The Electronic Health Literacy and Utilization of Technology for Health in a Remote Hawaiian Community: Lana‘i

Abstract

The Lana‘i Community Health Center (LCHC) like other health care organizations, is striving to implement technology-enabled care (TEC) in the clinical setting. TEC includes such technological innovations as patient portals, mobile phone applications, wearable health sensors, and telehealth. This study examines the utilization of communication technology by members of the Lana‘i community and LCHC staff and board members in the home and in their daily lives and evaluates the community's electronic health literacy. Quantitative surveys and qualitative focus groups were utilized. These revealed that members of the Lana‘i community and LCHC staff and board members regularly utilize technology, in the form of smart cell phones, WiFi, and internet texting. This community has integrated technology into their daily lives, even though they live on an isolated island with 3,102 people; however, despite this integration, the electronic health literacy of this population appears insufficient for proper understanding and utilization of TEC, limiting the potential of patient portals or remote monitoring of patient generated data for chronic disease prevention and management without additional education and mentoring. It is therefore in the best interest of the LCHC and other health organizations wishing to implement TEC in a rural community such as Lana‘i to include a strong educational component with use of TEC, and perhaps establish a mentor/partnership program for the highly-challenged patient.

Introduction

Electronic health literacy is defined as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.”¹ It requires the following six core literacy skills: traditional, information, scientific, media, and computer.¹ Lana‘i Community Health Center (LCHC) is incorporating technology-enabled care (TEC) into its clinical practice, to better meet the needs of this rural community, a community that lacks access to both primary care and specialty health care providers (HCPs). Although LCHC has successfully implemented various TEC initiatives, including a patient portal, Bluetooth enabled blood pressure monitors, a clinic website, and telemedicine, understanding the patient's knowledge, literacy, and use of available communication technology is valuable in planning and implementing further enhancements, particularly for older patients with chronic conditions. These efforts to use technology to improve the health status follow national trends, as 95% of Americans own a cell phone, 77% own a smart phone,² and 88% use internet.³ Patients can now access personal medical records and communicate securely with HCPs via patient portals. In 2016, the physician shortage in the United States was nearly 94,700, and is projected to increase toward 95,900 by 2025; using TEC as an interface between providers and patients helps to address this barrier to accessing healthcare,^4,5 with the goal of improving health outcomes.

LCHC is a Federally Qualified Health Center located in Lana‘i City, which has a population of 3,102 people living within 1.1 square miles, on the island of Lana‘i, whose total land area is 141.07 square miles.^6,7 The median age on the island is 38.4 years, with 16.7% of the population older than 65 and 27.7% under 20.⁷ Being isolated from the major hospitals and medical specialists in Honolulu, O‘ahu and those in Kahului, Maui, the population of Lana‘i relies on two outpatient clinics and a small critical access hospital for its acute and chronic medical needs. This study examines how communication technology is utilized by members of the Lana‘i community and LCHC staff and board members in their daily lives and examines the study participants' electronic health literacy.

Methods

This research project was approved by the University of Hawai‘i Human Studies Program, CHS # 2016-30924, which declared this study “exempt.” LCHC staff identified three populations for this study: people who attend the Lana‘i Senior Center; middle and high school students in biology classes at the Lana‘i High and Elementary School; and LCHC staff and board members. All of the LCHC staff working during the time the focus groups were held were invited to participate in the research project. All staff members were given thirty minutes away from their work duties in order to participate in the focus groups. The LCHC board members were invited to participate in a focus group that was held prior to their scheduled board meeting. Two additional focus groups were also conducted with participants from one of the LCHC's free zumba fitness classes and with members of a nurse assistant program at the local community college. Not all members of the targeted groups participated in the focus groups. LCHC provided food and refreshments for the majority of the focus groups. The first author of this article facilitated all eleven focus groups in this study. Individuals willing to participate in a focus group were asked to sign the IRB approved consent form and to indicate whether they agreed to be audio-recorded (which was to be used for later transcription). Anyone under eighteen years of age had their parent or guardian sign the consent form prior to participating and was verbally asked by the facilitator if they wished to participate in the focus group. A quantitative questionnaire was administered before each focus group, including demographic questions and questions adapted from the Electronic Health Literacy Scale (eHEAL) (see Appendix 1 and 2.) The eHEAL questionnaire is a validated tool to reliably and consistently capture electronic health literacy “consumer comfort and skill in using information technology for health.”¹ Two questions were added to the validated eHEAL questionnaire to assess for participant feelings toward the usefulness of the internet to make health decisions and the importance of being able to access health information on the internet (questions 1 and 2, respectively).

