Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

July 2012

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

West Los Angeles VA Medical Center

Los Angeles, CA

Paul G. Shekelle, M.D., Ph.D., Director

Investigators:

Principal Investigator: 

Caroline Lubick Goldzweig, M.D., M.S.

Co-Investigators: 

Paul G. Shekelle, M.D., Ph.D.

Ali Alexander Towfigh, M.D.

Neil M. Paige, M.D., M.S.H.S. 

Greg Orshansky, M.D.

David A. Haggstrom, M.D., M.A.S.

Research Associates:

Isomi Miake-Lye, B.A.

Jessica M. Beroes, B.S.

Systematic Review:

Secure Messaging between Providers 

and Patients, and Patients’ Access to 

Their Own Medical Record

Evidence on Health Outcomes, Satisfaction, Efficiency and Attitudes
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PREFACE

Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA.

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes 

and to support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Goldzweig CL, Towfigh AA, Paige NM, Orshansky G, Haggstrom 

DA, Beroes JM, Miake-Lye IM, Shekelle PG. Systematic Review: Secure Messaging between 

Providers and Patients, and Patients’ Access to Their Own Medical Record. Evidence on Health 

Outcomes, Satisfaction, Efficiency and Attitudes. VA-ESP Project #05-226, 2012.

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the West Los Angeles VA Medical Center, Los Angeles, CA 

funded by the Department of Veterans Affairs, Veterans Health Administration, Office 

of Research and Development, Quality Enhancement Research Initiative. The findings 

and conclusions in this document are those of the author(s) who are responsible for 

its contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, 

grants or patents received or pending, or royalties) that conflict with material presented 

in the report.
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TABLE OF CONTENTS

EXECUTIVE 

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Data Synthesis............................................................................................................................................... 1

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Conclusions ................................................................................................................................................... 4

Discussion...................................................................................................................................................... 4

INTRODUCTION............................................................................................................................................... 5

METHODS

Topic Development........................................................................................................................................ 6

Search Strategy.............................................................................................................................................. 8

Study Selection.............................................................................................................................................. 8 

Data Abstraction ............................................................................................................................................ 9

Quality Assessment ....................................................................................................................................... 9

Data Synthesis............................................................................................................................................... 9

Rating the Body of Evidence....................................................................................................................... 10

Peer Review................................................................................................................................................. 10

RESULTS

Literature Flow ............................................................................................................................................ 11

Key Question #1. What is the association between secure messaging and health outcomes, patient 

satisfaction, adherence, efficiency or utilization, or automated email?....................................................... 13

Key Question #2. What is the association between patient access to their own medical record and 

health outcomes, patient satisfaction, adherence, efficiency or utilization, and attitudes about access? .... 19

SUMMARY AND DISCUSSION

Summary of Evidence by Key Question ..................................................................................................... 29

Limitations................................................................................................................................................... 30

Discussion.................................................................................................................................................... 30

Recommendations for Future Research....................................................................................................... 31

Conclusions ................................................................................................................................................. 31

REFERENCES ................................................................................................................................................... 32

APPENDIX A. Search Strategy............................................................................................................... 36

APPENDIX B. Study Selection Form.................................................................................................... 38 

APPENDIX C. Criteria Used in Quality Assessment...................................................................... 39

APPENDIX D. Peer Review Comments/Author Response ............................................................ 40

APPENDIX E. Evidence Tables................................................................................................................ 48
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FIGURES AND TABLES

Figure 1. Literature Flow......................................................................................................................... 12

Table 1. Tethered Personal Health Record Systems and Functionalities............................................... 20

Table 2. Conclusions and Strength of Evidence by Key Question and Outcome .................................. 29
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EVIDENCE REPORT

INTRODUCTION 

As internet access and the use of mobile devices becomes more widely available, and as it 

is increasingly used by patients to access health information, many healthcare systems are 

capitalizing on this trend by offering patients electronic methods to communicate with providers 

and to learn about their health and medical problems. Some organizations or practices have 

developed stand-alone systems that allow for secure messaging between patients and their 

providers. Others, particularly those with existing electronic health record systems (EHRs), are 

developing companion applications specifically designed for patients that give patients access 

to email communication, access to their medical records and to test reports, and access to 

educational information on preventive care or disease-specific care. Much of this development 

is based on a perception that this is something that patients desire; and, that these systems will 

enhance patient satisfaction, improve care or make it more efficient. 

As the Veterans Health Administration (VHA) expands the capabilities of its personal health 

record system, My HealtheVet (MHV), and places greater emphasis on encouraging its use, it 

is interested in understanding how best to prioritize different functionalities and which of them 

will provide the greatest benefits to Veterans. This systematic review was designed to evaluate 

the literature surrounding secure messaging systems and electronic applications that give 

patients access to their own medical records, specifically investigating the evidence that these 

systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, 

and adherence. Additionally, the review examined studies that evaluated attitudes, particularly 

regarding patients having online access to their own medical information; and specific patient 

characteristics associated with use of personal health record systems. The review distinguished 

between electronic systems that were “tethered” or tied to existing healthcare institution systems 

similar to how MHV is tethered to VHA’s EHR, versus those that were “stand-alone.” 
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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):

(A) tethered secure messaging program vs. conventional (unsecured) e-mail

1. tethered programs are integrated with electronic health record; most 

similar to VA

(B) different implementation strategies (triage team (VA) model vs. other)

2) Patient access to their own medical record

 Functionality variation (subsets):

(A) online tethered program vs. online stand-alone program vs. paper record 

(lower priority)

(B) allergy list vs. medication list vs. laboratory results vs. procedure/imaging 

results vs. physician notes

	 3) Online medication refills
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4) Patient self-reported data

 Functionality variation (subsets):

(A) different types of data (blood glucose, weight, blood pressure, food journal, 

activity journal)

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

visit2.

System-level outcomes:

H. efficiency

1. telephone medicine utilization

2. system workload

a. 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
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(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. 
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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.
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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.
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RESULTS

LITERATURE FLOW

We reviewed 4,607 titles and abstracts from the electronic search, and an additional 64 from 

content experts for a total of 4671 references. A title screen excluded 4,274 as unrelated 

to our topic, with 397 remaining for further review. After applying our screener form to 

the full-text articles, 218 references were excluded. Of these, there were 84 that were not 

relevant to consumer health information technology, another 57 did not address any of the 

four specified functionalities, and 80 had study designs warranting exclusion (non-systematic 

review, commentary or news, or other ambiguous designs). We sorted these articles based on 

functionality, study design, and outcomes. Inclusion based on functionality retained articles 

relating to two of the functionalities, patient access to medical records (N=121) and secure 

messaging (N=153), with articles relating to online reminders (N=14) and patient self-reported 

data (N=74) no longer of interest after the discussion with the Performance Evaluation Clinical 

Advisory Board Working Group (see Methods, p. 9). These categories were not mutually 

exclusive, however, so an article about secure messaging that also related to online reminders 

would be included, for example. Of the 13 articles identified by peer reviewers, eight met the 

criteria for inclusion, and were added to the appropriate categories below.

Within the included functionalities, further inclusion restrictions based on study design and 

outcomes were applied. Within the secure messaging functionality (N=154), the 26 articles with 

a hypothesis testing study design that related to health outcomes (N=9), patient satisfaction 

(N=7), adherence (N=2), or efficiency or utilization (N=18). The other 128 articles relating to 

secure messaging were excluded either because their study design was descriptive or a systematic 

review (N=42), or they did not address one of the desired outcomes (N=86). For patient access 

to medical records (N=131), descriptive quantitative studies relating to tethered medical records 

addressing health outcomes, patient satisfaction, and adherence (N=6); efficiency or utilization 

(N=9); patient characteristics (N=4); or attitudes (N=12) were included, in addition to 5 articles 

which addressed non-tethered record, for a total of 31 articles. Additionally, four descriptive 

qualitative articles addressing barriers or facilitators to patient access to medical records were 

also included. The other 93 articles relating to patient access to medical records were excluded 

either because their study design was descriptive qualitative, and did not address barriers or 

facilitators to use, or systematic review (N=12), or they did not address one of the desired 

outcomes (N=81).Figure 1 details the inclusion of articles and the number of references related 

to each of the key questions. The abstracted data for the included articles can be found in the 

evidence tables, which are organized by report section (see Appendix E).
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Figure 1. Literature Flow

Literature Search

N=4607

Content experts

N=64

Excluded at title 

screen: 4274

Distiller Uploads

N=397 Excludes: 218

Not HIT: 84*

Other functionality: 57

Study design: 80

Peer Review

N=13

8 new includes

5 not included 

(outside of scope or 

already included)

Assessed in Detail

N=182

Secure Messaging**: 

154

Hypothesis Testing: 26

Health Outcomes: 9

Patient Satisfaction: 7

Adherence: 2

Efficiency/Utilization: 18

Pt Access to Record**: 

131

Descriptive 

Quantitative or 

Hypothesis Testing: 31

Health Outcomes, 

Patient Satisfaction, 

Adherence: 6

Efficiency/Utilization: 9

Attitudes: 12

Patient Characteristics: 4

Non-Tethered: 5

Descriptive Qualitative 

on 

Barriers/Facilitators: 4

Online Reminders**: 14

Patient Self-Report**: 74

* Not HIT includes duplicates found during data abstraction; ** Functionality categories were not mutually 

exclusive. 
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KEY QUESTION #1. What is the association between secure 

messaging and health outcomes, patient satisfaction, adherence, 

efficiency or utilization, or automated email?

