Secure Email Message Research Articles

FINDINGS FROM A PILOT PRAGMATIC CLINICAL TRIAL EMBEDDING CAREGIVER PROGRAMS IN OUTPATIENT SETTINGS

Abstract Many interventions targeting family/informal caregivers of community-dwelling persons living with dementia have been tested in clinical trials, but few efficacious interventions have been offered in “real world” settings using embedded pragmatic clinical trial (ePCT) methods. This pilot ePCT engaged outpatient geriatrics and memory care clinics in two health systems to implement two caregiver support programs. We used patient portals in electronic health records (EHR) and caregiver registries to invite caregivers to receive one of two remotely-delivered caregiver support programs: the efficacious partly-synchronous Tele-Savvy (TS) program; or the completely-asynchronous Caregiving During Crisis (CDC) program. Random assignment (3TS:2CDC) was employed. Outcome measures were: self-reported caregiving mastery; perceived stress; and caregivers’ reaction to behavioral issues. Measures were collected using self-administered questionnaires sent via patient portals or secure email messaging before randomization and 3 months later (3m). In total, 74 caregivers participated: 59.5% received TS; 73.0% females, 17.6% Black caregivers, with average age 65.5+/-11.8 years. Thirty-four (45.9%) caregivers completed 3m. Compared to the caregivers in CDC, the TS caregivers experienced moderate-to-large effect size improvements in caregiver mastery and frequency of depressive behaviors (mastery: TS Cohen’s d=0.65, CDC d=0.00; depressive frequency: TS d=-0.64, CDC d=-0.04); caregivers in both groups reported moderate decrease in stress (TS d=-0.68; CDC d=-0.54). Implementation evaluation findings included: successful EHR buildout to capture and store caregiver-reported outcomes at one site; recruitment challenges due to caregiver difficulties gaining patient portal access and disinterest in randomization; and sub-optimal provider engagement in inviting caregivers to join the study through the EHR.

A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes.

Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence. To assess an intervention to encourage MOP services to increase its use and medication adherence. Randomized encouragement trial. 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12months. Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis. During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients. ClinicalTrials.gov registration number: NCT02621476.

Effect of Using an Exercise and Nutrition Secure Email Message on the Implementation of Health Promotion in a Large Health Care System

Background and Program: Secure email messaging is used to provide timely communication between healthcare providers and patients with medical information and education. There have been increasing rates of overweight and obesity among military healthcare patients. To address this issue, we utilized a secure email messaging system that is primarily used for medication refills. This commentary demonstrates the extent to which the message was viewed and how much the message was liked. Preliminary Results: Of the 16,020 individuals emailed, 7,011 participants (43.8%) opened the email, and 1,023 patients (14.6% of those who opened it) completed the survey. Satisfaction rate for the health promotion message was 77.2%. Participants reported an intent to eat more fruit and vegetables (49.6%), decrease portion sizes (38.8%), and increase physical activity (51.1%), while 33.6% reported having no intent to change. Conclusion: The majority were satisfied with the health promotion message. This email method enables a single provider to have increased contact with patients. It is unknown if this message reached higher risk or harder to reach participants, a patient subset that could benefit most from this type of communication. This study is unique in that to our knowledge it is the first one to use secure email messaging in the military healthcare system for health promotion.

169-LB: A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence

Medication non-adherence is a major contributor to poor diabetes outcomes. Observational studies show positive associations between mail order pharmacy (MOP) use and adherence, and suggest that mail order is cost-saving to patients. However, no prospective trials have examined the effect of encouraging MOP use on medication adherence. We conducted a randomized encouragement trial in 2017 in three health plans: Kaiser Permanente (KP) Northern California, KP Hawaii, and Harvard Pilgrim Health Care (HPHC). Patients were eligible if they had diabetes, poor adherence (Proportion of Days Covered &amp;lt;80%) to at least one class of cardiometabolic medications, and had not used MOP in the prior 12 months. Patients were randomized to receive either no intervention (controls) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use for diabetes patients; HPHC intervention patients received the letter only. We compared the percentages of patients in both arms that began using mail order and that became adherent to cardiometabolic medication classes during the 12-month follow-up. A total of 63,012 patients were included: mean age was 60; 45% were female; 41% were non-Hispanic white; 12% were black; 25% were Hispanic/Latino, and 22% were Asian/Native Hawaiian/Pacific Islander. During follow-up, 12% of intervention patients used the mail order pharmacy vs. 10% of controls (p&amp;lt;.001); the percent of cardiometabolic medications delivered via mail was 42% vs. 39% (p&amp;lt;.01). Metformin adherence improved in the intervention group relative to controls at the two KP sites (52% vs. 49%, p&amp;lt;.01). This randomized trial shows that simple outreach to encourage MOP use modestly improved its use, and improved adherence to a key class of diabetes medications in some settings. Clinicians and health systems should consider such low-cost interventions to actively promote MOP among diabetes patients. Disclosure J. Schmittdiel: None. C.M. Trinacty: None. J. Wharam: None. O. Duru: Advisory Panel; Self; Healthwise. R. Neugebauer: None. S.D. Brown: None. D. Ross-Degnan: None. A.J. Karter: None. W.T. Dyer: None. B. Ramachandran: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial.

Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits. To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes. We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system. Eligible patients had at least 1year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal. Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care. Glycemic control; change in HbA1c 6 and 12months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences. During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms. A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation. NCT02375932.

Low-Intensity Outreach to Increase Uptake of HIV Preexposure Prophylaxis Among Patients with Sexually Transmitted Infections.

We piloted a low-intensity outreach intervention to increase linkage to PrEP care among HIV-uninfected individuals with rectal sexually transmitted infections or syphilis. We sent a secure email message or letter with information about accessing PrEP. Of those sent an email, 12.4% were linked to PrEP care; linkage differed by race/ethnicity, ranging from 0% of Black individuals to 32% of Hispanic individuals (P = 0.019). No individuals sent letters were linked to PrEP care. A one-time secure email to high-risk patients is feasible to increase linkage to PrEP care. Studies are needed to evaluate scalable interventions to increase PrEP uptake in at-risk populations.

Do Headache Patients Require More Care in Between Visits Than Other Neurology Outpatients?

There is evidence that time spent in patient care in between patient visits is increasing and a contributor to physician burnout. The extent of this work on providers in the field of headache medicine is unknown. To establish whether headache outpatients require a high level of care in addition to clinic visits, based on the quantity of remote encounters per patient (phone calls and secure email communication to the clinics), in comparison to other neurologic clinics. In an academic referral clinic, a total of 3164 established patients were included in this retrospective analysis, 275 from the headache clinic, the remainder from various other neurology clinics (2 physician providers per clinic except 3 physician providers in the headache clinic). Patients presenting for a follow-up visit between January 2014 and April 2016 were observed for a 12-month period during which the number of a) telephone and b) secure email (MyChart) encounters per patient was recorded, and in addition, the number of entries related to each of these encounters. This analysis did not require IRB approval as per institutional guidelines. Headache clinic patients required a high frequency of remote encounters (composite of both telephone and email messages) per patient, second only to the MS clinic patients. Use of secure email messaging (MyChart) per patient was much higher in the headache clinic compared to all other clinics. Patients in a headache clinic in an academic tertiary care setting require a high intensity of remote outpatient care, more so than patients in other neurology subspecialty clinics and general neurology clinic, with the exception of the neuroimmunology/MS clinic. This is to a large extent secondary to the very frequent use of secure email linked to the electronic medical record by headache patients.

Targeted Secure Messages to Facilitate Access to Tobacco Treatment Counseling for Veterans: Feasibility Study.

