Issues and questions to consider in implementing secure electronic patient provider web portal communications systems

Transcription

1 international journal of medical informatics 79 (2010) journal homepage: Issues and questions to consider in implementing secure electronic patient provider web portal communications systems Douglas S. Wakefield a,, David Mehr b, Lynn Keplinger c, Shannon Canfield b, Rajitha Gopidi a, Bonnie J. Wakefield d, Richelle J. Koopman b, Jeffery L. Belden b, Robin Kruse b, Karl M. Kochendorfer b a University of Missouri, Center for Health Care Quality and Department of Health Management and Informatics, United States b University of Missouri, Department of Family and Community Medicine, United States c University of Missouri, Department of Medicine, United States d Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Department of Veterans Affairs Medical Center Iowa City, IA and the University of Missouri Sinclair School of Nursing, United States article info abstract Article history: Received 20 January 2010 Received in revised form 19 April 2010 Accepted 21 April 2010 Keywords: Patient web portal Secure web communications Electronic patient provider communications Purpose: Patients are increasingly interested in using Internet-based technologies to communicate with their providers, schedule clinic visits, request medication refills, and view their medical records electronically. However, healthcare organizations face significant challenges in providing such highly personal and sensitive communication in an effective and user-friendly manner. Methods: Based on the literature and our experience in providing a secure web-based patient provider communication portal in primary care clinics, a framework was developed that identifies key issues and questions to consider in implementing secure electronic patient provider communications systems. Results: The framework serves to categorize the many lessons learned from our implementation process and the specific issues and questions healthcare organizations need to consider in implementing such systems related to seven areas: strategic fit and priority; selection process & implementation team; integration into communications and workflows; HIPAA issues & clinic policies; systems implementation & training; marketing & enrollment; on-going performance monitoring. Conclusion: The framework provides a useful guide for organizations looking to implement secure electronic patient provider communication systems Elsevier Ireland Ltd. All rights reserved. 1. Introduction To better serve and to strengthen relationships with patients, healthcare organizations are increasingly implementing secure web-based patient provider communication portals [1 5]. Communications typically include some combination of secure , appointment scheduling, and medication refill requests. In addition, systems may also support patient communication of clinical data (e.g., blood pressures and Corresponding author at: Center for Health Care Quality, CE548, One Hospital Drive, Columbia, MO 65212, United States. Tel.: address: wakefielddo@health.missouri.edu (D.S. Wakefield) /$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved. doi: /j.ijmedinf

2 470 international journal of medical informatics 79 (2010) blood glucoses) to the provider and allow patients to electronically view portions of their medical records. Whether simply secure communication or an expanded product, such systems present many regulatory, logistical, and operational challenges. Because these systems may include a wide array of clinical care, information exchange, and service request functions, integration into existing patient care and communication workflows requires careful planning. Further, because potential patient users are most likely Internet-savvy consumers, who are already familiar with and on-line purchasing and banking services, they will expect healthcare organizations to have similarly, user-friendly, and secure systems. Therefore, carefully considering several key issues and questions during the planning phase is essential to ensure a smooth launch and high patient and provider acceptance and satisfaction. This paper provides a brief review of the current literature related to the implementation and management of secure patient provider electronic communications, our conceptual framework for understanding this process, and key implementation issues and questions that flow from the framework. 2. Secure messaging in healthcare organizations In the outpatient setting, efforts to reduce costs and increase clinical productivity have resulted in an increased pace of healthcare delivery and a decrease in the time available for face-to-face provider patient communications. Ironically these time constraints have occurred as providers are attempting to care for increasingly clinically complex patients. Both patients and providers have been frustrated by the quality and effectiveness of these brief encounters; patients may forget to tell the provider important information, fail to ask essential questions, or fail to understand or remember what their physician told them [6 8]. Providing patients the ability to securely communicate electronically with their providers between visits can potentially improve communication, reduce frustration, and enhance patient doctor relationships and patient satisfaction [2,9 19]. Evidence suggests a growing patient interest in, and in some cases limited willingness to pay for, on-line access to their providers [7,11,20 26]. In the future electronic access may also play a role in patients choice of providers. Web messaging, a secure form of communication over a web portal, allows patients and providers separated by both space and time to share information asynchronously. A key difference between traditional and secure web messaging is that the latter is a dedicated system, used only for patient provider and provider provider