This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Offering hospitalized patients’ enrollment into a health system’s patient portal may improve patient experience and engagement throughout the care continuum, especially across care transitions, but this process is less studied than portal engagement in the ambulatory setting. Patient portal disparities exist and may lead to differences in access or outcomes. As such, it is important to study upstream factors in a typical hospital workflow that could lead to those disparities in safety-net settings.
The objective of this study was to evaluate sociodemographic characteristics associated with interest in a health care system’s portal among hospitalized patients and reasons for no interest.
Nurses assessed interest in a Web-based patient portal, expressed by the patient as “yes” or “no,” as part of the admission nursing assessment among patients at an academic urban safety-net hospital and recorded responses in the electronic health record (EHR), including reasons for no interest. We extracted patient responses from the EHR.
Among 23,994 hospitalizations over a 2-year period, 35.90% (8614/ 23,994) reported an interest in a Web-based portal. Reasons for
In a safety-net system, patient interest at the time of hospitalization in a Web-based enterprise portal—a required step before enrollment—is low with significant disparities by sociodemographic characteristics. To avoid worsening the digital divide, new strategies are needed and should be embedded within routine workflows to engage vulnerable safety-net patients in the use of Web-based health technologies.
Patient portals are websites that offer access to personal health information on the Web, such as test results, medical histories, immunization histories, and secure messaging with providers. Health care systems—leveraging federal incentives for meaningful use of electronic health records (EHRs)—are promoting patient portals to improve quality and safety, engagement, and care coordination with a goal of improved patient outcomes. Although the evidence is mixed about the benefits to health outcomes [
Demographic factors such as age and education affect patient interest and use of patient portals [
Safety-net health care systems, systems that care for vulnerable, uninsured, or predominantly Medicaid patient populations, may face additional challenges engaging patients in their portals. For patients in safety-net settings, health care systems must be able to assess interest in enrollment, including frequently explaining to patients what a portal is and how portals may be useful for their care across the care continuum. Although portals have traditionally been studied across ambulatory settings [
No study has systematically assessed interest in a health network’s portal within a typical hospital workflow among hospitalized urban safety-net patients. This study examined the interest in an enterprise-wide Web-based portal reported by hospitalized patients, how interest varied by sociodemographic characteristics, and the barriers among those declining portal interest.
This cross-sectional study evaluated hospitalized patients’ interest in enrolling in a health care system’s portal at an urban academic safety-net hospital. The patient portal offered information about the hospitalization (hospital after-visit summary with discharge instructions, summary of hospital course, and test results), as well as ambulatory patient portal content (primary and specialty care after-visit summaries, medications, allergies, problem lists, test results, and secure messaging with primary care providers). Eligible patients included adults (aged 18 years and over) admitted to acute medical, surgical, or gynecologic obstetric units over a 2-year period (September 2015-September 2017). This sample excludes patients under 18 years of age, admitted to skilled nursing or psychiatric units or reporting existing portal accounts.
Nursing leadership provided universal education to bedside nurses about the content and value of the patient portal and how to assess interest using an EHR-built admission assessment question stem (
The data for this analysis were abstracted from the EHR nursing assessments as well as the EHR sociodemographic section (age, gender, race/ethnicity, language, insurance type, and homelessness).
The primary outcome was the proportion of patients with portal interest recorded as
We then used logistic regression with measured sociodemographic covariates to calculate the unadjusted and adjusted odds of portal interest during at least one admission. Statistical analysis was performed using Stata version 15.1 (StataCorp). The University of California San Francisco Institutional Review Board approved this study.
Among 16,507 unique patients, the average age was 53 years (SD 19.17): 42.16% (6960/16,507) were women, 26.43% (4362/16,507) white, 28.02% (4625/16,507) Hispanic, 18.56% (3063/16,507) African American, 19.06% (3147/16,507) Asian, 7.93% (1309/16,507) other. Furthermore, 49.35% (8146/16,507) preferred a non-English language--10.67% (1761/16,507) Spanish and 5.40% (892/16,507) Chinese. 80.50% (13,288/16,507) had Medicaid or Medicare, and 14.17% (2339/16,507) reported homelessness. There was an average of 1.4 admissions per patient in this cohort during the period studied (see
When analyzed across 23,995 admissions, patients reported interest in the portal during 35.90% (8614/ 23,994) of admissions. The most commonly documented reasons for
Demographic characteristics of adults asked about portal interest during admissions to an urban academic safety-net hospital between September 2015 and September 2017.
Patient Characteristics (N=16,507) | Statistics | |
Age (years), mean (SD) | 53.06 (19.17) | |
Women, n (%) | 6960 (42.16) | |
White | 4362 (26.43) | |
Hispanic | 4625 (28.02) | |
African American/black | 3063 (18.56) | |
Asian | 3147 (19.06) | |
Native Hawaiian/Pacific Islander | 222 (1.34) | |
American Indian/Alaskan Native | 120 (0.73) | |
Other/mixed | 967 (5.86) | |
English | 8361 (50.65) | |
Spanish | 1761 (10.67) | |
Cantonese, Mandarin, or Toishanese | 892 (5.40) | |
Other Asian languages, n (%) | 208 (1.26) | |
Other, n (%) | 5285 (32.02) | |
Medicaid or county health plan for uninsureda | 8278 (50.15) | |
Medicare | 5010 (30.35) | |
Commercial insurance | 1300 (7.88) | |
Other insurance | 1919 (11.63) | |
Yesb, n (%) | 2339 (14.17) | |
No, n (%) | 12478 (75.59) | |
Unknown, n (%) | 1690 (10.24) | |
Admissions, mean (range) | 1.4 (1-33) |
aThese health care access programs (administered by the county Medicaid managed care organization) provide medical services for uninsured county residents (aged 18-64 years) or adults who provide county-supported in-home support services.
bPatients reported
Patient interest in an online healthcare system portal during at least one admission to an academic safety net hospital (n=16507 patients, September 2015-September 2017).
