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The American Journal of Managed Care January 2018
Measuring Overuse With Electronic Health Records Data
Thomas Isaac, MD, MBA, MPH; Meredith B. Rosenthal, PhD; Carrie H. Colla, PhD; Nancy E. Morden, MD, MPH; Alexander J. Mainor, JD, MPH; Zhonghe Li, MS; Kevin H. Nguyen, MS; Elizabeth A. Kinsella, BA; and Thomas D. Sequist, MD, MPH
The Health Information Technology Special Issue: Has IT Become a Mandatory Part of Health and Healthcare?
Jacob Reider, MD
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Bridging the Digital Divide: Mobile Access to Personal Health Records Among Patients With Diabetes
Ilana Graetz, PhD; Jie Huang, PhD; Richard J. Brand, PhD; John Hsu, MD, MBA, MSCE; Cyrus K. Yamin, MD; and Mary E. Reed, DrPH
Electronic Sharing of Diagnostic Information and Patient Outcomes
Darwyyn Deyo, PhD; Amir Khaliq, PhD; David Mitchell, PhD; and Danny R. Hughes, PhD
Hospital Participation in Meaningful Use and Racial Disparities in Readmissions
Mark Aaron Unruh, PhD; Hye-Young Jung, PhD; Rainu Kaushal, MD, MPH; and Joshua R. Vest, PhD, MPH
A Cost-Effectiveness Analysis of Cardiology eConsults for Medicaid Patients
Daren Anderson, MD; Victor Villagra, MD; Emil N. Coman, PhD; Ianita Zlateva, MPH; Alex Hutchinson, MBA; Jose Villagra, BS; and J. Nwando Olayiwola, MD, MPH
Electronic Health Record Problem Lists: Accurate Enough for Risk Adjustment?
Timothy J. Daskivich, MD, MSHPM; Garen Abedi, MD, MS; Sherrie H. Kaplan, PhD, MPH; Douglas Skarecky, BS; Thomas Ahlering, MD; Brennan Spiegel, MD, MSHS; Mark S. Litwin, MD, MPH; and Sheldon Greenfield, MD
Racial/Ethnic Variation in Devices Used to Access Patient Portals
Eva Chang, PhD, MPH; Katherine Blondon, MD, PhD; Courtney R. Lyles, PhD; Luesa Jordan, BA; and James D. Ralston, MD, MPH
Hospitalized Patients' and Family Members' Preferences for Real-Time, Transparent Access to Their Hospital Records
Michael J. Waxman, MD, MPH; Kurt Lozier, MBA; Lana Vasiljevic, MS; Kira Novakofski, PhD; James Desemone, MD; John O'Kane, RRT-NPS, MBA; Elizabeth M. Dufort, MD; David Wood, MBA; Ashar Ata, MBBS, PhD; Louis Filhour, PhD, RN; & Richard J. Blinkhorn Jr, MD

Bridging the Digital Divide: Mobile Access to Personal Health Records Among Patients With Diabetes

Ilana Graetz, PhD; Jie Huang, PhD; Richard J. Brand, PhD; John Hsu, MD, MBA, MSCE; Cyrus K. Yamin, MD; and Mary E. Reed, DrPH
Racial/ethnic minorities and patients living in poorer neighborhoods were more likely to access their personal health record exclusively with a mobile device.

Objectives: Some patients lack regular computer access and experience a digital divide that causes them to miss internet-based health innovations. The diffusion of smartphones has increased internet access across the socioeconomic spectrum, and increasing the channels through which patients can access their personal health records (PHRs) could help bridge the divide in PHR use. We examined PHR use through a computer-based Web browser or mobile device.

Study Design: Cross-sectional historical cohort analysis.

Methods: Among adult patients in the diabetes registry of an integrated healthcare delivery system, we studied the devices used to access their PHR during 2016.

Results: Among 267,208 patients with diabetes, 68.1% used the PHR in 2016; 60.6% of all log-ins were via computer and 39.4% were via mobile device. Overall, 63.9% used it from both a computer and mobile device, 29.6% used only a computer, and 6.5% used only a mobile device. After adjustment, patients who were black, Hispanic, or Asian; lived in lower socioeconomic status (SES) neighborhoods; or had lower engagement were all significantly more likely to use the PHR only from a mobile device (P <.05). Patients using the PHR only via mobile device used it less frequently.

Conclusions: Mobile-ready PHRs may increase access among patients facing a digital divide in computer use, disproportionately reaching racial/ethnic minorities and lower SES patients. Nonetheless, even with a mobile-optimized and app-accessible PHR, differences in PHR use by race/ethnicity and SES remain. Continued efforts are needed to increase equitable access to PHRs among patients with chronic conditions.

