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Patient portals are becoming increasingly popular worldwide even though their impact on individual health and health system efficiency is still unclear.
The aim of this systematic review was to summarize evidence on the impact of patient portals on health outcomes and health care efficiency, and to examine user characteristics, attitudes, and satisfaction.
We searched the PubMed and Web of Science databases for articles published from January 1, 2013, to October 31, 2019. Eligible studies were primary studies reporting on the impact of patient portal adoption in relation to health outcomes, health care efficiency, and patient attitudes and satisfaction. We excluded studies where portals were not accessible for patients and pilot studies, with the exception of articles evaluating patient attitudes.
Overall, 3456 records were screened, and 47 articles were included. Among them, 11 studies addressed health outcomes reporting positive results, such as better monitoring of health status, improved patient-doctor interaction, and improved quality of care. Fifteen studies evaluated the impact of digital patient portals on the utilization of health services with mixed results. Patient characteristics were described in 32 studies, and it was reported that the utilization rate usually increases with age and female gender. Finally, 30 studies described attitudes and defined the main barriers (concerns about privacy and data security, and lack of time) and facilitators (access to clinical data and laboratory results) to the use of a portal.
Evidence regarding health outcomes is generally favorable, and patient portals have the potential to enhance the doctor-patient relationship, improve health status awareness, and increase adherence to therapy. It is still unclear whether the use of patient portals improves health service utilization and efficiency.
In recent years, electronic tools that allow patients to interact with health care professionals have considerably increased with consequences on the awareness of citizens about their own health [
In this context, patient portals are thought to allow patients secure access to health-related information and to communicate and share information with providers [
A systematic literature review in 2013, which addressed the effect of patient portals on patient clinical care, reported that evidence was limited to evaluate whether patient portals had a positive, negative, or neutral impact on users’ health [
A search of relevant articles was performed in the PubMed and Web of Science databases using the query reported in
Eligible studies were primary studies reporting on the impact of patient portal adoption in relation with health outcomes, health care efficiency, and patients’ attitudes and satisfaction. Articles included were published from January 1, 2013, to October 31, 2019, and written in English, Italian, Spanish, or French. We excluded studies describing portals that were not accessible for patients, as well as pilot studies, with the exception of studies evaluating patients’ attitudes.
Two authors screened the articles, and each reference retrieved was screened by two researchers independently, with any disagreement finally discussed and resolved by a third researcher, if necessary. The following information was extracted from the studies: first author name, publication year, study country, study design, study population, study setting, study duration and time, health information technology, study objective, main findings according to health outcomes, health care efficiency/utilization, patient characteristics, and patient attitudes and satisfaction. The systematic literature review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 checklist [
The database search, after duplicate removal, identified a total of 3456 records. According to the inclusion/exclusion criteria, the screening resulted in the inclusion of 47 full-text articles (
The study designs were grouped into six categories according to the characteristics of the articles. Overall, 17 were descriptive quantitative studies [
With regard to country, 33 (70%) studies were based in the United States [
Various patient portals have been described in the studies.
Most of the portals were not addressed to a defined population subgroup, and only some of them were specific to a clinical specialty/condition, such as endocrinology-diabetes [
The population included in the studies was heterogeneous in terms of sample size (from 24 [
The results were summarized in four categories, albeit the same study could belong to more than one category. In particular, 11 studies analyzed health outcomes and adherence, intended as a change in individual or population health, attributable to health-related interventions. Adherence is the degree to which a patient follows medical advice, especially drug compliance. Overall, 15 studies focused on health care efficiency/utilization (utilization of health care services), 32 studies referred to patient characteristics, and 30 studies analyzed attitudes and satisfaction.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
Eleven articles presented results on patient outcomes (
In particular, a significant association was found between patients’ preventive health behaviors and portal use [
An improved clinical condition over time was observed in the management of asthma in children, where the group using the patient portal reported better flare control compared to the control group [
Concerning mental health, patients using the portal had a positive impact related to the clinical condition in many domains [
Finally, higher medication adherence was described in portal users compared with nonusers, especially among pediatric patients with asthma and patients with rheumatic disorders [
Summary of the findings on health outcomes and adherence.
