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Table 1.  Sample Characteristics, 2017-2020
Sample Characteristics, 2017-2020
Table 2.  Factors Associated With Smartphone-Only Internet Access and Patient Portal Use, 2017-2020
Factors Associated With Smartphone-Only Internet Access and Patient Portal Use, 2017-2020
1.
Lyles  CR, Fruchterman  J, Youdelman  M, Schillinger  D.  Legal, practical, and ethical considerations for making online patient portals accessible for all.   Am J Public Health. 2017;107(10):1608-1611. doi:10.2105/AJPH.2017.303933 PubMedGoogle ScholarCrossref
2.
Perzynski  AT, Roach  MJ, Shick  S,  et al.  Patient portals and broadband internet inequality.   J Am Med Inform Assoc. 2017;24(5):927-932. doi:10.1093/jamia/ocx020 PubMedGoogle ScholarCrossref
3.
Pew Research Center. Mobile fact sheet. Accessed October 31, 2018. https://www.pewinternet.org/fact-sheet/mobile/
4.
Graetz  I, Huang  J, Brand  RJ, Hsu  J, Yamin  CK, Reed  ME.  Bridging the digital divide: mobile access to personal health records among patients with diabetes.   Am J Manag Care. 2018;24(1):43-48.PubMedGoogle Scholar
5.
von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Int J Surg. 2014;12(12):1495-1499. doi:10.1016/j.ijsu.2014.07.013 PubMedGoogle ScholarCrossref
6.
Lye  CT, Forman  HP, Daniel  JG, Krumholz  HM.  The 21st Century Cures Act and electronic health records one year later: will patients see the benefits?   J Am Med Inform Assoc. 2018;25(9):1218-1220. doi:10.1093/jamia/ocy065 PubMedGoogle ScholarCrossref
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    Research Letter
    Health Informatics
    July 26, 2021

    Use of Electronic Health Record Patient Portal Accounts Among Patients With Smartphone-Only Internet Access

    Author Affiliations
    • 1Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
    • 2Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville
    • 3Department of Health Services Research, Management, and Policy, University of Florida College of Public Health and Health Professions, Gainesville
    • 4Department of Head and Neck Endocrinology, Moffitt Cancer Center, Tampa, Florida
    JAMA Netw Open. 2021;4(7):e2118229. doi:10.1001/jamanetworkopen.2021.18229
    Introduction

    Unequal access to information and communication technology, or the digital divide, is a key determinant of patient portal adoption.1,2 The digital divide stems from many factors, such as portal usability, digital literacy, internet access, and high broadband costs.1,2 The latter have led many US residents (approximately 20%) to opt for smartphone-only internet access, especially individuals from minority racial/ethnic groups and adults with low income.3 Smartphone-only internet access could bridge the digital divide in patient portals by providing internet access, or it could exacerbate disparities, given challenges with mobile portal access (eg, data usage limits, lack of mobile-friendly sites).4 To address this gap, this study examined whether smartphone-only internet access was associated with patient portal use.

    Methods

    For this cross-sectional study, data from January 2017 through June 2020 were obtained from the 2017-2020 Health Information National Trends Survey, which includes questions about patient portal use and internet access in the last 12 months. The survey assesses factors associated with patient portal use, including health care access (eg, insurance coverage), digital literacy (eg, use of internet to view health information), demographic details (eg, income), and health characteristics (eg, comorbidities). We selected factors that are independently associated with patient portal usage.1,2

    We compared smartphone-only internet access and patient portal use based on sample characteristics, using the Pearson χ2 test. We ran 2 multivariable logistic regressions controlling for year to examine which factors were associated with smartphone-only internet access and patient portal use. We removed individuals with missing data or no internet access, or who did not report a health care visit in the last 12 months. We checked for multicollinearity across covariates. We used sampling and jackknife replicate weights to account for the stratified survey design and develop nationally representative estimates. Analyses were conducted in Stata, version 16 (StataCorp). A 2-sided P = .05 was used to determine statistical significance. This study was exempted by the Advarra institutional review board because of the use of publicly available data. The results are reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.5

