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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
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 Health Record "Super-Users" and "Under-Users" in Ambulatory Care Practices
Juliet Rumball-Smith, MBChB, PhD; Paul Shekelle, MD, PhD; and Cheryl L. Damberg, PhD
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
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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

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
The study examined the variation in devices used (desktop/laptop computer, mobile device, or both device types) by patients of different racial/ethnic backgrounds to access the online patient portal.

Objectives: We examined racial/ethnic variation in the devices used by patients to access medical records through an online patient portal.

Study Design: Retrospective, cross-sectional analysis.

Methods: Using data from 318,700 adults enrolled in an integrated delivery system between December 2012 and November 2013, we examined: 1) online patient portal use that directly engages the electronic health record and 2) portal use over desktops/laptops only, mobile devices only, or both device types. The primary covariate was race/ethnicity (non-Hispanic white, black, Hispanic, and Asian). Other covariates included age, sex, primary language, and neighborhood-level income and education. Portal use and devices used were assessed with multiple and multinomial logistic models, respectively.

Results: From December 2012 to November 2013, 56% of enrollees used the patient portal. Of these portal users, 62% used desktops/laptops only, 6% used mobile devices only, and 32% used both desktops/laptops and mobile devices. Black, Hispanic, and Asian enrollees had significantly lower odds of portal use than whites. Black and Hispanic portal users also were significantly more likely to use mobile devices only (relative risk ratio, 1.73 and 1.44, respectively) and both device types (1.21 and 1.07, respectively) than desktops/laptops only compared with whites.

Conclusions: Although racial/ethnic minority enrollees were less likely to access the online patient portal overall, a greater proportion of black and Hispanic users accessed the patient portal with mobile devices than did non-Hispanic white users. The rapid spread of mobile devices among racial/ethnic minorities may help reduce variation in online patient portal use. Mobile device use may represent an opportunity for healthcare organizations to further engage black and Hispanic enrollees in online patient portal use.

Am J Manag Care. 2018;24(1):e1-e8
Takeaway Points

The increasing availability of mobile devices and applications has the potential to extend patient engagement through the use of patient portals. This study examined racial/ethnic variation in the devices used (desktop/laptop computer, mobile device, or both device types) by patients to access medical records through an online patient portal. 
  • Black and Hispanic online patient portal users were significantly more likely to use mobile devices exclusively and both device types than desktop/laptop computers exclusively compared with non-Hispanic white portal users. 
  • Mobile device use may represent an opportunity for healthcare organizations to further engage black and Hispanic enrollees in online patient portal use.
Online patient portals have the potential to be important health communication and care coordination tools for patients and providers and to improve access to healthcare for patients.1-3 Healthcare systems and clinics use patient portals to fulfill key metrics of federal Meaningful Use requirements, including direct patient engagement; this occurs when patients view, download, and transmit health information online and use secure messaging to communicate with providers.4 In 2010, the use of secure online patient portals by adults nationally doubled from 2 years before to 7%,5 while integrated and academic healthcare systems reported use by more than 40% of patients.2,6,7 Patient portals provide secure access to and interaction with healthcare-related services and information in electronic health records (EHRs).8-10 Patient portal functions may include secure messaging with providers, requesting medication refills and appointments, and viewing laboratory results and other portions of the EHR. Use of portals has been linked to improved care quality, patient satisfaction, and health outcomes.11-14

Portal enrollment and use are generally lower among racial/ethnic minority patient populations.7,10,12,15,16 Specifically, black, Hispanic, and Asian patients have been found to have lower enrollment and use of patient portals than non-Hispanic white patients, even after adjusting for internet access and use.7,9,10,12,15-17 However, new technologies, such as smartphones and other mobile devices, may help attenuate differences in patient portal use among racial/ethnic minority patients. Mobile device browsers can be used to access patient portal websites, and healthcare organizations are implementing mobile applications with similar sets of services.18 Blacks and English-speaking Hispanics are more likely to own a smartphone and use a wider range of its applications (eg, internet, email) than whites.19 Compared with whites, blacks and English-speaking Hispanics also are more likely to rely on their smartphones for access to the internet.19,20 Although racial/ethnic minorities are more likely to own and rely on mobile devices, the current extent of access to patient portals with mobile devices is unknown.

We examined the relationship of race/ethnicity to patient portal use and devices used to access the portal among enrollees in an integrated healthcare delivery system. We focused on patient portal functions associated with the Meaningful Use criteria, specifically measuring patient healthcare management tasks that engage the healthcare provider and healthcare system. Similar to previous findings, we hypothesized that non-Hispanic whites would be more likely to use the patient portal than racial/ethnic minority enrollees. Given the high rates of smartphone use among racial/ethnic minorities, we further hypothesized that black and Hispanic enrollees would have a higher proportion of patient portal use via mobile devices (compared with desktop/laptop computers) than non-Hispanic white enrollees.


