Skip to main content
NCBI home page
JAMIA Open logoLink to JAMIA Open
. 2026 May 5;9(3):ooag064. doi: 10.1093/jamiaopen/ooag064

Timely nudges promote patient portal enrollment and sustained engagement: a randomized controlled trial

Sasha C Brietzke 1,2,#,✉, Maheen Shermohammed 3,#, Amir Goren 4, Gail M Rosenbaum 5, Michelle N Meyer 6,7,#, Christopher F Chabris 8,9,#
PMCID: PMC13143434  PMID: 42094799

Abstract

Objective

Patient portals support health management, yet enrollment remains low. This study evaluated whether timely email nudges increase patient portal enrollment compared with usual system portal invitations, whether message framing influences enrollment, and whether patients nudged to enroll go on to engage with the portal at similar rates as those who enroll organically.

Materials and Methods

In this pre-registered randomized controlled trial at a large health system, 5009 patients aged ≥ 18 with recently released laboratory results were randomized over 15 days to: (1) an “Ease” email suggesting immediate access to laboratory results, upon enrollment, (2) a “Transparent” email outlining registration steps needed to access their results, or (3) no email. The primary outcome was portal enrollment within one week. Secondary outcomes included enrollment rates over four years and post-enrollment portal engagement. Post hoc analysis examined the impact of time-sensitive test results.

Results

Compared with control, receiving either nudge increased one-week portal enrollment (10.8% vs 3.9%; OR 2.99, P < .001). This difference remained significant through one year post-nudge (36.5% vs 33.1%; OR 1.23, P = .005). Message framing had no significant effect on enrollment. Among emailed patients, nudges were more effective with time-sensitive laboratory results (OR 1.46; P < .001). Among enrollees, long-term portal usage was similar across groups.

Discussion and Conclusion

Beyond standard marketing efforts, timely nudges highlighting the immediate benefit of accessing laboratory test results can meaningfully increase patient portal enrollment—especially when results are time-sensitive. These low-cost, one-time interventions can drive adoption without sacrificing long-term engagement.

Keywords: patient portals, health behavior, communication, randomized controlled trial

Introduction

Patient portals are widely regarded as effective tools for enhancing patient engagement in healthcare. These secure online platforms provide patients convenient access to medical records, scheduling, laboratory results, and direct communication with clinicians. By enabling continuous access to medical information, portals help support patients’ health decisions, increase preventative care uptake (eg, cancer screening), and foster better self-management of chronic diseases (eg, medication adherence).1–6 Yet despite their potential, portal enrollment rates remain low, especially among patients who stand to benefit most.7–9 This underutilization poses a challenge for healthcare systems aiming to improve patient outcomes and experience, and reduce costs.

Several interventions to increase patient portal enrollment and usage have been evaluated.7,9–15 One nonrandomized prospective cohort study found that portal registrations increased when providers showed patients a two-minute video during exam room visits compared with paper instructions or no intervention; however, about 18% of patients declined to watch the video.10 Other studies have tested face-to-face educational interventions with mixed success.9,11–14 These in-person strategies require substantial staff time and may be difficult to scale in large healthcare systems.

Behavioral science-based nudges—small changes in how choices are presented to influence decisions—have been shown to cause significant behavior change in some healthcare contexts.16–25 Because they can be delivered electronically and automatically, often at little to no (ongoing) expense, nudges reduce or eliminate the need for staff time and resources. Part of their success may be due to effective message framing that motivates patients to act. For instance, gain-framed messages can increase physical activity, while personalized risk framing can improve vaccination uptake.23,26 These findings suggest that effective message framing may address common barriers to portal use, including low perceived need and concerns about enrollment difficulty.

Another common attribute of successful nudge interventions is timeliness.27 Randomized trials indicate that delivering nudges when they are most relevant—such as the start of flu season, shortly before an appointment when they can be acted on, or when breast cancer screenings are past due—can substantially increase the uptake of health behaviors.28–30 Therefore, we hypothesized that messages sent at a time when a benefit of the portal—viewing laboratory test results—was immediately relevant and salient would be effective. This may be especially true for time-sensitive tests, such as disease diagnostics, where the alternative of waiting days for results to arrive by mail or phone, or to be discussed at an upcoming appointment, is especially unattractive.

