time (10, 23). Baartman and de Bruijn (24) consider competence to be defined by the factors of skill, knowledge and attitude. In order to promote the competence of users in dealing with the ePHR, all three dimensions must, therefore, be addressed by suitable interventions.
However, digital competence is often self-reported rather than objectively tested, potentially misrepresenting OA’ actual ePHR skills. While skills and system knowledge are crucial for effective ePHR use, sufficient facilitative support remains important. The provision of manuals, technical assistance, social support and training sessions can achieve this (17). Conversational agents can be utilized to perform question answering, as well as provide guidance through the ePHR system. The first evidence for AI-based ePHR coaches shows they are perceived as valuable and confidence-boosting for older users when navigating the technology (25). A recent meta-analysis by Dong et al. (26) assessed digital health literacy interventions for OA. However, only seven studies were included in the meta-analysis, showing the need for further research to develop practical and effective eHealth interventions for OA. Thus, the current study aims to address this gap by evaluating the impact of an ePHR coaching platform on user competence and knowledge.
In summary, ePHRs are expected to play an increasingly important role in the self-management of disease and care for OA (27). Therefore, it is of utmost importance to empower OA to independently use ePHRs and enhance their competence and knowledge in using ePHRs through specifically tailored training programs. For this reason, the following study will examine knowledge gains and increases in skill among people aged 50 years and over, following use of the high-fidelity prototype of the e-learning platform, ePA Coach. Prior work has tested its interface and usability, but the actual impact on competence remains unknown (10). By using the learning platform, users can acquire the content and skills needed for sovereign use of the German ePHR by both young-old adults (YOA, ages 50–64 years) and OA (ages 65 + years). In addition to testing the usability of the website, the study will explore how the use of the learning platform impacts the intent to use the ePHR in the future. The research presented here forms part of the project “ePA Coach - Digital Sovereignty and the Electronic Health Record”, a project funded by the German Federal Ministry of Education and Research. The following research questions will be determined:
Primary research question:
RQ1: Does one week of ePA Coach use influence knowledge and skills for ePHR usage among
participants?
Secondary research questions:
RQ2: Are the effects on knowledge and skills, required for the competent use of the ePHR, different between older adults and young-old adults?
RQ3: How does ePA Coach platform use impact the intention to use the German ePHR among participants?
RQ4: What were the trends of usage behavior on the ePA Coach platform and how do these relate to knowledge and skill development?
RQ5: How do older adults and young-old adults rate the usability of the ePA Coach learning platform
and how does the perceived usability influence the study outcomes?