First author, year | Country | Health information technology | Study design | Sample size | Main findings |
Ancker, 2019 [ |
United States | Blood glucose flow sheet (EpicCare and Weill Cornell Connect portal) | Observational, hypothesis testing | 53 patients | Pregnant: average BMI dropped while average blood pressure increased significantly more in the 9 months among uploaders than nonuploaders. |
Fiks, 2015 [ |
United States | MyAsthma (clinical interface in MyChart) | RCTb | 60 families of children | No significant differences in baseline control, quality of life, or parent activation between the two study arms ( |
Fiks, 2016 [ |
United States | MyAsthma | Descriptive, mixed methods | 237 families | Portal users with uncontrolled asthma had significantly more medication changes after using the portal relative to the year earlier (increase of 14%). |
Huang, 2019 [ |
United States | MyPennMedicine (branded version of Epic MyChart) | Observational, hypothesis testing | 10,000 patients | Patients’ preventive health behaviors were significantly associated with portal use. The proportions of annual flu vaccination, blood pressure checks, and lipid level screening were substantially higher in portal users compared with nonusers (ORc=1.58, 1.13, and 1.50, respectively; |
Jhamb, 2015 [ |
United States | Free patient portal tethered to an ambulatory EHRd | Observational, hypothesis testing | 1098 patients | In the fully adjusted model (controlling for hyperlipidemia, nephrolithiasis, history of kidney transplant, CCIe, proteinuria, eGFRf, number of nephrology and outpatient visits, and university affiliated PCPg), the association was not significant (OR 1.11, 95% CI 0.99-1.24). |
Kipping, 2016 [ |
Canada | Ontario Shores HealthCheck Patient Portal | Observational, hypothesis testing | 91 patients | The overall Mental Health Recovery Measure score increased from 70.4 (SD 23.6) at baseline to 81.7 (SD 25.1) at follow-up ( |
Lau, 2014 [ |
Canada | BCDiabetes.ca | Observational, hypothesis testing | 1957 patients | Overall, 28 of 50 users had a follow-up HbA1c ≤7%, whereas 22 of 50 did not (56% success rate). |
Manard, 2016 [ |
United States | Online patient portal | Observational, hypothesis testing | 1571 patients | After adjusting for age, users were more likely to achieve BPh control (HRi 1.24, 95% CI 1.06-1.45). After adjustment for sociodemographics, portal use was no longer associated with BP control (HR 0.98, 95% CI 0.83-1.16). |
Quanbeck, 2018 [ |
United States | Seva | Interventional, other than RCT | 268 patients | Significant reductions in the numbers of risky drinking days, which declined by 44% ([0.7-1.25]/1.25) from baseline to 6 months, and illicit drug-use days, which declined by 34% ([2.14-3.22]/3.22). Two of the three abstinence outcomes showed significant improvements (any illicit drug use and/or any drink or drug). Significant effects were found for two of the three quality of life scores (overall quality of life and mental health). |
Riippa, 2015 [ |
Finland | Patient portal by The Finnish Medical Society, Duodecim | Interventional, other than RCT | 876 patients | Minor differences in patient-reported physical and mental health changes that changed the sign from the matched (physical health mean=1.2, 95% CI −3.3 to 5.7; mental health mean=0.8, 95% CI −3.6 to 5.2) to the unmatched sample (physical health mean=−0.4, 95% CI −4.7 to 3.9; mental health mean=−0.4, 95% CI −4.8 to 4.0). Patient activation improved more in the intervention group, but it was not statistically significant. There was no marked short-term impact on health status based on the SF-36v2 measure. |
Van der Vaart, 2014 [ |
Netherlands | Medisch Spectrum Twente | Interventional, other than RCT | 360 patients | Overall, 56% of the respondents had a score of 7 (out of 8) on medication adherence. |
aPGHD: patient-generated health data.
bRCT: randomized controlled trial.
cOR: odds ratio.
dEHR: electronic health record.
eCCI: Charlson Comorbidity Index.
feGFR: estimated glomerular filtration rate.
gPCP: primary care practice.
hBP: blood pressure.
iHR: hazard ratio.
