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Patient portals (ie, electronic personal health records tethered to institutional electronic health records) are recognized as a promising mechanism to support greater patient engagement, yet questions remain about how health care leaders, policy makers, and designers can encourage adoption of patient portals and what factors might contribute to sustained utilization.
The purposes of this state of the science review are to (1) present the definition, background, and how current literature addresses the encouragement and support of patient engagement through the patient portal, and (2) provide a summary of future directions for patient portal research and development to meaningfully impact patient engagement.
We reviewed literature from 2006 through 2014 in PubMed, Ovid Medline, and PsycInfo using the search terms “patient portal” OR “personal health record” OR “electronic personal health record”. Final inclusion criterion dictated that studies report on the patient experience and/or ways that patients may be supported to make competent health care decisions and act on those decisions using patient portal functionality.
We found 120 studies that met the inclusion criteria. Based on the research questions, explicit and implicit aims of the studies, and related measures addressed, the studies were grouped into five major topics (patient adoption, provider endorsement, health literacy, usability, and utility). We discuss the findings and conclusions of studies that address the five topical areas.
Current research has demonstrated that patients’ interest and ability to use patient portals is strongly influenced by personal factors such age, ethnicity, education level, health literacy, health status, and role as a caregiver. Health care delivery factors, mainly provider endorsement and patient portal usability also contribute to patient’s ability to engage through and with the patient portal. Future directions of research should focus on identifying specific populations and contextual considerations that would benefit most from a greater degree of patient engagement through a patient portal. Ultimately, adoption by patients and endorsement by providers will come when existing patient portal features align with patients’ and providers’ information needs and functionality.
Patient engagement has been identified as an essential dimension of the multifaceted solution to the cost/quality crisis in US health care. The patient-centric definition of patient engagement by the Agency for Healthcare Research and Quality (AHRQ) is “the involvement in their own care by individuals (and others they designate to engage on their behalf), with the goal that they make competent, well-informed decisions about their health and health care and take action to support those decisions” [
Currently, there is an increasing awareness of health care system’s responsibility to provide easily accessible ways for patients to be engaged in their own care by creating effective partnerships that lead to the patient’s ability to make competent and well-informed decisions [
An ePHR that directly links, or is “tethered”, to an EHR is most commonly referred to as a patient portal. In general, patient information from the EHR such as the problem list, allergies, and lab test results populate the patient portal. In some instances, patients may enter data to populate the EHR. In contrast, an untethered ePHR is under the control of the patient. This means an individual manually enters all information or grants permission for the information to be transferred to the ePHR, from a specific source like a laboratory or pharmacy, and determines who will have access. Thus, the value of an untethered ePHR is determined by a person’s willingness to manage and maintain their ePHR information. Because there is little that health care organizations can do to initiate patient engagement using an untethered ePHR, this literature review is focused exclusively on the patient portal, directly linked to an EHR.
Patient portals were introduced and adopted by a few large health care organizations in the late 1990s (eg, MyChart at the Palo Alto Medical Foundation and Indivo at Boston Children’s Hospital) [
The current principal driver of patient portal development is the meaningful use (MU) criteria of the CMS EHR incentive program [
Due to the advances in technology and consumer readiness in the mid-2000s, the review was limited to recent literature to better reflect current trends in design, functionality, and perceived user readiness of patient portals. We reviewed literature from 2006 through 2014 in PubMed, Ovid Medline, and PsycInfo using the search terms “patient portal” OR “personal health record” OR “electronic personal health record”. Bibliographies and the literature reviews from these sources were used to identify additional studies [
Of the 440 articles identified by the search, 176 were excluded based on title and abstract. Further review based on the final inclusion criterion resulted in 120 articles, which were reviewed in depth (see
Literature review flow chart.
We grouped the studies into five major topics based on the research questions, explicit and implicit aims of the studies, and related measures addressed. The topics identified included patient adoption, provider endorsement, health literacy, usability, and utility (
Summary of articles on categories of patient portals for patient engagement.