electronic communications, and requires unique user identifiers and log-in procedures to maintain communication security [4,8,23,25,26]. Information shared via web messaging may include laboratory and other diagnostic test results, information about health status, information resources relevant to the patients conditions, responses to patient queries related to diagnosed conditions or prescribed treatments, appointment scheduling, referral requests, prescription refill requests, and e-visits. Potential advantages of web messaging include easier communication documentation, improved convenience due to its asynchronous nature, and reduced logistic problems due to time and space constraints that are inevitable in face-toface and telephone communications [12,16,23]. Despite the potential to improve communication and patient satisfaction, adoption of web messaging has been slow [27,28]. Concerns with web-based secure communications have been expressed by both patients and providers. Patients concerns include timeliness of responses, loss of interpersonal relationships, people other than their provider viewing their messages, and difficulty using the communication portal [1,8,29 32]. Providers concerns with opening this line of communication include fit with current workflow, potentially being flooded with messages leading to increased workload, and not being reimbursed for the time spent responding to messages [9,13,24,31 34]. Other provider concerns include patients inappropriately using web messaging for sensitive or complex topics requiring face-to-face communications, or emergencies and patient review on-line of their medical records or diagnostic test results in the absence of explanation by the physician [17,27,28,32,35,36]. Potential benefits of web-based secure messaging systems include avoidance of unnecessary visits and telephone calls for tasks such as prescription renewals, referral requests, appointment scheduling, lab reports, information updates, simple queries about diagnosed conditions and concerns, dosage adjustments, and non-acute symptom treatment in chronic disease management [8,10,12,16]. There is evidence that the introduction of web messaging has resulted in improved patient satisfaction and communication [9 12,16 19]. The majority of patients registering for web messaging have been women and those with more chronic illnesses [12,28,37]. Alternatively, web messaging allows users to discuss sensitive issues that could be avoided due to shyness and inconvenience [11,39]. Patient users perceive improved management of their chronic conditions [4,18,37,38,40,41] and may have fewer annual visits [38,42]. Rather than being inundated with messages [11,16], physicians may actually experience increased productivity [12,35,38,43,47 50], plus being able to answer patient messages at their convenience [44,45]. There is also evidence that physicians tend to recommend web messaging to their colleagues [35,46]. Finally, there is growing use of web portals to address the unique needs of specific patient populations [4,18,23,41,44,47 50]. Studies have found that the communication content of patient messages tends to be appropriate: addressing nonurgent care issues, adherent to recommended messaging guidelines (e.g., AMIA guidelines for on-line communication) [13,28,33,45,46,51,52] with physician messages directly answering patient queries while providing a level of emotional support and empathy [39]. Moreover, use of web messaging appears to decrease as the complexity and sensitivity of patients clinical issues increase [39]. Overall, patients, providers and clinic staff express positive attitude towards web-based secure communications [11,14,15,17,27,28,33].Process efficiency has improved for referral, scheduling and refill requests [1,35,43]. On the negative side, web messaging has left some users frustrated due to difficulty in connecting, unmet expectations regarding message responsiveness, loss of interpersonal relationships, and feelings of isolation [16].

3 international journal of medical informatics 79 (2010) Fig. 1 Issues and questions to consider in implementing secure web-based electronic patient provider communications system. 3. Secure communication issues and questions framework Building on earlier work addressing implementation of patient portals and electronic health records [5,9,53] and based on our experience implementing a secure patient provider webbased communications system in an academic health center s primary care outpatient clinics, Fig. 1 presents a framework identifying seven areas to consider when implementing such systems. Using this framework, we categorize the many lessons learned in the form of issues and questions to prospectively consider when deciding to adopt and implementing a web-based secure patient provider communication system. By design, this framework is depicted as being sequential in nature beginning with issues and questions related to the strategic fit and ending with on-going operation and management concerns Strategic fit and priority Implementing a secure patient provider web-based communications system will generate both direct and indirect costs for the organization and may require changes in workflows and provider patient interactions. The decision to implement a system should also take into consideration whether the system might serve as the electronic platform for future service delivery options, such as on-line only provider visits (e-visits) or consultations. Because of the potential for unanticipated future uses, it is useful to obtain input from the organizations various stakeholders (i.e., providers, clinical and support staff) about potential applications and impacts. Because patients are increasingly comfortable using electronic communications for other personal business activities, it is also important to understand their assumptions and expectations about potential system uses and to evaluate the system s user friendliness. For example, if potential users are very interested in seeing their laboratory results, they may be quite disappointed if that option is not provided as part of the system. Thus, the decision to implement a secure communications system clearly should link directly to the organizations overall shortand long-term strategic and information technology plans and be informed by information from key internal stakeholders and patients. In making the decision about whether to implement a secure communications system, it is useful to consider the following issues and questions: 1. How does a secure patient provider electronic communications system fit our overall organizational, and health information technological, strategic plans and priorities? 