The Veterans Health Administration (VHA) estimated that one in four veterans in the U.S. have diabetes. Over 30 million Americans had diabetes in 2015 (1). Potential complications of diabetes include kidney failure, heart attack, lower-limb amputations, and blindness (2). Good glycemic control is associated with better patient outcomes, but almost half of patients with type 2 diabetes do not achieve glycemic control, or cholesterol or blood pressure control (3-5).
In type 2 diabetes, effective patient-provider communication and patient self-management is associated with the improved management of side effects, monitoring of blood test results, and screening for potential complications (6). Patients’ who are more knowledgeable about their risk factor levels have been shown to have improved clinical outcomes (7,8). When a collaborative relationship exists between patients and their health care providers, clinical outcomes tend to be improved (9,10).
Patient portals, personal health records and electronic medical records provide opportunities to leverage information technology to improve chronic disease management and outcomes (11,12). In 2003, VHA introduced My HealtheVet, an internet-based patient portal containing a personal health record. My HealtheVet is connected to their VHA electronic medical record and allows several functions such as online prescription refills or self-entry in food or physical activity journals. The VHA deployed the Blue Button feature in 2010 as part of its online combined personal health record and patient portal, My HealtheVet. The Blue Button allows patients to access components of their electronic health record such as medications, laboratory results, procedures, vitals, and past and future appointments. The introduction of patient web portals and personal health records constitute an important development in diabetes care. Patients with diabetes and other chronic illnesses can now view health information such as medications, laboratory results, and patient education.
The goal of the current feasibility study was to determine the number of veterans seen for type 2 diabetes at a large medical center in the southeastern region of the U.S. and to examine whether they had registered for the My HealtheVet patient web portal according to age, sex, race, Hispanic ethnicity, and era of military service.
The current study was conducted as “preparatory to research” in support of a grant application for a larger and more detailed proposed study. Prior to a review of computerized patient records (CPRs), a determination was made by the director of the institutional review board (IRB) office and the Associate Chief of Staff for Research that the study was exempt from IRB review. One of the authors (SS Coughlin) met with key informants including the coordinator of the My HealtheVet office at the Charlie Norwood VAMC and the nurse diabetes educator. Existing patient records were reviewed including My HealtheVet web portal registration by veterans treated for type 2 diabetes (ICD-10 code E-11) at the Charlie Norwood VAMC. De-identified number of outpatient clinic patients seen for diabetes were examined by age categories, sex, race, Hispanic ethnicity, and era. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained using EpiInfo version 126.96.36.199.
A total of 49,341 veterans receive care at the Charlie Norwood VAMC. Of those patients, 10,951 have been seen for type 2 diabetes (mean age 65.47 years). Of the 49,341 patients, 21,372 patients (43.3%, mean age 63.89 years) are using My HealtheVet and 10,465 patients (21.2%) use secure messages. Of 10,950 diabetic patients, only 1,256 (11.5%) have registered for My HealtheVet (Table 1). Women with diabetes were more likely to be registered for My HealtheVet than their male counterparts (13.92% vs. 11.24%; OR=1.28; 95% CI: 1.05–1.55), as shown in Table 2. Veterans with diabetes who served during WW II or the Korean War were less likely to use My HealtheVet than those who served during more recent eras (OR=0.33; 95% CI: 0.24–0.44). Use of the patient portal was highest among diabetic patients ages 51–55 years (15.59%).
The current study indicates that use of the My HealtheVet web portal among veterans seen for diabetes at a large medical center in the southeastern U.S. is very low. Although My HealtheVet includes a feature that allows diabetic patients to type in their blood glucose results, graph it, and forward this information to their provider at the VAMC, few patients take advantage of this resource. Veterans who meet with the My HealtheVet coordinator are provided with a copy of the VA My HealtheVet Handbook and are asked to sign a form authorizing their electronic medical record to be linked to their My HealtheVet account. The coordinator does not screen veterans for computer literacy. When patients are seen at outpatient clinics, a clinical reminder in the CPRs prompts the nurse, physician, or clinic clerk to remind the veteran to register for My HealtheVet if they have not already registered. Veterans receive prompts to register for My HealtheVet on patient letters and from the VAMC pharmacy and Facebook account.
A limited number of studies have examined the use of patient web portals for diabetes health care (13). Few of these studies have been conducted at VA healthcare facilities. Although results-to-date have been mixed, results from prior studies suggest that secure messaging between diabetes patients and their clinician is associated with improved disease management (13). Improvements in low density lipoprotein (LDL) cholesterol and blood pressure have also been observed in some studies of web portals for patients with diabetes (6). The patient web portal features that may improve diabetes care (e.g., secure messaging or patient education) have not been clearly identified by published studies. Previous studies show that diabetic patients often do not use web portals, when offered, perhaps because of computer illiteracy or a lack of internet access (14).
With respect to limitations, the current study did not examine the specific reasons that diabetes patients had registered for My HealtheVet or whether they used it over time. Future studies should examine whether veterans who use My HealtheVet for secure messaging are active secure message users or whether they send secure messages to their provider only rarely. A further limitation is that the current study was cross-sectional in nature and lacked information about the temporal relationship between treatment for diabetes and My HealtheVet registration. The current study examined prevalent cases of diabetes which could have been diagnosed recently or in the past. In addition, no information was available about computer literacy and health literacy. Health illiteracy is frequent among diabetes patients and can impair diabetes management (15-18). Patients with lower computer literacy may have difficulty learning how to use a web portal (12,15) suggesting the need for educational programs.
Previous studies of the use of My HealtheVet or Blue Button by veterans with diabetes (6,19), or veterans with diabetes or other chronic health conditions have been cross-sectional surveys (19-21) or a retrospective cohort (observational) study design (5) and have not employed a prospective randomized controlled trial design. A low percentage of Veterans with diabetes are active users of My HealtheVet. Additional studies are needed to identify My HealtheVet portal design features and veteran characteristics that will increase use of this patient portal which may improve diabetes care.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Disclaimer: The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
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Cite this article as: Coughlin SS, Carbone LD, Heboyan V, Williams LB, Hatzigeorgiou C, Rangachari P, De Leo G. Use of My HealtheVet patient web portal among veterans seen for diabetes mellitus at a medical center in the southeastern United States. mHealth 2017;3:50.