Upon completion of the quantitative questionnaire the survey instrument was collected and the standardized focus group introduction, assembled by the authors, was read and included the purpose of the project, introduction of the facilitator, and ground rules for the session (see Appendix 3). At this point, the audio-recording of the focus group began, using a conference room speakerphone connected to a MacBook Air laptop running the Audacity 2.1.0 audio-recording software (Audacity Team; https://audacityteam.org). The same standardized focus group questions were used in all focus groups, with three additional questions included in those focus groups containing LCHC healthcare providers (see Appendix 4.) The audio-recording software was stopped once all participants were given the chance to contribute to the final focus group question.

Eleven focus groups were completed and transcribed by the same facilitator. Each participant was assigned a number to mask their identity. The transcriptions were then analyzed for themes, based on the theme analysis methodology described by Krueger and Casey⁸ and grouped into the following categories: people who attend the Lana‘i Senior Center; middle and high school students in biology classes at the Lana‘i High and Elementary School; and LCHC staff and board members. Basic statistical analysis of the quantitative questionnaire data, including mean, median, and mode, were conducted with Microsoft Excel, version 15.33 (Microsoft; Redmond, Washington). Advanced statistical analysis was performed with SPSS, version 23 (IBM; Armonk, New York), including an independent sample t-test and multiple one-way analysis of variance (ANOVA).⁹ The independent sample t-test was used to determine whether there was a significant difference between male and female responses to the adapted eHEAL questions. ANOVA were conducted on each eHEAL question to determine where there was a statistically significant difference between the answers of various age groups (10–19, 20–29, 30–39, 40–49, 50–59, 60–69, and 70–89) and education levels (some school, high school, some college, associate degree, bachelor degree, master degree, and advanced degree) of the participants. The 70–79 and 80–89 age groups were combined for data analysis due to the limited number of participants in each group. One participant reported that she completed a trade school for the education level question and was included in “some college” group for data analysis.

Results

Sixty-nine participants completed both focus groups and questionnaires. Average age of all participants was 43 with both mean and mode for the study group being 34.5 years of age. Sixty-nine percent of the participants were female (one participant did not answer the gender question). Most participants (67%) were full or part Filipino and 25% were full or part Native Hawaiian. Fifty-seven percent of participants had at most a high school level of education, with sixteen percent having a bachelor's degree or higher level of education, as seen in Table 1. Most participants had a smart cell phone (83%), but only 57% had a cell phone data plan. Most participants regularly use Bluetooth (54%), WiFi (86%) and internet texting capabilities (74%). Few participants use a patient portal (16%), either available at LCHC, through their insurance company, or at another clinic, despite most participants having a portable or tablet computer, 62% and 58%, respectively, as seen in Table 2.

Table 1.

Demographics of all participants in the focus groups, by age group and gender.

