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Journal of the American Medical Informatics Association : JAMIA logoLink to Journal of the American Medical Informatics Association : JAMIA
. 2019 Apr 4;26(10):960–967. doi: 10.1093/jamia/ocz030

Patient portal utilization: before and after stage 2 electronic health record meaningful use

Kea Turner 1,✉, Young-Rock Hong 1, Sandhya Yadav 1, Jinhai Huo 1, Arch G Mainous III 1
PMCID: PMC7647198  PMID: 30947331

Abstract

Objective

Patient portal functionalities, such as patient–physician e-communication, can benefit patients by improving clinical outcomes. Utilization has historically been low but may have increased in recent years due to the implementation of Stage 2 Meaningful Use for electronic health records. This study has 2 objectives: 1) to compare patient portal utilization rates before Stage 2 (2011–2013) and after Stage 2 (2014–2017), and 2) to examine whether disparities in patient portal utilization attenuate after Stage 2.

Materials and Methods

We conducted an observational study using a pooled cross-sectional analysis of 2011–2017 National Health Interview Survey data (n = 254 183).

Results

The mean percent use of patient portals significantly increased from the pre-Stage 2 to the post-Stage 2 period (6.9%, 95% CI, 6.2–7.5; P < .001). Non-Hispanic Black individuals (OR 0.81, 95% CI, 0.76–0.86; P < .0001) and Hispanic individuals (OR 0.79, 95% CI, 0.74–0.84; P < .0001) have lower odds of using patient portals compared to non-Hispanic White individuals. Although we found independent effects of race/ethnicity, we did not find a statistically significant interaction between race/ethnicity and time. We found a similar level of increase in patient portal utilization from the pre- to postperiod across racial and ethnic groups.

Discussion

Health care policies such as Stage 2 Meaningful Use are likely contributing to increased patient portal utilization across all patients and helping to attenuate disparities in utilization between subgroups of patients.

Conclusion

Further research is needed to explore which patient portal functionalities are perceived as most beneficial to patients and whether patients have access to those functionalities.

Keywords: electronic health record, meaningful use, e-health, patient portal, personal health record, personal health information management

INTRODUCTION

Patient portals can provide patients with the tools necessary to participate in, manage, and coordinate their health care.1 For example, patient portals can be used by health care providers to give patients access to tools, such as online appointment scheduling, prescription refill, or patient–physician e-communication.2,3 When surveyed about patient portals, patients overwhelmingly report interest in patient portals and believe that patient portal availability is an important criterion for selecting a provider.3–8 When used consistently, patient portals can benefit patients by improving patient–provider trust, patient satisfaction, medication adherence, and clinical outcomes.9–15 Despite the benefits, patient portal utilization has been low among patients.16–20

Studies have shown that patient portal utilization is low but has increased over time. A nationally representative study from 2018 found that 63% of patients who had a medical visit within the past year did not use a patient portal.21 Although overall usage is low, several studies have demonstrated increased usage of patient portals over time. For example, 1 study found that patient–physician e-communication increased from 30% to 40% from 2013 to 2014 among patients with access to a patient portal.22 Utilization, however, varies across patient populations. Patients with lower income, lower education, Black race, Hispanic ethnicity, public or no insurance, male gender, rural residence, and older age are significantly less likely to use patient portals.16–19,21–25 Conversely, patients with a greater number of chronic conditions are significantly more likely to use patient portals.20,24 Initial studies of patient portals found that many patients lacked access to patient portals from their provider17,26–29; however, more recent studies have suggested that access may be increasing. For example, a recent study found that 52% of patients were offered access to a patient portal in 2017 compared to 42% of patients in 2014.30 Studies have not yet explored whether federal incentive programs, such as Meaningful Use, have increased access and thus utilization of patient portals.

Stage 2 Meaningful Use was an important driver for expanding patient access to patient portals. Stage 2 required eligible providers to offer patients the ability to view, download, and transmit personal health information and e-communicate with their provider through a patient portal, which is tethered to the electronic health record (EHR).31 Most of the studies examining patient portal utilization are conducted at 1 point in time or examine trends prior to the implementation of Stage 2 Meaningful Use.16–20 Therefore, it is important to conduct a more recent analysis that examines the temporal trend of patient portal use before and after Stage 2 Meaningful Use implementation. Studies have also shown that factors, such as race, ethnicity, and health insurance, influence patients’ propensity to use patient portals.16–19,23,24,32,33 However, these differences might be explained by provider EHR adoption—studies have shown that providers with a higher proportion of Black, Hispanic, or Medicaid patients are less likely to adopt EHRs.34–37 Many of these studies were conducted in the early stages of Meaningful Use implementation before incentives were available. Therefore, it is possible that Meaningful Use incentives have helped to attenuate these disparities.

