Barriers to Patient Portal Access and Use: Evidence from the Health Information National Trends Survey

Sherine El-Toukhy; Alejandra Méndez; Shavonne Collins; Eliseo J. Pérez-Stable

doi:10.3122/jabfm.2020.06.190402

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Figure 1.
Knowledge of patient portals content among 2151 participants in the 2017–2018 Health Information National Trends Survey 5, Cycles 1 and 2, US.

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Table 1.

Weighted Sample Characteristics of 6789 Participants in the 2017–2018 Health Information National Trends Survey 5, Cycles 1 and 2, US

	n	% Weighted	LL	UL
Gender
Men	2759	48.9	48.7	49.1
Women	4030	51.1	50.9	51.3
Age, years
18 to 39	1248	30.6	28.7	32.4
40 to 59	2391	42.3	40.5	44.1
≥ 60	3150	27.1	26.9	27.4
Race/ethnicity
Latino	995	15.8	15.5	16.2
White	4297	65.2	64.7	65.7
Black	923	10.5	10.0	11.0
Other*	574	8.4	8.2	8.7
Annual household income
< $20,000	1254	17.3	15.9	18.8
$20,000 to $49,999	1829	26.1	24.5	27.7
$50,000 to $74,999	1237	18.5	17.0	20.0
≥ $75000	2470	38.1	36.2	39.9
Education
< High school	504	8.8	7.6	10.0
High school graduate	1279	22.6	21.4	23.8
Vocational school, some college	2040	36.4	35.3	37.6
College graduate, postgraduate	2967	32.2	31.9	32.4
Employment
Employed	3423	57.9	55.8	59.9
Unemployed	3366	42.1	40.1	44.2
Marital status
Single	1169	30.2	30.0	30.5
Married, living as married	3595	53.9	53.1	54.7
Separated, widowed	2024	15.9	15.1	16.6
Place of birth
United States	5826	85.5	84.4	86.5
Foreign born	963	14.5	13.5	15.6
Speak English
Very well	6042	88.3	87.2	89.3
Well, not well, not at all	747	11.7	10.7	12.8
Regular provider
Yes	4848	65.4	63.6	67.3
No	1941	34.6	32.7	36.4
Health insurance
Yes	6441	91.6	91.5	91.7
No	348	8.4	8.3	8.5
General health
Excellent/good	5638	84.1	82.6	85.6
Fair/poor	1151	15.9	14.4	17.4
Census region
Northeast census region	1065	17.9	17.9	17.9
Midwest census region	1249	21.0	21.0	21.0
South census region	2893	37.6	37.6	37.6
West census region	1582	23.5	23.5	23.5
Rural/urban designation
Metro	5863	86.1	84.8	87.3
Urban	834	12.4	11.2	13.7
Rural	92	1.5	1.0	2.0

LL, lower limit; UL, upper limit.
n = 6789; Imputed subjects have 20 records, thus imputed n is 1/20th of a subject rounded to the nearest integer.
↵* Asians, Pacific Islanders, and multiple races.

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Table 2.

Multivariate Logistic Regression Models of Associations between Patient Characteristics and Patient Portals Access and Use in the Health Information National Trends Survey 5, Cycles 1 and 2, US