Focus Group*	Age Group	Gender	Number of Participants	Ethnicities Identified With	Current/Maximum Education
Biology	10 – 19	Female	15	Chinese, Filipino, Native Hawaiian, Other, Other Asian, Other Pacific Islander, Portuguese, White	Some School
	10 – 19	Male	15	Chinese, Filipino, Japanese, Native Hawaiian, Other, Other Asian, Portuguese, White	Some School
	10 –19	Unknown	1	Other Pacific Islander	Some School
CNA	20 –29	Female	1	Filipino, White	High School
	60 –69	Female	1	White	Advanced Degree
	70 – 79	Female	1	White	Associates
LCHC	20 – 29	Female	6	Filipino, Native Hawaiian, Other Pacific Islander	High School, Some College, Associates, Bachelor Degree
	30 – 39	Female	6	Chinese, Filipino, Native Hawaiian, Other Asian, White	High Schoo, Bachelor Degree, Master Degree
	40 – 49	Female	5	Filipino, Native Hawaiian	Some College, Master Degree
	60 – 69	Female	2	Japanese, White	Associates, Advanced Degree
	30 – 39	Male	3	Filipino, Japanese, Native Hawaiian, Portuguese	Associates, Master Degree, Bachelor Degree
	50 –59	Male	1	Filipino	Some College
Senior	50 – 59	Female	1	Chinese, Native Hawaiian, Portuguese	High School
	70 – 79	Female	2	Chinese, Filipino, Japanese, Native Hawaiian, White	High School
	80 – 89	Female	1	Filipino	High School
Zumba	20 – 29	Female	1	Hispanic, White	Some College
	30 – 39	Female	4	Chinese, Filipino, Hispanic, Native Hawaiian, White	High School, Trade School, Some College
	50 – 59	Female	1	Hispanic, White	Some College
	40 – 49	Male	1	Other	Master Degree
	60 – 69	Male	1	White	Some College

^*“Biology” refers to high school biology class focus groups at the Lana‘i High and Elementary School; “Zumba” class refers to the focus group with the LCHC zumba class; “LCHC” refers to the LCHC staff and board member focus groups; “CNA” refers to the focus group from the local community college nurse assistant program; and “Senior” refers to the focus group at the Lana‘i Senior Center.

Table 2.

Percentage of participants regularly utilizing the below technology types or who have the following technology in their home, by age group. See Appendix 1 for complete set of questions used.

Age Group	10 – 19 (n = 31)	20 – 29 (n = 8)	30 – 39 (n = 13)	40 – 49 (n = 6)	50 – 59 (n = 3)	60 – 69 (n = 4)	70 – 89 (n = 4)	Total (N = 69)
Basic Cell Phone	16%	0%	0%	83%	0%	0%	100%	13%
Smart Cell Phone	97%	100%	92%	33%	33%	25%	0%	83%
Land Line	52%	38%	23%	83%	33%	50%	50%	42%
Portable CPU	61%	75%	54%	67%	67%	100%	0%	62%
Tablet CPU	55%	75%	77%	33%	33%	50%	0%	58%
Fitness Tracker	10%	25%	15%	0%	33%	0%	0%	14%
Other	10%	0%	80%	67%	0%	0%	0%	60%
WiFi	97%	100%	92%	33%	67%	50%	25%	86%
Wired Internet	45%	25%	46%	50%	0%	50%	25%	39%
Bluetooth	68%	88%	38%	67%	33%	0%	0%	54%
Video Conference	65%	75%	62%	83%	33%	50%	0%	59%
Cell Photo Data Plan	58%	38%	69%	50%	67%	50%	0%	57%
Internet Texting	87%	88%	77%	33%	33%	75%	0%	74%
Patient Portal	60%	25%	38%	0%	0%	0%	0%	16%
Other	0%	0%	0%	0%	0%	0%	0%	0%

Based on responses to the eHEAL questionnaire, participants felt that the internet is useful in helping them to make decisions regarding their health and they feel it is important to be able to access health resources on the internet, as seen in Table 3 and Figure 1.

Table 3.

