36

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

APPENDIX A. Search Strategy

CONSUMER HEALTH INFORMATION TECHNOLOGY

SEARCH METHODOLOGIES

DATABASE SEARCHED & TIME PERIOD COVERED: 

 PubMed – 1990-12/3/2010

LANGUAGE: 

 English

SEARCH STRATEGY #1: 

“Electronic Health Records”[Mesh] OR “electronic health record” OR “electronic health records” OR 

“electronic medical record” OR “electronic medical record” OR messaging OR email* OR “computerized 

alert” OR “computerized alerts” OR “computerized reminder” OR “computerized reminders” OR 

“computerised reminder” OR “computerised reminders” OR electronics, medical OR informatic*[tiab] 

OR computerized physician order entry OR computerised physician order entry OR computer provider 

order entry OR cpoe OR e-prescrib* OR e-prescription* OR electronic prescrib* OR electronic 

prescription* OR e-health 

AND 

patient*[ti] OR consumer*[ti] OR patient*[mh] OR consumer*[mh] OR tether* OR secure OR selfreport* OR self report* 

NOT 

case report OR case reports OR case report[pt] OR case reports[pt]

NUMBER OF RESULTS: 2381

SEARCH STRATEGY #2: 

“Electronic Health Records”[Mesh] OR “electronic health record” OR “electronic health records” OR 

“electronic medical record” OR “electronic medical record” OR messaging OR email* OR “computerized 

alert” OR “computerized alerts” OR “computerized reminder” OR “computerized reminders” OR 

“computerised reminder” OR “computerised reminders” OR electronics, medical OR informatic*[tiab] 

OR computerized physician order entry OR computerised physician order entry OR computer provider 

order entry OR cpoe OR e-prescrib* OR e-prescription* OR electronic prescrib* OR electronic 

prescription* OR e-health 

AND 

reminder* 

NOT 

case report OR case reports OR case report[pt] OR case reports[pt] 

NOT 

Results of Search Strategy #1

NUMBER OF RESULTS: 353

SEARCH STRATEGY #3: 

[“Electronic Health Records”[Mesh] OR “electronic health record” OR “electronic health records” OR 

“electronic medical record” OR “electronic medical record” OR messaging OR email* OR “computerized 

alert” OR “computerized alerts” OR “computerized reminder” OR “computerized reminders” OR 

“computerised reminder” OR “computerised reminders” OR electronics, medical OR informatic*[tiab] 
37

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

OR computerized physician order entry OR computerised physician order entry OR computer provider 

order entry OR cpoe OR e-prescrib* OR e-prescription* OR electronic prescrib* OR electronic 

prescription* OR e-health OR “Medical Records Systems, Computerized”[Mesh]

AND 

patient*[ti] OR consumer*[ti] OR patient*[mh] OR consumer*[mh] OR tether* OR secure OR selfreport* OR self report* 

NOT 

case report OR case reports OR case report[pt] OR case reports[pt]] 

OR 

[“Electronic Health Records”[Mesh] OR “electronic health record” OR “electronic health records” OR 

“electronic medical record” OR “electronic medical record” OR messaging OR email* OR “computerized 

alert” OR “computerized alerts” OR “computerized reminder” OR “computerized reminders” OR 

“computerised reminder” OR “computerised reminders” OR electronics, medical OR informatic*[tiab] 

OR computerized physician order entry OR computerised physician order entry OR computer provider 

order entry OR cpoe OR e-prescrib* OR e-prescription* OR electronic prescrib* OR electronic 

prescription* OR e-health OR “Medical Records Systems, Computerized”[Mesh]

AND 

reminder* 

NOT 

case report OR case reports OR case report[pt] OR case reports[pt]] 

NOT 

Results of Search Strategy #1

NUMBER OF RESULTS: 2804

TOTAL OF ALL SEARCHES AFTER REMOVAL OF DUPLICATES: 4607
38

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

APPENDIX B. Study Selection Form

ID: 

1. Is this consumer HIT?

o Not HIT (STOP) 

o HIT 

2. Functionalities discussed in the article:

o Messaging programs 

o Patient access to own medical record 

o Patient self-reported data (specify) 

o Online preventive or chronic care reminders 

(specify) 

o Other (STOP) 

3. What is the study design?

o Descriptive qualitative 

o Descriptive quantitative 

o Hypothesis testing 

o Systematic review 

o Non-systematic review (STOP) 

o Commentary/news (STOP) 

o Other (STOP) 

o N/A, Not reported (STOP) 

4. Study Origin

o US 

o Non-US 

o Not clear/Unknown 

5. If STOP, save for background?

o Yes 

6. Is study from a VA peer organization?

o Kaiser Permanente 

o Group Health Cooperative 

o Geisinger Health System 

o Partners HealthCare 

o Palo Alto Medical Foundation 

o None 

o Not Reported 

o VA 

Which outcomes are reported?

7. Clinical Outcomes

o Health outcomes 

o Patient satisfaction 

o Provider satisfaction 

o Patient-provider communication 

o Self-management 

o Adherence (medication, visit) 

o Other (specify) _____________

8. System-level outcomes

o Efficiency/Utilization 

o Privacy breaches 

o Patient safety 

o Other (specify) _____________

9. Other outcomes

o Attitudes 

o Usability 

 
39

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

APPENDIX C. Criteria Used in Quality Assessment

A summary of GRADE’s approach to rating quality of evidence58

Study design Initial quality of a body of 

evidence Lower if Higher if Quality of a body of evidence

Randomized 

trials

High Risk of Bias

 -1 Serious

 -2 Very serious

Inconsistency

 -1 Serious

 -2 Very serious

Indirectness

 -1 Serious

 -2 Very serious

Imprecision

 -1 Serious

 -2 Very serious

Publication Bias

 -1 Likely

 -2 Very likely

Large Effect

 +1 Large

 +2 Very large

Dose response

 +1 Evidence 

 of a gradient

All plausible residual 

 confounding

 +1 Would reduce a 

 demonstrated effect

 +1 Would suggest a spurious 

 effect if no effect was 

 observed

High (four plus: ⊕⊕⊕⊕)

Moderate (three plus: ⊕⊕⊕)

Low (two plus: ⊕⊕)

Very low (one plus: ⊕)

Observational 

studies

Low
40

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

APPENDIX D. Peer Review Comments/Author 

Response

Prompt Comment Response

Are the 

objectives, 

scope, and 

methods for 

this review 

clearly 

described?

The dates of the literature review are stated as “1999 through 

12/03/2010”...to improve consistency provide start and end 

dates in same format (e.g. 01/01/1999 through 12/03/2010).

This suggestion has been 

incorporated.

Are there any 

published or 

unpublished 

studies that 

we may have 

overlooked?

The exclusion of descriptive qualitative studies appears to 

be a shortcoming considering the infancy of this field and 

the limited availability of data about the use and efficacy 

of Secure Messaging, Personal Health Records, and Webbased Management Systems. The inclusion of at a minimum 

a summary of the qualitative findings to date could provide 

insights to the facilitators and barriers to use and possibly 

inform the “why” factor to these reported quantitative 

findings.

