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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.
Among the study sample, 74% registered for the patient portal and 56% used the portal during the study period (Table 2). Portal registration and use was highest among white enrollees (81% and 64%, respectively) and lowest among black enrollees (64% and 44%). The majority of portal users accessed the following: medical test results (87%), secure messaging (68%), and medication refill requests (54%). Compared with whites, racial/ethnic minority users were less likely to use secure messaging and submit refill requests, but similarly or more likely to view medical conditions, immunizations, and allergies. Compared with enrollees whose primary language was English, enrollees with another primary language were significantly less likely to use the patient portal. These portal users were less likely to use secure messaging, request appointments and medication refills, and view after-visit summaries (eAppendix [available at ajmc.com]).

The devices used to access the portal varied by race/ethnicity (Table 3). Sixty-two percent used desktop computers only, 6% used mobile devices only, and 32% used both device types. White portal users had the highest proportion using only desktop computers (63%), whereas Black and Hispanic portal users had a higher proportion using only mobile devices (10% and 9%, respectively) compared with lower mobile-only use among white portal users (5%). Using both device types to access the portal was higher among all racial/ethnic minority portal users. 

Variations in Portal Use by Race/Ethnicity and Primary Language

After adjustment for age, gender, primary language, neighborhood-level education, and neighborhood-level income, differences in portal use remained significant for all racial/ethnic minority enrollees compared with white enrollees (Table 4). Black, Asian, and Hispanic enrollees had significantly lower odds of portal use than white enrollees (odds ratios [ORs]: 0.49, 0.70, and 0.70, respectively). Additionally, enrollees whose primary language was not English had significantly lower odds of portal use than those whose primary language was English (OR, 0.24). 

Variations in Devices Used to Access the Portal

Device used to access the patient portal varied among all portal users (Table 5). In the unadjusted model, all racial/ethnic minority portal users were significantly more likely to use mobile devices and both device types than desktops only compared with white portal users. After adjustment, compared with white portal users, black and Hispanic portal users were more likely to use mobile devices only than desktops only to access the portal (relative risk ratio [RRR], 1.73 and 1.44, respectively; both P <.05) and more likely to use both device types (RRR, 1.21 and 1.07; both P <.05). After adjustment, Asian portal users were less likely to use both device types than desktops only (RRR, 0.93; P <.05) compared with whites. Asian portal users also were no longer significantly different from white users in their use of mobile devices only. Primary language was not significantly associated with device used. 

DISCUSSION

We observed important racial and ethnic variations in use of the online patient portal and in the proportion of devices enrollees used to access the portal in an integrated healthcare system. Although most patient portal users continued to use solely desktop or laptop computers to access the portal, 10% of black and 9% of Hispanic enrollees used mobile devices exclusively to access their patient portals during the study year. Black and Hispanic portal users were more likely than white portal users to use mobile devices only or both device types to access their portals. Although overall portal use was high among all enrollees, racial/ethnic minority enrollees remained less likely to use the portal compared with white enrollees. Almost two-thirds of white enrollees used the portal, yet approximately half or less of racial/ethnic minority enrollees used the portal.

Our study is one of the first to examine variations in the devices enrollees use to access the patient portal. The higher mobile-only portal access among black and Hispanic users may be linked to greater smartphone dependency, preferences and attitudes toward mobile device use (not explained by income or education), and affordability of different devices.19,20,23 In addition to higher ownership rates of mobile devices and a wider usage of mobile data applications, 12% of blacks and 13% of English-speaking Hispanics are smartphone dependent (ie, lacking alternatives to their smartphone for internet access) compared with 4% of whites.19,20,24,25 This suggests that a proportion of our mobile-only population may not otherwise have the ability to access their patient portal. Longitudinal studies are needed to assess whether the use of mobile devices and applications to access patient portals are similar across racial/ethnic minorities or if higher uptake of mobile devices among racial/ethnic minorities may attenuate racial/ethnic differences in portal use over time. Surprisingly, Asian portal users had a similar likelihood of exclusive mobile device use but a lower likelihood of using both device types compared with white users. This finding merits further research, as smartphone ownership and home internet use are highest among Asians.24,25 With 62% of smartphone owners using their phones to access health information,19 this cross-sectional analysis suggests that the mobile-only user population represents an opportunity for healthcare organizations to engage black and Hispanic patients in portal use. However, it is important to recognize that individuals and households who rely on mobile devices as their only computer are often younger, lower-income, racial/ethnic minority populations who are more vulnerable to financial and technical constraints (eg, cost of maintaining a cell phone plan, data allowances).19,25 Further research is needed to better understand the barriers that these and other vulnerable populations (eg, elderly patients or those with lower educational attainment) face in accessing patient portals.17 

As previously observed,15,26 patient portal use was lower among racial/ethnic minority patients. Although black and Asian enrollees in our healthcare system were previously found to have lower odds of portal use,15 the similarity in observed difference in portal use in Asians and Hispanics compared with whites (both ORs, 0.70) was unexpected. Nationally, Asians have the highest internet accessibility and use of all races/ethnicities,25 and previous studies have observed either no significant difference or more portal use in Asians compared with whites.7,15,26 Our finding may be driven by factors not captured in our data, and further investigation should explore how portal use may vary across Asian subgroups or factors such as patient portal awareness among Asian enrollees. Lower portal use among racial/ethnic minorities in our sample appeared to be due to lower use of active functions (eg, secure messaging and medical refills), rather than passive functions (eg, viewing medical tests).26 Addressing the use of more complex functions may help increase overall use among racial/ethnic minority patients. Similar to findings of previous studies,12,26 portal use was lower among enrollees whose primary language was not English. However, primary language was not associated with device used. This suggests that language is an important barrier to portal use, but not to how patients access the portal. Differences in portal use may arise from difficulties in navigating an English-language patient portal, which contains the dual barriers of language literacy and health literacy. Additional reasons, such as computer literacy and communication preferences, should also be explored. Lower portal use among racial/ethnic minority populations underscores existing concerns about the digital divide and its potential to amplify healthcare-related disparities among vulnerable racial/ethnic minority enrollees.27 Differences in portal use by race/ethnicity and primary language suggest that targeted promotion and development of the patient portal may be needed.17,28 

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