Total Adapted eHEAL Questionnaire Average.^*

Questions	Average	Interpretation
How useful do you feel the internet is in helping you in making decisions about your health?	4.2	Unsure - Useful
How useful do you feel the internet is in helping you in making decisions about your health?	4.2	Unsure - Useful
I know what health resources are available on the internet.	3.7	Disagree - Undecided
I know where to find helpful health resources on the internet.	3.7	Disagree - Undecided
I know how to find helpful health resources on the internet.	3.8	Disagree - Undecided
I know how to use the internet to answer my questions about health	3.9	Disagree - Undecided
I know how to use the health information I find on the internet to help me	3.8	Disagree - Undecided
I have the skills I need to evaluate the health resources I find on the internet	3.6	Disagree - Undecided
I can tell high quality health resources from low quality health resources on the internet	3.3	Disagree - Undecided
I feel confident in using information from the internet to make health decisions	3.4	Disagree - Undecided

^*See Appendix 2 for questions adapted from the Electronic Health Literacy Scale included in the pre-focus group questionnaire.

Figure 1.

Adapted eHEAL Questionnaire Average for Each Age Bracket. See Appendix 2 for corresponding questions adapted from the Electronic Health Literacy Scale included in the pre-focus group questionnaire.

There was a statistically significant difference between the age groups as determined by one way ANOVA for all but one of the eHEAL questions as seen in Table 4 (question 7, see Appendix 2). Regarding education level, there was a statistically significant difference between the education groups for all but two of the eHEAL questions as determined by one way ANOVA as seen in Table 4 (questions 7 and 10, see Appendix 2). There was no statistically significant difference between males and females for any of the eHEAL questions, nor for questions regarding the utilization of health information found on the internet and confidence using information from the internet to make health decisions, as seen in Table 4.

Table 4.

One Way ANOVA and Independent T-Test Tables for Statistical Analysis of eHEAL Questionnaire for each Age Bracket, Educational Level, and Gender.

eHEAL Question		1	2	3	4	5	6	7	8	9	10
Age	df	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)
	F	9.300	10.282	8.859	4.322	5.964	7.020	1.904	3.576	3.902	4.761
	P	.000	.000	.000	.001	.000	.000	.094	.004	.002	.000
Education Level	df	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)	F(6,62)
	F	7.308	3.579	2.956	3.313	3.183	4.031	1.376	5.228	3.229	1.884
	P	.000	.004	.013	.007	.009	.002	.238	.000	.008	.098
Gender	df	6.6	6.6	6.6	6.6	6.6	6.6	6.6	6.6	6.6	6.6
	t	−1.343	−1.035	−0.565	−0.309	−1.057	−1.623	−0.004	−1.076	−1.035	−1.547
	P	.184	.304	.574	.758	.294	.109	.997	.286	.305	.127

None of the four participants in the Senior Center focus group use technology to access healthcare information. They observed that, in general, HCPs are too busy and unable to provide adequate patient education, and that using at home medical devices are difficult when living alone. One senior noted: “I take pretty good care of myself without technology” and others agreed that they lived to be elderly without using technology. They did not like the use of TEC by their HCPs. The seniors did not feel that the lack of HCP time to provide health education would adversely affect their overall health, as one participant noted: “What you don't know won't hurt you.” All seniors agreed that if they had a medical question they would ask their peers at the Senior Center in person, or call one another over the phone, rather than attempting to use a computer to answer their question. One participant also noted that she had been given a home blood pressure cuff by her HCP, but due to the size of her arm, it was impossible to place the instrument properly to obtain a blood pressure.

Eleven community adults participated in focus groups. These adults acknowledge that technology is integral to health, has improved access to healthcare, and should be further utilized. Google search is the first place they go to seek medical advice, primarily related to diagnosis and triaging concerns, and to determine whether or not they or a family member require a physician. Common websites visited for health information included PubMed, WebMD, the Mayo Clinic, health insurance websites, YouTube, and forums. Overall, adult participants agreed that websites like Wikipedia also serve as a good starting place to find general information about a symptom or diagnosis but, as one participant noted, “I just wouldn't take it to the bank.”