We evaluated the descriptive 

qualitative papers and identified 

those that were potentially studies 

of patient portals that discussed 

barriers and facilitators. We 

identified four such studies for 

inclusion, two of which were 

of the same system, that we felt 

were reasonable to include. A 

fifth study involved focus groups 

evaluating a “potential” system 

and was not included. A sixth 

study evaluated patient opinions 

regarding access to records from a 

kiosk in the practice waiting room 

in London and was not included.

J Gen Intern Med. 2003 Sep;18(9):736-44.

Effect of a triage-based E-mail system on clinic resource 

use and patient and physician satisfaction in primary care: a 

randomized controlled trial.

The email system presented does 

not match our definition of secure 

messaging. Insecure email was 

outside the purview of our current 

scope.

Randomized Trials:

1. McCarrier KP, Ralston JD, Hirsch IB, et al. Web-based 

collaborative care for type 1 diabetes: a pilot randomized 

trial. Diabetes Technol Ther. Apr 2009;11(4):211-217. (U of 

Washington Study)

2. Simon GE, Ralston JD, Savarino J, Pabiniak C, Wentzel C, 

Operskalski BH. Randomized trial of depression follow-up 

care by online messaging. J Gen Intern Med. 2011. (Group 

Health Study)

McCarrier: Our original search 

only found the companion to this 

article. We have now included this 

article as well.

Simon and Lyles: These articles 

were too recent for our original 

search, however our updated 

search did include them. They 

have now been incorporated into 

the report. 
41

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Are there any 

published or 

unpublished 

studies that 

we may have 

overlooked?

Papers Addressing Potential Disparities in Access to SM and 

Patient Access to Records:

1. Lyles CR, Harris LT, Jordan L, et al. Patient race/ethnicity 

and shared medical record use among diabetes patients. Med 

Care. 2011. (Group Health)

2. Roblin DW, Houston TK, 2nd, Allison JJ, Joski PJ, 

Becker ER. Disparities in use of a personal health record in a 

managed care organization. J Am Med Inform Assoc. Sep-Oct 

2009;16(5):683-689. (Kaiser)

3. Sarkar U, Karter AJ, Liu JY, et al. The literacy divide: 

health literacy and the use of an internet-based patient portal 

in an integrated health system-results from the diabetes study 

of northern California (DISTANCE). J Health Commun. 

2010;15 Suppl 2:183-196. (Kaiser)

Roblin: This article has now been 

included in a new section on 

patient characteristics associated 

with use of a patient portal/ 

tethered PHR.

Sarkar: We have included this 

article in a new section on patient 

characteristics associated with use 

of a patient portal/tethered PHR.

Wald JS, Grant R, Schnipper J, Gandhi T, Poon E, Businger 

A, Orav E, Williams D, Volk L, Middleton B. Survey analysis 

of Patient Experience using a Practice-linked PHR for Type 2 

Diabetes Mellitus. AMIA Annu Symp Proc 2009:678-82.

{post 12/3/2010}Wright A, Poon EG, Wald J, Feblowitz JC, 

Schnipper JL, Grant RW, Gandhi TK, Volk LA, Bloom A, 

Williams DH, Gardner K, Epstein M, Nelson L, Businger 

A, Li Q, Bates DW, Middleton B. Randomized controlled 

trial of health maintenance reminders provided directly to 

patients through an electronic PHR. J Gen Int Med 2012 Jan; 

27(1):85-92. Epub 2011 Sep 9. http://www.ncbi.nlm.nih.gov/

pubmed/21904945

{post 12/3/2010}Yamin CK, Emani S, Williams DH, Lipsitz 

SR, Karson AS, Wald JS, Bates DW. The digital divide in 

adoption and use of a personal health record. Arch Int Med 

2011; 171(6):568-574. {This paper may be relevant since 

many studies are limited by selection bias in the study 

participants.}

Grant RW, Wald JS, Schnipper JL, Gandhi TK, Poon EG, 

Orav EJ, Williams DH, Volk LA, Middleton B. Practicelinked Online Personal Health Records for Type 2 Diabetes: 

A Randomized Controlled Trial. Arch Int Med 2008; 

168(16):1776-82.

Grant RW, Wald JS, Poon EG, Schnipper JL, Gandhi TK, 

Volk LA, Middleton B. Design and implementation of a webbased patient portal linked to an ambulatory care electronic 

health record: patient gateway for diabetes collaborative care. 

Diabetes Technol Ther. 2006; 8:576-86.

Wald 2009: This article reports 

on a subset of patients that are 

included in the Grant 2008 article 

below and the previously included 

Wald 2010 artucle, and is thus an 

exclude.

Wright: This article is about 

reminders, which was not part of 

the revised focus for this report.

Yamin: This article was too recent 

for our original search, but was 

captured by our search strategy 

in an update search, and is now 

included. 

Grant 2008: This article is now 

included.

Grant 2006: Although our search 

did capture this article, it was 

marked as an exclude because 

it was descriptive qualitative 

and did not address barrier or 

facilitators to use.
42

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Are there any 

published or 

unpublished 

studies that 

we may have 

overlooked?

Wald JS. Variations in Patient Portal Adoption in Four 

Primary Care Practices. AMIA Annu Symp Proc 2010:837-

41. {Supports the idea that it may be difficult to draw strong 

conclusions from practices/patients where adoption is weak; 

the implication for future VA work is to establish “level of 

adoption” metrics for comparability.}

The Value of Personal Health Records. David C. Kaelber, MD, 

PhD, Sapna Shah, MS, Adam Vincent, MPP, Eric Pan MD, MSc, 

Julie M. Hook, MA, MPH, Doug Johnston, MTS, David W. 

Bates, MD, MSc, Blackford Middleton, MD, MPH, MSc. © 2008 

by the Center for Information Technology Leadership (CITL). 

Published and distributed by the Healthcare Information and 

Management System Society (HIMSS). Requests for permission 

to reproduce any part of this work should be directed to: Ellen 

S. Rosenblatt, Manager of Operations Center for Information 

Technology Leadership Partners HealthCare System, Inc. One 

Constitution Center Information Systems Department, Second 

Floor West Charlestown, MA 02129 erosenblatt@partners.org. 

ISBN: 978-0-9800697-4-7

Wald 2010: This paper is a 

descriptive qualitative paper 

that was included in our search 

and that is now included in the 

new section on barriers and 

facilitators.

Kaelber: This was already 

included, and is described in the 

“Patient Access and Efficiency/

Utilization.”42

Not including search terms such as ‘personal health record’, 

‘patient portal’, ‘secure email’ and ‘text messaging’ may have 

reduced identification of potentially appropriate papers.

We will incorporate this 

suggestion into any future 

updated search, however for this 

report we rely on the original 

search and reference mining of 

included articles and the review 

by experts to identify potentially 

important missing studies. In 

the peer review process just 

completed, only three such 

articles (out of more than 60 

already included) were identified, 

supporting a conclusion that the 

number of additional relevant 

studies now already identified is 

likely to be very small (<5%).

Please write 

additional 

suggestions 

or comments 

below. If 

applicable, 

please indicate 

the page and 

line numbers 

from the draft 

report.

There are some run-on sentences in the introduction, page 5. We have edited the introduction.

Recommend tabling key research question results and 

“GRADES”.

We have included such a table 

in the Summary and Discussion 

section.