	Access		Facilitators of Use		Use Behavior
	Provider Maintains Medical Records, aOR (95% CI)	Provider Offers Medical Records Access, aOR (95% CI)	Provider Encourages Medical Record Use^†, aOR (95% CI)	Confident Medical Records Safe, aOR (95% CI)	Access Own Medical Record, aOR (95% CI)	Access Family Medical Record^†, aOR (95% CI)
Gender (ref: men)
Women	1.7 (1.4-2.0)	1.7 (1.5-2.0)	1.6 (1.3-2.0)	1.2 (0.9-1.4)	1.5 (1.2-1.8)	1.6 (1.0-2.3)
Age (ref: 18 to 39 years)
40 to 59 years	1.2 (0.9-1.6)	0.9 (0.8-1.2)	0.9 (0.7-1.3)	0.9 (0.7-1.1)	1.1 (0.9-1.4)	0.9 (0.6-1.3)
≥ 60 years	1.4 (1.0-1.8)	0.8 (0.7-1.0)	0.8 (0.6-1.0)	1.0 (0.8-1.3)	0.8 (0.6-0.9)	0.7 (0.4-1.2)
Race/ethnicity (ref: White)
Latino	1.2 (0.9-1.5)	0.9 (0.7-1.1)	0.8 (0.6-1.2)	1.3 (0.9-1.8)	0.9 (0.7-1.2)	1.1 (0.7-1.8)
Black	1.2 (0.8-1.7)	0.8 (0.7-1.0)	1.0 (0.8-1.5)	1.0 (0.8-1.4)	0.9 (0.7-1.2)	0.8 (0.4-1.6)
Other*	0.9 (0.5-1.4)	0.8 (0.6-1.0)	0.8 (0.6-1.2)	0.9 (0.7-1.3)	1.2 (0.9-1.7)	1.2 (0.7-2.1)
Education (ref: college/post grad)
< High school	0.5 (0.3-0.8)	0.4 (0.3-0.7)	0.5 (0.2-1.0)	1.4 (0.9-2.1)	0.3 (0.2-0.5)	0.7 (0.3-1.7)
High school grad	0.6 (0.4-0.7)	0.6 (0.4-0.7)	0.4 (0.3-0.6)	1.0 (0.8-1.4)	0.4 (0.3-0.5)	0.3 (0.1-0.5)
Vocational, some college	0.6 (0.5-0.8)	0.6 (0.5-0.8)	0.6 (0.5-0.8)	1.2 (0.9-1.5)	0.5 (0.4-0.7)	0.5 (0.4-0.8)
Marital status (ref: married, living as married)
Single	0.6 (0.4-0.8)	0.5 (0.4-0.6)	0.4 (0.3-0.6)	1.0 (0.8-1.3)	0.6 (0.5-0.8)	0.2 (0.1-0.6)
Separated, widowed	0.7 (0.5-0.9)	0.6 (0.5-0.7)	0.6 (0.5-0.8)	1.0 (0.9-1.3)	0.6 (0.5-0.7)	0.4 (0.2-0.8)
Speak English (ref: very well)
Well, not well, not at all	0.7 (0.5-0.9)	0.6 (0.4-0.8)	0.8 (0.5-1.2)	0.8 (0.6-1.1)	0.7 (0.5-0.9)	1.2 (0.7-2.2)
Health insurance (ref: yes)
No	0.5 (0.3-0.9)	0.5 (0.3-0.8)	0.7 (0.3-1.5)	0.9 (0.5-1.4)	0.4 (0.2-0.7)	0.8 (0.3-2.3)
Regular provider (ref: yes)
No	0.3 (0.2-0.4)	0.4 (0.4-0.5)	0.5 (0.4-0.6)	0.7 (0.6-0.9)	0.4 (0.3-0.5)	0.6 (0.4-0.9)
General health (ref: excellent/good)
Fair/poor	0.9 (0.7-1.1)	0.9 (0.8-1.2)	1.0 (0.8-1.4)	0.7 (0.5-0.9)	0.9 (0.7-1.1)	1.0 (0.6-1.6)
Census region (ref: Northeast)
Midwest	0.8 (0.6-1.2)	0.9 (0.7-1.3)	1.0 (0.7-1.7)	1.2 (0.9-1.6)	1.2 (0.9-1.7)	1.1 (0.6-2.1)
South	0.7 (0.5-0.9)	0.8 (0.6-1.0)	0.9 (0.7-1.5)	1.1 (0.9-1.4)	1.0 (0.8-1.4)	1.2 (0.7-2.1)
West	0.8 (0.6-1.1)	0.9 (0.6-1.1)	1.1 (0.8-1.7)	0.9 (0.7-1.2)	1.3 (0.9-1.7)	1.5 (0.9-2.6)
Rural/urban designation (ref: metro)
Urban	1.0 (0.7-1.5)	0.7 (0.5-0.9)	0.6 (0.4-0.9)	1.0 (0.8-1.4)	0.6 (0.4-0.8)	0.9 (0.5-1.9)
Rural	0.7 (0.3-1.5)	0.6 (0.3-1.2)	0.6 (0.2-1.6)	0.9 (0.4-2.1)	0.7 (0.4-1.4)	0.5 (0.01-30.3)

