Disparities in registration and use of an online patient portal among older adults: findings from the LitCog cohort

BACKGROUND AND SIGNIFICANCE

The adoption of electronic health records (EHRs) by hospitals and providers in the United States is rising.¹ This trend is likely to continue following the Health Information Technology for Economic and Clinical Health act, which authorized incentive payments to increase provider adoption and meaningful use of EHRs.² Patient portals are secure websites for patients, typically maintained by provider practices, that offer access to a variety of functions linked to a physician’s EHRs.³ Most patient portals offer similar basic functions, including the ability to view protected health information (e.g., lab results, medication lists, immunizations), refill prescription medications, schedule appointments, and send secure messages to providers.⁴ Evidence from randomized trials suggests patient portals can improve health outcomes and patient satisfaction,^5–8 but data have been inconsistent.⁴

Federal incentives for health systems and providers may not translate to increased, equitable adoption of patient portals by patients. Reports suggest ∼30–70% of eligible patients accept the offer of a patient portal.^9–12 The differential acceptance of this technology between population sub-groups may exacerbate disparities in health outcomes. Initial reports suggest low levels of use among socio-demographic sub-groups such as racial and ethnic minorities,^11,12 those with less education,^4,12 and older patients.^11,13,14 It is important to document these disparities as a first step toward preventing downstream effects on health and health care.

Older patients may be a particularly important group to study, as they are more likely to have chronic conditions, a factor which has been shown to increase uptake of patient portals.⁴ However, the usability of patient portals is a significant barrier,^9,15–18 and this may be a particular problem for older adults less familiar with information technology. National data suggests older adults are less likely to make use of online health information, including treatment and quality comparison tools, and advice about chronic conditions and disease prevention.¹⁹ Older adults are likely to be the most frequent users of healthcare, but objective portal usage data among this population group are lacking.

Health literacy is an additional risk factor that may explain lower uptake and use of patient portals. The Institute of Medicine defines the construct as the “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”²⁰ A study of diabetic patients reported no relationship between self-reported health literacy and accessing a patient portal,²¹ although a larger and more comprehensive report linked low self-reported health literacy with lower levels of patient portal registration, logins, and use of patient portal functions.²² However, people are typically poor judges of their own abilities,²³ and self-report literacy measures do not assess the same latent construct as objective health literacy assessments.²⁴ This is supported by the low to moderate correlation that is observed when comparing objective and subjective assessments.^25,26 Research documenting the association between objective health literacy assessments and patient portal use is needed to highlight potential disparities.

OBJECTIVE

Limited health literacy is more prevalent among older adults,²⁷ with a meta-analysis suggesting nearly 40% of adults aged over 50 have limited basic skills.²⁸ As patient portal adoption and use is inversely associated with age,^11,13,14 we investigated this topic further among a cohort of older adults who had completed objective health literacy assessments and were current patients in a health system offering patient portal access. In a two-step process using a sample of older adults, we aimed to establish whether socio-demographic factors and health literacy were associated with 1) registering for a patient portal account and 2) using the portal’s functions after registration.

METHODS

RESULTS

DISCUSSION

In this sample of older American adults recruited from an urban general internal medicine ambulatory care clinic, we linked cohort data to information available on patients’ registration and subsequent use of an online patient portal. Despite the majority of the cohort being offered the opportunity to register their patient portal, a little over half decided to complete this task. There were stark racial, health literacy, and educational disparities in patient portal registration, even after adjustment in multivariable models. For example, 22% of patients with limited health literacy registered their patient portal accounts compared with 73% of those with adequate health literacy skills. A similar magnitude of difference was observed between races and educational levels. In contrast to existing research among the general adult population, in this sample of older adults healthier patients were more likely to have registered their patient portal than those reporting chronic conditions.⁴

There were fewer disparities in the use of the patient portal’s functions, but some observations have important clinical consequences. Highly educated patients were consistently more likely to use the patient portal for prescription refill requests. Alternative methods are available, but they can be more time consuming for the patient and cannot be used when the clinic is closed. The more frequent use of this function by more educated patients may facilitate more timely prescription renewal, resulting in disparities in medication adherence.^33,34 For example, in a large observation cohort of diabetic patients, nonuse of the refill function on an online patient portal was associated with poorer adherence to statins.³⁵

An equally concerning observation was that White patients were over 10 times more likely to have checked test results online. Currently within the study practice, there are no formal processes to ensure that patients with online test results review them. It is possible to manually view each patient’s record and determine whether online test results have been read, but this process remains cumbersome and variably employed. Patients who do not review their test results may therefore be at risk of adverse health outcomes if clinical instructions contained within their release are missed. Adequate safety measures, such as an automatic system for alerting physicians that a test result has not been inspected, should be put in place to minimize potential adverse events, especially those that disproportionately affect African American patients.

