Communication Preferences and Satisfaction of Secure Messaging Among Patients and Providers in the Military Healthcare System

Communication Preferences and Satisfaction of Secure Messaging Among Patients and Providers in... Abstract Introduction Use of electronic secure messaging (SM) is rapidly growing in various healthcare settings. However, there is a large number of patients that choose not use SM or use it minimally. Thus, understanding preferences for patient–provider communication modalities is critically important, particularly among military healthcare beneficiaries. The purpose of this study was to assess preferences for patient–provider communication modalities (in person, telephone, SM, or mail) among a sample of patients, providers, and staff located at five Air Force military treatment facilities across the USA. Methods We recruited patients, providers, and staff, from five family health clinics to complete a short survey. We measured participants’ preferences for communication modality for various healthcare concerns, such as responses to non-urgent medical questions, test results, and medication renewal information. We also measured satisfaction with MiCare, the Air Force’s SM system. We conducted chi-square analyses and Fisher’s exact tests to assess differences in communication preferences by patients, providers, and staff and we computed frequencies in satisfaction responses. Results We found that while providers and staff (N = 70) prefer to communicate with patients about various healthcare concerns online through MiCare, patients (N = 1,260) prefer to communicate in-person or through the telephone. Patients were generally satisfied with MiCare; however, there was a large proportion of patients who were undecided about MiCare’s impact on the quality of care they received (40.3%). Additionally, although the majority of providers and staff believed MiCare improved their efficiency (58.0%) and communication with patients (72.3%), 65.7% of providers and staff believed MiCare had increased their workload. Conclusion MiCare is a promising tool to improve patient–provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare. INTRODUCTION Use of electronic secure messaging (SM), a function within many web-based patient portals, is rapidly growing.1–3 SM allows patients to communicate securely with their healthcare provider about clinical concerns and administrative tasks, such as scheduling appointments and prescription refills.4 While older studies have shown SM decreases office visits,5,6 telephone contacts,6,7 and provider workload,6 recent studies have shown that SM may have an opposite effect8–10 or no effect at all.11–13 Additionally, studies examining the impact of SM on patient health outcomes are inconsistent; however, there is a moderate level of evidence that SM improves glucose outcomes in patients with diabetes.14 Despite these inconsistencies, patients and providers generally believe SM positively impacts quality of care and patient satisfaction.4,8,10,14 Although the use of SM is growing in healthcare settings, there is a large number of patients that choose not to use SM or use this feature minimally. For example, in one study, 70% of the patient portal users were classified as low-messaging users, accessing this feature zero or one time.15 In another study, only 14% of patient portal users exchanged one or more secure messages with a primary or specialty care provider.16 In a large national study among veterans, only 2% of registered patient portal users used SM with their clinical provider.17 To our knowledge, no study has estimated the rate of SM among patients within the military healthcare system; thus, the use of SM among active duty, retired service members, and dependents is unclear. The military healthcare system serves approximately 9.4 million beneficiaries worldwide annually,18 many of whom are eligible to use SM. Therefore, understanding preferences for patient–provider communication, specifically preferences related to SM, is critically important and may help increase use of SM among this population. To our knowledge, however, no study has assessed patient–provider communication preferences within military healthcare settings. To address this gap, we assessed preferences for patient–provider communication modalities (in-person, telephone, SM, or mail) among a sample of patients, providers, and staff at family health clinics located at five Air Force military treatment facilities (MTFs) across the USA. METHODS MiCare MiCare is the U.S. Air Force’s web-based SM system for patients and healthcare providers within the military healthcare system. It is currently being implemented at all 76 Air Force MTFs worldwide.19 In addition to enabling patients to securely communicate with their assigned healthcare team, MiCare allows patients to manage their appointments, renew medications, receive test and lab results, request a copy of their immunization records, and access patient education materials.20 Patients must register to use MiCare, which can be initiated in-person at any Air Force MTF. After registering in-person, patients are sent an email to authenticate their email address and complete the registration process. All registered patients, providers, and staff are given a unique log-in name and password to access and use MiCare. To further maintain security of patients’ personal identifiable information, electronic messages sent through MiCare are encrypted and only patients’ assigned healthcare team can access their messages.20 Study Design and Procedures We conducted a cross-sectional survey with a convenience sample of patients, providers, and staff assigned to family health clinics at five Air Force MTFs. Data collection occurred fall 2014–spring 2015. To recruit patients, a letter of information about the study and paper survey were distributed to patients as they checked-in for their appointment by clinic staff. Patients completed the survey as they waited to see their healthcare provider and returned completed surveys to a designated box located in the waiting room. All completed patient surveys were mailed to research staff by the MiCare site coordinator. Survey data were then entered into an electronic database for analysis. To recruit providers and staff, flyers were posted in clinic areas frequently visited by providers and staff (e.g., breakroom). An electronic email invitation with a link to the survey was sent to the family health clinic staff by the clinic MiCare site care coordinator. Providers and staff completed the electronic surveys at a time convenient for them. Data from providers and staff were then downloaded and cleaned for analysis. All surveys were anonymous and required approximately 5–10 min to complete. Because this was a quality improvement study, the study protocol was exempt from Institutional Review Board approval. Participants To be eligible to participate in the study, patients had to be age 18–65 yr and assigned to a primary care manager at the family health clinic located at any of the five selected Air Force MTFs. Providers and staff had to be assigned to one of the family health clinics located at the five selected MTFs. Measures We collected demographic data from patients, which included age and military duty status (active duty, dependent, or retired). For analytic purposes, age was categorized as 15–24 yr, 25–44 yr, 45–64 yr, and 65 yr and older. We also collected demographic data from providers and staff, which included military duty status (active duty, government service, or contract), duty title, years worked within a family health clinic, and years of experience in his/her specialty. For analytic purposes, military duty status was categorized as active duty or government services/contract; duty title was categorized as physician/physician assistant, nurse, and clinical technician; years worked within a family health clinic was categorized as less than one year, 2–4 yr, and 5 or more years; and years of experience in his/her specialty was categorized as less than one year, 2–4 yr, and 5 or more years. We collected preferences for patient–provider communication modalities by asking patients, providers, and staff their preferences for receiving/giving information related to: non-urgent medical questions, test results, pre-procedure instructions, treatment instructions, appointment notifications, medication renewal information, medication information in general, how to use