2. How does the proposed secure electronic communications system and proposed functionality fit with specific short- and long-term strategic priorities including: market share; patient satisfaction; physician satisfaction; employee satisfaction; patient care quality & safety; regulatory compliance; and/or workflow efficiency? 3. If applicable, how well does the proposed electronic communication link to our current (or planned) electronic health record (EHR)? 4. What types of secure electronic communication functionality are needed to meet the organization s strategic priorities? Potential options could include: secure patient provider , passive viewing of EHR by patient, EHR data entry by patients, scheduling visits and tests, requesting medication refills, hosting patients personal health records, providing e-visits, reviewing and paying bills, patient education, and, internal operational and/or clinical effectiveness research. If direct viewing of the EHR by the patient is allowed, which portion of the EHR will patients be allowed to view on-line (e.g., test results and notes), and within what time frames (e.g., immediately after results become available, after a set time period, after the provider has reviewed the results) will viewing be allowed? 5. Who will be the primary users (i.e., all vs. selected categories of patients, physicians, midlevel providers, assistants) of the secure communications system? 6. What are the anticipated costs of implementation in relation to available capital? What are the anticipated on-going operational funding and personnel resources necessary to support this initiative? 7. What is the priority (i.e., low, medium, high) and timeframe (i.e., within 3 months; 3 6 months; 6 12 months; >12 months) for implementing a secure patient provider electronic communications system? 8. Is there a potential revenue stream based on the secure communications such as fees for e-visits? What is the business model for the use of the different functions of the secure communication system? 9. Will this secure communication system provide all of the required functions being required by the emerging meaningful use standards proscribed by the American Reinvestment & Recovery Act (ARRA) of 2009 [54]? 3.2. Selection process & implementation team Like other major decisions involving health information technology (HIT), it is critical to have a well thought out product selection process and to identify the key implementation team members early. Identifying the executive champion/owner and key stakeholders early in the process is essential. Sim-

4 472 international journal of medical informatics 79 (2010) ilarly, it is also advantageous to identify and begin having key members of the selection and implementation teams work together early in the process. For example, unless there is a direct channel to key organizational decision-makers a project can bog down because different organizational units are not coordinating their efforts. Clearly these key individuals must not only have a full understanding and appreciation of how implementation of web-based secure communication system fits into the organization s strategic priorities but also an appreciation of patient preferences and expectations, and provider and staff concerns. That is, what are the needs and concerns of the secure communication system s various customers (i.e., patients, providers and staff)? To accomplish this it can be helpful to conduct focus groups and/or surveys prior to selecting a specific secure communications system. The following issues and questions are useful to consider during the selection process and formation of the implementation team. 1. Who will be the executive owner(s) of the secure patient provider electronic communications system (i.e., CIO, COO, CFO, CMO, and CMIO), and who in the organization will have administrative ownership of and responsibility for the initial rollout, marketing and customer service, and system maintenance? 2. What do we know about our patients current use of and expectations for electronic communications with other service providers and their preferences for electronic communications with their healthcare providers? 3. Who will lead the selection process and implementation team? Who, and which stakeholders, need to be represented on the selection and implementation team (i.e., providers, nurses and allied health, clerical, patients)? 4. What required response items will be included in the vendor request for proposal (RFP)? Specific items might include: listing of specific functionalities; demonstrated patient acceptance in terms of ease of use and intuitive operation; interoperability with existing EHR and other HIT systems; hosting/support options; 3 5 year total implementation and operational costs and fees, training requirements and resources; list of current users and references; vendor s financial stability; planned upgrades; requirements for on-sited demonstrations; evidence of vender long-term financial stability? 5. Selection process issues to consider include: Will on-site or off-site demonstrations be used? What is the weighting scheme for the required RFP items? What is the timeframe for RFP development, review and selection? 