Investigators identified 26 hypothesis-testing articles about secure messaging. A number of studies evaluated multiple outcomes, and these studies are included in each relevant section: health outcomes, patient satisfaction, adherence, and efficiency/utilization of care. The hypothesis-testing studies that include SM support the following conclusions.

• There is moderate-strength evidence to suggest:
  • SM (especially as part of a web-based management system) can improve glucose outcomes in patients with diabetes.
  • SM increases patient satisfaction.
• There is low-strength evidence to suggest:
  • Adding a web-based pharmacist to SM improves blood pressure outcomes in patients with hypertension.
  • SM with a web-based management system improves ulcerative colitis symptoms.
  • SM improves adherence to colorectal cancer screenings and heart failure management.
• There is conflicting, low-strength evidence on how SM may influence healthcare utilization or efficiency.

Question #2
What is the association between patient access to their own medical record and health outcomes, patient satisfaction, adherence, efficiency or utilization, and attitudes about access?

There were 31 articles related to patients having electronic access to their own medical records. These articles were divided into studies that evaluated "tethered" systems -- where patients had access to information through a system (usually web-based) tied to a provider-based electronic record and that included functionalities such as secure messaging -- and those that evaluated non-tethered systems. The studies were further sub-divided into those that were hypothesis-testing, evaluating outcomes such as health outcomes, satisfaction, adherence, healthcare efficiency or healthcare utilization and attitudes; and those that were descriptive and qualitative. The evidence reviewed regarding patient access to their own medical records, when this is tethered to an electronic health record (patient portal), supports the following conclusions.

• There is moderate-strength evidence to suggest:
  • The use of patient portals is lower among certain racial or ethnic groups, in particular African Americans.
  • The use of patient portals is lower in persons with lower literacy or education level.
• There is low-strength evidence to suggest that patient portals:
  • Improve health outcomes for chronic diseases such as diabetes, hypertension, or heart failure.
  • Can improve medication decisions at a subsequent visit for patients with diabetes, when combined with the ability to submit an electronic care plan.
  • Can influence the utilization of healthcare services.
• There is insufficient evidence to reach conclusions regarding:
  • The potential effect of patient portals on efficiency.
  • The potential effect of patient portals on patient attitudes.

Overall Conclusions
Data are sparse, but support the conclusion that the use of secure messaging can improve glucose outcomes in patients with diabetes and increase patient satisfaction. Data from other studies suggest that patient access to tethered portals, when combined with a care manager, can improve health outcomes for chronic diseases such as diabetes and hypertension. This finding supports the conclusions from other studies that suggest that health information technology (HIT) is a tool that, if implemented alone, may have modest or even no measurable effect. However, HIT can enable the implementation of more comprehensive programs (e.g., a web-based care management system) that can have meaningful effects on the quality of healthcare.

Future Research
Any research within VA is going to be pragmatic by design, since VA is already implementing secure messaging and allowing patients access to their own records (meaning that any kind of randomized study where this is withheld is not practical). Nevertheless, a time-series study of the implementation of SM or patient portals across institutions would be feasible and could provide reasonable, hypothesis-testing data to assess the effect of increasing SM or patient portal use on quality, productivity, and patient satisfaction. Such a study would need to use both within-institution and across-institution comparisons to deal with the possibility of secular trends in quality, productivity, and satisfaction, as well as the "institution effect."

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference
Goldzweig CL, Towfigh AA, Paige NM, Orshansky G, Haggstrom DA, Beroes JM, Miake-Lye IM, Shekelle PG. Systematic Review: Secure Messaging between Providers and Patients, and Patients' Access to Their Own Medical Record. Evidence on Health Outcomes, Satisfaction, Efficiency and Attitudes. VA-ESP Project #05-226, 2012.

View the full report.