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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 on Health Outcomes, Satisfaction, Efficiency and Attitudes [Internet]. Washington (DC): Department of Veterans Affairs (US); 2012 Jul.

METHODS

TOPIC DEVELOPMENT

This project was nominated by Kim Nazi, Veterans and Consumers Health Informatics Office/Office of Informatics and Analytics, with input from a technical expert panel that included David Haggstrom, Tom Houston, Keith McInnes; Performance Evaluation Clinical Advisory Board Working Group.

The original key questions were listed in the following format:

Proposed Study Selection: Peer-reviewed articles assessing the effects of select personal health record functionalities on clinical outcomes, patient-centered outcomes, and system-level outcomes, especially among organizations most similar to the VA.

Proposed Data Extraction: Data on study participants (patient, health care provider or organization), study design, functionality, functionality variation (subsets), outcomes, and VA peer organizations will be extracted.

Population: include all studies in relevant peer-reviewed literature; make special note of VA peer organizations, i.e., integrated delivery systems whose experience with care delivery & online health activities may generalize best to the VA, including:

  • Kaiser Permanente
  • Group Health Cooperative
  • Geisinger Health System

without insurance component:

  • Partners HealthCare
  • Palo Alto Medical Foundation

Functionalities: Note: we have listed these in order of priority

  1. Secure messaging programs
    • Functionality variation (subsets):
      1. tethered secure messaging program vs. conventional (unsecured) e-mail
        1. tethered programs are integrated with electronic health record; most similar to VA
      2. different implementation strategies (triage team (VA) model vs. other)
  2. Patient access to their own medical record
    • Functionality variation (subsets):
      1. online tethered program vs. online stand-alone program vs. paper record (lower priority)
      2. allergy list vs. medication list vs. laboratory results vs. procedure/imaging results vs. physician notes
  3. Online medication refills
  4. Patient self-reported data
  5. Online preventive or chronic care reminders

Outcomes:

  • Clinical outcomes
    A.

    quality of care (performance measures, clinical processes)

    B.

    health outcomes

  • Patient-centered outcomes
    C.

    patient satisfaction

    D.

    provider satisfaction

    E.

    quality of patient-provider communication

    F.

    self-management

    G.

    adherence

    1. medication
    2. visit
  • System-level outcomes
    H.

    efficiency

    1. telephone medicine utilization
    2. system workload
      1. provider time
    3. inappropriate use
    I.

    privacy breaches

    J.

    patient safety

These characteristics were then structured into the following sample Key Questions:

  1. Is secure messaging (function #1) associated with the following outcomes?
    • Clinical outcomes
      a.

      quality of care (performance measures, clinical processes)

      b.

      health outcomes

    • Patient-centered outcomes
      c.

      patient satisfaction

      d.

      provider satisfaction

      e.

      quality of patient-provider communication

      f.

      self-management

    • System-level outcomes
      g.

      efficiency (reduced use of telephone resources; reduced use of in-person visits)

      h.

      breaches of privacy

  2. Is patient access to their own medical record (function #2) associated with the following outcomes?
    • Clinical outcomes
      a.

      quality of care (performance measures, clinical processes)

      b.

      health outcomes

    • Patient-centered outcomes
      c.

      patient satisfaction

      d.

      provider satisfaction

      e.

      quality of patient-provider communication

      f.

      self-management

    • System-level outcomes
      g.

      efficiency (reduced use of telephone resources)

      h.

      breaches of privacy

  3. Is patient access to online medication refills (function #3) associated with the following outcomes?
    • Clinical outcomes
      a.

      medication adherence

      b.

      quality of care (performance measures, clinical processes)

      c.

      health outcomes

    • Patient-centered outcomes
      d.

      patient satisfaction

      e.

      provider satisfaction

      f.

      quality of patient-provider communication

      g.

      self-management

    • System-level outcomes
      h.

      efficiency (reduced use of telephone resources)

      i.

      breaches of privacy

SEARCH STRATEGY

We searched PubMed for relevant literature from 01/01/1999 through 12/03/2010, using standard search terms such as electronic health record, patient, messaging, and computerized reminder (see Appendix A for complete search strategy). We limited the search to peer-reviewed articles published in the English language.

STUDY SELECTION

Two reviewers assessed for relevance the full text articles identified from the title screening of the literature searches. Each article was reviewed using a standard screener form (see Appendix B). Initial inclusion criteria were: 1) discussion of relevant functionalities, namely messaging programs, patient access to their own medical record, patient self-reported data, or online reminders; 2) study design of descriptive qualitative, descriptive quantitative, hypothesis testing, or systematic review.

After we data screened 4,607 titles to identify approximately 400 relevant articles and abstracted sufficient to classify them by study type, key question, and outcome, we then presented these data to the Performance Evaluation Workgroup on December 1, 2011; after which the workgroup determined that Key Questions #1 and #2 were the highest priority, and Key Question #3 was dropped. Furthermore, for Key Question #1 only hypothesis testing articles were of interest, and for Key Question #2, only hypothesis testing or descriptive quantitative articles were of interest. This revision narrowed our inclusion criteria to only hypothesis testing studies that assessed specific outcomes for Key Question #1, and hypothesis testing and descriptive quantitative studies assessing similar specific outcomes for Key Question #2. The specific outcomes for both Key Questions are detailed in the literature flow section of the results below.

DATA ABSTRACTION

We abstracted the following data for each included study: study design, study date, HIT intervention, setting, outcome measures, and findings.

QUALITY ASSESSMENT

We assessed the quality of individual studies using study design (trials and observational designs of higher rigor such as controlled before-and-after studies and time series analyses being less prone to bias than pre-post studies), recruitment and retention or follow up data, the degree to which the intervention was described and the degree to which any effect could be attributed to a specific component (of a multi-component intervention), and the relevance of the outcome measured to the outcomes specified in the key questions. We assessed studies for applicability to the VA health care system.

In specific we assessed studies coming from integrated health care delivery systems, such as Kaiser and Group Health Cooperative as being more relevant to VA health care than studies coming from academic or non-academic non-VA sites. We also judged studies about chronic conditions common in VA (such as diabetes and hypertension) as more relevant than conditions rare in VA (in vitro fertilization). In addition to quality evaluation of individual studies, we evaluated the overall quality of the evidence for each key question as proposed by the GRADE Working Group.

DATA SYNTHESIS

We constructed evidence tables showing the study characteristics and results for all included studies, organized by key question, intervention, or clinical condition, as appropriate. We critically analyzed studies to compare their characteristics, methods, and findings. We compiled a summary of findings for each key question or clinical topic, and drew conclusions based on qualitative synthesis of the findings.

RATING THE BODY OF EVIDENCE

We assessed the overall quality of evidence for outcomes using a method developed by the GRADE Working Group (see Appendix C), which classified the grade of evidence across outcomes according to the following criteria:

  • High = Further research is very unlikely to change our confidence on the estimate of effect.
  • Moderate = Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
  • Low = Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
  • Insufficient = Any estimate of effect is very uncertain.

PEER REVIEW

A draft version of this report was reviewed by six technical experts and/or clinical leaders. Their comments and our responses are presented in Appendix D.

Cover of Systematic Review: Secure Messaging Between Providers and Patients, and Patients’ Access to Their Own Medical Record
Systematic Review: Secure Messaging Between Providers and Patients, and Patients’ Access to Their Own Medical Record: Evidence on Health Outcomes, Satisfaction, Efficiency and Attitudes [Internet].
Goldzweig CL, Towfigh AA, Paige NM, et al.
Washington (DC): Department of Veterans Affairs (US); 2012 Jul.

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