Barriers and Enablers to Asynchronous Secure Messaging Use in Hospital-Based Ambulatory Specialty Clinics in Ontario, Canada: Convergent Mixed Methods Study.

Background: The COVID-19 pandemic accelerated the adoption of virtual care, including patient-to-provider asynchronous secure messaging (ASM). However, while ASM offers access and convenience, the surge in message volume can increase physician workload and contribute to burnout. Furthermore, it has raised additional concerns about message appropriateness, medicolegal liability, and sustainability of this communication virtual care modality. Objective: This study aims to explore the experience with ASM in Ontario in specialty ambulatory care to inform current practice support strategies. We sought to characterize messaging usage quantitatively while also exploring experience with messaging, contextual barriers, and facilitators qualitatively. Methods: We used a convergent mixed methods design, analyzing aggregated electronic health record (EHR) usage and qualitative interview data. The study was conducted at a large ambulatory care hospital in Ontario, Canada, across four high-messaging specialty clinics: mental health, rheumatology, dermatology, and surgery. Quantitative data (October 2019 to Octtober 2022) included message volumes, response patterns, and timing. Semistructured interviews with physicians, nurses, administrative staff, and patients (n=19), conducted in 2022 explored ASM workflows, barriers, and facilitators. Quantitative data were analyzed descriptively, stratified by clinic. Qualitative data were analyzed using thematic analysis, informed by an interpretative phenomenological orientation. Findings from the two strands were then compared to identify areas of convergence and divergence. Results: Message volumes surged post pandemic, particularly in mental health, ranging from about 6000 in surgery, rheumatology, and dermatology to close to 13,000 messages in mental health across the study period. Message rate per patient per month was 0.6 (SD 0.2; mental health), 0.5 (SD 0.2; rheumatology), 0.2 (SD 0.2; dermatology), and 0.2 (SD 0.1; surgery). Physicians averaged 12.6 (SD 8.0) messages/month (rheumatology) and 7.6 (SD 4.4) messages/month (mental health) in clinics without nursing support. Nurses handled 27.4 (SD 11.6) messages/month (surgery) and 19.2 (SD 14.1) messages/month (dermatology). Three percent (1263/38,370) to 10% (3619/36,022) of provider messages were sent outside regular hours. The majority of conversations (2156/6859, 46% to 6913/13,615, 62%) had only a single reply. Physicians reported challenging experiences due to increased workload, lack of compensation, and poor integration into local clinical workflows. High patient-to-physician ratios and limited nursing support for message triage were associated with a poor messaging experience. Patients and administrative staff valued messaging for its convenience, accessibility, and efficiency. A key finding was insufficient engagement across all user groups in decisions about messaging implementation. Conclusions: The study highlights a disconnect between the high perceived value of ASM for patients and administrative staff and the challenging experiences of physicians. Successful implementation requires thoughtful integration into care models, clear guidelines for appropriate use, and proper triage and "channel management" to guide patients to appropriate modalities. Future research should explore triaging algorithms as part of a digital front door, specialty-specific variations, and the crucial role of nursing staff in message channel management.