Background Patient portals are now widely available and increasingly adopted by patients and providers. Despite the growing research interest in patient portal adoption, there is a lack of follow-up studies describing the following: whether patients use portals actively; how frequently they use distinct portal functions; and, consequently, what the effects of using them are, the understanding of which is paramount to maximizing the potential of patient portals to enhance care delivery. Objective To investigate the characteristics of primary care patients using different patient portal functions and the impact of various portal usage behaviors on patients’ primary care service utilization and appointment adherence. Methods A retrospective, observational study using a large dataset of 46,544 primary care patients from University of Florida Health was conducted. Patient portal users were defined as patients who adopted a portal, and adoption was defined as the status that a portal account was opened and kept activated during the study period. Then, users were further classified into different user subgroups based on their portal usage of messaging, laboratory, appointment, and medication functions. The intervention outcomes were the rates of primary care office visits categorized as arrived, telephone encounters, cancellations, and no-shows per quarter as the measures of primary care service utilization and appointment adherence. Generalized linear models with a panel difference-in-differences study design were then developed to estimate the rate ratios between the users and the matched nonusers of the four measurements with an observational window of up to 10 quarters after portal adoption. Results Interestingly, a high propensity to adopt patient portals does not necessarily imply more frequent use of portals. In particular, the number of active health problems one had was significantly negatively associated with portal adoption (odds ratios [ORs] 0.57-0.86, 95% CIs 0.51-0.94, all P<.001) but was positively associated with portal usage (ORs 1.37-1.76, 95% CIs 1.11-2.22, all P≤.01). The same was true for being enrolled in Medicare for portal adoption (OR 0.47, 95% CI 0.41-0.54, P<.001) and message usage (OR 1.44, 95% CI 1.03-2.03, P=.04). On the impact of portal usage, the effects were time-dependent and specific to the user subgroup. The most salient change was the improvement in appointment adherence, and patients who used messaging and laboratory functions more often exhibited a larger reduction in no-shows compared to other user subgroups. Conclusions Patients differ in their portal adoption and usage behaviors, and the portal usage effects are heterogeneous and dynamic. However, there exists a lack of match in the patient portal market where patients who benefit the most from patient portals are not active portal adopters. Our findings suggest that health care delivery planners and administrators should remove the barriers of adoption for the portal beneficiaries; in addition, they should incorporate the impact of portal usage into care coordination and workflow design, ultimately aligning patients’ and providers’ needs and functionalities to effectively deliver patient-centric care.

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Background Patient portals have drawn much attention, as they are considered an important tool for health providers in facilitating patient engagement. However, little is known about whether the intensive use of patient portals contributes to improved management of patients’ health in terms of their confidence in acquiring health information and exercising self-care. There is a lack of randomized trials with these outcomes measured both pre- and postadoption of patient portals. Objective The aim of this study was to examine the causal relationship between the usage of patient portals and patients’ self-efficacy toward obtaining health information and performing self-care. Methods This study was a secondary data analysis that used data from a US national survey, the National Cancer Institute’s Health Information National Trends Survey 5 Cycle 1. Patient portal usage frequency was used to define the treatment. Survey items measuring self-efficacy on a Likert-type scale were selected as the main outcomes, including patients’ confidence in obtaining health information and performing self-care. To establish causality using survey data, we adopted the instrumental variables method. To determine the direction of the causal relationship in the presence of high-dimensional confounders, we further proposed a novel testing framework that employs conditional independence tests in a directed acyclic graph. The average causal effect was measured using the two-stage least squares regression method. Results We showed that frequently using patient portals improves patients’ confidence in obtaining health information. The estimand of the weighted average causal effect was 0.14 (95% CI 0.06-0.23; P<.001). This means that when increasing the portal usage intensity, for instance, from 1-2 times to 3-5 times per year, the expected average increase in confidence level measured on a Likert-type scale would be 0.14. However, we could not conclusively determine the causal effect between patient portal usage and patients’ confidence in exercising self-care. Conclusions The results support the use of patient portals and encourage better support and education to patients. The proposed statistical method can be used to exploit the potential of national survey data for causal inference studies.

BACKGROUND Patients with cancer were reported to use patient portals far more frequently than other patient populations and patient portals have shown the potential to deepen relationships between care providers and cancer patients by increasing transparency of health information and supporting communication. OBJECTIVE The objective of this study was to examine the causal relationship between the usage of patient portals and cancer patients’ health self-efficacy outcomes. METHODS The National Institute’s HINTS 5 Cycle 1 (2017), Cycle 2 (2018), Cycle 3 (2019), and Cycle 4 (2020) data were used to perform a secondary data analysis. Patients who reported being ever diagnosed with cancer were included in the study population. Their portal usage frequency was considered as an intervention. Patients’ perceptions of self-efficacious health information-seeking behaviors, their capability to perform self-care, and the quality of care received were the primary outcomes considered and they were measured by survey respondents’ self-reported information. A set of conditional independence tests based on the causal directed acyclic graph were developed to examine the causal relationship between patient portal usage and the targeted outcomes. RESULTS We observed patient portals’ impact on strengthening cancer patients’ ability to take care of their own health and identified heterogeneous causal relationships between frequent patient portal usage and cancer patients’ perceived quality of care. We could not conclusively determine the causal effect between patient portal usage and patients’ confidence in getting advice or information about health or cancer care related topics. CONCLUSIONS The results advocate patient portals and promote the need to provide better support and education to patients. The proposed statistical method exploits the potential of national survey data for causal inference studies.

BACKGROUND Much attention has been drawn to patient portals as an important tool for health providers to facilitate patient engagement. However, little is known about whether the use of patient portals contributes to improved management of patients’ health, within the context of their confidence in acquiring health information and their ability to monitor and take good care of their own health, due to the lack of an observational or randomized dataset with measurements of self-efficacy outcomes both pre- and post-adoption of patient portals. OBJECTIVE To develop a testing framework that allows for causal inference and use it to investigate whether the exposure to patient portals, or intensively using a patient portal, will improve patients’ self-efficacy towards obtaining health information and taking care of themselves. METHODS This study was a secondary data analysis that used data from the National Cancer Institute’s HINTS 5 Cycle 1 data. Patient portal usage frequency was used to define the treatment, and survey items measuring self-efficacy were selected as the main outcomes, including patients’ confidence in getting health information and taking care of their own health. To enable establishing causality from survey data, we propose a novel testing framework that can identify the causal relationship using instrumental variables and conditional independent tests. RESULTS Using patient portals is shown to improve patients’ confidence of getting health information. The estimand of the weighted average causal effect from two-stage least squares regression is 0.15, with a 95% Confidence Interval (0.06, 0.23), p<0.001. It means that increasing the portal usage intensity, for instance, from 1-2 times to 3-5 times, the expected average increase in the response score (measured on a Likert-type scale) is 0.15. However, we cannot conclude a causal effect of using patient portals on patients’ confidence in self-care. CONCLUSIONS The proposed statistical method exploits the potential of national survey data for causal inference studies and the results advocate patient portals and promote the need to provide better support and education to patients. It also urges randomized controlled studies to further investigate this identified treatment effect.