From the automated email, I think there is a lot more research 

in the health behavior literature, Wayne Velicer, Vic Strecher, 

and many others have done this. Some has even extended to 

text messaging. Thus, I think that this section is not complete.

Because this was not the focus 

of the review, and based on the 

likelihood that our search did not 

adequately identify much of the 

literature in this area, we have 

removed this section from the 

report.

Please correct all instances of My HealtheVet to be branded as 

shown here: “My HealtheVet”

This change has been 

incorporated.
43

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Please write 

additional 

suggestions 

or comments 

below. If 

applicable, 

please indicate 

the page and 

line numbers 

from the draft 

report.

It seems that there is logic to the order in which the GRADE 

of evidence is presented but it is unclear from the report what 

that logic is? It is clearly not higher to lower grades, but I 

wondered why? E.g. p 4

The order was based on the 

order of the outcomes in the key 

questions, and then within each 

outcome the evidence is sorted 

with GRADE going from high to 

low. A new table has been added 

for clarification.

I find it very surprising that there is insufficient evidence to 

reach conclusions about the effect of patient access to their 

own medical record on their attitudes. Is this because most 

attitudinal studies were not examined since the scope was on 

hypothesis testing? Should that be qualified if that’s the case?

In order to reach conclusions 

about satisfaction, we required 

a study to statistically test 

satisfaction, either between 

groups (with and without access 

to their own medical records) 

or across time (before and after 

access to their own medical 

records). Without these data, 

we can reach only limited 

conclusions. We started from the 

position that in order to reach 

cause-and-effect conclusions 

a hypothesis would need to be 

stated and then tested.

I am finding that the comparison of use of PHR portal alone 

versus PHR portal WITH Secure Messaging has been useful 

in my own work. Instead the report compares SM with portal 

versus SM alone. Given that the model in the industry has 

evolved from PHR portal to portal WITH SM is there any way 

to reflect this in your analysis?

The original focus of the review 

was to evaluate secure messaging 

alone and then to evaluate the 

area of “patient access to medical 

records.” In the patient access to 

medical records section, all of 

the tethered systems described in 

the ‘Outcomes, Satisfaction and 

Adherence” section and all but 

one in the “Efficiency/Utilization” 

section include secure messaging 

as a component of their PHRs. In 

the one instance where this is not 

the case, it is specifically noted in 

the text.30

Page 5: Dr. Nazi’s office is Veterans and Consumers Health 

Informatics Office/Office of Informatics and Analytics

This change has been 

incorporated.

P17. Missing period in para 2, could RVUs be defined? This change has been 

incorporated.
44

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Please write 

additional 

suggestions 

or comments 

below. If 

applicable, 

please indicate 

the page and 

line numbers 

from the draft 

report

Consider further review and discussion of the interdependence 

of secure messaging and patient medical record access in the 

studies reviewed. Several of the intervention studies and most 

of the observational studies were in healthcare systems that 

intentionally tied together secure messaging and patient access 

to portions of the electronic medical record. Several of these 

interventions saw these two functions as interdependent for 

many patients, particularly for those needing self management 

support and collaborative care for chronic conditions. Parsing 

out the individual contribution of one of these activities may 

be less fruitful than seeing the value of the package.

As in the response to the comment 

above, the synthesis of “patient 

access to medical records” 

consisted of interventions that 

also included secure messaging, 

so the synthesis of the two 

interventions is already contained 

in the report. In addition, in the 

Summary and Discussion section, 

we have also discussed this point. 

Discuss results in the context of evolving definitions of patient 

medical electronic medical record access across the studies. 

For some of these studies, the record is a passive document 

viewed online by the patients. For others, the record is more 

interactive for patients and part of the ongoing care and 

communication tasks many patients face. In the latter case, 

the record can include secure patient provider messaging, 

medication refill functionality, and structured health risk 

assessment and feedback. Although current studies are not 

sufficient to determine the evidence behind the different 

approaches to patient access of the medical records, these 

differences may end up playing a role in outcomes as evidence 

evolves.

In order to inform this issue, 

we have included more detailed 

descriptions of the tethered 

systems described in the studies.

Evaluation and discussion of equity in access to SM and 

patient access to medical records is missing. Secure messaging 

and patient access to the medical record should be seen as 

part of how we deliver care to all patients. Some historically 

vulnerable and underserved patient populations are less 

likely to use these services. As the VA and other similar 

organizations consider implementation of SM and patient 

access to the record, understanding and addressing these 

differences is essential for equitable care. I have provided a 

few references above to consider if the reviewers decided to 

encompass this domain.

We have included a new section 

entitled “Patient Access and 

Patient Characteristics” which 

reviews the evidence relevant to 

this comment.

Page 15, second paragraph, third to last sentence. The 

randomized study of patients with diabetes referenced was 

done at the U of Washington, not Group Health (Ralston et al, 

Diabetes Care). 

We thank the reviewer and author 

of the study for this observation, 

and have made the correction.
45

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Please write 

additional 

suggestions 

or comments 

below. If 

applicable, 

please indicate 

the page and 

line numbers 

from the draft 

report

Page 15, 3rd paragraph, in reference to Group Health 

randomized trial of essential hypertension. The review appears 

to erroneously imply that the control group did not have 

access to SM and the electronic medical record. All three 

study arms, including the usual care arm, had access to SM 

with PCP and other members of healthcare team and had 

access to similar portion of the electronic medical record. One 

intervention arm was given a home blood pressure cuff; the 

other intervention arm was given the blood pressure cuff and 

additionally access to pharmacist-based care management. All 

patients in the study were signed up and had access to the SM 

and electronic records. The strength of the study is showing 

how pharmacist care management over SM improves to BP 

control among patient who have access to SM and the services 

of the electronic record. May be particularly relevant to the 

VA’s access efforts for mental health care.

We thank the reviewer and author 

for this clarification and have 

revised the description of the 

study and our conclusion. 

For Key Question #1, the Grant 2008 paper would justify 

adding to RESULTS (if authors agree): “There is ___ strength 

evidence that secure messaging (especially as part of a webbased management system) can improve medication decisions 

during a subsequent visit, reducing clinical inertia (Grant 2008 

Arch Int Med).

We have added this conclusion 

(slightly modified) to the 

conclusion and given it a 

GRADE classification of “low” 

due to sparse data and concern 

about the generalizability of the 

intervention and practice settings.

For Key Question #1, the association of secure messaging 

with many things (pt satisfaction, adherence, outcomes, etc.) 

is tempered by attitudes, workflow, service orientation, and 

factors beyond the tool itself. This is touched upon in the 

conclusion.

Not sure if this “finding” can be considered given the report 

methodology, but I feel it’s important because these factors are 

critical for understanding the current evidence and will likely 

impact future evidence as well. One paper that addresses 

practice (and other) factors are: Wald JS. Variations in Patient 

Portal Adoption in Four Primary Care Practices. AMIA Annu 

Symp Proc 2010:837-41. 

We have now incorporated 

this reference in an expanded 

discussion of this issue.

Not sure if this synthesis should include any high level 

comments about why the findings are largely indeterminate. 

Overall penetration of secure messaging and patient access 

to health records is still quite low, and given this, a paucity of 

rigorous data is not unexpected. 

