Patterns of Electronic Portal Use among Vulnerable Patients in a Nationwide Practice-based Research Network: From the OCHIN Practice-based Research Network (PBRN)

Lorraine S. Wallace; Heather Angier; Nathalie Huguet; James A. Gaudino; Alex Krist; Marla Dearing; Marie Killerby; Miguel Marino; Jennifer E. DeVoe

doi:10.3122/jabfm.2016.05.160046

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Table 1.

Baseline Patient Sociodemographic Characteristics of OCHIN Community Network Adults ≥18 Years of Age Who Were Issued a MyChart Access Code

Sociodemographic characteristics	Patient Logins
Sociodemographic characteristics	Refused or Never Logged in	1	2–23	≥24
Total patients	26,204 (71.7)	1,724 (4.7)	6,557 (17.9)	2,604 (5.7)
Sex
Female^{^†}	15,965 (60.9)	1,114 (64.6)	4,242 (64.7)	1,399 (67.8)
Male^{^‡}	10,239 (39.1)	610 (35.4)	2,315 (35.3)	665 (32.2)
Age (years)
18–29	5,783 (22.1)	342 (19.8)	1,147 (17.5)	336 (16.3)
30–39	4,721 (18.0)	345 (20.0)	1,231 (18.8)	377 (18.3)
40–49	4,616 (17.6)	341 (19.8)	1,170 (17.8)	348 (16.9)
50–64	7,391 (28.2)	499 (28.9)	2,069 (31.6)	709 (34.4)
65–74	2,361 (9.0)	149 (8.6)	737 (11.2)	229 (11.1)
≥75	1,332 (5.1)	48 (2.8)	203 (3.1)	65 (3.1)
Race
White	22,241 (84.9)	1,554 (90.1)	6,066 (92.5)	1,960 (95)
Nonwhite	3,084 (11.8)	129 (7.5)	361 (5.5)	78 (3.8)
Unknown	879 (3.4)	41 (2.4)	130 (2.0)	26 (1.3)
Ethnicity
Non-Hispanic	21,451 (81.9)	1,557 (90.3)	6,045 (92.2)	1,930 (93.5)
Hispanic	3,825 (14.6)	114 (6.6)	369 (5.6)	98 (4.7)
Unknown	928 (3.5)	53 (3.1)	143 (2.2)	36 (1.7)
Health Insurance
Private	6,035 (23)	586 (34)	2,283 (34.8)	506 (24.5)
Public	11,120 (42.4)	590 (34.2)	2,248 (34.3)	945 (45.8)
Uninsured	8,973 (34.2)	542 (31.4)	2015 (30.7)	612 (29.7)
Unknown	76 (0.3)	6 (0.3)	11 (0.2)	1 (0.0)
Number of primary care visits during study period
0	1,286 (4.9)	62 (3.6)	148 (2.3)	5 (0.2)
1	5,615 (21.4)	301 (17.5)	888 (13.5)	55 (2.7)
2	4,317 (16.5)	317 (18.4)	1,230 (18.8)	143 (6.9)
3 or 4	5,836 (22.3)	410 (23.8)	1,834 (28.0)	406 (19.7)
5–8	5,569 (21.3)	374 (21.7)	1,614 (24.6)	744 (36.0)
>8	3,581 (13.7)	260 (15.1)	843 (12.9)	711 (34.4)
Household income
<100% FPL	9,940 (37.9)	529 (30.7)	1942 (29.6)	724 (35.1)
100–199% FPL	3,624 (13.8)	226 (13.1)	1042 (15.9)	391 (18.9)
200–399% FPL	869 (3.3)	115 (6.7)	469 (7.2)	147 (7.1)
≥400% FPL	2,022 (7.7)	176 (10.2)	850 (13)	224 (10.9)
Unknown	9,749 (37.2)	678 (39.3)	2,254 (34.4)	578 (28.0)
Preferred language
English	23,161 (88.4)	1,658 (96.2)	6,390 (97.5)	2,019 (97.8)
Other	882 (3.4)	39 (2.3)	96 (1.5)	32 (1.6)
Spanish	2161 (8.2)	27 (1.6)	71 (1.1)	13 (0.6)
Number of chronic conditions^{^§}
0	15,669 (59.8)	1,058 (61.4)	3,844 (58.6)	888 (43.0)
1	6,420 (24.5)	441 (25.6)	1759 (26.8)	664 (32.2)
≥2	4,115 (15.7)	225 (13.1)	954 (14.5)	512 (24.8)

