The Impact of Digital Patient Portals on Health Outcomes, System Efficiency, and Patient Attitudes: Updated Systematic Literature Review

Introduction

In recent years, electronic tools that allow patients to interact with health care professionals have considerably increased with consequences on the awareness of citizens about their own health [1]. The adoption of these technologies might represent an important measure to improve the quality and efficiency of health care services and is a key feature for the construction of a more equitable, effective, and safe health care system [2]. Indeed, the rapid growth and diffusion of digital health, including health information sources, such as electronic medical records (EMRs), has made online access to information by patients and health care professionals a crucial component of health care delivery [3].

In this context, patient portals are thought to allow patients secure access to health-related information and to communicate and share information with providers [4]. Besides guaranteeing protected access to EMRs, more advanced patient portals allow secure message exchange between health professionals and citizens, consultation of educational material adapted to patients’ own characteristics, appointment scheduling, automatic renewal of medical prescriptions for chronic diseases, and facilitation of payments. Despite their potential benefits, several studies have proved underuse or inappropriate use of patient portals and their limited impact [5]. Furthermore, the majority of studies available on this topic have focused on users’ characteristics and satisfaction, and few studies have considered the consequences on health outcomes [6-8]. Patient portals are relatively new technologies with continuous updates. Several types are released every year, and this may explain the lack of research in this area [5].

A systematic literature review in 2013, which addressed the effect of patient portals on patient clinical care, reported that evidence was limited to evaluate whether patient portals had a positive, negative, or neutral impact on users’ health [4]. Some of the most effective examples refer to patients with chronic diseases, such as diabetes, hypertension, and depression, specifically when the portal is included in a shared health care pathway [9-13]. The effect of patient portals on health care utilization and efficiency, instead, is unclear due to the scarcity of studies examining the impact of patient portals on key indicators, such as inpatient hospitalizations, emergency department (ED) and outpatient visits, length of stay, and telephone contacts [14]. The aim of this systematic review was to update the study performed in 2013, by summarizing evidence on the impact of digital patient portals on patients’ health outcomes, health care efficiency, and patients’ attitudes and satisfaction.

Methods

Search Strategy

A search of relevant articles was performed in the PubMed and Web of Science databases using the query reported in Multimedia Appendix 1. The resulting records were entered in a dedicated work sheet to be subsequently screened according to the inclusion/exclusion criteria. Following the removal of duplicates, the selection was made by reading titles and abstracts, and then the full texts.

Inclusion/Exclusion Criteria

Eligible studies were primary studies reporting on the impact of patient portal adoption in relation with health outcomes, health care efficiency, and patients’ attitudes and satisfaction. Articles included were published from January 1, 2013, to October 31, 2019, and written in English, Italian, Spanish, or French. We excluded studies describing portals that were not accessible for patients, as well as pilot studies, with the exception of studies evaluating patients’ attitudes.

Selection Process and Data Extraction

Two authors screened the articles, and each reference retrieved was screened by two researchers independently, with any disagreement finally discussed and resolved by a third researcher, if necessary. The following information was extracted from the studies: first author name, publication year, study country, study design, study population, study setting, study duration and time, health information technology, study objective, main findings according to health outcomes, health care efficiency/utilization, patient characteristics, and patient attitudes and satisfaction. The systematic literature review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 checklist [15].

Results

Characteristics of the Included Studies

The database search, after duplicate removal, identified a total of 3456 records. According to the inclusion/exclusion criteria, the screening resulted in the inclusion of 47 full-text articles (Figure 1).

The study designs were grouped into six categories according to the characteristics of the articles. Overall, 17 were descriptive quantitative studies [8,16-31], two were descriptive mixed-methods studies [32,33], 14 were observational hypothesis testing studies [20,34-46], seven were descriptive qualitative studies [47-53], five were interventional studies, other than randomized controlled trials (RCTs) [54-58], and three were RCTs [59-61].

With regard to country, 33 (70%) studies were based in the United States [17,18,20,21,31,32,34,43-46,49,60], three in Canada [35,36,50], three in the Netherlands [19,26,57], two in Finland [55,56], two in the United Kingdom [16,48], one in Australia [22], one in France [59], one in Israel [47], and one in Sweden [24].

Various patient portals have been described in the studies. Multimedia Appendix 2 provides details on the functionalities of the portals, and Multimedia Appendix 3 provides qualitative descriptions of the portals.

Most of the portals were not addressed to a defined population subgroup, and only some of them were specific to a clinical specialty/condition, such as endocrinology-diabetes [8,21,26,34,36,41], primary care [33,37,38,40,60], mental health [31,35,54], multiple chronic conditions [40,55,56], pulmonology and asthma [32,44,60], rheumatology [50,57,59], cardiology [37,44], internal medicine [40,61], nephrology [30,46], pregnancy [34], cancer [53], and gastroenterology [48].

