Abstract
Purpose:
To investigate the trend of patient portal use in the general population and the barriers to adoption.
Participants:
We analyzed 3 iterations of the Health Information National Trends Survey (HINTS) collected in 2014, 2017, and 2018.
Measures:
Patient portal use, high-speed Internet access, data safety confidence, prior experience of online patient provider communication (OPPC), and demographic variables.
Analysis:
Logistic regression analyses were conducted separately for the 3 iterations of HINTS.
Results:
The use of patient portals increased from 25.6% in 2014 to 30.5% in 2017, and 31.4% in 2018. These users were more likely to be white female with higher levels of education or income. Meanwhile, high-speed Internet access, prior experience of OPPC, and data safety confidence were positive predictors of patient portal use in all 3 iterations.
Conclusion:
The use of patient portals in the general public remains low and a significant digital divide persists, presenting a major challenge on meaningful use of electronic health record. We call for more effective interventions to address these gaps. Such interventions should target people of low socioeconomic status and focus on improving eHealth literacy and patients’ confidence in data safety.
Introduction
Use of patient portals of electronic health records (EHR) offers the benefits of reducing medical costs, increasing access, and improving health-care quality. 1 The 2009 Health Information Technology for Economic and Clinical Health Act mandated use of EHR in all health-care organizations and meaningful use of EHR, especially the use of patient portals. 2 Under this legislature, by 2014, most hospitals and clinics have adopted EHR and given their patients access to their patient portals, 3 which allows patients to make appointments, view and download their testing reports, and communicate with their providers via online secure messaging. 2 However, it’s unclear the use of patient portals has increased along with the fast evolution of “internet of things” and nationwide adoption of EHR and what factors might influence the adoption.
A key factor that influences technology adoption is digital divide, which is defined as uneven distribution in the access to, use of, or impact of information technologies between demographics and regions. 4 To date, only a handful of studies have investigated the gaps related to patient portal use. The existing studies suggested that people with higher level of socioeconomic status (SES) were more likely to use patient portals. The barriers to adoption also include a low level of health literacy, negative experiences with the EHR, and concerns over data safety. 5 The current literature on patient portal use is limited in 2 aspects. One, most studies were based on convenient samples from a hospital or community with limited insights from national samples and trend analysis. And 2, a few studies based on national samples have studied broader use of electronic personal health records without a focus on patient portal use. 6,7
To address the above literature gaps, we used national survey data to investigate the use of patient portals in the general population. We aim to answer the following research questions: (1) What was the prevalence of patient portal use in the American adults from 2014 to 2018? (2) Has the digital divide been persistent in patient portal use? (3) What were the factors associated with patient portal use and how did these associations change over time?
Methods
Design and Sample
We analyzed the data from 3 iterations of the Health Information National Trends Survey (HINTS) collected in 2014, 2017, and 2018. The HINTS adopted the stratified sampling method to recruit participants, which is detailed at https://hints.cancer.gov/. The final sample size was 3677 in 2014, 3285 in 2017, and 3504 in 2018, respectively.
Measures
Patient portal use was measured by asking whether participants have accessed patient portals of EHR in the past 12 months (yes = 1 and no = 0).
High-speed Internet access was measured using 4 items (no = 0, yes = 1) on their Internet access through: (1) regular dial-up telephone line; (2) broadband; (3) cellular network, and (4) wireless network. Those who selected the latter 3 were considered as having high-speed Internet access.
Data safety confidence was measured by asking respondents to rate how confident they felt that safeguards were in place to protect their medical records from being seen by people without their permission. A 3-point Likert scale was used, ranging from 1 = not confident to 3 = very confident.
Prior experience of online patient provider communication (OPPC) was measured by asking respondents to identify their online communication tools with health-care providers, including e-mail, video conferencing, mobile apps, and social media. 8 Responses were dichotomous (no = 0, yes = 1) and added up to create one index for analysis.
Demographic variables included age, gender (0 = female, 1 = male), education (ranging from 1 = less than 8 years to 7 = postgraduate), race (1 = non-Hispanic white, 0 = others), and household income (ranging from 1 = less than $10 000 to 9 = $200 000 or more).
Analysis
First, descriptive analyses were run to demonstrate sample characteristics. Second, 3 separate logistic regression analyses were conducted for the 3 iterations of HINTS. In each model, patient portal use was the dependent variable, while demographics, Internet access, confidence in data safety, and prior experience of OPPC were independent variables.
Results
The average age of the participants at 3 assessments was around 55 years; about 60% were female; 65% had some college or above education; 51% to 62% were non-Hispanic white; a majority had an annual household income between $35 000 and $74 999. The proportion of population with high-speed Internet changed from 72.2% in 2014 to74.6% in 2017, and 76.3% in 2018. Most people had good confidence in data safety; the mean values of this measure (ranged 1-3) were 1.98, 1.95, and 2.17, respectively. The level of prior OPPC has increased over time, with index values changing from 0.31 to 0.52 and 0.55. Similarly, patient portal use has increased from 25.6% in 2014, to 30.5% in 2017, and to 31.4% in 2018.