The community adults that had accessed patient portals explained that online health information provided by patient portals has improved access to healthcare by enabling them to interact “intellectually” with HCPs. They noted that previously they were reliant on the HCPs review of their lab data and for patient education. Since this information is now available online via a patient portal, patients can present to clinic knowing more about their condition and ask their HCP more thoughtful questions. However, participants did not feel that emails following clinic visits were useful: “They show results of an appointment I was at a couple hours ago; so, I figure I know; I was there.” Community adults felt comfortable using video conferencing technology (VCT) for clinic visits with HCPs who were not located on their island. For children needing to see a HCP not available on island, the group felt that they would only be comfortable using VCT if the child was physically with the off-island HCP, and the parent could participate from Lana‘i via VCT.

Participants in these community adult groups had numerous suggestions on how healthcare systems and organizations could improve the utilization of technology, agreeing that an online VCT urgent care-style clinic would “revolutionize medicine as [we] know it.” Participants requested online appointment scheduling through the patient portal. They did not feel that including additional health information, such as patient education materials related to diabetes mellitus management, on the clinic patient portal would be helpful, as it would require logging into the patient portal and they felt that Google results are more conveniently accessed and reasonably reliable. Several participants appreciate the number of health education materials available on YouTube, preferring to listen to a presentation by a HCP rather than read and interpret health information themselves.

Twenty-three LCHC staff and board members participated in five focus groups. Two main topics that emerged in these groups were that technology has improved access to medical knowledge and that technology should be further utilized by healthcare systems and organizations. Unlike the other non-LCHC focus groups that use Google as the first place to look for health information online, the staff at LCHC use more advanced medical search engines with subscriptions provided through their employer to look for health information online. Members of the LCHC focus groups agreed that they avoided using Google due to the lack of peer reviewed material in the results. Participants generally trusted online health information from websites with the “trust” logo on the web browser or any website with “American” or “Association” in the title. Websites with many advertisements, such as Wikipedia or WebMD, were seen as less trustworthy. Participants also appreciated accessing online lab results, allowing patients to be reassured more quickly than waiting for a HCP to call them with the results. Interestingly, not a single participant in the LCHC employee focus groups had logged into the patient portal, despite receiving emails after every HCP visit. They agreed that VCT on a cell phone or laptop to access HCPs for urgent care consults would be helpful, and stated that they would follow their HCPs on social media as they generally trust their HCPs opinions. LCHC staff also agreed that a digital, universal, immunization record online would be extremely helpful. Similar to other groups, participants requested being able to schedule clinic appointments online, with one participant stating, “I can even do it for my vet!”

HCPs within the LCHC focus groups felt that technology has improved access to and quality of healthcare. One HCP commented that “without access to what we have now, the patients on Lana‘i would be at a significant disadvantage [compared to patients on the other Hawaiian Islands].” HCPs did mention that a single, universal electronic medical record would be ideal. The HCPs worried about reliance on technology, particularly as demonstrated during power outages on the island, when neither patients nor HCPs know medication lists or medical histories often needed for a clinic visit (though, LCHC has a generator that provides power in the event of outages). Finally, there was mutual concern that the patient-HCP relationship deteriorates due to technology in the exam room during every clinical encounter.

Thirty-one community middle and high school students participated in three focus groups, reporting that technology has improved their access to medical knowledge; however, they noted reservations about personal health information being available online. Similar to the other focus groups, students utilize Google search for online health information, but specifically avoid using Wikipedia, because teachers tell them it is not reliable, and WebMD, due to the number of advertisements. Most students also used online health information to decide whether or not to see a HCP in person, and some observed that they and their families used online health information to ensure the HCP gave them the correct medication, one participant stating: “My family kind of doesn't trust the doctors [on Lana‘i].”

Some students were resistant to using a patient portal to access personal health information online or using VCT to see a HCP, fearing that “people could hack [the patient portal],” that the patient portal is not a safe repository for private information. Cyberbullying was also of concern, where someone might be able to access their private health information online via a patient portal and use the information to bully them. Consequently, most students agreed that they would “rather go see my doctor [in person] than use VCT.”