Some of the findings may suffer from a ceiling effect.... 

Meaning that patients practicing greater health engagement 

with providers and in terms of self-management may be more 

likely to adopter new technology sooner, making it harder to 

demonstrate strong improvement.

We have incorporated these into 

the limitations.
46

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Please write 

additional 

suggestions 

or comments 

below. If 

applicable, 

please indicate 

the page and 

line numbers 

from the draft 

report

Comments on language: specific language and definitions 

could be helpful early on, with consistency throughout. Secure 

messaging, per VA-developed language, refers to secure 

email defined by online communication between patients and 

providers or healthcare team members. ‘Messaging system’ is 

less clear (e.g. page 14), and could include automated email, 

text or other technology such as interactive voice response 

(IVR). This review is focused on specific functionality 

delivered largely through patient portals and/or personal health 

record systems. Consider briefly defining functions early on; 

using either secure email or secure messaging, and avoid 

‘messaging’ in other instances.

We have included definitions 

and have eliminated the section 

on automated email to avoid 

confusion. 

Comment on category of Efficiency/Utilization (page 

16+): This grouping includes study findings across 3 types 

of measures: patient-level utilization of care or services 

delivered, provider-delivered care or workload measures, 

and patient-level characteristics or factors. The 3rd type of 

measure, characteristics of users and non-users, is important 

yet not a component of the category title. Impact on care 

utilization and provider workload should be distinct from one 

another.

We have now incorporated a new 

section on patient characteristics. 

Comment on Automatic Email Systems (page 19): there are 

several types of automatic messaging systems, including email 

notifications, text notification and others, such as IVR. Based 

on the search terms used, it appears the scoping was for the 

1st type of notification only. If so, it would be valuable to 

describe the types of papers that were excluded. If not, there is 

some concern that the search terms used may have limited the 

studies identified.

This section has been deleted in 

this version. 

Comment on ‘SM users’: it would be helpful to clarify if a 

study examined patients who were enrolled or authenticated 

(identity-proofed) to use the PHR or secure email portal, 

or, whether actual use of SM was employed to identify the 

individuals. This is nuanced, but creates differences in study 

denominators.

This is an important distinction, 

however, most of the primary 

studies are not clear on this point.

Comments on ‘access to their own record’: there are 

significant differences in the record content available for 

patients to view through a PHR. The VA offered access to 

medications and wellness reminders (at end of 2010); Kaiser 

and Group Health provided lab results and problem lists; few 

systems offered access to clinical notes. These distinctions 

should be described, even if there is insufficient evidence to 

discern the impact related to specific content or increasing 

level of health record access.

We have included more detailed 

descriptions of the tethered 

systems described in the studies.

Page 14: ‘web-based pharmacy group’ – suggest modify to 

web-based system plus pharmacist

We have modified this 

description. 

Various pages: On-line can be one word: online; Diabetic 

patients should be patients with diabetes, patients with CHF, 

etc.

These changes have been 

incorporated throughout the text.
47

Secure Messaging between Providers and Patients, and 

Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

Prompt Comment Response

(Continued)

Please write 

additional 

suggestions 

or comments 

below. If 

applicable, 

please indicate 

the page and 

line numbers 

from the draft 

report

Summary and Discussion (page 27): there appears to be a 

summary but no discussion.

We have now put the conclusions 

and GRADE information in 

a table and added text to the 

discussion.

Limitation: all of these studies have relevance for the VA. 

Comments about fee-for-service or academic centers raise 

issues of external validity.

We have modified this text. 

Conclusion: studies showed patient satisfaction and reportedly 

improved communication with secure messaging alone. 

‘Web-based management program’ could gain specificity 

with personal health record systems having access to online 

information and services... allowing patients to participate in 

their health and healthcare.

We have revised this section to 

include more information about 

this conclusion.

Please 

provide any 

recommendations on 

how this 

report can 

be revised to 

more directly 

address 

or assist 

implementation needs.

Include relevant qualitative/descriptive research findings 

section/summary.

We have incorporated relevant 

qualitative descriptive studies 

about barriers and facilitators 

within the patient access section. 

Consider adding to the review a discussion of the evidence 

for coupling secure messaging and patient access to medical 

records, particularly for chronic conditions.

We have further emphasized these 

points. 
48

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

vidence Tables

nce Table

HIT Intervention Setting Outcome Measures Findings

Online depression care management using secure messaging through a patient website linked to the medical 

ecord.

Group Health Cooperative (9 primary care clinics)

Depression severity (Hopkins Symptom Checklist)

Intervention patients had lower depression severity at the end of the evaluation period and higher proportions experienced 50% or greater decreases in depression scores (55% vs. 41%, OR=1.8, 95% CI: 1.0-3.1)

Web-group receiving disease

pecific education and self

eatment. Web-patients can 

ontact Web-doctor through mail/text message

2 hospitals each in Denmark & Ireland;No mention of EHR

Feasibility of the approach, its influenceon patients’ compliance, knowledge, quality of life (QoL), disease outcomes (relapse), safety and health care costs

Adherence to 4 weeks of acute treatment was increased by 31% in Denmark and 44% inIreland compared to the control groups. In Denmark IBD knowledge and QoL were significantly improved in web patients. Median relapse duration was 18 days (95% CI10 to 21) in the web versus 77 days (95% CI 46 to 108) in the control group. The number of acute and routine visits to the outpatient clinic was lower in the web than in the control group. No difference in the relapse frequency, hospitalization, surgery or adverse events was observed.

t access to EHR; Secure 

messaging

Kaiser Permanente 

Health Outcomes (HEDIS measures)

Patients with diabetes who used secure messaging with providers had better HEDIS measures with respect to Hgb, BP, and LDL, and also had greater improvements in HEDIS measures

ecure messaging Group Health 

Cooperative 

High quality DM care Lower outpatient utilization

Use of messaging was associated with better glycemic control [a1c <7.0%, RR 1.36 (1.16-1.58)] Use of messaging was associated with higher rate of outpatient visits [1.39 (1.26-1.53)]

Web-based care management UW General 

Internal Medicine Clinic

Primary: HgbA1c change after 12 month intervention. Secondary: total plasma cholesterol an systolic and diastolic blood pressure

A1c levels declined significantly in the intervention group compared with the usual care group (change -0.7%, p=0.01). More participants in the intervention group than in the usual-care group had A1c<7% after 12 months (33vs 11%; p=0.03). At 12 months mean changes in systolic blood pressure, diastolic blood pressure, and total cholesterol were not significantly different between groups. 

nternet-based health record 

hat provides patients 

with general and personal 

nformation about treatment for nfertility 

ontrol group: no access to 

ystem

University Medical Center Netherlands

Patient empowerment; patient satisfaction; meaning of infertility programs; social support; anxiety; depression

No significant differences were observed in patient empowerment, patient satisfaction, meaning of infertility problems, social support, anxiety, or depression. No adverse effects were noted in the use of internet-based health record
49

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

Web-based Care Management 

received notebook computer, 

lucose and blood pressure 

monitoring device and access 

o care management website)

VA Medical Center, Boston

HgbA1c, Systolic and Diastolic Blood Pressure. 