3.3. Integration in patient care communications and workflows By its very nature, introducing a secure communications system potentially changes not only the nature and types of communications, but also the current workflows associated with how providers and patients communicate. For example, patients experienced in using and other forms of electronic transactions will expect easy to use interfaces and same-day if not almost immediate responses from their providers. Providers scheduled to see patients in the hospital and/or clinic all day long may not have opportunity or desire to answer s as they arrive or as quickly as patients may desire, particularly if there is no compensation associated with this work. As with current processes related to screening and forwarding telephone messages from patients, new processes will be needed for screening and forwarding patient s to their providers. If messages go directly to providers, processes will be needed to identify more urgent messages and to provide for times that providers are unavailable, such as on vacation. An additional potential challenge involves patients seen by multiple providers, either from the same or different specialties, and patient s expectations that e- mail communications would automatically be shared among the providers, regardless of whether the providers belong to different organizations. Thus, it is necessary to carefully evaluate current-state patient provider telephone communication processes, patterns and content to design the future state webbased communications processes. To this end the following issues and questions can be useful to consider: 1. How will implementing a secure patient provider communication system affect clinic/hospital patient provider communications and workflows? Who is accountable for, and, what actions will need to be taken to ensure adequate and timely IT and administrative support for clinic staff? Specific areas of needed support include marketing and patient enrollment support; developing and maintaining a user/customer database; maintaining and updating the secure communications interface and web-site; establishing effective electronic communication triage and proxy screening to support providers. 2. In a multi-specialty group practice setting, will patients have and other secure communications access (i.e., , viewing medical records, and scheduling appointments) with all primary care providers and medical or surgical specialists that they are being seen by, or will the secure communications connection be limited to designated primary care providers? A related issue of major concern is how patients can be accurately linked to their designated provider(s). Because patients may be seen by multiple providers, simply using billing records to establish the presence of an on-going patient provider relationship may be inadequate. Likewise, patients may think that their primary provider is different from the provider identified by the organization. Finally providers may leave the organization, which could leave affected patients unlinked to any provider. This issue of assigning patients to providers is particularly challenging for large multi-specialty practices and academic medical centers. 3. Who in the clinic or hospital will directly receive and screen electronic communications from the patient (i.e., the patient s physician, assigned nurse, clerk, or other surrogate), and how will after-hours, weekend or vacation coverage by other providers be handled in terms of access to or receiving electronic communications from patients? 4. Will communications such as visit scheduling or prescription refill requests be automatically routed to the provider, someone designated as her/his clinical proxy for purposes of communicating with patients, or will patients be able to directly schedule a visit by selecting from a list of scheduled openings listed on-line? Related to all such

5 international journal of medical informatics 79 (2010) electronic requests will be a need to ensure that a system is in place monitoring the timeliness and responsiveness to patient requests. 5. What actions will clinic/hospital staff be expected to take (i.e., respond directly to sender, copy sender s information into EHR, etc.) when receiving clinical data from patients? Such data could include home monitoring (e.g., home blood glucose or blood pressure readings), clinical values sent by the patient that were obtained from other providers, or data entered into an electronic personal health record. How or when will patients providers be notified that such information is being imported into the system? Clearly specific organizational policies must be developed to address the potential importing of such information from the patient directly into the patient s medical record. 6. Will the organization use a software product to structure patient inquiries so that complete histories of patient concerns can be collected with the first message, rather than through 3 4 turns of successive electronic messages between patient and provider [55]? 7. What will the organizational policy be for informing patients about potential delays in response if communications are used, and will there be automatic monitoring to ensure that s sent by patients are responded to within a specified time frame (e.g., 24 h, next regular business day, etc.)? 