BackgroundStudies show that combining nicotine replacement therapy (NRT) with tobacco treatment counseling is most effective for smoking cessation. However, tobacco treatment counseling has been underutilized across the nation. A secure email message sent to patients already taking NRT was hypothesized to increase the utilization of tobacco treatment counseling among Veterans in New Jersey. Secure messaging for communication between patients and providers was implemented through a web-based password-protected, secure messaging account, where Veterans get notified through their personal email when they have a message awaiting them. ObjectiveThe main objective of this project was to determine if there was a significant increase in adoption of tobacco treatment counseling among Veterans who received a secure message describing the options for tobacco treatment counseling available to them. Secondary objectives were to demographically characterize Veterans who were and were not enrolled in secure messaging, as well as those who opened or did not open a message. Finally, because the language and content of the messages were changed across project phases, this project also sought to determine (by analysis of response rates) the type of language that was most effective at eliciting a response.MethodsOver two phases, messages were sent to two samples of Veterans prescribed NRT within the prior 90 days of each phase. In phase 1, one message was sent in December 2015 (message 1). In phase 2, one message was sent in July 2016 (message 2) and the same message (message 3) was resent in August 2016 to persons who did not open message 2. Messages 2 and 3 were more directive than message 1. Response rates to message 1 versus message 2 were compared. A logistic regression analysis determined effect of age and gender on enrollment in secure messaging across both phases. The effectiveness of each phase at increasing tobacco treatment counseling was analyzed using a McNemar test.ResultsMessage 2, sent to 423 Veterans, had a significantly higher response rate than message 1, sent to 348 Veterans (18%, 17/93 vs 8%, 6/78, P=.04). Phase 2 (ie, messages 2 and 3) significantly increased utilization of tobacco treatment counseling (net increase of six tobacco treatment counseling adopters, P=.04), whereas phase 1 (ie, message 1) did not (net increase of two tobacco treatment counseling adopters, P=.48). Women (odds ratio [OR] 1.6, 95% CI 1.1-2.3) and those aged 30 to 49 years (compared to other age groups) were more likely to be enrolled in secure messaging. Gender and age were not significant predictors of opening or replying to either message.ConclusionsAlthough the effect was small, secure messaging was a useful modality to increase tobacco treatment counseling. Directive content with a follow-up message appeared useful. Female Veterans and/or Veterans aged between 30 and 49 years are more likely to use secure messaging.

P153 Using information technology to improve linkage into sexual health care in patients receiving hiv post exposure prophylaxis for sexual exposure (PEPSE) in emergency departments

IntroductionHIV PEPSE should be commenced within 72 hours (ideally 24) after possible exposure to HIV. Patient education on PEPSE includes advice on attendance at Emergency Department (ED) if outside opening hours of local sexual health services (SHS). Our healthboard serves a population of 1.2 million with four EDs. An initial four month audit revealed 12 patients who received a 5-day starter pack of PEPSE at ED and no communication between departments; patients were told to self-refer to SHS. We recognised there was no robust mechanism to ensure these high risk patients were not lost to follow up (LTFU). HIV testing at baseline was also poor in this setting, highlighting importance of linkage into SHS.MethodsHIV PEPSE 5 day pack leaflets were altered to ask the dispensing clinican to refer patient via secure email or telephone message to the sexual health advisers.ResultsProspective four month re-audit revealed 19 patients attended ED for PEPSE and all subsequently attended SHS for follow up(100%). 12/19(63%) were referred by email, 6/19(32%) via answering machine, 1/19(5%) self referred. 11/19(60%) reported unprotected receptive anal intercourse with someone from a high risk group.DiscussionFollowing implementation of the email/telephone referral intervention, we found an increased number of patients received HIV PEPSE from EDs in the health board area and all were successfully linked into sexual health services. We cannot be sure that this increase is due to the prevention of patients being LTFU; other reasons include an increased awareness of PEPSE and where to obtain.

Large-Scale Survey Findings Inform Patients' Experiences in Using Secure Messaging to Engage in Patient-Provider Communication and Self-Care Management: A Quantitative Assessment.