OBJECTIVE

To address this literature gap, this study has 2 aims: 1) to compare patient portal utilization rates prior to Stage 2 Meaningful Use implementation (2011–2013) and after Stage 2 Meaningful Use implementation (2014–2017), and 2) to examine whether disparities in patient portal utilization attenuate after Stage 2 Meaningful Use implementation.

MATERIALS AND METHODS

Data source and sample selection

Our study used the 2011–2017 National Health Interview Survey (NHIS) data. The NHIS is a nationwide cross–sectional household interview survey, conducted each year by the National Center for Health Statistics (NCHS). The NHIS uses a multistage area probability design to select a nationally representative sample and provides information on health status, health care services, and health behaviors of the noninstitutionalized US population.38 We merged 3 NHIS components—the adult sample file, person file, and family file—using a unique person identifier to comprise both family- and individual-level information. Our study sample included respondents who were aged 18 years or older at the time of survey. We excluded respondents with missing information on patient portal use (n = 3303), education (n = 966), employment (n = 98), health insurance (n = 766), and usual source of care (n = 2824), which accounted for 3.4% of the total sample (Supplementary MaterialTable S1). Nearly 9% of the sample (n = 15 488) had missing information on family income, so we used the Five Multiple Imputation data provided by NCHS to impute missing values from the NHIS family income questions.39 The final study sample consisted of 224 278 respondents.

Patient portal utilization

Our primary outcome was use of patient portals which included 4 binary variables: 1) filled a prescription online, 2) scheduled a medical appointment online, 3) communicated with a health care provider by email, and 4) any use of these 3 information management tools. In the NHIS, respondents were asked to answer the question “During the past 12 months, have you ever used computers for any of the following: 1) schedule an appointment with a health care provider (online medical appointment), 2) communicate with a health care provider by email (online communication), and 3) fill a prescription (online prescription refill).” The respondents were categorized as a patient portal user if any of these 3 options were selected.

Independent variables

Independent variables in our analyses included year of survey (2011–2017), age (18–44, 45–64, and 65 or greater), sex (male and female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and Other), and marital status (married and unmarried). Since year 2014 was the beginning of Stage 2 Meaningful Use, we categorized 2011–2013 as the pre-Stage 2 Meaningful Use period and 2014–2017 as the post-Stage 2 Meaningful Use period. We also included the following: 1) employment status (employed and not employed), 2) education (less than high school, high school or GED, some college, bachelor’s degree, or graduate degree or higher); 3) family income (low income [Federal Poverty Level; FPL < 200%], middle income [FPL 200%–400%], and high income [FPL > 400%]); 4) census region (Northeast, Midwest, South, and West); 5) health insurance (private, Medicare including dual eligible, Medicaid, other public, and uninsured); 6) usual source of care (USC) (having USC and no USC); 7) number of chronic conditions (0, 1, 2, and 3 or more); and 8) number of health care visits in the past year (0, 1, 2, 3, or 4, and 5 or more).

Statistical analyses

The unadjusted association of each potential explanatory variable with patient portal use was assessed using Wald F tests. Temporal trends in patient portal use, including 3 types of patient portal tools, were tested using the Cochran-Armitage trend test. We used linear regression to calculate the difference in mean percent use of patient portals for the pre-Stage 2 Meaningful Use period and the post-Stage 2 Meaningful Use period. We conducted multivariable logistic regression models to identify independent predictors of patient portal use. We also tested for the pre- and postdifference in the association of patient portal use with race/ethnicity and health insurance type by adding interaction terms into separate models.

All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC). To account for selection probability, oversampling, and nonresponse in the survey, we used PROC SURVEY procedures and NHIS survey weights. Statistical significance was tested at P < .05. The study was deemed exempt from review by the University of Florida Institutional Review Board.

