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The American Journal of Managed Care January 2018
Measuring Overuse With Electronic Health Records Data
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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.
There are several important limitations to note. First, we were unable to determine many enrollee characteristics, such as literacy (including reading/writing, computer, and health), internet accessibility, mobile device use preferences (eg, accessing the internet and potentially sensitive information), and individual socioeconomic factors. Although we were unable to control for internet accessibility, particularly mobile device ownership, previous studies measuring any internet use found racial/ethnic disparities to persist in portal use.15,16 Third, we observed higher levels of missing information for language and race/ethnicity; however, these data were self-reported in Group Health datasets according to organizational standards. Prior studies have also reported high rates of missing information among these variables.7,16 Notably, Meaningful Use Stage 1 requires healthcare organizations to have these fields populated for more than 50% of patients, as both fields need to be better populated to measure possible enrollee disparities.29 Fourth, we measured portal use as using eligible portal functions on at least 2 days. This may have biased the portal user sample toward patients with chronic medical conditions and away from younger, healthier patients who seldom use healthcare services. However, we believe this measure better captures meaningful engagement in care compared with other metrics of website use and allows all categories of devices used (ie, both device types) to be endorsed equally. Fifth, most Web server log entries did not have identifiers to link enrollees to devices, and we matched patient portal records to identifiable log entries using the function’s timestamp; we validated this approach through use and data capture in the EHR and portal test environment.22 Although this approach may have resulted in some underestimation of overall portal use, we do not believe this method caused any systematic bias by race/ethnicity. Finally, Group Health is an integrated delivery system and its racial/ethnic composition differs from that of the general population; these findings may not be generalizable to other healthcare systems. However, this study more accurately captures devices used to access the portal by collecting electronic data, rather than relying on self-reported use data; this removes the information bias that is a common concern in patient behavior studies.


Mobile devices are playing a large role in healthcare, from providing on-demand health information to helping patients and providers monitor and manage chronic conditions. However, researchers and healthcare organizations need to ensure that our increasing reliance on mobile technology does not exacerbate disparities in care and access among vulnerable populations.27 In addition to reconfirming racial/ethnic differences in online patient portal use, we found black and Hispanic portal users to be more likely to use mobile devices to access the patient portal. Mobile devices present an opportunity for healthcare organizations to increase their patient engagement among black and Hispanic enrollees. The accessibility and functionality of patient portals through mobile applications and mobile browsers may help reduce differences in patient portal use.

Author Affiliations: RTI International (EC), Waltham, MA; Medical Directorate, University Hospitals of Geneva (KB), Geneva, Switzerland; UCSF Division of General Internal Medicine and Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital (CRL), San Francisco, CA; Kaiser Permanente Washington Health Research Institute (LJ, JDR), Seattle, WA.

Source of Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Dr Chang was supported in part by a postdoctoral fellowship from the Group Health Foundation. 

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (EC, KB, CRL, JDR); acquisition of data (LJ, JDR); analysis and interpretation of data (EC, KB, CRL, LJ, JDR); drafting of the manuscript (EC); critical revision of the manuscript for important intellectual content (EC, KB, CRL, JDR); statistical analysis (EC); administrative, technical, or logistic support (LJ); and supervision (JDR). 

Address Correspondence to: Eva Chang, PhD, MPH, RTI International, 307 Waverly Oaks Rd, Ste 101, Waltham, MA 02452. Email:

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