ORIGINAL RESEARCH
Matthew Sakumoto, MD1* , Jiancheng Ye, MS2 , Richard Kalu, MD, MPH3 , Kathryn Jackson, MS4 , Sarah S Rittner, MA5 , Timothy Long, MS6 , Mita Sanghavi Goel, MD, MPH, FACP7 and Theresa L. Walunas, PhD8
1Department of Medicine, University of California, San Francisco, USA; 2Center for Health Information Partnerships, Northwestern University, Chicago, USA; 3Department of Surgery, Lehigh Valley Health, Pennsylvania, USA; 4Center for Health Information Partnerships, Northwestern University, Chicago, USA; 5SASU Project Management, Chicago, USA; 6Health Choice Network, Miami, USA; 7Department of General Internal Medicine, Northwestern University, Chicago, USA; 8Center for Health Information Partnerships, Northwestern University, Chicago, USA
Keywords: community health, patient engagement, patient portal, telehealth, urban health usability
Introduction: Patient portals can be the “front door” to telehealth—secure clinician messaging, video visit links, and digital after visit summaries are accessed via the patient portal. Patient portal tools often require similar patient skills and attitudes as telehealth adoption. Analyzing patients’ perceptions and beliefs around this digital patient engagement tool may lead to insights regarding telehealth, particularly in historically underrepresented patient populations.
Methods: Participants from a Federally Qualified Health Center (FQHC) in Chicago were surveyed on general technology use, healthcare-specific technology use, and barriers and facilitators to patient portal use.
Results: The 149 respondents (81% response rate) represented a unique population base with 96% African American, 74% with the educational attainment of some college or less, and 48% with at least one chronic medical condition. Technology access and use were high with 78% computer ownership and 98% mobile phone ownership (with 75% smartphone ownership). In terms of patient portal perception, 75% rated perceived usefulness (U) as high. Perceived ease of use (E) domains similarly had 70% or higher agreement from patients, and potential barriers and facilitators in the attitudes toward use (A) section included a preference to calling their doctor, and the minority of patients viewing the portal as an unsafe way to communicate, too complicated to use, or taking too much time. Additional stratification analysis by demographic variables (age, gender, educational attainment, and number of chronic conditions) revealed differences in portal perception across the usefulness, ease of use, and attitude domains.
Discussion: Insights from barriers, attitudes, and capacity to use patient portal tools deliver important insight into the overall adoption of other digital health modalities, including telehealth. In an urban historically underserved patient population, technology access and use are quite high, and mobile phone access was nearly ubiquitous with a large majority using the internet function on their mobile device. Different age groups, genders, levels of educational attainment, or degrees of comorbidity have different values and needs. Therefore, each subpopulation needs targeted messaging of different portal benefits.
Conclusions: Our research provides initial insights into patient-level factors influencing patient portal attitudes, with implications toward telehealth adoption. Demographic differences have a significant impact on attitudes toward technology adoption. Equitable uptake of portal and telehealth services will require tailored messaging, training, and multiple modes of communication, including web based and mobile.
Citation: Telehealth and Medicine Today © 2022, 7: 373 - http://dx.doi.org/10.30953/tmt.v7.373
Copyright: © 2022 The Authors. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, adapt, enhance this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0.
Received: September 18, 2022; Accepted: October 18, 2022; Published: November 14, 2022
Funding Statement: This research was supported entirely by internal funds via a grant from the Northwestern University Clinical and Translational Sciences (NUCATS) Institute.
Financial and non-Financial Relationship and Activities: Dr. Sakumoto is a Review Board Member for Telehealth and Medicine Today. All other authors declare no potential conflicts of interest.
*Corresponding Author: Matthew Sakumoto, Email: Matthew.Sakumoto@ucsf.edu
Patient portals are the “front door” to telehealth. Telehealth encompasses more than video visits, and patient portal adoption is a necessary first step toward telehealth adoption. Telehealth, broadly defined as “the remote provision of healthcare via telecommunications technology” such as secure clinician messaging, video visit links, and digital after-visit summaries are all accessed via the patient portal. Patient portal tools often require similar patient skills and attitudes as telehealth adoption. Analyzing patients’ perceptions and beliefs around this digital patient engagement tool may lead to insights regarding telehealth.1 The digital divide is also a concern, as patients have different levels of trust and ability to access new modalities of care. Overall, these barriers to digital health access manifest as low uptake of digital health interventions among underserved populations.2–5
It is important to represent diverse patient populations when analyzing patient portal uptake trends. Adoption and use of portals by patients have been variable and high use has been difficult to achieve, particularly among patient populations that already experience healthcare disparities.6,7 Given the central focus on patient portals to connect patients with their healthcare information and care teams, there is a significant concern that low usage by safety net patient populations will lead to increased healthcare disparities, particularly among African American populations, who already experience disparities in access to care.8–10
The Technology Acceptance Model (TAM) is a commonly used theory that postulates that an individual’s attitude toward and behavioral intention to use a technology is influenced predominantly by the perceived usefulness (U) of and perceived ease of use (E) of the technology in the context of key external factors such as primary demographics and general technology use.11–13 The TAM has been used extensively to explain the adoption of technology in other fields, including internet use, internet banking, and physician acceptance of telemedicine.14–17 Prior studies show that the TAM has also been shown to be useful in predicting care team adoption of health information technology.18 Thus far, the literature is scant with the TAM framework and the patient as the end-user, with only one qualitative study of patient adoption of patient portals,19 and quantitative analysis remains incomplete.
