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DOI: 10.4338/ACI-2017-05-RA-0088
Clinical Practice Informs Secure Messaging Benefits and Best Practices
Address for correspondence
Publication History
01 June 2017
15 August 2017
Publication Date:
14 December 2017 (online)
- Background and Significance
- Objectives
- Methods
- Results
- Discussion
- Conclusion
- Clinical Relevance Statement
- Multiple Choice Questions
- References
Abstract
Background Clinical care team members in Department of Veterans' Affairs (VA) facilities nationwide are working to integrate the use of Secure Messaging (SM) into care delivery and identify innovative uses. Identifying best practices for proactive use of SM is a key factor in its successful implementation and sustained use by VA clinical care team members and veterans.
Objectives A collaborative project solicited input from VA clinical care teams about their local practices using SM to provide access to proactive patient-centered care for veterans and enhance workflow.
Methods This project implemented a single-item cross-sectional qualitative electronic survey via internal e-mail to local coordinators in all 23 Veterans Integrated Service Networks (VISNs). Content analysis was used to manage descriptive data responses. Descriptive statistics described sample characteristics.
Results VA clinical care team members across 15 of 23 VISNs responded to the questionnaire. Content analysis of 171 responses produced two global domains: (1) benefits of SM and (2) SM best practices. Benefits of SM use emphasize enhanced and efficient communication and increased access to care. Care team members incorporate SM into their daily clinical practices, using it to provide services before, during, and after clinical encounters as a best practice. SM users suggest improvements in veteran care, clinical team workflow, and efficient use of health resources. Clinical team members invested in the successful implementation of SM integrate SM into their daily practices to provide meaningful and useful veteran-centered care and improve workflow.
Conclusion VA clinical care team members can use SM proactively to create an integrated SM culture. With adequate knowledge and motivation to proactively use this technology, all clinical team members within the VA system can replicate best practices shared by other clinical care teams to generate meaningful and useful interactions with SM to enrich veterans' health care experience.
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Keywords
patient provider communication - messaging - ambulatory care/primary care - process improvement - diffusion of innovationBackground and Significance
Secure Messaging (SM) is an asynchronous communication tool within the Department of Veterans' Affairs (VA) My HealtheVet (MHV) patient portal. Similar to e-mail, SM provides a convenient and secure way for veterans to communicate electronically with their VA health care teams and other VA staff. Implementation of SM began on a voluntary basis in 2008; however, by 2012 it became mandatory for all VA primary care teams to ensure nationwide availability for veterans to communicate electronically with their primary care teams. Teams can establish a triage process for incoming messages that aligns with their existing processes (e.g., a nurse may triage and respond and complete or assign an incoming message from a veteran to a specific staff member). Based on guidelines for appropriate use for delivery of care and communication with veteran patients, SMs from veterans must be responded to and completed within 3 business days or the message is escalated and alerts are generated to notify the team. SMs may be reassigned not only to other team members but also to other SM teams both locally and nationally. SMs may be saved to the patient's electronic record as necessary to keep all care providers informed and, as appropriate, documented as an online evaluation and management encounter.
SM is an effective tool for supporting patient access to care and enhancing patient–provider communication, patient engagement, and self-management. This is accomplished through more efficient utilization of health services and resources, resulting in improved patient outcomes.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] To this end, VA has established MHV coordinators throughout the VA health care system to enroll patients and support their use of this patient-facing portal. A national My HealtheVet Coordinator Workgroup prioritizes goals related to enrollment, use, and functioning of SM across the VA health care system. The workgroup includes subject matter experts, operational partners, and local MHV coordinators. A systematic literature review conducted by VA researchers suggests that use of a patient portal including SM was associated with improved patient satisfaction and improved outcomes for patients with chronic diseases including diabetes and hypertension.[13] A VA study conducted by Shimada et al demonstrated that sustained use of SM improved glycemic control and LDL (low-density lipoprotein) cholesterol for patients with type 2 diabetes mellitus.[14] These studies suggest that use of SM as part of an integrated patient portal results in improved patient satisfaction, compliance, and communication, yielding improved patient outcomes. However, as with most innovations in health care, there is variation in perceived value and use. To date, most SMs are initiated by veterans, with the health care team responding to questions or requests. Yet the potential for SM to be used proactively, with the health care team initiating a message to the patient, may provide additional benefits. Further expansion to all surgical and specialty care teams has been significant; however, not all potential users (i.e., clinical care team members) are fully invested, motivated, or aware of how to fully integrate SM into care delivery. Identifying and disseminating local best practices for innovative and proactive use of SM is a key factor in its successful implementation and sustained use by VA clinical care team members and veterans to generate meaningful and useful interactions with SM.
