title: Patient Use of Electronic Prescription Refill and Secure Messaging and Its Association With Undetectable HIV Viral Load: A Retrospective Cohort Study.
abstract: Electronic personal health records (PHRs) can support patient self-management of chronic conditions. Managing human immunodeficiency virus (HIV) viral load, through taking antiretroviral therapy (ART) is crucial to long term survival of persons with HIV. Many persons with HIV have difficulty adhering to their ART over long periods of time. PHRs contribute to chronic disease self-care and may help persons with HIV remain adherent to ART. Proportionally veterans with HIV are among the most active users of the US Department of Veterans Affairs (VA) PHR, called My HealtheVet. Little is known about whether the use of the PHR is associated with improved HIV outcomes in this population.
  
  
  
  The objective of this study was to investigate whether there are associations between the use of PHR tools (electronic prescription refill and secure messaging [SM] with providers) and HIV viral load in US veterans.
  
  
  
  We conducted a retrospective cohort study using data from the VA's electronic health record (EHR) and the PHR. We identified veterans in VA care from 2009-2012 who had HIV and who used the PHR. We examined which ones had achieved the positive outcome of suppressed HIV viral load, and whether achievement of this outcome was associated with electronic prescription refill or SM. From 18,913 veterans with HIV, there were 3374 who both had a detectable viral load in 2009 and who had had a follow-up viral load test in 2012. To assess relationships between electronic prescription refill and viral control, and SM and viral control, we fit a series of multivariable generalized estimating equation models, accounting for clustering in VA facilities. We adjusted for patient demographic and clinical characteristics associated with portal use. In the initial models, the predictor variables were included in dichotomous format. Subsequently, to evaluate a potential dose-effect, the predictor variables were included as ordinal variables.
  
  
  
  Among our sample of 3374 veterans with HIV who received VA care from 2009-2012, those who had transitioned from detectable HIV viral load in 2009 to undetectable viral load in 2012 tended to be older (P=.004), more likely to be white (P<.001), and less likely to have a substance use disorder, problem alcohol use, or psychosis (P=.006, P=.03, P=.004, respectively). There was a statistically significant positive association between use of electronic prescription refill and change in HIV viral load status from 2009-2012, from detectable to undetectable (OR 1.36, CI 1.11-1.66). There was a similar association between SM use and viral load status, but without achieving statistical significance (OR 1.28, CI 0.89-1.85). Analyses did not demonstrate a dose-response of prescription refill or SM use for change in viral load.
  
  
  
  PHR use, specifically use of electronic prescription refill, was associated with greater control of HIV. Additional studies are needed to understand the mechanisms by which this may be occurring.
authors.affiliation: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.|Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States.
authors.forename: D Keith
authors.identifier: 0000-0002-9941-5470
authors.initials: DK
authors.lastname: McInnes
authors.affiliation: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.|Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States.|Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
authors.forename: Stephanie L
authors.identifier: 0000-0002-6517-5122
authors.initials: SL
authors.lastname: Shimada
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States.
authors.forename: Amanda M
authors.identifier: 0000-0001-7191-2507
authors.initials: AM
authors.lastname: Midboe
authors.affiliation: Veterans and Consumers Health Informatics Office, Office of Connected Care, Veterans Health Administration, Washington, DC, United States.
authors.forename: Kim M
authors.identifier: 0000-0002-0966-5602
authors.initials: KM
authors.lastname: Nazi
authors.affiliation: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.
authors.forename: Shibei
authors.identifier: 0000-0001-5058-3134
authors.initials: S
authors.lastname: Zhao
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States.
authors.forename: Justina
authors.identifier: 0000-0003-4806-5260
authors.initials: J
authors.lastname: Wu
authors.affiliation: School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, MA, United States.
authors.forename: Casey M
authors.identifier: 0000-0002-8176-8104
authors.initials: CM
authors.lastname: Garvey
authors.affiliation: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.|Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
authors.forename: Thomas K
authors.identifier: 0000-0002-2909-4018
authors.initials: TK
authors.lastname: Houston
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D057286:Electronic Health Records; D055695:Electronic Prescribing; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology*; D055991:Health Records, Personal; D006801:Humans; D008297:Male; D050316:Medical Order Entry Systems; D008875:Middle Aged; D012189:Retrospective Studies; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data; D014728:Veterans; D019562:Viral Load
keywords: HIV; electronic mail; electronic prescribing; health records, personal; secure messaging; self care; veterans; viral load