BackgroundSecure email messaging is part of a national transformation initiative in the United States to promote new models of care that support enhanced patient-provider communication. To date, only a limited number of large-scale studies have evaluated users’ experiences in using secure email messaging.ObjectiveTo quantitatively assess veteran patients’ experiences in using secure email messaging in a large patient sample.MethodsA cross-sectional mail-delivered paper-and-pencil survey study was conducted with a sample of respondents identified as registered for the Veteran Health Administrations’ Web-based patient portal (My HealtheVet) and opted to use secure messaging. The survey collected demographic data, assessed computer and health literacy, and secure messaging use. Analyses conducted on survey data include frequencies and proportions, chi-square tests, and one-way analysis of variance.ResultsThe majority of respondents (N=819) reported using secure messaging 6 months or longer (n=499, 60.9%). They reported secure messaging to be helpful for completing medication refills (n=546, 66.7%), managing appointments (n=343, 41.9%), looking up test results (n=350, 42.7%), and asking health-related questions (n=340, 41.5%). Notably, some respondents reported using secure messaging to address sensitive health topics (n=67, 8.2%). Survey responses indicated that younger age (P=.039) and higher levels of education (P=.025) and income (P=.003) were associated with more frequent use of secure messaging. Females were more likely to report using secure messaging more often, compared with their male counterparts (P=.098). Minorities were more likely to report using secure messaging more often, at least once a month, compared with nonminorities (P=.086). Individuals with higher levels of health literacy reported more frequent use of secure messaging (P=.007), greater satisfaction (P=.002), and indicated that secure messaging is a useful (P=.002) and easy-to-use (P≤.001) communication tool, compared with individuals with lower reported health literacy. Many respondents (n=328, 40.0%) reported that they would like to receive education and/or felt other veterans would benefit from education on how to access and use the electronic patient portal and secure messaging (n=652, 79.6%).ConclusionsSurvey findings validated qualitative findings found in previous research, such that veterans perceive secure email messaging as a useful tool for communicating with health care teams. To maximize sustained utilization of secure email messaging, marketing, education, skill building, and system modifications are needed. These findings can inform ongoing efforts to promote the sustained use of this electronic tool to support for patient-provider communication.

Patient-to-physician messaging: volume nearly tripled as more patients joined system, but per capita rate plateaued.

Patients want to be able to communicate with their physicians by e-mail. However, physicians are often concerned about the impact that such communications will have on their time, productivity, and reimbursement. Typically, physicians are not reimbursed for time spent communicating with patients electronically. But under federal meaningful-use criteria for information technology, physicians can receive a modest incentive for such communications. Little is known about trends in secure e-mail messaging between physicians and patients. To understand these trends, we analyzed the volume of messages in a large academic health system's patient portal in the period 2001-10. At the end of 2010, 49,778 patients (22.7 percent of all patients seen within the system) had enrolled in the portal, and 36.9 percent of enrolled patients (8.4 percent of all patients) had sent at least one message to a physician. Physicians in the aggregate saw a near tripling of e-mail messages during the study period. However, the number of messages per hundred patients per month stabilized between 2005 and 2010, at an average of 18.9 messages. As physician reimbursement moves toward global payments, physicians' and patients' participation in secure messaging will likely increase, and electronic communication should be considered part of physicians' job descriptions.

Engaging patients in medication reconciliation via a patient portal following hospital discharge

Few ambulatory medication reconciliation tools exist. Transitions between inpatient and outpatient care can result in medication discrepancies. An interdisciplinary team designed a new 'Secure Messaging for Medication Reconciliation Tool' (SMMRT) within a patient web portal and piloted it among 60 patients at a Veterans Affairs hospital, an integrated system with a shared electronic health record. Recently discharged patients used SMMRT to view their medications in a secure email message and replied using SMMRT's interactive form, verifying their medication regimens and clarifying any inaccuracies. In total, 108 medication discrepancies and 23 potential adverse drug events (ADEs) were seen. Nearly 50% of the potential ADEs were classified as serious. Overall, participants were enthusiastic about SMMRT; 90% said they would use SMMRT again. Enabling patients to conduct medication reconciliation through a web portal is feasible in the transition from inpatient to outpatient care and may improve medication safety.

Timely Response to Secure Messages From Primary Care Patients

To assess delays in response to patient secure e-mail messages in primary care. Secure electronic messages are initiated by primary care patients. Timely response is necessary for patient safety and quality. A database of secure messages. A random sample of 353 secure electronic messages initiated by primary care patients treated in 4 clinics. Message not opened after 12 hours or messages not responded to after 36 hours. A total of 8.5% of electronic messages were not opened within 12 hours, and 17.6% did not receive a response in 36 hours. Clinic location, being a clinic employee, and patient sex were not related to delays. Patients older than 50 years were more likely to receive a delayed response (25.7% delayed, P = .013). The risk of both kinds of delays was higher on weekends (P < .001 for both). The e-mail message system resulted in high rates of delayed response. Delays were concentrated on weekends (Friday-Sunday). Reducing delayed responses may require automatic rerouting of messages to message centers staffed 24-7 or other mechanisms to manage this after-hours work flow.

