Secure Messaging Intervention in Patients Starting New Antidepressant to Promote Adherence: Pilot Randomized Controlled Trial.

BACKGROUND: There are a range of effective pharmacological and behavioral treatments for depression. However, approximately one-third of patients discontinue antidepressants within the first month of treatment and 44% discontinue them by the third month of treatment. The major reasons reported for discontinuation were side effect burden, patients experiencing that the medications were not working, and patients wanting to resolve their depression without using medication. OBJECTIVE: This study tested the acceptability, feasibility, and preliminary effectiveness of an SMS messaging intervention designed to improve antidepressant adherence and depression outcomes in veterans. The intervention specifically targeted the key reasons for antidepressant discontinuation. For example, the secure message included reminders that it can take up to 6 weeks for an antidepressant to work, or prompts to call their provider should the side effect burden become significant. METHODS: This pilot was a 3-armed randomized controlled trial of 53 veterans undergoing depression treatment at the Iowa City Veterans Affairs Health Care System. Veterans starting a new antidepressant were randomized to secure messaging only (SM-Only), secure messaging with coaching (SM+Coach), or attention control (AC) groups. The intervention lasted 12 weeks with follow-up assessments of key outcomes at 6 and 12-weeks. This included a measure of antidepressant adherence, depressive symptom severity, and side effect burden. RESULTS: The 2 active interventions (SM-Only and SM+Coach) demonstrated small to moderate effect sizes (ESs) in improving antidepressant adherence and reducing side effect burden. They did not appear to reduce the depressive symptom burden any more than in the AC arm. Veteran participants in the SM arms demonstrated improved medication adherence from baseline to 12 weeks on the Medication Adherence Rating Scale compared with those in the AC arm, who had a decline in adherence (SM-Only: ES=0.09; P=.19; SM+Coach: ES=0.85; P=.002). Depression scores on the 9-Item Patient Health Questionnaire decreased for all 3 treatment arms, although the decline was slightly larger for the SM-Only (ES=0.32) and the SM+Coach (ES=0.24) arms when compared with the AC arm. The 2 intervention arms indicated a decrease in side effects on the Frequency, Intensity, and Burden of Side Effects Ratings, whereas the side effect burden for the AC arm increased. These differences indicated moderate ES (SM-Only vs AC: ES=0.40; P=.07; SM+Coach: ES=0.54; P=.07). CONCLUSIONS: A secure messaging program targeting specific reasons for antidepressant discontinuation had small-to-moderate ES in improving medication adherence. Consistent with prior research, the intervention that included brief synchronic meetings with a coach appeared to have a greater benefit than the SMS-alone intervention. Veterans consistently engaged with the SMS messaging in both treatment arms throughout the study period. They additionally provided feedback on which texts were most helpful, tending to prefer messages providing overall encouragement rather than specific wellness recommendations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03930849; https://clinicaltrials.gov/study/NCT03930849.

Patient and Provider Experience of Electronic Patient Portals and Secure Messaging in Mental Health Treatment.

Objective: Electronic health record patient portals were promoted to enhance patient engagement. However, organizations often deny patient access to records of treatment for mental health disorders. This study explores patient and provider experience of patient electronic access to the mental health treatment record and the use of secure messaging. Materials and Methods: Online surveys of a sample of mental health patients (N = 168) and providers (N = 80) addressed their experience using patient portals and secure messaging. Results: Only 29 of the 80 providers (36%) worked at organizations which provided patients electronic access to mental health records. Of these 29 providers, 72% endorsed that patients requested a change in the provider note, 69% endorsed patients asked more questions, 55% endorsed patients reported they experienced significant distress after accessing portal, and 21% reported patients engaged in negative and/or self-destructive behavior toward themselves or others. Of patients with access to mental health notes (N = 37), 86% endorsed that they gained a better understanding of what was discussed in the appointment, 84% trusted their health care provider more, 76% felt comforted or relieved after reading their health information, and 57% reported they were better able to take medications as prescribed. Both patients and providers enjoyed the efficiency of secure messaging. Open-text responses are also presented. Conclusions: The implementation of electronic access to mental health notes requires a transition from viewing the medical record as the exclusive tool of providers to that of a collaborative tool for patients and providers to achieve treatment goals.

Racial differences in patient consent policy preferences for electronic health information exchange.

