Byrne JM et al. 2009 "Initial experience with patient-clinician secure messaging at a VA medical center."

Byrne JM, Elliott S, Firek A. Initial experience with patient-clinician secure messaging at a VA medical center. J Am Med Inform Assoc 2009;16(2):267-270.
"The authors implemented what is possibly the first secure messaging system in a VA Medical Center. Since reimbursement for secure messaging is not of great concern and clinical data systems are fully computerized, several evaluation strategies were used to assess clinical adoption. To address known concerns of clinicians, the authors analyzed secure messaging use and performed a content analysis. Message volumes were low and content analysis demonstrated that messages were appropriate. Despite this, a clinician survey showed that clinical adoption was impeded by several factors including the introduction of secure messaging to selected patients, workload concerns, and clinician communication preferences. In addition, the authors believe that clinicians experienced clinical adoption inertia resulting from the overload of information in a highly computerized clinical environment. The authors learned that to promote clinician adoption they must demonstrate workload benefits from secure messaging and more fully analyze the clinical computing workload that clinicians experience."
To evaluate the clinical adoption of a secure messaging system in a Veterans Administration (VA) Medical Center.
Type Clinic
Primary care
Other Information
The site consisted of "[a]pproximately 35,000 patients receive primary care from 5 teams consisting of 7-8 physicians/nurse practitioners..., 4 or 5 licensed vocational nurses (LVN), a registered nurse (RN), a case manager, and 3 patient services assistants."
Type of Health IT
Secure messaging
Type of Health IT Functions
"Messaging security is achieved using [an] ... encrypted website and a secure server with a fire wall blocking access to unauthorized users. Messages are permanently stored in an [Structured Query Language] SQL database. New Portal Mail messages generate e-mail alerts without identifying information to providers in Microsoft Outlook and to patients in their personal e-mail accounts." "Patient messages are forwarded to the primary care team. Two staff members on each team review messages and, based on content, forward messages to appropriate clinic staff."
Context or other IT in place
An electronic health record (EHR) and patient portal were already in place.
Workflow-Related Findings
Users and non-users of the secure messaging both indicated weak agreement with statements that they had "adequate means of communicating with their patients" and that "[in] communicating with patients by all means available to me, I am able to respond to their concerns within 48 [hours]."
"With one extreme outlier removed, non-users estimated spending slightly more time returning telephone calls than users...and saw more unscheduled patients per half day...However, [secure messaging] users answered neutrally to questions on whether telephone calls and unscheduled patients were decreased [by using the secure messaging system]."
"Clinician users agree that message content is appropriate...and that [the secure messaging system] improves the efficiency...and quality...of patient communication."
"Of the 39 primary care clinicians, 21 (53%) registered and communicated with a patient at least once, 17 (43%) continued to use [the messaging system] through the end of 2006, 15 (38%) continued to use it through Jun 2007, and 6 (15%) stopped using the system."
"The clinician users introduce [the secure messaging system] to selected patients..., not to all patients … We believe that our clinicians' selection may in part be related to judgments about patients' capability to use the system or to use it judiciously."
"[C]linician users view telephone communication as less efficient than non-users and thus may be substituting one form of communication with another rather than adopting secure messaging to decrease workload. Therefore, clinician attrition and nonacceptance of our secure messaging system may be related to physician communication preferences and ongoing skepticism
that it will reduce workload."
Study Design
Only postintervention (no control group)
Study Participants
Thirty-three primary care clinicians completed a patient communication survey. Twelve of these reported using secure messaging.