To determine whether the TAM could be used to understand portal use and to better understand how patients in community health center settings could be encouraged to use patient portals, we performed a pre-portal implementation study to assess key TAM components (technology access, perceived usefulness, perceived ease of use, and attitudes toward using the portal) among a predominantly African-American patient population at an urban Federally Qualified Health Center (FQHC) and determined variations in subpopulations of patients based on age, gender, educational attainment, and chronic conditions.
We recruited 150 participants from the adult internal medicine clinic, women’s clinic and pharmacy and laboratory services for waiting areas at a Federally Qualified Health Center (FQHC) in Chicago. Data were collected between July and August, 2014 before the deployment of their electronic health record-tethered patient portal. Eligible participants were English-speaking, 18 years of age or older and receiving care at the FQHC. One participant completed the survey twice, and their second set of survey results was removed, so the final study population was 149 participants.
Research assistants (authors MS and RK) approached potential participants in the waiting areas of the adult internal medicine clinic, the women’s clinic, and pharmacy and laboratory services. Research assistants confirmed eligibility and obtained informed consent that included participation in the survey and permission to extract clinical conditions (including chronic conditions) and administrative data (demographics) from their electronic health records. We used a nonprobability sampling method based on convenience and availability. Those who completed the survey received a $25 pharmacy gift card.
The technology acceptance model has been successfully used in business environments to model technology uptake.12–14 The TAM posits that in combination with key external variables (such as demographics), perceived usefulness (U) and perceived ease of use (E) of a technology impact attitudes toward using (A) and behavioral intention to use the technology, which ultimately determines whether a given individual will use the technology. We developed a 20-min survey, by adapting the validated TAM instrument13 and Pew Internet and American Life Surveys on mobile technology use and use of the Internet for healthcare information.20,21 The survey included five core domains: demographic information (age, gender, race/ethnicity, and education level), general use of technology, access to technology, perceptions of technology for communicating about health care, and preferences for how to communicate about healthcare. We also included a modified version of the survey performed by Goel et al. to assess barriers and facilitators of patient portal use.22 The entire survey is provided in Supplemental Section A. The survey was administered, either on paper or through the use of a tablet computer, using SNAP survey software (SnapSurveys, Bristol, United Kingdom).
Survey data were supplemented with health information from the electronic medical records of the survey participants to assess the number of chronic conditions each participant experienced. Chronic conditions considered were those described in the Dartmouth Atlas of Chronic Disease,23 which were mapped to appropriate International Classification of Disease 9th Edition (ICD-9) codes for identification in the medical record.24 The chronic disease categories assessed included: malignant cancer, chronic pulmonary disease, coronary artery disease, congestive heart failure, peripheral vascular disease, severe chronic liver disease, diabetes with end organ damage, renal failure, and dementia. Data were extracted for all participants from the AllianceChicago electronic data warehouse where the FQHC EHR data are housed, following the completion of the survey data collection. AllianceChicago is a Health Center Controlled Network that provides central EHR and data warehousing infrastructure for a national network of FQHCs.
We generated descriptive statistics for all demographic variables. Categorical variables are reported as counts or proportions as appropriate. Patient responses were coded and reported as frequencies based on demographic variables. Given the non-normal distribution, we performed Pearson chi-square tests to compare group differences. All statistical analyses were two-sided and performed using STATA, version 15 (StataCorp, LLC, College Station, TX) and R, version 3.44 (R Foundation, Vienna, Austria). Statistical significance was defined at p < 0.05.
This study was reviewed and approved by the Northwestern University Institutional Review Board (STU00068642) and the Near North Health Service Corporation Scientific Review Committee.
