Association for Public Policy Analysis & Management

The Defense Health Agency (DHA) in the U.S. Department of Defense aims to increase the rate at which patients register for and use secure messaging to communicate with their healthcare providers. Military treatment facilities (MTFs) provide secure online messaging to allow patients to send questions to their providers, get lab results, and renew prescriptions. However, only 47% of MTF enrollees were registered in the secure messaging system, and only 6% utilized it, as of April 2017 — leaving about 1.8 million patients who did not have access to use this benefit. Research suggests that individuals may not enroll because of lack of information, lack of motivation, and negative attitudes toward the system.

The Office of Evaluation Sciences (OES) collaborated with DHA’s Patient Centered Medical Home Office and the Family Medicine Clinic at Naval Medical Center Camp Lejeune (NMCCL) to design two interventions to increase patient registration to use secure messaging.

The first intervention consisted of providers making a personal appeal to register in the secure messaging system during a patient’s visit, on-site staff assistance in signing patients up, and staff providing a checkout sheet to patients with instructions for registering later. The intervention was implemented from mid-July 2016 through January 2017. We evaluated the impact of this intervention by comparing patient registration for secure messaging at the NMCCL Family Medicine Clinic with family medicine clinics at seven other demographically similar MTFs selected by DHA. At the NMCCL Family Medicine Clinic, the number of patients registered for secure messaging rose by 15.0% between the month prior and the final month of the trial. At the seven comparison sites, the average number of patients registered for secure messaging rose just 3.0%. This constituted a greater than five-fold increase in the rate at which registrations grew.

The second intervention involved reminder emails that were sent to patients following primary care appointments. Two to four days following the personal appeal intervention, the patient was sent an email from their provider encouraging them to use the secure messaging system. We tested this intervention using a randomized evaluation: Patients of roughly half of the providers in the NMCCL Family Medicine Clinic, who were assigned at random to a treatment condition, received follow-up emails. Patients of the remaining providers (the control condition) received no follow-up emails. We analyzed the average provider’s number of patients registered in the secure messaging system in each month of the trial period and the change in numbers of registered patients over the course of the trial period, and observed no significant difference between the treatment and control conditions.

For more than half of MTF enrollees, the benefits of registering for secure messaging to communicate with providers and staff remain untapped. Although we found evidence that an in-person intervention was associated with an increase in the rate at which patients registered for this benefit, we found no evidence that emails sent as follow-ups were effective in bringing about an additional increase in patient registrations.