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Objectives
The goal of this project was to improve the integration of SM into the fabric of VA health care by identifying and disseminating SM best practices reported by front-line VA clinical care team members to provide proactive, patient-centered care to veterans and enhance provider workflow.
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Methods
The VHA system is divided into 23 network areas called Veterans Integrated Service Networks (VISNs). This field-initiated collaborative project used a cross-sectional study design to distribute a single-item electronic survey via internal e-mail to local MHV coordinators in all 23 VISNs. MHV coordinators used e-mail and interpersonal contact to solicit input from their local clinical communities. Individual methods used by coordinators were not collected as part of this data collection process.
As a part of the operational mission of the VA to increase the proactive use of SM by clinical care team members, survey findings were disseminated using multiple methods. VA leverages multiple strategies for informing, educating, and motivating adoption of best practices by VA employees and as such the research team, operational representatives, and the national My HealtheVet Coordinator Workgroup collaborated to create a series of products for dissemination including a multimedia video and a “playbook' of best practices. These products were disseminated on a series of leadership calls, distributed to national workgroups, and posted on internal shared sites to be accessible to all VA employees. These dissemination efforts are further detailed in the discussion section.
Data Collection Instrument
A single-item questionnaire was developed to elicit information about how front-line providers use SM to: (1) improve communication; (2) improve efficiency; (3) increase patient access; and (4) improve workflow in clinical practice. These four areas are key priorities to the MHV Workgroup. Providers were specifically asked: “Please explain how you are using Secure Messaging to improve communication, efficiency, patient access, or workflow in your practice.” Open-ended responses were collected to encourage clinical care teams to think broadly and describe their practices in their own words.
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Data Management and Security
Responses were organized by row using an Excel spreadsheet. Responses were de-identified, assigned unique response IDs and entered in individual cells. Corresponding cells in each response row contained respondent demographic information that included the Respondent's Role, VISNs, Medical Center, and Service Unit. The spreadsheet was housed on a server protected by the VA firewall and raw data were shared using encrypted e-mail only.
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Data Analysis
A rapid, content analysis of responses was conducted by two trained qualitative researchers. Researchers created a data reduction matrix[15] using a Microsoft Excel workbook to organize response data by domains and subdomains that represented clinical care team member's experiences using SM. First-level coding was guided by the four domains stated in the single-item questionnaire. Data were organized into descriptive titles representing the four primary questionnaire constructs: (1) communication, (2) efficiency, (3) patient access, and (4) workflow improvements. Constructs were not mutually exclusive and could be single-, double-, triple-, or quadruple-coded to account for multiple topics within a single entry. For example, a response could be coded “efficiency” and “communication” if it indicated that using SM to follow up with patients instead of calling them on the phone saves time and creates a record of contact that the patients can review as many times as they need. Responses were then sorted into four separate spreadsheets representing each of the four constructs. The sorted spreadsheet responses were coded using a second-level, thematic coding technique, which drilled down on subdomains within each domain. Researchers used memos to describe and operationalize codes and document their decision-making process. Memos helped researchers refine subdomains iteratively during the coding process. Following thematic coding, all data were sorted into two global domains: (1) benefits of SM and (2) SM best practices.
Finally, a panel of subject matter experts from the MHV Coordinators Workgroup and VA national offices reviewed and validated data findings. A total of nine review sessions were conducted over 2 months to validate data and reach agreement. The dataset collected for the current study are available from the corresponding author on reasonable request; however, the majority of data generated during this study are included in this published article as [Supplementary Material] (available in the online version).