    Results

    The sample contained 8790 adults. Most participants were women (5196 [59.1%]), non-Hispanic White (6325 [72.0%]), and aged 35 to 49 years (1964 [22.3%]) or 50 to 64 years (2995 [34.1%]). The number of US residents with smartphone-only internet access increased from 21.6% in 2017 to 31.1% in 2020 (P < .001) (Table 1). Patient portal use increased from 44.0% (766 of 1742 respondents) in 2017 to 54.8% (1208 of 2204 respondents) in 2020 (P < .001). Controlling for other factors, non-Hispanic Black participants (odds ratio [OR], 1.32; 95% CI, 1.01-1.72) and Hispanic participants (OR, 1.33; 95% CI, 1.04-1.72) had significantly higher odds of smartphone-only internet access compared with non-Hispanic White participants (Table 2). Individuals in the highest income category (≥$75 000) had significantly lower odds of smartphone-only internet access compared with those with lower income (<$20 000) (OR, 0.57; 95% CI, 0.40-0.80). Controlling for other factors, smartphone-only internet access was associated with significantly lower odds of portal use compared with having a wired connection (OR, 0.82; 95% CI, 0.74-0.91). After controlling for smartphone-only internet access, higher income (≥$75 000) was associated with significantly higher odds of portal use compared with that for individuals with lower income (<$20 000) (OR, 1.93; 95% CI, 1.62-2.30).

    Discussion

    As of 2020, 1 in 4 US residents reported having smartphone-only internet access, which was negatively associated with patient portal use. This study was conducted after the passage of the 21st Century Cures Act, which aimed to enhance mobile portal access,6 suggesting further work is needed to optimize such access. After accounting for smartphone-only internet access, some patients (eg, those with lower income) were still less likely to use portals, suggesting multimodal strategies are needed for overcoming the digital divide. Recent policy initiatives aimed at expanding broadband access will likely alleviate some digital barriers; however, other strategies (eg, technology training) are still needed.

    This study has several limitations, including the inability to account for language preference—a key barrier to portal adoption—and the use of self-reported data. Nonetheless, it offers important implications for how smartphone-only internet access may affect the digital divide in patient portal use.

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    Article Information

    Accepted for Publication: May 20, 2021.

    Published: July 26, 2021. doi:10.1001/jamanetworkopen.2021.18229

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Turner K et al. JAMA Network Open.

    Corresponding Author: Kea Turner, PhD, Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Dr, MRC-CANCONT, Tampa, FL 33612-9416 (kea.turner@moffitt.org).

    Author Contributions: Drs Turner and Hong had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Turner, Alishahi Tabriz, Jim.

    Acquisition, analysis, or interpretation of data: Turner, Nguyen, Hong, Patel.

    Drafting of the manuscript: Turner, Patel.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Turner.

    Administrative, technical, or material support: Turner, Alishahi Tabriz.

    Supervision: Jim.

    Conflict of Interest Disclosures: Dr Jim reported consulting for RedHill Biopharma, Janssen Scientific Affairs, and Merck and receiving grants from Kite Pharma outside the submitted work. No other disclosures were reported.

    References
    1.
    Lyles  CR, Fruchterman  J, Youdelman  M, Schillinger  D.  Legal, practical, and ethical considerations for making online patient portals accessible for all.   Am J Public Health. 2017;107(10):1608-1611. doi:10.2105/AJPH.2017.303933 PubMedGoogle ScholarCrossref
    2.
    Perzynski  AT, Roach  MJ, Shick  S,  et al.  Patient portals and broadband internet inequality.   J Am Med Inform Assoc. 2017;24(5):927-932. doi:10.1093/jamia/ocx020 PubMedGoogle ScholarCrossref
    3.
    Pew Research Center. Mobile fact sheet. Accessed October 31, 2018. https://www.pewinternet.org/fact-sheet/mobile/
    4.
    Graetz  I, Huang  J, Brand  RJ, Hsu  J, Yamin  CK, Reed  ME.  Bridging the digital divide: mobile access to personal health records among patients with diabetes.   Am J Manag Care. 2018;24(1):43-48.PubMedGoogle Scholar
    5.
    von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Int J Surg. 2014;12(12):1495-1499. doi:10.1016/j.ijsu.2014.07.013 PubMedGoogle ScholarCrossref
    6.
    Lye  CT, Forman  HP, Daniel  JG, Krumholz  HM.  The 21st Century Cures Act and electronic health records one year later: will patients see the benefits?   J Am Med Inform Assoc. 2018;25(9):1218-1220. doi:10.1093/jamia/ocy065 PubMedGoogle ScholarCrossref
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