While a nudge may prompt a patient to sign up or use the portal once, it is not clear whether it would translate to ongoing behaviors, such as regular portal logins or the use of advanced features. Similar questions have been explored in other health contexts, including long-term medication adherence and smoking cessation.22,31 Accordingly, it is important to determine whether cost-effective interventions can convert non-users to regular rather than one-time users.

In April 2020, only 45% of Geisinger patients who had an encounter (ie, a documented digital or in-person interaction with the system) within the prior 12 months were enrolled in MyChart, despite system-wide efforts to increase adoption. We conducted a preregistered, randomized controlled trial in May 2020 to test whether delivering timely email nudges shortly after laboratory tests become available causes greater patient portal enrollment than do usual system efforts. We also preregistered a comparison between messages emphasizing the ease of enrollment (Ease) and messages transparently acknowledging the required enrollment step (Transparent). We further conducted an exploratory, post hoc analysis to test whether nudges tied to time-sensitive laboratory results cause greater enrollment than those tied to less time-sensitive results. Finally, we explored whether the effects of timely nudges extend beyond initial enrollment to influence long-term portal usage over a four-year period.

Methods

Design

Patients at Geisinger, a large Pennsylvania health system, were randomized to one of three study arms in a parallel-group design. This project followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines. The Geisinger IRB determined that this healthcare operations project did not constitute research and that a follow-up research analysis was exempt from review and the requirement for informed consent under 45 CFR §46.104(d)(4)(iii). The analysis plan, as well as primary and secondary outcomes, were preregistered on ClinicalTrials.gov (NCT04333199).

Study sample

All patients enrolled in the trial were aged 18 years or older, had an email address on file, and did not have an active Geisinger MyChart account at the time of enrollment. Additionally, each patient had a laboratory or diagnostic test ordered by a clinician within the 30 days preceding the email intervention whose results (hereafter referred to as “lab results”) had been available in the MyChart backend the day prior to the email send date. Baseline demographic characteristics of the randomized patients are shown in Supplementary Table 1.

Sample size justification

Stakeholders approved a 15-day trial period, during which we projected enrolling approximately 1810 patients per arm. An a priori power analysis indicated that the trial had 95% power to detect a 5 percentage point difference with two-tailed P < .05.

Intervention conditions

We randomly assigned 5009 Geisinger patients using simple randomization in base R version 3.6.032 to receive either a timely email inviting them to activate MyChart to view their results immediately rather than waiting (3340 [67%] randomized; 2750 [55%] sent email) or no email beyond usual health system efforts (1669 [33%] randomized, 1669 [33%] sent no email); details shown in Figure 1, the CONSORT diagram.

Figure 1.

For image description, please refer to the figure legend and surrounding text.

Open in a new tab

CONSORT flow diagram of patient allocation and intervention delivery.

Patients randomized to be sent an email emphasizing timely access to results were further randomly assigned 1:1 to receive either a Transparent-framed or Ease-framed email. The Transparent email explicitly described the brief registration process and included a call-to-action button labeled “Get Started with myGeisinger” that took users to the registration site (1669 [33%] assigned; 1351 [27%] sent email). To test whether disclosing a multi-step process to view lab results might discourage enrollment, the Ease email omitted any mention of the registration steps and instead included a button labeled “View My Lab Results,” which, when clicked, took users to the same registration site (see Supplementary Figure 1 for exact wording of the messages in each email). To test whether eliding the registration steps caused adverse reactions, we measured whether patients unsubscribed from Geisinger emails.

Within the email groups, 590 total emails were never delivered, either because the email delivery software flagged them as invalid (N = 404) or because they bounced upon delivery (N = 186). All emails were sent during the 15 days from May 18 through June 1, 2020.

Analysis

Our primary question was whether a timely email improves patient portal enrollment within one week compared with no timely email. This was evaluated using logistic regression (a generalized linear model with a binary distribution and log-link function) in an intent-to-treat design (N = 5009): patients who were randomized to be sent an email but whose addresses were flagged as invalid by the email delivery software were retained for comparisons with the no email control group, where it was not possible to flag those who would similarly not have received emails.

