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Health Services Research & Development

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FORUM - Translating research into quality health care for Veterans

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Research Highlight

In line with this FORUM's focus on care management, we report on recent research related to Secure Messaging's potential to support care management and shared decision making outside the "bricks and mortar" of in-person clinic visits. VA serves a Veteran population with a heavy burden of chronic illness. As the Veteran population ages, the prevalence of VA users with multiple chronic conditions will continue to rise. Health care management is currently centered on the intermittent transaction of the clinical visit, which does not work well for chronic, complex conditions. Transactional care with three-month follow-up visits fosters clinical inertia on the part of the provider, and does not achieve optimum control. The National Academy of Medicine has advised a shift toward continuous care for chronic conditions, including the use of technologies, such as patient portals, personal health records, and Secure Messaging, which, in VA, offers asynchronous online communication between patients and their clinical team.


With over 2 million Veterans able to use Secure Messaging through the My HealtheVet patient portal, VA is one of the largest adopters of this form of communication in the United States. VA investigators have demonstrated that facility adoption of Secure Messaging is associated with reduction in urgent care visits, and use of Secure Messaging by Veterans with diabetes is associated with improvements in hemoglobin A1c. Currently, most use of Secure Messaging is reactive, with clinical teams responding to patient requests, as opposed to clinical teams reaching out to seek information from patients and engage them in their care. Engaging patients and providers in shared agenda setting and encouraging information sharing about goals has been demonstrated to increase patient perceptions of autonomy and to improve adherence and outcomes. Yet implementation of shared agenda setting in primary care is challenging due to time constraints on the in-person encounter.

With funding from VA's Quality Enhancement Research Initiative, we recently completed an evaluation of proactive pre-visit Secure Messaging. Our goal was to implement a pre-visit cue to patients via Secure Messaging to share the "three things they would like to talk to the doctor about." Two weeks prior to a clinic visit, pre-visit Secure Messages were sent to VA primary care patients. When patients responded, the primary care team received a response alert. In pre-implementation work, primary care teams voiced strong support for the pre-visit Secure Message concept, but experienced problems integrating it within existing workloads. In response, we developed a revised implementation program that centralized a "pre-visit Secure Messaging champion" who assumed the work of sending out pre-visit messages for all teams.

During implementation across two VA facilities, 14 clinical teams were trained in how to manage pre-visit responses from patients. To facilitate training, needs assessment data collected from teams revealed a preference for scenarios illustrating the role of pre-visit planning through Secure Messaging, Secure Messaging templates to support uptake, as well as training guides and related educational materials about use of pre-visit messages among different stakeholders. These resources and accompanying content were disseminated through in-person team training sessions.

To assess impact of implementation, we monitored rates of reading and responding to Secure Messages, coded the content of the messages (e.g., related to diagnoses, symptoms, tests, medications, and psychosocial and preventive health issues), and then reviewed charts for documentation of provider action in response to the patient concerns in message replies.

Of 1,967 patients who were sent pre-visit messages, 756 (38 percent) read the messages, and 201 (10 percent) replied with an agenda (concerns to discuss at the visit). Patient messages included concerns about medications (43 percent), tests (35 percent), pain (32 percent), other symptoms (48 percent), and psychosocial or preventive issues (10 percent). Of the 561 concerns included in these 201 messages, 81 percent were documented to have been addressed by their physician, either in a pre-visit Secure Message response, or in the note from the clinic visits. Among concerns that were medication-related, 93 percent were addressed. However, if the concern was psychosocial in nature or related to preventive health, documentation showed that providers addressed only 54 percent in the episode of care.

Several recent systematic reviews have reinforced that interventions designed to increase shared agenda setting, decision support, and patient engagement in care have resulted in improved care management and outcomes. We found that some, but not all patients utilized the patient portal to respond with agenda items for the appointment. With training, providers were responsive to patient concerns; however, our review of clinical documentation found variability in the extent to which different kinds of concerns were addressed. Beyond this study, further work is needed to increase patient response to pre-visit preparation cues and to further support providers in their efforts to be responsive to patient agendas.

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