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.
Online medical records are being used to organize processes in clinical and outpatient settings and to forge doctor-patient communication techniques that build mutual understanding and trust.
We aimed to understand the reasons why patients tend to avoid using online medical records and to compare the perceptions that patients have of online medical records based on demographics and cancer diagnosis.
We used data from the Health Information National Trends Survey Cycle 3, a nationally representative survey, and assessed outcomes using descriptive statistics and chi-square tests. The patients (N=4328) included in the analysis had experienced an outpatient visit within the previous 12 months and had answered the online behavior question regarding their use of online medical records.
Patients who were nonusers of online medical records consisted of 58.36% of the sample (2526/4328). The highest nonuser rates were for patients who were Hispanic (460/683, 67.35%), patients who were non-Hispanic Black (434/653, 66.46%), and patients who were older than 65 years (968/1520, 63.6%). Patients older than 65 years were less likely to use online medical records (odds ratio [OR] 1.51, 95% CI 1.24-1.84,
Studies should consider social factors such as gender, race/ethnicity, and age when monitoring trends in eHealth use to ensure that eHealth use does not induce greater health status and health care disparities between people with different backgrounds and demographic characteristics.
Communication is a key element in providing high-quality health care services [
Information exchange is not only limited to the visit. It is moving beyond that, as patients have the opportunity to access their information regardless of location or time via technologies [
The ability of patients or individuals to access their online medical records serves as one of the backbones to improve patient engagement in and the outcomes of our health care system. Historically, patients have had low access to online medical records. For instance, only 3 out of 10 patients were offered access to medical records in 2013, and almost half of those offered access viewed their online records at least once [
Data for this study were derived from the National Cancer Institute’s 2019 Health Information National Trends Survey (HINTS). HINTS is a nationally representative survey (of the US noninstitutionalized adult population) that collects data on the American public’s need for, access to, and use of health-related information [
The following questions correspond to the measures used in the analysis of the study. The first question was, “How many times did you access your online medical record in the last 12 months?” We used this question to identify users and nonusers of online medical records. The respondents who reported accessing their medical record at least once were coded as
Questions for nonusers and corresponding factors.
Factor name | Questiona |
SpeakDirectly | You prefer to speak to your health care provider directly? |
NoNeed | You did not have a need to use your online medical record? |
ConcernedPrivacy | You were concerned about the privacy or security of your medical records’ website? |
NoRecord | You do not have an online medical record? |
LogInProb | You found it difficult to login (for example, you had trouble remembering your password)? |
Uncomfortable | You are not comfortable or experienced with computers? |
MultipleRec | You have more than one online medical record? |
aAll questions had binary (yes or no) responses.
Descriptive statistics for the HINTS 5 Cycle 3 populations were generated for demographic variables (gender, age, race/ethnicity) and the cancer diagnosis variable. We investigated the relationship between the use of online medical records and the demographic or diagnosis variables using an unadjusted model—Fisher exact test. We focused on patients who had not used online medical records to better understand the reasons behind their avoidance of this particular technology. We report odds ratios (OR) and corresponding 95% confidence intervals; statistical significance was determined based on
HINTS 5 Cycle 3 had a total of 4328 respondents, and 57.74% of the respondents (2499/4328) were female. Most respondents were older than 50 years (2926/4328, 67.61%) and non-Hispanic White (2992/4328, 69.13%), and 16% of respondents (693/4328) had been diagnosed with cancer (
Demographic characteristics of the patients.
Characteristic | Respondents (N=4328), n (%) | ||
|
|
||
|
Male | 1829 (42.26) | |
|
Female | 2499 (57.74) | |
|
|
||
|
18-34 | 580 (13.40) | |
|
35-49 | 822 (18.99) | |
|
50-64 | 1406 (32.49) | |
|
≥65 | 1520 (35.12) | |
|
|
||
|
Hispanic | 683 (15.78) | |
|
Non-Hispanic White | 2992 (69.13) | |
|
Non-Hispanic Black | 653 (15.09) | |
|
|
||
|
Have cancer | 693 (16.01) | |
|
No cancer | 3635 (83.99) |
Among the 4328 respondents, 2526 (58.36%) were nonusers. The ratio of nonusers across demographics ranged between 53% to 67%, with patients who were Hispanic (460/683, 67.35%) and patients who were non-Hispanic Black being highest (434/653, 66.46%). Patients who were non-Hispanic White (1360/2992, 45.45%) and patients between 18 and 34 years of age had the highest online medical record use (269/580, 46.38%).
Use of online medical records.
