Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Department of Veterans Affairs, Bedford, MA, United States.
Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States.
J Med Internet Res. 2020 Nov 18;22(11):e22307. doi: 10.2196/22307.
Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care.
Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA's online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed.
We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams.
Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P<.001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P<.001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%).
The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties.
ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468.
尽管患者与临床团队成员之间的安全消息传递（SM）是连续护理的推荐组成部分，但患者的采用率仍然相对较低。我们设计了一个多组件支持采用计划（SAP），以通过退伍军人事务部（VHA）的在线患者门户（My HealtheVet [MHV]）增加使用 SM 的患者的采用率。
我们的目标是（1）进行一项多站点、随机、鼓励设计试验，以测试旨在通过 VHA 的在线患者门户（My HealtheVet [MHV]）增加患者对 SM 的参与度的 SAP 的有效性，以及（2）评估 SAP 和患者对 SM 的采用对感知提供者自主性支持和沟通的影响。还评估了患者采用 SM 的障碍。
我们在 3 家 VHA 设施中随机选择了 1195 名有 MHV 门户账户但从未使用过 SM 的患者。一半被随机分配接受 SAP，另一半作为对照组接受常规护理。SAP 包括通过邮寄教育材料、向患者发送主动 SM 和基于电话的动机访谈来鼓励采用 SM。我们在 9 个月和 21 个月时检查了 SAP 接受者和对照组之间 SM 采用率的差异。进行后续电话调查，以评估感知提供者自主性支持和与临床团队进行电话沟通的自我报告。
与对照组相比，接受 SAP 的患者的 SM 采用率显著更高（101/595，17.0%比 40/600，6.7%；P<.001）。SAP 中的大多数采用者在没有接受动机访谈的情况下发送了他们的第一条消息（71/101，70.3%）。这种 10 个百分点的采用率差异在鼓励结束后整整一年仍持续存在（23.7%，142/600 在 SAP 组中，而 13.5%，80/595 在对照组中，P<.001）。我们从 1195 名参与者中的 49.54%（592/1195）获得了后续调查数据。与对照组相比，SAP 参与者报告了更高的感知提供者自主性支持（5.7 比 5.4，P=.007）和更少使用电话与提供者沟通（68.8%比 76.0%，P=.05）。患者报告采用 SM 的障碍包括自我效能感（例如，不舒适使用计算机，24%）、没有感知到对 SM 的需求（22%）以及门户密码或登录困难（17%）。
多组件 SAP 成功地将 SM 的使用率提高了比标准护理高 10 个百分点；新的 SM 采用者报告说，他们对提供者自主性支持的感知有所改善，并且与他们的提供者通过电话进行沟通的次数减少了。尽管通过 SAP 提供了鼓励和技术援助，但采用率仍低于预期，21 个月时仅达到 24%（比对照组高 10%）。有限的感知到对 SM 的需求等常见采用障碍可能更难解决，并且需要与与患者自我效能或技术困难相关的障碍不同的干预措施。
ClinicalTrials.gov NCT02665468；https://clinicaltrials.gov/ct2/show/NCT02665468.