A secondary prespecified question was whether either email version outperformed the other. This was assessed by examining whether a patient opened the email, clicked on the registration link in the email, enrolled in the portal within one week, or unsubscribed from email communications within one month. We evaluated each outcome measure using a logistic regression. These analyses included patients who were successfully sent the emails (N = 2075).

We conducted exploratory post-hoc analyses to test whether the effects of the timely nudge (vs no email) and email framing (Ease vs Transparent) on one-week portal enrollment were moderated by demographic characteristics (age, sex, race, ethnicity, and Medicaid insurance status), as well as by patients’ prior exposure to the health system.

Further exploratory analyses examined whether the time-sensitivity of lab results moderated the effect of the timely nudge. We categorized lab result types as “more time-sensitive” or “less time-sensitive” based on consultation with Geisinger clinicians independent of the study team. We ran a logistic regression predicting patient portal enrollment as a function of study arm (Timely Email vs No Email), time sensitivity (More Time Sensitive vs Less Time Sensitive), and their interaction (Arm × Time Sensitivity). Separate logistic regression models were also run for patients randomized to be emailed and for those who were not emailed to estimate how the level of time sensitivity influences subsequent patient portal enrollment within each arm. We further assessed differences in enrollment rates by time sensitivity within the two email framing conditions (Ease and Transparent) to explore variations in response to the email message type.

To examine longer-term outcomes, we conducted exploratory analyses of patient portal engagement behaviors over the four years post-intervention among the patients who enrolled. We defined engagement in two ways: logging in to the portal and scheduling appointments through the portal. Given their appropriateness for positively skewed count data, we used generalized linear models with negative binomial distributions and log-link functions to evaluate relative rates of passive and active engagements across arms.

For all tests, odds ratios (ORs) or incidence rate ratios (IRRs) were calculated, along with 95% confidence intervals (CIs); two-tailed P values < .05 were used to determine statistical significance. All analyses were conducted in R version 4.0.3.32

Results

Our primary hypothesis was supported: Patients randomized to receive a timely email nudge were at 2.99 times the odds (95% CI: 2.28-3.92; P < .001) of enrolling in the patient portal within one week, compared with patients randomized to receive no email (see Figure 2A for estimated marginal means).

Figure 2.

For image description, please refer to the figure legend and surrounding text.

Open in a new tab

Enrollment in the patient portal at 1 week (A) and over time through 4 years (B) among patients who were randomized to be sent a timely email nudge vs those who did not. Error bars reflect 95% confidence intervals.

Examining portal enrollments over the course of four years post-nudge, we observed a statistically significant increase in patient portal enrollment for emailed patients (vs patients not emailed) at one month, six months, and one year after the initial timely nudge (see Figure 2B; see Supplementary Table 2 for enrollment rates and odds ratios), but not beyond one year.

There was no significant difference between the two email groups (Ease vs Transparent) in message opening behavior (OR = 1.04; 95% CI: 0.90-1.21; P=.57; see Figure 3A), but patients sent the Ease-framed email clicked the registration link significantly more than patients sent the Transparent-framed email (OR = 1.86; 95% CI: 1.57-2.20; P < .001). Despite a greater number of registration link clicks, the Ease-framed email did not statistically significantly increase the odds of one-week patient portal enrollment compared with the Transparent-framed email (OR = 1.18; 95% CI: 0.94-1.48; P = .15). Further, we found no statistically significant difference between Ease- and Transparent-framed emails in unsubscribing from system emails within one month after the email was sent (OR = 0.97, 95% CI: 0.14-6.87; P =.97). Over the four years following the nudge, the Ease-framed email consistently performed better than the Transparent-framed email numerically; however, these differences were always either not statistically significant or marginally significant (see Figure 3B and Supplementary Table 3).

Figure 3.

For image description, please refer to the figure legend and surrounding text.

Open in a new tab

Email open rates, registration clicked links, one-week enrollment, one-month unsubscribe rates (A) and four-year enrollment (B), comparing the Ease and Transparent email conditions. Error bars reflect 95% confidence intervals.