Fifteen articles described the relationship between portal use and health care service efficiency and utilization (
Summary of the findings on health care efficiency.
First author, year | Country | Health information technology | Study design | Sample size | Main findings |
Ancker, 2019 [ |
United States | Blood glucose flow sheet (EpicCare and Weill Cornell Connect portal) | Observational, hypothesis testing | 53 patients | Uploaders had more clinical visits and portal logins before initial data upload. |
Bidmead, 2016 [ |
England (United Kingdom) | Patients Know Best (PKB) | Descriptive, qualitative | 56 patients | The portal enabled clinicians to manage stable patients, facilitating clinical and cost-effective use of specialist nurses, and improved two-way communication and more optimal use of outpatient appointments and consultant time. It also facilitated a single rationalized pathway for stable patients, enabling access to information and proactive support. |
Fiks, 2015 [ |
United States | MyAsthma (clinical interface in MyChart) | RCTa | 60 families of children | The intervention group had a marginally significant reduction in the proportion of parents missing at least 1 day of work (reduction of 47%, |
Fiks, 2016 [ |
United States | MyAsthma | Descriptive, mixed methods | 237 families | Portal users with uncontrolled asthma had significantly more primary care asthma visits after using the portal than the year earlier (increases of 16%). |
Foster, 2019 [ |
United States | Epic MyChart | Observational, hypothesis testing | 208,635 tests | ED visits: 80.56% (n=20,430) of patients had a single ED visit with laboratory testing, 16.04% (n=4069) had two or three ED visits, 3.16% (n=802) had four to 10 ED visits, and only 0.24% (n=60) had more than 10 ED visits. Activation rates were lower for those with only a single ED visit (7312/20,430, 35.79%) compared with either those with two to three ED visits (1770/4069, 43.50%; |
Griffin, 2016 [ |
United States | My UNC Chart | Observational, hypothesis testing | 2975 patients | The odds of being readmitted within 30 days for active users was 66% higher than that for nonusers, holding all other variables constant in the model. There was no significant difference in 30-day readmission between nonusers and light users. |
Jahn, 2018 [ |
United States | My HealtheVet | Descriptive, qualitative | 29 participants | Secure messaging tasks were inefficient as related to clinical document sharing (it took almost 5 minutes for providers to only attach and send a clinical document). |
Kipping, 2016 [ |
Canada | Ontario Shores HealthCheck Patient Portal | Observational, hypothesis testing | 91 patients | Fewer missed appointments and a reduced number of requests for information in the year following portal implementation. The odds of a portal user attending an appointment were 67% (CI 56%-79%) greater than for nonusers over the follow-up period. Compared with 2014, in 2015, there was an 86% and 57% decrease in requests for information among users and nonusers, respectively (61% overall). |
North, 2014 [ |
United States | Mayo Clinic Health System | Observational, hypothesis testing | 2357 primary care patients | Primary care patients who sent at least one secure message or e-visit had a mean of 2.43 (SD 2.3) annual face-to-face visits before the first message and 2.47 (SD 2.8) after, with a nonsignificant difference ( |
Plate, 2019 [ |
United States | MyChart; Epic Systems Corporation | Observational, hypothesis testing | 6426 patients | Active MyChart status was not associated with 90-day ED return ( |
Quanbeck, 2018 [ |
United States | Seva | Interventional, other than RCT | 268 patients | Significant reduction in hospitalizations and a trend toward fewer ERe visits. Increase in HIV screening rates. Change in the rates of HIV risk behaviors (eg, condom use) and receiving other addiction treatments appeared to be nonsignificant. |
Riippa, 2015 [ |
