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The American Journal of Managed Care November 2018
A Randomized, Pragmatic, Pharmacist-Led Intervention Reduced Opioids Following Orthopedic Surgery
David H. Smith, PhD, RPh; Jennifer L. Kuntz, PhD; Lynn L. DeBar, PhD, MPH; Jill Mesa; Xiuhai Yang, MS; Jennifer Schneider, MPH; Amanda Petrik, MS; Katherine Reese, PharmD; Lou Ann Thorsness, RPh; David Boardman, MD; and Eric S. Johnson, PhD
Understanding and Improving Value Frameworks With Real-World Patient Outcomes
Anupam B. Jena, MD, PhD; Jacquelyn W. Chou, MPP, MPL; Lara Yoon, MPH; Wade M. Aubry, MD; Jan Berger, MD, MJ; Wayne Burton, MD; A. Mark Fendrick, MD; Donna M. Fick, RN, PhD; David Franklin, BA; Rebecca Killion, MA; Darius N. Lakdawalla, PhD; Peter J. Neumann, ScD; Kavita Patel, MD, MSHS; John Yee, MD, MPH; Brian Sakurada, PharmD; and Kristina Yu-Isenberg, PhD, MPH, RPh
From the Editorial Board: Glen D. Stettin, MD
Glen D. Stettin, MD
A Narrow View of Choosing Wisely
Daniel B. Wolfson, MHSA, Executive Vice President and COO, ABIM Foundation
Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
Overdose Risk for Veterans Receiving Opioids From Multiple Sources
Guneet K. Jasuja, PhD; Omid Ameli, MD, MPH; Donald R. Miller, ScD; Thomas Land, PhD; Dana Bernson, MPH; Adam J. Rose, MD, MSc; Dan R. Berlowitz, MD, MPH; and David A. Smelson, PsyD
Effects of a Community-Based Care Management Model for Super-Utilizers
Purvi Sevak, PhD; Cara N. Stepanczuk, MPP; Katharine W.V. Bradley, PhD; Tim Day, MSPH; Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Keith Kranker, PhD; Kate Stewart, PhD; and Lorenzo Moreno, PhD
Predicting 30-Day Emergency Department Revisits
Kelly Gao; Gene Pellerin, MD; and Laurence Kaminsky, PhD
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Patients' Adoption of and Feature Access Within Electronic Patient Portals
Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
Hospital Cancer Pain Management by Electronic Health Record–Based Automatic Screening
Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD

Patients' Adoption of and Feature Access Within Electronic Patient Portals

Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
We found race and age disparities not only in who adopted patient portal technology but also in which features were accessed by those who were adopters.

Objectives: We describe online portal account adoption and feature access among subgroups of patients who traditionally have been disadvantaged or represent those with high healthcare needs.

Study Design: Retrospective cohort study of insured primary care patients 18 years and older (N = 20,282) receiving care from an integrated health system.

Methods: Using data from an electronic health record repository, portal adoption was defined by 1 or more online sessions. Feature access (ie, messaging, appointment management, visit/admission summaries, and medical record access and management) was defined by user-initiated “clicks.” Multivariable regression methods were used to identify patient factors associated with portal adoption and feature access among adopters.

Results: One-third of patients were portal adopters, with African Americans (odds ratio [OR], 0.50; 95% CI, 0.46-0.56), Hispanics (OR, 0.63; 95% CI, 0.47-0.84), those 70 years and older (OR, 0.48; 95% CI, 0.44-0.52), and those preferring a language other than English (OR, 0.43; 95% CI, 0.31-0.59) less likely to be adopters. On the other hand, the likelihood of portal adoption increased with a higher number of comorbidities (OR, 1.04; 95% CI, 1.02-1.07). Among adopters, record access and management features (95.9%) were accessed most commonly. The majority of adopters also accessed appointment management (76.6%) and messaging (59.1%) features. Similar race and age disparities were found in feature access among adopters.

Conclusions: The diversity of portal features accessed may bode well for the ability of portals to engage some patients, but without purposeful intervention, reliance on portals alone for patient engagement may exacerbate known social disparities—even among those with an activated portal account.