OBJECTIVE: This study aimed to explore the association between demographic variables, such as race and gender, and patient consent policy preferences for health information exchange as well as self-report by VHA enrollees of information continuity between Veterans Health Administration (VHA) and community non-VHA heath care providers. MATERIALS AND METHODS: Data were collected between March 25, 2016 and August 22, 2016 in an online survey of 19 567 veterans. Three questions from the 2016 Commonwealth Fund International Health Policy Survey, which addressed care continuity, were included. The survey also included questions about consent policy preference regarding opt-out, opt-in, and "break the glass" consent policies. RESULTS: VHA enrollees had comparable proportions of unnecessary laboratory testing and conflicting information from providers when compared with the United States sample in the Commonwealth Survey. However, they endorsed medical record information being unavailable between organizations more highly. Demographic variables were associated with gaps in care continuity as well as consent policy preferences, with 56.8% of Whites preferring an opt-out policy as compared with 40.3% of Blacks, 44.9% of Hispanic Latinos, 48.3% of Asian/Pacific Islanders, and 38.3% of Native Americans (P < .001). DISCUSSION: Observed large differences by race and ethnicity in privacy preferences for electronic health information exchange should inform implementation of these programs to ensure cultural sensitivity. Veterans experienced care continuity comparable to a general United States sample, except for less effective exchange of health records between heath care organizations. VHA followed an opt-in consent policy at the time of this survey which may underlie this gap.

Current Practices in Electronic Capture of Patient-Reported Outcomes for Measurement-Based Care and the Use of Patient Portals to Support Behavioral Health.

Electronic health records combined with tethered patient portals now support a range of functions including electronic data capture of patient-reported outcomes, trend reporting on clinical targets, secure messaging, and patient-mediated health information exchange. The applications of these features require special consideration in psychiatric and behavioral health settings. Nonetheless, their potential to engage patients suffering from disorders in which passivity and withdrawal are endemic to their mental health condition, is great. This article presents the growing research base on these topics, including discussion of key issues and recommendations for optimal implementation of patient portals in behavioral health settings.

A Decade of Veteran Voices: Examining Patient Portal Enhancements Through the Lens of User-Centered Design.

BACKGROUND: Health care systems have entered a new era focused on patient engagement. Patient portals linked to electronic health records are recognized as a promising multifaceted tool to help achieve patient engagement goals. Achieving significant growth in adoption and use requires agile evaluation methods to complement periodic formal research efforts. OBJECTIVE: This paper describes one of the implementation strategies that the Department of Veterans Affairs (VA) has used to foster the adoption and sustained use of its patient portal, My HealtheVet, over the last decade: an ongoing focus on user-centered design (UCD). This strategy entails understanding the users and their tasks and goals and optimizing portal design and functionality accordingly. Using a case study approach, we present a comparison of early user demographics and preferences with more recent data and several examples to illustrate how a UCD can serve as an effective implementation strategy for a patient portal within a large integrated health care system. METHODS: VA has employed a customer experience analytics (CXA) survey on its patient portal since 2007 to enable ongoing direct user feedback. In a continuous cycle, a random sample of site visitors is invited to participate in the Web-based survey. CXA model questions are used to track and trend satisfaction, while custom questions collect data about users' characteristics, needs, and preferences. In this case study, we performed analyses of descriptive statistics comparing user characteristics and preferences from FY2008 (wherein "FY" means "fiscal year") to FY2017 and user trends regarding satisfaction with and utilization of specific portal functions over the last decade, as well as qualitative content analysis of user's open-ended survey comments. RESULTS: User feedback has guided the development of enhancements to core components of the My HealtheVet portal including available features, content, interface design, prospective functional design, and related policies. Ten-year data regarding user characteristics and portal utilization demonstrate trends toward greater patient engagement and satisfaction. Administration of a continuous voluntary Web-based survey is an efficient and effective way to capture veterans' voices about who they are, how they use the patient portal, needed system improvements, and desired additional services. CONCLUSIONS: Leveraging "voice-of-the-customer" techniques as part of patient portal implementation can ensure that such systems meet users' needs in ways that are agile and most effective. Through this strategy, VA has fostered significant adoption and use of My HealtheVet to engage patients in managing their health.

The Characteristics of Pain in Patients Diagnosed with Depression and Heart Failure.