We additionally examined whether patients’ demographic characteristics, as well as length of time in, or utilization of, the health system moderated the effect of the timely email nudge. Interaction analyses showed no statistically significant moderation of the nudge’s effect by age, sex, race, ethnicity, or Medicaid insurance status (P >.05 for all interactions, see Supplementary Table 4). In both the timely email nudge and control arms, those who chose to enroll in MyChart (enrollees) had been in the system for fewer years and had had fewer prior encounters, compared with non-enrollees (see Supplementary Table 5). Interaction analyses showed no moderation on enrollment by years in system (OR = 1.00, 95% CI: 0.97-1.03, P = .95) or prior encounters (OR = 1.00, 95% CI: 0.997-1.005, P = .41), suggesting that history with the system did not make patients more or less susceptible to the nudges. When comparing the two nudge emails, we similarly found no statistically significant moderation of the effect of email framing by age, sex, race, ethnicity, or Medicaid insurance status (P > .05 for all interactions, see Supplementary Table 6). Prior encounters also did not moderate the effect on enrollment (OR = 1.00, 95% CI: 0.996-1.004, P =.99), but years in the system did (OR = 0.97, 95% CI: 0.945-0.998, P = .04). Namely, the Ease-framed email enrollees had been in the health system for nearly as many years as the non-enrollees, while those assigned to the Transparency-framed email had been in the system less time, consistent with the patterns we observed elsewhere (see Supplementary Table 7). That is, the Ease-framed email may have had relatively greater appeal to those in the system longer. However, given the small and inconsistent magnitude of these differences and the exploratory nature of these analyses, these findings should be interpreted cautiously.

Exploratory analysis of time sensitivity of lab results

We next explored other factors that might differentially motivate patients to enroll in the patient portal. One possibility is that the timely nudge was more effective with patients awaiting time-sensitive results (eg, receiving lab results for infectious diseases that may guide decision-making on treatment or isolation) than with those awaiting less time-sensitive tests. After consulting with a team of Geisinger clinicians, we coded patients’ lab results as time-sensitive if at least one of their results was deemed by the clinicians to be time-sensitive and as routine otherwise (more time-sensitive tests N = 5771; less time-sensitive tests N = 2880; see Figure 4a; see Supplementary Table 8 for full breakdown of lab test categorizations).

Figure 4.

For image description, please refer to the figure legend and surrounding text.

Open in a new tab

Categorization of lab tests based on time-sensitivity (A), with one-week enrollment rates among patients with more time-sensitive vs less time-sensitive lab results shown separately for patients who were sent a timely email and patients who were not (B). Error bars reflect 95% confidence intervals.

Among patients who were emailed, those awaiting more time-sensitive results were more likely to enroll in MyChart than those awaiting less time-sensitive results (OR = 1.46, 95% CI, 1.17-1.82; P < .001; see Figure 4b and Supplementary Table 9), with similar effects observed for the Ease and Transparent-framed emails (see Supplementary Figure 2 and Supplementary Table 10). In contrast, among patients who were not emailed, time sensitivity did not affect enrollment (OR = 1.0, 95% CI, 0.61-1.64, P = 1). These results suggest that simply having a time-sensitive lab result waiting did not result in greater portal enrollment in the absence of the nudge, whereas time sensitivity may have mattered among those receiving the nudge. However, the overall interaction between study arm (Timely Nudge vs No Email) and time sensitivity (More vs Less Time Sensitive) was not statistically significant (P = .17), suggesting that differences in the effectiveness of the nudged based on time-sensitivity of the lab result should be interpreted with caution.

Timely nudges led to regular passive and active usage of the patient portal over four years

To understand whether timely nudges lead to sustained MyChart engagement, we assessed MyChart usage for four years following the nudge. Specifically, we examined whether nudged and non-nudged patients who enrolled within seven days of the intervention showed similar rates of portal logins and use of the portal to schedule appointments.