Patients with an adequate level of health literacy were nearly 8 times more likely than those with limited health literacy to use the secure patient–physician messaging function. Inspection of the messages among this cohort suggested patients used this function to update their provider (e.g., appointments with other clinicians) and ask advice about chronic and acute health problems (e.g., referrals or self-care tasks). The providers of low health literacy patients may therefore receive fewer updates about their health, and they may be less informed about their patient’s wellbeing prior to an appointment. Patient–physician dialogue is an important part of patient engagement, and this finding suggests that communication inequalities may be created through the implementation of patient portals.³⁶ Health literacy disparities may be particularly important among older populations as this patient group are at greater risk of having inadequate basic skills.^27,28

Broadly, our findings suggest research should focus on addressing the barriers faced by older underserved populations at the registration stage of patient portal initiation. There is an established “digital divide” in Internet connectivity,³⁷ and this is likely to be a contributing factor.^4,38 National data indicate that while nearly 90% of the population uses the Internet, levels are lower among older groups (age 65+, 57%), African Americans (81%), and Hispanics (83%).³⁷ Estimates for educational differences range from 76% among those with a high school education or less up to 97% among those with a Bachelor’s degree or more. In 2009, nine of Chicago’s 76 neighborhood communities had <50% home connectivity, and 19 had <65%.³⁹ Healthcare systems adopting online technologies such as patient portals should continuously monitor Internet connectivity rates within their population to avoid exacerbating disparities. This may be particularly relevant to healthcare systems who serve predominantly older patient groups. Attention should be paid to home Internet connectivity, as patients may have access at a less convenient location which would inhibit regular patient portal use. It should be noted that the digital divide is less pronounced when considering smartphones,⁴⁰ suggesting that patient portals should have a smartphone interface to allow access from multiple devices.

Additional barriers faced by patients include difficulties with usability,^9,15–18 forgetting to enroll after being provided with an access code,⁴¹ a lack of interest in the functions available,⁴¹ and negative attitudes toward technology.^41,42 While trust can be a barrier to sharing electronic health data,⁴³ this is not always supported by patient-reported data.^15,41,44,45 These factors could be particularly relevant to older patient groups who have less experience with information technology.³⁷ There is also some evidence to suggest disparities in barriers to patient portal registration and use,⁴¹ but further work is needed to identify the underlying causes of inequalities in patient portal use. Our finding that lower health literate patients were less likely to use the messaging function may indicate that they lack the ability or confidence to compose written communications, or have lower levels of awareness that this function exists. The lower levels of result checking among African American patients suggests a similar barrier, and physicians should ensure that all patients are aware of how they will be notified about medical test outcomes, and provide alternatives if the patient portal is unsuitable. User-testing and improving functionality are important elements of introducing patient portals, and may help to ameliorate disparities.

Most patients in this sample had messaged their physician (90%), checked a test result (96%), and requested a reauthorization of a prescription (55%), but few monitored their vital statistics (11%). The low prevalence of vital statistic monitoring suggests that if patients are to become more effective consumers in the healthcare environment, promotion of the availability of such functions may be needed. The most comprehensive review in the area concluded that health outcomes are only likely to be affected if patient portals are offered in tandem with active case management such as in-person visits and healthcare provider monitoring.⁴ There are an array of online health technologies available in today’s marketplace,^46–49 and if patient portals are to keep pace, more comprehensive tools may be needed to attract users.

This study has limitations that should be acknowledged. We were unable to control for Internet connectivity; it is therefore unclear if disparities in registration indicated a lack of opportunity or interest. Levels of social support were not recorded, which may be an important mechanism for bridging the digital divide between health literacy groups.²¹ The concept of eHealth literacy may also be important to navigating an online patient portal,⁵⁰ but we were unable to record the construct here. After restricting the sample to investigate differences in use of the patient portal’s functions, sample sizes for minority groups were small. This is likely to have compromised our ability to detect study effects, and resulted in wide confidence intervals for some estimates. These data were collected from a single institution, and findings should be replicated at other sites and with other patient portals. Data were also from a sub-set of the LitCog sample, as no patient portal was available at the Federally Qualified Health Centers used for patient recruitment. As a result, education and literacy levels were high and we may have underestimated the magnitude of disparities that would occur if this technology was rolled out among more deprived populations. Although we controlled for the number of chronic conditions, we were unable to account for the broad array of reasons that a patient might log on to the patient portal and use its functions. However, investigations related to using the prescription reauthorization and test result functions were restricted to include only those for whom the outcome was relevant.

CONCLUSION

The introduction of patient portals is widespread and disparities in their registration and subsequent use are being documented. This study is among the first to demonstrate that objectively measured health literacy is associated with registering a patient portal account, and the magnitude of this effect was similar to that of race. More educated patients were also more likely to register their accounts. There were fewer notable disparities in the use of patient portal functions; however, literacy disparities in secure messaging, educational differences in prescription ordering, and race inequalities in checking test results are all cause for concern.

CONTRIBUTORS

All authors have contributed to writing the manuscript and review of the final text. Dr Smith and Dr Wolf act as guarantors for the content. Specific contributions are as follows:

Planning: Smith, Wolf, O’Conor, Goel

Conduct, data extraction, and analysis: Smith, O’Conor, Curtis, Aitken, and Goel

Reporting: Smith, O’Conor, Aitken, Curtis, Goel, Wolf

COMPETING INTERESTS

We report no conflict of interests.

FUNDING

Financial disclosure: This project was supported by the National Institute on Aging (R01 AG030611), the National Center for Research Resources (5UL1RR025741), and the National Center for Advancing Translational Sciences (Grant 8UL1TR000150). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Smith is currently supported by a Cancer Research UK Fellowship.