Patient-Centered Communication, Disparities, and Patient Portals in the US, 2017-2022

ABSTRACT

Objectives: To identify the relationship between patient-centered communication and portal offers and use among insured adult patients and to understand the role of patient-centered communication in equitable access to portals.

Study Design: Using data from 4 cycles of the Health Information National Trends Survey across 2017-2022, we determined how patient-centered communication and sociodemographic characteristics of adult insured patients in the US are associated with offers of and access to online patient portals.

Methods: We conducted multivariable logistic regression analysis to examine associations of patient-centered communication and sociodemographic characteristics of adult insured patients in the US with offers of and access to online patient portals.

Results: Across the period of 2017-2022, approximately two-thirds of insured adult patients on average reported being offered a patient portal, and approximately half reported accessing a portal. Patients with lower-than-average patient-centered communication and those who are men, are Hispanic, have less than a college degree, and have no internet are less likely than their counterparts to report being offered or accessing a portal.

Conclusions: Although patient-centered communication is an important factor in facilitating patient portal offers and access, it does not appear to be a driver of demographic divides in portal use.

Am J Manag Care. 2024;30(1):19-25. https://doi.org/10.37765/ajmc.2024.89483

Takeaway Points

Over the period of 2017-2022, approximately two-thirds of insured adult patients in the US reported being offered a patient portal and approximately half accessed one.

• Patient perceptions of better communication with providers were associated with increased likelihood of both being offered a portal and using it.
• Despite the positive impact of patient-centered communication, disparities in portal access persist for some patients in racialized minority groups and patients with less education as well as those without internet access.
• Successful adoption of online portals and other digital health tools will require explicitly addressing patient-centered needs and tackling fundamental social and economic inequities to ensure that such tools benefit all.

After years of federal incentives and investments by health care providers^1-4 and spurred by the growth in virtual care during the COVID-19 pandemic,^5-7 more patients are using online portals: the secure websites through which they can access their electronic health records, schedule doctor appointments, order prescription refills, and communicate with providers.⁸ However, a vast body of research shows disparate access to and use of patient portals across patient populations, including by race and ethnicity, gender, socioeconomic status, age, and other factors.^9-14 Because patient portals can increase patient engagement with their health,^15-18 the broader diffusion of these technologies—without further intervention to reverse current disparities in portal access—may further impede efforts to expand equity in health care and public health.¹⁹

Previous research shows that health care providers’ efforts to offer and encourage portal use play an important role in facilitating patient access to portals.^10-12 One possible underlying reason that has yet to be explored is that patient-centered communication (PCC) is the avenue by which providers facilitate patient portal use. PCC is provider communication that respects and responds to patients’ preferences, needs, and values to guide medical care.^20,21 PCC is considered essential for high-quality care²² and is positively associated with uptake of beneficial health behaviors,^23,24 including greater likelihood of some preventive screening tests,²⁵ lower levels of health care avoidance,²⁶ and greater use of digital communication tools.²⁷ Specifically, high-quality communication in the face-to-face medical encounter has been shown to facilitate later online communication,²⁸ and patient portals effectively complement in-person communication with health care providers.²⁹

Yet PCC is not equitable across patient groups. Members of racialized minority groups report worse communication with providers.^30-33 Aspects of PCC also vary by age, gender, and socioeconomic status.³⁴ Such research suggests that disparities in PCC may themselves be a barrier to access to patient portals. That is, low portal access among racialized minority groups may be because of lower levels of PCC. Interventions to improve PCC among racialized minority groups would thereby likely narrow divides in portal use. However, other research suggests that information technologies such as portals and mobile access overcome some deficiencies in doctor-patient communication for racialized minority group patients.^35,36 Under those conditions, we would expect that among those with lower levels of PCC, patients in racialized minority groups may be more likely to use portals. Therefore, efforts to improve PCC among racialized minority group patients could unintentionally reduce portal use, thereby exacerbating divides in portal use.