Am J Manag Care. 2018;24(1):43-48
Takeaway Points
In an integrated delivery system, mobile access to personal health records (PHRs) may increase their use among patients with limited computer access, but differences in PHR use by race/ethnicity and neighborhood socioeconomic status (SES) remain. 
  • Seventy percent of PHR users accessed it with a mobile device at least once in 2016, with nearly 40% of all log-ins done using a mobile device. 
  • Patients who were black, Hispanic, or Asian or who lived in lower SES neighborhoods were significantly more likely to use the PHR exclusively via a mobile device. Still, these groups of patients were less likely to use the PHR at all in 2016.
Although more than 200,000 health-promoting mobile apps are available for patient download, with 1.7 billion users worldwide, research is needed to identify the clinical usefulness of mobile tools in self-management and care quality for patients.1,2 Importantly, the majority of these apps lack any integration with patients’ ongoing healthcare services and providers.3,4 Apps that are integrated with a clinical electronic health record (EHR) and that make patient-reported data available to clinicians may hold the most promise to improve well-coordinated, high-quality healthcare delivery. Within healthcare, this timely expansion to mobile-connected devices complements the growing availability of personal health records (PHRs). PHRs could be particularly relevant for patients with chronic conditions, such as diabetes, who require ongoing self-management that can be facilitated via PHRs.

However, the long-standing digital divide, defined as the gulf between individuals with and without ready access to the internet, is well documented.5 EHR requirements from CMS (Stage 3 Meaningful Use objectives) include that physicians provide patients with electronic access to their health records and tailored patient education via a Web-based tethered PHR that is linked to the patient’s EHR, also known as a patient portal.6 Although Meaningful Use financial incentives continue to promote the widespread adoption of PHRs among eligible providers, they do not require that PHRs be easily accessible via mobile devices.6 Therefore, with only computer-based access, many patients might be left out.

Previous research shows that use of computer-based PHRs has been consistently lower among racial and ethnic minorities and patients with lower education and health literacy levels.7-13 Recently, the diffusion of smartphone technology has increased mobile access to the internet and apps among individuals most likely to be affected by the digital divide, including racial/ethnic minorities and those with lower socioeconomic status (SES).14 Mobile-accessible PHRs can help engage patients in managing their health through convenient and timely access to personal health data, provider messaging, refilling prescriptions, or scheduling appointments.15 With many healthcare innovations, specifically advancements in PHRs, changes have favored those who have social advantages, such as higher education, greater income or wealth, more knowledge of how to navigate the healthcare system, and nonminority race/ethnicity. In this manuscript, we focus specifically on a different type of technological innovation: the introduction of PHRs that are more easily accessible using mobile devices.

Diabetes is more prevalent among individuals of lower SES and racial/ethnic minorities.16 Patients with diabetes often have other chronic conditions with complex clinical needs that require ongoing self-management.17-19 Diabetes self-management is crucial and requires extensive self-monitoring, adherence to medications, proper diet, and adequate exercise.20 Any practical realization of a model for coordinated safe care must rely on timely availability and use of comprehensive electronic clinical information that is not only available to providers through an EHR, but also to patients through a PHR.21-23 Previous studies have found that PHR use was associated with improved diabetes quality measures.15,24-26 Thus, mobile-accessible PHRs could be particularly relevant for patients with diabetes. Yet, in the absence of mobile-accessible PHRs, we found that lack of computer access accounted for most of the variation in PHR use by race and income.13 Consequently, we expect that mobile access to PHRs may facilitate PHR use among individuals who are mobile dependent. Little is known about the use of PHRs that are easily accessible and optimized for use via mobile devices. 

Within an integrated delivery system that provided all members with multiple channels to access their PHR, we examined the channel through which an adult population of patients with diabetes used their PHR (ie, through a computer-based Web browser, smartphone-accessible website, or mobile apps). We also assessed the association between patient characteristics and PHR use via mobile device.



Kaiser Permanente Northern California is an integrated delivery system that provides comprehensive care, including inpatient, outpatient, and pharmacy services, to more than 3 million members via employer-sponsored, individual, or publicly sponsored insurance. Members who register to use the password-protected patient PHR can access it free of charge via computer browser, mobile-optimized website, or mobile app. The computer-based Web portal has been available to members for more than 10 years, and the mobile-optimized website and Android or iOS apps have been available to members since 2013. The PHR offers patients a number of services, including the ability to exchange secure messages with providers on their healthcare team, view lab results, request medication refills, view portions of their health records, schedule office visits, and pay bills. The mobile-accessible and computer browser versions of the PHR offer comparable functions, although features changed slightly over time.