The VHA’s My HealtheVet (MHV) application already allows for secure messaging (SM) 

between Veterans and their providers but because this functionality is relatively new, there is 

little known about the impact of SM on the health of Veterans who use SM. This was a key 

area of interest for the MHV team. Because of this, we focused on hypothesis testing studies 

of SM that evaluated its relationship to different types of outcomes, focusing more specifically 

on health outcomes, patient satisfaction, adherence, efficiency of care and utilization of care. 

This accounted for the majority of the hypothesis testing studies about SM and the results 

are described in the section that follows. We also found a small number of hypothesis testing 

studies of automated email systems, which can be distinct from SM systems that offer two-way 

communication between patients and providers. These automated email studies are described at 

the end of this section.

We identified 26 hypothesis testing articles about SM. A number of studies evaluated multiple 

outcomes and these studies are therefore included in each relevant section: health outcomes, 

patient satisfaction, adherence, and efficiency/utilization of care.

Secure Messaging and Health Outcomes

Nine hypothesis testing papers evaluated health outcomes and many focused on health conditions 

pertinent to VA.1,2,3,4,5,6,7,8,9 Seven of these studies were randomized controlled trials (RCTs).5,6,8,7,1,4,9

Four papers focused on SM and diabetes or related conditions.2,3,5,6 In the article by Zhou,2 the 

investigators examined the relationship between SM and performance on standard HEDIS measures 

for diabetes and hypertension among Southern California Kaiser Permanente patients with these 

conditions. In regression analysis, patients with diabetes and/or hypertension who participated 

in SM were statistically significantly more likely to see improvements from baseline in all of the 

HEDIS measures (diabetes process and intermediate outcome measures and blood pressure control). 

Two or more emails in a two-month period (as compared to only one) were associated with better 

performance on some measures (“dose-response effect”). In a separate matched cohort analysis, 

matching patients who used SM with those who did not, email use was associated with improvement 

in most of the diabetes measures but not in blood pressure control in patients with hypertension.

Another study from Group Health Cooperative was a cross-sectional analysis evaluating outcomes 

for patients with diabetes who had completed the process of identity verification required to 

participate in SM, comparing those who used the service to those who did not.3 They adjusted for 

a number of patient characteristics including medical comorbidity and depression severity, as well 

as provider characteristics such as age, sex and specialty. In terms of quality, they found that the 

rate of A1c<7% was 36% higher in patients with the highest rate of SM use (>= 12 threads/year); 

though SM was not associated with better blood pressure control and was modestly associated with 

better lipid control. This analysis could not ascertain whether the utilization of SM was responsible 

for the improved outcomes as patients who used SM more may simply have been more engaged 

in their health. Interestingly, primary care visit rates in this study were 32% higher in patients with 

high use of SM (three to four additional outpatient visits per year).
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Two RCTs evaluated web-based educational programs for diabetes that included SM as 

a component of the system. One RCT evaluated Veteran patients with diabetes who were 

randomized to usual care versus web-based care management that included receipt of a notebook 

computer, a blood pressure monitor, a glucometer, free internet service and access to a diabetes 

care management website.5

 The intervention patients were able to send and receive secure 

messages to and from their care manager. They also had access to educational links and webbased diabetes resources. While hemoglobin A1c levels decreased over time in both groups, the 

intervention group demonstrated a greater decline over time (decrease of 1.6% versus 1.2% in 

usual care group). Blood pressure declines were also greater in the intervention patients with 

hypertension (-10 versus -7 mm Hg) while there were no differences in lipid levels. In the second 

study from the University of Washington,6

 patients were similarly randomized to usual care 

versus web-based and in-person care management with access to SM functionality. Hemoglobin 

A1c levels were 0.7% lower in the intervention group compared to usual care when evaluated 

nine to 12 months after the start of the study (95% CI 0.2-1.3, p=0.01). There were no differences 

in blood pressure or lipid control between the groups.

Another study from Group Health Cooperative evaluated the impact of managing depression care 

using online secure messaging available through a patient website linked to the medical record.9

48% of patients with new prescription for an antidepressant and who were registered for online 

messaging consented to participate and were randomized to usual care with their prescribing 

physician versus usual care augmented by three planned contacts via messaging with a mental 

health nurse care manager, which included structured assessments and nurse communication 

with the patients’ providers. Intervention patients had lower depression severity at the end of the 

evaluation period and higher proportions experienced 50% or greater decreases in the depression 

scale of the Hopkins Symptom Checklist (55% v 41%, OR=1.8, 95% CI 1.0 to 3.1). Utilization 

rates for visits, telephone encounters and non-study online messages did not differ between the 

groups. 

Four additional studies evaluated web-based systems that allowed patient access to medical 

information and SM but that were not focused solely on SM. 7,8,1,4 The two most relevant to 

VA included a study from Group Health and one from the University of Colorado.7,8 The 

Group Health study randomized patients with hypertension to usual care versus one of two 

intervention groups. All participants were given access to Group Health’s patient website and 

all were encouraged to work with their providers to improve their blood pressure control. One 

intervention group was given a home BP monitor and training on the use of the patient website 

while the other intervention group was also given access to a pharmacist care manager who 

initiated case management via SM and face-to-face visits.7 Only the pharmacy case management 

group demonstrated significant improvements in BP control with 25% more patients with 

controlled BP compared to usual care (mean decrease -8.9 mm Hg) and 20% more compared 

to the other intervention group (mean decrease -6.0 mm Hg). The second study randomized 

patients with congestive heart failure (CHF) to usual care versus access to a web-based medical 

record system that also included an educational guide and a messaging system.8 There were no 

significant differences between the intervention and usual care groups in the primary outcome 

of self-efficacy nor in measures of health status. General adherence to medical advice was 

better in the intervention group (2.3 points higher on a 0-100 scale) but there was no difference 

in medication adherence; and no difference overall in patient satisfaction. While there were 
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no differences in mortality, hospitalizations or clinic visits, there was a significant increase in 

emergency room visits in the intervention group. In this study, email messages did not seem 

to replace telephone calls and particularly early in the intervention, there were more messages 

(phone and email combined) from intervention patients than phone messages from the control 

group. The other studies included one focused on Danish and Irish patients with ulcerative 

colitis who were randomized to a web-based educational and care management program with 

email and text messaging capabilities versus usual care and found improved adherence to acute 

care, improved knowledge and quality of life and fewer clinic visits in the intervention group;1

 a 

second study that randomized couples undergoing in-vitro fertilization (IVF) in the Netherlands 

to usual care versus access to an internet-based personal health record with email capability 

and found no differences in patient empowerment (e.g. self-efficacy, knowledge) or secondary 

outcomes such as patient satisfaction, change in anxiety or change in depression.4

Secure Messaging and Patient Satisfaction

Seven hypothesis testing studies evaluated patient satisfaction and SM,10,11,8,4,12,13,14 four of 

which were RCTs or controlled clinical trials.10,11,8,4 The first RCT involved an academic internal 

medicine clinic affiliated with the University of Colorado in Denver which was using an 

electronic medical record (EMR) system.10 Six hundred and six patients with experience using 

an internet browser were randomized to have access to a patient portal with SM that allowed 

requests for appointments, medication refills, and clinical communication with the provider, or 

usual telephone care. Patient satisfaction was assessed at baseline and at six months and was 

significantly higher in the intervention group in the areas of communication with the clinic (rated 

better by 44% of portal group versus 11% of controls), overall rating of clinic services (rated 

very good or excellent by 59% of portal group versus 48% of controls), and ratings of non-urgent 

messaging, prescription refills, referral requests and appointment scheduling (generally 20% 

improvement in portal group compared to controls). 

The second RCT involved physicians and patients affiliated with a Penn State faculty-based clinic.11

Four of eight participating physicians were assigned to offer email communication to their patients. 