Finland | Patient portal by The Finnish Medical Society, Duodecim | Interventional, other than RCT | 876 patients | The effect on the cost of care was ambiguous; costs decreased by an average of €91 in the unadjusted model, but increased by €48 in the adjusted model. Due to the controversial result, the unadjusted analysis showed an 89% probability of cost-effectiveness with no willingness to pay for increased patient activation, whereas in the adjusted sample, the probability of the portal being more cost-effective than care as usual exceeded 50% at a willingness to pay €700 per clinically significant increase in the patient activation score. For doctor visits, portal access (n=80): 3.8 (SD 3.3) and control (n=57): 3.0 (SD 3.1) ( |
Tsai, 2019 [ |
United States | Epic’s personal health record system | Descriptive, quantitative | 109,200 patients | Active users had more outpatient and inpatient visits and fewer ER visits. Patients without a portal account had on average fewer outpatient visits per month (0.31 vs 0.89, |
Wallace, 2016 [ |
United States | MyChart by Epic health record system | Interventional, other than RCT | 36,549 patients | The number of visits for 12 months was strongly associated with an increased likelihood of MyChart activation and with more frequent MyChart logins. |
Zhong, 2018 [ |
United States | MyUFHealth (also known as MyChart by Epic) | Observational, hypothesis testing | 15,659 nonusers and 5494 users | At the time of adoption, the quarterly PCPf office visit RRg of users to nonusers was 1.33 (95% CI 1.27-1.39; |
aRCT: randomized controlled trial.
bED: emergency department.
cASA: American Society of Anesthesiology.
dOR: odds ratio.
eER: emergency room.
fPCP: primary care physician.
gRR: rate ratio.
Concerning emergency room (ER) visits, a decreasing trend was described [
A reduction in hospitalizations was described for asthma [
Concerning clinicians’ attitudes, the portal seemed to enable a new way of managing stable patients, facilitating clinical and cost-effective use of specialist nurses (improved two-way communication, and more optimal use of outpatient appointments and consultant time). The portal also facilitated a single rationalized pathway for stable patients, enabling access to information and proactive support [
Portal use by patients reduced missing appointments [
Finally, concerning other aspects, only one study took into consideration the associated costs with ambiguous results. In this study, costs decreased in the unadjusted model but increased after adjusting for relevant variables [
Concerning patients’ characteristics, 32 articles presented relevant results that were mainly related to demographic information, such as age, gender, education, and household status (
Summary of the findings on patient characteristics.
First author, year | Country | Health information technology | Study design | Sample size | Main findings |
Abel, 2018 [ |
United States | My HealtheVet (MHV) and Clinical Video Telehealth (CVT) | Descriptive, quantitative | 2,171,325 patients | African American and Latino patients were significantly less likely to engage in use compared with White patients. Low-income patients with free care were significantly less likely to be users. Patients with schizophrenia or schizoaffective disorder were significantly less likely to be users than those with other mental health diagnoses (ORa 0.50, CI 0.47-0.53 and OR 0.75, CI 0.69-0.80, respectively). Although rural patients had 17% lower odds of My HealtheVet adoption compared with urban patients (OR 0.83, 95% CI 0.80-0.87), they were more likely to engage in Clinical Video Telehealth and dual use (OR 2.45, 95% CI 1.95-3.09 for Clinical Video Telehealth and OR 2.11, 95% CI 1.81-2.47 for dual use). |
Ancker, 2019 [ |
United States | Blood glucose flow sheet (EpicCare and Weill Cornell Connect portal) | Observational, hypothesis testing | 53 patients | Pregnant patients: Uploaders were similar to the comparison group in terms of race, ethnicity, age, and socioeconomic status. Uploaders had more clinical encounters and portal logins before initial data upload, earlier establishment of patient portal accounts, and worse baseline blood pressure. |