Demographics of study participants are detailed in Table 1. A total of 183 eligible participants were approached to participate in the study, and 149 met our eligibility criteria and completed the survey (response rate: 81.4%). The primary demographics of the participants are described in Table 1. Of the 149 respondents, 143 (96%) identified as African American, 2 (1%) as Hispanic or Latinx, 1 (1%) as Caucasian, and 3 (2%) did not identify in any of these categories and were grouped as “Other”. The mean age of the participants was 46 years, and 92 (62%) were women. We also assessed education levels: 41 (28%) had achieved a GED/completed high school or less, 68 (46%) reported some collegiate-level education and 40 (27%) were college graduates. Finally, the number of chronic conditions our study participants experienced was determined from their medical records: 77 (52%) had no documented conditions, 37 (25%) had one chronic condition, 20 (14%) had two and 13 (9%) had three or more chronic conditions.
To better understand how our participants used technology and the Internet, participants were asked to describe access to technology, frequency of technology use, and use of technology for healthcare. These results are described in Table 2. Overall, we observed a high rate of technology access among our participants: 78% owned a computer, 88% had an email address, 93% used the Internet, and 98% owned a mobile phone, which could be a standard mobile phone or smartphone. For those that owned a computer, 69% used it daily or more frequently. For those that owned a mobile phone, 97% used it to make phone calls, 85% to send text messages, 76% used voicemail functions, 75% used the Internet from their phone, and 68% sent email. While Internet use was high, only 38% of participants had looked for medical information for themselves or others in the past 12 months and only 34% were aware of patient portal technology.
Patient responses to survey questions across the TAM domains are detailed in Table 3. TAM domains include perceived usefulness (U), perceived ease of use (E), and attitudes toward use (A). Overall, the portal had high perceived usefulness with all portal features rated as being “important” or “very important” by 75% or more of patients. These categories were combined since both connote positive perceived usefulness on our five-point Likert scale. For examination of individual portal features, only “very important” ratings were used to provide more granular differentiation and stratification. The top five “very important” rated functions were viewing test results (75%), requesting medication refills (73%), managing medical issues (68%), scheduling appointments (68%), and reviewing current medications (66%). Portal functions related to communication or coordination were slightly lower with “Very Important” ratings for the following functions: provide doctor with home blood pressure or glucose readings (53%), email doctor regarding medical issues (42%), communicate after hours (40%), and share medical records with other doctors (38%). A notable outlier is a low desire to share medical records with family (15% rated “very important”). All questions in the Perceived Ease of Use domain had 70% or higher agreement from patients, with the exception of the portal would “not require a lot of mental effort” (57%). Lastly, the Attitudes Toward Use section highlighted a main reason for not using the portal was a preference to calling their doctor (66%). An additional set of reasons for not using the portal included: viewing the portal as unsafe way to communicate (35%), too complicated to use (20%), taking too much time (14%), or not useful (11%).
In addition to overall trends, we investigated whether key demographic variables (age, gender, educational attainment, and number of chronic conditions) were associated with differences in TAM domains.
Overall, as shown in Table 4, there was a trend toward lower perceived usefulness ratings, with a drop off at age ≥ 65. Statistically significant differences in levels of agreement were noted for requesting refills, emailing doctors regarding medical issues, asking questions regarding medical issues, and doing office tasks online. Similar decreases by age were noted in ease of use domains with lower levels of agreement for age ≥ 65 in predicting portal use (53%), personal life/Internet compatibility (53%), and compatibility with other technology in use (73%). Finally, there was a trend toward more negative attitudes toward the portal with both 50 – 64 and 65+ age groups preferring to call their doctor (73% and 93%, respectively), and the patient portal taking too much time (24% and 27%, respectively).