medications, change in prescriptions, and follow-up appointments. Response options included “speak in person”, “telephone message”, “speak on phone”, “online MiCare”, “official U.S. mail”, or “not applicable”. For analytic purposes, responses were categorized as in-person, telephone, or online MiCare. In addition to those that responded not applicable, those that responded official U.S. mail were excluded from the analyses due to having a low response rate. We collected patients’ satisfaction with MiCare by asking patients their level of agreement with 10 statements related to their communication with their provider, quality of healthcare, and overall well-being as a result of using MiCare. Examples of statements include, “MiCare has improved communication with my provider” and “MiCare has improved the quality of care I receive”. Response options were on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree” plus “not applicable, not registered”. We collected providers’ and staff’s satisfaction with MiCare by asking providers and staff their level of agreement with nine statements related to their communication with patients, quality of care they deliver, and workload as a result of using MiCare. Examples of statements include, “MiCare has improved communication with patients” and “MiCare has improved my efficiency.” Response options were on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree” plus “not applicable, not registered”. For analytic purposes, responses were categorized as “strongly agree/somewhat agree”, “strongly disagree/somewhat disagree”, and “undecided” for patients, providers, and staff. Those that responded “not applicable, not registered” were excluded from the analyses. Analysis We first computed descriptive characteristics of the sample and conducted chi-square analyses to identify differences in preferences for communication modality by patient, provider, and staff demographics. We used Fisher’s exact test in cases where expected cell count values were less than five. We then combined providers and staff responses and conducted chi-square analyses to assess differences in communication preferences by patients and providers/staff. p-Values of 0.05 or less were considered statistically significant. We also calculated the frequency of satisfaction responses for both patients and providers. We conducted all analyses using SPSS software (Version 18, IBM Corporation, Armonk, NY, USA). RESULTS Table I presents the descriptive characteristics of the sample. As shown, most patient participants were 25 yr old or older, and on active duty status. Most provider participants were on active duty status, and clinical technicians. About 37% of providers had worked in a family health clinic for 1 yr or less and 34% had 2–4 yr of experience in his/her specialty. Table I. Participant Characteristics n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) Note. N’s are different because of missing values Table I. Participant Characteristics n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) Note. N’s are different because of missing values Table II presents the distribution for preferences of communication modality by patient demographics. Preferences for communication modality differed by age across all health topics. A higher proportion of patients aged 15–24 yr reported preferring to receive responses to non-urgent medical questions (57.1%), test results (47.8%), medication renewal information (56.8%), and schedule follow-up appointments (55.3%) via telephone than older patients. A higher proportion of patients aged 65 and older reported preferring to receive pre-procedure instructions (52.4%), treatment instructions (63.9%), instructions on how to use medication (56.5%), and notification of a change in prescription (54.5%) in-person than younger patients. Finally, a slightly higher proportion of patients aged 45–64 yr reported preferring to receive general medication information online through MiCare (44.2%) than younger and older patients. Table II. Preferred Communication Modality by Patient Demographics Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** *p ≤ 0.001; **p ≤ 0.01; ***p < 0.05. Table II. Preferred Communication Modality by Patient Demographics Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** *p ≤ 0.001; **p ≤ 0.01; ***p < 0.05. Patients’ preferences for communication modality differed by military duty status for six health topics (Table II). A higher proportion of Active Duty military personnel reported preferring to receive appointment notifications (70.9%), medication renewal information (50.4%), and schedule a follow-up appointment (49.0%) through the telephone than retired military personnel and dependents. A higher proportion of Active Duty military personnel also reported preferring to receive pre-procedure instructions (42.3%) and treatment instructions (50.6%) in-person than retired military personnel and dependents. However, a higher proportion of retired patients preferred to receive test results online through MiCare (43.5%) than active duty and dependents. Table III presents the distribution of communication preferences by provider and staff demographics. A higher proportion of physicians and physician assistants reported preferring to provide treatment instructions (83.3%) in-person than other providers and staff. Additionally, a higher proportion of providers and staff that had 2-4 years of experience in his/her specialty preferred to provide appointment notifications online through MiCare (81.0%) than providers and staff with less or more experience. Preferences for communication modality did not differ by military duty status or years worked in a family health clinic for any health topic. Table III. Preferred Communication Modality by Provider and Staff Demographics Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) *p < 0.05. Table III. Preferred Communication Modality by Provider and Staff Demographics Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) *p < 0.05. Preferences for communication modality by patient, providers, and staff are presented in Table IV. While a high proportion of patients reported preferring to receive responses to non-urgent medical questions (41.8%), receive test results (38.1%), receive appointment notifications (62.1%), receive medication renewal information (41.5%), and schedule a follow-up appointment (43.5%) through the telephone, a higher proportion of providers and staff reported preferring to accomplish these tasks online through MiCare than patients. Table IV. Differences in Preferred Communication Modality by Patients and Providers/Staff Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* *p < 0.05. Table IV. Differences in Preferred Communication Modality by Patients and Providers/Staff Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* *p < 0.05. Patients’ and providers’ satisfaction with MiCare is presented in Table V. Over half of the patients surveyed strongly agreed or agreed somewhat that MiCare had improved: their communication with their provider (57.5%), communication with their assigned healthcare primary care team (57.9%), access to care (55.9%), and the healthcare information they received (55.3%). The majority of patients also agreed that MiCare was easy to use (68.1%) and 59.0% agreed that MiCare offered the functions they need to manage their personal healthcare. Most patients surveyed also agreed that they were satisfied with the timeliness of MiCare responses to their concerns (61.2%). However, a similar proportion of patients who agreed, were undecided if MiCare improved the quality of care they received (48.2% vs. 40.3%), their overall well-being and quality of life (40.3% vs. 44.9%), and their ability to receive medication renewals (44.7% vs. 43.3%), respectively. Table V. Satisfaction with MiCare by Patients and Providers/Staff Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) aResponse options included strongly agree and somewhat agree. bResponse options included strongly disagree and somewhat disagree. Table V. Satisfaction with MiCare by Patients and Providers/Staff Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) aResponse options included strongly agree and somewhat agree. bResponse options included strongly disagree and somewhat disagree. Over half of the providers and staff strongly agreed or agreed somewhat that MiCare improved their efficiency (58.0%), efficiency of his/her team (55.9%), and communication with patients (72.3%). The majority of providers also agreed that MiCare was easy to use (75.4%), offered functions that they need to provide quality healthcare (66.2%), and gave them more control in addressing patients’ concerns (61.4%). However, less than half of the providers agreed that MiCare had improved the quality of care that they delivered (48.4%). Additionally, the majority of providers agreed that MiCare had increased their workload (65.7%) and a similar proportion of providers that agreed, disagreed that MiCare improved their available time during the duty day (36.9% vs. 38.5%). DISCUSSION This study assessed patients’, providers’, and staff’s preferences for communication modalities for various healthcare topics. We also assessed their satisfaction with the U.S. Air Force’s web-based SM system, MiCare. Communication preferences significantly differed by various patient and provider/staff demographics including age, military status, duty title, and years of experience in specialty. In general, we found that most patients preferred to address many healthcare concerns, such as responding to non-urgent medical questions and receiving test results, through the telephone while most providers and staff preferred to address these issues online through MiCare. This finding is consistent with similar previous studies that have found civilian patients prefer to receive health information in-person or through the telephone rather than online.21–23 Limited internet access,21 previous negative experiences using SM,4 concerns about burdening his/her provider,4 lack of provider endorsement,4 and limited health literacy22 may influence patients’ preferences for communication modalities. One previous study found that the most important consideration for patients when selecting a communication modality was speed of communication; nearly 52% of patients desired a communication method that was rapid.23 Research is needed to identify the factors that may influence patients’ communication preferences specifically within the military healthcare system. Over half of the patients surveyed believed MiCare improved communication with their providers and primary care teams, access to care, and healthcare information they received. Additionally, most of the patients were satisfied with the timeliness of MiCare responses. These satisfaction rates are similar to rates in previous patient satisfaction studies with similar SM systems.24–27 However, in this study, a large proportion of patients were undecided about MiCare’s impact on the quality of care they received, overall well-being and quality of life, and ability to receive medication renewals. Previous studies have found patient satisfaction with SM increases as SM use increases.26 Therefore, it could be plausible that the patients in this study did not use MiCare for very long or used it infrequently, and thus, have lower satisfaction rates for some of these topics. Nevertheless, these findings indicate some quality improvements can be made to MiCare’s implementation, particularly with medication renewals. Less than half of the providers and staff agreed that MiCare had improved the quality of care that they delivered, and the majority of providers believed that MiCare had increased their workload. Additionally, over one-third of providers and staff did not believe MiCare improved their available time during the duty day. These findings are consistent with previous studies that have found SM systems increases provider workload.8,10 This increase in workload may be due to message volume, ambiguity of messages sent by patients, and inappropriate use of SM by patients.8 However, although there may be increases in workload, over half of the providers and staff in this study believed MiCare improved their efficiency, their team’s efficiency, and communication with patients, which is consistent with previous studies.8,10 Thus, MiCare is a promising communication tool for providers and staff and future studies should be conducted to identify strategies to reduce providers’ and staff’s workload as a result of using MiCare. Although this study is among the first studies to assess patients’ and providers’ preferences for communication within a military healthcare setting, there are some limitations that must be considered. First, the convenience sample consisted of only patients, providers, and staff from five family health clinics; thus, the findings may not be generalized to patients and providers attending other clinics or MTFs across the USA. Second, our sample size of providers and staff was small; however, the sample size is consistent with previous studies assessing barriers and facilitators to SM among healthcare providers.8,28,29 Finally, we did not assess factors that may influence patients’ preferences for communication such as their internet access, health literacy, or frequency of MiCare use. Future studies should consider these factors when assessing patients’ communication preferences and satisfaction with MiCare. CONCLUSION This study’s findings indicate that while providers and staff prefer to communicate with patients about various healthcare concerns online through MiCare, patients prefer to communicate in-person or through the telephone. Although a large proportion of patients were generally satisfied with MiCare, there was a large proportion of patients who were undecided if MiCare improved the quality of care they received. Additionally, the majority of providers and staff believed MiCare improved their efficiency; however, many providers and staff believed MiCare had increased their workload. Previous studies have shown SM can have meaningful effects on quality of care when implemented as part of a larger comprehensive patient management system,14 and the majority of patients, providers, and staff in this study believed MiCare improved their patient–provider communication. Thus, MiCare continues to be a promising tool to improve patient–provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare. Acknowledgements The authors would like to thank the site coordinators who helped with data collection and the patients, providers, and staff who participated in this study. Previous Presentations A portion of the findings from this manuscript have been presented at the TriService Nursing Research Program (TSNRP) Research and Evidence-Based Practice Dissemination Course (2017) as a poster presentation: Garnder, C.L. (2017). Patient to Health Team Communication Preferences and Perceptions of Secure Messaging. Presented at the TSNRP Research and Evidence-based Practice Dissemination Course. Ellicott City, MD. REFERENCES 1 Ford EW , Hesse BW , Huerta TR : Personal health record use in the united states: Forecasting future adoption levels . J Med Internet Res 2016 ; 18 ( 3 ): e73 . Google Scholar CrossRef Search ADS PubMed 2 Shenson JA , Cronin RM , Davis SE , Chen Q , Jackson GP : Rapid growth in surgeons’ use of secure messaging in a patient portal . Surg Endosc 2016 ; 30 ( 4 ): 1432 – 40 . Google Scholar CrossRef Search ADS PubMed 3 Cronin RM , Davis SE , Shenson JA , Chen Q , Rosenbloom ST , Jackson GP : Growth of secure messaging through a patient portal as a form of outpatient interaction across clinical specialties . Appl Clin Inform 2015 ; 6 ( 2 ): 288 – 304 . Google Scholar CrossRef Search ADS PubMed 4 Wade-Vuturo AE , Mayberry LS , Osborn CY : Secure messaging and diabetes management: experiences and perspectives of patient portal users . J Am Med Inform Assoc 2012 ; 20 ( 3 ): 519 – 25 . Google Scholar CrossRef Search ADS PubMed 5 Bergmo TS , Kummervold PE , Gammon D , Dahl LB : Electronic patient–provider communication: Will it offset office visits and telephone consultations in primary care? Int . J Med Inf 2005 ; 74 ( 9 ): 705 – 10 . Google Scholar CrossRef Search ADS 6 Zhou YY , Garrido T , Chin HL , Wiesenthal AM , Liang LL : Patient access to an electronic health record with secure messaging: impact on primary care utilization . Am J Manag Care 2007 ; 13 ( 7 ): 418 – 24 . Google Scholar PubMed 7 Liederman EM , Lee JC , Baquero VH , Seites PG : Patient‐physician web messaging . J Gen Intern Med 2005 ; 20 ( 1 ): 52 – 7 . Google Scholar CrossRef Search ADS PubMed 8 Hoonakker PL , Carayon P , Cartmill RS : The impact of secure messaging on workflow in primary care: Results of a multiple-case, multiple-method study . Int J Med Inf 2017 ; 100 : 63 – 76 . Google Scholar CrossRef Search ADS 9 Liss DT , Reid RJ , Grembowski D , Rutter CM , Ross TR , Fishman PA : Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH . Ann Fam Med 2014 ; 12 ( 4 ): 338 – 43 . Google Scholar CrossRef Search ADS PubMed 10 Bishop TF , Press MJ , Mendelsohn JL , Casalino LP : Electronic communication improves access, but barriers to its widespread adoption remain . Health Aff (Millwood) 2013 ; 32 ( 8 ): 1361 – 7 . Google Scholar CrossRef Search ADS PubMed 11 Meng D , Palen TE , Tsai J , McLeod M , Garrido T , Qian H : Association between secure patient-clinician email and clinical services utilisation in a US integrated health system: a retrospective cohort study . BMJ Open 2015 ; 5 ( 11 ): e009557 . 