Managing Type 2 Diabetes: The Impact of Secure Patient-Provider Messaging

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Higher frequency of messages sent was associated with a greater likelihood of achieving HbA1c <8%.
Higher frequency of messages sent was associated with a greater likelihood of achieving HbA1c <8%.

Secure messaging between patients and healthcare providers through Internet websites, commonly known as “patient portals,” allows patients and providers to communicate with each other via electronic messages outside of office visits.1,2 The use of secure messaging is becoming more and more widespread among healthcare institutions. Secure patient-provider messaging is frequently used between office visits to manage chronic conditions such as type 2 diabetes.1

Secure Messaging and Diabetes Care

Internet-based messaging was initially established to improve patient access to clinicians without the added burden of time and cost of traveling to the clinicians' office. Clinician access is further facilitated by the nature of Internet-based messaging because the clinician and patient do not need to be available at the same moment in time to send or respond to the message. Instead, patients may send a message at a time of their choosing, and clinicians may respond when their schedule allows.1

According to Sukyung Chung, PhD, from the Palo Alto Medical Foundation in California, secure patient-provider messaging improves patient satisfaction significantly and has a positive impact on the overall experience of care. In addition, secure messaging may help alleviate the time pressure that clinicians often experience. “Physicians have a limited amount of time to see patients in the office and to answer telephone calls,” Dr Chung said in an interview with Endocrinology Advisor. The asynchronous nature of secure messaging may allow clinicians to communicate with patients in a way that fits into their schedule.

Secure patient-provider messaging may also increase patient engagement and self-management. “Brief, intermittent office visits with physicians are not well designed for coaching patients to self-manage their own condition, which really requires more ongoing engagement between visits,” James Ralston, MD, MPH, from Kaiser Permanente Washington Health Research Institute in Washington, told Endocrinology Advisor. “Secure messaging presents a great opportunity for patients and healthcare providers to collaborate on self-management issues like glycemic control, diet, and exercise.”

However, responding to patient messages outside of visits can be time-consuming for providers. In addition, time spent interacting with patients via secure messaging is often not reimbursed in the traditional fee for service model. “If secure messaging takes over a significant portion of the day, and you can't get reimbursed for that time, it's hard to support secure messaging to engage with patients outside of office visits,” Dr Ralston said.

Secure Messaging and Diabetes Outcomes

Whereas secure patient-provider messaging affects patient access to clinicians, provider workflow, and the economics of clinical practice, its impact on clinical outcomes in type 2 diabetes was unclear until recently.1 Prior studies showed that secure messaging was associated with better diabetes management and outcomes, but these studies may not be generalizable to the community setting because they were conducted as clinical trials or in integrated delivery organizations.2-5

Dr Chung and colleagues examined secure messaging usage patterns and whether secure messaging reduces in-person office visits and improves diabetes outcomes in a large community outpatient practice. Results of the study were published in Diabetes Care.1

A total of 20,655 patients enrolled in a patient online portal had at least 1 visit to 394 different providers between 2011 and 2014. Only messages classified as “medical advice request” were included. Provider specialties were primary care, endocrinology, ophthalmology, podiatry, nephrology, and nutrition.1

Diabetes outcomes included hemoglobin A1c (HbA1c) <8%, blood pressure <130/90 mm Hg, medical attention for nephropathy, and eye examination.1

Nearly three-quarters of patients sent 1 or more messages in a year. Approximately 15% sent only 1 message, and more than 25% sent ≥5 messages.1

Increasing message frequency was associated with more office visits. Patients who sent ≥5 messages in a year had the most face-to-face visits (4.8 visits/year), which was significantly higher than the number of visits by patients who sent no messages (3.2 visits/year; P <.01).1

Higher frequency of messages sent was associated with a greater likelihood of achieving HbA1c <8%. Compared with patients who sent 1 message per year, patients who sent 2 messages (odds ratio [OR], 1.17), 3 messages (OR, 1.38), and 4 or more messages (OR, 1.55) per year were more likely to achieve HbA1c control (P <.01 for all comparisons). Patients who sent no messages were at increased risk for failing to achieve glycemic control (vs any message; OR, 0.83; P <.01).1

Similarly, higher visit frequency correlated with higher rates of HbA1c control, although to a lesser extent. However, patients with fewer visits and more messages sent had higher rates of glycemic control than patients with more visits and no messages sent.1

Patients who sent more messages or made more clinic visits were also more likely to have eye examinations, HbA1c screening, and monitoring of nephropathy in a timely manner.1

“It's time-consuming for clinicians to respond to patient messages outside of office visits, but secure messaging pays off because it promotes positive behavior changes in patients and better self-management of diabetes,” Dr Chung said.

“I think there are two pathways that may explain why secure messaging is associated with better diabetes outcomes. Having contact with the physician between visits may strengthen the patient-physician relationship and may reinforce the medical advice discussed during in-person visits. Secure messaging may also facilitate immediate assessment or treatment when a patient has a specific problem,” she said.

Secure Messaging: When Should It Be Used?

Although evidence suggests that secure messaging has the potential to improve diabetes outcomes, Dr Ralston noted that secure messaging is most effective if it is the “right fit” for both the patient and the clinician. “The patient needs to have the right amount of literacy and fluency in the language being used for communication,” he said. “If those elements are not there, then stick with phone and in-person communication.”

“On the provider side, you really need a model of care that helps support secure messaging. Traditional fee for service just does not work well for that because most providers in this environment don't get paid for secure messaging,” Dr Ralston said. “Organizational factors may help encourage clinicians to use secure messaging. Health care systems like Kaiser Permanente are not as beholden to the fee for service model, and it's easier to match whatever access the patients need with what you can provide.”

Finally, secure messaging may be more appropriate in certain clinical contexts than others. “Secure messaging works great if you're collaborating on what might be straightforward discussions around glucose readings. But if decision making and conversations become more complex, secure messaging is not a good fit,” Dr Ralston pointed out. “You still need good in-person and phone access for these kinds of other needs.”

References

  1. Chung S, Panattoni L, Chi J, Palaniappan L. Can secure patient-provider messaging improve diabetes care? Diabetes Care. 2017;40:1342-1348.
  2. Harris LT, Koepsell TD, Haneuse SJ, Martin DP, Ralston JD. Glycemic control associated with secure patient-provider messaging within a shared electronic medical record: a longitudinal analysis. Diabetes Care. 2013;36:2726-2733.
  3. Shimada SL, Allison JJ, Rosen AK, Feng H, Houston TK. Sustained use of patient portal features and improvements in diabetes physiological measures. J Med Internet Res. 2016;18:e179.
  4. Petullo B, Noble B, Dungan KM. Effect of electronic messaging on glucose control and hospital admissions among patients with diabetes. Diabetes Technol Ther. 2016;18:555-560.
  5. Ralston JD, Hirsch IB, Hoath J, Mullen M, Cheadle A, Goldberg HI. Web-based collaborative care for type 2 diabetes: a pilot randomized trial. Diabetes Care. 2009;32:234-239. 
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