3.4. Aligning organizational policies with health insurance portability & accountability act (HIPAA) requirements Maintaining patient confidentiality in communications between providers and patients is essential both from regulatory and patient-expectation perspectives. However, patients may be cared for by multiple providers from different organizations, and patients may desire to share parts or all of their medical record and communications with all of their providers, with family members, and/or significant others. For patients already using , who may already be using it to communicate with health-care providers, the need for establishing a separate mechanism for secure communications may be confusing or be seen as an unnecessary bother. Further complicating the confidentiality issue is whether to limit parental access to communications between teenagers and their providers. While clinical practice is to privately discuss sensitive issues, such as sexual activity with adolescents, institutions may perceive that access to electronic information belongs to parents or guardians. Institutions will have to decide whether to limit parental rights to view their child s medical record or medication list, which might include oral contraceptives or treatment for a sexually transmitted infection, if the teenagers do not want this information shared with their parents. In the case of divorced parents with unequal custody authority, there are potential issues about which parent, and under what circumstances, will have access to the child s medical record. Thus it is not sufficient to just implement a secure electronic communication system, but it is also necessary to review and align existing organizational policies and procedures and HIPPA requirements with the introduction of a secure patient provider communications portal. The following questions are illustrative of some of the confidentiality issues to consider: 1. Will all providers and patients be required to only use the dedicated secure patient provider system to communicate clinical information via , or will other systems be allowed? 2. How will current organizational policies and procedures related to who has access to a minor s health record (i.e., married/divorced parents, step parents, etc.) be incorporated into allowing electronic viewing of the minor s medical record? Will all portions of a teenager s electronic health record be accessible by the parents or adult guardian? 3. How will access be handled for adults either caring for or serving as legal guardians of their elderly parents? That is, how will permission for access to the same electronic health record be given to more than one authorized user? As more individuals have access to an individual s EHR, the organization will need to develop processes for approving such access and long-term storage of documentation of the permissions given. 4. Will all clinically related secure message exchanges between patients and providers be retained, and if so for how long? 5. For parents with more than one child, will separate access codes and accounts need to be set up for each child, or will the parent only have to use one access code and account in order to providers or view their children s medical records? How will the situation be handled in which a parent sends a secure message regarding their child but uses her own account? 3.5. System implementation & training Preparing the secure communications system for go-live requires careful planning and execution of both the technical aspects of the HIT implementation, as well as training staff and providers to use the system. Patients will expect a fully functional secure communication system that works and with staff who are prepared to assist in using it. Thus, it is essential to test all aspects of the system to ensure that it is functioning as desired and to provide adequate training to staff designated to assist patients in enrolling or actually using the system. The following types of questions related to implementation and training can be helpful to consider: 1. Will management of the implementation and on-going operation of the secure communications system be internally led/controlled or outsourced to a firm specializing in this type of service? 2. Who are the key personnel from the organization s information technology, clinical care, clerical and support services, and administrative staff that will be assigned to support system implementation and staff training? If outsourced to an external organization, how will the appropriateness and adequacy of the implementation and training processes be assessed and ensured? 3. Is there a project management plan detailing specific project tasks, implementation milestones, and personnel

6 474 international journal of medical informatics 79 (2010) responsible for the pre-go-live (i.e., build, system testing, and training), go-live (i.e., system turn on, superuser support), and post-go-live (i.e., trouble shooting, system monitoring and modification) phases of the project? 4. What capital decisions, acquisitions, and IT system upgrades will need to be made, and by what dates? 5. What training types, intensities and modalities for delivering training will be needed for staff to enroll patients, clinicians interacting with patients about their potential use of the system, and training for enrolled patients to use the system, both at initial enrollment and as new features are introduced? 3.6. Marketing & enrollment Organizations will need to determine which patients will be targeted to enroll in the secure messaging system. For example in the case of a primary care clinic, the decision may be made to target only those patients for whom there is an expectation of a long-term provider patient relationship. Alternatively in a large multi-specialty group practice or integrated healthcare delivery system, only patients seen on an on-going basis in a primary care clinic or in one or more of the specialty clinics may be targeted for enrollment. Regardless, it is important to consider in advance which patients will be encouraged to sign up to use the secure messaging system and to develop marketing materials specifically targeting them. There are also a number of organizational issues to consider in terms of how the new secure communications system will be marketed to prospective users. First and foremost, it must be clear to prospective enrollees whether it will be free or have an associated fee. Potential