Comparing enrolled participants in the timely nudge and the no email control group, we found no statistically significant difference in the mean number of logins (IRR = 1.02, 95% CI: 0.69-1.45; P = .93; see Figure 5A) or scheduled appointments (IRR = 0.65, 95% CI: 0.31-1.26; P = .23; see Figure 5B and Supplementary Table 11), suggesting that the intervention led non-users to become typically-engaged MyChart users. Likewise, we observed no significant differences between email framings in either logins (IRR = 1.29, 95% CI: 0.96-1.73, P = .09) or appointments (IRR = 0.88, 95% CI: 0.50-1.51, P = .64; see Supplementary Table 12) over the subsequent four years.

Figure 5.

For image description, please refer to the figure legend and surrounding text.

Open in a new tab

Mean number of portal logins (A) and scheduled appointments (B) over four years among patients who enrolled in the patient portal within one week of randomization, by intervention condition. Error bars reflect 95% confidence intervals.

Discussion

This study of a cost-effective, scalable intervention demonstrates that emailing patients just once with a patient portal enrollment invitation emphasizing immediate access to currently available lab results can effectively and substantially increase enrollment above usual system efforts, particularly among patients awaiting time-sensitive results. Nudged patients were significantly more likely to enroll in the portal within a week compared with those who were sent no timely email. These effects continued to be statistically significant up to a year after the initial nudge, and the nudged group had numerically higher enrollment rates over four years. The lasting difference in enrollment between email and no email groups indicates that the emails successfully nudged enrollment among patients who would not have otherwise enrolled, as opposed to merely nudging earlier enrollment. Our conclusion that this nudge converted patients who would not have otherwise enrolled is further supported by the finding that patients who enrolled in response to this intervention had been in the system for many years and had had multiple prior opportunities to enroll.

The null finding in the comparison of Ease and Transparent framing conditions aligns with previous health-related nudge studies revealing that messaging can have a significant effect relative to no messaging, but variations in messaging typically have non-significant or weak differential effects.25,29,33 The Ease-framed email led to more registration link clicks than the Transparent-framed message. However, there was no difference in enrollment rates, suggesting that more patients who received the Ease-framed email may have abandoned the registration process midway. One plausible explanation is that the call-to-action in the Ease-framed email (“View My Lab Results”) created expectations of immediate access that were not met due to the multi-step registration process, likely increasing drop-off due to unmet expectations or frustration. As a practical implication, health systems may benefit from pairing a salient call-to-action with more accurate expectations about the steps required to access results. Even so, unsubscribe rates were low and did not differ between the two conditions, indicating that the Ease-framed email did not provoke measurable backlash.

While this trial primarily aimed to increase enrollment, it also explored subsequent engagement with the portal to understand whether such a lightweight nudge can lead to sustained portal usage. Patients who enrolled in response to the timely email nudge showed similar long-term engagement with the portal—measured by logins and active scheduling of appointments—as patient portal enrollees who had not received the intervention. This finding suggests that the one-time nudge effectively converted non-users into typical users and highlights the potential of timely nudges to enroll new users that integrate into the portal ecosystem without additional engagement strategies.

Patients were most likely to enroll in the patient portal when they awaited time-sensitive results, such as results for an infectious disease, compared with those awaiting less time-sensitive results, such as routine blood work. While we did not assess explicitly why this might be the case, several mechanisms may be involved. More time-sensitive lab results may increase patient arousal or anxiety and motivate them to attain cognitive closure (ie, determine what the results indicate).34,35 Another possibility is that patients may feel more motivated by available results for single instance tests, like for infectious diseases such as strep throat, because they are often tied to time-bound actionable steps, such as isolating or starting treatment. Obtaining these results may foster a sense of control and resolution, reinforcing self-efficacy—the belief in one’s ability to effectively manage a situation.36 In contrast, chronic conditions, like diabetes, require ongoing lifestyle changes that are harder to achieve and lack a clear endpoint, making them feel less manageable. Relatedly, the infectious nature of many of the time-sensitive tests may evoke pro-social motivations,37,38 particularly the desire to protect loved ones, rather than the more routine tests that may less directly affect others.