Patients of all eight physicians were asked about their home email use and those of the participating 

physicians who were regular home email users were offered the opportunity to participate in the 

study and if consented, were given access to a secure email account for a six month period. Patients 

of the other four physicians continued with regular telephone contact with the clinic. All patients 

were surveyed at baseline, three months and six months. For the 100 patients analyzed, 67 in the 

email group and 35 in the control (the study excluded 72 patients who did not respond to all of 

the questionnaires), patient satisfaction was significantly higher in the email group in the areas of 

convenience of communicating with their physician and the amount of time spent contacting their 

physician. One hundred percent of patients in the intervention group and 97% of patients in the 

control group felt that patients should be able to email their doctors. Providers were not as satisfied 

as patients though the number of physicians involved in the study (eight) was not sufficient to 

draw statistical conclusions. There were trends toward increased satisfaction among intervention 

physicians in the areas of convenience, time spent and volume of messages. 

The third randomized trial from the University of Colorado was discussed in the previous section 

as well and randomized patients with CHF to usual care versus access to a web-based medical 
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record system that also included an educational guide and a messaging system.8 As noted, this 

study did not demonstrate significant differences in patient satisfaction. 

The final RCT has also been previously described and randomized couples undergoing in-vitro 

fertilization (IVF) in the Netherlands to usual care versus access to an internet-based personal 

health record with email capability and found no differences in patient satisfaction.4

Of the three remaining studies evaluating SM and patient satisfaction, two were cross-sectional 

survey studies, and one was a case-control study of implementation that included a patient 

survey. In the first, the investigators surveyed patients who use the internet for health information 

regarding their email practices with physicians.12 Of the 1881 individuals who completed the 

survey, 17% reported electronic communication with their physicians or physician staff, and 

satisfaction was highest in those who reported that their physician always responded (OR 15.9) 

compared to those who reported responses less than 100% of the time. The two remaining studies 

evaluated a web-based SM system being implemented at a clinic affiliated with the University 

of California Davis Health System.13,14 In the first paper,14 eight providers, their patients, and 

their staff were surveyed about the system. Two hundred thirty eight of 645 patients with email 

addresses (36.9%) responded to the survey with 97% having used the system at least once 

(49.6% used it only once or twice). Satisfaction was related to receiving a response right away 

or by the next business day. The second study evaluated patient satisfaction one year later and 

surveyed 5971 patients from 4320 email addresses with a response rate of 40.3% (1743/4320).13

Their findings again associated higher satisfaction with more timely responses. 

Secure Messaging and Adherence

There were two papers of clinical trials that evaluated SM and adherence, both of which were 

randomized.15,8 One specifically evaluated SM reminders and one evaluated an online medical record 

with SM as one component. In a study from Northwest Permanente in Portland, OR,15 investigators 

with an established EMR randomized 2100 patients with SM accounts who were due for colorectal 

cancer screening to usual care or to receive a letter reminder or a secure email reminder to pick up 

a fecal occult blood test at the lab. The cohort was subsequently reduced to 1409 patients because 

of logistical issues with performing the intervention leaving 494 in the usual care group, 458 in the 

letter group and 457 in the SM group. The two intervention groups were significantly more likely 

to undergo screening than the usual care group, and at similar rates (7.8% usual care, 23.6% letter, 

22.7% email). They concluded that email was as effective a prompt as a letter. The final study of 

an online medical record for CHF from the University of Colorado which has been previously 

described, assessed adherence to medications and general adherence to medical regimens and found 

that the latter was significantly improved in the intervention group users versus controls.8

Secure Messaging and Efficiency/Utilization

There were 18 studies that evaluated SM and some aspect of efficiency or healthcare 

utilization.1,16,17,3,18,19,20,21,22,14,23,6,24,25,26,8,13,7 Six studies were randomized controlled trials,1,20,6,26,8,7

ten were observational analyses,16,17,3,19,21,22,14,23,24,13 and two were survey analyses.18,25 Four 

studies evaluated provider productivity and provider attitudes,13,22,14,26 seven studies evaluated 

characteristics of users of SM systems,18,16,25,24,21,17,19 and eight studies evaluated the impact of SM 

on utilization of healthcare services.24,23,3,8,6,7,20,1
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There were four papers that evaluated SM and physician productivity.13,22,14,26 Three papers 

described results of the same intervention with slightly different types of analyses of physician 

productivity.13,22,14 These papers evaluated a secure web-messaging system being implemented at 

a clinic affiliated with the University of California Davis Health System that was described in the 

patient satisfaction section. The first was a pre-post study that found that intervention providers 

had higher overall averages of visits/day for the 5- month study period compared to the same 

period in the previous year (increasing from 24.8 to 29.5 visits/day, p=0.02).13 The second study 

compared the intervention providers with providers at a control clinic site before and after the 

intervention.22 Again, intervention physicians averaged 11% more visits/day than those in the 

control group (25.5 vs. 22.9) and averaged 10% more RVUs/day (relative value units) than the 

controls, though RVUs per visit did not differ. This was viewed as a positive finding for this feefor-service environment. The third study retrospectively compared SM and telephone volumes 

for the intervention clinic and a control clinic.14 Case call volume averaged 18.2% less than 

control (21.6 vs. 26.4, p=0.002) and case message (phone plus web) volume averaged 13.7% less 

than control (phone only) (22.8 vs. 26.4, p=0.025). Patient enrollment rose rapidly during this 

time, presumably accounting for the decrease in contacts/1000 panel patients. The fourth paper 

on physician productivity evaluated the introduction of a web-based communication tool for 

patients in a University of Michigan academic primary care practice and found that physicians 

in the intervention group (whose patients were given access to the web-messaging tool) did not 

experience a decrease in the volume of personal email and telephone messages, which remained 

similar to that of the control physicians despite the addition of a modest number of web-based 

messages.26

Two studies from Group Health Cooperative evaluated the characteristics of patients who used 

SM.18,16 The first compared these patients to those who had registered for access to the patient web 

site but had not utilized SM. SM users were more likely to be middle aged (50-65 years old), female, 

and with a higher overall level of morbidity.18 They were less likely to be insured by Medicaid. As 

would be expected, patients treated by providers with higher levels of SM use and with a higher 

proportion of younger patients on their panels were also more likely to use SM. The second study 

focused on patients with diabetes in Group Health and evaluated predictors of initial use of SM when 

it became available in 2003, and then subsequent use.16 Initial use was associated with younger age, 

male sex, living in a higher socioeconomic status neighborhood and greater provider level of SM 

use. Older patients were more likely to subsequently sign up for SM if they switched to a high-use 

physician. Increasing morbidity also was associated with subsequent SM use. A third study similarly 

evaluated characteristics of patients who used the SM application associated with “PAMFOnline,” 

a personal health record system operated by the Palo Alto Medical Foundation.25 Users had opted to 

pay an annual fee of $60 for unlimited messaging ability in addition to the general functionalities of 

the PHR. Compared to the general PAMF patient population, PAMFOnline messaging users were 

older, had more active problems, took more medications and used PAMF to conduct more office 

visits. In a fourth study from Kaiser Permanente Northwest that compared SM users to non-users, 

users were older and more likely to have diabetes.24

The three remaining studies in this area included one from a single surgical practice that found 

that email users were significantly younger than non-users but found no sex differences in use;21

a study from Europe that identified young (<25) , higher educated and urban patients as most 

likely to consider the availability of email access when choosing a new doctor;17 and a study 
18

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of a Florida physician survey which found that physicians in large group practices (50 or more 

physicians) were more likely, and Asian-American physicians were less likely to communicate 

with patients via email.19

Data regarding healthcare utilization and SM differed among the various studies. There were two 

studies evaluating implementation of SM at two different Kaiser Permanente regions.24,23 The 

first involved patients from KP Northwest and evaluated utilization in a pre-post fashion for a 

retrospective cohort of members registered for KP HealthConnect Online (the SM application) 

for longer than 13 months and compared utilization for a sample of this cohort to a group of 

non-registered patients matched for age, sex, chronic conditions and primary care physician.24

In the pre-post cohort analysis, annual primary care office visit rates decreased significantly 

from 2.47 to 2.24 visits per member per year. Similarly, SM user visit rates decreased more than 

the visit rate for non-users (10.3% vs. 3.7%, (p<0.003). The second study evaluated the impact 

of KP HealthConnect implementation in Kaiser Permanente Hawaii and compared healthcare 

utilization post-implementation (2007) to that of 2004.23 This study found significant decreases in 

age/sex-adjusted total office visits per member (decrease of 26.2%) and significant increases in 

total scheduled telephone visits per member. Total contacts including secure messages and office 

and telephone visits increased significantly from 5.18 contacts per member per year to 5.61. A 

third study from Group Health Cooperative that has been previously described compared patients 

with diabetes who had completed the process of identity verification required to participate 

in SM to those who did not.3

 Controlling for a number of variables including overall medical 

comorbidity and diabetes severity, primary care visit rates were statistically significantly higher 

in the SM users (32% higher), as were specialty visits and emergency visits. These results 

indicate that data is conflicting regarding whether SM results in increased or decreased visit rates 

and there may be unmeasured factors in these studies related to the system, the patients or the 

healthcare environment which contribute to the findings.

