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Currently accepted at: Journal of Medical Internet Research

Date Submitted: Jun 8, 2019
Open Peer Review Period: Jun 11, 2019 - Jul 30, 2019
Date Accepted: Aug 13, 2019
(closed for review but you can still tweet)

This paper has been accepted and is currently in production.

It will appear shortly on 10.2196/14976

The final accepted version (not copyedited yet) is in this tab.

Growing disparities in Patient-Provider Messaging Following Supportive Public Policy: A Trend Analysis using Health Information National Trends Survey Data

  • Nicole Senft; 
  • Evan Butler; 
  • Jordan Everson; 



Under the HITECH Act, public policy introduced since 2011 has supported provider adoption of electronic medical records and patient-provider messaging. It is unclear how disparities in use of policy-influenced online health tools have changed over time relative to use of online tools that were not targeted by policy.


To characterize the impact of public policy on disparities in patient-provider messaging by comparing its use with rates of looking for health information online, which was not targeted by public policy.


We used nationally representative Health Information National Trends Survey data from 2003-2018 (N=37,300) to describe disparities in patient-provider messaging and looking for health information online. We first reported the percentage of individuals across education and racial/ethnic groups who reported using these tools in each survey year. We then compared changes in unadjusted disparities during pre-policy (2003-2011) and post-policy (2011-2018) periods. Using multivariable linear probability models, we examined adjusted effects of education and race/ethnicity in three periods: pre-policy (2003-2005), early-policy (2011-2013) and post-policy (2017-2018). Models controlled for sociodemographic factors and general health. In the post-policy period, an additional model tested whether access to the internet, healthcare providers, or providers that used an electronic medical record explained remaining disparities.


From 2003-2018, overall rates of provider messaging increased from 4% to 36%. The gap between the highest and lowest education groups increased by 10 percentage points from 2003-2011 (p<.001), and 22 additional points from 2011-2018 (p<.001). The gap between Hispanics and non-Hispanic whites increased by 3.2 points from 2003-2011 (p=.42) and an additional 11 points from 2011-2018 (p=.01). Trends for Blacks resembled those for Hispanics, while trends for Asians resembled non-Hispanic Whites. In contrast, education-based disparities in looking for health information did not significantly change from 2003-2011 or 2011-2018. Racial disparities narrowed by 15 percentage points from 2003-2011 (p=.008) and did not significantly change from 2011-2018. Results of adjusted models were similar to unadjusted associations, though smaller in magnitude. Including access to the internet, providers, and providers with electronic medical records in the model attenuated, but did not eliminate, disparities based on education. However, disparities by race/ethnicity were no longer statistically significant when accounting for access.


Disparities in provider messaging widened over time, particularly after the introduction of supportive public policy. Meanwhile, disparities in looking for health information online have remained stable or narrowed. Public policy aimed at increasing provider messaging may have disproportionately benefited socioeconomically advantaged groups. Future policy could address disparities by incentivizing providers treating these populations.


Please cite as:

Senft N, Butler E, Everson J

Growing disparities in Patient-Provider Messaging Following Supportive Public Policy: A Trend Analysis using Health Information National Trends Survey Data

Journal of Medical Internet Research. (forthcoming/in press)

DOI: 10.2196/14976


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