Patient portals and broadband internet inequality.

BACKGROUND: Patient portals have shown potential for increasing health care quality and efficiency. Internet access and other factors influencing patient portal use could worsen health disparities. METHODS: Observational study of adults with 1 or more visits to the outpatient clinics of an urban public health care system from 2012 to 2015. We used mixed effects logistic regression to evaluate the association between broadband internet access and (1) patient portal initiation (whether a patient logged in at least 1 time) and (2) messaging, controlling for demographic and neighborhood characteristics. RESULTS: There were 243 248 adults with 1 or more visits during 2012-2015 and 70 835 (29.1%) initiated portal use. Portal initiation was 34.1% for whites, 23.4% for blacks, and 23.8% for Hispanics, and was lower for Medicaid (26.5%), Medicare (23.4%), and uninsured patients (17.4%) than commercially insured patients (39.3%). In multivariate analysis, both initiation of portal use (odds ratio [OR] = 1.24 per quintile, 95% confidence interval [CI], 1.23-1.24, P < .0001) and sending messages to providers (OR = 1.15, 95%CI, 1.09-1.14, P < .0001) were associated with neighborhood broadband internet access. CONCLUSIONS: The majority of adults with outpatient visits to a large urban health care system did not use the patient portal, and initiation of use was lower for racial and ethnic minorities, persons of lower socioeconomic status, and those without neighborhood broadband internet access. These results suggest the emergence of a digital divide in patient portal use. Given the scale of investment in patient portals and other internet-dependent health information technologies, efforts are urgently needed to address this growing inequality.

Addressing Disparities in Diabetes Management Through Novel Approaches to Encourage Technology Adoption and Use.

Type 2 diabetes (T2D) is one of the nation's leading drivers of disability and health care utilization, with elevated prevalence among individuals with lower education, income, and racial/ethnic minorities. Health information technology (HIT) holds vast potential for helping patients, providers, and payers to address T2D and the skyrocketing rates of chronic illness and associated health care costs. Patient portals to electronic health records (EHRs) serve as a gateway to consumer use of HIT. We found that disparities in portal use portend growing T2D disparities. Little progress has been made in addressing identified barriers to technology adoption, especially among populations with elevated risk of T2D. Patients often lack digital literacy skills and continuous connectivity and fear loss of the relationship with providers. Providers may experience structural disincentives to promoting patient use of HIT and apply hidden biases that inhibit portal use. Health care systems often provide inadequate training to patients and providers in use of HIT, and lack resources devoted to obtaining and optimizing use of data generated by HIT. Lastly, technology-related barriers include inadequate consideration of user perspectives, lack of evidence for patient-focused apps, and lack of features to enable providers and health care systems to readily obtain aggregate data to improve care and facilitate research. After discussing these barriers in detail, we propose possible solutions and areas where further research is needed to ensure that individuals and health care systems obtain the full benefit of the nation's planned $38 billion HIT investment. A digital inclusion framework sheds new light on barriers posed for patients with social health inequalities. We have determined that partnerships with community organizations focused on digital inclusion could help health systems explore and study new approaches, such as universal screening and referral of patients for digital skills, health literacy, and Internet connectivity.