RESULTS

Sample characteristics

Among the 254 183 individuals in the sample, 17.2% of respondents had used at least 1 patient portal tool during the study period (Table 1). We observed a higher proportion of patient portal users among respondents who were female (18.8% vs 14.4% male), married (20.3% vs 13.6% unmarried), aged 45–64 (19.5% vs 17.0% 18–44 vs 13.6% 65+), and non-Hispanic White (19.6% vs 12.2% non-Hispanic Black vs 10.0% Hispanic). Use of patient portals also varied among respondents with different insurance status: private insurance (22.2%), Medicare insurance (12.9%), Medicaid insurance (8.1%), other public insurance (16.9%), and no insurance (5.4%). The proportion of patient portal users increased as the number of health care visits increased (5.1% for no office visit to 24.3% for 5 or more office visits) or as the number of chronic conditions increased (15.1% for no comorbidities to 17.3% for 3 or more comorbidities).

Table 1.

Baseline Characteristics of Study Sample by Use of Patient Portal: NHIS 2011-2017

Used Any Patient Portal Tools
YES
 NO
Characteristics Total No. No. Row %*, (95% CI) No. Row %, (95% CI)
Total 224 278 35015 17.2 (16.8–17.6) 189 263 82.8 (82.4–83.2) P value
Survey Year < .0001
 2011 32 064 3731 12.6 (12.0–13.1) 28 333 87.4 (86.9–88.0)
 2012 33 277 3751 12.5 (11.9–13.0) 29 526 87.5 (87.0–88.1)
 2013 33 400 4448 14.6 (14.0–15.2) 28 952 85.4 (84.8–86.0)
 2014 35 414 4653 14.7 (14.0–15.3) 30 761 85.3 (84.7–86.0)
 2015 32 386 5621 19.2 (18.4–20.0) 26 765 80.8 (80.0–81.6)
 2016 31 875 6607 21.5 (20.6–22.5) 25 268 78.5 (77.5–79.4)
 2017 25 862 6204 24.9 (23.8–26.0) 19 658 75.1 (74.0–76.2)
Age Group < .0001
 18-44 94 996 15 643 17.0 (16.5–17.5) 79 353 83.0 (82.5–83.5)
 45-64 75 685 13 204 19.5 (18.9–20.0) 62 481 80.5 (80.0–81.1)
 65+ 53 597 6168 13.6 (13.0–14.1) 47 429 86.4 (85.9–87.0)
Sex < .0001
 Male 100 307 13 652 14.8 (14.3–15.2) 86 655 85.2 (84.8–85.7)
 Female 123 971 21 363 19.4 (18.9–19.9) 102 608 80.6 (80.1–81.1)
Race/Ethnicity < .0001
 Non-Hispanic White 143 062 26 073 19.6 (19.1–20.1) 116 989 80.4 (79.9–80.9)
 Non-Hispanic Black 30 604 3239 12.2 (11.6–12.8) 27 365 87.8 (87.2–88.4)
 Hispanic 34 997 3063 10.0 (9.4–10.5) 31 934 90.0 (89.5–90.6)
 Other 15 615 2640 19.2 (18.0–20.5) 12 975 80.8 (79.5–82.0)
Marital Status < .0001
 Not married 125 594 16 533 13.6 (13.2–14.1) 109 061 86.4 (85.9–86.8)
 Married 98 684 18 482 20.3 (19.8–20.8) 80 202 79.7 (79.2–80.2)
Employment < .0001
 Not employed 96 547 11 370 13.3 (12.9–13.7) 85 177 86.7 (86.3–87.1)
 Employed 127 731 23 645 19.8 (19.2–20.3) 104 086 80.2 (79.7–80.8)
Education < .0001
 Less than High School 32 364 880 3.3 (3.0–3.6) 31 484 96.7 (96.4–97.0)
 High School or GED 56 955 4474 8.9 (8.6–9.3) 52 481 91.1 (90.7–91.4)
 Some College 69 381 11 033 17.2 (16.7–17.7) 58 348 82.8 (82.3–83.3)
 Bachelor’s 41 424 10 807 27.8 (27.1–28.6) 30 617 72.2 (71.4–72.9)
 Graduate or Higher 24 154 7821 34.2 (33.2–35.3) 16 333 65.8 (64.7–66.8)
Family Income Level < .0001
 Low (FPL < 200%) 89 893 6979 8.4 (8.1–8.7) 82 914 91.6 (91.3–91.9)
 Middle (FPL 200–400) 70 005 10 636 15.9 (15.4–16.3) 59 369 84.1 (83.7–84.6)
 High (FPL > 400) 64 380 17 400 27.8 (27.1–28.4) 46 980 72.2 (71.6–72.9)
Census Region < .0001
 Northeast 36 863 5325 15.4 (14.6–16.2) 31 538 84.6 (83.8–85.4)
 Midwest 48 500 7576 17.2 (16.4–18.0) 40 924 82.8 (82.0–83.6)
 South 80 155 11 425 15.7 (14.9–16.5) 68 730 84.3 (83.5–85.1)
 West 58 760 10 689 21.0 (20.0–21.9) 48 071 79.0 (78.1–80.0)
Type of Insurance < .0001
 Private 109 324 23 999 22.8 (22.2–23.3) 85 325 77.2 (76.7–77.8)
 Medicare 58 727 6729 13.4 (12.9–13.9) 51 998 86.6 (86.1–87.1)
 Medicaid 18 317 1442 8.4 (7.8–9) 16 875 91.6 (91.0–92.2)
 Other Public 7552 1260 17.7 (16.5–18.9) 6292 82.3 (81.1–83.5)
 Uninsured 30 358 1585 5.5 (5.1–5.9) 28 773 94.5 (94.1–94.9)
Usual Source of Care < .0001
 No 31 989 2377 7.8 (7.3–8.2) 29 612 92.2 (91.8–92.7)
 Yes 192 289 32 638 18.8 (18.3–19.2) 159 651 81.2 (80.8–81.7)
Number of Visits in Past 12 Months < .0001
 0 39 471 1870 5.1 (4.8–5.4) 37 601 94.9 (94.6–95.2)
 1 38 753 4759 13.4 (12.9–14.0) 33 994 86.6 (86.0–87.1)
 2 58 654 10 307 19.5 (18.9–20.2) 48 347 80.5 (79.8–81.1)
 3–4 46 979 9255 22.3 (21.7–23.0) 37 724 77.7 (77.0–78.3)
 5+ 40 421 8824 24.3 (23.5–25.0) 31 597 75.7 (75.0–76.5)
Number of Comorbidities** < .0001
 0 105 451 14 972 15.1 (14.7–15.6) 90 479 84.9 (84.4–85.3)
 1 60 790 10 706 19.8 (19.1–20.4) 50 084 80.2 (79.6–80.9)
 2 30 583 5306 20.0 (19.2–20.7) 25 277 80.0 (79.3–80.8)
 3+ 27 418 4022 17.3 (16.6–18.0) 23 396 82.7 (82.0–83.4)
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Abbreviations: FPL, federal poverty level; GED, general equivalency diploma.