There was a significant decrease in HgbA1c compared to baseline in both groups (P<0.001) at all serial points of measurement. (3,6,9,12 months). There was a greater decline in HgbA1c over time in the web-based care management group when compared to the education and usual care group (p<0.05). Those in the highest tertile of data uploads had significantly greater decline in HgbA1c than those in the lowest tertile (P<0.05). Hypertensive participants in the web-based care-management group had a significantly greater decline in SBP after 12 months (P<0.01). The frequency of website logins or data uploads was not a predictor for change in blood pressure. 

A web interface giving patients 

ccess to the medical record,  guide to heart failure, and a 

messaging system

Academic Medical CenterExisting EHR

Use, Physician and patient survey

Frequency of use was 0.4 hit-days per enrolled patient per month. Clinical notes and laboratory results were the most frequently viewed items. Electronic messaging supplemented rather than replaced telephone messages. Measures of self-efficacy were not statistically significantly different between groups. General adherence increased in the intervention groups. 

Home blood pressure (BP) monitoring and secure patient Web site only vs. home BP monitoring and secure patient Web site plus pharmacist care management delivered through Web communication

Group Health Cooperative (10 medical centers)

Percentage of patients with controlled BP (<140/90) and changes in systolic and diastolic BP at 12 months

Patients in the home BP monitoring and Web site only group had a nonsignificant increase in the percentage of patients with controlled BP compared 

with usual care (36% vs. 31%, P=.21). Adding Web-based pharmacist care to home BP monitoring and the Web site significantly increased the percentage of patients with controlled BP (56%) compared with usual care (P .001) and home BP monitoring and Web site only (P .001). Compared with usual care, the patients who had baseline systolic BP ≥160 mm Hg and received home BP monitoring and the Web site plus pharmacist care had a greater net reduction in systolic and diastolic BP.

ecure messaging portal 

hrough established EMR

Academic internal med clinic in Denver

Use, patient satisfaction Portal group patients reported improved communication with the clinic and 

higher satisfaction with overall care

atients of intervention group 

sed email to communicate 

with physicians

Academic medical clinic

Use, patient and provider satisfaction

Patient satisfaction significantly increased in the email group compared to the control group in areas of convenience and amount of time spent contacting the physician. Physician satisfaction increased for convenience and amount of time and volume of messages. 

Relay Health System, a web based patient-provider 

ommunication system

Academic Medical CenterExisting EHR 

Use, Satisfaction 9% of intervention physicians’ patients used the system. Fewer than 10% 

of the patients sent over 5 messages, 45% of patient sent a single message. Messages about medications, “other medical questions ,” and general chronic symptoms comprised half of all messages. Half of all messages were responded to in four hours, 86% within 16 hours. Telephone call volume was 18.2% less for intervention physicians than control. Patients were in general satisfied and found messaging easy to use. Providers were marginally satisfied, but found it easy to use and were neutral on the effect on workflow.
50

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

nternet-based health record 

hat provides patients 

with general and personal 

nformation about treatment for nfertility

ontrol group: no access to 

ystem

University Medical Center Netherlands

Patient empowerment; patient satisfaction; meaning of infertility programs; social support; anxiety; depression

No significant differences were observed in patient empowerment, patient satisfaction, meaning of infertility problems, social support, anxiety, or depression. No adverse effects were noted in the use of internet-based health record

A web interface giving patients 

ccess to the medical record,  guide to heart failure, and a 

messaging system

Academic Medical CenterExisting EHR

Use, Physician and patient survey

Frequency of use was 0.4 hit-days per enrolled patient per month. Clinical notes and laboratory results were the most frequently viewed items. Electronic messaging supplemented rather than replaced telephone messages. Measures of self-efficacy were not statistically significantly different between groups. General adherence increased in the intervention groups. 

Relay Health System, a web based patient-provider 

ommunication system

Academic Medical Center Existing EHR

Use, Physician and patient surveys

37% of patients responded to the survey. 89% of patients found the system easy to use. 50% of patients used the system once or twice. 6 of 8 clinicians were satisfied or very satisfied with the system.

-mail to communicate with 

hysicians

Survey link from website of 1) Intelihealth (health media company) and 2) CareGroup Healthcare System (Harvardaffiliated integrated health delivery network)

Use, clinical topics discussed through e-mail, perceived benefits, overall satisfaction

16.5% (of 1881) individuals reported using electronic mail to communicate with their physicians. Most frequent topics were results of lab testing (85%) and prescription renewals (85%). 21% of users inappropriately e-mailed about urgent or sensitive issues (suicidality, chest pain). 95% perceived e-mail to be more efficient than telephone. 82% of respondents were satisfied with the e-mail communication.

ecure email reminder system 

or colorectal cancer screening

Kaiser Permanente

Completion of CRC screening

CRC screening rates for patients receiving usual care (7.8%), email (22.7%), letter (23.6%) p<0.0005 usual care vs. letter p<0.0005 usual care vs. email p=7.11 letter vs. email

A web interface giving patients 

ccess to the medical record,  guide to heart failure, and a 

messaging system

Academic Medical CenterExisting EHR

Use, Physician and patient survey

Frequency of use was 0.4 hit-days per enrolled patient per month. Clinical notes and laboratory results were the most frequently viewed items. Electronic messaging supplemented rather than replaced telephone messages. Measures of self-efficacy were not statistically significantly different between groups. General adherence increased in the intervention groups. 
51

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

Web-group receiving disease

pecific education and self

eatment. Web-patients can 

ontact Web-doctor through mail/text message

2 hospitals each in Denmark & Ireland;No mention of EHR

Feasibility of the approach, its influence on patients’ compliance, knowledge, quality of life (QoL), disease outcomes (relapse), safety and health care costs

Adherence to 4 weeks of acute treatment was increased by 31% in Denmark and 44% in Ireland compared to the control groups. In Denmark IBD knowledge and QoL were significantly improved in web patients. Median relapse duration was 18 days (95% CI 10 to 21) in the web versus 77 days (95% CI 46 to 108) in the control group. The number of acute and routine visits to the outpatient clinic was lower in the web than in the control group. No difference in the relapse frequency, hospitalization, surgery or adverse events was observed.

hared medical record: secure 

messaging, medication refills, 

ppointment requests, view test 

esults, after-visit summaries, 

medical problem lists

Group Health Cooperative; probable EHR

Patients’ use of shared medical record (SMR)

32.2% of enrollees used the SMR; median rate was 1.02 user-days/month. Numbers of users and rate of use increased over time. (Likelihood of initial SMR use was associated with assigned PCP’s use of secure messaging.)