However, 44% of unique patients reported interest in the patient portal during at least one admission.
In adjusted models (
Odds of expressing interest in a patient portal among patients at an urban academic safety-net hospital (n=16,507 unique patients).
Sociodemographic characteristic | Unadjusted odds ratio | Adjusted odds ratioa | |||
Male | Ref | —b | Refc | — | |
Female | 1.01 | 0.85 | 1.04 | 0.25 | |
18-29 | Ref | — | Ref | — | |
30-39 | 0.99 | 0.91 | 1.01 | 0.9 | |
40-49 | 1.04 | 0.49 | 1.09 | 0.15 | |
50-65 | 0.82 | <.001 | 0.85 | 0.003 | |
>65 | 0.47 | <.001 | 0.5 | <.001 | |
White | Ref | — | Ref | — | |
Hispanic | 0.98 | 0.65 | 0.93 | 0.15 | |
African American | 0.95 | 0.24 | 0.87 | 0.01 | |
Asian | 0.76 | <.001 | 0.91 | 0.1 | |
Native Hawaiian/Pacific Islander | 1.31 | 0.05 | 1.09 | 0.52 | |
American Indian/Alaskan Native | 1.01 | 0.95 | 0.94 | 0.74 | |
Other | 1 | 0.96 | 0.92 | 0.24 | |
English | Ref | — | Ref | — | |
Spanish | 0.78 | <.001 | 0.69 | <.001 | |
Cantonese, Mandarin, or Toishanese | 0.46 | <.001 | 0.54 | <.001 | |
Other Asian | 0.77 | 0.07 | 0.9 | 0.47 | |
Other | 0.78 | <.001 | 0.78 | <.001 | |
Medicaid | Ref | — | Ref | — | |
Medicare | 0.6 | <.001 | 0.91 | 0.07 | |
Commercial insurance | 1.03 | 0.64 | 0.94 | 0.34 | |
Other insurance | 0.94 | 0.2 | 0.98 | 0.71 | |
Not homeless | Ref | — | Ref | — | |
Homeless | 0.77 | <.001 | 0.6 | <.001 | |
Unknown homeless status | 0.91 | 0.07 | 0.85 | 0.003 |
aLogistic regression adjusted for all the variable listed in the table.
bNot applicable.
cRef: reference value.
Fewer than half of the patients admitted to a safety-net hospital were documented by nurses as interested in the patient portal during at least one of their admissions to a safety-net hospital, with significantly lower odds of portal interest among older, nonwhite, non-English-speaking, and homeless patients. This is the first attempt at universally quantifying how many hospitalized patients are interested in a health care system’s portal and highlighting the prevalence of patient barriers to portal engagement within a safety-net setting.
A notable finding from this analysis was that the proportion of hospitalizations during which patients expressed portal interest (31%) was lower than the proportion of patients expressing portal interest during at least one hospitalization (44%), a finding that remained true across sociodemographic categories. This finding suggests that offering the patient portal to a patient who has previously declined may be useful for subsequent engagement. Organizational, technical, or workflow protocols that fail to offer portal enrollment to patients who previously declined may exacerbate disparities. In safety-net systems, the simple intervention of standardizing offers with every hospitalization may be an important tool for engaging patients in these technologies.
Most hospitals—particularly safety-net hospitals with limited resources—may rely on their existing staff to engage patients in their portal. This paper reveals what may naturally happen in a typical workflow where engagement happens universally as a required part of admission. A strength of this study is that the nursing staff were essential partners and allies for portal promotion given their role in providing direct clinical care; this study was driven strongly by nursing leadership. As portal interest screening was incorporated as a required component of the initial admission nursing assessment, this study allowed us to capture sufficient data to understand demographic characteristics associated with portal use.
Nonetheless, there are limitations to nurses alone as the only source of assessing patient interest, with potential bias in interpreting patients’ reasons for
Although Web-based portals have historically been associated with ambulatory care services, interest and research on their use for hospitalized patients are rising. Acute care portals that provide patients with health care information and communication with their teams during hospitalization have been studied for usability [
This study is the first to begin to understand issues around portal use among inpatients, specifically in a safety-net setting. Research suggests that vulnerable populations need significant support to register and use a portal website [
adjusted odds ratio
electronic health record
Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content. SS takes responsibility for the integrity of the work as a whole, from inception to publication. Authorship credit was based only on (1) substantial contributions to conception and design or acquisition of data or analysis and interpretation of data and (2) drafting the article or revising it critically for important intellectual content. This study was funded by AHRQ Grants R00HS022408, 1K08HS022561, and P30HS023558, National Library of Medicine Grant G08 NLM012166, and it received funding from the Gordon and Betty Moore Foundation. The funders did not play any role in the review or approval of the manuscript for publication. Publication made possible in part by support from the University of California San Francisco Open Access Publishing Fund.
None declared.