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Results
One hundred and seventy-one responses to the survey item were collected from clinical care team members representing 15 of the 23 VISNs. Clinical care team type of VA service, respondent role, and geographic VISNs are shown in [Table 1]. Responses represented two global domains: (1) benefits of SM and (2) SM best practices. A comprehensive list of responses is organized in [Supplementary Material] (available in the online version).
Abbreviations: LCSW, licensed clinical social worker; MHV, My HealtheVet; PM&R, physical medicine and rehabilitation.
Clinical care team member reports addressed access, trust, quality and continuity of communication, and care. Team members reported SM enhances continuity in communication among care team members and veterans. SM increases access to communicate with veterans, while simultaneously providing a multitude of workflow benefits; limiting duplication of efforts, and increasing efficient use of time and resources (e.g., paper, labels, postage). Team members also reported a perceived reduction in miscommunication and related errors. Efficiency in response times and reductions in miscommunications and errors all contribute to a key benefit of improving veteran's access to care and their experience of care and reducing their frustration to ensure high-quality service delivery. Domains and exemplar quotes relevant to clinical team members–identified benefits of SM are presented in [Table 2].
Most notable in this dataset, clinical care team member reports identified best practices that benefitted both veterans and clinical care teams. Reported best practices were related to creating an SM culture. SM culture is best defined as the standard by which meaningful use of SM is fully integrated throughout the process of health care delivery. Creating an effective SM culture is critical for effective and sustained implementation because accepted and expected SM use is a cultural standard by user groups in delivering and receiving health care.
Responses indicate creating a positive SM culture is an assimilation of proactively educating staff about SM and endorsing its proactive use, asking staff to prioritize SM enrollment, integrating SM into daily clinical practice, using SM for proactive outreach, leveraging SM across VA services, and integrating SM into their current workflow. Respondents described the most effective practices for integrating SM into provider's workflow or “triaging.” These include: establishing SM responsibilities by clinical role; requiring that clinical care team members designate protected time to review and respond to SM; using SM to follow up after a visit or missed appointment; using SM for preappointment preparation; and responding to SMs within 24 hours. Two other subdomains that emerged from the data were practices of managing population health and reflecting on correspondence to promote patient-centered tone and language. Subdomains and exemplar quotes relevant to clinical team members–identified SM best practices are presented in [Table 3].
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Discussion
As part of an organization-wide initiative to integrate SM into VA care delivery, this project was designed to solicit input directly from front-line VA clinical care teams to identify benefits and best practices related to using SM. The overall goal was to disseminate these findings nationally to demonstrate how VA clinical care teams can use SM in a useful and meaningful way to support proactive veteran-centered care and enhance clinical workflow. This article leverages the experiences of this user group to give insight into their SM experience to inform a peer-driven approach to innovation implementation and adoption, by tapping into the practices of motivated users who perceived benefits from their experience using SM. The purpose of this project was to seek insights about the meaningful use of SM by front-line clinicians and staff to inform efforts to promote its sustained proactive meaningful use nationally across all clinical care teams. As such, the quantity of responses is not as meaningful as the quality of the responses. A benefit and/or best practice does not need to be reported multiple times to be meaningful and/or innovative.
First, data indicate clinical care team member respondents perceived several benefits to using SM. When compared with previous data collected from veterans,[16] [17] about their perceived benefits associated with SM use, these clinical narratives mirror that SM enhances access, trust, quality, and continuity and illustrated a multitude of workflow benefits including efficient use of time and resources. Beyond benefits, the core objective of this project was to identify and disseminate best practices which would demonstrate the usefulness of SM. The most compelling practice was clinical care team members' use of SM proactively to create an integrated SM culture in which SM is viewed as an integral part of providing clinical care, no less important than taking a patient's blood pressure or writing a prescription. Clinical care teams created a culture of SM by integrating the use of this electronic communication tool into clinical practice and service provision before, at, and after the point of care. Proactively educating staff and enrolling patients, endorsing use among user groups, and integrating the tool into daily practice and workflow provided a multiprong approach to integrating this tool into the culture of care delivery. Establishing this culture enhances provider buy-in, utilization, and promotion through communication.