Use of the internet by patients 

o communicate with providers

European population (not specific)

Use, patient surveys, phone interviews, attitudes

In 2007, approximately 1.8% of population had used internet to order a rx, 3.2% to schedule an appt, and 2.5% to ask a health question. Among those using the internet for health purposes, more than 4 out of 10 considered it important when choosing a doctor

ecure messaging Group Health 

Cooperative 

High quality DM care Lower outpatient utilization

Use of messaging was associated with better glycemic control [a1c <7.0%, RR 1.36 (1.16-1.58)] Use of messaging was associated with higher rate of outpatient visits [1.39 (1.26-1.53)]

ecure Messaging Group Health 

Cooperative 

Characteristics of users of secure messaging

Higher use rates associated with: Females [OR 1.15 (1.10-1.19)] greater morbidity [OR 5.64 (5.07-6.28)] PCP use with other patients [OR 1.94 (1.67-2.26)] Lower use associated with: Age over 65 [0.65 (0.59-0.71)] Medicaid vs. commercial insurance [OR 0.81 (0.68-0.96)]

Use of email by providers to 

ommunicate with patients

Ambulatory primary care and specialists in Florida

Use, provider surveys Of 4,203 physicians completing the survey, 16.6% had used email to 

communicate with patients. Only 6.7% adhered to at least half of the 13 selected guidelines for email communication
52

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

ecure web messaging system Primary care 

clinic in Norway

Use, efficiency Forty-six percent of pts given access to messaging system used the online 

communication at least once. The reduction in office visits over time was greater for the intervention group than for the control group (p=0.034).

nformational sheet was given 

o patients listing surgeons 

mail address as first option. 

articipants were also 

nstructed that e-mail was he preferred communication 

method. 

Single Surgical Practice at University of Sydney Endocrine Surgical Unit

E-mail utilization (characterization of user)

In the study group 50 of 306 patients (16%) utilized email communication, compared to 10 of 352 (3%) in the control group (P=0.0001). Email users represented a younger population, mean age 46.2 vs. 54.6 years (P=0.0004) in the study group and mean age 44.2 vs. 54.6 in the control group (P=0.03) . No difference in sex distribution. In the study group, 101 emails were sent by 50 patients and a majority of patients sent only one message (56%) and focused on only one issue. Most common reason for sending an email was to obtain general clinical information (n=123, 62%).

Relay Health System, a web based patient-provider 

ommunication system

Academic Medical CenterExisting EHR

Use, Physician Productivity

9% of intervention physicians’ patients used the system. Intervention physicians averaged 11% more visits per day than control physicians (25.5 vs. 22.9). Intervention physicians averaged 10% more RVUs per day. RVUs per visit were not different between intervention and control. 

Relay Health System, a web based patient-provider 

ommunication system

Academic Medical CenterExisting EHR 

Use, Satisfaction 9% of intervention physicians’ patients used the system. Fewer than 10% 

of the patients sent over 5 messages, 45% of patient sent a single message. Messages about medications, “other medical questions,” and general chronic symptoms comprised half of all messages. Half of all messages were responded to in four hours, 86% within 16 hours. Telephone call volume was 18.2% less for intervention physicians than control. Patients were in general satisfied and found messaging easy to use. Providers were marginally satisfied, but found it easy to use and were neutral on the effect on workflow.

mplementation of KP 

HealthConnect in primary 

are completed November 

004. Implementation of KP 

HealthConnect in specialty care 

ompleted June 2005. Patient

rovider secure messaging 

unction available Sept 2005

Kaiser Hawaii – integrated health care delivery system

Utilization of office visits, telephone visits, secure messaging and ED/Urgent Care 

Total office visits decreased 26.2% between 2004 and 2007 (p<0.001). Total scheduled telephone visits increased nine-fold. Increase in Secure messages between 2005 and 2007 was statistically significant (p<0.001). Rate of urgent 

care (19%, p< 0.001) and ED visits (11%, p<0.001) increased between 2004 and 2007

Web-based care management UW General 

Internal Medicine Clinic

Primary: HgbA1c change after 12 month intervention. Secondary: total plasma cholesterol and systolic and diastolic blood pressure

A1c levels declined significantly in the intervention group compared with the usual care group (change -0.7%, p=0.01). More participants in the intervention group than in the usual-care group had A1c<7% after 12 months (33vs 11%; p=0.03). At 12 months mean changes in systolic blood pressure, diastolic blood pressure, and total cholesterol were not significantly different between groups. 
53

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

atient access to secure 

messaging

Kaiser Permanente Northwest (KPNW)

Office visit rate and telephone contact rate. 

In the cohort study annual adult primary care visit rates decreased by 9.7% (2.47-> 2.24 office visits per member/year P<0.01). In the matched control study annual adult primary care visit rates decreased by 10.3% (P<0.001). Annual primary care telephone contact rate increased by 29.9% vs. 16.2% on the study group. (P<0.1)

Analyzed electronic patient

hysician messages Palo Alto Medical 

Foundation

Content Analysis of Secure Patient Messages. 

22% of clinical messages sent to physicians contained sufficient patient history taking data and decision-making components to warrant reimbursement according to authors eVisit criteria. 

atients of intervention 

hysicians were encouraged 

o use a web based tool to 

ommunicate with staff

Academic Medical Center No existing EHR

Use of web messaging, Physician and patient survey of attitudes

In the intervention group, 1,038 patients registered and 2,238 messages were sent. 42% of patients sent no messages, 22% of patients sent >3 messages. Over 20% were appointment-related, 15% were referral requests, 12% were prescription related. During the 40 week study period, the number of patient emails and telephone calls were not affected by the intervention, being 2 fold and 10 fold greater respectively. Intervention physicians were more positive about web communication then control physicians. 

A web interface giving patients 

ccess to the medical record,  guide to heart failure, and a 

messaging system

Academic Medical Center Existing EHR

Use, Physician and patient survey

Frequency of use was 0.4 hit-days per enrolled patient per month. Clinical notes and laboratory results were the most frequently viewed items. Electronic messaging supplemented rather than replaced telephone messages. Measures of self-efficacy were not statistically significantly different between groups. General adherence increased in the intervention groups. 

Relay Health System, a web based patient-provider 

ommunication system

Academic Medical Center Existing EHR

Use, Physician and patient surveys

37% of patients responded to the survey. 89% of patient found the system easy to use. 50% of patients used the system once or twice. 6 of 8 clinicians were satisfied or very satisfied with the system.

Home blood pressure (BP) monitoring and secure patient Web site only vs. home BP monitoring and secure patient Web site plus pharmacist care management delivered through Web communication

Group Health Cooperative (10 medical centers)

Percentage of patients with controlled BP (<140/90) and changes in systolic and diastolic BP at 12 months

Patients in the home BP monitoring and Web site only group had a nonsignificant increase in the percentage of patients with controlled BP compared 

with usual care (36% vs. 31%, P=.21). Adding Web-based pharmacist care to home BP monitoring and the Web site significantly increased the percentage of patients with controlled BP (56%) compared with usual care (P .001) and home BP monitoring and Web site only (P .001). Compared with usual care, the patients who had baseline systolic BP ≥160 mm Hg and received home BP monitoring and the Web site plus pharmacist care had a greater net reduction in systolic and diastolic BP.
54

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

 Tables

HIT Intervention Setting Outcome Measures Findings

nd Adherence

ual care plus access to a nurse 

actitioner case manager and the 

b-based disease management 

odule.

University of Washington Diabetes Care Center

Hemoglobin A1c, Psychosocial selfefficacy

A1c values did not differ significantly after a year of follow-up. There was an increase in psychosocial self-efficacy (difference of 0.3, 95% CI: 0.01-0.59, p=0.04).

eb-Based diabetes care management 

 diabetes as part of an intervention 

sed in the chronic care model and 

luded a case manager for training, 

view of blood source readings, 

mmunication with patients, 

ustment of diabetes medications, 

d discussion with the patients’ PCP.