Study Population 

Our study population included all adult (≥18 years) members of an integrated delivery system, Kaiser Permanente Northern California, who were in the health plan diabetes clinical registry as of the last quarter of 2015. We chose to focus on patients with diabetes in order to examine patients with a chronic condition who would likely have ongoing need for healthcare services and self-management functions available in PHRs. This analysis was part of a larger study focused on how patients with diabetes use technology to manage their care. We included all patients who maintained continuous health plan coverage in 2016. Because our study focused on patient characteristics, we excluded PHR use via designated proxies. 

Data and Measures

We used automated datasets to capture PHR use by channel (mobile app, mobile website, or computer browser) in 2016 among the full study population. To calculate PHR use counts, we identified use episodes by counting the number of days during the year with any PHR use (eg, multiple log-ins in 1 day counted as a single episode). In addition, we measured if patients used 3 key PHR functions (order prescription refill, send secure message, or view lab result) at any time in 2016. We also used EHR data to capture patient characteristics (age, gender, race/ethnicity) and linked patients’ residential addresses to 2010 US Census measures of education and income to define neighborhood SES at the Census block group level. Census block groups are defined as neighborhoods of lower SES if at least 20% of residents have household incomes below the federal poverty level or at least 25% of residents 25 years or older have less than a high school education.27 We also identified patients’ additional chronic conditions, other than diabetes, during the last quarter of 2015 using the health plan’s clinical chronic condition registries for asthma, coronary artery disease, heart failure, and hypertension. As an indicator of patient engagement in 2015, we used clinical quality registries to create an overall measure of patients’ histories of adherence to chronic condition medications (with 80% or more days covered by medications) and to preventive care recommendations (up-to-date flu shot, blood pressure measure, low-density lipoprotein [LDL] cholesterol measure, and glycated hemoglobin [A1C] measure for those with diabetes). We categorized patients as being highly engaged in their care if they were adherent to their chronic condition oral medications for diabetes, hypertension, or cholesterol (≥80% of days covered) and recommended preventive care services (flu vaccine and A1C, LDL cholesterol, and blood pressure screening) in 2015.

Statistical Analysis

We studied patient characteristics associated with the channel(s) used to access the PHR during 2016 (computer and mobile, computer only, and mobile only). We used multivariable logistic regression to measure the association between PHR use (any use in 2016 vs no use) and patient characteristics, as well as multinomial logistic regression to measure the association between device used (mobile only, computer only, or mobile and computer) among PHR users and patient characteristics (age, gender, race/ethnicity, neighborhood SES, number of chronic conditions, and health engagement). For both models, we calculated the adjusted percentage of patients using the PHR and device type by patient characteristics, assuming patients in the subgroup had the same other characteristics as the full study population (margins command in Stata). We included the main effects of each covariate and first order interaction of all covariates (except for age group and number of other chronic conditions due to an empty cell problem). All analyses were conducted using Stata 14 (StataCorp LP; College Station, Texas).

The Kaiser Foundation Research Institute Institutional Review Board reviewed and approved the study protocol.


Table 1 shows characteristics of the 267,208 patients with diabetes included in the study and their adjusted rates of PHR use in 2016. In that year, 49.1% were 65 years or older, 47.7% were female, 43.7% were white, 22.6% were Asian, 21.6% were Hispanic, 10.2% were black, 24.0% lived in low SES neighborhoods, and 75.1% had multiple chronic conditions. Nearly one-third of all study patients (31.9%) did not use the PHR in 2016. More than half (58.0%) of patients were categorized as highly engaged, meaning that they were adherent to their oral medications for chronic conditions and received the flu vaccine and recommended screenings for A1C, LDL cholesterol, and blood pressure in 2015. 

During 2016, 181,981 patients (68.1% of the total number) accessed their PHR 8.9 million times: 60.6% of log-ins were via a computer, 19.9% via mobile device browser, and 19.5% via smartphone apps. Of all PHR users, 6.5% used it only with a mobile device, 29.6% only with a computer, and 63.9% used both a computer and mobile device (Figure 1). Patients who accessed the PHR only via a mobile device used it less frequently (median of 11 days with PHR use) than those using only a computer (15 days) or both a computer and mobile device (30 days). Most PHR users used it to view lab results (81.0%), send a secure message (75.8%), and order a prescription refill (66.0%). For the 3 key functions, use was highest among patients who accessed the PHR via both a computer and mobile device and lowest among those who used only a mobile device (Table 2).

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