As shown in Table 1, gender, income, education, and race were significant predictors over the years. Specifically, men, people with lower levels of education and income, and non-white were less likely to use patient portals. Race was a strong predictor in 2014 and 2017, but no longer significant in 2018. Likewise, in 2014, people aged 75 or older were less likely to use patient portals; but in 2017 and 2018, age became a nonsignificant predictor of patient portal use. Other significant factors associated with patient portal use were data safety confidence, high-speed Internet access, and prior OPPC. These factors were persistent over 3 assessment points.
Factors Associated With Patient Portal Use Among American Adults in 2014, 2017, and 2018.
Abbreviations: NH, non-Hispanic; OR, odds ratio; OPPC, online patient provider communication.
a P < .01.
b P < .001.
c P < .05.
Discussion
The current adoption rate of patient portals (31.4% in 2018) indicates that we are behind the scheduled meaningful use of EHR, despite wide accessibility of EHR in health-care organizations and ubiquitous Internet access.
The findings of the association of SES and patient portal use were consistent with literature on digital health divide. 9 We found that education and income were significant predictors of portal use over time; but the significant differences between age groups and racial groups observed in 2014 were no longer significant in 2018, suggesting narrower divides between racial groups and age groups. The narrowing digital divide between the oldest group (75 years or older) and the rest of the population might be attributed to wider adoption of Internet use among the older adults and growing efforts of senior-friendly eHealth programs. 10 The racial gaps observed in 2014 but diminished afterward might be due to the correlation between race and other SES factors such as education and income. On the other hand, gender gaps have increased over the same time period. In 2018, the probability for men to use patient portals was only 64% that of women after controlling for potential confounders. Such a big gender gap in patient portal use was not observed in other eHealth behaviors, 10 which merits further studies.
The data confirmed that high-speed Internet access was a significant predictor of patient portal use over time. As more health resources are available on patient portals, those without broadband access would potentially face aggravating health disparities. As advocated by American Medical Informatics Association, “broadband access is or will become a social determinant of health.” 11 Meanwhile, the high ownership rate of smartphones is transcending high-speed Internet access. The relationship between Internet access and patient portal use requires further examination in the coming years.
Prior experience of OPPC was also a significant predictor over time. Active communication with health-care providers was an indicator of patient trust and engagement, which were associated with portal use. 12 It is notable that OPPC in the American population has increased substantially over the years, 8 but patient portal use has remained lagging behind.
Our data also revealed that confidence in data safety was positively associated with patient portal use. Previous studies found that concern over data safety or privacy was the major barrier to using electronic personal health records. In fact, the past decade has witnessed rapid expansion of health information technology and skyrocketing number of data breach incidents, which might have eroded public confidence in data safety and restrained wider adoption of patient portals.
This study has the following major limitations. First, patient portal use was measured with a binary variable. It is ideal to measure how people use patient portals. Second, we only tested a small number of factors associated with patient portal use. Other factors at individual, community, health care, and societal levels might also be important. Third, the cross-sectional survey design prohibits causality interpretation of the data.
The current study represents one of the first efforts to investigate the trend of patient portal use in the general population after nationwide adoption of EHR in 2014. We found that adoption of patient portals remains low and a significant digital divide persists. To reduce the digital gap in patient portal use, we call for structural interventions to provide broadband access in low-income communities, culturally appropriate programs to promote eHealth literacy, and evidenced-based policies to enhance public confidence in data safety.
So What?
What is already known on this topic?
Use of patient portals is a critical component of meaningful use of electronic health records (EHR). However, we know little about the trend of American use of patient portals since nationwide adoption of EHR in 2014.
What does this article add?
By analyzing 3 waves of a national survey collected in 2014, 2017, and 2018, we found that patient portal use among the general American adults had increased slowly over 4 years with a persistent digital divide. Patient portal use was associated with higher level of socioeconomic status, high-speed Internet access, prior experience of communicating with providers online, and confidence in data safety.
What are the implications for health promotion practice and research?
Our study confirmed the persistent digital health divide in patient portal use. Health promotion practitioners should consider the limited access and use of digital health resources in the underserved populations in their practice and outreach. Our findings provide important data for health promotion researchers to design appropriate programs at community and policy levels to promote patient portal use.
Footnotes
Authors’ Note
Y.A.H. and S.J. contributed equally. Y.A.H. conceptualized the study, S.J. and P.L.L. analyzed the data, Y.A.H. and S.J. drafted the manuscript, all authors edited the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from Health Informatics Education Fund.