Setting, Data Sources, and Study Participants

This study was conducted in Group Health Cooperative (now Kaiser Permanente Washington), a mixed-model healthcare delivery system in Washington state. Approximately 400,000 members receive their care through Group Health’s integrated delivery system, which includes 25 Group Health-owned facilities and approximately 1000 Group Health physicians. The online patient portal has been available on the patient website ( during the time of the study, currently since 2003 and on a mobile application (for both iPhone and Android) since 2011. Enrollees are informed of the website and portal functions upon enrollment. Mobile application use is encouraged via several marketing methods, including the patient website and screensavers throughout clinics. To access the patient portal, patients register online on the patient website (through a desktop/laptop or mobile Web browser) and verify their identity at a clinic or register in person at any clinic.3 Once registered, patients can access a number of features, including portal functions. Access is available to all patients in the integrated delivery system and is available only in English. 

This cross-sectional study drew from 5 enrollee data sources: administrative data for individual demographic information, Web server logs to identify devices used to access functions, EHR records to identify functions accessed, online prescription refill data to identify medication refill requests, and 2010 US Census data for Census block-level demographic information.

Study enrollees were adults (≥18 years) who were enrolled in Group Health’s integrated delivery system for any length of time from December 2012 to November 2013 and who had a primary care provider in a clinic owned and operated by Group Health. Adults receiving care in Group Health’s contracted network were excluded because some portal functions were not available to them.3

The Group Health Research Institute’s Institutional Review Board approved this study. 


Our primary outcomes of interest were 1) portal use among study enrollees and 2) devices used to access the patient portal among portal users.

We defined portal use as having used any of 8 eligible portal functions that directly engaged patients with the EHR on at least 2 days within the study period. The 8 portal functions align with federal Meaningful Use requirements: secure messaging with providers, requesting medication refills and appointments, and viewing after-visit summaries, medical test results, medical conditions, allergies, and immunizations.3,21 We defined portal use as 2 uses on 2 days to identify meaningful engagement with the EHR (rather than a single log-on) and to allow for multiple devices to be used for accessing functions.

Devices used to access the patient portal were identified through server logs.22 We parsed HTTP request strings from Web server log data to identify specific devices (eg, smartphones, tablets, desktops/laptops) and mode of accessing the data (eg, Web browser, mobile application). Log data were matched with EHR records within a time window. All 8 portal functions were accessible through all devices and modes of access.

We categorized devices used as desktop computer only, mobile devices only, and both device types. “Desktop computer only” captured both desktop and laptop computer use; our methodology could not distinguish between these devices and the similar user interface (eg, a physical keyboard) of laptop and desktop computers warranted their combination. “Mobile devices only” indicated use of smartphones and tablets to access the portal through the mobile application or Web browser. “Both device types” indicated use of desktop/laptop computers and mobile devices.

Independent Variables

Our independent variables were race/ethnicity, age, gender, primary language, and neighborhood-level education and income. 

We obtained race/ethnicity, gender, age (18-34, 35-49, 50-64, or ≥65 years), and primary language (English or any other language) from administrative data. These variables were collected mostly by administrative staff at enrollee registration in the plan. Self-reported race/ethnicity was our primary independent variable and was categorized as Hispanic, non-Hispanic white, non-Hispanic black, non-Hispanic Asian, and non-Hispanic other. “Other” included enrollees who self-identified as Native American, Hawaiian/Pacific Islander, or with 2 or more races.

Because enrollee education and income had not been collected at registration, we linked enrollees’ home addresses to Census block group-level data and determined the percentage of individuals in the Census block group who completed high school and the group’s median household income.7 


For bivariate analyses, we examined descriptive characteristics by race/ethnicity using χ2 tests and examined pairwise comparisons for device use and portal use by race/ethnicity (compared with white) using 2-sample tests of proportions. We used multiple logistic regression to determine independent associations between race/ethnicity and portal use among all study enrollees. We used multinomial logistic regression to determine the relationship between race/ethnicity and devices used to access the patient portal among portal users. We report these findings as relative risk ratios; values greater than 1 suggest greater relative risk than the reference group, whereas values less than 1 suggest lower relative risk. Sensitivity analyses including the “missing” race/ethnicity and primary language category from regression models were conducted to assess the impact of missing information on results. We present descriptive information for enrollees missing race/ethnicity and primary language, but excluded these categories from the regression models because results with these categories were similar in significance and direction.

All analyses were conducted using Stata version 13.0 (StataCorp LLC; College Station, Texas). 


Descriptive Characteristics

Among 318,700 Group Health enrollees, 68% were white; 4%, black; 8%, Asian; and 5%, Hispanic (Table 1). Enrollees varied significantly across demographic characteristics. Twenty-six percent of white enrollees were 65 years or older compared with 11% to 14% of racial/ethnic minority enrollees. Asians and Hispanics had significantly higher proportions of enrollees with a primary language other than English (17% and 7%, respectively). Blacks had the lowest proportion living in high educational attainment areas (89%) and the highest proportion in the lowest median household income areas (43%). Mean months of enrollment during the study period did not vary by race/ethnicity (data not shown). 

Race/ethnicity and primary language were missing for 10% and 9%, respectively, of study enrollees. Race/ethnicity data also were most likely to be missing among younger male enrollees. 

Unadjusted Patient Portal Use and Devices Used to Access the Patient Portal

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