Heart failure (HF) is a costly and growing health problem that is routinely complicated by chronic pain and depression. The purpose of this paper is to describe the characteristics of pain and pain management in depressed HF patients. In this descriptive cross-sectional study, we analyzed data from 62 participants with depression and class II-IV HF. Study variables of interest were collected from the Brief Pain Inventory, Beck Depression Inventory, and Rand-36. Almost all participants (98%) had some pain in the past month and most had pain in the last 24 hours (66%). The median pain score was 4 (0-10 scale) with the majority reporting moderate to severe pain. The median pain interference score was 4.42 (0-10 scale) with the majority reporting moderate to extreme interference. Medication to treat pain was used by all participants who reported pain, with only 5% also using nonpharmacologic treatment. The majority of participants reported moderate or severe pain while also having moderate to extreme pain interference. Nonpharmacologic pain treatments were severely underused. Women were more likely to have higher levels of pain intensity and more pain interference than men, suggesting that additional screening for the impact of pain is especially important in women. The wide variety of body areas affected, along with moderate to high intensity pain and considerable interference scores reported, indicate that pain was ineffectively treated. Nonpharmacologic treatments should be considered to decrease the impact of pain.

The Relationships Among Pain, Depression, and Physical Activity in Patients With Heart Failure.

INTRODUCTION: Increasing patients' physical activity levels holds many opportunities to facilitate health and well-being among those with heart failure (HF) by improving HF symptoms and decreasing depression and pain. Given low exercise participation rates, an essential first step to increase exercise rates is to evaluate how pain and depression may further influence engagement in exercise programs. AIMS: The aims of this study were to describe the level of physical activity and exercise that patients with HF with depression achieve and to investigate the relationships among pain, depression, total activity time, and sitting time. METHODS: In this correlational cross-sectional study, we analyzed data from 61 participants with depression and New York Heart Association class II to IV HF. RESULTS AND CONCLUSIONS: The total time spent being active was less than 1 hour per day. Depressed patients with HF have much lower physical activity levels than the general public. Decreasing sitting time and increasing light activity levels hold promise to improve pain and depression symptoms.

The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange.

INTRODUCTION: Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. MATERIALS AND METHODS: Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. RESULTS: Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. CONCLUSIONS: This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

Medication List Discrepancies and Therapeutic Duplications Among Dual Use Veterans.

A concerning level of discrepancies exists between the VA and non-VA medication lists of dual use veterans, raising the risk of adverse drug events.

Patient Education for Consumer-Mediated HIE. A Pilot Randomized Controlled Trial of the Department of Veterans Affairs Blue Button.

OBJECTIVES: Consumer-mediated health information exchange (HIE) is one of the three types of HIE designated by the Office of the National Coordinator. HIE is intended to improve the quality of care while reducing cost, yet empirical support for this claim is mixed. Future research should identify the contexts whereby HIE is most effective. METHODS: This study was conducted as a pilot two-arm randomized controlled trial. In the intervention arm, 27 veterans were taught how to generate a Continuity of Care Document (CCD) within the Blue Button feature of their VA patient portal and were then asked to share it with their community non-VA provider. In the attention control condition, 25 Veterans were taught how to look up health information on the Internet. The impact of this training on the next non-VA medical visit was examined. RESULTS: Nineteen (90%) veterans in the intervention arm shared their CCD with their non-VA provider as compared with 2 (17%) in the attention control arm (p<0.001). Both veterans and non-VA providers indicated high satisfaction with the CCD. Comparison of medical records between the VA and non-VA providers did not indicate improved medication reconciliation (p=0.72). If veterans shared their CCD prior to their non-VA providers ordering laboratory tests, the number of duplicate laboratories was significantly reduced (p=0.02). CONCLUSIONS: In this pilot randomized controlled trial, training 52 veterans to share their CCD was feasible and accepted by both patients and providers. Sharing this document appeared to reduce duplicate laboratory draws, but did not have an impact on documented medication list concordance.

Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews With Patients and Providers.