2015–009557. Google Scholar CrossRef Search ADS PubMed 12 Garrido T , Meng D , Wang JJ , Palen TE , Kanter MH : Secure e-mailing between physicians and patients: transformational change in ambulatory care . J Ambul Care Manage 2014 ; 37 ( 3 ): 211 – 8 . Google Scholar CrossRef Search ADS PubMed 13 North F , Crane SJ , Chaudhry R , et al. : Impact of patient portal secure messages and electronic visits on adult primary care office visits . Telemedicine and e-Health 2014 ; 20 ( 3 ): 192 – 8 . Google Scholar CrossRef Search ADS PubMed 14 Goldzweig CL , Towfigh AA , Paige NM , et al. Systematic Review: Secure Messaging Between Providers and Patients, and Patients’ Access to Their Own Medical Record: Evidence on Health Outcomes, Satisfaction, Efficiency and Attitudes [Internet]. Washington (DC): Department of Veterans Affairs (VA-ESP Project #05-226); 2012 Jul. 15 Yamin CK , Emani S , Williams DH , et al. : The digital divide in adoption and use of a personal health record . Arch Intern Med 2011 ; 171 ( 6 ): 568 – 74 . Google Scholar CrossRef Search ADS PubMed 16 Ralston JD , Rutter CM , Carrell D , Hecht J , Rubanowice D , Simon GE : Patient use of secure electronic messaging within a shared medical record: a cross-sectional study . J Gen Intern Med 2009 ; 24 ( 3 ): 349 – 55 . Google Scholar CrossRef Search ADS PubMed 17 Shimada SL , Brandt CA , Feng H , et al. : Personal health record reach in the veterans health administration: a cross-sectional analysis . J Med Internet Res 2014 ; 16 ( 12 ): e272 . Google Scholar CrossRef Search ADS PubMed 18 Evaluation of the TRICARE program : Fiscal year 2017 report to Congress. May 2017. Available at https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/Annual-Evaluation-of-the-TRICARE-Program; accessed October 13, 2017. 19 Stock J AF healthcare messaging service now fully implemented. U.S. Air Force Web site. March 24, 2014. Available at http://www.af.mil/News/ArticleDisplay/tabid/223/Article/475062/af-healthcare-messaging-service-now-fully-implemented.aspx; accessed October 13, 2017. 20 Connect to Secure Messaging. Air Force Medical Service Web site. Available at http://www.airforcemedicine.af.mil/MiCare/; accessed October 13, 2017. 21 Graetz I , Gordon N , Fung V , Hamity C , Reed ME : The digital divide and patient portals: Internet access explained differences in patient portal use for secure messaging by age, race, and income . Med Care 2016 ; 54 ( 8 ): 772 – 9 . Google Scholar CrossRef Search ADS PubMed 22 Tieu L , Sarkar U , Schillinger D , et al. : Barriers and facilitators to online portal use among patients and caregivers in a safety net health care system: a qualitative study . J Med Internet Res 2015 ; 17 ( 12 ): e275 . Google Scholar CrossRef Search ADS PubMed 23 Choudhry A , Hong J , Chong K , et al. : Patients’ preferences for biopsy result notification in an era of electronic messaging methods . JAMA Dermatol 2015 ; 151 ( 5 ): 513 – 21 . Google Scholar CrossRef Search ADS PubMed 24 Haun JN , Patel NR , Lind JD , Antinori N : Large-scale survey findings inform patients’ experiences in using secure messaging to engage in patient-provider communication and self-care management: a quantitative assessment . J Med Internet Res 2015 ; 17 ( 12 ): e282 . Google Scholar CrossRef Search ADS PubMed 25 Haun JN , Lind JD , Shimada SL , et al. : Evaluating user experiences of the secure messaging tool on the veterans affairs’ patient portal system . J Med Internet Res 2014 ; 16 ( 3 ): e75 . Google Scholar CrossRef Search ADS PubMed 26 Neuner J , Fedders M , Caravella M , Bradford L , Schapira M : Meaningful use and the patient portal: patient enrollment, use, and satisfaction with patient portals at a later-adopting center . Am J Med Qual 2015 ; 30 ( 2 ): 105 – 13 . Google Scholar CrossRef Search ADS PubMed 27 Baer D : Patient-physician e-mail communication: the Kaiser Permanente experience . J Oncol Pract 2011 ; 7 ( 4 ): 230 – 3 . Google Scholar CrossRef Search ADS PubMed 28 Fix GM , Hogan TP , Amante DJ , McInnes DK , Nazi KM , Simon SR : Encouraging patient portal use in the patient-centered medical home: three stakeholder perspectives . J Med Internet Res 2016 ; 18 ( 11 ): e308 . Google Scholar CrossRef Search ADS PubMed 29 Klein DM , Fix GM , Hogan TP , Simon SR , Nazi KM , Turvey CL : Use of the blue button online tool for sharing health information: Qualitative interviews with patients and providers . J Med Internet Res 2015 ; 17 ( 8 ): e199 . Google Scholar CrossRef Search ADS PubMed Author notes The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Air Force, U.S. Department of Defense, or the U.S. Government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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Communication Preferences and Satisfaction of Secure Messaging Among Patients and Providers in the Military Healthcare System

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© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Introduction Use of electronic secure messaging (SM) is rapidly growing in various healthcare settings. However, there is a large number of patients that choose not use SM or use it minimally. Thus, understanding preferences for patient–provider communication modalities is critically important, particularly among military healthcare beneficiaries. The purpose of this study was to assess preferences for patient–provider communication modalities (in person, telephone, SM, or mail) among a sample of patients, providers, and staff located at five Air Force military treatment facilities across the USA. Methods We recruited patients, providers, and staff, from five family health clinics to complete a short survey. We measured participants’ preferences for communication modality for various healthcare concerns, such as responses to non-urgent medical questions, test results, and medication renewal information. We also measured satisfaction with MiCare, the Air Force’s SM system. We conducted chi-square analyses and Fisher’s exact tests to assess differences in communication preferences by patients, providers, and staff and we computed frequencies in satisfaction responses. Results We found that while providers and staff (N = 70) prefer to communicate with patients about various healthcare concerns online through MiCare, patients (N = 1,260) prefer to communicate in-person or through the telephone. Patients were generally satisfied with MiCare; however, there was a large proportion of patients who were undecided about MiCare’s impact on the quality of care they received (40.3%). Additionally, although the majority of providers and staff believed MiCare improved their efficiency (58.0%) and communication with patients (72.3%), 65.7% of providers and staff believed MiCare had increased their workload. Conclusion MiCare is a promising tool to improve patient–provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare. INTRODUCTION Use of electronic secure messaging (SM), a function within many web-based patient portals, is rapidly growing.1–3 SM allows patients to communicate securely with their healthcare provider about clinical concerns and administrative tasks, such as scheduling appointments and prescription refills.4 While older studies have shown SM decreases office visits,5,6 telephone contacts,6,7 and provider workload,6 recent studies have shown that SM may have an opposite effect8–10 or no effect at all.11–13 Additionally, studies examining the impact of SM on patient health outcomes are inconsistent; however, there is a moderate level of evidence that SM improves glucose outcomes in patients with diabetes.14 Despite these inconsistencies, patients and providers generally believe SM positively impacts quality of care and patient satisfaction.4,8,10,14 Although the use of SM is growing in healthcare settings, there is a