Elements | Age (in years) | ||||
18–34 (n = 40) | 35–49 (n = 43) | 50–64 (n = 51) | ≥ 65 (n = 15) | p-value* | |
Usefulness | |||||
Request refills | 95% | 95% | 92% | 73% | 0.04 |
Email doctor with regard to medical issues | 90% | 91% | 71% | 67% | 0.02 |
Ask questions re medical issues | 95% | 93% | 86% | 67% | 0.02 |
Do office tasks online | 95% | 84% | 76% | 60% | 0.01 |
View lab results | 95% | 88% | 86% | 87% | 0.58 |
Manage medical issues | 88% | 88% | 80% | 67% | 0.21 |
Schedule appointments | 93% | 98% | 84% | 80% | 0.09 |
Ease of use | |||||
Easy to use | 93% | 81% | 82% | 80% | 0.44 |
Predict that I will use portal | 70% | 84% | 75% | 53% | 0.012 |
Using Internet fits into my life | 90% | 93% | 67% | 53% | <0.001 |
Compatible with other technology I use | 95% | 98% | 80% | 73% | 0.01 |
Not require a lot of mental effort | 58% | 65% | 53% | 53% | 0.67 |
Attitudes | |||||
Prefer to call my doctor | 55% | 58% | 73% | 93% | 0.03 |
Take too much time | 5% | 5% | 24% | 27% | 0.01 |
Unsafe way to communicate | 30% | 28% | 45% | 40% | 0.29 |
*Values in bold face are statistically significant. |
When there were gender differences in perception of the usefulness of portal features, women tended to rate features as important more frequently than men, especially viewing screening tests (97% vs 88%), viewing clinic notes (93% vs 82%), and communicating after hours (86% vs 67%). However, men rated sharing medical records with family as important more frequently than women (54% vs 37%). Women also generally viewed ease of use domains more favorably, agreeing that they would use the portal (82%), and that using the Internet fits into their life (86%). Finally, when there were differences in attitudes toward portal use, men tended to have more negative views of patient portals, noting them to be not useful (19% vs 5%) and too complicated (30% vs 14%) (Table 5).
Elements | Men (n = 57) | Women (n = 92) | p-value* |
Usefulness | |||
Schedule appointments | 86% | 92% | 0.21 |
Request refills | 91% | 92% | 0.8 |
View lab results | 91% | 88% | 0.54 |
Review current meds | 91% | 93% | 0.61 |
Manage medical issues | 77% | 87% | 0.12 |
View screening tests | 88% | 97% | 0.03 |
View clinic notes | 82% | 93% | 0.04 |
Communicate after hours | 67% | 86% | 0.01 |
Share medical records with family | 54% | 37% | 0.04 |
Ease of use | |||
Predict that I will use portal | 61% | 82% | 0.01 |
Using Internet fits into my life | 68% | 86% | 0.01 |
Not require a lot of mental effort | 58% | 58% | 0.97 |
Easy to use | 86% | 84% | 0.71 |
Attitudes | |||
Not useful | 19% | 5% | 0.01 |
Prefer to call my doctor | 70% | 63% | 0.37 |
Too complicated to use | 30% | 14% | 0.02 |
Unsafe way to communicate | 42% | 32% | 0.19 |
*Boldface values: statistically significant finding. |
Overall perceived usefulness of portal features was similar across education levels. However, for scheduling appointments, 100% of patients with GED or less rated it as important compared with those with some college (84%) and college or greater (90%). Those with higher education attainment such as college or greater had the lowest level of agreement on select perceived ease of use questions. For example, only 68% agreed that “learning to operate [the portal] will be easy for me” and 73% agreed that the portal would be “easy to use.” Finally, those with a college degree or greater had a higher frequency of negative attitudes toward portals rating them as “too complicated to use” (35%) and “taking too much time” (25%) (Table 6).
Elements | ≤ GED (n = 41) | Some college (n = 68) | College + (n = 40) | p-value* |
Usefulness | ||||
Schedule appointments | 100% | 84% | 90% | 0.03 |
Request refills | 93% | 93% | 90% | 0.87 |
View lab results | 93% | 87% | 90% | 0.62 |
Manage medical issues | 88% | 84% | 78% | 0.46 |
Ease of use | ||||
Predict that I will use portal | 80% | 76% | 63% | 0.15 |
Not require a lot of mental effort | 61% | 60% | 50% | 0.51 |
Easy to use | 85% | 91% | 73% | 0.03 |
Learning to operate will be easy for me | 95% | 90% | 68% | 0.001 |
Attitudes | ||||
Not useful | 7% | 10% | 15% | 0.53 |
Too complicated to use | 7% | 19% | 35% | 0.01 |
Take too much time | 7% | 10% | 25% | 0.04 |
Unsafe way to communicate | 29% | 31% | 50% | 0.08 |
*Boldface values: statistically significant finding. |
Perceived usefulness of portal features and perception of ease of use remained similar across the number of chronic conditions. However, there was a trend toward patients with two chronic conditions having the highest frequency of negative attitudes toward patient portals. For example, 40% of patients with two chronic conditions thought that the portal was “not useful,” compared with those with 0–1 (6%) or 3+ conditions (7%). Similarly, 35% of patients with two chronic conditions thought the portal would “take too much time,” compared with those with 0–1 (11%) or 3+ conditions (0%) (Table 7).