SM represents a communication platform that can be used in varying ways by local clinical care teams. Using SM to manage population health is a critical example of the broad reach and efficiency this tool can provide, particularly to areas of specialty care such as health promotion and disease prevention, and infectious disease management. Finally, and maybe most notable, the practice of perceiving SM messages as correspondence can enhance communication by using patient-centered tone and language. Synchronous communication, such as face-to-face conversations and phone calls, does not allow for editing of tone and language, whereas SM, an asynchronous communication method, allows the sender to review and edit message content to ensure language is appropriate, supportive, and patient-centered. This surfaced as a best practice which can promote the vital and often unstated values of trust and high-quality communication among veterans and their health care team members. In a large system, with the potential for patients to feel lost and depersonalized, this practice promotes the personal touch of empathy, compassion, and respect that can be crucial in all forms of communication when delivering care to patients.
Dissemination of Findings
Several products were developed to support dissemination of these findings throughout the VA. Findings were distilled into a 7-minute educational video for national dissemination. This product was designed and produced with VA clinical team members to optimize relevance and usefulness. Survey responses were also used to create a “Secure Messaging Best Practices Playbook” as a companion reference piece to the SM Best Practices video. The “Secure Messaging Best Practices Playbook” provides the user with a comprehensive document that can be easily navigated to sections of the users' interest ([Supplementary Material], available in the online version). The video was published on VA's national MHV and SM workgroup web sites and disseminated to VA's national primary care, social work, patient advocate, dental, patient care services, caregiver support, and case manager networks. This content was also presented by VA Office of Connected Care leadership on a national MHV coordinator teleconference meeting. This work was also used to develop a chapter in the VA Undersecretary's book entitled, “Best Care Anywhere.”
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Limitations
The limitations of this project should be considered when interpreting these data. First, this is a convenience sample of VA staff; the representativeness and generalizability applies only to the VISNs and VA clinical care team members who responded. Nor do we have specific data on how local coordinators solicited responses to the survey item from clinical care team members. Second, there is threat for response bias. It should also be noted that this sample is heavily weighted toward the nursing perspective, but it also supports anecdotal reports that nursing staff are often the care team members communicating through SM. Additionally, data represented approximately 65% of VA VISNs with more than 53% of respondents from three VISNs; thus, ability to generalize findings to those underrepresented is limited. However, qualitative data responses are based on representation and saturation; as such, data findings present meaningful results for informing SM benefits and best practices. Third, as with any descriptive study that is cross-sectional in nature, the study does not allow statements on motivation for SM use. However, it does provide much needed descriptive data to understand clinical team members' experiences in using SM to deliver health care. Fourth, the generalizability of these findings outside the VA system, within private sector clinical care systems, is limited and does not account for economic incentives, which are different across these care settings. Finally, although this study provided important data on clinical care team members' experiences and perceptions about the use of SM, we cannot comment on how veterans' experience these reported practices. However, insight into veterans' experiences using SM has been explored by this research in previous studies.[16] [17]
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Future Research
Future research would benefit from this field of inquiry by addressing contextual facilitators and barriers to clinical team members' use of SM and interventions to overcome barriers. To enhance use of SM by care team members other than nursing (e.g., physicians, specialty care), future research should focus on provider experiences and needs, specifically targeting responses from these clinical roles for a more well-rounded perspective. Future implementation research should evaluate specific implementation strategies for promoting adoption and sustained integrated and meaningful use by clinical care teams, and determining if different groups respond to different implementation strategies. Additionally, future research should explore the appropriate use and effects of SM in care management and patient outcomes, and costs associated with the use of SM in care delivery.
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Conclusion
SM represents a communication platform that can be used in many useful and meaningful ways by local clinical care teams. Soliciting input directly from local clinical care teams can be an effective strategy for identifying best practices that can then be further disseminated to encourage implementation of these practices throughout the national system. Local clinical care teams report that the proper use of SM can improve veterans' care and clinical team workflow, and support the efficient use of the VA's health resources. However, knowing how to effectively use the tool to deliver health care is a key factor in its sustained proficient use. Using actual clinical narratives to inform other VA providers about how to benefit from SM use is critical to improving provider uptake of the tool. Front-line providers have the credibility and contextual knowledge to describe acceptable and useful practices for integrating SM into their daily practice to provide veteran-centered care and improve workflow. With adequate knowledge and motivation, efforts to proactively use SM can be replicated by all clinical team members within the VA system.
