4 SDOH Driving Health Disparities in Patient Portal Use

June 08, 2021 - As patient portal use and access become more commonplace in healthcare, it would be prudent for health IT leaders and clinicians alike to understand the health disparities that can also emerge with patient portal use.

The latest data shows that patient portal offerings are near universal. 2019 data from the Office of the National Coordinator for Health IT showed that 99 percent of large hospitals and 97 percent of all hospitals in aggregate offer patient portal access to patients. That is the most recent year for which ONC has data.

But that patient portal access and use isn’t seen uniformly across patient populations. Like other aspects of medicine, patient portal use sees health disparities, and that’s largely because of inequities in access. In other words, not every patient has the same opportunity to make the most out of patient portal access.

Below, PatientEngagementHIT explores some of the most common social determinants of health affecting patient portal use and adoption. This list is not exhaustive but represents some of the broadest SDOH categories influencing health IT use.

Race disparities

Years of data have shown some racial health disparities in patient portal adoption and use. Particularly, people of color are less likely to use the health IT than their White counterparts.

READ MORE: Is the Digital Divide the Newest Social Determinant of Health?

In September 2020, a Journal of Medical Internet Research study showed that Black and Hispanic race were tied to low patient portal use or adoption rates. Particularly, Hispanic patients were more likely to say they did not need the patient portal. The study did not provide specific insights as to why Black patients were less likely to use the patient portal.

A separate November 2018 study in the American Journal of Managed Care (AJMC) showed that Black and Hispanic patients again were less likely to adopt the patient portal than White patients. The study also found a link between limited English language proficiency, which could explain some of the racial health disparity for Hispanic patients.

The root of these racial health disparities could be the link between race and other social determinants of health. As demonstrated by the above-mentioned language barriers, populations of color are more likely to experience social determinants of health than their White counterparts, meaning people of color could be facing other barriers to patient portal use.

However, patient trust in the medical establishment is also a key factor at play. Black patients, particularly, have born witness to atrocities and experienced implicit bias in medicine that has eroded patient trust. That limited trust could decrease the odds a Black patient will engage in her care via the patient portal.

Income disparities

Income, too, can influence patient portal adoption. For one thing, it can dictate whether a patient actually has access to a device on which she can view her patient portal, or broadband to support it.

But it can also be linked to other factors that might get in the way of patient portal use.

That same JMIR study showed that having an income below $20,000 predicted preference for in-person patient-provider communication. Low-income individuals—as well as those without a high school diploma, two populations that may overlap—were also more likely to report limited digital health literacy. These populations told the researchers they were not comfortable using a computer, which hampered patient portal access.

Another 2018 study from the University of Michigan found that Medicaid patients were less likely to have adopted the patient portal. Medicaid patients, who are typically low-income, said they preferred in-person communication with their clinicians.

Researchers said better patient education about the patient portal would be important for ensuring all patients could reap the benefits of the tool. Positive provider testimony proved helpful, the data showed. Incentive payments could help motivate more providers to deliver this digital patient education.

But stronger interventions may also be necessary. Access to a device and the infrastructure to support is remain salient. And until those issues can be resolved, the income-based digital divide will likely continue.

Broadband disparities

Broadband, one of the biggest talking points in the digital patient engagement space, is massively influential in whether an individual uses the patient portal. A patient might be fully activated in her care, but without adequate internet access, cannot use health IT.

A 2019 report from the ONC found that 51 percent of patients were given access to a patient portal in 2017 and 2018, but that access wasn’t universally seen. Patients reporting good internet access and living in urban areas were more likely to use the patient portal than their peers.

Those findings replicated themselves, albeit more modestly, in the ONC’s 2021 report, which looked at 2019 data. Rural organizations, which are among the most likely to experience broadband issues, were less likely to offer data transmit capabilities for patients. They were only slightly less likely to offer data view and download capabilities.

Addressing the broadband access issue will certainly require a bigger legislative fix that is out of the hands of individual clinicians. However, clinicians can still workaround some of these issues by tapping other patient engagement modalities. Telephone calls and other low-tech options can help support remote patient-provider communication.

These workarounds, although not ideal, will be essential to promoting health equity. Multi-modal patient engagement strategies help reach all patients with various backgrounds, helping to achieve equitable health outcomes.

Age disparities

Finally, age can be a predictor of patient portal adoption disparities. Conventional wisdom dictates that older adults will be less comfortable with digital health tools, meaning older populations may see lower patient portal adoption rates.

As recently as January 2021, data has shown patient portal adoption rates lower among older patients. Data from the University of Michigan’s National Poll on Healthy Aging showed that 45 percent of adults ages 65 to 80 don’t have a patient portal account, and 40 percent of those between 50 and 80 don’t have one.

But other reports are showing that age isn’t as big of a factor as previously thought. Patient portal adoption among older adults is growing, according to a March 2020 study from Northwestern University Feinberg School of Medicine. The researchers posited older adults are not offered patient portal access at the same rate as their younger peers, but when they do, they take advantage of it.

Across the 62 patients and family caregivers included in a study, the researchers observed 1,254 patient portal messages sent. In other words, older adults who access the patient portal make the most of it, making the argument that providers should offer access more frequently.

Those offers should come with some patient education, considering the chance of low digital health literacy.

Understanding the SDOH that drive health disparities in patient portal use can be complex because many overlap or intersect. For example, income might conflate with broadband access. It will be essential for healthcare providers to consider social determinants of health screening results when referring patients to health IT solutions like the patient portal.

From there, clinicians can help uncover resources that could help patients overcome hurdles to patient portal access. A clinician treating a Medicaid patient might be able to connect a patient with a smartphone if that state’s Medicaid benefits include a device.

But more than that, clinicians can use social determinants of health information to create new strategies for patient data access and patient engagement. A clinician who leans heavily on secure patient portal messaging might turn to telephone communication for older patients who prefer that over the patient portal.

In making such considerations, clinicians can close the gap on patient engagement, something that is critical for closing overall health disparities and building toward health equity.