title: Patient-initiated Electronic Messages and Quality of Care for Patients With Diabetes and Hypertension in a Large Fee-for-Service Medical Group: Results From a Natural Experiment.
abstract: BACKGROUND
  Few studies have examined the association between patient-initiated electronic messaging (e-messaging) and clinical outcomes in fee-for-service settings.
  
  
  OBJECTIVE
  To estimate the association between patient-initiated e-messages and quality of care among patients with diabetes and hypertension.
  
  
  METHODS
  Longitudinal observational study from 2009 to 2013. In March 2011, the medical group eliminated a $60/year patient user fee for e-messaging and established a provider payment of $3-5 per patient-initiated e-message. Quality of care for patients initiating e-messages was compared before and after March 2011, relative to nonmessaging patients. Propensity score weighting accounted for differences between e-messaging and nonmessaging patients in generalized estimating equations.
  
  
  METHODS
  Large multispecialty practice in California compensating providers' fee-for-service.
  
  
  METHODS
  Patients with diabetes (N=4232) or hypertension (N=15,463) who had activated their online portal but not e-messaged before e-messaging became free.
  
  
  METHODS
  Quality of care included HEDIS-based process measures for hemoglobin (Hb) A1c, blood pressure, low-density lipoprotein (LDL), nephropathy, and retinopathy tests, and outcome measures for HbA1c, blood pressure, and LDL. E-messaging was measured as counts of patient-initiated e-message threads sent to providers. Patients were categorized into quartiles by e-messaging frequency.
  
  
  RESULTS
  The probability of annually completing indicated tests increased by 1%-7% for e-messaging patients, depending on the outcome and e-messaging frequency. E-messaging was associated with small improvements in HbA1c and LDL for some patients with diabetes.
  
  
  CONCLUSIONS
  Patient-initiated e-messaging may increase the likelihood of completing recommended tests, but may not be sufficient to improve clinical outcomes for most patients with diabetes or hypertension without additional interventions.
authors.affiliation: *Abt Associates, Cambridge, MA †Qualis Health, Seattle, WA ‡Sutter Health, Emeryville, CA §Palo Alto Medical Foundation Research Institute, Palo Alto, CA.
authors.forename: Sean R
authors.initials: SR
authors.lastname: McClellan
authors.forename: Laura
authors.initials: L
authors.lastname: Panattoni
authors.forename: Albert S
authors.initials: AS
authors.lastname: Chan
authors.forename: Ming
authors.initials: M
authors.lastname: Tai-Seale
mesh_terms: D000368:Aged; D001794:Blood Pressure; D001835:Body Weight; D002140:California; D003920:Diabetes Mellitus / Q000503:physiopathology / Q000628:therapy*; D003928:Diabetic Nephropathies / Q000175:diagnosis; D003930:Diabetic Retinopathy / Q000175:diagnosis; D034742:Electronic Mail / Q000706:statistics & numerical data*; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data*; D005260:Female; D006442:Glycated Hemoglobin; D006801:Humans; D006973:Hypertension / Q000503:physiopathology / Q000628:therapy*; D008077:Lipoproteins, LDL / Q000097:blood; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D012959:Socioeconomic Factors
chemical_list: D006442:Glycated Hemoglobin; D008077:Lipoproteins, LDL