large number of patients that choose not to use SM or use this feature minimally. For example, in one study, 70% of the patient portal users were classified as low-messaging users, accessing this feature zero or one time.15 In another study, only 14% of patient portal users exchanged one or more secure messages with a primary or specialty care provider.16 In a large national study among veterans, only 2% of registered patient portal users used SM with their clinical provider.17 To our knowledge, no study has estimated the rate of SM among patients within the military healthcare system; thus, the use of SM among active duty, retired service members, and dependents is unclear. The military healthcare system serves approximately 9.4 million beneficiaries worldwide annually,18 many of whom are eligible to use SM. Therefore, understanding preferences for patient–provider communication, specifically preferences related to SM, is critically important and may help increase use of SM among this population. To our knowledge, however, no study has assessed patient–provider communication preferences within military healthcare settings. To address this gap, we assessed preferences for patient–provider communication modalities (in-person, telephone, SM, or mail) among a sample of patients, providers, and staff at family health clinics located at five Air Force military treatment facilities (MTFs) across the USA. METHODS MiCare MiCare is the U.S. Air Force’s web-based SM system for patients and healthcare providers within the military healthcare system. It is currently being implemented at all 76 Air Force MTFs worldwide.19 In addition to enabling patients to securely communicate with their assigned healthcare team, MiCare allows patients to manage their appointments, renew medications, receive test and lab results, request a copy of their immunization records, and access patient education materials.20 Patients must register to use MiCare, which can be initiated in-person at any Air Force MTF. After registering in-person, patients are sent an email to authenticate their email address and complete the registration process. All registered patients, providers, and staff are given a unique log-in name and password to access and use MiCare. To further maintain security of patients’ personal identifiable information, electronic messages sent through MiCare are encrypted and only patients’ assigned healthcare team can access their messages.20 Study Design and Procedures We conducted a cross-sectional survey with a convenience sample of patients, providers, and staff assigned to family health clinics at five Air Force MTFs. Data collection occurred fall 2014–spring 2015. To recruit patients, a letter of information about the study and paper survey were distributed to patients as they checked-in for their appointment by clinic staff. Patients completed the survey as they waited to see their healthcare provider and returned completed surveys to a designated box located in the waiting room. All completed patient surveys were mailed to research staff by the MiCare site coordinator. Survey data were then entered into an electronic database for analysis. To recruit providers and staff, flyers were posted in clinic areas frequently visited by providers and staff (e.g., breakroom). An electronic email invitation with a link to the survey was sent to the family health clinic staff by the clinic MiCare site care coordinator. Providers and staff completed the electronic surveys at a time convenient for them. Data from providers and staff were then downloaded and cleaned for analysis. All surveys were anonymous and required approximately 5–10 min to complete. Because this was a quality improvement study, the study protocol was exempt from Institutional Review Board approval. Participants To be eligible to participate in the study, patients had to be age 18–65 yr and assigned to a primary care manager at the family health clinic located at any of the five selected Air Force MTFs. Providers and staff had to be assigned to one of the family health clinics located at the five selected MTFs. Measures We collected demographic data from patients, which included age and military duty status (active duty, dependent, or retired). For analytic purposes, age was categorized as 15–24 yr, 25–44 yr, 45–64 yr, and 65 yr and older. We also collected demographic data from providers and staff, which included military duty status (active duty, government service, or contract), duty title, years worked within a family health clinic, and years of experience in his/her specialty. For analytic purposes, military duty status was categorized as active duty or government services/contract; duty title was categorized as physician/physician assistant, nurse, and clinical technician; years worked within a family health clinic was categorized as less than one year, 2–4 yr, and 5 or more years; and years of experience in his/her specialty was categorized as less than one year, 2–4 yr, and 5 or more years. We collected preferences for patient–provider communication modalities by asking patients, providers, and staff their preferences for receiving/giving information related to: non-urgent medical questions, test results, pre-procedure instructions, treatment instructions, appointment notifications, medication renewal information, medication information in general, how to use medications, change in prescriptions, and follow-up appointments. Response options included “speak in person”, “telephone message”, “speak on phone”, “online MiCare”, “official U.S. mail”, or “not applicable”. For analytic purposes, responses were categorized as in-person, telephone, or online MiCare. In addition to those that responded not applicable, those that responded official U.S. mail were excluded from the analyses due to having a low response rate. We collected patients’ satisfaction with MiCare by asking patients their level of agreement with 10 statements related to their communication with their provider, quality of healthcare, and overall well-being as a result of using MiCare. Examples of statements include, “MiCare has improved communication with my provider” and “MiCare has improved the quality of care I receive”. Response options were on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree” plus “not applicable, not registered”. We collected providers’ and staff’s satisfaction with MiCare by asking providers and staff their level of agreement with nine statements related to their communication with patients, quality of care they deliver, and workload as a result of using MiCare. Examples of statements include, “MiCare has improved communication with patients” and “MiCare has improved my efficiency.” Response options were on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree” plus “not applicable, not registered”. For analytic purposes, responses were categorized as “strongly agree/somewhat agree”, “strongly disagree/somewhat disagree”, and “undecided” for patients, providers, and staff. Those that responded “not applicable, not registered” were excluded from the analyses. Analysis We first computed descriptive characteristics of the sample and conducted chi-square analyses to identify differences in preferences for communication modality by patient, provider, and staff demographics. We used Fisher’s exact test in cases where expected cell count values were less than five. We then combined providers and staff responses and conducted chi-square analyses to assess differences in communication preferences by patients and providers/staff. p-Values of 0.05 or less were considered statistically significant. We also calculated the frequency of satisfaction responses for both patients and providers. We conducted all analyses using SPSS software (Version 18, IBM Corporation, Armonk, NY, USA). RESULTS Table I presents the descriptive characteristics of the sample. As shown, most patient participants were 25 yr old or older, and on active duty status. Most provider participants were on active duty status, and clinical technicians. About 37% of providers had worked in a family health clinic for 1 yr or less and 34% had 2–4 yr of experience in his/her specialty. Table I. Participant Characteristics n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) Note. N’s are different because of missing values Table I. Participant Characteristics n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) n (%) Patients  Age (yr) (N = 1060)   15–24 174 (16.4)   25–44 495 (46.7)   45–64 367 (34.6)   65 and above 24 (1.9)  Military status (N = 1153)   Active duty 582 (46.2)   Dependent 282 (22.4)   Retired 288 (22.9) Providers and staff  Military status (N = 65)   Active duty 49 (70.0)   Government service 15 (21.4)   Contract 1 (1.4)  Duty title (N = 56)   Physician or physician assistant 7 (12.5)   Nurse 13 (23.2)   Clinical technician 36 (64.2)  Years worked in family health clinic (N = 59)   ≤1 26 (44.1)   2–4 yr 23 (39.0)   5+ years 10 (16.9)  Years of experience in specialty (N = 62)   ≤1 9 (14.5)   2–4 yr 24 (38.7)   5+ years 29 (46.8) Note. N’s are different because of missing values Table II presents the distribution for preferences of communication modality by patient demographics. Preferences for communication modality differed by age across all health topics. A higher proportion of patients aged 15–24 yr reported preferring to receive responses to non-urgent medical questions (57.1%), test results (47.8%), medication renewal information (56.8%), and schedule follow-up appointments (55.3%) via telephone than older patients. A higher proportion of patients aged 65 and older reported preferring to receive pre-procedure instructions (52.4%), treatment instructions (63.9%), instructions on how to use medication (56.5%), and notification of a change in prescription (54.5%) in-person than younger patients. Finally, a slightly higher proportion of patients aged 45–64 yr reported preferring to receive general medication information online through MiCare (44.2%) than younger and older patients. Table II. Preferred Communication Modality by Patient Demographics Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** *p ≤ 0.001; **p ≤ 0.01; ***p < 0.05. Table II. Preferred Communication Modality by Patient Demographics Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** Age (years) Military Status 15–24 25–44 45–64 65 and above Active Duty Retired Dependent n (%) n (%) n (%) n (%) n (%) n (%) n (%) Receive responses to non-urgent medical questions  Telephone 93 (57.1)* 201 (44.2)* 126 (37.3)* 8 (40.0)* 260 (48.1) 103 (40.1) 113 (43.6)  In Person 33 (20.2)* 60 (13.2)* 57 (16.9)* 4 (20.0)* 83 (15.3) 42 (16.3) 37 (14.3)  Online MiCare 37 (22.7)* 194 (42.6)* 155 (48.9)* 8 (40.0)* 198 (36.6) 112 (43.6) 109 (42.1) Receive test results  Telephone 75 (47.8)* 196 (43.0)* 118 (35.2)* 6 (30.0)* 231 (43.3)* 93 (36.5)* 110 (42.8)*  In Person 55 (35.0)* 104 (22.8)* 72 (21.5)* 5 (25.0)* 150 (28.1)* 51 (20.0)* 56 (21.8)*  Online MiCare 27 (17.2)* 156 (34.2)* 145 (43.3)* 9 (45.0)* 152 (28.5)* 111 (43.5)* 91 (35.4)* Receive pre-procedure instructions  Telephone 60 (37.5)* 155 (34.3)* 107 (32.3)* 6 (28.6)* 182 (34.5)*** 94 (35.7)*** 85 (32.3)***  In Person 76 (47.5)* 166 (36.7)* 113 (34.1)* 11 (52.4)* 223 (42.3)*** 84 (31.9)*** 95 (37.4)***  Online MiCare 24 (15.0)* 131 (29.0)* 111 (33.5)* 4 (19.0)* 122 (23.1)*** 85 (32.3)*** 77 (30.3)*** Receive treatment instructions  Telephone 53 (33.3)* 130 (28.7)* 104 (30.8)* 4 (18.2)* 159 (29.6)** 86 (33.1)** 75 (29.1)**  In Person 86 (54.1)* 210 (46.4)* 130 (38.5)* 14 (63.9)* 272 (50.6)** 98 (37.7)** 112 (43.4)**  Online MiCare 20 (12.6)* 113 (24.9)* 104 (30.8)* 4 (18.2)* 107 (19.9)** 76 (29.2)** 71 (27.5)** Receive appointment notification  Telephone 125 (78.1)* 323 (69.3)* 197 (57.6)* 10 (45.5)* 387 (70.9)*** 162 (60.7)*** 167 (63.7)***  In Person 14 (8.8)* 24 (5.2)* 24 (7.0)* 7 (31.8)* 36 (6.6)*** 16 (6.0)*** 20 (7.6)***  Online MiCare 21 (13.1)* 119 (25.5)* 121 (35.4)* 5 (22.7)* 123 (22.5)*** 89 (33.3)*** 75 (28.6)*** Receive medication renewal information  Telephone 88 (56.8)* 208 (46.2)* 125 (37.3)* 5 (23.8)* 267 (50.4)*** 109 (41.8)*** 97 (38.3)***  In Person 32 (20.6)* 42 (9.3)* 44 (13.3)* 9 (42.9)* 67 (12.6)*** 32 (12.3)*** 38 (15.0)***  Online MiCare 35 (22.6)* 200 (44.4)* 166 (49.6)* 7 (33.3)* 196 (37.0)*** 120 (46.0)*** 118 (46.6)*** Receive general medication information  Telephone 67 (42.1)* 171 (37.3)* 124 (37.6)* 8 (38.1)* 208 (38.7) 101 (39.5) 95 (37.1)  In Person 55 (34.6)* 92 (20.0)* 60 (18.2)* 6 (28.6)* 129 (24.0) 47 (18.4) 62 (24.2)  Online MiCare 37 (23.3)* 196 (42.7)* 146 (44.2)* 7 (33.3)* 201 (37.4) 101 (42.2) 99 (38.7) Receive instructions on how to use (take) medications  Telephone 50 (31.8)* 129 (28.4)* 85 (25.8)* 4 (17.4)* 159 (29.6) 70 (27.2) 64 (24.9)  In Person 76 (48.4)* 144 (31.7)* 109 (33.0)* 13 (56.5)* 202 (37.5) 86 (33.6) 96 (37.4)  Online MiCare 31 (19.7)* 181 (39.9)* 136 (41.2)* 6 (26.1)* 177 (32.9) 100 (39.1) 97 (37.7) Notification of a change in prescription  Telephone 81 (50.9)* 180 (39.6)* 105 (31.9)* 6 (27.3)* 215 (39.7) 88 (34.4) 99 (39.0)  In Person 59 (37.1)* 148 (32.6)* 114 (34.7)* 12 (54.5)* 194 (35.9) 92 (35.9) 89 (35.0)  Online MiCare 19 (11.9)* 126 (27.8)* 110 (33.4)* 4 (18.2)* 132 (24.4) 76 (29.7) 66 (26.0) Schedule a follow-up appointment  Telephone 89 (55.3)* 223 (48.2)* 148 (44.2)* 6 (27.3)* 269 (49.0)** 125 (49.0)** 113 (44.0)**  In Person 48 (29.8)* 101 (21.8)* 62 (18.5)* 8 (36.4)* 141 (25.7)** 46 (17.5)** 61 (23.7)**  Online MiCare 24 (14.9)* 1339 (30.0)* 125 (37.3)* 8 (36.4)* 139 (25.3)** 92 (35.0)** 83 (32.3)** *p ≤ 0.001; **p ≤ 0.01; ***p < 0.05. Patients’ preferences for communication modality differed by military duty status for six health topics (Table II). A higher proportion of Active Duty military personnel reported preferring to receive appointment notifications (70.9%), medication renewal information (50.4%), and schedule a follow-up appointment (49.0%) through the telephone than retired military personnel and dependents. A higher proportion of Active Duty military personnel also reported preferring to receive pre-procedure instructions (42.3%) and treatment instructions (50.6%) in-person than retired military personnel and dependents. However, a higher proportion of retired patients preferred to receive test results online through MiCare (43.5%) than active duty and dependents. Table III presents the distribution of communication preferences by provider and staff demographics. A higher proportion of physicians and physician assistants reported preferring to provide treatment instructions (83.3%) in-person than other providers and staff. Additionally, a higher proportion of providers and staff that had 2-4 years of experience in his/her specialty preferred to provide appointment notifications online through MiCare (81.0%) than providers and staff with less or more experience. Preferences for communication modality did not differ by military duty status or years worked in a family health clinic for any health topic. Table III. Preferred Communication Modality by Provider and Staff Demographics Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) *p < 0.05. Table III. Preferred Communication Modality by Provider and Staff Demographics Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) Duty Title Military Status Years worked in Family Health Clinic Years of Experience in Specialty Physician or Physician Assistant Nurse Clinical Technician Active Duty Gov’t Service ≤1 2–4 5+ ≤ 1 2–4 5+ n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Provide responses to non-urgent medical questions  Telephone 0 (0.0) 2 (15.4) 3 (9.4) 5 (11.4) 3 (27.3) 4 (17.4) 1 (4.3) 2 (28.6) 2 (25.0) 2 (8.7) 3 (12.0)  In Person 0 (0.0) 0 (0.0) 3 (9.4) 3 (6.8) 1 (9.1) 3 (13.0) 1(4.3) 0 (0.0) 0 (0.0) 0 (0.0) 4 (16.0)  Online MiCare 6 (100.0) 11 (84.6) 26 (81.3) 36 (81.8) 7 (63.6) 16 (69.6) 21 (91.3) 5 (71.4) 6 (75.0) 21 (91.3) 18 (72.0) Provide test results  Telephone 0 (0.0) 3 (23.1) 10 (38.5) 13 (35.1) 2 (18.2) 7 (38.9) 4 (21.1) 2 (25.0) 3 (50.0) 5 (25.0) 5 (27.7)  In Person 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (9.1) 0 (0.0) 1 (5.3) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.5)  Online MiCare 7 (100.0) 10 (76.9) 16 (61.5) 24 (64.9) 8 (72.7) 11 (61.1) 14 (73.7) 7 (75.0) 3 (50.0) 15 (75.0) 16 (72.7) Provide pre-procedure instructions  Telephone 0 (0.0) 7 (58.3) 6 (30.0) 9 (30.0) 6 (60.0) 7 (43.8) 4 (25.0) 1 (20.0) 2 (33.3) 8 (42.1) 5 (33.3)  In Person 3 (75.0) 2 (16.7) 8 (40.0) 12 (40.0) 1 (10.0) 6 (37.5) 7 (43.8) 1 (20.0) 3 (50.0) 4 (21.1) 7 (46.7)  Online MiCare 1 (25.0) 3 (25.0) 6 (30.0) 9 (30.0) 3 (30.0) 3 (18.8) 5 (31.3) 3 (60.0) 1 (16.7) 7 (36.8) 3 (20.0) Provide treatment instructions  Telephone 0 (0.0)* 7 (58.3)* 6 (28.6)* 10 (30.3) 6 (60.0) 7 (38.9) 4 (25.0) 2 (33.3) 2 (28.6) 8 (42.1) 5 (29.4)  In Person 5 (83.3)* 1 (8.3)* 11 (52.1)* 14 (42.4) 3 (30.0) 9 (50.0) 7 (43.8) 1 (16.7) 4 (57.1) 6 (31.6) 8 (47.1)  Online