In our rural academic general internal medicine clinic, we found an overall high uptake in patient portal use with 82% active users who regularly logged on and interacted with the clinic providers using the messaging function through the portal. The high rates of utilization demonstrated that rural patients are seeking out the patient portal to communicate to their health care providers and are able to access online resources with expansion of smart phone use and cellular and high speed internet availability throughout the region [15, 16]. Rural patients often have to travel significant distances to see their providers and an online platform enabling communication with the clinic and their health care providers can be a valuable tool to improve health outcomes outside of traditional office visits.
Importantly, we identified disparities in patient portal use with older patients, active smokers, underweight and obese patients, and the great majority of patients with examined chronic conditions demonstrating lower rates of portal utilization. A systematic review also found that multiple studies have shown lower use by racial and ethnic minorities but unlike the findings of our study, they also identified studies that showed greater use with increased numbers of medical problems [8].
We believe that older patients and those with multiple chronic diseases (including obesity) could be the patients who could benefit the most from use of a patient portal. These patients often have multiple specialists, medications and treatment plans and the ability to access their progress notes, review clinic visit summaries and messaging their providers with questions or health updates has the potential to improve their understanding of their treatment plans, communication with their health care team, patient engagement and their health outcomes. A key element of the Chronic Care Model is self-management support and a well-designed clinical practice could use patient portal messaging to educate patients and identify barriers in managing their chronic illnesses [17]. Unfortunately, we were not able to survey or interview patients with chronic diseases for this research project to identify the underlying reasons for the lower utilization. However, we speculate that the lower utilization rates are likely due to many different and interrelated contributors including education and income levels, access to technology, engagement with and trust in their health care team and knowledge about use of the patient portal. Clarifying these important contributors for lack of use is an important area for future research.
This study was also unique in that it examined a population of patients with a significantly higher percentage in patient portal use compared to previously published studies that may reflect increasing availability of high speed internet, cellular service and smart phone use since the publication of the previous studies [1, 9, 18]. The high rates of enrollment and use may also be a result of the clinic and providers’ encouragement and recommendations for portal use. Our institution has had an online patient portal for 20 years which was transitioned to the EpicCare™ electronic health record in 2011. The institution has actively encouraged patients to enroll in the patient portal and keeps them engaged with pre-visit questionnaires, messaging and prescription management. Providers within the clinic also encourage patients to enroll in the portal to review their progress notes and lab and radiology results and instructions on how to activate their account are included in every printed after visit summary for patients who have not activated their account.
This study was also able to quantify the volume of messages sent and received by patients which is important to quantify for appropriate clinic staffing. Over the one year study period, there were 137,730 patient portal messages sent and received by the clinic from the 22,955 active portal users. Unfortunately, our data was not able to be broken down into the percentage of messages that were initiated by patients and those that were sent by the clinic but as most of the messages sent by the clinic are in response to patient initiated messaging, both are important to characterize as they both require time and resources to address the patient portal messages. As patient portal use increases in use and begins to replace traditional face-to-face clinic visits and patient telephone calls, primary care clinics need to adapt their clinic staffing models to adequately address the needs of patient portal messaging.
Limitations of this study include that this was a single site study and a lack of data on social determinants of health such as patient education, income, digital literacy, or access to the internet or cellular service at their residence. All of these factors may significantly impact online patient portal use but unfortunately these data are not routinely available through data extraction from the electronic health record. While we were able to identify differences in patient portal use, we were not able to interview patients to identify causes or barriers that would help explain the observed differences in this study. Additionally, we were not able to validate data about race and confirm the reliability of documentation of chronic conditions with patients as the data that we obtained for this study was de-identified and the accuracy of problem lists and visit diagnoses could not be verified. Further research with focus groups and individual patient interviews would be very helpful to identify potential social determinants of health that are associated with decreased patient portal usage and to clarify barriers to accessing the patient portal in our rural region. More research should also be performed to evaluate the clinical outcomes of patients who utilize the patient portal and investigate whether use of the patient portal has an impact on rates of hospitalizations, emergency room visits, patient satisfaction, and other disease specific outcomes for diabetes or hypertension management. We also had a very small number of minority patients in our study population and additional studies in rural centers with a more diverse patient population are needed to identify racial and economic factors that prevent utilization of the patient portal.