*

Percentages are weighted to be nationally representative.

**

Comorbidities include hypertension, diabetes, coronary heart diseases, angina, heart attack, other heart disease, stroke, emphysema, asthma, chronic obstructive pulmonary disease, ulcer, and any type of cancer.

Patient portal utilization

The trend analysis from 2011 to 2017 shows that the use of patient portals increased from 12.5% in 2011 to 25.0% in 2017 (Figure 1). The rate of patient portal use in 2014 (14.7%) was similar to that in 2013 (14.6%), and then begins to increase more sharply from 2015 (19.2%) through 2017 (24.9%). When comparing the difference in mean percent use of patient portals for the pre-Stage 2 Meaningful Use period and the post-Stage 2 Meaningful Use period, we observed a significant increase in any patient portal tool use (6.9%, 95% CI, 6.2–7.5; P < .001) (see Table 2). Similarly, we found a significant increase in online appointments scheduled (5.7%, 95% CI 5.2–6.2; P < .001), online patient–physician communication (5.5%, 95% CI, 5.0–5.9; P < .001), and online prescription refills (1.8%, 95% CI, 1.4–2.1; P < .001)—although the difference for this category was small relative to the other categories.

Figure 1.

Figure 1.

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Trends in Patient Portal Utilization in 2011–2017 in the US. Note. The dashed line represents the expected time trend for any patient portal tool use based on 2011–2014 (Pre-Stage 2 Meaningful Use).

Table 2.