Three studies of online medical records with SM capability also looked at utilization.8,6,7 One 

study involving patients with CHF that has been previously described that randomized patients 

to access to the system found that intervention patients had significant increases in overall 

emergency department visits but no differences in mortality, hospitalizations or heart failure 

clinic visits.8 Another study in patients with diabetes randomized to access to an online care 

management application that has also been previously described found no differences in primary 

care or specialty care visits or inpatient days though there was additional time spent by the care 

managers in the intervention group.6 The third involved patients with hypertension randomized 

to usual care, access to the web-based application and access to the web-based application with 

pharmacy case management, and has also been previously described.7 This study found no 

differences in primary care visits, inpatient or urgent care/emergency use at one year. Telephone 

encounters were higher in the pharmacy arm than the other two though these patients had a 

modest but statistically significant decrease in specialty office visits.

Finally, two European studies found that patients randomized to SM with their general 

practitioner had fewer office visits than those without access, though there were no differences in 

the number of telephone consultations between groups,20 and patients with ulcerative colitis who 

had access to a web-based care management program with messaging had fewer routine visits 

than control patients.1
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Summary for Key Question #1

The hypothesis testing studies that include secure messaging support the following conclusions:

• There is moderate strength evidence that secure messaging (especially as part of a webbased management system) can improve glucose outcomes in patients with diabetes. 

(GRADE = moderate)

• There is low strength evidence that adding a web-based pharmacist to secure messaging 

improves blood pressure outcomes in patients with hypertension. (GRADE = low) 

• There is low strength evidence that secure messaging with a web-based management 

system improves ulcerative colitis symptoms. (GRADE = low)

• There is moderate strength evidence that secure messaging increases patient satisfaction. 

(GRADE = moderate)

• There is low strength evidence that secure messaging improves adherence to colorectal 

cancer screenings or heart failure management. (GRADE = low)

• There is low strength evidence that secure messaging influences either positively or 

negatively efficiency or utilization. (GRADE = low)

KEY QUESTION #2. What is the association between patient access to 

their own medical record and health outcomes, patient satisfaction, 

adherence, efficiency or utilization, and attitudes about access?

There were 31 articles related to patient’s having electronic access to their own medical records. 

These articles were divided into studies that evaluated “tethered” systems, where patients 

accessed information through a system (usually web-based) tied to a provider-based electronic 

record and that included functionalities such as secure messaging; and those that evaluated nontethered systems. The studies were further subdivided into those that were hypothesis testing, 

evaluating outcomes such as health outcomes, satisfaction, adherence, healthcare efficiency or 

healthcare utilization and attitudes; and, those that were descriptive qualitative. The latter studies 

were generally survey studies and generally evaluated attitudes about patient access to their own 

records. 

Patient Access to Medical Records through Tethered Systems

Of the articles evaluating patient access to their own medical record through a system tethered 

to a provider-based electronic record, seven were RCTs,8,6,27,4,7,28,29 four were observational 

hypothesis testing studies,16,30,31,32 and nine were descriptive quantitative studies.33,34,35,36,37,38,39,40,41

Only one study was a cost-benefit analysis study.42

The systems described in these studies included a number of functionalities as part of their 

intervention. These are listed in Table 1. As can be seen, almost all systems included secure 

messaging, access to test results and progress notes/visit summaries, and education/disease 

management, meaning the effects cannot be disentangled and these four functionalities represent 

a “core” set for patient portals.
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alth Record Systems and Functionalities

Test results

Secure messaging

Progress notes/visit summaries

Educational materials/disease management

Med renewal

Make appts

Patient uploads/diary

On-line reminders

h Yes Yes Yes Yes Yes Yes Yes (health 

assessment tools)

h Yes Yes Yes Yes Yes Yesh Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes (eJournal)Yes Yes Yes (eJournal)Yes Yes Yes Yes Yes YesYes Yes Yes Yes Yes YesYes Yes Yes Yes

ren’s Yes - 

imaging

Yes Yes – discharge 

instructions

Yes Yes Yes Yes

Univ 

Yes Yes Yes
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Patient Access and Health Outcomes, Satisfaction, and Adherence

Seven articles evaluated health outcomes, health status, satisfaction or adherence with respect to 

a tethered record system. Six were randomized controlled trials. The first involved patients with 

congestive heart failure (n=107) being treated in a specialty clinic at the University of Colorado 

Hospital in Denver, CO, who received usual care or were given access to a secure web-based 

system (“SPPARO”) that included access to their medical record (notes, labs and test results), an 

education guide and a secure messaging system (described in SM section).8

 Participants received 

questionnaires at baseline, 6 months and 12 months. The study found no significant difference in the 

primary endpoint which was a change in the self-efficacy domain of the Kansas City Cardiomyopathy 

Questionnaire nor in other measures of health status, though there was a trend towards improvement 

in the intervention group. There was also a non-statistically significant trend towards greater patient 

satisfaction with doctor patient-communication but not in other satisfaction domains. This study was 

the only one to evaluate adherence and found that general adherence to medical advice was improved 

in the intervention group while there was no statistically significant improvement in medication 

adherence. In the second study,6

 eighty three patients with diabetes from a University of Washington 

General Internal Medicine Clinic were randomized to usual care versus care augmented by webbased and in-person care management for a period of 12 months. Intervention patients met with the 

nurse care manager who introduced them to the web-based system that provided access to test results, 

clinical summaries of diabetes care, secure messaging, online reminders, educational materials and 

the ability to upload glucose readings. Intervention patients were encouraged to send weekly glucose 

readings and send secure messages as needed. Hemoglobin A1c levels were significantly lower in the 

intervention group (change -0.7%, p=0.01). More intervention patients had A1c levels <7% (33 vs. 

11%, p=0.03) though there were no significant differences in blood pressure or cholesterol. A similar 

intervention from the same institution was evaluated in a diabetes specialty clinic.28 In this study, 77 

patients with Type I diabetes were randomized to usual care from the Diabetes Care Center or usual 

care plus access to a nurse practitioner case manager and the web-based disease management module. 

A1c values did not differ significantly after a year of follow-up. There was an increase in psychosocial 

self-efficacy as measured by the Diabetes Empowerment Scale in the intervention group (difference 

of 0.3, 95% CI 0.01 to 0.59, p=0.04). 

In the fourth study from Group Health (which has been previously described),7 investigators 

randomized patients with hypertension to one of three groups, all of whom had access to a 

tethered patient portal with secure messaging, access to test results and clinic visit summaries, 

ability to renew meds and make appointments, and access to educational materials. The three 

groups included a control group that received usual care, a second group that received a home 

blood pressure monitor and patient portal training, and a third group that received the above 

intervention together with access to pharmacist – initiated case management via SM and face-toface visits. Only the web-based pharmacy group demonstrated significant improvements in BP

control with 25% more patients with controlled BP compared to usual care (mean decrease -8.9 

mm Hg) and 20% more compared to the other intervention group (mean decrease -6.0 mm Hg). 

There was also greater aspirin use in the web and pharmacy group compared to the others (20% 

more compared to web-only group and 30% more compared to usual care). 

The fifth study from Partners HealthCare involved patients with diabetes who had active 

accounts with Partner’s patient portal, Patient Gateway, which provided access to test results, 
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secure messaging, medication renewal and appointment management, and educational 

materials29. Intervention patients (126) came from 11 practices where they were given access 

to a diabetes mellitus-specific personal health record that had modules for medication review, 

diabetes-related clinical data, and the ability to generate a “Diabetes Care Plan” to share with 

their primary care providers; while control patients from the remaining practices (118) had 

access to a system that allowed them to update their family history and review cancer screening 

and other non-diabetes related preventive services and submit updates or requests regarding 

these aspects of care. After one year of follow-up, there were no differences in A1c levels, blood 

pressure or LDL-C levels between groups. Fifty percent of intervention patients completed a 

Diabetes Care Plan and these patients were more likely to have a medication adjustment for 

diabetes, hypertension or hyperlipidemia than patients in the control arm who submitted a 

preventive care journal update or request (53% v 15%, p<0.001). 

The sixth study randomized couples undergoing in-vitro fertilization (IVF) in the Netherlands 

to usual care versus access to an internet-based personal health record of all digital information 

available concerning their fertility treatments that also had secure messaging, education and 

discussion functionality.4

 They found no differences in patient empowerment (e.g. self-efficacy, 

knowledge) or secondary outcomes such as patient satisfaction, change in anxiety or change in 

depression between the two groups.

In a cross-sectional survey study from Group Health Cooperative in Seattle, WA,33 investigators 

randomly surveyed 2002 users of their web-based patient record system (MyGroupHealth) which 

provided patients the potential for access to their medical record including lab results, secure 

messaging, medication refill services, appointment management, after-visit summaries, health 

information and discussion groups. There was a 46% response rate with respondents generally 

reporting high satisfaction with MyGroupHealth (94% satisfied or very satisfied). Patients were 

more satisfied with specific functionalities such as medication refills, patient-provider messaging 

and medical test results than they were with MyGroupHealth overall, though were not as satisfied 

with some of the other features. 