Am J Manag Care. 2018;24(11):e352-e357
Takeaway Points

Healthcare organizations are increasingly using online portals to engage patients and enhance access to health information. Our findings illustrate that focusing on improving the diversity of the population that has an activated portal account alone may not be enough to prevent disparities. We found disparities not only in who adopted portal technology but also in which features were accessed by those with an activated portal account.
  • African Americans, Hispanics, those 70 years and older, and those preferring a non-English language were significantly less likely to be portal adopters.
  • Compared with white portal adopters, African American portal adopters were less likely to access each of the portal features evaluated.
  • Portal adopters who were 70 years and older were less likely to access most portal features, including those that were more interactive.
Since 2011, CMS has provided financial incentives to healthcare providers who implement and “meaningfully use” certified health information technology. Incentives to date have focused on providing patients the ability to view, download, and transfer data electronically. Although the incentives do not specify how organizations are to meet these criteria, most primary care practices and other healthcare delivery organizations have chosen to purchase electronic health records (EHRs) and accompanying patient portal software to meet these requirements.1,2 Neither how these online portals are being adopted nor their potential influence on known health disparities has been fully explored.

In most primary care practices, patient portals enable users to view personal health information, such as laboratory test results, discharge summaries, and notes from recent visits, thus fulfilling the CMS requirement to view, download, and transfer data electronically.3,4 In some practices, portal users can also schedule appointments and refill prescriptions or send other secure, unstructured messages to providers. Other practices enable users to record personal health information, such as allergies or preventive service use. Despite the array of functionalities that currently exist within commercially available patient portals, we know of just 2 studies that have examined which features adopters access once they have an activated portal account.5,6 Thus, although studies repeatedly have found traditionally vulnerable populations less likely to be portal adopters as defined by account activation,7-24 to our knowledge, just 1 prior study has reported findings specific to whether disparities exist in how those adopting portal technology engage with available health-related portal features once they have an activated account.8 It is important to understand whether disparities in health-related portal feature access exist among those who have an account, because portal technology is increasingly being used to target care delivery to those with specific chronic diseases.21,25,26

We describe how a patient portal was initially used among an insured, sociodemographically diverse population receiving primary care within an integrated health system. This system was selected for its relatively early adoption of patient portal technology and for the comprehensiveness of portal features initially made available to patients. We report the extent to which members of traditionally disadvantaged subgroups of the population (ie, those from minority races, those for whom English is not a first language, and those of Hispanic ethnicity) and those known to have disproportionate health needs (ie, older patients and those with more comorbidities) had activated portal accounts (ie, were portal adopters). Among adopters, we further evaluate which health-related portal features were accessed. Of particular interest was the extent to which adopters accessed features that enable viewing test results and health history information versus accessing the more interactive features that allow adopters to manage and exchange health-related information. In doing so, we provide important information regarding the patient portal foundation upon which subsequent patient engagement capabilities are being built, and we identify subgroups at risk of being left behind as healthcare organizations increasingly rely on portal technology to enable patients to electronically view, download, and transmit their health information to a third party.



The study was conducted in an integrated health system serving metropolitan Detroit, Michigan. The health system’s institutional review board approved all aspects of the study protocol. In 2012, the health system purchased an enterprise license for EpicCare EMR, a commercial medical record software program, and its accompanying patient portal, MyChart.27 As originally implemented, patients seen in any of the health system’s 26 primary care clinics were able to use MyChart via a desktop computer, tablet, or mobile device to securely schedule appointments, receive appointment reminders, view test results, request prescription refills, view and manage information about their health, and send secure messages to care teams.

Portal implementation was a systemwide initiative, with patient- and clinician-targeted campaigns. Screen savers introducing MyChart were launched on examination room computers and other work­stations. Posters were placed in clinic elevators, clinician work areas, examination rooms, and waiting rooms. Informational brochures were available in all clinics. Each component of the campaign instructed patients on how to request a MyChart activation code via the health system’s website or call center. Activation codes were also included on patient discharge summaries. All clinical staff received MyChart training, and front desk staff were instructed to inquire about patients’ account activation status. Work processes were adjusted to prioritize answering patient portal messages over telephone messages.

Study Population

We identified patients 18 years or older enrolled in the health system’s affiliated health plan with at least 1 visit to their primary care physician between April 1, 2013, and March 31, 2014. Patients younger than 18 years, those without a primary care visit, and those with indeterminate portal activation status (eg, those with account information but no evidence of a session) were excluded.

Data Sources

Patient sociodemographic information, comorbidities, primary care visits, and portal activation information were obtained from the health system’s EHR data repository. These patient-level data were joined with clinic-level information available from health system administrative files.

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