Integrating Secure Messaging into Provider Workflow

Dr. David Kaelber, MD, PhD, MPH is a practicing internist and pediatrician and the CMIO for the MetroHealth System, the public healthcare system of Cuyahoga County in Northeast Ohio. He is also an Associate Professor at Case Western Reserve University’s School of Medicine. Dr. Kaelber recently spoke at a HIMSS regional event in Cleveland at the HIMSS Innovation Center on Beyond Meaningful Use Stage 2.

We started with the principle that secure messaging should be wrapped in to our personal health record strategy. The personal health record is the cornerstone of our patient engagement strategy and secure messaging is a component of that. Common messages from patients are around lab results, imaging results and diagnoses which they see in their personal health record. Our integration of free Medline Plus content within the personal health record means that some of the questions patients might otherwise ask they can answer themselves.  We also took the approach that the workflow for secure messaging should mirror our telephone messaging process. Patients can not call providers directly, they call their office. Messages go to a non-provider first, then are triaged to appropriate team members.  The messages which need physician  response or input are forwarded to the physician.  To be successful takes time – it is a culture change for physicians, the healthcare team, and patients. Physician leadership and adoption of secure messaging is key to adopt by patients and the rest of the healthcare team.  The 5% secure messaging requirement as part of the Stage 2 patient engagement Meaningful Use measures should help with secure messaging deployment and adoption and transform how we care for patients.

Providers were concerned about adding to their workload by needing to respond to messages. Our experience to date is that generally there is no net add to work, but rather a different kind of work.  Patients are using secure messaging instead of phone calls.  Also, we discovered that it enhances patient satisfaction – many patients want to use it. One should approach secure messaging with classic change management – let’s try it and see what it’s like, as be prepared to adjust based on our own experience.  Our rollout plan was to include secure messaging with the roll out of our personal health record. Two outpatient clinics were first, then two months later we turned it on throughout our healthcare system, changing some based on the experience of our first two clinics. It makes sense to pilot first. Once a few providers are using it, highlight patient and provider success stories at staff meetings, newsletters and other communication vehicles.  Personal stories can help.

We developed similar work pools in our electronic health record for secure messaging as we had for phone calls.  I recommend that you setup for patients to select a type of message.  This helps triage and route messages more efficiently.  We set-up 6 types – appointment requests, referral requests, medication questions, medication refills, non-urgent med questions, and technical support questions.

For patients in lower socio-economic groups, we found that smart phones were much more common than home computers or laptops, so make sure that your secure messaging strategy and software take this difference in devices into account.  Secure messages must have a mobile app, but there may be workflow issues. For example, our personal health record requires going to a website the first time with an activation code to configure your login and password.  This cannot be done easily through a smart phone.  Therefore, we have gone to a process of in clinic sign-up where patients can use the computers in our offices as part of their visit to select their logins and passwords.  Then they can exclusively use their smart phone app for secure messaging.  It does not matter that they do not have access to a computer or a laptop with internet access at home.  In the Hispanic community, the first question is, what percent can communicate in English? At least in our Hispanic population, a significant percentage are able to communicate in English.  If you have a significant percentage of patients that do not speak English, you need to think through secure messaging work flows carefully.  As a non-Spanish speaking provider myself, it is relatively easy for me to obtain remote phone translation services for a face-to-face visit.  However, if a patient sends me/my team a message in Spanish, these remote phone translation services are not set-up to assist with this translation, either of the initial Spanish message from the patient or in the reply to the patient, which then should also be in Spanish.  

You need to think about your strategy and process for proxy access, especially if your practice has pediatric patients or a significant elderly population.  You must make sure that HIPAA and other privacy issues are addressed while at the same time making the proxy sign-up and use process not onerous for patient proxies. Patient proxies should have secure messaging access, however it should not be by using the patient’s login and password.  The Meaningful Use Stage 2 secure messaging measure applies equally to adult and pediatric providers.  However, practically pediatric providers will only be able to achieve this measure through messages from patient proxies.

You also need to develop a realistic timeline.  Our technical roll out took about 3 months, and is now maturely deployed. But 2.5 years later, secure messaging is still not universally adopted by our physicians, healthcare teams, and patients. Currently, only about 20% of our eligible providers are meeting the Meaningful Use Stage 2, 5% of patients sending secure messages measure.  You need an adoption plan.

Keywords: 
secure messaging, Meaningful Use, patient engagement