Patient Access and Efficiency/Utilization

Nine studies evaluated tethered patient record systems and their impact on efficiency or 

utilization.27,6,8,7,16,33,30,34,42 Four were randomized controlled trials.27,6,8,7 The University of 

Colorado study of SPPARO for patients with CHF, previously described, found a significant 

increase in overall emergency department visits in the intervention group compared to the 

controls (20 v 8 visits, p=0.03) but no differences in hospitalizations.8 The University of 

Washington study of patients with diabetes,6

 also previously described, found no differences 

among the three groups in outpatient visits, primary care provider or specialty physician visits, 

or inpatient days though the care manager self-reported an average of four hours per week 

managing the patients. The Group Health study of patients with hypertension, described above,7

found that the mean number of secure message threads initiated by patients (includes initial 

message and follow-up responses), were highest in the group that included access to the web 

system and a pharmacist (4.2 compared to 2.7 in the web-only group and 1.8 in the usual care 

group), as well as higher numbers of phone encounters (mean 7.5 compared to 3.8 in the webonly group and 4.0 in the usual care group, p<0.001). Primary care visits, inpatient and urgent 
23

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care/emergency room utilization did not differ significantly. There was a modest but significant 

decrease in percent of patients with visits to specialists in the web and pharmacy group compared 

to the other groups (numbers not provided in text). Finally, there were more antihypertensive 

medications used in the intervention group compared to the web-only and usual care groups (RR 

2.2, p<0.01 for web-only and p<0.001 for usual care). A fourth study from Partners HealthCare 

surveyed patients who had been randomly assigned to two arms of a study of “eJournal” use, 

a component of Patient Gateway (PG), a secure EHR-connected internet patient portal that has 

been described above.27 Eligible patients having a PG account and an assigned PCP from a study 

site either received access to medication/allergies/diabetes eJournal modules (Arm 1) or to health 

maintenance/family history/personal history eJournal modules (Arm 2) and were reminded prior 

to certain types of appointments to complete an “eJournal” and submit it to their provider prior to 

the visit, updating or adding to information already available in their outpatient EHR. Providers 

had the option of reviewing the eJournal and uploading it to the EHR. Three percent of eligible 

patient users (3979) agreed to enroll in the study and 59.3% of these patients completed a postintervention survey. Of the 84 providers whose patients submitted at least one eJournal, 29 (34%) 

completed the post-intervention survey. Between 64 and 78% of patients opened at least one 

eJournal and 97% of patients edited an existing entry. There were more eJournal entries in Arm 

1, but this group received more reminders because they had more eligible visits. All providers 

in Arm 1 reported no change in visit length, while 47% of providers in Arm 2 felt that the visits 

were longer (p<0.013). 

Four studies were observational and reported data regarding use of tethered patient health 

record systems.16,33,30,34 One study from Group Health Cooperative evaluated patterns of use for 

its “shared medical record” (SMR) system which included secure messaging, ability to request 

medication refills and appointments, ability to view test results, after-visit summaries, problem 

and allergy lists and immunizations.16 Investigators followed 6185 enrollees with diabetes 

over an average of 2.8 years. About one-third of enrollees utilized the SMR with younger age, 

male sex, higher socioeconomic status and higher PCP use of secure messaging significantly 

associated with patient use. Higher morbidity was significantly associated with earlier sign-up 

and on-going use (rate ratio 1.3, p<0.001). The most frequently used features were tests result 

reviews, medication refill requests and secure messaging. A second study from Group Health 

Cooperative33 evaluated SMR use from 2002 to 2005 and found that ID-verified enrollment 

increased from 3% to 25% and that registration for basic services increased from 9% to 14%. A 

study from Geisinger Health System conducted an online survey of active users of “MyChart,” 

with a 33% response rate.34 They found that 3% of users were using MyChart on behalf of a 

spouse or parent. Another study evaluated a web-based patient—accessible EHR for patients 

with congenital heart disease—that in most cases gave the patients access to history and physical 

reports, patient care instructions and imaging data from surgery but did not include secure 

messaging.30 Of the first 270 offered access, 252 (93%) became users, with use more common 

while the patients (mostly infants getting cardiac surgery) were hospitalized than after discharge 

(median 6 v 4 logins, P<=0.001). There were more views of imaging data than textual data 

(median 8 page views v 5, P<0.001). 

Finally, there was one study that performed a cost-benefit analysis of the “potential value to the 

US” of different types of personal health record systems (PHRs) comparing provider-tethered, 

payer-tethered, third-party (e.g. Microsoft, Google, Dossia) and interoperable systems.42 The 
24

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investigators performed a literature review to evaluate data on costs and benefits but augmented 

their models using expert opinion and evidence from non-PHR sources because of the paucity 

of quantitative evidence surrounding PHRs. Assuming a ten year roll-out period, all PHRs 

demonstrated an initial net negative value but eventually reached a break-even point and began 

to provide benefit. Interoperable PHRs had the earliest break-even point at three years followed 

by payer-tethered and third-party PHRs by four years. Provider tethered PHRs did not break even 

during the initial 10 year period.

Attitudes about Patient Access

There were twelve studies that assessed attitudes about patient access to their own medical records 

or related issues.27,32,31,35,36,34,45,41,38,39,40,37 Three studies were hypothesis testing,27,32,31 with one 

randomized controlled trial.27 In this RCT from Partners HealthCare (which has been previously 

described), patients were provided with the opportunity to submit an eJournal using a tethered 

patient portal prior to specific types of visits. About 60% of participants responded to a postintervention survey of which 34.4% reported submitting an eJournal to their doctor’s office. 

Fifty-eight percent of patients agreed or strongly agreed that the eJournal gave their provider more 

accurate information and 55.9% of patients felt more prepared for their visits, but only 37.2% 

agreed or strongly agreed that communication with their provider improved, 37.7% of patients 

felt more satisfied with the visit and only 24.5% that the quality of care at the visit improved. 

Comparing the two different arms of the study, Arm 1 patients (access to medication/allergies/

diabetes eJournal modules) were more likely than Arm 2 patients (access to health maintenance/

family history/personal history eJournal modules) to feel prepared for their visit (59% v 51%, 

P<0.02) and Arm 1 physicians were more likely to feel their patients were prepared for the visit 

compared to Arm 2 patients (100% v 43%, p<0.04). A second hypothesis testing study from the 

University of Colorado evaluated attitudes of patients and physicians using SPPARO, an online 

record system for patients with CHF that has been previously described.31 Pre-intervention, 

physicians were much more likely than patients to endorse concerns that patients with access 

to SPPARO would have more questions (71 v 37%), would worry more (71 v 5%), would find 

reports confusing (57 v 13%), and would find notes offensive (29 v 3%). Over the course of the 

trial, physician concerns in these domains decreased (though not significantly, perhaps due to the 

small number of physician participants). The final hypothesis testing study evaluated attitudes 

of Veterans with diabetes regarding their internet use and their interest in various aspects of My 

HealtheVet (MHV), VA’s tethered patient web portal.32 Surveys were mailed to eligible Veterans 

receiving primary care from a Durham VA outpatient clinic. Two hundred one Veterans completed 

the surveys for a 53% response rate. In a multivariate analyses, the investigators found that age and 

trust in the internet were independent predictors of interest in using MHV for diabetes management 

with odds of being “very interested” increasing by 1.4 for each decade younger a respondent was, 

and by 2.3 if the respondent had “a lot/some” trust in the internet. 

Of the remaining studies, only four evaluated existing systems.35,36,34,45 In a study from Geisinger 

Health System,34 investigators conducted an online survey of registered users of “MyChart,” a 

tethered personal health record system. Of 4282 users invited to participate, 33% completed the 

survey (60% of whom were female). Patients reported high rates of understanding of medical 

information and test results, with higher rates of understanding for more highly educated 

respondents. Only approximately 30% of respondents had concerns about confidentiality and 
25

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security. In a study from Partners HealthCare,35 investigators surveyed a random sample of 2000 

patients who held an account with Patient Gateway (PG), a secure patient web portal. There 

was a 23% response rate. The most highly rated features were the administrative functions such 

as the ability to renew prescriptions, ask administrative questions or obtain referral approvals. 

38% felt that PG improved communication with the provider practice while 30% disagreed and 

32% were unsure. Another study from Partners evaluated patient attitudes about a new module 

within Patient Gateway to improve medication safety.45 The module allowed patients to review 

their medication and allergy lists and make comments about its accuracy, about their compliance, 

and about problems with compliance or side effects. Of 12,278 patients invited to participate, 

only 7% 812) were eligible for the study and completed a medications journal within Patient 

Gateway. A smaller number completed a survey (687). 70% found the journal very easy or easy 

to complete while 53% thought it gave providers more accurate information (39% were neutral). 