alienation may occur if fees are subsequently added once patients have become accustomed to using the system. Options for promoting the secure messaging system can vary widely ranging from posting signs in the clinic or office about the system s availability to direct mail announcements, use of looped promotional video tapes playing in the office, and/or having someone in the organization such as the provider, nurse or clerical personnel take time to talk with the patient about the system s potential benefits and recommend its use. Regardless of the strategy to make potential users aware of the system, it is essential to have consistent promotional messages presented in an appropriate manner for the patient s age and literacy level. Once patients have decided to enroll, the enrollment process should be user-friendly, efficient, and accurate. Enrollment options may include on-line, in-person, or over the telephone. Whatever option is used, it is essential to have a clear and consistent process to verify the identity of the person being enrolled and/or given access to the system. However, if this is a separate step from enrollment, this may create log-in problems, which may or may not be addressable by the help desk. Some questions to consider related to marketing and the enrollment processes include the following: 1. Which patients will be encouraged to enroll in the secure communication system? 2. How will the secure communications system be presented/promoted to potential users (i.e., during scheduled visits, special promotions, etc.)? 3. What role will physicians and other providers play in recruiting patients to use the secure communication system? Will providers be actively encouraging patients to sign up? 4. Who will explain features and answer potential enrollees questions? Who is responsible/authorized to enroll patients? 5. How will enrollment be carried out (i.e., in-person, via the web, by telephone, etc.), and how will enrollee identity be verified? 6. What web-site tutorials, FAQs, or other resources such as log-in and password reminders, are available to assist enrollees in logging in, understanding and using the secure communications system? Will live help either in the form of a telephone or -based help desk be available? 3.7. On-going system use and performance monitoring As with all HIT applications, once implemented there is an on-going need to monitor utilization and system performance and manage the organizational resources being devoted to it. If the secure communications system is viewed as part of a long-term strategy to strengthen ties between patients and their providers, it will be essential to periodically monitor metrics such as: message volumes, types, and response timeliness of providers; medication refill and visit scheduling requests; numbers and frequencies of patients electronically viewing their medical records; and patient, provider and staff satisfaction. In particular monitoring provider response times to patient s may provide important information about the timeliness and resource intensity of responding to patients via . Costs of system maintenance and upgrades plus on-going staff support also require on-going monitoring and management. To this end it is useful to consider the following types of issues and questions: 1. Who has responsibility for tracking/monitoring use of the secure communications system as well as general system performance? 2. What mechanism will be used to ensure that patientgenerated s sent to providers are responded to in a timely manner? 3. Is there a formalized policy describing expectations for the nature and type of content appropriate to communicate via the secure messaging system? 4. How will patient, provider and staff satisfaction with the system be monitored on an on-going basis? 5. Which departmental budgets should be amended to include implementation and on-going support and responsibility? What are the on-going post-implementation costs associated with marketing, enrollment and daily operations? 6. What is the plan for operations when the system has temporary failures? 4. Conclusion As patients increasingly share in the financial cost of the care they receive, it is incumbent on healthcare organizations to

7 international journal of medical informatics 79 (2010) Summary points What is known: Patient desire and expectations for electronic communication with healthcare providers is growing. Secure web portals offering a variety of ways to enhance patient provider communication are increasing being implemented by healthcare providers & organizations. What study adds: Provides a framework for planning and implementing secure patient provider web portals. Identifies specific questions and issues healthcare providers & organizations should consider if implementing such systems. develop new ways of meeting patients expectations. Secure web-based systems can be used to enhance patient provider communications, facilitate visit scheduling, respond to medication refill requests, provide for bill paying, and increase patient access to their medical records. These enhancements are all consistent with healthcare organizations movement towards patient-centered care and their goals of maintaining current and growing future market share. Additionally, the use of secure web-based communication systems as part of the patient provider interaction will likely be part of the emerging concept of meaningful use, currently being developed by the federal government to define which entities will qualify for funding for implementing EMRs [54]. The preliminary proposal by a committee of experts calls for organizations to provide patients with timely electronic access to their health information by 2011, and by 2013 proposed requirements will include secure messaging, home device uploads and integration with a personal health record (PHR). While there may be many potential benefits for healthcare organizations to implement