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Clinical Relevance Statement
VA clinical care team members can use SM proactively to create an integrated SM culture. Care team members generate this culture by incorporating SM into their clinical practices, using it to provide services before, at, and after clinical encounters. An integrated SM culture can support the efficient use of health resources, improve clinical team workflow, and foster excellence in veteran care.
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Multiple Choice Questions
When creating a culture of Secure Messaging, which of the following must be considered?
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Educating clinicians about benefits and best uses of Secure Messaging.
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Educating veterans about benefits and best uses of Secure Messaging.
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Promoting use of Secure Messaging by clinicians and veterans.
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All of the above.
The correct answer is D. Educating clinicians and veterans about benefits and best uses of Secure Messaging and promoting their use of Secure Messaging is critical to supporting sustained meaningful use of Secure Messaging in delivering and receiving clinical care services.
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Conflict of Interest
None.
Acknowledgments
The development of this article was supported by the Department of Veterans' Affairs, Veterans Health Administration, and in part by the Center of Innovation for Disability and Rehabilitation Research at the James A. Haley Veterans Hospital and the Veterans and Consumers Health Informatics Office.
Note
The contents of this article do not represent the views of the Department of Veterans' Affairs or the United States Government. All the authors have approved the final version of the article.
Protection of Human and Animal Subjects
Procedures were reviewed and are in compliance with ethical standards of the local institutional review board and with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects.
Funding
None.
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References
- 1 Nazi KM. The personal health record paradox: health care professionals' perspectives and the information ecology of personal health record systems in organizational and clinical settings. J Med Internet Res 2013; 15 (04) e70
- 2 Harris LT, Koepsell TD, Haneuse SJ, Martin DP, Ralston JD. Glycemic control associated with secure patient-provider messaging within a shared electronic medical record: a longitudinal analysis. Diabetes Care 2013; 36 (09) 2726-2733
- 3 Ye J, Rust G, Fry-Johnson Y, Strothers H. E-mail in patient-provider communication: a systematic review. Patient Educ Couns 2010; 80 (02) 266-273
- 4 Roter DL, Larson S, Sands DZ, Ford DE, Houston T. Can e-mail messages between patients and physicians be patient-centered?. Health Commun 2008; 23 (01) 80-86
- 5 Ralston JD, Martin DP, Anderson ML. , et al. Group health cooperative's transformation toward patient-centered access. Med Care Res Rev 2009; 66 (06) 703-724
- 6 Garrido T, Meng D, Wang JJ, Palen TE, Kanter MH. Secure e-mailing between physicians and patients: transformational change in ambulatory care. J Ambul Care Manage 2014; 37 (03) 211-218
- 7 Shimada SL, Hogan TP, Rao SR. , et al. Patient-provider secure messaging in VA: variations in adoption and association with urgent care utilization. Med Care 2013; 51 (03) (Suppl. 01) S21-S28
- 8 Andreassen HK, Trondsen M, Kummervold PE, Gammon D, Hjortdahl P. Patients who use e-mediated communication with their doctor: new constructions of trust in the patient-doctor relationship. Qual Health Res 2006; 16 (02) 238-248
- 9 Houston TK, Sands DZ, Jenckes MW, Ford DE. Experiences of patients who were early adopters of electronic communication with their physician: satisfaction, benefits, and concerns. Am J Manag Care 2004; 10 (09) 601-608
- 10 Zhou YY, Garrido T, Chin HL, Wiesenthal AM, Liang LL. Patient access to an electronic health record with secure messaging: impact on primary care utilization. Am J Manag Care 2007; 13 (07) 418-424
- 11 Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Aff (Millwood) 2010; 29 (07) 1370-1375
- 12 Harris LT, Haneuse SJ, Martin DP, Ralston JD. Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis. Diabetes Care 2009; 32 (07) 1182-1187