Year | Provider endorsement | Health literacy | Usability | Patient adoption | Utility | Total # of articles |
2006 | 0 | 0 | 0 | 1 | 2 | 3 |
2007 | 1 | 1 | 1 | 2 | 3 | 4 |
2008 | 0 | 1 | 1 | 4 | 6 | 8 |
2009 | 0 | 0 | 1 | 3 | 4 | 7 |
2010 | 1 | 2 | 2 | 7 | 7 | 11 |
2011 | 3 | 3 | 2 | 11 | 8 | 17 |
2012 | 1 | 3 | 3 | 11 | 10 | 16 |
2013 | 2 | 3 | 5 | 12 | 17 | 27 |
2014 | 0 | 3 | 5 | 11 | 19 | 27 |
Total | 8 | 16 | 20 | 62 | 76 | 120 |
Levels of evidence adapted from Melnyk & Fineout-Overholt, 2005
Type of study | Level of evidence | # of studies | |
RCT | 2 | 14 | |
Cohort/Quasi-experimental | 3 | 4 | |
|
4 |
|
|
Non-experimental (survey, correlational, etc) |
|
66 | |
Qualitative/Mixed method |
|
26 | |
Pilot study/case report | 5 | 10 |
Before a patient portal can serve as a tool for individuals to become more engaged and involved in their own care, patients must first adopt it. CMS 2014 stage 2 MU regulations define adoption in terms of institutional reporting for reimbursement and require that 5% of the institutions’ patient population (1) download or view electronic health information and (2) use secure electronic messages (eg, email) [
Of the 62 articles [
The term “digital divide” is often used to describe major potential barriers to access of electronic tools such as a patient portal and refers to disparities among subgroups based on access to the Internet and computer literacy. However, this term does not encompass the many other factors that may contribute to adoption such as language barriers, age, race and ethnicity, social economic status, and level of patient activation [
Provider endorsement and continued engagement with the patient portal have been identified as important factors in a patient’s decision to adopt and continue to use the patient portal functions to achieve and sustain anticipated positive outcomes [
Four of the studies sought to capture attitudes of clinicians towards patient portals prior to having firsthand experience interacting with them. Prior to actual use of patient portals, clinicians expressed concerns related to patient engagement including: the potential for inducing patient anxiety regarding test results; the accuracy of patient entered data; the potential liability for tracking and acting on critical clinical information, such as blood glucose levels and blood pressure readings; implications for changes in the patient-provider relationship; and the anticipated increased workload [
Retrospective studies showed that the pre-portal concerns regarding patient anxiety about test results were not justified as demonstrated by numerous patients who found the test result feature one of the most useful [
The definition of health literacy developed for the National Library of Medicine and used by the Healthy People 2010 initiative is “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” [
Noblin et al [
Four studies directly addressed the impact of health literacy of intended users on the successful completion of specific tasks [
Schnipper et al [
Monkman & Kushniruk [
Usability testing is the term used to describe the assessment of how easy a user interface is to operate. The word “usability” also refers to methods for improving ease of use during the design process [
Of the 20 studies that addressed usability of patient portals, 6 performed some form of heuristic and usability testing with objective observation and various forms of “think aloud” sessions [
Schnipper et al [
Much of the literature surrounding usability confirms that adoption and sustained use of technology are directly related to ease of navigation and the perceived usefulness of the available information [
Utility refers to the availability of needed features. Utility and usability are equally important and together determine whether something is useful [
While numerous descriptive and qualitative studies attest to the desire for personalized patient portal functionality, there is little research about what kind of personalization would lead to greater patient engagement. Currently, the greatest research focus is on chronic disease medication management and preventative services. Only 3 RCTs specifically tested the efficacy of patient-tailored interventions [
Collaborative communication refers to the ability for patients and providers to share timely and pertinent information, enabling patients to participate as active members of the care team beyond the hospital or clinic setting. SM and medication reconciliation are the two most common patient portal functions that offer the opportunity for such communication. Both functions also pose the greatest potential changes to provider workflow and overall impact on the patient-provider relationship.
