Background: Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care. Objective: Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA’s online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed. Methods: We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams. Results: Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P<.001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P<.001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%). Conclusions: The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties. Trial Registration: ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468

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中文翻译：

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患者-临床团队安全消息传递对沟通模式和患者体验的影响：随机鼓励设计试验

背景：虽然患者和临床团队成员之间的安全信息 (SM) 是持续护理的推荐组成部分，但患者的接受度仍然相对较低。我们设计了一个多组件支持采用计划 (SAP)，以增加使用退伍军人健康管理局 (VHA) 进行初级保健的患者对 SM 的采用。目标：我们的目标是 (1) 进行多站点、随机、鼓励设计试验，以测试 SAP 的有效性，该 SAP 旨在通过 VHA 的在线患者门户 (My HealtheVet [MHV]) 提高患者与 SM 的参与度，以及 (2) 评估SAP 和患者级别 SM 的采用对感知提供者自主支持和沟通的影响。还评估了患者报告的采用 SM 的障碍。方法：我们随机分配了 3 个 VHA 机构的 1195 名拥有 MHV 门户帐户但从未使用过 SM 的患者。一半随机接受 SAP，一半作为接受常规护理的对照。SAP 包括通过邮寄教育材料鼓励采用 SM、发送给患者的主动 SM 以及基于电话的动机访谈。我们在 9 个月和 21 个月检查了 SAP 接受者和控制者之间 SM 采用率的差异。进行了后续电话调查以评估感知的提供者自主支持和与临床团队电话沟通的自我报告。结果：随机分配至 SAP 的患者采用 SM 的比率显着高于对照组（101/595，17.0% vs 40/600，6.7%；P<.001）。SAP 中的大多数采用者在没有进行激励性访谈的情况下发送了他们的第一条消息 (71/101, 70. 3%）。在鼓励结束后，采用率的 10 个百分点差异持续了整整一年（SAP 组为 23.7%，142/600，对照组为 13.5%，80/595，P<0.001）。我们从 49.54% (592/1195) 的参与者那里获得了后续调查数据。与对照组患者相比，SAP 参与者报告了更高的感知提供者自主支持（5.7 对 5.4，P=.007）和较少使用电话与他们的提供者交流（68.8% 对 76.0%，P=.05）。患者报告的采用 SM 的障碍包括自我效能感（例如，不习惯使用计算机，24%）、认为不需要 SM（22%）以及使用门户密码或登录困难（17%）。结论：多组分 SAP 成功地增加了 SM 的使用，比标准护理高 10 个百分点；新的 SM 采纳者报告说，他们对提供者自主支持的看法有所改善，并且更少地使用电话与他们的提供者进行交流。尽管如此，尽管通过 SAP 提供了鼓励和技术援助，采用率仍低于预期，在 21 个月时仅达到 24%（高于控制水平 10%）。与患者自我效能或技术困难相关的障碍相比，采用的常见障碍（例如对 SM 的感知需求有限）可能更具挑战性，需要不同的干预措施。试验注册：ClinicalTrials.gov NCT02665468；https://clinicaltrials.gov/ct2/show/NCT02665468 在 21 个月时仅达到 24%（比对照高 10%）。与患者自我效能或技术困难相关的障碍相比，采用的常见障碍（例如对 SM 的感知需求有限）可能更具挑战性，需要不同的干预措施。试验注册：ClinicalTrials.gov NCT02665468；https://clinicaltrials.gov/ct2/show/NCT02665468 在 21 个月时仅达到 24%（比对照高 10%）。与患者自我效能或技术困难相关的障碍相比，采用的常见障碍（例如对 SM 的感知需求有限）可能更具挑战性，需要不同的干预措施。试验注册：ClinicalTrials.gov NCT02665468；https://clinicaltrials.gov/ct2/show/NCT02665468

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