Data are n (%).
All comparisons within groups using χ² test were significant at P < .001.
↵† Includes male-to-female transgender patients.
↵‡ Includes female-to-male transgender patients.
↵§ Across all entire sample, the most common chronic diseases were chronic pulmonary disease, diabetes without chronic complications, and mild liver disease.
FPL, federal poverty level.

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Table 2.

Adjusted Relative Risk of Using MyChart Once, 2 to 23 Times, and ≥24 Times, by Patient Sociodemographic Characteristics

Sociodemographic Characteristics	Risk Ratio (95% Confidence Interval)
Sociodemographic Characteristics	Logged in Once (n = 1,724)	Logged in 2–23 Times (n = 6,557)	Logged in ≥24 Times (n = 2,604)
Sex
Female^*	1.00	1.00	1.00
Male^{^†}	0.81 (0.69–0.96)	0.81 (0.72–0.91)	0.80 (0.72–0.90)
Age group (years)
18–29	1.00	1.00	1.00
30–39	1.23 (1.00–1.53)	1.29 (1.16–1.43)	1.21 (1.01–1.46)
40–49	1.21 (0.96–1.54)	1.20 (1.05–1.39)	1.01 (0.77–1.31)
50–64	1.04 (0.79–1.36)	1.22 (1.04–1.44)	1.09 (0.87–1.38)
65–74	1.10 (0.72–1.68)	1.65 (1.21–2.24)	1.17 (0.87–1.57)
≥75	0.64 (0.35–1.17)	0.85 (0.56–1.27)	0.52 (0.34–0.81)
Race
White	1.00	1.00	1.00
Nonwhite	0.61 (0.38–0.99)	0.45 (0.27–0.75)	0.25 (0.15–0.43)
Unknown	0.93 (0.56–1.56)	1.02 (0.70–1.48)	0.86 (0.57–1.29)
Ethnicity
Non-Hispanic	1.00	1.00	1.00
Hispanic	0.68 (0.50–0.94)	0.61 (0.44–0.84)	0.51 (0.35–0.74)
Unknown	0.89 (0.60–1.30)	0.66 (0.53–0.83)	0.71 (0.42–1.21)
Health insurance
Private	1.00	1.00	1.00
Public	0.64 (0.53–0.77)	0.56 (0.45–0.70)	0.76 (0.60–0.98)
Uninsured	0.81 (0.66–1.00)	0.80 (0.67–0.96)	1.01 (0.78–1.31)
Unknown	1.33 (0.66–2.69)	1.04 (0.40–2.67)	4.12 (0.36–47.1)
Number of primary care visits during study period
0	1.00	1.00	1.00
1	1.09 (0.69–1.72)	1.2 (0.79–1.84)	2.60 (1.18–5.76)
2	1.54 (0.98–2.42)	2.19 (1.42–3.38)	8.78 (4.04–19.1)
3 or 4	1.60 (1.02–2.49)	2.60 (1.64–4.13)	19.3 (9.06–41.1)
5–8	1.68 (1.07–2.63)	2.64 (1.64–4.25)	39.1 (18.3–83.5)
>8	1.94 (1.17–3.20)	2.31 (1.34–3.99)	59.4 (26.9–131.3)
Household income
<100% FPL	1.00	1.00	1.00
100–199% FPL	1.05 (0.90–1.22)	1.22 (1.10–1.36)	1.50 (1.34–1.68)
200–399% FPL	1.90 (1.48–2.44)	1.89 (1.59–2.23)	2.62 (2.05–3.35)
≥400% FPL	1.39 (1.08–1.79)	1.68 (1.39–2.02)	1.64 (1.29–2.08)
Unknown	1.13 (0.91–1.41)	0.94 (0.70–1.27)	0.94 (0.62–1.45)
Language
English	1.00	1.00	1.00
Other	0.79 (0.48–1.31)	0.60 (0.36–0.99)	0.82 (0.45–1.48)
Spanish	0.23 (0.12–0.43)	0.17 (0.090–0.31)	0.10 (0.038–0.28)
Number of chronic conditions
0	1.00	1.00	1.00
1	0.99 (0.90–1.10)	1.02 (0.90–1.16)	1.26 (1.07–1.48)
≥2	0.82 (0.64–1.05)	0.86 (0.71–1.05)	1.16 (0.86–1.57)