Several limitations of this study must be acknowledged. First, the data were collected early in the COVID-19 pandemic, a period that may have increased overall patient engagement with health systems. Patients may have been more likely to enroll in MyChart during this time regardless of the intervention, potentially limiting the generalizability of the study. Second, given the demographics of the patient population that Geisinger serves, our sample predominantly comprised white patients, representing a broad range of ages and socioeconomic status but not fully representing the experiences and behaviors of more racially and ethnically diverse populations. Third, although the study addressed barriers related to patients’ awareness of one of the benefits of MyChart—immediate lab results—it did not address privacy concerns, which other qualitative studies have highlighted as significant barriers to health portal use.38 Finally, our results surrounding time sensitivity, nudge longevity, and engagement were all exploratory and hypothesis-generating. Future work should replicate and extend these findings.

Collectively, these findings demonstrate that a light-touch, scalable, one-time intervention—at strategic time points when patients are more inclined to act—can meaningfully increase patient portal enrollment. After completion of this trial, Geisinger implemented an automatic email notification when test results become available, as part of ongoing efforts to nudge patient portal activation. Other health systems should consider implementing similarly timed messages and explore other opportunities to present the benefits of desired actions as immediate and personally relevant to patients.

Supplementary Material

ooag064_Supplementary_Data
ooag064_supplementary_data.docx (333.4KB, docx)

Acknowledgments

We would like to acknowledge Amanda Jones and Bryanna Pardoe for their collaboration and assistance with sending patient emails, Jesse J. Manikowski for his help extracting and collating data from the EHR, and Donna Wolk and Ann Marie Tice for their help in categorizing lab tests based on time sensitivity.

Contributor Information

Sasha C Brietzke, Behavioral Insights Team, Geisinger Health System, Danville, PA, 17822, United States; Department of Bioethics and Decision Sciences, Geisinger College of Health Sciences, Danville, PA, 17822, United States.

Maheen Shermohammed, Behavioral Insights Team, Geisinger Health System, Danville, PA, 17822, United States.

Amir Goren, Behavioral Insights Team, Geisinger Health System, Danville, PA, 17822, United States.

Gail M Rosenbaum, Behavioral Insights Team, Geisinger Health System, Danville, PA, 17822, United States.

Michelle N Meyer, Behavioral Insights Team, Geisinger Health System, Danville, PA, 17822, United States; Department of Bioethics and Decision Sciences, Geisinger College of Health Sciences, Danville, PA, 17822, United States.

Christopher F Chabris, Behavioral Insights Team, Geisinger Health System, Danville, PA, 17822, United States; Department of Bioethics and Decision Sciences, Geisinger College of Health Sciences, Danville, PA, 17822, United States.

Author contributions

Sasha C. Brietzke (Data curation, Formal analysis, Methodology, Project administration, Software, Validation, Visualization, Writing—original draft), Maheen Shermohammed (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing—review & editing), Amir Goren (Conceptualization, Formal analysis, Methodology, Project administration, Resources, Supervision, Writing—review & editing), Gail M. Rosenbaum (Formal analysis, Methodology, Supervision, Validation, Writing—review & editing), Michelle N. Meyer (Conceptualization, Formal analysis, Methodology, Project administration, Resources, Supervision, Writing—review & editing), and Christopher F. Chabris (Conceptualization, Formal analysis, Methodology, Project administration, Resources, Supervision, Writing—review & editing)

Supplementary material

Supplementary material is available at JAMIA Open online.

Conflicts of interest

The authors have no competing interests to declare.

Funding

This project was funded by Geisinger Health System.

Data availability

Deidentified data and associated scripts used in this manuscript are available on OSF: https://doi.org/10.17605/OSF.IO/VZNB6.

