Abstract
This cross-sectional study assesses data from the 2017-2020 Health Information National Trends Survey to examine whether smartphone-only internet access is associated with patient portal use.
Introduction
Unequal access to information and communication technology, or the digital divide, is a key determinant of patient portal adoption.1,2 The digital divide stems from many factors, such as portal usability, digital literacy, internet access, and high broadband costs.1,2 The latter have led many US residents (approximately 20%) to opt for smartphone-only internet access, especially individuals from minority racial/ethnic groups and adults with low income.3 Smartphone-only internet access could bridge the digital divide in patient portals by providing internet access, or it could exacerbate disparities, given challenges with mobile portal access (eg, data usage limits, lack of mobile-friendly sites).4 To address this gap, this study examined whether smartphone-only internet access was associated with patient portal use.
Methods
For this cross-sectional study, data from January 2017 through June 2020 were obtained from the 2017-2020 Health Information National Trends Survey, which includes questions about patient portal use and internet access in the last 12 months. The survey assesses factors associated with patient portal use, including health care access (eg, insurance coverage), digital literacy (eg, use of internet to view health information), demographic details (eg, income), and health characteristics (eg, comorbidities). We selected factors that are independently associated with patient portal usage.1,2
We compared smartphone-only internet access and patient portal use based on sample characteristics, using the Pearson χ2 test. We ran 2 multivariable logistic regressions controlling for year to examine which factors were associated with smartphone-only internet access and patient portal use. We removed individuals with missing data or no internet access, or who did not report a health care visit in the last 12 months. We checked for multicollinearity across covariates. We used sampling and jackknife replicate weights to account for the stratified survey design and develop nationally representative estimates. Analyses were conducted in Stata, version 16 (StataCorp). A 2-sided P = .05 was used to determine statistical significance. This study was exempted by the Advarra institutional review board because of the use of publicly available data. The results are reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.5
Results
The sample contained 8790 adults. Most participants were women (5196 [59.1%]), non-Hispanic White (6325 [72.0%]), and aged 35 to 49 years (1964 [22.3%]) or 50 to 64 years (2995 [34.1%]). The number of US residents with smartphone-only internet access increased from 21.6% in 2017 to 31.1% in 2020 (P < .001) (Table 1). Patient portal use increased from 44.0% (766 of 1742 respondents) in 2017 to 54.8% (1208 of 2204 respondents) in 2020 (P < .001). Controlling for other factors, non-Hispanic Black participants (odds ratio [OR], 1.32; 95% CI, 1.01-1.72) and Hispanic participants (OR, 1.33; 95% CI, 1.04-1.72) had significantly higher odds of smartphone-only internet access compared with non-Hispanic White participants (Table 2). Individuals in the highest income category (≥$75 000) had significantly lower odds of smartphone-only internet access compared with those with lower income (<$20 000) (OR, 0.57; 95% CI, 0.40-0.80). Controlling for other factors, smartphone-only internet access was associated with significantly lower odds of portal use compared with having a wired connection (OR, 0.82; 95% CI, 0.74-0.91). After controlling for smartphone-only internet access, higher income (≥$75 000) was associated with significantly higher odds of portal use compared with that for individuals with lower income (<$20 000) (OR, 1.93; 95% CI, 1.62-2.30).
Table 1. Sample Characteristics, 2017-2020.
| Characteristic | Overall, No. (%) (N = 8790) | Smartphone-only internet access, No. (%) (n = 2444) | P value | Patient portal adoption, No. (%) (n = 4379) | P value |
|---|---|---|---|---|---|
