BACKGROUND/RATIONALE:
Research findings indicate patients value Secure Messaging (SM) to electronically communicate with their providers. Use of SM is associated with reduced outpatient visits and telephone contacts, while improving patient satisfaction and outcomes for chronic conditions. SM, a MyHealtheVet (MHV) electronic communication tool, is a VHA implementation priority to improve Veteran access to care. Successful deployment of SM will support improved access to care, and improved healthcare outcomes in the Veteran population.

OBJECTIVE(S):
The primary aim of this project was to describe Veterans' experiences when using the SM feature on MHV. Findings from this research explored why Veterans choose to, or not to, use the SM, identify facilitators and barriers to use to inform systems improvements, educational approaches, and marketing strategies.

METHODS:
This was a prospective mixed-methods descriptive study. In Phase 1: A purposive sampling was used to identify a sample of N = 33 Veterans, from Tampa and Boston with ability to use the SM feature on MHV to conduct this prospective study. Two types of participants were recruited at each site: (1) high volume users; and (2) low volume- or non- users. High volume user was defined by the quantity of SM during the study period (5< messages). Low volume user was defined by minimal or no use of SM during the study period (5> messages). Data collection procedures included: (1) In-person interviews; (2) usability testing; (3) SM secondary data collection; and (4) three-month follow-up telephone interviews. For Phase 1 data, content analysis methods were used to manage transcript data to identify domains and taxonomies related to Veteran experiences using SM. Quantitative data was summarized with descriptive statistics to describe sample characteristics. In Phase 2 (study extension): Veterans were contacted by mail to complete a one-time self-administered paper-and-pencil mail-in survey (N = 826; Tampa n = 483, Boston n = 343) designed to gather quantitative data about their SM use. For Phase 2 data, quantitative data were summarized with descriptive statistics using frequency counts and proportions.

FINDINGS/RESULTS:
PHASE 1 - The majority of participants were older white males (n=26, 78.8 %), all had at least a high school education and 63.6% (n=21) had an annual income of $35,001 or more. Overall, data indicate that Veterans who participated in this study are satisfied with SM and find it relatively easy to use. However, participants reported some barriers; specifically confusion about the process required to sign-up for SM; getting started; and misperceptions about the meaning of "secure" (i.e. not being aware that their SM's are received by their primary care team instead of their primary care physician). Though participants were able to complete most user-testing tasks necessary to use SM, MHV site navigation, setting user preferences, categorizing messages and formulating subject headers were not user-friendly tasks in the current system. Secondary SM data: n=18 (54.5%) sent a total of 66 SM threads (series of SMs from one original SM) during the three-month review period. Several SMs sent by Veterans did not get a SM response, however some indicated response through other mechanisms. Response times from VA team members ranged from 8 minutes to 136 hours (>5 days). Though data methods were largely convergent, some data sources indicated discrepancy between Veterans reports and objective data collection. For instance, approximately 80% of participants reported using SM at least once in the past 3 months, however SM content collection indicated only 55% of Veteran participants sent SMs. Similarly, the majority of Veterans reported receiving SM responses within 24-48 hours, however a review of the SM content suggested that response times ranged anywhere between 8 minutes to 136 hours (>5 days). Analysis of SM content data also revealed that some Veterans sent messages to inquire about sensitive health topics such as sexually transmitted diseases (STDs) and erectile dysfunction (ED); these topics were not revealed in interviews. The use of mixed methods provided insight to the uses of SM that could not be gleaned from Veterans' self-reports alone. Participant suggestions provide multiple mechanisms for overcoming barriers to SM use. Data highlight a need for promotional/educational strategies to increase Veterans awareness of and uses for SM; facilitate Veteran adoption and skilled use of SM and MHV; and align expectations for the use of these tools.

PHASE 2 - Data were provided by n = 105 females and n = 721 males; n = 732 (88.6%) self-identified as White/Caucasian, and n = 712 (86.2%) self-identified as non-Hispanic/Latino. The majority, n = 812 (98.3%) had a high school degree or higher. The majority of respondents reported using SM (n = 560), n = 215 reported not using SM, interestingly, n = 47 reported not knowing if they had used SM. The majority (n = 571) of respondents reported being satisfied with SM and that SM was easy to use (n = 541, 65.5%). Consistent with the qualitative data, survey respondents reported that SM was useful because it could be used to contact their healthcare providers on their own time, and because SM saves time. Also consistent with qualitative data, respondents reported most often using SM for medication refills (n = 473); medication (n = 303) & health related questions (n = 301); managing appointments (n = 298); and test results (n = 292). Some participants (n = 344, 41.6%) reported that SM could be improved to make it a more useful tool. The vast majority (n = 658, 79.7%) agreed that Veterans would benefit from education on accessing and using MHV and SM.


IMPACT:
This project was designed for local, VISN, and national impact on the implementation and sustainability of the SM feature on MHV through examination of users' experiences. Findings support a program of research for ongoing evaluation of SM implementation and subsequent comparative effectiveness trials to improve patient care and outcomes.

---

External Links for this Project

---

PUBLICATIONS:

Journal Articles

1. Haun JN, Lind JD, Shimada SL, Martin TL, Gosline RM, Antinori N, Stewart M, Simon SR. Evaluating user experiences of the secure messaging tool on the Veterans Affairs' patient portal system. Journal of medical Internet research. 2014 Mar 6; 16(3):e75. [view]
2. Haun J, Lind JD, Shimada SL, Simon SR. Secure Messaging as a tool to facilitate Veteran-provider communication. Annals of anthropological practice. 2013 Jan 1; 37(2):57-74. [view]

Conference Presentations

1. Haun JN, Luther SL, Powell-Cope GM, Simon S, Shimada S, Lind JD. Developing a Conceptual Framework for Understanding Veterans' Experiences Using Secure Messaging on MyHealtheVet. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD. [view]
2. Haun JN, Lind J, Shimada SL, Simon SR, Luther SL. Leveraging Patient Data to Evaluate the Secure Messaging Feature on My HealtheVet. Poster session presented at: American Medical Informatics Association Annual Symposium; 2012 Nov 3; Chicago, IL. [view]

DRA: Health Systems
DRE: Technology Development and Assessment
Keywords: none
MeSH Terms: none