References

  • 1. Delbanco T, Walker J, Bell SK, et al.  Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157:461-470. 10.7326/0003-4819-157-7-201210020-00002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Krist AH, Woolf SH, Rothemich SF, et al.  Interactive preventive health record to enhance delivery of recommended care: a randomized trial. Ann Fam Med. 2012;10:312-319. 10.1370/afm.1383 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3. Saberi P, Catz SL, Leyden WA, et al.  Antiretroviral therapy adherence and use of an electronic shared medical record among people living with HIV. AIDS Behav. 2015;19:177-185. 10.1007/s10461-014-0982-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4. Ammenwerth E, Schnell-Inderst P, Hoerbst A.  The impact of electronic patient portals on patient care: a systematic review of controlled trials. J Med Internet Res. 2012;14:e162. 10.2196/jmir.2238 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. Kruse CS, Bolton K, Freriks G.  The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17:e44. 10.2196/jmir.3171 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Kruse CS, Argueta DA, Lopez L, Nair A.  Patient and provider attitudes toward the use of patient portals for the management of chronic disease: a systematic review. J Med Internet Res. 2015;17:e40. 10.2196/jmir.3703 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Graetz I, Gordon N, Fung V, Hamity C, Reed ME. The digital divide and patient portals internet access explained differences in patient portal use for secure messaging by age, race, and income. 2016. www.lww-medicalcare.com [DOI] [PubMed]
  • 8. Turner K, Clary A, Hong YR, Tabriz AA, Shea CM.  Patient portal barriers and group differences: cross-sectional national survey study. J Med Internet Res. 2020;22:e18870. 10.2196/18870 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Grossman LV, Masterson Creber RM, Benda NC, Wright D, Vawdrey DK, Ancker JS.  Interventions to increase patient portal use in vulnerable populations: a systematic review. J Am Med Inform Assoc. 2019;26:855-870. 10.1093/jamia/ocz023 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. North F, Hanna BK, Crane SJ, Smith SA, Tulledge-Scheitel SM, Stroebel RJ.  Patient portal doldrums: does an exam room promotional video during an office visit increase patient portal registrations and portal use?  J Am Med Inform Assoc. 2011; 18: i24-27. 10.1136/amiajnl-2011-000381 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11. Ramsey A, Lanzo E, Huston-Paterson H, Tomaszewski K, Trent M.  Increasing patient portal usage: preliminary outcomes from the MyChart genius project. J Adolesc Health. 2018;62:29-35. 10.1016/j.jadohealth.2017.08.029 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12. Ryan Greysen S, Harrison JD, Rareshide C, et al.  A randomized controlled trial to improve engagement of hospitalized patients with their patient portals. J Am Med Inform Assoc. 2018;25:1626-1633. 10.1093/jamia/ocy125 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Lyles CR, Tieu L, Sarkar U, et al.  A randomized trial to train vulnerable primary care patients to use a patient portal. J Am Board Fam Med. 2019;32:248-258. 10.3122/jabfm.2019.02.180263 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Stein JN, Klein JW, Payne TH, et al.  Communicating with vulnerable patient populations: a randomized intervention to teach inpatients to use the electronic patient portal. Appl Clin Inform. 2018;9:875-883. 10.1055/s-0038-1676333 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Leveille SG, Walker J, Ralston JD, Ross SE, Elmore JG, Delbanco T.  Evaluating the impact of patients’ online access to doctors’ visit notes: designing and executing the OpenNotes project. BMC Med Inform Decis Mak. 2012;12:32. 10.1186/1472-6947-12-32 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Thaler RH, Sunstein CR.  Nudge: Improving Decisions about Health, Wealth, and Happiness. Yale University Press; 2008. 10.1016/s1477-3880(15)30073-6 [DOI] [Google Scholar]