| Uses internet to view health information | |||||
| Yes | 7446 (84.7) | 2094 (28.1) | .12 | 4013 (53.9) | <.001 |
| No | 1344 (15.3) | 350 (26.0) | 366 (27.2) | ||
| Usual source of carea | |||||
| Yes | 6915 (78.7) | 1807 (26.1) | <.001 | 3687 (53.3) | <.001 |
| No | 1875 (21.3) | 637 (34.0) | 692 (36.9) | ||
| Uninsured | |||||
| Yes | 264 (3.0) | 95 (36.0) | .003 | 71 (26.9) | <.001 |
| No | 8526 (97.0) | 2349 (27.5) | 4308 (50.5) | ||
| Age, y | |||||
| 18-34 | 1308 (14.9) | 625 (47.8) | <.001 | 647 (49.5) | .001 |
| 35-49 | 1964 (22.3) | 580 (29.5) | 997 (50.8) | ||
| 50-64 | 2995 (34.1) | 770 (25.7) | 1507 (50.3) | ||
| 65-74 | 1801 (20.5) | 368 (20.4) | 921 (51.1) | ||
| ≥75 | 722 (8.2) | 101 (14.0) | 307 (42.5) | ||
| Sex | |||||
| Men | 3594 (40.9) | 727 (20.2) | <.001 | 1651 (45.9) | <.001 |
| Women | 5196 (59.1) | 1717 (33.0) | 2728 (52.5) | ||
| Race/ethnicity | |||||
| Non-Hispanic White | 6325 (72.0) | 1613 (25.5) | <.001 | 3263 (51.6) | <.001 |
| Non-Hispanic Black | 1556 (17.7) | 514 (33.0) | 723 (46.5) | ||
| Hispanic | 909 (10.3) | 317 (34.9) | 393 (43.2) | ||
| Other | 839 (9.5) | 267 (31.8) | 409 (48.7) | ||
| Income, $ | |||||
| <20 000 | 965 (11.0) | 369 (38.2) | <.001 | 332 (34.4) | <.001 |
| 20 000-34 999 | 960 (10.9) | 289 (30.1) | 361 (37.6) | ||
| 35 000-49 999 | 1083 (12.3) | 325 (30.0) | 502 (46.4) | ||
| 50 000-74 999 | 1703 (19.4) | 489 (28.7) | 834 (49.0) | ||
| ≥75 000 | 4079 (46.4) | 972 (23.8) | 2350 (57.6) | ||
| Education | |||||
| High school diploma or less | 3863 (43.9) | 1147 (29.7) | <.001 | 1607 (41.6) | <.001 |
| College degree | 2832 (32.2) | 799 (28.2) | 1523 (53.8) | ||
| Postgraduate | 2095 (23.8) | 498 (23.8) | 1249 (59.6) | ||
| Married | |||||
| Yes | 5211 (59.3) | 1334 (25.6) | <.001 | 2759 (52.9) | <.001 |
| No | 3579 (40.7) | 1110 (31.0) | 1620 (45.3) | ||
| Rural residence | |||||
| Yes | 973 (11.1) | 298 (30.6) | .04 | 410 (42.1) | <.001 |
| No | 7817 (88.9) | 2146 (27.5) | 3969 (50.8) | ||
| Multiple chronic conditionsb | |||||
| Yes | 2639 (30.0) | 717 (27.2) | .38 | 1352 (51.2) | .08 |
| No | 6151 (70.0) | 1727 (28.1) | 3027 (49.2) | ||
| Deafness or hearing impairment | |||||
| Yes | 534 (6.1) | 122 (22.8) | .008 | 247 (46.3) | .09 |
| No | 8256 (93.9) | 2322 (28.1) | 4132 (50.0) | ||
| Year | |||||
| 2017 | 1742 (19.8) | 377 (21.6) | <.001 | 766 (44.0) | <.001 |
| 2018 | 1818 (20.7) | 476 (26.2) | 810 (44.6) | ||
| 2019 | 3026 (34.4) | 905 (29.9) | 1595 (52.7) | ||
| 2020 | 2204 (25.1) | 686 (31.1) | 1208 (54.8) |
Refers to having a particular clinician whom a patient consults when health care is needed (eg, primary care clinician).
Having 2 or more chronic conditions (diabetes, hypertension, heart condition, chronic lung disease, and depression or anxiety disorder).
Table 2. Factors Associated With Smartphone-Only Internet Access and Patient Portal Use, 2017-2020.
| Variable | Smartphone-only internet access (n = 8790) | Patient portal use (n = 8790) | ||
|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | |
| Smartphone only | ||||
| Yes | NA | NA | 0.82 (0.74-0.91) | <.001 |
| No | NA | NA | 1 [Reference] | NA |
| Uses internet to view health information | ||||
| Yes | 0.92 (0.67-1.26) | .60 | 2.66 (2.33-3.05) | <.001 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Usual source of carea | ||||
| Yes | 0.85 (0.70-1.04) | .12 | 1.90 (1.69-2.13) | <.001 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Uninsured | ||||
| Yes | 0.87 (0.54-1.41) | .58 | 0.51 (0.38-0.68) | <.001 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Age, y | ||||
| 18-34 | 1 [Reference] | NA | 1 [Reference] | NA |
| 35-49 | 0.37 (0.30-0.46) | <.001 | 0.92 (0.79-1.07) | .28 |
| 50-64 | 0.31 (0.25-0.39) | <.001 | 0.92 (0.80-1.06) | .26 |
| 65-74 | 0.24 (0.19-0.30) | <.001 | 0.95 (0.81-1.12) | .57 |
| ≥75 | 0.12 (0.09-0.17) | <.001 | 0.69 (0.56-0.85) | .001 |
| Sex | ||||
| Men | 0.48 (0.40-0.58) | <.001 | 0.69 (0.63-0.76) | <.001 |
| Women | 1 [Reference] | NA | 1 [Reference] | NA |
| Race/ethnicity | ||||
| Non-Hispanic White | 1 [Reference] | NA | 1 [Reference] | NA |
| Non-Hispanic Black | 1.32 (1.01-1.72) | .04 | 0.92 (0.81-1.05) | .21 |
| Hispanic | 1.33 (1.04-1.72) | .03 | 0.85 (0.73-0.98) | .03 |