For all focus group participants who do use technology to access healthcare information, the general workflow to find health information online went as follows: type symptom, disease, or medication into Google search; look for familiar trustworthy website names in the top three search results, such as PubMed, WebMD, or the Mayo Clinic; review the online material to triage a symptom, learn more about a disease, or to find out more information about a medication; if unfamiliar words were present in the material, the participants would then type the name into Google search to determine its meaning; and once educated by the material, the participants would decide whether they needed to see a HCP for help.

Discussion

TEC will increase access, improve quality, and lower cost of health care if effectively implemented. There is a general sense that technology will drive the transformation of the health care system; however, technology is viewed as enabling patients to receive better care. This study provides valuable insight into two essential aspects of using technology to better manage patients. The first is access and current knowledge of communication technology, ie, phones, tablets, and computers, and the second is the electronic health literacy of this population.

The population in Lana‘i utilizes smart phones (83%) more than laptops (62%) or tablets (58%); with the mobile technologies being more common than the standard landline house phone (42%). The use of technology is following a general trend of using smaller unit mobile technology. The economic status of the Lana'i population may explain the decision to drop the traditional house phone in favor of a smart phone. As expected, mobile technology is more popular with the younger study participants. In addition, internet texting (74%) and video conferencing (59%) are common, but more so with the younger population.

Based on the statistical analysis of the resulting adapted eHEAL questionnaire comparing gender, age, and educational levels, the main statistical differences were found between age groups and education levels, as expected. Of note, only one question had no statistical difference noted between any of the sub-categories of analysis, the adapted eHEAL question regarding the utilization of health information found on the internet. This suggests that all participants, despite education level, gender, or age, feel that they lack the ability to utilize information they find on the internet to make health decisions. There is a high use of TEC to access health information, but most of the population has concerns related to interpreting the information and making medical decisions. Again, the use of TEC is most common in the younger, well-educated persons. Yet, the patients who would most benefit from appropriate use of TEC are older patients with chronic conditions and multiple co-morbidities, such as hypertension and diabetes, which require patient self-management and monitoring.

It is notable that even though potential access to the EHR patient portal through communication technology is high in the Lana‘i community, only 16% of respondents had actually used the patient portal. Currently roughly one third of patients at LCHC are enrolled in the LCHC patient portal. In comparison, the Kaiser Permanente Health Maintenance Organization, which utilizes a patient portal called My Health Manager, reports that 5.37 million patients out of their 10.2 million patient population are enrolled on their patient portal, 70% of eligible adult members.¹⁰ Of note, the Kaiser data looks only at the number of registered users, similar to the LCHC patient portal enrollment data, not the utilization of patient portals, which was the goal of this study. The Lana‘i population is comfortable using communication technology to connect to the outside world, access information and entertainment, communicate with friends and family through videoconferencing, but has limited knowledge of how best to use technology to improve access to health care. Patients at LCHC are offered access to the patient portal as part of meaningful use, a Centers for Medicare & Medicaid Services incentive program for electronic health record technology implementation,11 but the uptake has been slow, and it has not been a high priority of the LCHC to educate and train patients beyond the educational information provided when patients elect to sign-up; the majority of LCHC patients indicate that they highly value the ‘face-time’ spent with their HCP, and encouraging patients to use the patient portal is contradictory in some ways to the organization's emphasis on personal care. Meaningful use requires that the patient is offered access and does not require utilization. In addition, the content and usability of the patient portal may limit the value for patients particularly those with low health literacy. Availability does not assure value and is very vendor dependent related to structure and usability of the patient portal.

This study provides valuable information to structure our remote monitoring and community-based care program. Most households have access to a smart phone or other communication devices that have Bluetooth capabilities. The older patient may not be the owner, but by working with the family, remote monitoring of home blood pressure and glucose results can be shared with the care team through TEC. In addition, with the HIPAA compliant telehealth technology licensed by LCHC, virtual visits are supported by existing technology to the patient's home.