aOR, adjusted odds ratio; CI, confidence interval.
n = 6789.
↵* Asians, Pacific Islanders, and multiple races.
↵† Question was omitted in 2018 H5C2, so n = 3285 based on H5C1 only.
Bolded cells are statistically meaningful.
Participants in H5C2 were asked the number of times that they accessed their own medical records only if they responded “yes” to whether they have been offered online access to medical records. Participants then reported who offered them access (i.e., healthcare provider, health insurer, someone else). To harmonize the data, we coded participants who said “no/don’t know” to “have you been offered online access to your medical records?” as “no” and those who selected “healthcare provider” to “who offered you online access to your medical records?” as “yes.”
Logistic regression analysis modeled the probability of 1 (eg, provider maintained electronic medical records, provider offered access to electronic medical records).

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Table 3.

Multivariate Logistic Regression Models of Associations between Patient Characteristics and Use of Patient Portals Functionalities in the 2017–2018 Health Information National Trends Survey 5, Cycles 1 and 2, US

	View Results,† aOR (95% CI)	Message Healthcare Provider, aOR (95% CI)	Make Appointment,† aOR (95% CI)	Refill Medication, aOR (95% CI)	Complete Forms, aOR (95% CI)
Gender (ref: men)
Women	1.1 (0.6-2.0)	0.9 (0.7-1.2)	0.8 (0.5-1.2)	0.9 (0.7-1.2)	1.0 (0.8-1.4)
Age (ref: 18 to 39 years)
40 to 59 years	1.3 (0.7-2.3)	0.8 (0.5-1.1)	0.9 (0.5-1.5)	1.1 (0.7-1.7)	1.0 (0.7-1.6)
≥60 years	0.7 (0.4-1.4)	0.7 (0.5-0.9)	0.8 (0.4-1.3)	1.7 (1.1-2.5)	0.8 (0.5-1.0)