For example, the difficulty aligning information management tools with current provider workflow and care delivery priorities was highlighted in a study of an interactive medication reconciliation module that emailed primary care physicians when a patient added or changed information [
Other implications of electronic forms of communication via a patient portal are the potential to improve efficiency by way of substituting SM for face-to-face encounters and using SM reminders to decrease missed appointments and promote timely preventative care. However, research shows mixed results leading researchers to believe that the relationship between SM and utilization is more complex than the simple substitution of online for in-person care suggests. For example, while an earlier study at Kaiser Permanente showed a decrease in face-to-face encounters after the initiation of SM [
SM is also being used as a one-way communication tool to deliver reminders for preventative care and appointments. A 2011 study at seven Duke medical clinics showed that email reminders, in combination with scheduling functionality within the patient portal, demonstrated significant declines in “no-shows” [
SM reminders via email have also been shown to be generally successful at encouraging higher rates of preventative services use. For example, a multi-practice randomized controlled trial showed improvement in the rates of certain preventive screenings and vaccinations, but preventative services as a whole were not impacted [
The current principal driver of patient portal development is CMS and Medicaid EHR incentive program meaningful use (MU) criteria [
Current research has demonstrated that patients’ interest and ability to use patient portals is strongly influenced by personal factors such age, ethnicity, education level, health literacy, health status, and role as a caregiver. Health care delivery factors, mainly provider endorsement and patient portal usability, also contribute to patients’ ability to engage through and with the patient portal.
While health literacy has been identified as an important factor in the successful use of patient portals, few studies have used validated health literacy measures, making it difficult for future research to build on the findings. Research demonstrates that specific aspects of health literacy, mainly numeracy and familiarity with medical terminology, greatly impact the ability of patients to accurately input data and interpret the information provided in the patient portal. The direct relationship between health literacy and effective use of the patient portal supports the argument for the use of specific health literacy heuristics as part of overall usability testing.
Research also demonstrates that objective testing (as opposed to solely subjective) should also be a part of patient portal usability testing. Although objective usability testing is expensive and time consuming, studies demonstrate the need for continued work in this area in order to ensure patient portal interfaces promote patient comprehension and data entry accuracy. The promotion of content accuracy and patient comprehension impacts the overall usefulness of the information for both patients and providers.
The perceived usefulness of patient portals from the providers’ perspectives cannot be underestimated. Provider endorsement is one of the most influential factors impacting patients’ initial adoption, as well as its continued use as a tool for collaborative communication [
While current development and research is focused on demonstrating feasibility and efficiency of medication reconciliation and SM reminders, the research has revealed roadblocks to successful implementation rooted in the lack of provider workflow adaptations A greater understanding of the essential adjustments in provider workflow, including potential changes in the roles and responsibilities of the care team overall, is necessary in order to translate findings into practice. Few studies have focused on exploring how patient portal use should unfold within the context of the patient-provider interaction, or how it might impact the overall organization and workflow of the health care team including potential liability concerns, reimbursement, and relationships with patients.
Ultimately, successful implementation requires health care institutions to invest time and resources to systematically assess the health needs of their specific patient and caregiver populations, their individual stages of readiness to adopt a patient portal, and the types of assistance needed to do so [
In addition, external environmental and contextual factors, such as distance between patient and clinic, and complexity and trajectory of health concerns, may impact which form of access is preferred for a specific person, provider, location, and situation. Future directions of research should focus on identifying specific populations and contextual considerations that would benefit most from a greater degree of patient engagement through a patient portal. This information could then lead to the creation of health care service policies that promote the use of a patient portal by both providers and patients within the most appropriate settings.
If institutions are to engage patients via the patient portal in a way that encourages them to become active members of the care team, support their competence in making health-related decisions, and help them to act on those decisions, institutional leaders must consider the contributing factors that impact efficacy and sustained use of patient portals. According to this review, these factors include attention to the topical areas of patient adoption, provider endorsement, health literacy, usability, and utility. Ultimately, adoption by patients and endorsement by providers will come when existing patient portal features align with patients’ and providers’ information needs and functionality. Conceptualizing patient portals as a dynamic component of the patient-provider relationship and health care delivery system as a synergetic whole, rather than an isolated repository of information or a set of disconnected functions meant to collect patient data for provider use, may help to inform future research, improve patient portal design, and efforts to promote adoption and effectiveness.
A brief description of each article and the topical areas it addresses.
Agency for Health care Research and Quality
electronic personal health record
electronic health record
Centers for Medicare and Medicaid Services
meaningful use
secure messaging
TI was funded on T32: Technology Research in Chronic and Critical Illness (2NR008857, Erlen & DeVito Dabbs, Directors). The funding agency had no role in the preparation, review, or approval of the manuscript. The opinions, results, and conclusions reported in this paper are those of the authors and are independent of the funding source.
None declared.