Health disparities persist in patient portal signups, messaging

Patient portal enrollment low for racial minority patients

According to the JMIR study, nearly two-thirds of patients have activated their patient portals, showing that the technology has become somewhat mainstream among healthcare consumers.

But those activation rates aren't seen equally across race, the researchers said.

After assessing 72,417 patients at two academic medical centers, the researchers found that patient portal activation is still concentrated among White patients. Activation rates were 76.1% for White patients, 57.6% for Asian patients, 57% for Black patients and 55% for Hispanic patients.

Neighborhood factors such as higher educational attainment, stronger broadband access and higher median income were also linked to patient portal activation, the researchers found.

Still, addressing those factors is not enough to close digital racial health disparities, the researchers said.

"The more consequential finding is what neighborhood resources failed to do: substantial racial disparities in activation persisted within individual wards, including the most affluent, even after accounting for socioeconomic resources," they wrote. " Age was the strongest individual predictor, but it was the combination of race and place, not any single factor, that defined the divide."

Healthcare organizations might consider tailored interventions to close the digital divide, including by offering in-clinic patient portal enrollment, community health worker outreach and multi-lingual portal onboarding. Creating an opt-out system for the patient portal -- meaning patients must actively decide not to have a portal account -- could also be helpful.

Clinicians should also encourage patients to adopt the portal, the researchers said. However, organizations must retain adequate staff to help patients with that added enrollment, lest the burden fall on already-squeezed providers.

Finally, organizations might consider SMS message campaigns to help boost patient awareness of the portal.

Implicit bias seeps into inbox management

Closing the patient portal signup gap is only half the battle, according to the JAMA study, which was completed separately from the JMIR one. Healthcare organizations also need the personnel and health IT resources to ensure that everyone with a patient portal has an equally good experience.

Right now, healthcare is missing the mark.

Previous studies have shown that racial and ethnic minorities, and especially Black patients, have to wait longer to hear back from their healthcare providers after sending a message on the patient portal. Now, this latest study shows disparities in how often racial and ethnic minorities hear back from their intended provider, typically their usual source of care or the clinician they saw in the exam room.

Increasingly, medical organizations are using team-based care to help manage patient portal inbox volumes, which have grown exponentially since 2020. Depending on the message's content, a nurse or case manager might answer a question, leaving physicians to handle more complex queries.

This wouldn't be much of a problem if patient portal messages were triaged solely based on the severity or complexity of the request. But an analysis of more than 3 million patient portal message threads shows Black, Hispanic and Asian people are less likely to hear back from their intended recipient.

This was most pronounced among Black people, who had a 3.7 percentage-point gap in portal message responses compared to White people. Said otherwise, they were 11.6% less likely to hear back from their provider after messaging them.

Importantly, writing style -- not content -- accounts for most of that disparity.

Writing style was determined using natural language processing and included factors such as the use of a salutation, expressive punctuation, polite language and whether it was a proxy message sent on the patient's behalf.

Writing style accounted for 48% of the response disparity for Black patients, 34.9% for Hispanic patients and 60.5% for those without a college degree. It also accounted for 42.8% of the response differential for those enrolled in Medicaid.

This could indicate a fundamental implicit bias problem, the researchers suggested. Healthcare organizations should make their providers aware of these trends and equip them with implicit bias training to help better manage patient portal message triage.

Technology could also be helpful, the team added. Patient portal message templates could help standardize message content and writing style, helping the individuals in charge of triaging messages approach their work with less bias.

Meanwhile, AI chatbots could  help patients craft portal messages, potentially streamlining writing style and removing room for implicit bias.

Sara Heath is an executive editor at Xtelligent Healthcare Media, where she covers patient engagement, healthcare policy and health IT.