Changes in Patient Portal Utilization between Pre- (2011–2013) and Post-Stage 2 Meaningful Use (2014–2017)

Pre-Stage 2 MU Post-Stage 2 MU Absolute Difference Post vs Pre, % Change (95% CI) Adjusted Difference Post vs Pre, % Change (95% CI)bc,
Weighted %, (95% CI)a Weighted %, (95% CI)a
Scheduled medical appointment on internet 5.2 (4.9–5.4) 10.9 (10.5–11.3) 5.7 (5.2–6.2) 5.2 (4.8–5.6)
Communicated with health care provider by email 6.2 (5.9–6.5) 11.7 (11.3–12.1) 5.5 (5.0–5.9) 5.0 (4.6–5.4)
Filled a prescription on internet 7.2 (6.9–7.4) 8.9 (8.6–9.2) 1.8 (1.4–2.1) 1.3 (1.0–1.7)
Any use of patient portal tools 13.2 (12.8–13.6) 20.1 (19.5–20.7) 6.9 (6.2–7.5) 6.0 (5.5–6.5)
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Abbreviations: CI, confidence interval; MU, Meaningful Use.

a

Percentages are weighted to be nationally representative.

b

Adjusted for all individual characteristics listed in Table 1.

c

All differences (both unadjusted and adjusted) in percentage changes of online appointment, email communication, prescription refill, and use of any patient portal tools are significant at P < .0001.

Multivariable analysis revealed that the likelihood of patient portal use was greater for the following binary variables: female (odds ratio [OR] 1.30, 95% CI, 1.26–1.34; P < .0001), married individuals (OR, 1.16, 95% CI, 1.12–1.20; P < .0001), employed individuals (OR, 1.13, 95% CI, 1.08–1.19; P < .0001), and individuals with a usual source of care (OR, 1.29, 95% CI, 1.20–1.37; P < .0001) (Table 3). Similarly, compared to individuals with less than a high school education, individuals with higher levels of education have higher odds of using patient portals (eg, graduate-level education: OR, 7.83, 95% CI, 7.11–8.63; P < .0001). Compared to individuals with low-income (FPL < 200%), individuals with higher levels of income have higher odds of using patient portals (eg, high income: OR, 1.87, 95% CI, 7.11–8.63; P < .0001). Compared to the West census region, individuals living in other regions have higher odds of using patient portals (eg, West: OR, 1.80, 95% CI, 1.67–1.94; P < .0001). Odds of patient portal utilization also increased as an individual’s number of chronic conditions or health visits increased. For example, individuals with 1 chronic condition (OR, 1.32, 95% CI, 1.27–1.37; P < .0001), 2 chronic conditions (OR, 1.50, 95% CI, 1.43–1.59; P < .0001), or 3 or more chronic conditions (OR, 1.53, 95% CI, 1.44–1.62; P < .0001) have higher odds of using patient portals compared to individuals with no chronic conditions.

Table 3.

Multivariable Logistic Results: Predictors of Patient Portal Use

Any Patient Portal Tool Use
Odds Ratio 95% CI P value
Survey Year
 2011 1.00
 2012 1.00 0.94 1.07 .970
 2013 1.21 1.14 1.29 < .0001
 2014 1.21 1.13 1.29 < .0001
 2015 1.65 1.55 1.76 < .0001
 2016 1.94 1.81 2.09 < .0001
 2017 2.32 2.15 2.50 < .0001
Age Group
 18–44 1.00
 45–64 0.82 0.79 0.86 < .0001
 65+ 0.60 0.55 0.66 < .0001
Sex
 Male 1.00
 Female 1.30 1.26 1.34 < .0001
Race/Ethnicity
 Non-Hispanic White 1.00
 Non-Hispanic Black 0.81 0.76 0.86 < .0001
 Hispanic 0.79 0.74 0.84 < .0001
 Other 0.91 0.85 0.97 .007
Marital Status
 Not married 1.00
 Married 1.16 1.12 1.20 < .0001
Employment
 Not employed 1.00
 Employed 1.13 1.08 1.19 < .0001
Education
 Less than High School 1.00
 High School or GED 2.22 2.01 2.45 < .0001
 Some College 3.93 3.58 4.31 < .0001
 Bachelor’s 6.22 5.65 6.85 < .0001
 Graduate or Higher 7.83 7.11 8.63 < .0001
Family Income Level
 Low (FPL<200%) 1.00
 Middle (FPL 200–400) 1.31 1.25 1.38 < .0001
 High (FPL>400) 1.87 1.77 1.96 < .0001
Census Region
 Northeast 1.00
 Midwest 1.28 1.19 1.37 < .0001
 South 1.24 1.16 1.33 < .0001
 West 1.80 1.67 1.94 < .0001
Type of Insurance
 Private 1.00
 Medicare 0.76 0.69 0.83 < .0001
 Medicaid 0.63 0.57 0.69 < .0001
 Other Public 0.96 0.87 1.05 0.32
 Uninsured 0.63 0.58 0.68 < .0001
Usual Source of Care
 No 1.00
 Yes 1.29 1.20 1.37 < .0001
Number of Visits in Past 12 Months
 0 1.00
 1 2.03 1.88 2.18 < .0001
 2 3.07 2.86 3.30 < .0001
 3–4 3.94 3.65 4.25 < .0001
 5+ 4.65 4.31 5.02 < .0001
Number of Comorbidities
 0 1.00
 1 1.32 1.27 1.37 < .0001
 2 1.50 1.43 1.59 < .0001
 3+ 1.53 1.44 1.62 < .0001
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Abbreviations: CI, confidence interval; GED, general equivalency diploma.