University of Washington General Internal Medicine Clinic, 83 patients enrolled with Hsb A1c > 7.0% who spoke English and could use the computer with the internet

Hemoglobin A1c, Use of service

Compared to usual care, intervention with patients had a hemoglobin A1c < 7.0% at 12 months (33% vs. 11%, p=0.03). There was no difference between groups in blood pressure control or lipid levels. There was no difference between groups in the numbers of outpatient visits, primary care visits, specialty physician visits, or inpatient days.

ervention practices gave patients 

cess to a diabetes mellitus-specific 

rsonal health record with modules 

 medication review, clinical data, 

d care plans.

Partners HealthCare Hemoglobin A1c, 

blood pressure, LDL-C

After one year of follow-up, there were no differences in A1c levels, blood pressure, or LDL-C levels between groups. 

ernet-based health record that 

ovides patients with general and 

rsonal information about treatment 

 infertility 

ntrol group: no access to system

University Medical Center Netherlands

Patient empowerment; patient satisfaction; meaning of infertility programs; social support; anxiety; depression

No significant differences were observed in patient empowerment, patient satisfaction, meaning of infertility problems, social support, anxiety, or depression. No adverse effects were noted in the use of internet-based health record

access to records; secure messaging Academic subspecialty 

clinic in Colorado

Pt/provider communication, health outcomes, pt satisfaction, adherence

The intervention group was not found to be superior in self-efficacy but was superior in general adherence. There was a trend toward better satisfaction with pt/provider communication.
55

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

me blood pressure (BP) monitoring 

d secure patient Web site only 

 home BP monitoring and secure 

tient Web site plus pharmacist care 

anagement delivered through Web 

mmunication

Group Health Cooperative (10 medical centers)

Percentage of patients with controlled BP (<140/90) and changes in systolic and diastolic BP at 12 months

Patients in the home BP monitoring and Web site only group had a non-significant increase in the percentage of patients with controlled BP compared with usual care (36% vs. 31%, P=.21). Adding Webbased pharmacist care to home BP monitoring and the Web site significantly increased the percentage of patients with controlled BP(56%) compared with usual care (P .001) and home BP monitoring and Web site only (P .001). Compared with usual care, the patients who had baseline systolic BP ≥160 mm Hg and received home BP monitoring and the Web site plus pharmacist care had a greater net reduction in systolic and diastolic BP.

y Group Health patient website, 

ked to EpicCare

Group Health Cooperative 750,000 patients have access, 2000 patients invited for survey

Use, Satisfaction Over 3 years, the number of patients receiving ID verification to use 

My Group Health increased from 3% to 25%. Use increased over time. The most commonly used services were test results, medication refill requests, after visit summaries, and patient-provider clinical messaging.

ournal, a patient completed pre

its electronic journal submitted 

providers prior to an office visit. 

is eJournal was one component of 

tient Gateway, which had 21,533 

counts registered.

Primary and specialty practices at Brigham & Women’s hospital

Use, Patient and provider satisfaction 

About 3% of eligible patients consented to the study, of which about 50% were invited to submit a journal, of which between 64% to 78% opened the journal, and of these 97% of patients edited an existing entry. eJournal invitations for medications, allergies, and diabetes history were more likely to get completed and be viewed by patients and providers as being useful to the visit than were eJournal invitations for personal and family health history and health maintenance items. 

eb-Based diabetes care management 

 diabetes as part of an intervention 

sed in the chronic care model and 

luded a case manager for training, 

view of blood source readings, 

mmunication with patients, 

ustment of diabetes medications, 

d discussion with the patients PCP.

University of Washington General Internal Medicine Clinic, 83 patient enrolled with Hsb A1c > 7.0% who spoke English and could use the computer with the internet

Hemoglobin A1c, Use of service

Compared to usual care, intervention with patients had a hemoglobin A1c < 7.0% at 12 months (33% vs. 11%, p=0.03). There was no difference between groups in blood pressure control or lipid levels. There was no difference between groups in the numbers of outpatient visits, primary care visits, specialty physician visits, or inpatient days.

access to records; secure messaging Academic subspecialty 

clinic in Colorado

Pt/provider communication, health outcomes, pt satisfaction, adherence

The intervention group was not found to be superior in self-efficacy but was superior in general adherence. There was a trend toward better satisfaction with pt/provider communication.
56

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

ared medical record: secure 

ssaging, medication refills, 

pointment requests, view test 

ults, after-visit summaries, medical 

oblem lists

Group Health Cooperative; probable EHR

Patients’ use of shared medical record (SMR)

32.2% of enrollees used the SMR; median rate was 1.02 user-days/month. Numbers of users and rate of use increased over time. (Likelihood of initial SMR use was associated with assigned PCP’s use of secure messaging.)

y Group Health patient website, 

ked to EpicCare

Group Health Cooperative 750,000 patients have access, 2000 patients invited for survey

Use, Satisfaction Over 3 years, the number of patients receiving ID verification to use 

My Group Health increased from 3% to 25%. Use increased over time. The most commonly used services were test results, medication refill requests, after visit summaries, and patient-provider clinical messaging.

Rounds, a web-based electronic 

alth record, to which patients had 

cess to the history and physical 

port, patient care instructions, and 

 imaging data from surgery.

Miami Children’s Hospital, Congenital Cardiac Disease 

Use 93% of the patients or families used the system. Access was more 

common when the patients were in-hospital than out-of-hospital imaging data were most commonly viewed. 

access to records; web messaging Geisinger Health System, 

HMO in Pennsylvania

Use, patient attitudes, pt/provider communication; patient satisfaction; barriers; Pt’s and providers surveyed

Majority of users indicated that the system was easy to use. Minority of users was concerned about the confidentiality of their information. Patients preferred e-mail communication for requesting rx renewals, obtaining general medical information. Physicians were more likely to prefer telephone communication and less likely to prefer e-mail communication.

lue of Personal health record: 

Provider tethered Payer tethered

Third party PHR 

interoperable

n/a Net Value All PHRs have an initial net negative value. After 10 years, steadystate annual net value ranging from $13 billion to $29 billion. 

Interoperable PHRs provide the most value, followed by third-party, and payer tethered. Provider tethered show a consistent negative net value.

me blood pressure (BP) monitoring 

d secure patient Web site only 

 home BP monitoring and secure 

tient Web site plus pharmacist care 

anagement delivered through Web 

mmunication

Group Health Cooperative (10 medical centers)

Percentage of patients with controlled BP (<140/90) and changes in systolic and diastolic BP at 12 months

Patients in the home BP monitoring and Web site only group had a non-significant increase in the percentage of patients with controlled BP compared with usual care (36% vs. 31%, P=.21). Adding Webbased pharmacist care to home BP monitoring and the Web site significantly increased the percentage of patients with controlled BP(56%) compared with usual care (P .001) and home BP monitoring and Web site only (P .001). Compared with usual care, the patients who had baseline systolic BP ≥160 mm Hg and received home BP monitoring and the Web site plus pharmacist care had a greater net reduction in systolic and diastolic BP.
57

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

ournal, a patient completed pre

its electronic journal submitted 

providers prior to an office visit. 

is eJournal was one component of 

tient Gateway, which had 21,533 

counts registered.