56% felt more prepared for their visit; 35% were neutral on this issue. In the final study from 

Sweden,36 investigators piloted a system called “SUSTAINS” that allowed patients access to 

the hospital information system and laboratories, the general practitioner’s EHR and secure 

messaging. They surveyed 100 users of the system but did not report a response rate. 82% of 

“users” had no worries about security while 15% expressed “some concern; and only 2% were 

very concerned about the security risks of “full scale service.”

The remaining studies were surveys of attitudes regarding potential systems and all but one 

were from Europe or Canada. In one study from Intermountain HealthCare/University of Utah,37

investigators surveyed physicians prior to giving patients web access to their electronic medical 

record. Ninety-one of 150 email-using physicians responded to the survey. Providers approved 

of giving patients access to medication lists, normal lab studies, prescription refills, appointments 

and referrals (P<0.05) but were less likely to approve of giving patients access to abnormal 

lab studies, progress notes or care over the internet. A study from England assessed attitudes 

about a test system that was available via a booth at a London group practice.38 Investigators 

surveyed patients on their interest in viewing their records before and after seeing the system, 

their concerns about security and accuracy, their interest in editing their record and the impact 

on the doctor-patient relationship. Patients had high rates of interest in viewing their records and 

most felt that having access to a record would break down barriers with their providers. Small 

numbers were concerned about security or accuracy. A study from Canada surveyed 30 patients 

with lung transplants given access to a personal health record simulation environment and found 

that 60% of patients felt that having access to information about their medical care would help 

them manage their care at home.39 Another study from England gave 100 patients access to 

view their physician-held electronic medical records and found that most had little difficulty 

navigating or understanding most sections with the exception of referrals.40 Forty-eight percent 

were worried about security before seeing the record while 61% were confident of the security 

in use after seeing the record. Another study from Canada surveyed men with prostate cancer 

regarding their attitudes towards web-based personalized electronic health record information 

systems.41 The study included a convenience sample of 41 men and 18 spouses/significant others 

and found that 80% would be willing to try a web-based system. Between 36 and 55% of men 

had some concerns about accuracy, security and confidentiality of information.
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Patient Access and Patient Characteristics

There were four studies that evaluated the characteristics associated with use of patient portals. 

In one study from Group Health Cooperative, diabetes patients were surveyed regarding their 

use or non-use of a patient portal tethered to Group Health’s electronic health records system.46

Of 873 patients eligible for inclusion, 718 or 79% agreed to participate. 53% of participants 

had used the patient website, and in unadjusted analyses, Whites (compared to Blacks, Asians 

or other), younger patients, and those with higher education and income were more likely to be 

users of the patient portal. In a model adjusted for age, sex, health need, education, income, and 

provider factors, Blacks were 82% less likely and Asians 60% less likely to use the patient portal. 

When restricting to those who used the internet, Blacks were still 75% less likely to use the 

portal. 

In a second study from Kaiser Permanente Georgia,47 investigators surveyed a cohort of racially 

diverse enrollees and subsequently evaluated registration rates for Kaiser’s tethered personal 

health record, KP.org. Of the 1777 patients included in the evaluation, 35% registered with 

KP.org during the study period and these patients were significantly more likely to be white than 

African American (42 v 30%, p<0.01), to have diabetes or elevated lipids compared to low risk 

adults (36 and 38% v 30%, p=0.01), and to have a higher level of education (greater than high 

school). Differences in registration rates between whites and African Americans persisted when 

adjusting for different variables. 

Another study from Kaiser Permanente in Northern California evaluated patients with diabetes 

and their use of KP.org, focusing specifically on health literacy.48 14,102 patients who had 

completed a survey as part of a larger study evaluating ethnic and educational disparities in 

diabetes-related behaviors, processes of care and health outcomes, were included in the analysis. 

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 to not sign on to KP.org compared to 

Whites. Those with lower self-reported health literacy were 1.7 times less likely to sign on to 

KP.org. Among those with computer access, the racial/ethnic differences persisted as did the 

effect of limited health literacy. 

A fourth study from Partners HealthCare compared primary care patients who had activated 

their account giving them access to an online tethered personal health record (Patient Gateway) 

with those who had not as of September 2009.49 Of 75,056 included in the analysis, 43% were 

“adopter” – having registered for the portal. Rates of adoption were lower among all racial/ethnic 

minorities with blacks 50% less likely to be adopters compared to whites. Patients with selected 

comorbidities (asthma, CHF, diabetes, hypertension) were more likely to be adopters while 

patients with more visits were less likely to be adopters. 

Qualitative Studies on Patient Access – Barriers and Facilitators

There were four papers that utilized qualitative research methodology to evaluate personal 

health records and that identified specific barriers or facilitators to their success. In one paper 

from a University of Washington general internal medicine clinic, patients with Type 2 diabetes 

mellitus had access to a patient portal that allowed them to view their record, upload glucose 

readings, send secure messages with a case manager and provided disease-specific information.50
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Qualitative interviews with nine participants identified that for many, the portal provided a means 

for patients to discuss non-urgent matters related to their health but that frustrations with the 

system (e.g. technical, lack of timely response) could result in the patient feeling devalued. Two 

papers described results from a University of Pittsburgh evaluation of a diabetes-focused patient 

portal (UPMC Health Trak) that included secure messaging, preventive healthcare reminders 

and disease-specific tools and information.51,52 Focus groups of 39 patients identified forgotten 

passcodes, lack of knowledge about all aspects of the system, and an inability to view all records 

of interest as potential barriers. Facilitators included an enhanced sense of patient empowerment 

and ability to communicate regarding appointments as well as with providers between scheduled 

appointments. Focus group discussions also revealed that patient use and interest in the portal 

was associated with dissatisfaction with the existing patient-provider relationship – particularly 

related to communication with and responsiveness of the provider or office, and access to 

information. Patients with greater satisfaction with their existing patient-provider relationship 

were less interested in using the portal. Lastly, an assessment of variations in adoption at four 

primary care practices affiliated with Partners HealthCare found differences between high and 

low adoption practices in leadership and marketing practices.44 The addition of an incentive for 

patient enrollment was associated with 3-6 fold increases in adoption. 

Summary for Key Question #2 – Tethered Systems

The evidence reviewed regarding patient access to their own medical records, when this is 

tethered to an electronic health record, supports the following conclusions:

•	 There is low strength evidence that patients’ access to their own medical record improves 

health outcomes for chronic diseases such as diabetes, hypertension, or heart failure 

(GRADE = low).

•	 There is low strength of evidence that patient access to their own records, combined with 

the ability to submit an electronic care plan can improve medication decisions at a subsequent visit for patients with diabetes (GRADE = low).

•	 There is insufficient evidence to reach conclusions regarding the potential effect of patients’ access to their own medical record on efficiency (GRADE = insufficient).

•	 There is low strength evidence that patients’ access to their own medical record influences utilization (GRADE = low).

•	 There is insufficient evidence to reach conclusions regarding the potential effect on patients’ access to their own medical record on patient attitudes.

•	 There is moderate strength evidence that use of patient portals is lower among certain racial or ethnic groups, in particular African Americans (GRADE = moderate).

•	 There is moderate strength of evidence that use of patient portals is lower in persons with 

lower literacy or education level (GRADE = moderate). 

Patient Access to Medical Records: Non-Tethered Systems

There were five papers focusing on patient access to their own medical records using systems 

that were not necessarily tethered to a provider-based EHR.53,54,55,56,57 All were survey studies 

and four were from Europe or Canada. The one US study from the University of Washington 

evaluated the use of a web-based personal health record by disadvantaged people living at a lowincome housing facility.56 The study utilized nursing students to help residents utilize the system 
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and found that utilization was much higher on the days that the students were available or on 

the day after. 12 of 24 registered users completed a survey. Only two were able to complete the 

health record entry on their own, though 92% were satisfied with the system and most felt the 

system helped them manage their health information. A Swedish study evaluated patient attitudes 

towards a national pharmacy register using a web survey.53 Of 7860 unique site visitors, 22% 

completed the survey. Respondents generally rated the system highly and felt that it would help 

with medication safety and healthcare, particularly that given by the pharmacist. A study from 

Switzerland evaluated the attitudes of patients given “CardioCard,” a small CD-ROM containing 

cardiac medical information including study reports and reports of clinical examinations.55

Seventy three percent of 536 patients who received a CardioCard responded to the survey. 

Seventy three percent found it very useful or useful and 78% were willing to pay for it. Most 

(73%) did not access the card themselves and 88% did not have their physicians access the card. 

Only 5% were worried about data security. 

