The Use of Secure Messaging in Medical Specialty Care
The benefits of improving communication between health care providers and patients outweigh secure messaging’s implementation challenges.
Secure messaging (SM) is an encrypted, web-based mode of communication within the My HealtheVet (MHV) website. It was developed for the nonurgent, nonemergency communication of test results and other health information as well as for scheduling appointments and renewing medication prescriptions. Secure messaging is asynchronous, which means that communication between parties is not done at the same time. It was designed to address the need for a secure means of communication between patient and provider.1 Messages can be triaged across teams and saved to the Computerized Patient Record System (CPRS).
The VA patients who use MHV can upgrade their account through an in-person authentication process (IPA), which takes about 10 minutes. Any health care provider (HCP) team or administrator can use SM if set up in the system. Health care providers can only receive messages from patients who have been associated with their triage care group. Patients may only message an HCP with which they are associated. In general, this group would comprise their HCP and 1 or more specialty clinics where they have already been seen. Patients can choose an HCP from a limited drop-down menu.
Patients using SM choose a subject, such as appointments, medications, tests, or general. Patients are then able to type a message, and they are also able to see the threads of previous messages. They may access test results or attachments sent to them by the HCPs. Patients are notified of messages through their previously registered e-mail account, which displays a message asking them to log on to MHV.
Health care providers may access MHV either through the CPRS on the tools menu or as a link in an e-mail. Once HCPs log on, they will see their inbox and messages listed by sender and type of inquiry (ie, prescription refill, test question, and so forth). The HCPs can view escalated messages (those that have not been answered within 3 days), drafts, and sent and completed messages. Health care providers can also create special folders to store their messages.
The health care team can personalize how and to whom messages appear. There are 2 main models used by Specialty Care. The first involves a staff member designated to triage messages for the team. This staff member will see all incoming messages and forward them appropriately. For example, in one clinic model, the program assistant reviews all messages and then forwards them to the appropriate provider. The team pharmacist receives prescription requests, the HCP receives general or test inquiries from patients, and the program assistant retains and answers all communication related to appointments and cancellations. Another model involves employing a staff person or administrator as a co-user with each HCP. The HCP can then forward messages that may need administrative action.
The HCPs receive an e-mail notification with a link when a message has been received. Clicking on the link takes them directly to SM within MHV, where they can sign in to see all their messages. Users can also add a signature block, which will appear on all correspondence. They may also designate a surrogate to answer messages when they are unavailable, such as during administrative or personal leave. The HCPs also have the ability to create a SM even if the patient has not yet messaged them. Users can also send copies of messages to other staff members. Providers and staff have the ability to attach a file, which can be a test result, letter, records, etc. Messages can then be saved in the CPRS if desired.
Patients, however, cannot send attachments to their HCP. Only those HCPs who have seen the patient will be available for communication. This system eliminates the possibility of patients self-referring to a specialist and asking questions of HCPs who have never seen them. The HCPs and staff may also forward messages to the appropriate person.
Secure messaging can provide unique opportunities for communication and improvement in outcome measures in certain specialties. For example, in endocrinology patients may be asked to send home blood sugar or blood pressure (BP) readings in between visits, to allow for more rapid medication titration and achievement of treatment goals. A study by Harris and colleagues showed that the frequent use of electronic SM was associated with improved glycemic control.2
At the Atlanta VAMC, SM was implemented in the Primary Care Service Line prior to the Medicine Specialty Care Service Line. The implementation was a natural fit for the organized Primary Care teams. Implementation within the specialties brought forth a new set of issues. Many specialties were not formally organized with a team leader. There were often multiple HCPs in a division, some full time, some part time, in addition to subspecialty pharmacists, physician assistants, and nurse practitioners. Because the Atlanta VAMC is also a training hospital for the Emory University School of Medicine, new residents and fellows are included in the teams each month. It was, therefore, necessary for each specialty to design a message flow that would best fit its needs. Initially, there was concern that SM would add yet another layer of responsibilities to the already stretched HCPs.
