Impact of Patient-Clinical Team Secure Messaging on Communication Patterns and Patient Experience: Randomized Encouragement Design Trial

Abstract

Background Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care. Objective Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA’s online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed. Methods We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams. Results Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P<.001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P<.001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%). Conclusions The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties. Trial Registration ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468

Patient-Provider Text Messaging and Video Calling Among Case-Managed Patients Living With HIV: Formative Acceptability and Feasibility Study

“…Although we did not find unanimous consensus, patients’ and providers’ overall preference for using secure messaging because of privacy concerns mirrors prior insights regarding technology use, stigma, and privacy among people living with HIV [ 40 ]. However, enhanced security comes at the cost of additional requirements (eg, smartphone use) and logistical hurdles (eg, passwords), which have been identified as barriers to technology use [ 41 , 42 ]. Therefore, there is a need to consider issues surrounding security, access, and convenience when developing best practices related to the use of text messaging within HIV clinics.…”

Scoping review protocol to map the use of text-based two-way communication between patients and healthcare professionals after hospital discharge and identify facilitators and barriers to implementation

“…Particularly secure messaging, embedded in patient portals offered by Electronic Health Records vendors, such as MyHealtheVet (Department of Veterans Affair), MyChart (Epic), the secure email system of Kaiser Permanente and more, has significantly accelerated the use of text-based communication in the healthcare system, especially in the USA and other developed countries. [13][14][15][16][17] Where email was previously considered to be the most secure way of text-based communication with patients, secure messaging is now just as safe in terms of data protection and compliance with existing legislation. 16 In most developed countries, patient portals and secure messaging are even accessible through smartphone applications, making it an easy and ubiquitous solution for most patients to access healthcare services.…”

“…This includes formats such as electronic mail (email), phone-based texting and secure messaging. Particularly secure messaging, embedded in patient portals offered by Electronic Health Records vendors, such as MyHealtheVet (Department of Veterans Affair), MyChart (Epic), the secure email system of Kaiser Permanente and more, has significantly accelerated the use of text-based communication in the healthcare system, especially in the USA and other developed countries 13–17. Where email was previously considered to be the most secure way of text-based communication with patients, secure messaging is now just as safe in terms of data protection and compliance with existing legislation 16.…”

“…Benefits of text-based communication include new possibilities for care coordination, prevention of adverse events, empowering and engaging patients, which may positively affect clinical outcomes16 18 and patient satisfaction 7 13–15. Thus, the use of text-based communication between patients and physicians has been found to be an independent predictor of improved performance on quality outcomes for some patient groups18 and to be of particular value to specific groups of patients, such as those struggling with chronic diseases 19.…”

“…This suggests that there may be barriers to use, as known from other eHealth services 20 21. In a preliminary search of PubMed, we have found studies investigating the use of text-based communication to increase access to healthcare and facilitate two-way dialogue in the period post hospital discharge 14 16 22–24. The identified studies cover diverse patient populations with different focus, study designs and evaluation methods.…”