such systems, it is critical that such an undertaking be done in a thoughtful and organized manner. Failed or poorly managed implementations have the potential to be very costly, not only in terms of economic costs, but also in terms of potential threats to patient safety, lost provider productivity, and user dissatisfaction. This paper has presented a framework identifying seven key areas in planning and implementation of secure web-based systems for patient provider communication: the strategic fit, selection process and implementation team, workflow integration, HIPAA compliance; implementation and training planning, marketing and enrollment, and on-going performance monitoring and management. While the list of specific questions is not exhaustive, from our experience addressing them provides a solid foundation for what should be considered before implementing and operating a secure patient provider communications system. Acknowledgements This work was supported in part by grant number R18HS and by grant number K08HS from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. references [1] A. Hassol, J.M. Walker, D. Kidder, K. Rokita, D. Young, S. Pierdon, D. Deitz, S. Kuck, E. Ortiz, Patient experiences and attitudes about access to a patient electronic health care record and linked web messaging, J. Am. Med. Inform. Assoc. 11 (6) (2004) [2] C. Chen, T. Garrido, D. Chock, G. Okawa, L. Laing, The Kaiser permanente electronic health record: transforming and streamlining modalities of care, Health Affairs (Millwood) 28 (2) (2009) [3] J.D. Ralston, D.P. Martin, M.L. Anderson, P.A. Fishman, D.A. Conrad, E.B. Larson, D. Grembowski, Group health cooperative s transformation toward patient-centered access, Med. Care Res. Rev. 66 (6) (2009) [4] L.T. Harris, D.P. Martin, S.J. Haneuse, J.D. Ralston, Diabetes quality of care and outpatient utilization associated with electronic patient provider messaging: a cross-sectional analysis, Diabetes Care 32 (7) (2009) [5] C. Fullerton, P. Aponte, R. Hopkins, D. Bragg, D.J.U. Ballard, Lesson learned from pilot site implementation of an ambulatory electronic health record, Proc. Bayl. Univ. Med. Cent. 19 (4) (2006) [6] J.M. Bryne, S. Elliott, A. Firek, Initial experience with patient clinician secure messaging at a VA medical center, J. Am. Med. Inform. Assoc. 16 (2) (2009) [7] S.L. Zickmund, R. Hess, C.L. Bryce, K. McTigue, E. Olshansky, K. Fitzgerald, G.S. Fischer, Interest in the use of computerized patient portals: role of the provider patient relationship, J. Gen. Intern. Med. 23 (Suppl. 1) (2008) [8] D. McGeady, J. Kujala, K. Ilvonen, The impact of patient physician web messaging on healthcare service provision, Int. J. Med. Inform. 77 (1) (2008) [9] S.J. Katz, C.A. Moyer, The emerging role of online communication between patients and their providers, J. Gen. Intern. Med. 19 (9) (2004) [10] T.K. Houston, D.Z. Sands, M.W. Jenckes, D.E. Ford, Experiences of patients who were early adopters of electronic communication with their physician: satisfaction, benefits and concerns, Am. J. Manage. Care 10 (9) (2004) [11] C.T. Lin, L. Wittevrongel, L. Moore, B.L. Beaty, S.E. Ross, An internet-based patient provider communication system: randomized controlled trial, J. Med. Internet Res. 7 (2005) e47. [12] M. Wallwiener, C.W. Wallwiener, J.K. Kansy, H. Seeger, T.K. Rajab, Impact of electronic messaging on the patient-physician interaction, J. Telemed. Telecare 15 (5) (2009) [13] D.F. Sittig, Results of a content analysis of electronic messages ( ) sent between patients and their physicians, BMC Med. Inform. Decis. Making 3 (2003) 11. [14] S.L. Leong, D. Gingrich, P.R. Lewis, D.T. Mauger, J.H. George, Enhancing doctor patient communication using a pilot study, J. Am. Board Family Pract. 18 (3) (2005) [15] M.E. Matheny, T.K. Gandhi, E.J. Orav, Z. Ladak-Merchant, D.W. Bates, G.J. Kuperman, E.G. Poon, Impact of an

8 476 international journal of medical informatics 79 (2010) automated test results management system on patients satisfaction about test result communication, Arch. Intern. Med. 167 (20) (2007) [16] J.D. Ralston, D. Carrell, R. Reid, M. Anderson, M. Moran, J. Hereford, Patient web services integrated with a shared medical record: patient use and satisfaction, J. Am. Med. Inform. Assoc. 14 (6) (2007) [17] E.M. Liederman, C.S. Morefield, Web messaging: a new tool for patient physician communication, J. Am. Med. Inform. Assoc. 10 (3) (2003) [18] S.E. Ross, L.A. Moore, M.A. Earnest, L. Wittevrongel, C.T. Lin, Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial, J. Med. Internet Res. 6 (May (2)) (2004) e12. [19] J. Hereford, E. Bell, J. Lee, T. Eytan, Patient satisfaction with a web-based patient provider messaging system implemented across a statewide delivery system (Group Health Cooperative), in: AMIA Annu. Symp. Proc., 2003, p [20] K.G. Adler, Web portals in primary care: an evaluation of patient readiness and willingness to pay for online services, J. Med. Internet Res. 8 (4) (2006) e26. [21] Harris Interactive, Patient/physician online communication: many patients want it, would pay for it, and it would influence their choice of doctors and health plans, Health Care News 2 (8) (2002) 1 4. [22] J.B. Fowles, A.C. Kind, C. Craft, E.A. Kind, J.L. Mandel, S. Adlis, Patients interest in reading their medical record: relation with clinical and sociodemographic characteristics and patients approach to health care, Arch. Intern. Med. 164 (7) (2004) [23] C.L. Bryce, S. Zickmund, R. Hess, K.M. McTigue, E. Olshansky, K. Fitzgerald, G. Fischer, Value versus user fees: perspectives of patients before and after using a web-based portal of management of diabetes, Telemed. J. E: Health 14 (10) (2008) [24] K.D. Kleiner, R. Akers, B.L. Burke, E.J. Werner, Patient and physician attitudes regarding electronic communications in pediatric practices, Pediatrics 109 (5) (2002) [25] L. Sorensen, R. Shaw, E. Casey, Patient portals: survey of nursing informaticists, Stud. Health Technol. Inform. 