This study sets out to consider these competing possibilities by identifying the relationships between PCC and portal offers and use among insured adult patients and, further, by determining the role of PCC in equitable access to portals. This study builds on previous research on patient portal use and on the importance of PCC for health care access and quality. It contributes to our understanding of barriers to patient portal use as well as possible avenues for developing effective interventions to overcome such barriers.¹⁹

METHODS

The data underlying this research were sourced from 4 cycles of the Health Information National Trends Survey (HINTS): HINTS 5 cycle 1, cycle 3, and cycle 4, and HINTS 6. HINTS is a population-based survey fielded by the National Cancer Institute that investigates the use of and access to health-related information among adults in the US. More information about the survey design and access to the publicly available data can be found at the HINTS website.³⁷

HINTS 5 cycle 1 was conducted from January 25 through May 5, 2017, with 3285 surveys completed, corresponding to a response rate of 32.4%. HINTS 5 cycle 3 was conducted from January 22 to April 30, 2019, with 3372 surveys completed and a response rate of 30.2%. The HINTS 5 cycle 4 survey was conducted from February to June 2020, yielding 3865 completed surveys with a response rate of 37%. The most recent survey, HINTS 6, was conducted from March 7 to November 8, 2022, with 6252 completed surveys and a response rate of 28.1%. The 2018 HINTS 5 cycle 2 was excluded from this analysis for 2 reasons: (1) The offered question was phrased differently than in the other survey years. In the 2018 survey, participants were asked, “Have you ever been offered online access to your medical records by your health care provider or health insurer?” In the other survey years, this question was split into “Have you ever been offered online access to your medical records by your health care provider?” and “Have you ever been offered online access to your medical records by your health insurer?” and (2) It included a skip code such that if the respondent replied “no” to the question about being offered online access, they were not asked the question about accessing a portal. All the other iterations of the surveys ask both questions to all respondents. The 2021 survey (HINTS-SEER) was excluded because it solely sampled cancer survivors from 3 cancer registries (Iowa Cancer Registry, New Mexico Tumor Registry, and Greater Bay Area Cancer Registry), so the sampling frame is not comparable to the other survey years.

The analytical sample was restricted to those who reported having made a medical visit in the 12 months prior to the administered survey (86.2% of the full sample) and reported having health insurance coverage (92.0% of the full sample). From the 13,705 respondents who met both criteria, our analytical sample was further restricted to those who did not have missing responses on any of the study measures. Because of our interest in racial disparities, we made an exception for the measure of race and ethnicity and included an indicator for those who were missing values so that we could include them in the analysis. The final analytic sample included
11,786 respondents.

Measures

Respondents who were offered access to online medical records were identified with the survey question, “Have you ever been offered online access to your medical records by your health care provider?” Respondents who answered “yes” were counted as offered and those who answered “no” or “don’t know” were coded as not offered. Respondents who accessed a portal were identified based on response to the question, “How many times did you access your online medical record in the last 12 months?” Respondents who answered “none” were counted as nonusers, and those who answered 1 or more were counted as users. For the year 2022, respondents who answered “I do not have an online medical record or patient portal that was offered to me by a health care provider or insurer” were also considered to be nonusers.

All respondents were also posed 7 questions that assessed levels of patient-provider communication in the 12 months prior to the survey. Respondents were asked their level of agreement on a 4-point scale (always, usually, sometimes, never) and instructed to consider their communication with “all doctors, nurses, or other health professionals [they] saw during the past 12 months.” The questions were: “How often did your doctors, nurses, or other health professionals:

• “give you the chance to ask all the health-related questions you had?”
• “give the attention you needed to your feelings and emotions?”
• “involve you in decisions about your health care as much as you wanted?”
• “make sure you understood the things you needed to do to take care of your health?”
• “explain things in a way you could understand?”
• “spend enough time with you?”
• “help you deal with feelings of uncertainty about your health or health care?”

These variables were used to create the PCC scale (Cronbach α = 0.929), a validated scale³⁸ that has been used in previous studies using the HINTS data.^32,33 Consistent with the validated scale, we reversed the values of these 7 variables and calculated the mean for those respondents with valid values on at least 3 of the variables (those with fewer valid values were treated as missing). We then transformed the mean linearly to a 0 to 100 scale. For use in the multivariable analyses described later, the PCC scale was normalized.

Covariates in the multivariable logistic regression models were survey year and the respondent’s self-reported (binary) sex, age, race and ethnicity, education level, location (metro or nonmetro), general health, and internet usage.

Respondents self-reported their race and ethnicity, coded as non-Hispanic Asian, non-Hispanic Black, Hispanic, non-Hispanic White, and non-Hispanic of other race and ethnicity (which included those who were American Indian or Alaska Native and Native Hawaiian or other Pacific Islander and those who reported multiple races). Most measures had less than 1% missing values, except for race and ethnicity, which were missing for slightly more than 5% of cases. A separate category for “missing” on race and ethnicity was created to avoid the loss of data and because past studies have found significant associations between race and ethnicity and portal use. Sensitivity analysis showed that omitting the missing race and ethnicity category did not meaningfully change the reported results.

