BACKGROUND/RATIONALE:
Currently over 3 million Veterans have been registered for the VA Patient Portal, My HealtheVet (MHV). The portal's features, such as enabling Veterans to refill their medications, send secure messages to their clinical teams, and read their clinician's notes, are integral to VHA's goal of expanding Veteran-facing virtual modalities. Use of MHV features has been associated with improvements in diabetes physiologic measures. However, use of MHV features varies considerably, and little is known about how patients and clinical teams can best leverage features to improve self-management, healthcare processes and outcomes.

OBJECTIVE(S):
This study is designed to uncover the patient portal features associated with improved outcomes and clarify how patients can best leverage them to manage their diabetes. Our primary objectives are to Aim 1) generate new information for feature selection and personalizing interventions, Aim 2) generate details about how patients are effectively using the patient portal, and Aim 3) Conduct a small-scale experiment to test the feasibility of engaging Veterans in a supported adoption intervention to promote effective MHV use in Veterans with diabetes.

METHODS:
Aims 1 and 2 will use a longitudinal cohort-with-nested-case-control design to learn how patients with diabetes use the portal and what patterns of use are associated with better outcomes. Qualitative data from Aim 2 and Veteran co-investigators will provide direct Veteran input (strategies for success) into the intervention delivered in Aim 3.

Aim 1: In a national longitudinal cohort of Veterans with uncontrolled type 2 diabetes receiving care in the VHA, we will test the association of patient portal feature use with improvements in physiologic measures of control (HbA1c, LDL, and blood pressure) and whether the association differs for patients with mental health conditions or those in rural areas.

Aim 2: Our goal is to collect data on at least 200 patients with good glycemic (HbA1c) control (cases) and at least 200 with poor control (controls). Using surveys, secure message coding, and in-depth semi-structured interviews with a subset of about 40-50 patients (approximately 20-25 from each of the above groups), we will examine differences in portal feature use, communication with the clinical team (information sharing, information seeking, socio-emotional exchange), and in sharing information from their portals with family and/or non-VA providers.

Aim 3: We will conduct a small-scale experiment, using a randomized encouragement design, to test the feasibility of engaging Veterans in a supported adoption intervention to promote effective MHV use, in a sample of 200 Veterans with diabetes with or without comorbid mental health diagnoses. Participants randomized in the encouragement arm will receive additional support, such as a mailing, one-on-one and group sessions, and follow-up support. Those in the comparison condition will receive a mailing with only the goal setting content.

FINDINGS/RESULTS:
Findings are to be determined.

IMPACT:
This research will help clarify which portal features are associated with a greater likelihood of achieving controlled diabetes outcomes, and whether those features benefit all Veterans with diabetes equally, or whether the overall effect masks group-level differences which must be accounted for in order to optimize the quality of care for all. These findings will be of critical importance not only to VA, but to other healthcare systems as well that are currently implementing PHR portals, and that serve patient populations faced with complex, chronic healthcare needs.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002100-01A1
Link: https://reporter.nih.gov/project-details/9192078

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PUBLICATIONS:

Journal Articles

1. Robinson SA, Netherton D, Zocchi M, Purington C, Ash AS, Shimada SL. Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis. JMIR diabetes. 2021 Nov 19; 6(4):e32320. [view]
2. Zocchi MS, Robinson SA, Ash AS, Vimalananda VG, Wolfe HL, Hogan TP, Connolly SL, Stewart MT, Am L, Netherton D, Shimada SL. Patient portal engagement and diabetes management among new portal users in the Veterans Health Administration. Journal of the American Medical Informatics Association : JAMIA. 2021 Sep 18; 28(10):2176-2183. [view]
3. Robinson SA, Zocchi M, Purington C, Am L, DeLaughter K, Vimalananda VG, Netherton D, Ash AS, Hogan TP, Shimada SL. Secure Messaging for Diabetes Management: Content Analysis. JMIR diabetes. 2023 Mar 23; 8:e40272. [view]
4. Robinson SA, Zocchi MS, Netherton D, Ash A, Purington CM, Connolly SL, Vimalananda VG, Hogan TP, Shimada SL. Secure Messaging, Diabetes Self-management, and the Importance of Patient Autonomy: a Mixed Methods Study. Journal of general internal medicine. 2020 Oct 1; 35(10):2955-2962. [view]
5. Stewart MT, Hogan TP, Nicklas J, Robinson SA, Purington CM, Miller CJ, Vimalananda VG, Connolly SL, Wolfe HL, Nazi KM, Netherton D, Shimada SL. The Promise of Patient Portals for Individuals Living With Chronic Illness: Qualitative Study Identifying Pathways of Patient Engagement. Journal of medical Internet research. 2020 Jul 17; 22(7):e17744. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Diabetes and Other Endocrine Disorders
DRE: Treatment - Observational, Technology Development and Assessment, TRL - Applied/Translational
Keywords: Diabetes, Disparities, Personal Health Record
MeSH Terms: none