BACKGROUND: Information sharing between providers is critical for care coordination, especially in health systems such as the United States Department of Veterans Affairs (VA), where many patients also receive care from other health care organizations. Patients can facilitate this sharing by using the Blue Button, an online tool that promotes patients' ability to view, print, and download their health records. OBJECTIVE: The aim of this study was to characterize (1) patients' use of Blue Button, an online information-sharing tool in VA's patient portal, My HealtheVet, (2) information-sharing practices between VA and non-VA providers, and (3) how providers and patients use a printed Blue Button report during a clinical visit. METHODS: Semistructured qualitative interviews were conducted with 34 VA patients, 10 VA providers, and 9 non-VA providers. Interviews focused on patients' use of Blue Button, information-sharing practices between VA and non-VA providers, and how patients and providers use a printed Blue Button report during a clinical visit. Qualitative themes were identified through iterative rounds of coding starting with an a priori schema based on technology adoption theory. RESULTS: Information sharing between VA and non-VA providers relied primarily on the patient. Patients most commonly used Blue Button to access and share VA laboratory results. Providers recognized the need for improved information sharing, valued the Blue Button printout, and expressed interest in a way to share information electronically across settings. CONCLUSIONS: Consumer-oriented technologies such as Blue Button can facilitate patients sharing health information with providers in other health care systems; however, more education is needed to inform patients of this use to facilitate care coordination. Additional research is needed to explore how personal health record documents, such as Blue Button reports, can be easily shared and incorporated into the clinical workflow of providers.

VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes.

OBJECTIVE: To explore the experience of early patient adopters who accessed their clinical notes online using the Blue Button feature of the My HealtheVet portal. METHODS: A web-based survey of VA patient portal users from June 22 to September 15, 2013. RESULTS: 33.5% of respondents knew that clinical notes could be viewed, and nearly one in four (23.5%) said that they had viewed their notes at least once. The majority of VA Notes users agreed that accessing their notes will help them to do a better job of taking medications as prescribed (80.1%) and be better prepared for clinic visits (88.6%). Nine out of 10 users agreed that use of visit notes will help them understand their conditions better (91.8%), and better remember the plan for their care (91.9%). In contrast, 87% disagreed that VA Notes will make them worry more, and 88.4% disagreed that access to VA Notes will be more confusing than helpful. Users who had either contacted their provider or healthcare team (11.9%) or planned to (13.5%) primarily wanted to learn more about a health issue, medication, or test results (53.7%). CONCLUSIONS: Initial assessment of the patient experience within the first 9 months of availability provides evidence that patients both value and benefit from online access to clinical notes. These findings are congruent with OpenNotes study findings on a broader scale. Additional outreach and education is needed to enhance patient awareness. Healthcare professionals should author notes keeping in mind the opportunity patient access presents for enhanced communication.

Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal.

OBJECTIVE: The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs' (VA) personal health record portal, My HealtheVet. MATERIALS AND METHODS: An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers. RESULTS: Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans' self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button. CONCLUSIONS: This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.

Validity of the Patient Health Questionnaire, PHQ-9, administered through interactive-voice-response technology.

We compared the administration of the 9-item Patient Health Questionnaire (PHQ-9) to assess depressive symptoms using interactive voice response (IVR) technology with the method of administration using paper-and-pencil. Data were collected from 51 veterans participating in an 8-week randomized controlled trial of an illness management programme for heart failure. To counter possible bias in answering questions via IVR technology, the anchoring responses of the PHQ-9 questionnaire were reversed so that lower numbers corresponded to more severe depression. The mean for the pencil-and-paper administered PHQ-9 was 4.1 (SD = 4.5) and the mean for IVR administration was 2.8 (SD = 3.1). The internal consistency (Cronbach's alpha) of the PHQ-9 was 0.76 for IVR administration and 0.82 for paper administration. The intraclass correlation coefficient for the two modes of administration was 0.65, indicating moderate agreement. IVR administration of the PHQ-9 produces similar results to pencil-and-paper administration, but the former is not as sensitive to higher levels of depressive symptom severity. This suggests that a lower threshold for probable depression is warranted when assessing depressive symptoms with IVR.

A longitudinal community-based study of chronic illness, cognitive and physical function, and depression.

OBJECTIVE: Recent studies have tried to determine which aspects of chronic illness heighten the risk for depression, with functional impairment receiving the most attention. There is growing evidence that functional impairment accounts for most of the association between chronic illness and depression. This study examines the relative contribution of cognitive function, physical function, and chronic illness to depression 2 years later in a nationwide sample of elders aged 70 and older. METHODS: This is a longitudinal community-based study of 5,289 elders completing two waves of assessment in the Asset and Health Dynamics among the Oldest Old study. Depression assessment included an abbreviated version of the CES-D and of the Composite International Diagnostic Interview (the CESD-8 and the CIDI-S). Cognitive function, physical function, and presence of chronic illness assessed at Wave 1 were examined as predictors of depression at Wave 2 while controlling for Wave 1 CESD-8 score. RESULTS: In a full multivariate model, most baseline cognitive function, physical function, and chronic illness variables predicted depression as measured by the CESD-8 at Wave 2. The associations were markedly weaker between baseline variables and the Wave 2CIDI-S. The Wave 1 CESD-8 score predicted all-cause mortality by Wave 2 (Z =3.13; p Z = 0.002) even after controlling for key health and functioning variables. CONCLUSION: Chronic illness, physical function, and cognitive function all independently predict depressive morbidity in late-life. The CIDI-S appeared less informative about these key relationships when compared to the CESD-8. The significance of depressive symptoms was demonstrated by their independent association with all-cause mortality at 2-year follow-up.

