title: Patient portals and broadband internet inequality.
abstract: 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.
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Health Care Research and Policy, the MetroHealth System, Cleveland, OH, USA.|Department of Sociology, Case Western Reserve University, Cleveland, OH, USA.|Connect Your Community Institute, Cleveland, OH, USA.
authors.forename: Adam T
authors.initials: AT
authors.lastname: Perzynski
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Health Care Research and Policy, the MetroHealth System, Cleveland, OH, USA.
authors.forename: Mary Joan
authors.initials: MJ
authors.lastname: Roach
authors.affiliation: Department of Sociology, Case Western Reserve University, Cleveland, OH, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Shick
authors.affiliation: Connect Your Community Institute, Cleveland, OH, USA.
authors.forename: Bill
authors.initials: B
authors.lastname: Callahan
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Health Care Research and Policy, the MetroHealth System, Cleveland, OH, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Gunzler
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Health Care Research and Policy, the MetroHealth System, Cleveland, OH, USA.
authors.forename: Randall
authors.initials: R
authors.lastname: Cebul
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Health Care Research and Policy, the MetroHealth System, Cleveland, OH, USA.|Center for Clinical Informatics Research and Education, the MetroHealth System.
authors.forename: David C
authors.initials: DC
authors.lastname: Kaelber
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Reducing Health Disparities, the MetroHealth System.
authors.forename: Anne
authors.initials: A
authors.lastname: Huml
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Reducing Health Disparities, the MetroHealth System.
authors.forename: John Daryl
authors.initials: JD
authors.lastname: Thornton
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|Center for Health Care Research and Policy, the MetroHealth System, Cleveland, OH, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Einstadter
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D066310:Digital Divide; D005260:Female; D055991:Health Records, Personal; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D009820:Ohio; D000072638:Patient Portals / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D019037:Urban Health Services; D055815:Young Adult
keywords: digital divide; health disparities; internet; patient portals; personal health record