Conversely, several factors were associated with lower odds of using patient portals. For example, compared to individuals ages 18–44, individuals 65 and older had lower odds of using patient portals (OR, 0.60, 95% CI, 0.55–0.66; P < .0001). Similarly, non-Hispanic Black individuals (OR, 0.81, 95% CI, 0.76–0.86; P < .0001) and Hispanic individuals (OR 0.79, 95% CI 0.74–0.84; P < .0001) have lower odds of using patient portals compared to non-Hispanic White individuals. Compared to individuals with private insurance, individuals with Medicaid insurance (OR, 0.63, 95% CI, 0.57–0.69; P < .0001), Medicare insurance (OR, 0.76, 95% CI, 0.69–0.83; P < .0001), and no insurance (OR, 0.63, 95% CI, 0.58–0.68; P < .0001) have lower odds of using patient portals. We did not observe a statistically significant difference between private insurance and other public insurance.

Although we found independent effects of race, ethnicity, and insurance status, we did not find a statistically significant interaction between time (eg, pre-post variable) and race, ethnicity, or insurance status (Supplementary MaterialTable S2). We found a similar level of increase in patient portal utilization from the pre- to postperiod for all racial and ethnic groups and all insurance types.

DISCUSSION

This study examined the temporal trend of patient portal use and disparities in utilization before and after Stage 2 Meaningful Use implementation. The findings from this study suggest that use of patient portals has increased significantly in the past several years as providers prepared for and implemented the Stage 2 Meaningful Use program. The results also indicate that there are still disparities in patient portal utilization based on race, ethnicity, and type of insurance, but that these disparities may have attenuated after Stage 2 Meaningful Use implementation. Finally, our study revealed an unexpected finding—utilization of online prescription refill was much lower than other patient portal tools. We describe potential reasons for this below and provide recommendations for future research.

The findings suggest that patient portal utilization increased right after the implementation of the Stage 2 Meaningful Use program. The Stage 2 Meaningful Use program was implemented in stages, starting in 2014 for providers that enrolled in Stage 1 Meaningful Use in 2011 or 2012.40 Providers who enrolled in Stage 1 after 2012 were required to start Stage 2 after 2014, ranging from 2015 to 2020, depending on their enrollment date. The staged implementation of Meaningful Use may help to explain why we continue to see increases in patient portal utilization each year following 2014. Additionally, starting in 2015, eligible physicians who did not implement Meaningful Use were subjected to a payment adjustment penalty. Future studies should explore whether this trend in increased patient portal utilization continues beyond 2017, where our study ends. Stage 3 Meaningful Use also expands the requirements for patient portals, such as providing patient-specific health education resources for 35% of patients through the patient portal.40 Therefore, future studies could examine whether implementation of Stage 3 Meaningful Use increases patients’ utilization of patient portals (requirements for Stage 3 objectives will begin in 2018). There has also been recent efforts to improve patients’ access to health information across providers. For example, the 21st Century Cures Act of 2016 contained provisions to encourage patients’ access to longitudinal health information aggregated from multiple providers.41 Additionally, Apple Inc. recently created the Health Records application, which would serve as a supplement to patient portals by allowing patients to aggregate health information from multiple providers.42 Future studies should explore patients’ ability to integrate health information from multiple providers’ portals.