| Other | 0.80 (0.60-1.08) | .15 | 1.00 (0.85-1.17) | .97 |
| Income, $ | ||||
| <20 000 | 1 [Reference] | NA | 1 [Reference] | NA |
| 20 000-34 999 | 0.62 (0.43-0.90) | .01 | 1.06 (0.88-1.29) | .53 |
| 35 000-49 999 | 0.61 (0.43-0.88) | .009 | 1.50 (1.24-1.82) | <.001 |
| 50 000-74 999 | 0.60 (0.45-0.81) | .001 | 1.56 (1.31-1.87) | <.001 |
| ≥75 000 | 0.57 (0.40-0.80) | .001 | 1.93 (1.62-2.30) | <.001 |
| Education | ||||
| ≤HS diploma | 1 [Reference] | NA | 1 [Reference] | NA |
| College degree | 0.86 (0.71-1.05) | .14 | 1.35 (1.21-1.50) | <.001 |
| Postgraduate | 0.72 (0.58-0.89) | .002 | 1.51 (1.34-1.70) | <.001 |
| Married | ||||
| Yes | 1.00 (0.83-1.20) | .98 | 1.11 (1.01-1.23) | .04 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Rural residence | ||||
| Yes | 1.13 (0.89-1.45) | .32 | 0.76 (0.66-0.88) | <.001 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Multiple chronic conditionsb | ||||
| Yes | 1.25 (1.02-1.52) | .03 | 1.29 (1.17-1.44) | <.001 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Deafness or hearing impairment | ||||
| Yes | 0.86 (0.57-1.29) | .46 | 1.01 (0.83-1.22) | .93 |
| No | 1 [Reference] | NA | 1 [Reference] | NA |
| Year | ||||
| 2017 | 1 [Reference] | NA | 1 [Reference] | NA |
| 2018 | 1.26 (1.01-1.57) | .04 | 1.07 (0.93-1.23) | .33 |
| 2019 | 1.44 (1.14-1.82) | .003 | 1.56 (1.37-1.77) | <.001 |
| 2020 | 1.68 (1.29-2.19) | <.001 | 1.73 (1.51-1.98) | <.001 |
| Constant | 1.89 (1.21-2.95) | .006 | 0.13 (0.10-0.16) | <.001 |
Abbreviations: HS, high school; NA, not applicable; OR, odds ratio.
Usual source of care refers to having a particular provider whom a patient consults when health care is needed (eg, primary care clinician).
Multiple chronic conditions means having 2 or more chronic conditions (diabetes, hypertension, heart condition, chronic lung disease, and depression or anxiety disorder).
Discussion
As of 2020, 1 in 4 US residents reported having smartphone-only internet access, which was negatively associated with patient portal use. This study was conducted after the passage of the 21st Century Cures Act, which aimed to enhance mobile portal access,6 suggesting further work is needed to optimize such access. After accounting for smartphone-only internet access, some patients (eg, those with lower income) were still less likely to use portals, suggesting multimodal strategies are needed for overcoming the digital divide. Recent policy initiatives aimed at expanding broadband access will likely alleviate some digital barriers; however, other strategies (eg, technology training) are still needed.
This study has several limitations, including the inability to account for language preference—a key barrier to portal adoption—and the use of self-reported data. Nonetheless, it offers important implications for how smartphone-only internet access may affect the digital divide in patient portal use.
References
- 1.Lyles CR, Fruchterman J, Youdelman M, Schillinger D. Legal, practical, and ethical considerations for making online patient portals accessible for all. Am J Public Health. 2017;107(10):1608-1611. doi: 10.2105/AJPH.2017.303933 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Perzynski AT, Roach MJ, Shick S, et al. Patient portals and broadband internet inequality. J Am Med Inform Assoc. 2017;24(5):927-932. doi: 10.1093/jamia/ocx020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Pew Research Center. Mobile fact sheet. Accessed October 31, 2018. https://www.pewinternet.org/fact-sheet/mobile/
- 4.Graetz I, Huang J, Brand RJ, Hsu J, Yamin CK, Reed ME. Bridging the digital divide: mobile access to personal health records among patients with diabetes. Am J Manag Care. 2018;24(1):43-48. [PMC free article] [PubMed] [Google Scholar]
- 5.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495-1499. doi: 10.1016/j.ijsu.2014.07.013 [DOI] [PubMed] [Google Scholar]
- 6.Lye CT, Forman HP, Daniel JG, Krumholz HM. The 21st Century Cures Act and electronic health records one year later: will patients see the benefits? J Am Med Inform Assoc. 2018;25(9):1218-1220. doi: 10.1093/jamia/ocy065 [DOI] [PMC free article] [PubMed] [Google Scholar]