The final two studies surveyed patients on their attitudes regarding having access to online health 

information.57,54 One from England invited 1050 patients to participate in a survey with a 60% 

response rate (629 responses).57 Analyses were conducted for patients aged 21 and older. Most 

felt they should have access to their health records (83%) and 79% thought it was a good idea 

to make them electronic. 35% preferred print-outs of records and 50% had concerns about the 

security of their records held on computers. A study from Canada surveyed Chief Executive 

Officers of Canadian public and acute care hospitals to understand organizational readiness for 

patient accessible records.54 Eighty-three of 213 CEOs responded (39% response rate). Fiftyfour percent of hospitals had some sort of EHR. 87% of respondents identified hospital financial 

resources as the most important barrier to providing patient access to the EHR.

Data for the non-tethered systems confirms the generally positive attitudes from other survey 

studies of patients regarding their interest in having access to their medical records. The one 

study in a low income and elderly population identifies potential barriers related to computer and 

internet skills.
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SUMMARY AND DISCUSSION

SUMMARY OF EVIDENCE BY KEY QUESTION

A summary of the conclusions and strength of evidence is presented in Table 2.

Table 2. Conclusions and Strength of Evidence by Key Question and Outcome

Conclusion GRADE 

Classification

KEY QUESTION #1. What is the association between secure messaging and health 

outcomes, patient satisfaction, adherence, efficiency or utilization, or automated email?

Health Outcomes

Secure messaging (especially as part of a web-based management system) can 

improve glucose outcomes in patients with diabetes.

moderate

Adding a web-based pharmacist to secure messaging improves blood pressure 

outcomes in patients with hypertension.

low

Secure messaging with a web-based management system improves ulcerative 

colitis symptoms.

low

Patient Satisfaction

Secure messaging increases patient satisfaction. moderate

Adherence

Secure messaging improves adherence to colorectal cancer screenings or heart 

failure management.

low

Efficiency/Utilization

Secure messaging influences either positively or negatively efficiency or 

utilization.

low

KEY QUESTION #2. What is the association between patient access to their own medical record 

and health outcomes, patient satisfaction, adherence, efficiency or utilization, and attitudes 

about access?

Health Outcomes, Satisfaction, and Adherence

Patients’ access to their own medical record improves health outcomes for 

chronic diseases such as diabetes, hypertension, or heart failure.

low

Patient access to their own records, combined with the ability to submit an 

electronic care plan can improve medication decisions at a subsequent visit 

for patients with diabetes.

low

Efficiency/Utilization

There is insufficient evidence to reach conclusions regarding the potential 

effect of patients’ access to their own medical record on efficiency

insufficient

Patients’ access to their own medical record influences utilization. low

Attitudes

There is insufficient evidence to reach conclusions regarding the potential 

effect on patients’ access to their own medical record on patient attitudes.

insufficient

Patient Characteristics

Use of patient portals is lower among certain racial or ethnic groups, in 

particular African Americans.

moderate

Use of patient portals is lower in persons with lower literacy or education 

level.

moderate
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LIMITATIONS

The primary limitation of this systematic review is the quantity and quality of the original 

studies. Evidence was sparse for all but two of the outcomes assessed (the effect of SM 

on diabetes outcomes and patient satisfaction), and studies frequently had methodological 

problems including the use of study designs with greater risk of bias (pre/post studies), poor 

response rate or poor follow-up rate for surveys and cohort studies, and little explanation of 

the implementation process for the IT functionality, which has two consequences: it makes it 

challenging to distinguish between failure of the intervention and failure of the implementation 

in studies reporting no effect; and for studies that do report beneficial effects it leaves providers 

and policymakers at other institutions unclear about how to replicate the success. The above 

limitations are common to almost all systematic reviews of health information technology. 

An additional limitation of this review is that the functionalities of interest, secure messaging 

and patient access to their own records, were often part of a bundle of interventions, making 

attribution of any beneficial effect to any one functionality difficult. In practice, attributing 

the independent effect of individual functionalities may not be necessary or even meaningful, 

since many champions consider these two functionalities (plus others) as interdependent. 

Many champions consider the package of functionalities – secure messaging, patient access 

to renew medications and appointments, and online disease management tools to be core 

elements of a tethered personal health record. Additionally, there may be a “ceiling effect” 

present, meaning that patients practicing greater health engagement with providers and in terms 

of self-management may be more likely to adopt new technology sooner, making it harder to 

demonstrate strong improvement. Lastly, much of the evidence comes from non-VA settings – 

e.g., studies from academic tertiary care medical centers working in a fee-for-service or similar 

reimbursement environment – although several observational studies from Kaiser and from 

Group Health Cooperative tend to support the findings from the academic medical centers. The 

relevance of these settings to VA is a judgment for VA policymakers.

DISCUSSION

The literature surrounding secure messaging and patient access to their own records is evolving 

as the systems themselves become more complex. In some respects, evaluating the individual 

components of patient portals may no longer be relevant since most of the functionalities are not 

conceptualized as independent features, but rather as part of an overall package that is intended 

to facilitate information exchange with patients as well as patient communication with providers 

and healthcare institutions. Our review identifies a few core elements consistently described 

in most of the published evaluations that comprise the basic patient portal: secure messaging, 

access to test results, access to progress notes or visit summaries, and educational materials or 

disease management tools. 

The evaluation of the impact of these portals is further complicated when one considers that 

they are also being designed to align with a larger patient management system that includes case 

management, remote health care delivery and non-face-to-face care. Attributing outcomes to any 

one component becomes more and more difficult as these layers are added one to the other; yet it 

appears that utilizing patient portals as part of a broader effort to improve care, particularly one 

that involves case management, may in fact yield beneficial results. 
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These patient portals are also being created as part of a movement to make patients more active 

participants in their care, as opposed to passive receivers of information. Early consumer health 

systems provided educational materials to patients. Robust patient portals offer patients the 

ability to drive and direct their care. Yet our review has identified some potential key barriers 

to achieving more uniform access to these systems. Successful and widespread implementation 

will require attention to these disparities in use as well as tailored approaches to engage certain 

populations that are not readily embracing personal health record systems.

RECOMMENDATIONS FOR FUTURE RESEARCH

Any research within VA is going to be pragmatic by design, since VA is already implementing 

secure messaging and patient access to their own record (meaning that any kind of randomized 

study where this is withheld is not practical). Nevertheless, a time series study of the 

implementation of secure messaging across institutions would be feasible and could provide 

reasonable, hypothesis-testing data to assess the effect of increasing SM use on quality (via 

EPRP), productivity, and patient satisfaction. Such a study would need to use both withininstitution and across-institution comparisons to deal with the possibility of secular trends in 

quality, productivity and satisfaction as well as the “institution effect”. 

CONCLUSIONS

Data are sparse, but support that the use of secure messaging can improve glucose outcomes 

in patients with diabetes and increase patient satisfaction. Data from other studies suggest that 

secure messaging as part of a web-based management program is more effective than secure 

messaging alone. This finding supports the conclusions from other studies of health information 

technology that HIT is a tool, and if implemented by itself may have modest or even no 

measurable effect, but HIT can enable the implementation of more comprehensive programs 

(e.g., the web-based management system, in this case) that have meaningful effects on quality of 

care. 
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REFERENCES

1. Elkjaer, M., et al., E-health empowers patients with ulcerative colitis: a randomised 

controlled trial of the web-guided ‘Constant-care’ approach. Gut, 2010. 59(12): p. 1652-61.

2. Zhou, Y.Y., et al., Improved quality at Kaiser Permanente through e-mail between 

physicians and patients. Health Aff (Millwood), 2010. 29(7): p. 1370-5.

3. Harris, L.T., et al., Diabetes quality of care and outpatient utilization associated with 

electronic patient-provider messaging: a cross-sectional analysis. Diabetes Care, 2009. 

32(7): p. 1182-7.

4. Tuil, W.S., et al., Empowering patients undergoing in vitro fertilization by providing 

Internet access to medical data. Fertil Steril, 2007. 88(2): p. 361-8.

5. McMahon, G.T., et al., Web-based care management in patients with poorly controlled 

diabetes. Diabetes Care, 2005. 28(7): p. 1624-9.

6. Ralston, J.D., et al., Web-based collaborative care for type 2 diabetes: a pilot randomized 

trial. Diabetes Care, 2009. 32(2): p. 234-9.

7. Green, B.B., et al., Effectiveness of home blood pressure monitoring, Web 

communication, and pharmacist care on hypertension control: a randomized controlled 

trial. JAMA, 2008. 299(24): p. 2857-67.

8. Ross, S.E., et al., Providing a web-based online medical record with electronic 

communication capabilities to patients with congestive heart failure: randomized trial.

J Med Internet Res, 2004. 6(2): p. e12.

9. Simon, G.E., et al., Randomized trial of depression follow-up care by online messaging.

J Gen Intern Med, 2011. 26(7): p. 698-704.

