BACKGROUND/RATIONALE:
Over eight million Veterans receive care from VA; many of these Veterans have complex healthcare needs because of multiple chronic conditions, the need for highly specialized care, use of multiple healthcare systems, and long travel distances to the nearest VA facility. Effective personal health management, including information sharing, has the potential to improve self-management, increase provider-patient communication, increase coordination, and empower patients to become more engaged in their care. Although many people manage their personal health information using paper-based systems, improvements in technology and increased access to the internet have created new opportunities for patients to manage their information electronically. In 2003, VA nationally launched their web-based personal health record portal, My HealtheVet. There are varying levels of user access that can allow patients access to a variety of features from health educational materials to lab tests and results. As of September 2013, there were 2.49 million registered users; this was an increase of approximately 27% from the prior year. Over 80% registered users were VA patients (2.02 million), and 1.33 million had premium accounts which allow them to opt in to secure messaging and access data from the VA electronic medical record. These numbers demonstrate the significant number of VA patients who use My HealtheVet, and that the number has increased substantially over the past year.

OBJECTIVE(S):
In the proposed study our objectives were to (1) assess the association between My HealtheVet use and VA costs and utilization, focusing specifically on prevalence of missed appointments, hospitalizations and cost and (2) assess the association between My HealtheVet use and dual use of VA and Medicare services, focusing specifically on duplication of tests and medication in dual users.

METHODS:
We examined changes in utilization and costs over time for new My HealtheVet users in FY2013. Focusing on new users allowed us to compare changes in outcomes before and after the use of a My HealtheVet feature for both users and non-users while accounting for time trends. The comparison group included a sample of Veterans who have had at least two encounters at a VA facility during FY2013 and who are not registered My HealtheVet users. We will also compare changes in missed appointments, VA utilization, costs, and the other study outcomes by comparing new My HealtheVet users to current registered users not utilizing My HealtheVet during the study period, which also include data from FY2014-15. To examine possible associations between My HealtheVet use and outcomes, we used the appropriate multiple regression model for each outcome. These models were weighted using propensity scores to address potential differences between the comparison groups that might also impact the outcomes. Sample sizes for each analysis varied.

FINDINGS/RESULTS:
To accomplish our first aim, we performed a detailed comparison of VA utilization and costs before and after Veterans started using My HealtheVet. We then compared these changes with Veterans who never used My HealtheVet. Veterans who used My HealtheVet had significantly higher costs and utilization in year before the index date compared to non-users, and after adjusting for Veteran characteristics, the total VA health care costs increased by approximately $2000 more between the year before and after the index date compared to non-users. Between the first and second year after the index date, however, the total costs started decreasing for the My HealtheVet users but continued to increase for the non-users. By the third year after the index date, total costs were again increasing for both groups.

We also examined the association between the use of the appointment view feature and the number of missed appointments (no-shows). In the year after Veterans starting using the appointment view feature in My HealtheVet (or a comparable index date for the non-users), the overall predicted no-shows was 4.5 for users and 6.1 for the comparison group. This difference was much bigger, however, for younger Veterans. While the users of appointment views who were younger than 25 had a predicted number of 14 missed appointments, in the comparison group of the same age the predicted number of no-shows was 19.
While examining portal use, we also described the use of MHV by Veterans with chronic conditions, specifically mental health conditions. In a paper published in Administration and Policy in Mental Health and Mental Health Conditions Research, we presented the results of our findings comparing portal use by Veterans with mental health diagnoses. Veterans who had experienced military sexual trauma, or an anxiety disorder, or post-traumatic stress disorder, or depression had higher odds of portal use compared to Veterans who did not have these diagnoses. Diagnoses that were associated with lower odds of portal use included bipolar depression, substance use, psychosis, and adjustment disorders.

To accomplish Aim 2, we examined both overlapping medication use between VA and Medicare and duplication of hemoglobin 1AC testing. We found that 30% of Blue Button prescription view users received medications from both VA and Medicare Part D-covered pharmacies for the same drug classes with days' supplies that overlapped by 7 or more days compared to 23% of non-MyHealtheVet users (P<0.001). However, the percent of Veterans with overlapping medications varied by the number of medication supplies that Veterans received. For Veterans who obtained a larger number of 30-day supplies of medications, use of the Blue Button prescription view feature of MyHealtheVet was associated with less overlap in days' supplies of medication from the same drug class from VA and Part D-covered pharmacies. For dual users of VA and Medicare, HealtheVet Blue Button lab users had lower odds of having an excess number of hemoglobin 1AC lab tests.



IMPACT:
The impacts of the study highlight the complexity of examining the association between patient portal use, outcomes, and cost. Patient portals have the potential to improve communication between patients and providers, increase coordination through use of the Blue Button, and to increase patient engagement in managing their conditions. The results of our analyses suggest, however, that the associations between portal use and cost vary over time and that some Veterans might experience more benefits from portal use than others. Additional research is needed to understand how to optimize portal use.

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External Links for this Project

NIH Reporter

Grant Number: I01HX001637-01A1
Link: https://reporter.nih.gov/project-details/8861496

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PUBLICATIONS:

Journal Articles

1. Etingen B, Hogan TP, Martinez RN, Shimada S, Stroupe K, Nazi K, Connolly SL, Lipschitz J, Weaver FM, Smith B. How Do Patients with Mental Health Diagnoses Use Online Patient Portals? An Observational Analysis from the Veterans Health Administration. Administration and policy in mental health. 2019 Sep 1; 46(5):596-608. [view]
2. Wakefield BJ, Turvey C, Hogan T, Shimada S, Nazi K, Cao L, Stroupe K, Martinez R, Smith B. Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2020 Oct 1; 26(10):1211-1220. [view]
3. Connolly SL, Etingen B, Shimada SL, Hogan TP, Nazi K, Stroupe K, Smith BM. Patient portal use among veterans with depression: Associations with symptom severity and demographic characteristics. Journal of affective disorders. 2020 Oct 1; 275:255-259. [view]
4. Siddiqui S, Etingen B, Patrianakos J, Shimada S, Hogan T, Nazi K, Stroupe K, Smith B. Use of the Veterans Health Administration online patient portal among Veterans with spinal cord injuries and disorders. The journal of spinal cord medicine. 2022 Jun 28; 1-12. [view]
5. Stroupe KT, Nazi K, Hogan TP, Poggensee L, Wakefield B, Martinez RN, Etingen B, Shimada S, Suda KJ, Huo Z, Cao L, Smith BM. Web-based patient portal use and medication overlap from VA and private-sector pharmacies among older veterans. Journal of managed care & specialty pharmacy. 2021 Aug 1; 27(8):983-994. [view]

VA Cyberseminars

1. Smith B, Khan HT. Lessons Learned: Examining the Association of My HealtheVet, Healthcare Utilization, and Costs. VIReC Using Data & Information Systems in Partnered Research [Cyberseminar]. VA Information Resource Center. 2018 Apr 17. [view]

DRA: Health Systems
DRE: Treatment - Observational
Keywords: Care Management Tools, Cost-Effectiveness, Efficiency, Patient Safety, Reintegration Post-Deployment
MeSH Terms: none