Chan, 2018 [ |
United States | MyChart (EpicCare, Verona, WI) | Descriptive, quantitative | 17,699 patients | Positive associations between portal use and being aged 50-74 years, White, privately insured, English-speaking, and living outside San Francisco. |
Fiks, 2015 [ |
United States | MyAsthma (Clinical interface in MyChart) | RCTb | 60 families of children | Parents of children with moderate or severe asthma used the portal more frequently (75% were frequent users vs 47% were parents whose child had mild persistent asthma). |
Fiks, 2016 [ |
United States | MyAsthma | Descriptive, mixed methods | 237 families | Users were more likely to have children aged 6-9 years ( |
Foster, 2019 [ |
United States | Epic MyChart | Observational, hypothesis testing | 208,635 tests | Females (5546/13,149, 42.18%) were significantly more likely to activate the portal than males (3897/12,212, 31.91%; |
Gordon, 2016 [ |
United States | Kaiser Permanente Northern California patient portal | Observational, hypothesis testing/descriptive, quantitative | 231,082 patients/4980 patients | Older seniors (aged 70-74 and 75-79 years) were significantly less likely than those aged 65-69 years to have registered, and to have used the patient portal to send a secure message, view laboratory test results online, or order prescription refills at least once by the end of the year. Slightly over 70% had been diagnosed with a chronic cardiovascular condition, and 90% reported taking at least one prescription medication for a chronic condition. |
Gossec, 2017 [ |
France | Sanoia | RCT | 320 patients | In multivariate analyses, the only factor related to connecting more than twice to the platform was being a member of a patient association (OR 1.44, 95% CI 1.17-1.77; |
Griffin, 2016 [ |
United States | My UNC Chart | Observational, hypothesis testing | 2975 patients | Active users had a higher proportion of Caucasian patients, higher Charlson Comorbidity scores, and a higher proportion of patients admitted to an academic medical center than light users. |
Huang, 2019 [ |
United States | myPennMedicine (branded version of Epic MyChart) | Observational, hypothesis testing | 10,000 patients | Users were more likely to be younger (63.46 years [users] vs 66.08 years [nonusers]; |
Jhamb, 2015 [ |
United States | Free patient portal tethered to an ambulatory EHRc | Observational, hypothesis testing | 1098 patients | Users were younger and more likely to be non-Black, be married, have private insurance, and have higher neighborhood median household income. Users were less likely to have diabetes, coronary artery disease, or congestive heart failure, but were more likely to have had a kidney transplant. Older age, Black race, unmarried status, Medicaid or Medicare insurance (vs private), and lower neighborhood median household income were associated with not using the portal. |
Kipping, 2016 [ |
Canada | Ontario Shores HealthCheck Patient Portal | Observational, hypothesis testing | 91 patients | A similar proportion of patients (1756/3158, 55.6%) and portal users (266/432, 61.6%) were female. Age distribution was relatively similar. The majority of users were between 25 and 34 years. |
Krist, 2014 [ |
United States | AllscriptsTouchworks EHR | Descriptive, mixed methods | 112,893 patients | Older patients were more likely to create a PHRd account as they had chronic conditions. |
Laranjo, 2017 [ |
Australia | Portuguese National patient portal | Descriptive, quantitative | 109,619 participants | Geographic analysis revealed higher proportions of PHR adoption in urban centers when compared with rural noncoastal districts. |
Lau, 2014 [ |
Canada | BCDiabetes.ca | Observational, hypothesis testing | 1957 patients | Users tended to be younger (mean difference of 4.28 years; |
Manard, 2016 [ |