A National Action Plan To Support Consumer Engagement Via E-Health

Patient-centered care is considered one pillar of a high-performing, high-quality health care system. It is a key component of many efforts to transform care and achieve better population health. Expansion of health information technology and consumer e-health tools--electronic tools and services such as secure e-mail messaging between patients and providers, or mobile health apps--have created new opportunities for individuals to participate actively in monitoring and directing their health and health care. The Office of the National Coordinator for Health Information Technology in the Department of Health and Human Services leads the strategy to increase electronic access to health information, support the development of tools that enable people to take action with that information, and shift attitudes related to the traditional roles of patients and providers. In this article we review recent evidence in support of consumer e-health and present the federal strategy to promote advances in consumer e-health to increase patient engagement, improve individual health, and achieve broader health care system improvements.

Secure E-Mail Messaging to Selected Group Members Using PGP Technique

The E-mail messaging is one of the most popular uses of the Internet and the multiple Internet users can exchange messages within short span of time using To(Original recipient) ,Cc(Carbon Copy) and /or Bcc(Blind Carbon copy) facilities. Although the security of the important E-mail messages is an important issue, no such security is supported by the Internet standards. Recently one well known scheme, called PGP (Pretty Good Privacy) is proposed for personal security of E-mail messages, but it can transmit encrypted message to single recipient only,i.e. ,the same encrypted message can not be transmitted to the multiple recipients if Cc and Bcc options are used. This paper proposes two modifications of the PGP that avoid the limitation of the PGP of not transmitting same encrypted message to multiple receipients.The basic idea is that a group comprising To, Cc and Bcc recipients is initially formed, a group key among them is generated using any group key generation scheme, which is then used (instead of the using the public key of the single recipients as done in PGP) to encrypt the session key. Since the secret group key is known to all recipients, they can extract session key and decrypt the confidential message correctly. This is one of the proposed modifications of PGP technique. The other modification is to remove the use of public key cryptosystem in PGP and this is done simply by generating signature of the E-mail message using group key (instead of using the sender’s private key).It not only increases the processing speed of the PGP, but also simplifies it by avoiding to preserve the private key ring and public key ring of the participants.

The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care

We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.

Health Information Technology: On The Fast Track At Last?

Health Information Technology: On The Fast Track At Last?

MyChart —A New Mode of Care Delivery: 2005 Personal Health Link Research Report

MyChart is one of the new, innovative features of Kaiser Permanente (KP) HealthConnect—the comprehensive, integrated, organizational, and personal electronic health and medical record. MyChart, an Epic Systems Corporation (Verona, WI) product, is a secure member Web site where registered patients can view portions of their medical record, and exchange secure messages with their primary care physician (PCP) and other recently visited clinicians. The KP Northwest (KPNW) Region, in Portland, Oregon, was the first KP Region to implement MyChart. Starting in late 2002, KPNW initiated a pilot project of MyChart as a stand-alone Web address in two medical offices.1 KPNW named this feature Personal Health Link (PHL). By early 2005, all adult primary care physicians and affiliated clinicians (both groups are PCPs in this paper) were trained and set up to use PHL. Patients who registered for PHL could send secure e-mail messages directly to their primary care clinician, incurring no copayment or fees. MyChart is now available to KP patients in all Regions, except Ohio, through KP HealthConnect online at www.kp.org.

A preliminary assessment of Internet-based nuclear telecardiology to support the clinical management of cardiac disease in a remote community.

A portable nuclear medicine (NM) processing system was established in Kalgoorlie and an acute myocardial perfusion scintigraphy (MPS) service was provided for the local regional hospital. After scanning the patient, the data were processed on a laptop computer and JPEG images were transmitted to a secure Web server. A secure email message, with the URL link enclosed and a provisional indication of normal or abnormal findings, was sent to the referring clinician from the NM facility. Use of the Internet allowed for a group consultation between the NM technician, the referrer and the cardiologist in Perth. During a three-month study period, 42 patients were referred for exclusion of acute coronary syndrome. Of these, 21 (50%) demonstrated abnormal perfusion studies, two of which were classified as requiring urgent medical intervention. Seventeen studies were normal (41%) and four (10%) were designated equivocal. There was an alteration in the treatment plan for 32 patients (76%), including four for whom admission or further investigation was deemed unwarranted. The results suggest that MPS findings, distributed via the Internet, allow for earlier risk stratification and have a direct affect on clinical decision making.