Elements | 0–1 (n = 114) | 2 (n = 20) | 3+ (n = 15) | p-value* |
Usefulness | ||||
Schedule appointments | 92% | 80% | 87% | 0.34 |
Request refills | 93% | 95% | 80% | 0.34 |
View lab results | 91% | 85% | 80% | 0.53 |
Review current meds | 95% | 95% | 73% | 0.75 |
Manage medical issues | 86% | 70% | 80% | 0.33 |
Ask questions re-medical issues | 92% | 85% | 67% | 0.89 |
Ease of use | ||||
Predict that I will use portal | 75% | 75% | 60% | 0.81 |
Using Internet fits into my life | 84% | 60% | 67% | 0.46 |
Compatible with other technology I use | 92% | 80% | 73% | 0.68 |
Not require a lot of mental effort | 55% | 75% | 53% | 0.53 |
Easy to use | 86% | 95% | 60% | 0.5 |
Easy to have it do my task | 74% | 85% | 53% | 0.54 |
Learning to operate will be easy for me | 86% | 95% | 67% | 0.66 |
Attitudes | ||||
Not useful | 6% | 40% | 7% | <0.001 |
Prefer to call my doctor | 64% | 80% | 60% | 0.53 |
Too complicated to use | 17% | 35% | 20% | 0.19 |
Take too much time | 11% | 35% | 0% | 0.01 |
Unsafe way to communicate | 31% | 65% | 27% | 0.05 |
*Boldface values: statistically significant finding. |
Insights from barriers, attitudes, and capacity to use patient portal tools to deliver important insight into the overall adoption of other digital health modalities, including telehealth. Our results suggest that among an urban historically underserved patient population, technology access, and use are quite high and comparable to overall trends in mobile technology ownership.25 In fact, access to mobile phones was nearly ubiquitous with a large majority using the Internet function on their mobile device.
Perceived usefulness of various portal features was overall high, with the most useful features being viewing test results, requesting medication refills, reviewing current medications, scheduling appointments, and managing medical issues. Many of these patient-perceived top features are more administrative (appointment scheduling and medication refills), so additional effort may be needed to demonstrate the value of other communication options such as clinician messaging or telehealth via the portal.26,27 It is also important to note the effect of external factors (demographic variables) on technology adoption. Different age groups, genders, levels of educational attainment, or degree of comorbidity have different values and needs. Therefore, each subpopulation needs targeted messaging concerning different portal benefits.
In patients aged 65 years or older, perceived usefulness and perceived ease of use of portal tools were lower than in other age groups. Particular attention should be paid to this group, as this older population tends to have the most complex medical needs and could potentially benefit most from communication and care coordination via the patient portal.28 Our findings that women viewed patient portals more favorably than men are consistent with prior research associating women with more health-seeking behaviors overall.29,30 There were some surprising trends by education attainment. Most notably, those with a college education or greater had more negative associations on the perceived ease of use and attitudes toward use. We posit that those with a college education or greater have had more experience with different technologies and are more wary of the pitfalls of technology. Finally, there was an interesting signal toward an upside-down U-shaped curve of those with a moderate amount of comorbidity (exactly two chronic conditions) having the most negative attitudes toward portals. It is possible that patients with 0-1 chronic conditions interact infrequently with the health care system, so the portal provides added convenience on the few occasions they would need to schedule an appointment or refill. For patients with 3+ chronic conditions, they see their health care team very frequently, so a single portal access point would be useful. Patients in the two chronic condition groups may interact with the system just infrequently enough that another portal login and password would be perceived as too much of a burden or barrier.
This was a single-site study; however, it does provide insights into a historically marginalized African American patient population in a general internal medicine setting. Prior research has focused on disparities in subspecialty clinics.31–33 There is also the potential that the results are biased toward the perspective of those who opted in; however, the survey response rate was over 80%. An additional limitation is that data were collected in 2014. However, the challenges of the digital divide and disparities in access and attitudes remain pertinent today.
Our research provides initial insights into patient-level factors influencing patient portal attitudes, with implications toward telehealth adoption. Demographic differences have a significant impact on attitudes toward technology adoption. Equitable uptake of portal and telehealth services will require tailored messaging, training, and multiple modes of communication, including web based and mobile.
Drs. Sakumoto and Walunas wrote the manuscript. Drs. Sakumoto and Kalu conducted the patient surveys. Ms. Ye and Ms. Yee conducted all statistical analyses. Drs. Walunas and Goel designed the study. Ms. Rittner and Mr. Long provided system partnership, advocacy, and support. Drs. Goel and Walunas contributed equally. All authors reviewed the final manuscript.
We would like to acknowledge the staff at the participating community health centers, as well as the administration at Alliance, Chicago.
Copyright Ownership: This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, adapt, enhance this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0.