These are risk ratios, not odds ratios. We fit a maximum-likelihood multinomial logit model to estimate probability of (1) having no MyChart use, (2) logging in once on MyChart, or (3) logging in more than once on MyChart. The risk ratio is then the ratio of 2 probabilities conditional on the covariate of interest. This multinomial model included all covariates included in the table, and the risk ratios are all in reference to “no MyChart use.” Models accounted for clustering of patients within service areas by including robust clustered sandwich estimators of variance to estimate rate ratio confidence intervals. The bold values are statistically significant at P < .05.
↵* Includes male-to-female transgender patients.
↵† Includes female-to-male transgender patients.
FPL, federal poverty level.

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Table 3.

MyChart Activity as a Function of Login Group

	Activity, Mean (Minimum, Maximum)
	Logged in Once	Logged in 2–23 Times	Logged in ≥24 Times
Viewing activities
Test results	0.44 (0, 12)	3.17 (0, 22)	12.30 (0, 122)
Medications	0.53 (0, 10)	2.58 (0, 19)	9.51 (0, 148)
Allergies	0.51 (0, 6)	2.35 (0, 15)	7.29 (0, 57)
Current health issues	0.49 (0, 2)	2.14 (0, 15)	6.01 (0, 56)
Print wallet card	0.03 (0, 1)	0.14 (0, 5)	0.52 (0, 14)
Immunizations	0.52 (0, 6)	2.36 (0, 15)	7.13 (0, 56)
Preventive care	0.30 (0, 11)	1.86 (0, 16)	6.88 (0, 58)
Medical history	0.23 (0, 2)	0.93 (0, 13)	2.70 (0, 55)
My conditions	0.52, (0, 6)	2.44 (0, 15)	7.63 (0, 58)
Letters	0.12 (0, 2)	0.58 (0, 11)	2.20 (0, 97)
After-visit summary	0.06 (0, 1)	0.44 (0, 10)	2.00 (0, 69)
Upcoming appointments	0.13 (0, 10)	1.32 (0, 16)	7.68 (0, 146)
All viewing activities	3.89 (0, 64)	20.30 (0, 133)	71.86 (0, 547)
Online requests or services
Request a refill	0.03 (0, 2)	0.36 (0, 13)	2.77 (0, 82)
Request or cancel an appointment	0.09 (0, 3)	1.00 (0, 14)	5.99 (0, 96)
Update demographics (address, phone, E-mail)	0.03 (0, 1)	0.19 (0, 7)	0.75 (0, 13)
Download summary record	0.03 (0, 1)	0.09 (0, 4)	0,21 (0, 12)
All online activities	0.19 (0, 4)	1.64 (0, 17)	9.73 (0, 116)
Communication activities
Communicating with health care team	0.14 (0, 3)	1.34 (0, 16)	9.46 (0, 147)
Nonurgent medical question	0.05 (0, 2)	0.64 (0, 13)	5.31 (0, 113)
Prescription question	0.01 (0, 2)	0.16 (0, 8)	1.17 (0, 23)
Test results question	<0.01 (0, 2)	0.08 (0, 4)	0.31 (0, 9)
Visit follow-up question	<0.01 (0, 1)	0.09 (0, 8)	0.57 (0, 28)
All communicating activities	0.22 (0, 5)	2.32 (0, 29)	16.83 (0, 258)

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Table 4.