MiCare 1 (16.7)* 4 (33.3)* 4 (19.0)* 9 (27.3) 1 (10.0) 2 (11.1) 5 (31.3) 3 (50.0) 1 (14.3) 5 (26.3) 4 (23.5) Provide appointment notification  Telephone 1 (14.3) 2 (16.7) 11 (33.3) 12 (26.7) 2 (20.0) 6 (27.3) 5 (22.7) 2 (28.6) 5 (55.6)* 4 (19.0)* 5 (20.8)*  In Person 0 (0.0) 0 (0.0) 4 (12.1) 4 (8.9) 0 (0.0) 4 (18.2) 0 (0.0) 0 (0.0) 2 (22.2)* 0 (0.0)* 2 (8.3)*  Online MiCare 6 (85.7) 10 (83.3) 18 (54.5) 29 (64.4) 8 (80.0) 12 (54.5) 17 (77.3) 5 (71.4) 2 (22.2)* 17 (81.0)* 17 (70.8)* Provide medication renewal information  Telephone 1 (14.3) 1 (8.3) 5 (27.8) 7 (23.3) 4 (30.8) 5 (35.7) 3 (18.8) 1 (12.5) 2 (66.7) 2 (11.8) 5 (23.8)  In Person 0 (0.0) 0 (0.0) 2 (11.1) 2 (6.7) 0 (0.0) 0 (0.0) 2 (12.5) 0 (0.0) 0 (0.0) 2 (11.8) 0 (0.0)  Online MiCare 6 (85.7) 11 (91.7) 11 (61.1) 21 (70.0) 9 (69.2) 9 (64.3) 11 (68.8) 7 (87.5) 1 (33.3) 13 (76.5) 16 (76.2) Provide general medication info  Telephone 1 (14.3) 3 (23.1) 6 (26.1) 7 (20.6) 5 (38.5) 6 (33.3) 3 (16.7) 0 (0.0) 3 (42.9) 5 (27.8) 3 (13.6)  In Person 1 (14.3) 1 (7.7) 3 (13.0) 4 (11.8) 2 (15.4) 2 (11.1) 2 (11.1) 2 (25.0) 1 (14.3) 1 (5.6) 4 (18.2)  Online MiCare 5 (71.4) 9 (69.2) 14 (60.9) 23 (67.6) 6 (46.2) 10 (55.6) 13 (72.2) 6 (75.0) 3 (42.9) 12 (66.7) 15 (68.2) Provide instructions on how to use (take) medications  Telephone 2 (28.6) 4 (33.3) 3 (21.4) 6 (23.1) 6 (50.0) 6 (40.0) 2 (15.4) 1 (14.3) 3 (50.0) 5 (31.3) 3 (18.8)  In Person 1 (14.3) 1 (8.3) 8 (57.1) 8 (30.8) 2 (16.7) 5 (33.3) 4 (30.8) 2 (28.6) 3 (50.0) 3 (18.8) 6 (37.5)  Online MiCare 4 (57.1) 7 (58.3) 3 (21.4) 12 (46.2) 4 (33.3) 4 (26.7) 7 (53.8) 4 (57.1) 0 (0.0) 8 (50.0) 7 (43.8) Notification of a change in prescription  Telephone 1 (14.3) 4 (33.3) 3 (23.1) 4 (15.4) 5 (45.5) 2 (14.3) 3 (23.1) 1 (16.7) 1 (20.0) 4 (26.7) 3 (18.8)  In Person 3 (42.9) 4 (33.3) 7 (53.8) 14 (53.8) 2 (18.2) 8 (57.1) 6 (46.2) 2 (33.3) 4 (80.0) 6 (40.0) 7 (43.8)  Online MiCare 3 (42.9) 4 (33.3) 3 (23.1) 8 (30.8) 4 (36.4) 4 (28.6) 4 (30.8) 3 (50.0) 0 (0.0) 5 (33.3) 6 (37.5) Schedule a follow-up appointment  Telephone 1 (14.3) 3 (25.0) 9 (26.5) 10 (21.7) 5 (38.5) 9 (36.0) 3 (13.6) 1 (12.5) 3 (33.3) 8 (34.8) 4 (16.0)  In Person 3 (42.9) 0 (0.0) 9 (26.5) 12 (26.1) 1 (7.7) 7 (28.0) 5 (22.7) 0 (0.0) 4 (44.4) 3 (13.0) 5 (20.0)  Online MiCare 3 (42.9) 9 (75.0) 16 (47.1) 24 (52.2) 7 (53.8) 9 (36.0) 14 (63.6) 7 (87.5) 2 (22.2) 12 (52.2) 16 (64.0) *p < 0.05. Preferences for communication modality by patient, providers, and staff are presented in Table IV. While a high proportion of patients reported preferring to receive responses to non-urgent medical questions (41.8%), receive test results (38.1%), receive appointment notifications (62.1%), receive medication renewal information (41.5%), and schedule a follow-up appointment (43.5%) through the telephone, a higher proportion of providers and staff reported preferring to accomplish these tasks online through MiCare than patients. Table IV. Differences in Preferred Communication Modality by Patients and Providers/Staff Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* *p < 0.05. Table IV. Differences in Preferred Communication Modality by Patients and Providers/Staff Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* Patients Providers/Staff n (%) n (%) Responses to non-urgent medical questions  Telephone 526 (41.8)* 9 (12.9)*  In Person 186 (14.8)* 5 (7.1)*  Online MiCare 439 (34.8)* 47 (67.1)* Receive/provide test results  Telephone 480 (38.1)* 11 (15.7)*  In Person 288 (22.9)* 2 (2.9)*  Online MiCare 373 (29.6)* 36 (51.4)* Receive/provide pre-procedure instructions  Telephone 389 (30.9) 16 (22.9)  In Person 449 (35.6) 16 (22.9)  Online MiCare 297 (23.6) 12 (17.1) Receive/provide treatment instructions  Telephone 351 (27.8) 16 (22.9)  In Person 536 (42.5) 21 (30.0)  Online MiCare 265 (21.0) 10 (14.3) Receive/provide appointment notification  Telephone 780 (62.1)* 17 (24.3)*  In Person 84 (6.7)* 5 (7.1)*  Online MiCare 303 (24.0)* 37 (52.9)* Receive/provide medication renewal information  Telephone 523 (41.5)* 12 (17.1)*  In Person 153 (12.1)* 3 (4.3)*  Online MiCare 453 (36.0)* 31 (44.3)* Receive/provide general medication info  Telephone 441 (35.0)* 14 (20.0)*  In Person 264 (21.0)* 7 (10.0)*  Online MiCare 425 (33.7)* 31 (44.3)* Receive/provide instructions on how to use (take) medications  Telephone 321 (25.5) 12 (17.1)  In Person 419 (33.3) 14 (20.0)  Online MiCare 387 (30.7) 16 (22.9) Notification of a change in prescription  Telephone 435 (34.5) 9 (12.9)  In Person 409 (32.5) 19 (27.1)  Online MiCare 284 (22.5) 12 (17.1) Scheduling a follow-up appointment  Telephone 548 (43.5)* 17 (24.3)*  In Person 270 (21.4)* 14 (20.0)*  Online MiCare 328 (26.0)* 31 (44.3)* *p < 0.05. Patients’ and providers’ satisfaction with MiCare is presented in Table V. Over half of the patients surveyed strongly agreed or agreed somewhat that MiCare had improved: their communication with their provider (57.5%), communication with their assigned healthcare primary care team (57.9%), access to care (55.9%), and the healthcare information they received (55.3%). The majority of patients also agreed that MiCare was easy to use (68.1%) and 59.0% agreed that MiCare offered the functions they need to manage their personal healthcare. Most patients surveyed also agreed that they were satisfied with the timeliness of MiCare responses to their concerns (61.2%). However, a similar proportion of patients who agreed, were undecided if MiCare improved the quality of care they received (48.2% vs. 40.3%), their overall well-being and quality of life (40.3% vs. 44.9%), and their ability to receive medication renewals (44.7% vs. 43.3%), respectively. Table V. Satisfaction with MiCare by Patients and Providers/Staff Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) aResponse options included strongly agree and somewhat agree. bResponse options included strongly disagree and somewhat disagree. Table V. Satisfaction with MiCare by Patients and Providers/Staff Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) Agreea Disagreeb Undecided n (%) n (%) n (%) Patients  Micare has improved communication with my provider 593 (57.5) 121 (11.7) 317 (16.2)  Micare has improved communication with my assigned healthcare primary care management team 600 (57.9) 119 (11.5) 318 (30.7)  I am satisfied with the timeliness of Micare responses to my concerns 636 (61.2) 116 (11.2) 286 (27.6)  Micare has improved the quality of care I receive 496 (48.2) 118 (11.5) 415 (40.3)  I believe Micare use has improved my overall well-being and quality of life 415 (40.3) 153 (14.9) 462 (44.9)  Micare has improved my ability to receive medication renewals 442 (44.7) 118 (11.9) 428 (43.3)  Micare has improved my access to care 576 (55.9) 130 (12.6) 325 (31.5)  Micare has improved the healthcare information I receive 560 (55.3) 108 (10.7) 344 (34.0)  Micare is easy to use 688 (68.1) 126 (12.5) 196 (19.4)  Micare offers the functions I need to manage my personal healthcare 587 (59.0) 101 (10.2) 306 (30.8) Providers/Staff  MiCare has improved my efficiency 40 (58.0) 15 (21.7) 12 (17.4)  MiCare has improved the efficiency of my team 38 (55.9) 16 (23.5) 10 (14.7)  MiCare has improved the quality of care that I deliver 31 (48.4) 10 (15.6) 23 (35.9)  MiCare has improved communication with patients 47 (72.3) 10 (15.4) 8 (12.3)  MiCare has improved my available time during the duty day 24 (36.9) 25 (38.5) 16 (24.6)  Micare has increased my workload 44 (65.7) 10 (14.9) 13 (19.4)  MiCare is easy to use 52 (75.4) 7 (10.1) 8 (11.6)  MiCare offers the functions I need to provide quality healthcare 43 (66.2) 8 (12.3) 14 (21.5)  MiCare use gives me more control in addressing my patients’ concerns 35 (61.4) 3 (5.3) 19 (33.3) aResponse options included strongly agree and somewhat agree. bResponse options included strongly disagree and somewhat disagree. Over half of the providers and staff strongly agreed or agreed somewhat that MiCare improved their efficiency (58.0%), efficiency of his/her team (55.9%), and communication with patients (72.3%). The majority of providers also agreed that MiCare was easy to use (75.4%), offered functions that they need to provide quality healthcare (66.2%), and gave them more control in addressing patients’ concerns (61.4%). However, less than half of the providers agreed that MiCare had improved the quality of care that they delivered (48.4%). Additionally, the majority of providers agreed that MiCare had increased their workload (65.7%) and a similar proportion of providers that