Race/ethnicity (ref: White)
Latino	0.5 (0.3-1.0)	0.8 (0.5-1.2)	1.0 (0.5-2.1)	0.9 (0.7-1.4)	0.9 (0.6-1.5)
Black	0.8 (0.4-1.8)	1.0 (0.7-1.6)	1.6 (0.8-3.0)	1.0 (0.7-1.7)	0.7 (0.4-1.0)
Other*	0.8 (0.3-1.9)	0.7 (0.4-1.3)	1.5 (0.8-2.5)	1.2 (0.7-1.9)	0.7 (0.4-1.0)
Education (ref: college/post grad)
<High school	1.7 (0.4-6.5)	1.0 (0.3-2.9)	0.2 (0.04-1.0)	1.7 (0.6-5.0)	0.3 (0.1-0.9)
High school grad	0.9 (0.3-2.7)	1.0 (0.7-1.5)	1.1 (0.6-2.1)	0.9 (0.7-1.4)	0.6 (0.4-0.8)
Vocational, some college	1.1 (0.6-2.1)	1.0 (0.8-1.4)	0.9 (0.6-1.4)	1.0 (0.7-1.4)	0.7 (0.5-0.9)
Marital status (ref: married, living as married)
Single	0.8 (0.4-1.7)	1.3 (0.9-2.0)	1.4 (0.8-2.5)	1.3 (0.9-1.9)	1.3 (0.9-1.9)
Separated, widowed	0.9 (0.4-1.8)	0.9 (0.6-1.3)	0.9 (0.6-1.6)	0.9 (0.7-1.3)	0.9 (0.7-1.3)
Speak English (ref: very well)
Well, not well, not at all	0.8 (0.3-1.8)	0.8 (0.4-1.3)	1.4 (0.6-3.3)	0.5 (0.3-0.9)	0.7 (0.3-1.3)
Health insurance (ref: yes)
No	0.6 (0.1-5.7)	0.9 (0.4-2.5)	0.9 (0.2-4.5)	0.6 (0.2-1.9)	0.6 (0.1-2.2)
Regular provider (ref: yes)
No	0.8 (0.4-1.6)	0.7 (0.5-0.9)	1.0 (0.6-1.9)	0.8 (0.5-1.2)	0.8 (0.6-1.1)
General health (ref: excellent/good)
Fair/poor	1.1 (0.5-2.7)	1.3 (0.8-1.9)	1.1 (0.7-1.9)	1.6 (1.1-2.3)	1.4 (0.9-2.1)
Census region (ref: Northeast)
Midwest	0.7 (0.3-1.7)	1.0 (0.7-1.6)	0.9 (0.5-1.8)	0.7 (0.5-1.1)	1.2 (0.7-2.1)
South	1.2 (0.6-2.3)	1.0 (0.8-1.5)	1.5 (0.8-2.9)	0.9 (0.7-1.4)	1.8 (1.2-2.7)
West	2.8 (1.3-6.3)	2.5 (1.7-3.9)	3.5 (1.8-6.8)	1.5 (0.9-2.2)	1.6 (1.0-2.5)
Rural/urban designation (ref: metro)
Urban	1.0 (0.4-2.6)	0.9 (0.6-1.7)	1.3 (0.7-2.5)	1.0 (0.7-1.6)	0.7 (0.4-1.2)
Rural	1.9 (0.1-54.8)	0.8 (0.3-2.6)	2.4 (0.5-12.4)	1.8 (0.5-6.4)	1.4 (0.4-4.6)

