The CMS PHR pilot involves Medicare FFS beneficiaries in the South Carolina service area. The Medicare program provides health insurance to individuals who are 65 or older and certain younger disabled persons. In 2002, most Medicare beneficiaries (87 percent) were enrolled in traditional fee-for-service (FFS) Medicare, while others signed up for private health plans that contract to serve Medicare beneficiaries, known as Medicare Advantage plans.  Traditional FFS Medicare reimburses physicians a pre-determined amount for each service they provide, based on an established fee schedule. Physicians who ‘accept assignment’ agree to accept Medicare's fee as payment in full.
The demographic characteristics of Medicare FFS beneficiaries should be examined when designing PHR solutions targeted to them. Health knowledge, attitudes, and beliefs for specific subpopulations may also be important to consider. On the whole, the Medicare population tends to be female (56%), white (78%), between the ages of 65 and 84 (67%), in good or fair health (53%), and living with a spouse (44%). Most Medicare beneficiaries live in urban areas (73%), have at least a high school education (69%), and have some form of supplemental insurance coverage (79%). Half have incomes under 200 percent of poverty level, and almost a third of beneficiaries (30%) have no high school diploma. Chronic illness is highly prevalent among members of the Medicare population–especially the elderly. One survey of Medicare beneficiaries indicated that 65 percent of all elderly people had two or more chronic conditions, and 34 percent of seniors reported limitations in mobility or activities of daily living.  Another report found that 36 percent of Medicare beneficiaries have three or more chronic conditions.
Barriers to PHR Use among Medicare Beneficiaries
To date, little work has been done to examine what assistance may be needed to help elderly, disabled, and immigrant populations use PHRs. In a recent feasibility study of PHR usage in these populations, factors such as a lack of computer literacy, anxiety about using computers, cognitive and physical impairments, and the lack of health literacy were found to impede PHR use if additional support was not provided.
Distrust may be another significant barrier among underserved populations. A 2007 focus group study found that participants from underserved minority groups expressed distrust of electronic record systems that would require them to store personal health data in computers other than their own or those of their physicians. One alternative they would consider is the use of a ‘smart card’. ’§
Medicare beneficiaries are more likely to have impaired vision and mobility, as well as other health problems that can impede their use of PHRs.  Changes in vision that occur with age include reductions in the amount of light that reaches the retina, loss of contrast sensitivity, and loss of the ability to detect fine details, all of which makes reading a computer screen difficult. An estimated 21 percent of adults aged 65 years and older have impaired vision.
Medicare beneficiaries may also suffer from arthritis, Parkinson’s disease, and other conditions that reduce fine motor skills and their ability to use a keyboard or mouse. In addition, cognitive impairment as a result of Alzheimer’s, dementia, or seizures may limit their ability to remember their user name and password, or to recall how to use a PHR application’s functions. Thus, whether or not Medicare FFS beneficiaries adopt PHRs and find them to be useful depends as much on systems and graphical user interfaces (computer programs designed to allow users to interact easily with the computer, typically by making choices from menus or groups of icons) as on the data that the PHRs contain.
Low reading literacy and health literacy levels may also be barriers to PHR use among Medicare beneficiaries. Although there has been no published assessment of the reading level of the information contained in PHRs, information on most general websites is far beyond the reading level of most of the population. In addition, many individuals have difficulty reading and comprehending health information. A study of information technology use and literacy found that nearly one of two adults has difficulty understanding information necessary to make basic appropriate health decisions. The 2003 National Assessment of Adult Literacy determined that adults in the study’s oldest age group–65 and older–have lower average health literacy than adults in younger age groups. Among adults ages 65 and older, 59 percent had below basic or basic health literacy, compared with 32 percent of adults ages 40-49 and 28 percent of adults ages 25-39.
In addition, content and format of many health-oriented materials and IT applications do not meet the needs of many of the elderly and disabled. Health-oriented website content is often too technical for consumers to understand and may not be relevant to their culture or lifestyle. Consumers may also lack record keeping experience. Standard text format guidelines helpful to a senior citizen user for print and web materials–large font size, white space, appropriate reading level, active use of verbs, clear and short sentences, etc.–are often not followed. PHR computer navigation, scrolling, moving objects and animation, and search functions (particularly difficult for the aged with functional issues) hinder accessibility and use.
The elderly are less likely to have experience using computers, access to the Internet, and broadband connection than those under age 65. Many elderly individuals do not have computers at all, and would need to access their PHR from a public place (e.g., a library, senior center, health care facility). In a study of barriers to PHR use among the elderly, Lober et al. found computer literacy and computer anxiety were two major barriers. (Computer literacy skills were demonstrated when performing tasks such as turning the computer on, using a mouse or keyboard, or logging in. ‘Computer anxiety’ is a term used to describe a lack of willingness to attempt these tasks not due to an apparent physical or cognitive barrier.)
Although the percentage of elderly people who use computers is much lower than among the general population, an increasing number of older adults are accessing the Internet. In 1996, only 2 percent of adults 65 and older were ‘online’; by 2004 that number had risen to 22 percent. Kaiser Permanente, VHA, and Whatcom County have all reported that significant numbers of elderly and disabled members are signing up for and successfully using their PHRs. To entice Medicare beneficiaries to use a PHR, though, the tools must be designed to accommodate their needs.