agreed, disagreed that MiCare improved their available time during the duty day (36.9% vs. 38.5%). DISCUSSION This study assessed patients’, providers’, and staff’s preferences for communication modalities for various healthcare topics. We also assessed their satisfaction with the U.S. Air Force’s web-based SM system, MiCare. Communication preferences significantly differed by various patient and provider/staff demographics including age, military status, duty title, and years of experience in specialty. In general, we found that most patients preferred to address many healthcare concerns, such as responding to non-urgent medical questions and receiving test results, through the telephone while most providers and staff preferred to address these issues online through MiCare. This finding is consistent with similar previous studies that have found civilian patients prefer to receive health information in-person or through the telephone rather than online.21–23 Limited internet access,21 previous negative experiences using SM,4 concerns about burdening his/her provider,4 lack of provider endorsement,4 and limited health literacy22 may influence patients’ preferences for communication modalities. One previous study found that the most important consideration for patients when selecting a communication modality was speed of communication; nearly 52% of patients desired a communication method that was rapid.23 Research is needed to identify the factors that may influence patients’ communication preferences specifically within the military healthcare system. Over half of the patients surveyed believed MiCare improved communication with their providers and primary care teams, access to care, and healthcare information they received. Additionally, most of the patients were satisfied with the timeliness of MiCare responses. These satisfaction rates are similar to rates in previous patient satisfaction studies with similar SM systems.24–27 However, in this study, a large proportion of patients were undecided about MiCare’s impact on the quality of care they received, overall well-being and quality of life, and ability to receive medication renewals. Previous studies have found patient satisfaction with SM increases as SM use increases.26 Therefore, it could be plausible that the patients in this study did not use MiCare for very long or used it infrequently, and thus, have lower satisfaction rates for some of these topics. Nevertheless, these findings indicate some quality improvements can be made to MiCare’s implementation, particularly with medication renewals. Less than half of the providers and staff agreed that MiCare had improved the quality of care that they delivered, and the majority of providers believed that MiCare had increased their workload. Additionally, over one-third of providers and staff did not believe MiCare improved their available time during the duty day. These findings are consistent with previous studies that have found SM systems increases provider workload.8,10 This increase in workload may be due to message volume, ambiguity of messages sent by patients, and inappropriate use of SM by patients.8 However, although there may be increases in workload, over half of the providers and staff in this study believed MiCare improved their efficiency, their team’s efficiency, and communication with patients, which is consistent with previous studies.8,10 Thus, MiCare is a promising communication tool for providers and staff and future studies should be conducted to identify strategies to reduce providers’ and staff’s workload as a result of using MiCare. Although this study is among the first studies to assess patients’ and providers’ preferences for communication within a military healthcare setting, there are some limitations that must be considered. First, the convenience sample consisted of only patients, providers, and staff from five family health clinics; thus, the findings may not be generalized to patients and providers attending other clinics or MTFs across the USA. Second, our sample size of providers and staff was small; however, the sample size is consistent with previous studies assessing barriers and facilitators to SM among healthcare providers.8,28,29 Finally, we did not assess factors that may influence patients’ preferences for communication such as their internet access, health literacy, or frequency of MiCare use. Future studies should consider these factors when assessing patients’ communication preferences and satisfaction with MiCare. CONCLUSION This study’s findings indicate that while providers and staff prefer to communicate with patients about various healthcare concerns online through MiCare, patients prefer to communicate in-person or through the telephone. Although a large proportion of patients were generally satisfied with MiCare, there was a large proportion of patients who were undecided if MiCare improved the quality of care they received. Additionally, the majority of providers and staff believed MiCare improved their efficiency; however, many providers and staff believed MiCare had increased their workload. Previous studies have shown SM can have meaningful effects on quality of care when implemented as part of a larger comprehensive patient management system,14 and the majority of patients, providers, and staff in this study believed MiCare improved their patient–provider communication. Thus, MiCare continues to be a promising tool to improve patient–provider communication. However, future studies are needed to better understand why patients within the military healthcare system prefer communication modalities other than MiCare and to identify strategies to decrease provider and staff workloads while using MiCare. Acknowledgements The authors would like to thank the site coordinators who helped with data collection and the patients, providers, and staff who participated in this study. Previous Presentations A portion of the findings from this manuscript have been presented at the TriService Nursing Research Program (TSNRP) Research and Evidence-Based Practice Dissemination Course (2017) as a poster presentation: Garnder, C.L. (2017). Patient to Health Team Communication Preferences and Perceptions of Secure Messaging. Presented at the TSNRP Research and Evidence-based Practice Dissemination Course. Ellicott City, MD. REFERENCES 1 Ford EW , Hesse BW , Huerta TR : Personal health record use in the united states: Forecasting future adoption levels . J Med Internet Res 2016 ; 18 ( 3 ): e73 . Google Scholar CrossRef Search ADS PubMed 2 Shenson JA , Cronin RM , Davis SE , Chen Q , Jackson GP : Rapid growth in surgeons’ use of secure messaging in a patient portal . 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Available at http://www.airforcemedicine.af.mil/MiCare/; accessed October 13, 2017. 21 Graetz I , Gordon N , Fung V , Hamity C , Reed ME : The digital divide and patient portals: Internet access explained differences in patient portal use for secure messaging by age, race, and income . Med Care 2016 ; 54 ( 8 ): 772 – 9 . Google Scholar CrossRef Search ADS PubMed 22 Tieu L , Sarkar U , Schillinger D , et al. : Barriers and facilitators to online portal use among patients and caregivers in a safety net health care system: a qualitative study . J Med Internet Res 2015 ; 17 ( 12 ): e275 . Google Scholar CrossRef Search ADS PubMed 23 Choudhry A , Hong J , Chong K , et al. : Patients’ preferences for biopsy result notification in an era of electronic messaging methods . JAMA Dermatol 2015 ; 151 ( 5 ): 513 – 21 . 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Google Scholar CrossRef Search ADS PubMed 28 Fix GM , Hogan TP , Amante DJ , McInnes DK , Nazi KM , Simon SR : Encouraging patient portal use in the patient-centered medical home: three stakeholder perspectives . J Med Internet Res 2016 ; 18 ( 11 ): e308 . Google Scholar CrossRef Search ADS PubMed 29 Klein DM , Fix GM , Hogan TP , Simon SR , Nazi KM , Turvey CL : Use of the blue button online tool for sharing health information: Qualitative interviews with patients and providers . J Med Internet Res 2015 ; 17 ( 8 ): e199 . Google Scholar CrossRef Search ADS PubMed Author notes The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Air Force, U.S. Department of Defense, or the U.S. Government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Military MedicineOxford University Press

Published: May 8, 2018

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