	Monitor health^†	Make decisions	Add information	Download information	Request correction
	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)
Gender (ref: men)
Women	0.7 (0.5-1.1)	0.8 (0.6-1.2)	1.0 (0.8-1.4)	0.8 (0.5-1.1)	1.4 (0.8-2.3)
Age (ref: 18 to 39 years)
40 to 59 years	0.9 (0.6-1.7)	0.7 (0.5-1.0)	1.1 (0.8-1.7)	0.8 (0.5-1.0)	0.8 (0.4-1.6)
≥60 years	0.7 (0.4-1.2)	0.5 (0.3-0.8)	0.9 (0.6-1.4)	0.6 (0.4-0.9)	0.7 (0.3-1.7)
Race/ethnicity (ref: White)
Latino	0.9 (0.4-2.1)	1.0 (0.6-1.8)	1.0 (0.7-1.8)	1.0 (0.7-1.7)	1.2 (0.6-2.6)
Black	1.6 (0.8-3.2)	1.7 (1.0-2.9)	1.0 (0.7-1.8)	1.1 (0.7-1.9)	1.6 (0.8-3.0)
Other^*	1.2 (0.6-2.4)	1.0 (0.6-1.9)	0.7 (0.4-1.4)	0.9 (0.6-1.7)	0.9 (0.4-2.1)
Education (ref: college/post grad)
<High school	0.7 (0.1-4.4)	0.4 (0.2-0.9)	0.5 (0.2-1.2)	0.3 (0.1-0.8)	1.2 (0.3-4.6)
High school grad	0.9 (0.4-1.7)	0.9 (0.5-1.5)	0.9 (0.6-1.5)	0.5 (0.2-1.0)	0.6 (0.3-1.5)
Vocational, some college	0.8 (0.5-1.2)	0.8 (0.6-1.2)	0.8 (0.6-1.2)	0.9 (0.6-1.3)	0.9 (0.6-1.6)
Marital status (ref: married, living as married)
Single	0.9 (0.5-1.8)	0.9 (0.6-1.4)	1.5 (0.9-2.2)	0.9 (0.5-1.6)	1.2 (0.6-2.4)
Separated, widowed	0.7 (0.4-1.3)	0.8 (0.5-1.2)	0.9 (0.7-1.3)	1.3 (0.8-1.9)	1.6 (0.8-3.2)
Speak English (ref: very well)
Well, not well, not at all	1.2 (0.4-3.5)	1.1 (0.6-2.2)	0.9 (0.4-1.7)	1.6 (0.8-3.2)	2.2 (0.9-5.2)
Health insurance (ref: yes)
No	0.5 (0.05-4.3)	1.1 (0.3-4.6)	0.8 (0.2-4.0)	0.7 (0.2-3.0)	0.7 (0.02-22.2)
Regular provider (ref: yes)
No	0.6 (0.4-1.2)	0.7 (0.5-1.1)	0.7 (0.5-1.0)	1.0 (0.7-1.5)	0.9 (0.5-1.7)
General health (ref: excellent/good)
Fair/poor	0.9 (0.5-1.7)	1.5 (0.8-2.7)	1.3 (0.9-2.0)	1.2 (0.7-2.1)	1.7 (0.9-3.2)
Census region (ref: Northeast)
Midwest	1.9 (0.9-3.5)	1.0 (0.6-1.9)	1.6 (0.9-2.6)	0.9 (0.5-1.9)	1.3 (0.6-3.0)
South	1.5 (0.9-2.6)	0.9 (0.6-1.5)	1.8 (1.0-3.1)	1.3 (0.8-2.1)	1.3 (0.7-2.7)
West	1.8 (0.9-3.4)	1.5 (0.9-2.5)	2.4 (1.4-4.2)	1.1 (0.7-1.9)	1.9 (0.9-3.9)
Rural/ Urban designation (ref: metro)
Urban	1.6 (0.9-3.0)	0.9 (0.5-1.7)	1.1 (0.7-2.0)	1.7 (0.9-2.8)	1.1 (0.4-2.8)
Rural	2.0 (0.3-10.9)	1.2 (0.2-7.7)	2.2 (0.6-8.7)	3.9 (1.2-12.8)	3.0 (0.1-70.1)

aOR, adjusted odds ratio; CI, confidence interval.
n = 2,151 reflects those who accessed their own medical records one or more times in the past 12 months.
↵* Asians, Pacific Islanders, and multiple races.
↵† Question was omitted in 2018 H5C2, so n = 1033 (those who accessed their own medical records one or more times in the past 12 months based on H5C1 only).
Bolded cells are statistically meaningful.
Logistic regression analysis modeled the probability of 1 (e.g., patient viewed results, patient messaged healthcare provider).

Appendix Table 1: Multivariate Logistic Regression Models of Associations between Patient Characteristics, Internet Access, and Electronic Device Ownership, and Use of Personal and Family Patient Portals in the 2017–2018 Health Information National Trends Survey 5, Cycles 1 and 2, US