The population included in the studies was heterogeneous in terms of sample size (from 24 [52] to 2,171,325 patients [31]) and groups of included patients (eg, pediatric [32], older [31], oncology [52], and diabetic patients [60]).

The results were summarized in four categories, albeit the same study could belong to more than one category. In particular, 11 studies analyzed health outcomes and adherence, intended as a change in individual or population health, attributable to health-related interventions. Adherence is the degree to which a patient follows medical advice, especially drug compliance. Overall, 15 studies focused on health care efficiency/utilization (utilization of health care services), 32 studies referred to patient characteristics, and 30 studies analyzed attitudes and satisfaction.

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Health Outcomes and Adherence

Eleven articles presented results on patient outcomes (Table 1), such as prevention, diabetes, blood pressure control, asthma, mental health, and medication adherence.

In particular, a significant association was found between patients’ preventive health behaviors and portal use [45]. Considering diabetes [34,36] and blood pressure control [37], portal users were significantly more likely to control their HbA_1c levels successfully compared to nonusers.

An improved clinical condition over time was observed in the management of asthma in children, where the group using the patient portal reported better flare control compared to the control group [60].

Concerning mental health, patients using the portal had a positive impact related to the clinical condition in many domains [35], such as the reduction of drinking days [54]. However, concerning the health status, no marked short-term impact was described, and differences in patient-reported physical and mental health changes were minor [55].

Finally, higher medication adherence was described in portal users compared with nonusers, especially among pediatric patients with asthma and patients with rheumatic disorders [32,57].

Efficiency/Utilization

Fifteen articles described the relationship between portal use and health care service efficiency and utilization (Table 2). The use of a digital portal had an effect on the utilization of health care services in terms of the number of clinical visits, especially for asthmatic patients [32,60], while no statistically significant changes in the number of primary care visits was reported in association with the use of secure messaging [38].

Concerning emergency room (ER) visits, a decreasing trend was described [54,60], and active portal users showed more outpatient and inpatient visits and fewer ER visits per month, compared with patients without an account [28]. The number of visits over 6 months for asthmatic patients was lower among users than among nonusers (3 vs 9) [60]. User status was not significantly associated with ED access in the study by Plate et al, and the use of secure messages showed a nonsignificant result [39].

A reduction in hospitalizations was described for asthma [60] and mental health conditions [54]. Different findings were observed in patients with acute myocardial infarction, congestive heart failure, or pneumonia. In these cases, the odds of 30-day readmission for active users was 66% higher than that for nonusers, while no significant difference was described between nonusers and light users [44]. Considering patients who underwent total hip or knee arthroplasty, there was a significant association between 90-day readmission and sending two or more secure messages [39].

Concerning clinicians’ attitudes, the portal seemed to enable a new way of managing stable patients, facilitating clinical and cost-effective use of specialist nurses (improved two-way communication, and more optimal use of outpatient appointments and consultant time). The portal also facilitated a single rationalized pathway for stable patients, enabling access to information and proactive support [48].

Portal use by patients reduced missing appointments [35] and showed an improvement in appointment adherence after portal adoption [42]. However, no significant association between user/nonuser status and no-show appointments was found by one study [28]. The difference in cancellation rate proxies was also not significant between the user and nonuser groups [42].

Finally, concerning other aspects, only one study took into consideration the associated costs with ambiguous results. In this study, costs decreased in the unadjusted model but increased after adjusting for relevant variables [55]. An increase in HIV screening rates was described, but changes in the rates of HIV risk behaviors (eg, condom use) and modification of addiction treatments appeared nonsignificant in mental health patients [54]. Portal use had a positive effect on days of work lost due to asthma patients’ issues [60]. Moreover, information services were positively affected by portal use, as it led to a reduced number of requests [35].

Patient Characteristics

Concerning patients’ characteristics, 32 articles presented relevant results that were mainly related to demographic information, such as age, gender, education, and household status (Table 3).

In terms of age, results were not homogeneous. Higher use in older patients (aged >50 years) was described in four studies [18,20,21,33]. In a middle age and elderly cohort, the mean age of users was significantly lower [45]. On the other hand, younger patients were also the major users in disease/specialty-specific cohorts [32,35,46].

A total of 19 studies mentioned the origin and ethnicity of users [8,18,25,27,30-32,34,37-39,42-46,52,58]. White patients were usually the most likely to use the portals described in the different studies [18,27,30-32,37,38,43,45,52]. Two studies found no significant association between ethnicity and portal use [8,28].

Most of the articles found a positive association between female gender and portal use [28,35,38,42,43,58]. Only one study, conversely, found male gender to be a predictor of registering [27]. No statistically significant association between sex and user/nonuser status was found in two articles [36,45].