The challenge is to provide staff and patient education to effectively use the technology in a community that owns devices for purposes other than health. The vast majority of patients are motivated to self-manage chronic conditions in collaboration with their health care team. TEC can make access and support much easier, but it will require improved patient electronic health literacy in addition to general health literacy.

Limitations

Although diverse groups of the Lana‘i community participated, inclusion of a greater number of community adults and seniors would have improved assessment of this portion of the Lana‘i population. Despite all members of the LCHC employee and board member focus group belonging to this targeted demographic, due to their advanced medical training, an accurate reflection of the senior and adult electronic health literacy was not captured in this study. Also, the large proportion of middle and high school students in this study, who likely rely on parents or guardians to access such TEC as patient portals for them, further skewed the dataset toward a lack of electronic health literacy. Finally, the focus of this study was on the electronic health literacy of the Lana‘i community, not general health literacy, but it appears that a lack of general health literacy which was not the focus of this study in this population contributes to the lack of electronic health literacy.

Conclusion

Members of the Lana‘i community and LCHC staff and board members utilize technology, in the form of smart cell phones, at a greater rate, than the rest of the United States (83% vs 77%).¹ Most participants also regularly use WiFi and texting services, demonstrating that this community has integrated technology into their daily lives, despite living on an isolated island with 3,102 people.^5,6 However, both general and electronic health literacy of this population is insufficient to understand and properly utilize TEC, such as patient portals. Consequently, this community is unable to determine what, where, and how to find useful online health resources and how to effectively use these resources.

If LCHC, and other health systems, plan to continue to implement TEC initiatives, a campaign to increase general and electronic health literacy must first be undertaken. Also, with the goal to increase patient self-management and monitoring of chronic conditions through the use of TEC, which mainly impacts those patients over forty years of age, it is especially important to target this age group with educational interventions. Simultaneous with a general and electronic health literacy program, though, LCHC (and other organizations) must carefully assess what methods their patients are most comfortable using; all the electronic education in the world will not help the patient who prefers face-to-face contact. Therefore, it is critical for organizations to determine a balance of TEC and human contact that meets the patients' needs, and results in improved health. LCHC has initiated efforts to improve the overall general and electronic health literacy of the Lana‘i community through educational sessions for all community members, in order for this community to be able to better utilize TEC. LCHC also continues working with its staff and providers to more accurately identify the best methods for communication with patients - using both TEC and face-to-face contact.

Abbreviations

LCHC

Lana‘i Community Health Center

HCPs

health care providers

TEC

technology-enabled care

eHEAL

Electronic Health Literacy Scale¹

ANOVA

analysis of variance

VCT

video conferencing technology

Appendix 1. Demographic questions used in the pre-focus group questionnaire

Please circle ONE box under each category that is applicable to you:

1. Current age:

   1. 10 – 19
   2. 20 – 29
   3. 30 – 39
   4. 40 – 49
   5. 50 – 59
   6. 60 – 69
   7. 70 – 79
   8. 80 – 89
   9. 90 – 99
2. Gender:

   1. Male
   2. Female
   3. Other
3. Ethnicity you identify with:

   1. Native Hawaiian
   2. Filipino
   3. White
   4. Portuguese
   5. Chinese
   6. Japanese
   7. Other Pacific Islander
   8. Other Asian
   9. Other
   10. Not Stated
4. Current/Maximum education:

   1. Some School High School
   2. Some College
   3. Associate Degree (ie, AA, RN-AA)
   4. Bachelor Degree (ie, BA, BS)
   5. Master Degree (ie, MS, MA)
   6. Advanced Degree (ie, PhD, MD, JD)
   7. Other
5. Technology in the home (please place a mark in each box if you own, or someone in your home, owns the following:)

   1. Basic Cell Phone (ie, flip phone)
   2. Smart Cell Phone (ie, iPhone, Android)
   3. Land Line (ie, home phone)
   4. Portable Computer (ie, laptop)
   5. Tablet Computer (ie, iPad, Nook)
   6. Fitness Tracker (ie, Jawbone, Apple Watch)
   7. Other
6. Technology use (Please place a mark in each box of the items you are familiar with and regularly use:)