Statistical Analysis

The data were analyzed using multivariable logistic regression for associations of the normalized PCC scale with being offered and accessing a portal. All multivariable models included the previously described covariates. All analyses used survey weighting procedures with jackknife replicate weights to account for the complex survey design and nonresponse.

RESULTS

Between 2017 and 2022, on average 65.4% of insured adult patients reported being offered access to an online portal (Table 1). Over the same period, 49.7% of those patients on average reported accessing an online portal at least once during the previous year. The Figure shows that patients’ perception of PCC, based on the PCC scale, also varied over the period, with a drop in 2022, possibly related to the challenges in health care during the COVID-19 pandemic.

In multivariable analysis of having been offered an online portal by a health care provider, we found that PCC as measured by the PCC scale (see model 2 in Table 2) was significantly and positively associated with having been offered a patient portal. That is, for a 1-SD increase in PCC, we found a 33% greater likelihood of being offered a portal. Also note that the significant year variables indicate that more patients were offered portals in each subsequent year compared with 2017.

Although PCC increases the likelihood of being offered a portal, we did not see any changes in the relationships between other patient characteristics and being offered a portal, particularly where we see disparities in being offered. Specifically, we saw that Hispanic patients and those who did not report their race/ethnicity (coded as missing) were significantly less likely to be offered a portal compared with non-Hispanic White patients, even after PCC was added to the model (model 2). Indeed, there was no real change in the relationship between respondents’ race and ethnicity and being offered a portal with the addition of PCC to the model (compare coefficients in model 1 and model 2 in Table 2). We saw similar patterns for education and internet use. Patients with less than a college education were much less likely to be offered a portal than more educated patients, and those who did not use the internet were much less likely to be offered a portal, even after controlling for PCC. For female and older patients, who were more likely than male patients and those younger than 31 years, respectively, to be offered a portal, the inclusion of PCC also made no statistically significant difference.

Model 3 in Table 2 evaluates the interaction between PCC and race/ethnicity variables to determine whether portal offer likelihood differs across racialized minority groups given PCC level. In model 3, only the interaction of PCC and non-Hispanic Asian was significant and indicated that among those with average PCC, Asian patients had a higher likelihood of being offered a portal compared with non-Hispanic White patients. No other interactions were significant. The direct relationships for Hispanic patients and those missing race/ethnicity indicate significantly lower likelihood of being offered a portal. That is, these racialized minority group patients experienced significant disparities in offers of patient portals regardless of PCC. Although PCC did contribute to the likelihood of receiving an offer for a patient portal, it was not a moderator of the racial inequities in offers.

Portal Access

In multivariable analyses of portal access, racialized minority patients (Hispanic, non-Hispanic Black, and missing), men, and those with less than a college degree, younger than 31 years, living in a nonmetro area, and who do not use internet were all significantly less likely to have used a patient portal in the previous 12 months (Table 3). As with offers, each year was statistically significant, indicating a greater likelihood of patients accessing a portal, all else equal, in each subsequent year compared with 2017.

PCC was significantly associated with an increased likelihood of using a portal (see model 2 in Table 3). We also saw very similar patterns to the analysis of portal offers in that the relationships between respondents’ background and accessing a portal changed little after we included the PCC measure (compare coefficients in models 1 and 2 in Table 3). Moreover, PCC did not alter the disparities in patient access to portals for racialized minority group patients, for less educated patients, or for those who did not use the internet. That is, non-Hispanic Black patients, Hispanic patients, and patients not reporting race/ethnicity were significantly less likely to access an online patient portal compared with non-Hispanic White patients regardless of including PCC. The same pattern held for those with less than a college education compared with more educated patients.

To determine whether portal access differs across racialized minority groups given PCC level, model 3 shows the interactions between PCC and race and ethnicity. None of the interaction variables were significant, indicating that PCC did not moderate the relationship between race and ethnicity and likelihood of accessing a patient portal. Moreover, model 3 shows that Hispanic and non-Hispanic Black patients as well as patients with less than a college education were significantly less likely to access patient portals regardless of PCC.