In a cohort of patients with mental disorders, having schizophrenia or schizoaffective disorders was negatively associated with portal use [31]. Instead, depression was positively associated [37]. Moderate or severe asthma was more linked to portal use [32,60]. Moreover, having a diagnosis of diabetes, hypertension, heart failure, or cardiovascular disease was a significant predictor of portal use [20,40], with one exception [46]. On the other hand, there were contrasting results concerning the association between the number of comorbidities and portal use [27,37,41,42,44].

People living in rural areas were less likely to use patient portals than urban citizens in three studies [22,31,41], while higher education levels were often related to broader use of portals [23,25-27,30,32,52,57]. Only one study showed no significant association [8]. Higher income was also generally associated with portal use [31,37,45,46,58]. Only one study found no association between income and the use of secure messages [8].

Studies conducted in the United States showed that having a private insurance was positively associated with portal use [18,32,39,42,45,46,58], with only one study reporting the absence of this association [28].

Other patient characteristics positively associated with portal use were being a member of a patient association [59] and being admitted to an academic medical center [44].

Attitudes and Satisfaction

Patient attitudes were evaluated in terms of perceived barriers and facilitators toward portal use. The overall satisfaction was also assessed, and it refers to the extent to which the patient is content about health care. Thirty articles addressed these topics (Multimedia Appendix 4).

Nine articles clearly addressed the barriers to portal use. Some of the main issues were related to perceived or preconceived security concerns [8,48], limited knowledge [26,51], satisfaction with current care [51], paying for the service [54], disinterest in managing one’s own disease [26,57], personal/time constraints and not thinking about accessing the portal [57,61], doubts about the reliability of the patient portal to facilitate a timely and productive message exchange with providers [8], and prior negative experiences with secure messaging [8]. Other barriers were related to population characteristics, such as being a clinician older than 55 years or younger than 35 years and being male [33], and variation in provider availability for online appointment scheduling and response times to medical messages [25]. Limited computer and internet access [20,25,26,51,57], knowledge of technology [25,26,57], security concerns [25,48], and data integration [48] were also negative predictors of portal use.

On the other hand, nine articles specified the elements that facilitated portal use, including improved communication with specialists [22,48,60]; availability of information that led to an increased awareness of the health status [19,22,32,51,60] and tracking of disease control [32]; time-saving, convenient, and easy to use elements [19]; accuracy, timeliness, usefulness, and convenience of the functionalities included in the portal [22,50]; availability of surrogates (ie, daughter or family member) to act as intermediaries [51]; active involvement of the practice/staff in the promotion of the portal (ie, team approach strategy to engage staff in notifying patients) [33]; and active training of the patient for portal use [61]. Concerning satisfaction, patients were generally satisfied with the portals [8,17,21,29,49,50,59-61].

Discussion

Due to the considerable amount of literature published on the topic of patient portals, the aim of this review was to provide evidence and to gather information systematically. Similar to the review published in 2013 by Goldzweig et al [4], the outcomes were grouped into four aspects, namely, health outcomes and adherence, health care efficiency, patient characteristics, and attitudes and satisfaction, and showed nonunique results in terms of benefits brought by patient portals concerning patient experience and health. The functionalities available in the portals described by Goldzweig et al and our review were likewise the same.

Positive results were described relating to the enhancement of preventive behaviors [45], changes in chronic condition control with higher control of diabetes parameters [34,36], and asthma flares [60]. However, conflicting results were described concerning blood pressure control [34,37], mental health conditions [35,54,55], and medication adherence [32,57]. A possible explanation of these results is that these particular studies involved patients (often with a low sample size) who utilized portals for a short period of time, preventing them from having a possible consistent outcome. Similarly, concerning health outcomes, Goldzweig et al found generally positive results, which documented improvement in patients’ disease control and maintenance [4], even though many of the included studies in our review did not find a significant difference between portal users and nonusers. Adherence to therapy was always improved [4] similar to that in this review.

The number of clinical and ED visits [28,32,39,54,60] and hospital readmissions [39,44,54,60] did not always decline in patients using portals. The number of missed appointments decreased [35,42], but this finding was not always significant [28,42]. The nondeclining trends of hospitalizations and outpatient visits as a consequence of portal use are concordant in the two studies, although different findings were described. Indeed, different from our review, in which we found more often a decrease in the utilization of in-person services, the review by Goldzweig et al reported that most of the studies found an increased number of outpatient visits and hospitalizations. As patient portals are normally designed to reduce inappropriate health care utilization, this might be partially explained by the fact that provider and patient adaptations to the patient portals have evolved over time.