Primary and specialty practices at Brigham & Women’s hospital

Use, Patient and provider satisfaction 

About 3% of eligible patients consented to the study, of which about 50% were invited to submit a journal, of which between 64% to 78% opened the journal, and of these 97% of patients edited an existing entry. eJournal invitations for medications, allergies, and diabetes history were more likely to get completed and be viewed by patients and providers as being useful to the visit than were eJournal invitations for personal and family health history and health maintenance items. 

y HealtheVet Durham, VA Veterans with 

diabetes and Hgb A1c > 8.0%

Use, Access, Interest Of 201 patient surveys completed (53% response rate) 59% reported 

having internet access at home, being “moderately” comfortable with internet tasks, 18% had heard of My HealtheVet, and 9% had used it. 41% of patients were “very interested” in using it.

access to records; secure messaging Academic subspecialty 

clinic in Colorado

Pt and physician attitudes via survey and phone interviews; Efficiency

Patients were significantly more likely than physicians to anticipate benefits of SPPARO and less likely to anticipate problems. Attitudes of subjects did not diverge from controls after the intervention period. In post trial interviews, physicians and staff reported no change in their workload and no adverse consequences. All of the physicians ultimately supported the concept of giving patients online access to their clinical notes and test results.

tient Gateway, a secure web portal Partners HealthCare 2000 

patients

Patient prescriptions 23% of patients returned the survey. 70% of users of the web portal 

reported overall satisfaction as “good” or better. Respondents were about as evenly split on whether or not using the web portal improved communication with providers. The most frequently rated valuable functions were the ability to renew prescriptions, ask an administrative question, and obtain referral approvals.

access to EHR, secure messaging Community surgical clinics Use, barriers; Pts 

and providers surveyed

On average, the users accessed the system less than 5 times during the trial period. 82% of the users had not been at all worried about security risks during the trial, while 15% expressed “some concern”.

access to records; web messaging Geisinger Health System, 

HMO in Pennsylvania

Use, patient attitudes, pt/provider communication; patient satisfaction; barriers; Pt’s and providers surveyed

Majority of users indicated that the system was easy to use. Minority of users was concerned about the confidentiality of their information. Patients preferred e-mail communication for requesting rx renewals, obtaining general medical information. Physicians were more likely to prefer telephone communication and less likely to prefer e-mail communication.

eb based patient portal linked to 

mbulatory EMR (Diabetes)

Multi-hospital health care network in US

None Description of design, implementation plan, and evaluation plan. 

Plan to assess the impact with a clinic RCT among 14 primary care practices in the health care system
58

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

tient and significant other access to 

b based EHR

uestionnaire of health information 

I) needs of prostate cancer patients; 

estionnaire and focus group of web

sed EMR at meet HI needs

Prostate cancer support group Victoria, BC

Interest in access to EHR

75% of men desired the ability to access their health records through means other than by meeting with their health care provider, with the internet ranking as the most desired method. 70% of significant others desired the ability to access their men’s health record online.

tient access to their own electronic 

dical record

Group Practice (community) in London, UK

Accuracy Data Security Dr-Pt relationship Internet Access to EMR

82% of respondents were interested in viewing their medical record. 75% felt that access to their record would improve their relationship with their doctor. 80% were not concerned about security. 75% felt their record was accurate.

tient & Physician input into design 

d content of EPR

University Health Network in Toronto, Canada

Physician and patient’s perspective on who should have access to info.

Almost two-thirds of patients (63%) had seen some portion of their medical record (most commonly blood work or X-ray results) and a similar percentage believed a personal medical record would help them manage their personal health care. All physicians felt that patients should receive self-care instructions, yet only half agreed to receiving discharge summaries (10 out of 20) and a minority felt that the patients should be able to receive access to operative notes (5 out of 20, or 25%).

tient experience when assessing 

ir own online patient records

Urban practice in Oxford, UK serving 10,300 patients

Ease of use; confidentiality; security; expectations of content; receiving new information and bad news

Majority of patients found viewing their record useful and understood most of the content, although medical terms and abbreviations required explanation. Patients were concerned about security and confidentiality, including potential exploitation of records. They wanted the facility to give informed consent regarding access and use of data. Many found errors, although most were not medically significant. Many expected more detail and more information. Patients wanted to add personal information.

access to records “email using” physicians Physicians attitudes 

via surveys and phone interviews

Most felt the medication list, normal studies, prescription refills, appointments, and referrals should be provided to the patients (p<.05). However, they felt progress notes, abnormal labs, and care over the internet should not be provided.

tient portal access 5 Group Health Cooperative 

medical clinics in western Washington

SMR use Whites (compared to Blacks, Asians, or others), younger patients, 

and those with higher education and income were more likely to be users of the patient portal.
59

viders and Patients, and Patients’ Access to Their Own Medical Record Evidence-based Synthesis Program

HIT Intervention Setting Outcome Measures Findings

tient Gateway; an online tethered 

rsonal health record

Partners HealthCare Adoption/

registration

43% were “adopters,” with lower rates among racial/ethnic minorities compared to whites and higher rates among patients with selected comorbidities (asthma, CHF, diabetes, hypertension) compared to patients healthier patients.

P.org portal, a tethered personal 

alth record

Kaiser Permanente Northern California

use Only 40% registered for KP.org and 27% signed on one or more 

times. African Americans, Latinos, and Filipinos were more than twice as likely not to sign on to KP.org when compared to whites. Those with lower self-reported health literacy were 1.7 times less likely to sign on the KP.org.

P.org, a tethered personal health 

ord

Kaiser Permanente Georgia Time to registration 35% of participants registered during the study period and were more 

likely to be white than African American (42 vs. 30%, p<0.01), to have diabetes or elevated lipids compared to low risk adults (36 and 38% vs. 30%, p=0.01), and to have a higher levels of education.

My Dispensed Medications” a 

b-based register of dispensed 

dications accessible to patients.

SwedenN=1,000,000 are on the register, during the study 7,860 accessed the site and were offered the survey

Satisfaction 1,716 completed the survey (response rate = 22%). Patient ratings 

were high for usefulness and design of website. Getting control of prescriptions and getting an “overview” of prescriptions was listed by 70% of patients as their reasons for accessing the site.

e concept of patient accessible 

ctronic health records. All Chief 

ecutive Officers of Canadian public 

d acute care hospitals N=213

Canada This is not tethered to any electronic health record

Perceptions about providing patient access to electronic health records

The response rate to the survey was 39%. About half of responding hospitals already had some form of electronic health record, but almost no hospitals used it as the sole method for recording patient information. Financial barriers were the most commonly identified barrier to providing patient access. Patient computer literacy and physician buy-in were also considered important barriers.

rdioCard. Credit card-sized 

ctronic patient record

University Hospital in Switzerland

Usefulness Technical concerns Data security

73% found the card to be useful. Lack of hardware or insufficient computer knowledge was factors in non-use. Privacy was a concern.

access to records Low income housing 

facility

Use, patient attitudes, patient satisfaction, barriers; Pts surveyed

Among 24 residents, 50% participated in the survey. Only 16.7% were able to fill in the health records by themselves. 83% agreed that they have paid more attention to their health conditions and care using PHIMS. Ninety two percent answered that they are satisfied with the personal health record system in general.