United States | Online patient portal | Observational, hypothesis testing | 1571 patients | Users were significantly younger ( |
Mishra, 2019 [ |
United States | OpenNotes within the HealtheLife patient portal | Descriptive, quantitative | 1487 patients | Overall, 90% (n=784) were above 30 years, with 8% between 18 and 29 years; 40% were above 60 years; and 50% were between 30 and 59 years. One participant stated accessing the portal for a minor and another as a family surrogate. Moreover, 92% (n=797) had a college degree or greater, 24% (n=205) had a graduate degree, and 1% (n=12) had less than 12th grade education. Individuals in the 18-29 and >60 years groups were more likely to find the notes helpful. Greater note comprehension was correlated with greater education. Noncollege participants were more likely to access notes “many times” than college participants ( |
North, 2014 [ |
United States | Mayo Clinic Health System | Observational, hypothesis testing | 2357 primary care patients | The majority of patients sending messages were female, were White, lived locally, and were employed by the Mayo Clinic. |
Plate, 2019 [ |
United States | MyChart; Epic Systems Corporation | Observational, hypothesis testing | 6426 patients | Overall, 4623 people registered on MyChart logged into the patient portal at least once within 1 year from surgery, and 1803 (28%) patients were not registered users. Active users were significantly more likely to be young, have a healthy ASAi score (ASA 1 or 2), be Caucasian, be married, be employed, be privately insured, and be discharged to home. Patients not using MyChart had a higher ASA score (ASA 3 or 4) and were more likely to be African American, unmarried, and unemployed. Patients without MyChart were more likely to have Medicare or Medicaid insurance and be discharged to a skilled nursing facility. |
Portz, 2019 [ |
United States | My Health Manager (Kaiser Permanente Colorado patient portal) | Qualitative descriptive study | 24 patients | The mean age was 78 years. Patients were primarily White (12, 80%) and women (12, 80%). Education: high school graduate, 1 (7%); some college graduate, 7 (47%); and college graduate, 7 (47%). Income: <US $30,000, 2 (13%); US $30,000-49,999, 7 (47%); US $50,000-74,999, 2 (13%); >US $75,000, 2 (13%); chose not to answer, 2 (13%). |
Powell, 2018 [ |
United States | FollowMyHealth portal | Observational, hypothesis testing | 500 patients | No significant relationship between the number of logins and any of the demographic variables; however, when those with zero logins were removed from the model, age, distance separating the patient from his or her provider, and having a diagnosis of heart failure were all significant predictors of portal use ( |
Price-Haywood, 2017 [ |
United States | MyOchsner patient portals (Epic System), wearable technology, smartphone mobile apps | Descriptive, quantitative | 247 patients | Portal users had higher levels of education, lower rates of inadequate health literacy, and higher rates of using the internet and having an interest in websites or smartphone apps for tracking health. The odds of portal use increased with total eHEALS scores (health literacy scale) and decreased among Black patients. |
Riippa, 2014 [ |
Finland | No specific portal | Interventional, other than RCT | 876 patients | Patients with a severe diagnosis during the intervention showed the greatest positive change in patient activation (mean change 5.4, SD 8.4). Patients diagnosed 1-2 years ago (mean change 2.3, SD 15.7) and patients with no severe diagnoses (mean change 1.6, SD 13.1) showed a positive change in patient activation. |
Ronda, 2014 [ |
Netherlands | Digitaal Logboek | Descriptive, quantitative | 1390 patients | Multivariable analysis showed that increasing age and smoking were associated with not using the portal. A higher educational level, treatment by an internist, using insulin, polypharmacy, better diabetes knowledge, and more hyperglycemic episodes were less likely to be associated with not using the portal. |
