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The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income

Graetz, Ilana PhD; Gordon, Nancy ScD; Fung, Vick PhD; Hamity, Courtnee MPH; Reed, Mary E. DrPH

doi: 10.1097/MLR.0000000000000560
Original Articles

Background: Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups.

Objectives: To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences.

Research Design: Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference.

Subjects: One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate).

Measures: Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics.

Results: Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference.

Conclusions: As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

*Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN

Kaiser Permanente Northern California Division of Research, Oakland, CA

Mongan Institute for Health Policy, Massachusetts General Hospital

§Department of Medicine, Harvard Medical School, Boston, MA

Supported by the Kaiser Foundation Research Institute. The content, findings, and conclusions of this paper are the sole responsibility of the authors; the sponsors were not involved in any way in the determination of the content of this paper.

The authors declare no conflict of interest.

Reprints: Ilana Graetz, PhD, Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N Pauline Street, Suite 633, Memphis, TN 38163. E-mail:

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.