Characteristics | All, n (%) | Nonuser, n (%) | User, n (%) | Odds ratio (95% CI) | ||
All | 4328 | 2526 (58.36) | 1802 (41.64) | N/Aa | N/A | |
|
||||||
|
Male | 1829 (42.26) | 1130 (61.78) | 699 (38.22) | 1 | N/A |
|
Female | 2499 (57.74) | 1396 (55.86) | 1103 (44.14) | 0.78 (0.69-0.88) | |
|
||||||
|
18-34 | 580 (13.40) | 311 (53.62) | 269 (46.38) | 1 | N/A |
|
35-49 | 822 (18.99) | 450 (54.74) | 372 (45.26) | 1.04 (0.84-1.30) |
|
|
50-64 | 1406 (32.49) | 797 (56.69) | 609 (43.31) | 1.13 (0.92-1.38) |
|
|
≥65 | 1520 (35.12) | 968 (63.68) | 552 (36.32) | 1.51 (1.24-1.84) | |
|
||||||
|
Non-Hispanic White | 2992 (69.13) | 1632 (54.55) | 1360 (45.45) | 1 | N/A |
|
Hispanic | 683 (15.78) | 460 (67.35) | 223 (32.65) | 1.71 (1.43-2.05) | |
|
Non-Hispanic Black | 653 (15.09) | 434 (66.46) | 219 (33.54) | 1.65 (1.37-1.98) | |
|
||||||
|
Have cancer | 693 (16.01) | 365 (52.67) | 328 (47.33) | 1 | N/A |
|
No cancer | 3635 (83.99) | 2161 (59.95) | 1474 (40.05) | 1.31 (1.11-1.55) |
aN/A: not applicable.
Patients who avoided using online medical records were more likely to be male (OR 0.78, 95% CI 0.69-0.88,
In the second phase of the analysis, we only focused on nonusers (n=2526) and explored factors regarding their preference for not using online medical records. We compared the different demographics for each factor. The survey had 7 listed factors asked to each respondent. Each participant responded to each question with “yes” or “no.” We summarized the percentage for each demographic group among nonusers. The “desire to speaking directly to the health care provider” was the primary factor (1575/2526, 62.35%) influencing the nonuse of online medical records. Across all demographic characteristics, more than half of respondents answered “yes” for this question. For instance, 63.68% (889/1396) of female nonusers reported “desire to speaking directly” as one of the primary reasons. Almost half of the participants also expressed “no need” as a reason to avoid online medical records. The 18-34 years age group of nonusers had the highest rate of “no need” factor to explain their avoidance of online medical record use (194/311, 62.38%). Privacy concerns were not a primary reason to avoid online medical record use across all groups (range 12% to 23%).
Frequencies of reasons that explain nonuse of online medical records.
Characteristic | Factor, n (%) | |||||||
|
SpeakDirectly | NoNeed | ConcernedPrivacy | NoRecord | LogInProb | Uncomfortable | MultipleRec | |
|
1575 (62.35) | 1258 (49.80) | 499 (19.75) | 571 (22.60) | 435 (17.22) | 547 (21.65) | 228 (9.03) | |
|
|
|
|
|
|
|
|
|
|
Male | 686 (60.71) | 594 (52.57) | 214 (18.94) | 288 (25.49) | 170 (15.04) | 253 (22.39) | 109 (9.65) |
|
Female | 889 (63.68) | 664 (47.56) | 285 (20.42) | 283 (20.27) | 265 (18.98) | 294 (21.06) | 119 (8.52) |
|
|
|
|
|
|
|
|
|
|
18-34 | 166 (53.38) | 194 (62.38) | 39 (12.54) | 93 (29.90) | 45 (14.47) | 14 (4.50) | 26 (8.36) |
|
35-49 | 231 (51.33) | 252 (56.00) | 83 (18.44) | 114 (25.33) | 71 (15.78) | 48 (10.67) | 35 (7.78) |
|
50-64 | 530 (66.50) | 386(48.43) | 179 (22.46) | 173 (21.71) | 130 (16.31) | 163 (20.45) | 77 (9.66) |
|
≥65 | 648 (66.94) | 426 (44.01) | 198 (20.45) | 191 (19.73) | 189 (19.52) | 322 (33.26) | 90 (9.30) |
|
|
|
|
|
|
|
|
|
|
Non-Hispanic White | 1004 (61.52) | 922 (56.50) | 289 (17.71) | 375 (22.98) | 294 (18.01) | 334 (20.47) | 164 (10.05) |
|
Hispanic | 294 (63.91) | 172 (37.39) | 108 (23.48) | 100 (21.74) | 91 (19.78) | 118 (25.65) | 37 (8.04) |
|
Non-Hispanic Black | 277 (63.82) | 164 (37.79) | 102 (23.50) | 96 (22.12) | 50 (11.52) | 95 (21.89) | 27 (6.22) |
|
|
|
|
|
|
|
|
|
|
Have cancer | 260 (71.23) | 190 (52.05) | 74 (20.27) | 76 (20.82) | 79 (21.64) | 117 (32.05) | 50 (13.70) |
|
No cancer | 1315 (60.85) | 1068 (49.42) | 425 (19.67) | 495 (22.91) | 356 (16.47) | 430 (19.90) | 178 (8.24) |
The statistical analysis also yielded significant differences across the different demographics (
Reasons for not using online medical records.