146 (2009) [26] T. Delbanco, D.Z. Sands, Electrons in flight between doctors and patients, N. Engl. J. Med. 350 (17) (2004) [27] S.J. Katz, N. Nissan, C.A. Moyer, Crossing the digital divide: evaluating online communication between patients and their providers, Am. J. Manage. Care 10 (9) (2004) [28] C.B. White, C.A. Moyer, D.T. Stern, S.J. Katz, A content analysis of communication between patients and their providers: patients get the message, J. Am. Med. Inform. Assoc. 11 (4) (2004) [29] G.R. Couchman, S.N. Forjuoh, T.G. Rascoe, M.D. Reis, B. Koehler, K.L. Walsum, communications in primary care: what are patients expectations for specific test results? Int. J. Med. Inform. 74 (January (1)) (2005) [30] D.F. Sittig, S. King, B.L. Hazlehurst, A survey of patient provider communication: what do patients think? Int. J. Med. Inform. 61 (1) (2001) [31] A. Tjora, T. Tran, A. Faxvaag, Privacy vs. usability: a qualitative exploration of patients experiences with secure internet communication with their general practitioner, J. Med. Internet Res. 7 (2) (2005) e15. [32] S.J. Katz, C.A. Moyer, D.T. Cox, D.T. Stern, Effect of a triage-based system on clinic resource use and patient and physician satisfaction in primary care, J. Gen. Intern. Med. 18 (9) (2003) [33] E.M. Liederman, J.C. Lee, V.H. Baquero, P.G. Seites, The impact of patient physician web messaging on provider productivity, J. Healthcare Inform. Manage. 19 (2) (2005) [34] R.G. Neville, W. Marsden, C. McCowan, C. Pagliari, H. Mullen, A. Fannin, A survey of GP attitudes to and experiences of consultations, Inform. Prim. Care 12 (4) (2004) [35] A.F. Kittler, G.L. Carlson, C. Harris, M. Lippincott, L. Pizziferri, L.A. Volk, Y. Jagannath, J.S. Wald, D.W. Bates, Primary care physician attitudes towards using a secure web-based portal designed to facilitate electronic communication with patients, Inform. Prim. Care 12 (3) (2004) [36] J. Hobbs, J. Wald, Y.S. Jagannath, A. Kittler, L. Pizziferri, L.A. Volk, B. Middleton, D.W. Bates, Opportunities to enhance patient and physician contact, Int. J. Med. Inform. 70 (1) (2003) 1 9. [37] J.D. Ralston, C.M. Rutter, D. Carrell, J. Hecht, D. Rubanowice, G.E. Simon, Patient use of secure electronic messaging within a shared medical record: a cross-sectional study, J. Gen. Intern. Med. 24 (3) (2009) [38] Y.Y. Zhou, T. Garrido, H.L. Chin, A.M. Wiesenthal, L.L. Liang, Patient access to an electronic health record with secure messaging: impact on primary care utilization, Am. J. Manage. Care 13 (7) (2007) [39] D.L. Roter, S. Larson, D.Z. Sands, D.E. Ford, T. Houston, Can messages between patients and physicians be patient-centered? Health Commun. 23 (1) (2008) [40] R.W. Grant, J.S. Wald, J.L. Schnipper, T.K. Gandhi, E.G. Poon, E.J. Orav, D.H. Williams, L.A. Volk, B. Middleton, Practice-linked online personal health records for type 2 diabetes mellitus, Arch. Intern. Med. 168 (16) (2008) [41] B.B. Green, A.J. Cook, J.D. Ralston, P.A. Fishman, S.L. Catz, J. Carlson, D. Carrell, L. Tyll, E.B. Larson, R.S. Thompson, Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control: a randomized controlled trial, JAMA 299 (24) (2008) [42] T.S. Bergmo, P.E. Kummervold, D. Gammon, L.B. Dahl, Electronic patient provider communication: will it offset office visits and telephone consultations in primary care? Int. J. Med. Inform. 74 (9) (2005) [43] K. Reijonsaari, D. McGeady, J. Kujala, N. Ekroos, Effects of E-health on health care service production processes-case study: Palo alto online, in: International Conference on the Management of Healthcare & Medical Technology, Aalborg, Denmark, August 25 26, 2005, pp [44] R.C. Wu, D. Delgado, J. Costigan, J. Maciver, H. Ross, Pilot study of an internet patient physician communication tool for heart failure disease management, J. Med. Internet Res. 7 (1) (2005) e8. [45] S.G. Anand, M.J. Feldman, D.S. Geller, A. Bisbee, H. Bauchner, A content analysis of communication between primary care providers and parents, Pediatrics 115 (5) (2005) [46] J.S. Wald, K. Burk, K. Gardner, R. Feygin, E. Nelson, M. Epstein, E.G. Poon, B. Middleton, Sharing electronic laboratory results in a patient portal a feasibility pilot, Stud. Health Technol. Inform. 129 (Pt 1) (2007) [47] R. Hess, C.L. Bryce, S. Paone, G. Fischer, K.M. McTigue, E. Olshansky, S. Zickmund, K. Fitzgerald, L. Siminerio, Exploring challenges and potentials of personal health records in diabetes self-management: implementation and initial assessment, Telemed. J. E: Health 13 (5) (2007) [48] M.T. Britto, H.B. Jimison, J.K. Munafo, J. Wissman, M.L. Rogers, W. Hersh, Usability testing finds problems for novice users of pediatric portals, J. Am. Med. Inform. Assoc. 16 (5) (2009)

9 international journal of medical informatics 79 (2010) [49] A. Atreja, N. Mehta, D. Miller, S. Moore, K. Nichols, H. Miller, M. Harris, One size does not fit all: using qualitative methods to inform the development of an internet portal for Multiple Sclerosis patients, in: AMIA Annu. Symp. Proc., vols , [50] E. Shaw, M. Howard, D. Chan, H. Waters, J. Kaczorowski, D. Price, J. Zazulak, Access to web-based personalized antenatal health records for pregnant women: a randomized controlled trial, J. Obstet. Gynaecol. Can. 30 (1) (2008) [51] G. Ketteridge, H. Delbridge, L. Delbridge, How effective is communication for patients requiring elective surgery? ANZ J. Surg. 75 (8) (2005) [52] J. Car, A. Sheikh, consultations in health care. 2. Acceptability and safe application, BMJ 329 (7463) (2004) [53] C.M. Ruland, H. Brynhi, R. Andersen, T. Bryhni, Developing a shared electronic health record for patients and clinicians, Stud. Health Technol. Inform. 136 (2008) [54] Office of Health Information Technology, Meaningful Use, &parentname=CommunityPage&parentid=1&mode=2 (accessed 12/10/09). [55] J.W. Bachman, The patient computer interview: a neglected tool that can aid the clinician, Mayo Clin. Proc. 78 (1) (2003)