The studies differed also in terms of the population included, with conflicting results in portal adoption and age, gender, ethnicity, kind of disease, and number of comorbidities. Generally, having a higher income [31,37,45,46,58] and having a private insurance were associated with increased portal use [18,32,39,42,45,46,58].

The main barriers faced in using the portals were (1) user-related issues, such as time constraints [57,61], disinterest in managing the disease [26,57], and limited digital knowledge [26,51]; (2) clinician-related issues, such as age [33] and attitude toward the portal [33]; and (3) technology-related issues, such as limited internet access [25,26,51,57] or ability to use technology [25,26,57] and security concerns [25,48]. Privacy and security concerns, and ability to use technological appliances and systems were the most important barriers to utilization described in the studies retrieved by Goldzweig et al [4]. Indeed, other recent reviews on patient attitudes highlighted that privacy and security problems are the main barriers to the use of patient portals. These barriers are as evident in elderly patients (in whom there is also a limitation of portal use related to age) as in younger patients [62,63]. Moreover, technical problems due to patient capacity and difficulties in using the portal also represent important barriers. Thus, correct and adequate information on safety issues and education on the technical use of the portal represent the best facilitators. Furthermore, engaging patients and making them realize that the portal represents a useful tool to support the management of their pathology (especially for chronic diseases) without replacing the doctor-patient relationship are important to encourage the use of digital portals [13,62,64]. In addition, technical improvements in the usability of portals could increase patient enrollment.

Security problems are complex issues that must be considered in any part of medical care. The use of information technologies in health care that can be accessed by multiple types of users (physician, patient, caregiver, and hospital administrative staff) represents the basis of the discussion about computer security [65]. Indeed, uncertainties about security of clinical data might hinder adoption of systems by both hospitals and patients [48]. Patients expressed concern about their privacy and the privacy of their family members, and asked for further information about confidentiality, as vulnerable data might be accessed by external providers, such as insurance providers, who are the main actors of health care access in many countries [47].

The facilitators retrieved were the prompt availability of health information that caused an increase in the awareness of the health status [19,22,32,51,60], improved communication with health care professionals [22,48,60], and the accuracy, timeliness, usefulness, and convenience of the functionalities included in the portal [22,50]. In this latter argument, some functionalities of the portal were found to be more useful than others, including laboratory tests and imaging [23,24,29,43,52], medical notes [23,26], messaging with providers [52], medication refill [52], and current medication list [29]. Generally and as observed by Goldzweig et al [4], patients declared being satisfied with the use of digital tools [8,17,21,29,49,50,59-61].

Despite the considerable number of studies included, the high heterogeneity in terms of outcomes and described portal functionalities did not allow us to perform meta-analyses and to draw generalizable and strong conclusions concerning the utility of the unique features of the portals.

Technological and digital innovations in health care could contribute to achieving the health system goals of equity, efficiency, accessibility, quality, and sustainability, if they are purposefully designed and cost-effectively implemented. When designing a new patient portal or a new functionality, developers and providers should always consider to which health care need they are trying to respond and if other nondigital interventions may be more effective or as effective at a lower cost.

Moreover, the adoption of a new technology is a complex process, depending on the content and the context in which it is introduced. As an example, our review demonstrated that it is feasible to achieve better medication adherence in chronic disease patients through portal use, and highlighted the main facilitators (eg, prompt availability of reliable information and accessibility of communication with disease specialists) and barriers (eg, security and usability concerns, and limited digital knowledge) to portal use. Keeping in mind these contextual factors could ease the difficult task of identifying the best digital tool for a specific population.

Before designing or implementing a new tool, it can be useful to analyze the ideal conditions needed for the adaptation, transfer, absorption, up-scaling, and enhancement of digital technologies. By ideal conditions, we basically mean a situation where the new technology has demonstrated effectiveness in trials or pilots, the provider is committed to guarantee continuous improvement in user accessibility and usability, and the main barriers in the target population are given due consideration. In the absence of these conditions, satisfactory results may be difficult to reach or may take many years to be observed.

The benefits of digitalization cannot be taken for granted and the use of technology does not always lead to an improvement in patient care and health system performance; thus, there is a need for evidence, which is, to date, scarce. The identification of a set of main features with proven efficacy for a patient portal is a useful starting point for the development and implementation of patient-oriented portals. Further studies should be conducted in different aspects of digitalization in health care. None of the studies retrieved analyzed the cost-effectiveness of portal use. Similarly, none of the studies compared the portals to each other, which could be interesting to point out the best practices and features.

Even though a patient portal is not a new concept, its real utilization and implementation are still far from optimal, and it seem to be still considered a “future technology.” It is important to adapt the portal functions to the needs and capacities of patients, in order to facilitate the use of this technology and improve its dissemination. In particular, overcoming ethnic and literacy barriers to portal use represents a fundamental goal to create more equitable, effective, and safe health care systems.