Smith, 2015 [ |
United States | EpicCare | Descriptive, quantitative | 534 patients | Significant predictors of registering were as follows: gender (male 65.3% vs female 55.1%), race (White 71.7% vs African American 27.7% vs “other” races 41.7%), education (more educated people were more likely to register), number of chronic conditions (70.9% with zero conditions, 63.2% with one condition, and 50.0% with two or more conditions), health literacy (adequate 72.7% vs marginal 46.4% vs limited health literacy 21.7%). |
Sun, 2019 [ |
United States | Epic’s personal health record system | Observational, hypothesis testing | 38,399 patients | Almost one-third of patients (n=12,615; 32.9%, 95% CI 32.38%-33.32%) had used the portal for a mean of 2.5 (SD 1.9) years prior to the study period. Portal use was higher on weekdays ( |
Tsai, 2019 [ |
United States | Epic’s personal health record system | Descriptive, quantitative | 109,200 patients | Active portal users were on average older (49.45 vs 46.22 years) and frequently female (62.59% vs 54.91%). Both the differences in mean age ( |
Van der Vaart, 2014 [ |
Netherlands | Medisch Spectrum Twente | Interventional, other than RCT | 360 patients | Univariate analyses showed that age, marital status, education level, employment, health literacy, and internet-related characteristics were significantly related to portal use. Nonusers were more often older, single, lower educated, and unemployed. Respondents with higher health literacy were more inclined to login on the portal, and respondents who used the internet more often had more years of experience and perceived their own skills as better. |
Wade-Vuturo, 2013 [ |
United States | MyHealthAtVanderbilt patient portal | Descriptive, quantitative | 54 patients | Participant age, gender, race, income, and education level were not associated with using SMj to send a message to a provider for any reason or using SM to schedule an appointment. |
Wallace, 2016 [ |
United States | MyChart by Epic health record system | Interventional, other than RCT | 36,549 patients | Men, non-White patients, and Hispanic patients were significantly less likely to login once, 2 to 23 times, or 24 times than women, White patients, or non-Hispanic patients. Patients with public insurance were less likely to login than those with private insurance across all MyChart usage categories. Patients with income levels 100% of the FPLk were more likely to login one time than those below the FPL level. |
Wedd, 2019 [ |
United States | Unspecified patient portal | Descriptive, quantitative | 710 patients | Black patients were less likely to use the portal vs White patients among both kidney (Black 57% vs White 74%) and liver (Black 28% vs White 55%) transplant recipients. In adjusted multivariable analyses, kidney transplant recipients were more likely to use the portal if they had higher education. Among liver recipients, patients who were White and had higher education were more likely to use the portal. |
Zhong, 2018 [ |
United States | MyUFHealth (also known as MyChart by Epic) | Observational, hypothesis testing | 15,659 nonusers and 5494 users | The user group comprised 53.1% patients with more than four chronic problems (vs 40.2% of the matched nonuser group), and had more patients bearing 10 or more chronic problems (18.2% vs 12.2%). Individuals enrolled in the patient portal were mostly middle aged (31-64 years) and female. Married patients were more likely to adopt the portal. Medicare and Medicaid patients, and Black or African American patients were less likely to be adopters. Portal adoption was also associated with the baseline number of active medical problems ( |
aOR: odds ratio.
bRCT: randomized controlled trial.
cEHR: electronic health record.
dPHR: personal health record.
eLDL: low-density lipoprotein.
fSBP: systolic blood pressure.
gFM: family medicine.
hGIM: general internal medicine.
iASA: American Society of Anesthesiology.
jSM: secure messaging.
kFPL: federal poverty level.