10. Lin, C.T., et al., An Internet-based patient-provider communication system: randomized 

controlled trial. J Med Internet Res, 2005. 7(4): p. e47.

11. Leong, S.L., et al., Enhancing doctor-patient communication using email: a pilot study. 

J Am Board Fam Pract, 2005. 18(3): p. 180-8.

12. Houston, T.K., et al., Experiences of patients who were early adopters of electronic 

communication with their physician: satisfaction, benefits, and concerns. Am J Manag 

Care, 2004. 10(9): p. 601-8.

13. Liederman, E.M. and C.S. Morefield, Web messaging: a new tool for patient-physician 

communication. J Am Med Inform Assoc, 2003. 10(3): p. 260-70.

14. Liederman, E.M., et al., Patient-physician web messaging. The impact on message 

volume and satisfaction. J Gen Intern Med, 2005. 20(1): p. 52-7.

15. Muller, D., et al., The effectiveness of a secure email reminder system for colorectal 

cancer screening. AMIA Annu Symp Proc, 2009. 2009: p. 457-61.
33

Secure Messaging between Providers and Patients, and 

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

16. Weppner, W.G., et al., Use of a shared medical record with secure messaging by older 

patients with diabetes. Diabetes Care, 2010. 33(11): p. 2314-9.

17. Santana, S., et al., Online communication between doctors and patients in Europe: status 

and perspectives. J Med Internet Res, 2010. 12(2): p. e20.

18. Ralston, J.D., et al., Patient use of secure electronic messaging within a shared medical 

record: a cross-sectional study. J Gen Intern Med, 2009. 24(3): p. 349-55.

19. Brooks, R.G. and N. Menachemi, Physicians’ use of email with patients: factors 

influencing electronic communication and adherence to best practices. J Med Internet 

Res, 2006. 8(1): p. e2.

20. Bergmo, T.S., et al., Electronic patient-provider communication: will it offset office visits 

and telephone consultations in primary care? Int J Med Inform, 2005. 74(9): p. 705-10.

21. Ketteridge, G., H. Delbridge, and L. Delbridge, How effective is email communication for 

patients requiring elective surgery? ANZ J Surg, 2005. 75(8): p. 680-3.

22. Liederman, E.M., et al., The impact of patient-physician Web messaging on provider 

productivity. J Healthc Inf Manag, 2005. 19(2): p. 81-6.

23. Chen, C., et al., The Kaiser Permanente Electronic Health Record: transforming and 

streamlining modalities of care. Health Aff (Millwood), 2009. 28(2): p. 323-33.

24. Zhou, Y.Y., et al., Patient access to an electronic health record with secure messaging: 

impact on primary care utilization. Am J Manag Care, 2007. 13(7): p. 418-24.

25. Tang, P.C., W. Black, and C.Y. Young, Proposed criteria for reimbursing eVisits: content 

analysis of secure patient messages in a personal health record system. AMIA Annu 

Symp Proc, 2006: p. 764-8.

26. Katz, S.J., N. Nissan, and C.A. Moyer, Crossing the digital divide: evaluating online 

communication between patients and their providers. Am J Manag Care, 2004. 10(9): 

p. 593-8.

27. Wald, J.S., et al., Implementing practice-linked pre-visit electronic journals in primary care: 

patient and physician use and satisfaction. J Am Med Inform Assoc, 2010. 17(5): p. 502-6.

28. McCarrier, K.P., et al., Web-based collaborative care for type 1 diabetes: a pilot 

randomized trial. Diabetes Technol Ther, 2009. 11(4): p. 211-7.

29. Grant, R.W., et al., Practice-linked online personal health records for type 2 diabetes 

mellitus: a randomized controlled trial. Arch Intern Med, 2008. 168(16): p. 1776-82.

30. Burke, R.P., et al., Transforming patient and family access to medical information: 

utilisation patterns of a patient-accessible electronic health record. Cardiol Young, 2010. 

20(5): p. 477-84.
34

Secure Messaging between Providers and Patients, and 

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

31. Earnest, M.A., et al., Use of a patient-accessible electronic medical record in a practice 

for congestive heart failure: patient and physician experiences. J Am Med Inform Assoc, 

2004. 11(5): p. 410-7.

32. Cho, A.H., et al., Do diabetic veterans use the Internet? Self-reported usage, skills, and 

interest in using My HealtheVet Web portal. Telemed J E Health, 2010. 16(5): p. 595-602.

33. Ralston, J.D., et al., Patient web services integrated with a shared medical record: patient 

use and satisfaction. J Am Med Inform Assoc, 2007. 14(6): p. 798-806.

34. Hassol, A., et al., Patient experiences and attitudes about access to a patient electronic 

health care record and linked web messaging. J Am Med Inform Assoc, 2004. 11(6): p. 

505-13.

35. Volk, L.A., et al., Patients’ perceptions of a Web portal offering clinic messaging and 

personal health information. AMIA Annu Symp Proc, 2005: p. 1147.

36. Eklund, B. and I. Joustra-Enquist, Sustains--direct access for the patient to the medical 

record over the Internet. Stud Health Technol Inform, 2004. 100: p. 182-9.

37. Dorr, D.A., et al., Physicians’ attitudes regarding patient access to electronic medical 

records. AMIA Annu Symp Proc, 2003: p. 832.

38. Honeyman, A., B. Cox, and B. Fisher, Potential impacts of patient access to their 

electronic care records. Inform Prim Care, 2005. 13(1): p. 55-60.

39. Leonard, K.J., The role of patients in designing health information systems: the case of 

applying simulation techniques to design an electronic patient record (EPR) interface.

Health Care Manag Sci, 2004. 7(4): p. 275-84.

40. Pyper, C., et al., Patients’ experiences when accessing their on-line electronic patient 

records in primary care. Br J Gen Pract, 2004. 54(498): p. 38-43.

41. Pai, H.H. and F. Lau, Web-based electronic health information systems for prostate 

cancer patients. Can J Urol, 2005. 12(3): p. 2700-9.

42. Kaelber, D. and E.C. Pan, The value of personal health record (PHR) systems. AMIA 

Annu Symp Proc, 2008: p. 343-7.

43. Falcao-Reis, F. and M.E. Correia, Patient empowerment by the means of citizen-managed 

Electronic Health Records: web 2.0 health digital identity scenarios. Stud Health Technol 

Inform, 2010. 156: p. 214-28.

44. Wald, J.S., Variations in patient portal adoption in four primary care practices. AMIA 

Annu Symp Proc. 2010: p. 837-41.

45. Schnipper, J.L., et al., Design and implementation of a web-based patient portal linked to 

an electronic health record designed to improve medication safety: the Patient Gateway 

medications module. Inform Prim Care, 2008. 16(2): p. 147-55.
35

Secure Messaging between Providers and Patients, and 

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

46. Lyles, C.R., et al., Patient Race/Ethnicity and Shared Medical Record Use Among 

Diabetes Patients. Med Care, 2012.

47. Roblin, D.W., et al., Disparities in use of a personal health record in a managed care 

organization. J Am Med Inform Assoc, 2009. 16(5): p. 683-9.

48. Sarkar, U., 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. 15 Suppl 2: p. 183-96.

49. Yamin, C.K., et al., The digital divide in adoption and use of a personal health record.

Arch Intern Med, 2011. 171(6): p. 568-74.

50. Ralston, J.D., et al., Patients’ experience with a diabetes support programme based on an 

interactive electronic medical record: qualitative study. BMJ, 2004. 328(7449): p. 1159.

51. Hess, R., et al., Exploring challenges and potentials of personal health records in 

diabetes self-management: implementation and initial assessment. Telemed J E Health, 

2007. 13(5): p. 509-17.

52. Zickmund, S.L., et al., Interest in the use of computerized patient portals: role of the 

provider-patient relationship. J Gen Intern Med, 2008. 23 Suppl 1: p. 20-6.

53. Montelius, E., et al., Individuals appreciate having their medication record on the web: a 

survey of attitudes to a national pharmacy register. J Med Internet Res, 2008. 10(4): p. e35.

54. Urowitz, S., et al., Is Canada ready for patient accessible electronic health records? A 

national scan. BMC Med Inform Decis Mak, 2008. 8: p. 33.

55. Bernheim, A.M., et al., Early clinical experience with CardioCard - a credit card-sized 

electronic patient record. Swiss Med Wkly, 2006. 136(33-34): p. 539-43.

56. Kim, E., et al., Evaluation of patient-centered electronic health record to overcome 

digital divide. Conf Proc IEEE Eng Med Biol Soc, 2005. 2: p. 1091-4.

57. Pyper, C., et al., Access to electronic health records in primary care-a survey of patients’ 

views. Med Sci Monit, 2004. 10(11): p. SR17-22.

58. Balshem, H., et al., GRADE guidelines: 3. Rating the quality of evidence. J Clin 

Epidemiol. 64(4): p. 401-6.