Characteristic | Odds ratio (95% CI) | |||||||
|
|
SpeakDirectly | NoNeed | ConcernedPrivacy | NoRecord | LogInProb | Uncomfortable | MultipleRec |
|
||||||||
|
Male | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) |
|
Female | 1.13 (0.96-1.33) | 0.81 (0.69-0.96)* | 1.09 (0.89-1.34) | 0.74 (0.61-0.90)** | 1.21 (0.96-1.54) | 0.92 (0.76-1.12) | 0.87 (0.65-1.15) |
|
||||||||
|
18-34 | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) |
|
35-49 | 0.92 (0.68-1.24) | 0.76 (0.56-1.04) | 1.57 (1.02-2.44)* | 0.79 (0.56-1.11) | 1.10 (0.72-1.70) | 2.53 (1.34-5.06)** | 0.92 (0.52-1.63) |
|
50-64 | 1.73 (1.31-2.2)*** | 0.56 (0.42-0.74)*** | 2.01 (1.37-3.01) | 0.65 (0.47-0.88)** | 1.15 (0.78-1.70) | 5.44 (3.08-10.36)* | 1.17 (0.72-1.94) |
|
>65 | 1.76 (1.35-2.31)*** | 0.47 (0.36-0.62)*** | 1.79 (1.22-2.66)** | 0.57 (0.42-0.77)* | 1.43 (0.99-2.09) | 10.55 (6.06-19.89)*** | 1.12 (0.70-1.84) |
|
||||||||
|
Non-Hispanic White | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) |
|
Hispanic | 1.10 (0.88-1.38) | 0.46 (0.36-0.57)*** | 1.42 (1.09-1.84) | 0.93 (0.71-1.20) | 1.12 (0.85-1.46) | 1.34 (1.04-1.71) * | 0.78 (0.52-1.14) |
|
Non-Hispanic Black | 1.10 (0.88-1.38) | 0.46 (0.37-0.58)*** | 1.42 (1.09-1.84) | 0.95 (0.72-1.23) | 0.59 (0.42-0.82)** | 1.08 (0.83-1.41) | 0.59 (0.37-0.91)* |
|
||||||||
|
Have cancer | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) | 1.00 (1.00-1.00) |
|
No cancer | 0.62 (0.48-0.80)*** | 0.90 (0.71-1.13) | 0.96 (0.72-1.28) | 1.12 (0.85-1.50) | 0.71 (0.53-0.95)* | 0.52 (0.41-0.67)*** | 0.56 (0.40-0.80)** |
*
Female respondents were more likely to use online medical records, and they were more likely to have records (OR 0.74, 95% CI 0.61-0.90,
Patients with cancer preferred to speak directly to the health care providers (OR 0.62, 95% CI 0.48-0.80,
Many studies that aim to improve information sharing and technology use in health care settings are based on exploring design improvements in patient-centered tools. Some discuss the environmental and technical barriers of adopting these tools [
The results showed that online medical record use was improving compared to use in previous years—41% overall in 2019 compared to 28% in 2017 [
In this study, we explicitly focused on the reasons people avoid online medical record use across demographics. The major reason that emerged from the data is that patients would prefer to “see their physicians in person.” This was the primary reason for all groups except younger patients. Older patients were more likely to prefer to “speak in person with physicians” than younger patients. Furthermore, the preference to “speak in person with physicians” was also high for all race groups (1575/2526, 62.35%)
In the event of a population-wide infectious disease outbreak such as COVID-19, people’s online activities may affect public concerns and health behaviors. Many studies [
The technology acceptance model explains that people use technologies when they are perceived as useful and necessary [
Privacy has always been an issue for some users regarding the use of technologies for information sharing, especially information as sensitive and personal as medical records. Some participants also declared this as one of the factors for avoiding online medical record use. Respondents who were Black or Hispanic were more likely to have privacy concerns compared to those who were White. Historically, minorities have less trust in the health care system due to disparities they have experienced [
Finally, our study also showed that patients with cancer use online medical records more than patients who do not have cancer. This was consistent with the findings of previous studies [
This study also has limitations. First, the nature of HINTS data is cross-sectional and relies on subjective responses; therefore, it is not able to offer information on causality. Second, the low response rate (20%-30%) might raise some bias concerns, especially related to nonrespondents and sampling strategy. We should also note that the sampling and weighting strategy used by HINTS administrators helps minimize biases and improve national representativeness and generalizability of findings. Nonetheless, some local studies with more detail and a higher response rate should be conducted to validate the findings.
This study showed factors that lead people to avoid online medical record use across different demographics using a nationally representative survey. The findings show that there is an increased rate of online medical record use compared to previous years; however, this rate is still not at the expected level. The study shows that most patients still prefer speaking in person with their providers instead of using online medical records. Future studies should also look at how the education level of patients impacts these studied factors; our data did not have that component.
We also acknowledge that the recent COVID-19 pandemic has shifted the culture of virtual visits and online medical record use in health care. Future studies should look at online medical record use trends and factors during and after the pandemic to see how these have shifted. Finally, future designs and concepts of online medical communication technologies may also consider the importance of preparing a common ground for patients where different technology acceptance levels are respected.
Health Information National Trends Survey
Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health (award number R15NR018965). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
None declared.