In terms of age, results were not homogeneous. Higher use in older patients (aged >50 years) was described in four studies [
A total of 19 studies mentioned the origin and ethnicity of users [
Most of the articles found a positive association between female gender and portal use [
In a cohort of patients with mental disorders, having schizophrenia or schizoaffective disorders was negatively associated with portal use [
People living in rural areas were less likely to use patient portals than urban citizens in three studies [
Studies conducted in the United States showed that having a private insurance was positively associated with portal use [
Other patient characteristics positively associated with portal use were being a member of a patient association [
Patient attitudes were evaluated in terms of perceived barriers and facilitators toward portal use. The overall satisfaction was also assessed, and it refers to the extent to which the patient is content about health care. Thirty articles addressed these topics (
Nine articles clearly addressed the barriers to portal use. Some of the main issues were related to perceived or preconceived security concerns [
On the other hand, nine articles specified the elements that facilitated portal use, including improved communication with specialists [
Due to the considerable amount of literature published on the topic of patient portals, the aim of this review was to provide evidence and to gather information systematically. Similar to the review published in 2013 by Goldzweig et al [
Positive results were described relating to the enhancement of preventive behaviors [
The number of clinical and ED visits [
The studies differed also in terms of the population included, with conflicting results in portal adoption and age, gender, ethnicity, kind of disease, and number of comorbidities. Generally, having a higher income [
The main barriers faced in using the portals were (1) user-related issues, such as time constraints [
Security problems are complex issues that must be considered in any part of medical care. The use of information technologies in health care that can be accessed by multiple types of users (physician, patient, caregiver, and hospital administrative staff) represents the basis of the discussion about computer security [
The facilitators retrieved were the prompt availability of health information that caused an increase in the awareness of the health status [
Despite the considerable number of studies included, the high heterogeneity in terms of outcomes and described portal functionalities did not allow us to perform meta-analyses and to draw generalizable and strong conclusions concerning the utility of the unique features of the portals.
Technological and digital innovations in health care could contribute to achieving the health system goals of equity, efficiency, accessibility, quality, and sustainability, if they are purposefully designed and cost-effectively implemented. When designing a new patient portal or a new functionality, developers and providers should always consider to which health care need they are trying to respond and if other nondigital interventions may be more effective or as effective at a lower cost.
Moreover, the adoption of a new technology is a complex process, depending on the content and the context in which it is introduced. As an example, our review demonstrated that it is feasible to achieve better medication adherence in chronic disease patients through portal use, and highlighted the main facilitators (eg, prompt availability of reliable information and accessibility of communication with disease specialists) and barriers (eg, security and usability concerns, and limited digital knowledge) to portal use. Keeping in mind these contextual factors could ease the difficult task of identifying the best digital tool for a specific population.
Before designing or implementing a new tool, it can be useful to analyze the ideal conditions needed for the adaptation, transfer, absorption, up-scaling, and enhancement of digital technologies. By ideal conditions, we basically mean a situation where the new technology has demonstrated effectiveness in trials or pilots, the provider is committed to guarantee continuous improvement in user accessibility and usability, and the main barriers in the target population are given due consideration. In the absence of these conditions, satisfactory results may be difficult to reach or may take many years to be observed.
The benefits of digitalization cannot be taken for granted and the use of technology does not always lead to an improvement in patient care and health system performance; thus, there is a need for evidence, which is, to date, scarce. The identification of a set of main features with proven efficacy for a patient portal is a useful starting point for the development and implementation of patient-oriented portals. Further studies should be conducted in different aspects of digitalization in health care. None of the studies retrieved analyzed the cost-effectiveness of portal use. Similarly, none of the studies compared the portals to each other, which could be interesting to point out the best practices and features.
Even though a patient portal is not a new concept, its real utilization and implementation are still far from optimal, and it seem to be still considered a “future technology.” It is important to adapt the portal functions to the needs and capacities of patients, in order to facilitate the use of this technology and improve its dissemination. In particular, overcoming ethnic and literacy barriers to portal use represents a fundamental goal to create more equitable, effective, and safe health care systems.
Search string.
Functions and details of patient portals.
Qualitative descriptions of the portals and/or features studied in the included articles.
Summary of the findings on patient attitudes and satisfaction.
emergency department
electronic medical record
emergency room
randomized controlled trial
All authors contributed to the study conception and design. Material preparation and data collection were performed by EC, LV, AMP, AG, and AB. EC and LV screened the articles, with any disagreement finally discussed and resolved with AMP. The first draft of the manuscript was written by EC, LV, AMP, AG, and AB. WR and SB commented on the latest version of the manuscript. WR and SB supervised the study. All authors read and approved the final manuscript.
None declared.