The Effect of Patient Portals on Quality Outcomes and Its Implications to Meaningful Use: A Systematic Review

Background The Health Information Technology for Economic and Clinical Health (HITECH) Act imposes pressure on health care organizations to qualify for “Meaningful Use”. It is assumed that portals should increase patient participation in medical decisions, but whether or not the use of portals improves outcomes remains to be seen. Objective The purpose of this systemic review is to outline and summarize study results on the effect of patient portals on quality, or chronic-condition outcomes as defined by the Agency for Healthcare Research and Quality, and its implications to Meaningful Use since the beginning of 2011. This review updates and builds on the work by Ammenwerth, Schnell-Inderst, and Hoerbst. Methods We performed a systematic literature search in PubMed, CINAHL, and Google Scholar. We identified any data-driven study, quantitative or qualitative, that examined a relationship between patient portals, or patient portal features, and outcomes. We also wanted to relate the findings back to Meaningful Use criteria. Over 4000 articles were screened, and 27 were analyzed and summarized for this systematic review. Results We identified 26 studies and 1 review, and we summarized their findings and applicability to our research question. Very few studies associated use of the patient portal, or its features, to improved outcomes; 37% (10/27) of papers reported improvements in medication adherence, disease awareness, self-management of disease, a decrease of office visits, an increase in preventative medicine, and an increase in extended office visits, at the patient’s request for additional information. The results also show an increase in quality in terms of patient satisfaction and customer retention, but there are weak results on medical outcomes. Conclusions The results of this review demonstrate that more health care organizations today offer features of a patient portal than in the review published in 2011. Articles reviewed rarely analyzed a full patient portal but instead analyzed features of a portal such as secure messaging, as well as disease management and monitoring. The ability of patients to be able to view their health information electronically meets the intent of Meaningful Use, Stage 2 requirements, but the ability to transmit to a third party was not found in the review.

Monthly no-show rates across all medical clinics in the system were significantly reduced among patients registered for portal use.
Palen et al [11]. Retrospective study of patients >18 years old who had access to a patient portal. Online chronic disease management portals increase patient access to information and engagement in their health care, but improvements in the portal itself may improve usability and reduce attrition.
Delbanco et al [13]. Quasi-experimental design, no randomization (N=105 providers and N=13,564 patient); studies encounters with at least one doctor's note in a primary care setting at 3 large, but independent locations. 11,757 of 13,564 patients (86.78%) with notes available opened at least 1 note, but only 5391 (39.74%) completed a post intervention survey. Surveys reported up to 87% of these patients felt greater control of their care, up to 78% reported greater medication adherence, 36% had privacy concerns, and up to 42% reported sharing notes with others. Volume of electronic messaging between patients and providers increased 5%. Providers reported up to an 8% workload increase to answer patients' questions outside of visits. Of those providers, 21% reported taking additional time to write notes, and 36% reported changing documentation content.
A majority of patients who accessed their doctors' notes and filled out a survey reported positive, clinically relevant benefits and very few concerns about access.
Osborn et al [14]. Mixed methods design of patients with type 2 diabetes (N=75) to study quantitative data to identify differences between portal and non-portal users.
81% (61/75) attended a focus group and/or completed a survey. Portal users tended to be Caucasian/white, have higher income, be privately insured, have more education, and better A1C test results. All results were statistically significant (P<.05) except for education, which was mildly significant (P=.05).
Patients noted a preference to use the portal to manage prescriptions and medication adherence. More frequent users of the portal were more likely to have better glycemic control.
52% were registered users, among those 36% used SM. Greater levels of trust were associated with white, Latino, and older patients.
Patient-provider relationships encourage portal engagement.
Wade-Vuturo et al [16]. Mixed-methods, survey tool, non-experimental, qualitative study (N=15) Participants were 57.1 years old, 65% female, 76% Caucasian/white, 20% African American/black. SM was reported as enhancing patient satisfaction, efficiency and quality face-to-face visits, and access to clinical care outside traditional faceto-face visits. Greater SM use was significantly associated with patients' glycemic control (P=.29) Portal use enabled collaborative decision making about diabetes management. Nazi et al [17]. Web study (N=688) of Veterans 84% reported positive satisfaction agreeing that the information and services were helpful. 66% agreed that the portal increase quality of care, and 90% agreed that they would recommend the portal to another veteran.
Veterans demonstrated a high rate of motivation to access their own health information and viewed such action as an increase in quality of care.
Ketterer T et al [18]. Cross-sectional, retrospective analysis (N=84,105) 38% (31,360/84,105) enrolled, 26% (21,867) activated the account. Portal enrollment was lower for adolescents, Medicaid recipients, low-income families, Asian or other race, and Hispanic ethnicity, and higher for patients with more office encounters, and presence of autism on the problem list (95% CI).
Sociodemographic disparities exist in portal enrollment/activation in primary care pediatrics. Proximity had a negative effect, number of office encounters and comorbidity had a positive association on portal enrollment.
Zarcadoolas et al [19]. Qualitative study of four focus groups (N=28) with loweducation level, English-speaking consumers Portal users felt a high level of patient engagement / empowerment. These users extended office visits to ask additional questions of their provider. There was also an increase in preventative and overall health maintenance.
Portal users demonstrated enthusiasm about the increased utility and value of their medical encounter when augmented with the portal.
Shimada et al [20]. Cross-sectional, retrospective cohort study of 32 veterans affairs (VA) facilities implementing SM in primary care Technical assistance (coordinators), computer resources, and leadership support for coordinators were positively associated with increased SM adoption rates. Higher SM use was associated with lower urgent care (UC) rates, early adopters of SM achieved a greater decrease in UC utilization over time than later adopters.
A path of associations linking SM and reductions in UC utilization exists.

Schprechman et al [21]. Cross-sectional study of older adults aged 50-85 years (N=119)
Internet and email use were reported in 78.2% and 71.4% of this sample of patients with heart failure (HF), respectively. Controlling for age and education, higher health literacy predicted email, but not Internet use. Global cognitive function predicted email (P<.001) but not Internet use. Only 45% used the Internet to obtain information on HF.
The majority of HF patients use the Internet and email, but poor health literacy and cognitive impairment may prevent some patients from accessing these resources. (1) Enrollees felt they did not need the patient portal and had sufficient access to information elsewhere,(2) they preferred other types of communication such as phone or face-to-face, (3) they were unable to log in from lack of technical support. Patients were satisfied with the opportunity to send messages to health care providers through the portal, even if they did not use the Portals should be offered to the patients at an appropriate time when the patient needs the service and when they are receptive to information about the service.

feature.
Neuner et al [24]. Mixed-methods study of 2 independent data sources to examine patient enrollment in local portal in both primary care and specialty care settings (N=124,379) for 2010-2012 13.2% (16,418/124,379) of patients enrolled in the portal in 2010, and by 2012 enrollment increased to 23.1% (28,731). Median patient access of portal per year was 14 times, with a range of 1-660. Over 93% accessed the system at least twice, 78% accessed the system 4 or more times, and 15.3% accessed the system 50 or more times per year.
Portal users were slightly older and more likely to be female (P<.001 The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the post implementation periods, largely due by increased SM, quarterly office visits declined by 8%, 10% increases in SM threads, and phone encounters were associated with increases of 1.25% (95% CI, P<.001) and 2.74% increase in office visits (95% CI) in office visits, respectively.
Before and after a medical home redesign, proportional increases in SM and phone encounters were associated with additional primary care office visit for individuals with diabetes.