DISCUSSION

As in this study, a great deal of recent research documents health disparities in access to health technologies across race and ethnicity and socioeconomic characteristics.^10,11,19,33 Given the importance of PCC to health behavior and outcomes^21,22 and the demonstrated racial and ethnic disparities in doctor-patient communication,^30-33 we examined whether PCC may play a role in disparities in patient portal access and use because many studies recommend enhancing communication to address these disparities.^9-13 This study showed that across the 5-year span from 2017 to 2022, an average of approximately two-thirds of adult insured patients in the US reported being offered an online patient portal by their health care providers, and just approximately half (49.7%) accessed a patient portal. Importantly, perception of better PCC with providers is associated with an increased likelihood of both being offered a portal and using it. Because prior research shows that PCC is associated with patient trust and patient health behaviors,²³ we hypothesized that PCC may account for the significant disparities that have been shown in offers of and access to portals, particularly by race and ethnicity. However, including PCC in analyses of offers of and access to portals did not change the disparate levels of offers and access for racialized minority group patients, particularly Hispanic patients (lower likelihood of offers and access) and non-Hispanic Black patients (lower likelihood of access), and patients with less than a college education (lower likelihood of offers and access). In addition, the relationship of race and ethnicity interacted with PCC level did not account for disparities in portal offers or use.

Despite research indicating disparities in PCC, it does not appear to be a driver of demographic divides in portal use and access. In fact, the comparable positive relationship between PCC and portal access across several demographic groups suggests it is a powerful tool for facilitating patient uptake. Patient-provider communication is important for both offers and access to portals, so finding ways to increase provider time and training for communication with patients is needed to improve access. However, even high-quality PCC will not on its own address the significant and persistent disparities in portal offers and access.

Most interventions that have been studied to address disparities in portal use have been focused on the individual patient, such as education in how to use the portal,^14,39-42 rather than other aspects of the health care delivery environment, such as the doctor-patient relationship or the tools themselves.⁴³ Future work must examine more aspects of the clinical context, such as how resources vary across provider types⁴⁴ and the role of billing for e-visits,⁴⁵ as well as patient characteristics to identify ways to support and encourage portal use for health engagement that also address important disparities.^14,41,46 The significant role of internet access in portal offers and access in our study also suggests the need for ongoing community-wide infrastructure investments, such as in broadband.⁴⁷ Aspects of portal tools, including functionality, usability, and privacy, must also be considered because patients often express concerns that portals may impede communication with providers and that health data are not private or secure.^10,12 Given the growing costs and consequences of health data breaches, such work will be important to ensure continued portal access and use.

Limitations

The survey is cross-sectional and prevents inferring the causal role of PCC on being offered a portal and accessing it. Previous research indicates that interventions to improve PCC among providers can improve their communication across a range of domains,³⁸ suggesting it may plausibly be a driver of portal use, but future research is needed. The measure of PCC is self-reported, which tends to correspond weakly with objective measures, but the patient’s perspective may matter more for their own outcomes.³⁹ It is also important to keep in mind that although the analysis uses nationally representative survey data, the studied sample is restricted to insured patients rather than the general population. Although looking at insured patients has the benefit of selecting those most likely to have had exposure to a portal, it means that the sample is more educated and more likely to be non-Hispanic White compared with the adult population in the US overall. Given these demographic differences, our findings are relevant for insured patients but may not be for the general population.

CONCLUSIONS

National policies, as well as investments by health care and technology-related companies, continue to expand the reach of digital health services. Although the availability and use of online patient portals and other technologies have continued to increase steadily among patients in the US over the previous 5 years, inequalities in access persist. The successful adoption and use of online portals, telehealth, and other digital health tools will require explicitly addressing patient-centered needs and fundamental inequities in social and community factors that influence access to the internet and to health care to ensure that such tools are beneficial for all.

Author Affiliations: Department of Health Management and Policy, School of Public Health, University of Michigan (DA), Ann Arbor, MI; Department of Media and Information, Michigan State University (CC-C), East Lansing, MI; University of Michigan Medical School (AN), Ann Arbor, MI.

Source of Funding: This work was partially supported by a collaborative award from the National Science Foundation (NSF) Secure and Trustworthy Cyberspace Frontiers program under award No. 1955805. The views and conclusions contained herein are those of the authors and should not be interpreted as necessarily representing the official policies, either expressed or implied, of NSF.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DA, CC-C, AN); acquisition of data (DA); analysis and interpretation of data (DA, CC-C, AN); drafting of the manuscript (DA, CC-C, AN); critical revision of the manuscript for important intellectual content (DA, CC-C, AN); statistical analysis (DA, AN); obtaining funding (DA); and administrative, technical, or logistic support (DA).

Address Correspondence to: Denise Anthony, PhD, Department of Health Management and Policy, School of Public Health, University of Michigan, 1420 Washington Heights, M3174, Ann Arbor, MI 48109. Email: deniseum@umich.edu.

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