- 13 Goldzweig CL, Towfigh AA, Paige NM. , et al. Systematic Review: Secure Messaging Between Providers and Patients, and Patients' Access to Their Own Medical Record. Evidence-based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center. Washington, DC: Department of Veterans Affairs; 2012
- 14 Shimada SL, Allison JJ, Rosen AK, Feng H, Houston TK. Sustained use of patient portal features and improvements in diabetes physiological measures. J Med Internet Res 2016; 18 (07) e179
- 15 Beebe J. Rapid Assessment Process: An Introduction. Walnut Creek, CA: AltaMira Press; 2001
- 16 Haun JN, Lind JD, Shimada SL. , et al. Evaluating user experiences of the secure messaging tool on the Veterans Affairs' patient portal system. J Med Internet Res 2014; 16 (03) e75
- 17 Haun JN, Patel NR, Lind JD, Antinori N. Large-scale survey findings inform patients' experiences in using secure messaging to engage in patient-provider communication and self-care management: a quantitative assessment. J Med Internet Res 2015; 17 (12) e282
Address for correspondence
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References
- 1 Nazi KM. The personal health record paradox: health care professionals' perspectives and the information ecology of personal health record systems in organizational and clinical settings. J Med Internet Res 2013; 15 (04) e70
- 2 Harris LT, Koepsell TD, Haneuse SJ, Martin DP, Ralston JD. Glycemic control associated with secure patient-provider messaging within a shared electronic medical record: a longitudinal analysis. Diabetes Care 2013; 36 (09) 2726-2733
- 3 Ye J, Rust G, Fry-Johnson Y, Strothers H. E-mail in patient-provider communication: a systematic review. Patient Educ Couns 2010; 80 (02) 266-273
- 4 Roter DL, Larson S, Sands DZ, Ford DE, Houston T. Can e-mail messages between patients and physicians be patient-centered?. Health Commun 2008; 23 (01) 80-86
- 5 Ralston JD, Martin DP, Anderson ML. , et al. Group health cooperative's transformation toward patient-centered access. Med Care Res Rev 2009; 66 (06) 703-724
- 6 Garrido T, Meng D, Wang JJ, Palen TE, Kanter MH. Secure e-mailing between physicians and patients: transformational change in ambulatory care. J Ambul Care Manage 2014; 37 (03) 211-218
- 7 Shimada SL, Hogan TP, Rao SR. , et al. Patient-provider secure messaging in VA: variations in adoption and association with urgent care utilization. Med Care 2013; 51 (03) (Suppl. 01) S21-S28
- 8 Andreassen HK, Trondsen M, Kummervold PE, Gammon D, Hjortdahl P. Patients who use e-mediated communication with their doctor: new constructions of trust in the patient-doctor relationship. Qual Health Res 2006; 16 (02) 238-248
- 9 Houston TK, Sands DZ, Jenckes MW, Ford DE. Experiences of patients who were early adopters of electronic communication with their physician: satisfaction, benefits, and concerns. Am J Manag Care 2004; 10 (09) 601-608
- 10 Zhou YY, Garrido T, Chin HL, Wiesenthal AM, Liang LL. Patient access to an electronic health record with secure messaging: impact on primary care utilization. Am J Manag Care 2007; 13 (07) 418-424
- 11 Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Aff (Millwood) 2010; 29 (07) 1370-1375
- 12 Harris LT, Haneuse SJ, Martin DP, Ralston JD. Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis. Diabetes Care 2009; 32 (07) 1182-1187
- 13 Goldzweig CL, Towfigh AA, Paige NM. , et al. Systematic Review: Secure Messaging Between Providers and Patients, and Patients' Access to Their Own Medical Record. Evidence-based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center. Washington, DC: Department of Veterans Affairs; 2012
- 14 Shimada SL, Allison JJ, Rosen AK, Feng H, Houston TK. Sustained use of patient portal features and improvements in diabetes physiological measures. J Med Internet Res 2016; 18 (07) e179
- 15 Beebe J. Rapid Assessment Process: An Introduction. Walnut Creek, CA: AltaMira Press; 2001
- 16 Haun JN, Lind JD, Shimada SL. , et al. Evaluating user experiences of the secure messaging tool on the Veterans Affairs' patient portal system. J Med Internet Res 2014; 16 (03) e75
- 17 Haun JN, Patel NR, Lind JD, Antinori N. Large-scale survey findings inform patients' experiences in using secure messaging to engage in patient-provider communication and self-care management: a quantitative assessment. J Med Internet Res 2015; 17 (12) e282