Telehealth screen for depression in a chronic illness care management program.

Chronic illness accounts for the majority of healthcare expenditures in the United States. Innovative telemedicine programs have been developed to help lessen the chronic illness burden, yet few have been developed to address comorbidity. Programs accommodating comorbidity are needed because most older adults suffer from two or more chronic illnesses. One of the most common and serious comorbidities in chronic illness is major depression, which has been shown to exacerbate morbidity, mortality, and cost. This study presents data on a telephone-based interactive voice recording (IVR) home monitoring program that was expanded to include quarterly screens for depression using the Patient Health Questionnaire (PHQ). Patients in an ongoing telehealth heart failure program were administered the PHQ-2 and PHQ-9 in November 2005 (Round 1) and February 2006 (Round 2). Patients were informed about the screen beforehand and an emergency protocol was established. At both screens, more than 90% of the patients completed the screen. Approximately 30% of the patients endorsed one of the PHQ-2 items in both rounds. Patients endorsing either of the PHQ-2 items then completed the full PHQ-9. Nurse care-managers contacted those scoring above the threshold of 10 on the PHQ-9 indicating possible depression. One patient expressed suicidality and was appropriately assessed for safety. There was no indication that patients were less likely to complete the screen in Round 2, although their average depression scores were slightly lower when compared with Round 1. A regular telephonic IVR screen for depression can be integrated into a standard illness management protocol. Following a preestablished emergency plan for the assessment of suicidality was successful. This serves as a model for using technology to manage comorbid depression and chronic illness.

Relationship of coping styles with quality of life and depressive symptoms in older heart failure patients.

This study examines the relationship between coping styles, quality of life, and depressive symptoms in older heart failure patients. Eighty heart failure patients seeking treatment in an outpatient heart failure or family practice clinic participated in a study examining depression, disability, and heart failure. Patients completed a clinical interview and questionnaires about mood, functional impairment, comorbid illness, quality of life, and coping. Heart failure severity and maladaptive coping styles, including denial, self-distraction, and self-blame, negatively affected quality of life and depressive symptoms. The use of maladaptive coping strategies involves efforts that divert attention from the illness and suggests the need to provide heart failure patients the skills to directly address the stress associated with their illness. Interventions that target these coping strategies may help patients take a more active role in their heart failure management and may improve psychological and cardiac outcomes.

Alcohol use and health outcomes in the oldest old.

BACKGROUND: As the United States population ages, an unprecedented proportion of the population will be aged 70 and older. Knowledge of alcohol use and its consequences in this age group is not well known. In light of the disparate findings pointing to negative outcomes with excessive drinking yet also benefits of moderate drinking, the true risk of alcohol use in late life needs more investigation. METHODS: This study examined the correlates and 2-year health outcomes related to alcohol use in 7,434 elders aged 70 years or older. Data was collected as part of the Assets and Health Dynamics of the Oldest Old (AHEAD), a nationwide health and economic study of elders. Data from Wave 1 and Wave 2 of AHEAD are presented. Frequency and quantity of drinking was assessed by self-report as was health status, lifetime alcohol or psychiatric problems, presence of chronic illness, functional impairment, and depressive symptoms. Cognitive status was assessed using a brief measure. RESULTS: Approximately 44% of the sample reported any alcohol use in the past three months, with the majority of drinking less than daily. Daily drinking was associated with being Caucasian, married, in relatively good health, and having good affective and cognitive status. Drinking was not associated with negative health outcomes two years later and was protective against stroke and functional impairment. Decline in drinking between Wave 1 and Wave 2 was strongly associated with poor health. CONCLUSION: This study offers no evidence of negative health outcomes for drinking moderately and confirms the U-shaped curve often found in studies of alcohol and health. Nonetheless, cessation of drinking was associated with poor health suggesting the health benefits of moderate drinking may result from selection of a healthy group of people capable of sustained moderate drinking. Public health recommendations for moderate drinking must take this phenomenon into account.