  • 17. Patel MS, Volpp KG, Asch DA.  Nudge units to improve the delivery of health care. N Engl J Med. 2018;378:214-216. 10.1056/nejmp1712984 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Adusumalli S, Kanter GP, Small DS, et al.  Effect of nudges to clinicians, patients, or both to increase statin prescribing: a cluster randomized clinical trial. JAMA Cardiol. 2023;8:23-30. 10.1001/jamacardio.2022.4373 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19. Mehta SJ, Torgersen J, Small DS, et al.  Effect of a default order vs an alert in the electronic health record on hepatitis C virus screening among hospitalized patients: a Stepped-Wedge randomized clinical trial. JAMA Netw Open. 2022;5:e222427. 10.1001/jamanetworkopen.2022.2427 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20. Jenssen BP, Schnoll R, Beidas RS, et al.  Cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment for patients with cancer who smoke. J Clin Oncol. 2023;41:4511-4521. 10.1200/JCO.23.00355 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21. Takvorian SU, Gabriel P, Wileyto EP, et al.  Clinician- and patient-directed communication strategies for patients with cancer at high mortality risk: a cluster randomized trial. JAMA Netw Open. 2024;7:e2418639. 10.1001/jamanetworkopen.2024.18639 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Volpp KG, Troxel AB, Pauly MV, et al.  A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360:699-709. 10.1056/NEJMsa0806819 [DOI] [PubMed] [Google Scholar]
  • 23. Rosenbaum GM, Goren A, Shermohammed M, et al.   Algorithm-assisted personalized risk communication to encourage flu vaccination: three randomized field trials.  Nat Hum Behav. In press.  2026. 10.31234/osf.io/vtxza [DOI] [Google Scholar]
  • 24. Dai H, Saccardo S, Han MA, et al.  Behavioural nudges increase COVID-19 vaccinations. Nature. 2021;597:404-409. 10.1038/s41586-021-03843-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Santos HC, Goren A, Chabris CF, Meyer MN.  Effect of targeted behavioral science messages on COVID-19 vaccination registration among employees of a large health system: a randomized trial. JAMA Netw Open. 2021;4:e2118702. 10.1001/jamanetworkopen.2021.18702 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Gallagher KM, Updegraff JA.  Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review. Ann Behav Med. 2012;43:101-116. 10.1007/s12160-011-9308-7 [DOI] [PubMed] [Google Scholar]
  • 27. The Behavioural Insights Team. EAST: four simple ways to apply behavioural insights: Revised and updated edition. Published online 2024.
  • 28. Allgood PC, Maroni R, Hudson S, et al.  Effect of second timed appointments for non-attenders of breast cancer screening in England: a randomised controlled trial. Lancet Oncol. 2017;18:972-980. 10.1016/S1470-2045(17)30340-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Milkman KL, Patel MS, Gandhi L, et al.  A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor’s appointment. Proc Natl Acad Sci. 2021;118:e2101165118. 10.1073/pnas.2101165118 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Patel MS, Milkman KL, Gandhi L, et al.  A randomized trial of behavioral nudges delivered through text messages to increase influenza vaccination among patients with an upcoming primary care visit. Am J Health Promot. 2023;37:324-332. 10.1177/08901171221131021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Ho PM, Glorioso TJ, Allen LA, et al.  Personalized patient data and behavioral nudges to improve adherence to chronic cardiovascular medications. JAMA. 2025;333:49-59. 10.1001/jama.2024.21739 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. R Core Team. R: a language and environment for statistical computing. Published online 2020.
  • 33. Kasting ML, Head KJ, Cox D, Cox AD, Zimet GD.  The effects of message framing and healthcare provider recommendation on adult hepatitis B vaccination: a randomized controlled trial. Prev Med. 2019;127:105798. 10.1016/j.ypmed.2019.105798 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34. Kruglanski AW, Webster DM. Motivated closing of the mind: “Seizing” and “Freezing”. Vol 103. 1996. [DOI] [PubMed]
  • 35. Storbeck J, Clore GL.  Affective arousal as information: How affective arousal influences judgments, learning, and memory. Soc Personal Psychol Compass. 2008;25:1824-1843. 10.1111/j.1751-9004.2008.00138.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36. Bandura A.  Self-Efficacy: The Exercise of Control. W H Freeman/Times Books/ Henry Holt & Co; 1997. [Google Scholar]
  • 37. Batson CD, Kansas L. PROSOCIAL MOTIVATION: IS IT EVER TRULY ALTRUISTIC?
  • 38. Batson CD, Shaw LL.  Evidence for altruism: Toward a pluralism of prosocial motives. Psychol.l Inq.  1991;22:107-122. 10.1207/s15327965pli0202_1 [DOI] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

ooag064_Supplementary_Data
ooag064_supplementary_data.docx (333.4KB, docx)

Data Availability Statement

Deidentified data and associated scripts used in this manuscript are available on OSF: https://doi.org/10.17605/OSF.IO/VZNB6.

Articles from JAMIA Open are provided here courtesy of Oxford University Press

RESOURCES