Adjusted Incidence Rates for MyChart Activities by Patient Sociodemographic Characteristics

Sociodemographic Characteristics	Incidence Rate Ratios (95% CIs)
Sociodemographic Characteristics	Requesting	Viewing	Communicating
Sex
Female	1.00	1.00	1.00
Male	0.99 (0.93–1.05)	0.93 (0.88–0.98)	0.97 (0.88–1.08)
Age group (years)
18–29	1.00	1.00	1.00
30–39	0.98 (0.87–1.11)	0.99 (0.89–1.10)	1.12 (0.97–1.28)
40–49	1.00 (0.91–1.10)	0.98 (0.91–1.07)	1.22 (1.11–1.35)
50–64	1.03 (0.93–1.15)	0.94 (0.89–0.99)	1.31 (1.15–1.48)
65–74	0.78 (0.67–0.91)	0.82 (0.74–0.90)	1.25 (1.04–1.49)
≥75	0.70 (0.57–0.86)	0.79 (0.67–0.94)	0.98 (0.77–1.25)
Race
White	1.00	1.00	1.00
Nonwhite	0.94 (0.79–1.11)	0.94 (0.81–1.10)	0.69 (0.60–0.79)
Unknown	0.96 (0.82–1.11)	1.05 (0.87–1.25)	0.8 (0.59–1.09)
Ethnicity
Non-Hispanic	1.00	1.00	1.00
Hispanic	1.00 (0.88–1.13)	0.97 (0.89–1.05)	0.78 (0.67–0.91)
Unknown	0.68 (0.56–0.84)	0.85 (0.69–1.05)	1.23 (0.88–1.71)
Health insurance
Private	1.00	1.00	1.00
Public	1.33 (1.20–1.47)	1.16 (1.08–1.25)	1.23 (1.11–1.35)
Uninsured	1.23 (1.08–1.40)	1.13 (1.05–1.23)	1.13 (0.99–1.28)
Unknown	2.2 (0.81–5.97)	1.77 (0.84–3.72)	0.69 (0.25–1.87)
Number of primary care visits during study period
0	1.00	1.00	1.00
1	1.35 (0.87–2.08)	0.99 (0.78–1.25)	0.86 (0.37–2.01)
2	1.69 (1.05–2.71)	1.24 (0.99–1.54)	1.11 (0.48–2.57)
3 or 4	2.37 (1.62–3.46)	1.53 (1.26–1.87)	1.33 (0.61–2.90)
5–8	3.33 (2.23–4.97)	2.05 (1.66–2.52)	1.87 (0.87–4.03)
>8	4.91 (3.26–7.40)	2.59 (2.12–3.17)	2.69 (1.22–5.92)
Household income
<100% FPL	1.00	1.00	1.00
100–199% FPL	1.07 (0.98–1.17)	0.99 (0.94–1.05)	1.07 (0.96–1.19)
200–399% FPL	1.18 (0.97–1.44)	1.02 (0.90–1.16)	1.24 (1.00–1.53)
≥400% FPL	1.00 (0.89–1.14)	1.04 (0.94–1.15)	1.00 (0.91–1.10)
Unknown	0.96 (0.78–1.17)	0.95 (0.82–1.10)	0.98 (0.79–1.22)
Preferred language
English	1.00	1.00	1.00
Spanish	1.03 (0.81–1.33)	1.01 (0.81–1.26)	0.8 (0.56–1.14)
Other	1.04 (0.82–1.33)	1.09 (0.93–1.29)	1.13 (0.94–1.36)
Number of chronic conditions
0	1.00	1.00	1.00
1	1.13 (1.02–1.26)	1.14 (1.08–1.21)	1.09 (1.02–1.16)
≥2	1.19 (1.08–1.31)	1.20 (1.09–1.32)	1.10 (1.00–1.21)

Only patients who logged into MyChart were included in these models. These are incidence rate ratios, not odds ratios. We fit a separate zero-inflated maximum-likelihood Poisson model to estimate the number of each of the 3 activities. Models accounted for clustering of patients within service areas by including robust clustered sandwich estimators of variance to estimate rate ratio confidence intervals. Bold values are statistically significant at P < .05.
CI, confidence interval; FPL, federal poverty level.