   1. Wireless Internet (ie, WiFi)
   2. Wired internet (ie, Ethernet)
   3. Bluetooth (ie, phone, fitness tracker)
   4. Video Conferencing (ie, Skype, FaceTime)
   5. Cell Phone Data Plan
   6. Internet Texting (iMessage, Skype, Facebook)
   7. Patient Portal
   8. Other

Appendix 2. Questions adapted from the Electronic Health Literacy Scale included in the pre-focus group questionnaire.⁷

LCHC would like to ask you for your opinion and about your experience using the internet for health information. For each statement, tell me which response best reflects your opinion and experience right now.

1. How useful do you feel the internet is in helping you in making decisions about your health?

   1. 1 - Not useful at all

   2. 2 - Not useful

   3. 3 - Unsure

   4. 4 - Useful

   5. 5 - Very Useful

2. How important is it for you to be able to access health resources on the internet?

   1. 1 - Not very important

   2. 2 - Not important

   3. 3 - Unsure

   4. 4 - Important

   5. 5 - Very important

3. I know what health resources are available on the internet

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

4. I know where to find helpful health resources on the internet

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

5. I know how to find helpful health resources on the internet

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

6. I know how to use the internet to answer my questions about health

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

7. I know how to use the health information I find on the internet to help me

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

8. I have the skills I need to evaluate the health resources I find on the internet

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

9. I can tell high quality health resources from low quality health resources on the internet

   1. 1 - Strongly disagree

   2. 2 - Disagree

   3. 3 - Undecided

   4. 4 - Agree

   5. 5 - Strongly agree

10. I feel confident in using information from the internet to make health decisions

    1. 1 - Strongly disagree

    2. 2 - Disagree

    3. 3 - Undecided

    4. 4 - Agree

    5. 5 - Strongly agree

Appendix 3. Focus group ground rules.

1. I/WE WANT YOU TO DO THE TALKING.

   1. I/We would like everyone to participate.

   2. I may call on you if I haven't heard from you in a while.

2. THERE ARE NO RIGHT OR WRONG ANSWERS

   1. Every person's experiences and opinions are important.

   2. Speak up whether you agree or disagree.

   3. I/We want to hear a wide range of opinions.

3. WHAT IS SAID IN THIS ROOM STAYS HERE

   1. I/We want folks to feel comfortable sharing when sensitive issues come up.

4. WE WILL BE TAPE RECORDING THE GROUP

   1. I/We want to capture everything you have to say.

   2. I/We don't identify anyone by name in our report. You will remain anonymous.

Appendix 4. Focus group questions.

Questions for all focus groups:

1. Where do you search for information regarding your health online?

2. What online/digital resources do you trust/not trust?

3. Regarding your health, what subjects or topics have you looked up information on online in the previous 12 months?

4. How do you use the health information you gain from digital/online sources?

5. Do you feel safe accessing or sharing healthcare information online and in what scenarios do you feel safe/not safe?

6. How has technology improved access to healthcare services?

7. What apps are you using for your health?

8. What technologies would you be interested in having in the future that would support the way that you live your life today?

9. Is there someone in your household that uses technology to access digital/online health information for you or are you the digital/online health resource person for your household?

Questions for only those focus groups containing HCPs:

• 10. Do you feel that access to digital/online health information has improved patient healthcare access?

• 11. Do you feel that access to digital/online health information has improved the quality of patient healthcare?

• 12. Do you feel that the current movement to increase the use of technology in the clinical setting is a movement in the right direction?

Conflict of Interest Statement

We certify that we have no financial affiliation/interest (eg, employment, stock holdings, consultantships, honoraria) in the subject matter, materials, or products mentioned in this manuscript. Neither of the authors of this article have any conflict of interest to report, nor any interests represented with any products discussed or implied.