We also observed that differences in patient portal utilization based on race, ethnicity, and insurance type may have attenuated after Stage 2 Meaningful Use implementation. Consistent with other studies, we found that non-Hispanic Black and Hispanic patients were less likely to use a patient portal as well as individuals with Medicare or Medicaid insurance.16–19,23,24,32,33 A recent study found that Medicare and Medicaid beneficiaries were less likely to use patient portals compared to privately insured individuals and were more likely to report nonuse of patient portals because of their preference for speaking directly with a provider.21 The same study found that non-Hispanic Black and Hispanic patients were less likely to use a patient portal compared to non-Hispanic White patients and were more likely to report nonuse due to privacy concerns.21 A similar study reported patient preferences for face-to-face communication and privacy concerns as barriers to patient portal usage.30 These findings suggest that more patient education is needed to demonstrate that patient portals can be used to complement rather than replace in-person office visits.21,30

Although we observed significant differences based on race, ethnicity, and insurance type, we found that patient portal utilization increased by a similar level among all racial and ethnic groups from pre- to post-Stage 2 Meaningful Use—suggesting that racial- and insurance-based disparities may be slowly attenuating. It is possible that implementation of the Meaningful Use incentive program helped to improve EHR adoption among providers that serve a high proportion of Black, Hispanic, or Medicaid patients. A recent study found that EHR adoption disparities between providers that do and do not serve a high proportion of minority patients declined after Stage 1 Meaningful Use implementation.43 Similar studies have found that gaps in EHR adoption attenuated between providers in low- and high-poverty areas, urban and rural areas, and community health centers and physician-owned practices during the first few years following Health Information Technology for Economic and Clinical Health Act implementation.44,45 Additional research is needed to evaluate how disparities in EHR adoption have changed in light of both Stage 1 and Stage 2 Meaningful Use and how changes in EHR adoption have affected patients’ use of patient portals.

Another unexpected finding in our study is that the use of some patient portal tools (eg, e-communication and online appointment scheduling) increased by 6 or 7 percentage points from the pre- to postperiod, whereas the increase for online prescription refill was smaller (2.5 percentage points). A descriptive study examining patients’ utilization of patient portals found that more patients used e-communication than online prescription refill.46 The authors suggested that providers may not offer online prescription refill as frequently as other patient portal tools if they participate in e-prescribing, wherein providers write, store, and send prescriptions to pharmacists electronically.46 Additionally, it is possible that prescription refill is implemented by the pharmacy or that not all prescriptions need a refill. Further studies are needed to explore which tools are offered within the patient portal and which tools are perceived to be most useful among patients.

Limitations

Our study has a number of limitations. First, this study is observational and, therefore, we cannot conclude whether Stage 2 Meaningful Use was the driver of increased patient portal use over time. Second, NHIS data do not include several important factors related to patient portal utilization, such as rural residence and internet access. However, most Americans now have internet access (about 89%) due to investments by the federal government to eliminate the digital divide and increased smartphone ownership.47,48 Third, our study captures patients’ use of patient portals but does not capture providers’ adoption of patient portals. Future studies are needed to examine how providers’ adoption of patient portal has changed since Stage 2 Meaningful Use. One study reported that 47% of physicians offered patient portals in 2014 compared with 33% of physicians in 2013 suggesting an increase over time.49 Similar trends in patient portal adoption have been reported among hospitals, further evidence that access is increasing.50 Finally, there are policy changes that occurred simultaneously with Meaningful Use, such as the Affordable Care Act, making it difficult to discern whether the trends in patient portal utilization are shifting due to Meaningful Use, the Affordable Care Act, or both.

CONCLUSION

Patient portals can be used by patients to participate in, manage, and coordinate their health care. Health care policies such as Stage 2 Meaningful Use are likely contributing to increased patient portal utilization across all patients and helping to attenuate disparities in utilization between subgroups of patients. Further research is needed to explore which patient portal tools are perceived as most beneficial to patients and whether patients have access to those tools.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

AUTHOR CONTRIBUTIONS

KT conceived the research question and study design and wrote the manuscript. YRH conducted statistical analyses of the study results. SY assisted with the literature review for the manuscript. JH helped design aspects of the methodology and provided guidance on the interpretation of the analyses. AGM helped refine aspects of the study design and methodology. YHR, SY, JH, AGM reviewed and noted points of revision for the manuscript.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Journal of the American Medical Informatics Association online.

CONFLICT OF INTEREST STATEMENT

None declared.

Supplementary Material

ocz030_Supplementary_Data
Click here for additional data file. (17.8KB, docx)

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Associated Data

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Supplementary Materials

ocz030_Supplementary_Data
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