Patient Sociodemographic Characteristics Associated with Odds of Not Performing Each MyChart Activity

Sociodemographic Characteristics	Odds Ratio (95% Confidence Interval)
Sociodemographic Characteristics	Requesting	Viewing	Communicating
Sex
Female	1.00	1.00	1.00
Male	1.21 (1.10–1.32)	1.24 (1.12–1.38)	1.22 (1.12–1.34)
Age group (years)
18–29	1.00	1.00	1.00
30–39	0.81 (0.74–0.88)	0.80 (0.73–0.88)	0.74 (0.67–0.83)
40–49	0.87 (0.77–0.99)	0.87 (0.77–0.99)	0.81 (0.71–0.93)
50–64	0.86 (0.74–0.99)	0.86 (0.73–1.01)	0.78 (0.68–0.91)
65–74	0.72 (0.58–0.88)	0.69 (0.53–0.90)	0.68 (0.53–0.88)
≥75	1.34 (0.98–1.83)	1.35 (0.93–1.94)	1.29 (0.90–1.84)
Race
White	1.00	1.00	1.00
Nonwhite	2.37 (1.47–3.83)	2.40 (1.51–3.81)	2.41 (1.46–3.98)
Unknown	1.07 (0.75–1.53)	1.02 (0.75–1.39)	1.18 (0.87–1.60)
Ethnicity
Non-Hispanic	1.00	1.00	1.00
Hispanic	1.57 (1.15–2.14)	1.65 (1.23–2.21)	1.63 (1.22–2.16)
Unknown	1.30 (1.07–1.57)	1.47 (1.21–1.79)	1.35 (1.13–1.61)
Health insurance
Private	1.00	1.00	1.00
Public	1.48 (1.28–1.71)	1.60 (1.30–1.96)	1.54 (1.28–1.86)
Uninsured	1.13 (0.98–1.31)	1.19 (1.00–1.42)	1.15 (0.99–1.34)
Unknown	1.03 (0.40–2.71)	0.99 (0.43–2.30)	0.34 (0.15–0.77)
Number of primary care visits during study period
0	1.00	1.00	1.00
1	1.03 (0.67–1.56)	0.85 (0.57–1.26)	0.57 (0.41–0.79)
2	0.49 (0.34–0.71)	0.48 (0.33–0.69)	0.32 (0.22–0.46)
3 or 4	0.36 (0.25–0.53)	0.39 (0.26–0.57)	0.24 (0.17–0.35)
5–8	0.28 (0.19–0.40)	0.33 (0.23–0.49)	0.20 (0.14–0.28)
>8	0.24 (0.16–0.37)	0.31 (0.20–0.48)	0.17 (0.11–0.27)
Starting household income
<100% FPL	1.00	1.00	1.00
100–199% FPL	0.82 (0.73–0.92)	0.79 (0.73–0.86)	0.77 (0.70–0.84)
200–399% FPL	0.63 (0.53–0.75)	0.51 (0.43–0.59)	0.58 (0.49–0.67)
≥400% FPL	0.66 (0.55–0.80)	0.63 (0.53–0.75)	0.65 (0.54–0.78)
Unknown	1.09 (0.84–1.41)	1.05 (0.78–1.42)	1.13 (0.80–1.58)
Preferred language
English	1.00	1.00	1.00
Spanish	1.65 (1.06–2.55)	1.47 (0.87–2.46)	1.69 (1.07–2.67)
Other	6.17 (3.35–11.4)	6.07 (3.35–11.0)	5.74 (2.96–11.1)
Number of chronic conditions
0	1.00	1.00	1.00
1	0.89 (0.81–0.97)	0.94 (0.85–1.05)	0.92 (0.82–1.03)
≥2	0.98 (0.81–1.18)	1.07 (0.89–1.28)	1 (0.80–1.25)

Only patients who logged into MyChart were included in these models. Note that these are odds ratio for the odds of not performing an activity given an individual had logged in. These odds were modeled as part of individual zero-inflated maximum-likelihood Poisson models to estimate both (1) the odds of not performing an activity and (2) the number of each of the 3 activities. Bold values are significant at P < .05.
FPL, federal poverty level.