Box 1. Recommendations for health care organizations, electronic health record vendors, and researchers to continue improving the design and implementation of patient portals based on the findings from this state-of-the-art review.

Health care organizations

• Continue to invest in the infrastructure necessary to virtual services, including offering flexible, multimodal options that can meet the preferences and needs of diverse patient populations.  • Better support patients, especially through transitions in access to EHI and engagement in their health care.  • Understand and address clinician concerns and resistance to changing visit note documentation practices to better communicate with patients.  • Develop, evaluate, and disseminate the results of innovative portal efforts to equitably engage patients. Electronic health record vendors  • Make it easier to create a proxy account and offer patients more control over what formal proxies can access.  • Engage diverse patients in the design and testing of portals and features. Researchers

Future research directions include the need for more evidence to understand

• How to better support patients as they view their EHI, especially test results, outside of interactions with health care professionals (e.g., understanding the potential role of artificial intelligence tools such as chatbots).  • Direct consequences of immediate access to EHI, and especially test results, for patients across health care contexts (e.g., safety net).  • How newer mechanisms for viewing and leveraging one's clinical data will affect patient portal engagement.  • How to address persistent disparities in the uptake, use, and effectiveness of portals.  • How proxy accounts could be improved to better support caregiver needs and how to increase proxy account creation.  • How to build on the progress in portal engagement made during COVID-19 for sustainability outside of the public health crisis.

Abbreviation: EHI, electronic health information.