	Access Own Medical Record, aOR (95% CI)	Access Family Medical Record, aOR (95% CI)
Gender (ref: men)
Women	1.5 (1.2-1.8)	1.6 (1.0-2.3)
Age (ref: 18 to 39 years)
40 to 59 years	1.1 (0.9-1.4)	0.9 (0.6-1.4)
≥ 60 years	1.1 (0.9-1.5)	0.9 (0.5-1.6)
Race/ethnicity (ref: White)
Latino	0.9 (0.7-1.2)	1.1 (0.7-1.9)
Black	0.9 (0.7-1.2)	0.8 (0.4-1.5)
Other*	1.2 (0.9-1.7)	1.2 (0.7-2.0)
Education (ref: college/post grad)
< High school	0.5 (0.3-0.9)	0.8 (0.3-2.2)
High school grad	0.5 (0.4-0.7)	0.3 (0.2-0.6)
Vocational, some college	0.6 (0.5-0.7)	0.5 (0.4-0.8)
Marital status (ref: married, living as married)
Single	0.7 (0.5-0.9)	0.2 (0.1-0.6)
Separated, widowed	0.8 (0.6-0.9)	0.5 (0.3-0.9)
Speak English (ref: very well)
Well, not well, not at all	0.8 (0.6-1.1)	1.3 (0.6-2.4)
Health insurance (ref: yes)
No	0.4 (0.2-0.7)	0.9 (0.3-2.5)
Regular provider (ref: yes)
No	0.4 (0.3-0.5)	0.6 (0.4-0.9)
General health (ref: excellent/good)
Fair/poor	1.0 (0.8-1.3)	1.1 (0.7-1.8)
Census region (ref: Northeast)
Midwest	1.3 (0.9-1.8)	1.2 (0.6-2.2)
South	1.0 (0.8-1.4)	1.2 (0.7-2.1)
West	1.2 (0.9-1.6)	1.4 (0.8-2.5)
Rural/urban designation (ref: metro)
Urban	0.6 (0.4-0.8)	0.9 (0.5-2.1)
Rural	0.7 (0.3-1.5)	0.5 (0.01-29.3)
Dial-up (ref: yes)
No	1.7 (0.7-4.1)	1.0 (0.2-4.5)
Not ascertained^†	0.6 (0.2-1.5)	1.0 (0.2-4.5)
Broadband (ref: yes)
No	0.7 (0.6-0.8)	0.7 (0.5-1.0)
Cell network (ref: yes)
No	1.2 (1.0-1.5)	0.9 (0.7-1.4)
Wi-Fi (ref: yes)
No	0.7 (0.6-0.9)	0.8 (0.5-1.3)
Tablet (ref: yes)
No	0.6 (0.5-0.7)	0.8 (0.5-1.3)
Smartphone (ref: yes)
No	0.5 (0.4-0.6)	0.6 (0.3-1.2)

aOR, adjusted odds ratio; CI, confidence interval.
n = 6789 for access own medical records and n = 3285 for access family medical records.
↵* Asians, Pacific Islanders, and multiple races.
Among those who responded yes to “Do you ever go online to access the Internet or World Wide Web, or to send and receive email?” any internet use was at 82.0% (n = 5280; 95% CI, 80.6-83.3) with dial-up access at 2.3% (n = 140; 95% CI, 1.7-3.0), broadband access at 52.5% (n = 2749; 95% CI, 50.2-54.9), cell network at 66.2% (n = 3099; 95% CI, 64.3-68.1), and Wi-Fi access at 82.1% (n = 4178; 95% CI, 80.5-83.6).
Any electronic device ownership was at 98.0% (n = 6656; 95% CI, 97.5-98.4) with tablet ownership at 59.8% (n = 3894; 95% CI, 57.7-61.8), smartphone ownership at 79.5% (n = 5008; 95% CI, 78.2-80.8), and cellphone ownership at 15.5% (n = 1317; 95% CI, 14.1-16.8).
† “Not ascertained” (n = 750) were those who reported no internet access and, thus, were not asked questions about means to access the internet via dial up, broadband, cell network, Wi-Fi.
Table includes odds ratio for “not ascertained dial up” only because SAS calculates the first odds ratio for a group of linearly related outcomes, which is the case for “not ascertained” for dial-up, broadband, cell network, and Wi-Fi.
Bolded cells are statistically meaningful.
Logistic regression analysis modeled the probability of 1 (e.g., patient accessed their own medical records).