Patient Portals Facilitate Patient Engagement: A Systematic Review
Introduction
A patient portal is a secure online website that allows patients to have access to their personal health information. This means that patients can view their laboratory results, medications, and immunizations, as well as send messages to providers, schedule appointments, and make payments at any time and from anywhere with an Internet connection (“What is a patient portal?”, 2017).
The intention of portals is to offer patients more control over their health care and to increase patient engagement. Numerous studies have examined the relationship between patient portals and patient engagement, patient satisfaction, or health outcomes. Notably, increased use of patient portals has shown increased rates in patient engagement and patient satisfaction as well as improved health outcomes. Previously, systematic reviews have been conducted on patient portals and patient engagement, but these studies only focused on specific populations or settings, or they only focused on limited themes (Dendere et al., 2019).
The pervasiveness of patient portals is due to these predicted positive effects and government incentives to implement the technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 provided incentives for the meaningful use of electronic health records. Specific requirements for incentives included emphasizing patient-controlled data and interacting with patients through the portal, which increased the use of patient portals (“What is the HITECH Act?”, 2022). Due to this prevalence, it is important to analyze which aspects of patient portals that patients find helpful and which aspects can be improved upon.
This paper reviews literature describing aspects of patient portals and their relationship to patient engagement, patient satisfaction, and health outcomes; the goal is to identify factors and best practices that are essential for successful implementation of patient portals. This review aims to inform developers, health care organizations and providers, and policymakers of the importance of a patient portal that engages and satisfies the needs of patients.
Methods
This review followed the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement.
Search Strategy and Screening
The PubMed database was searched for articles using the keywords of patient portal, patient engagement, and patient satisfaction. The initial search was created using Medical Subject Heading (MeSH) terms and keywords relevant to the question of interest. This resulted in an exact search of (patient portals[MeSH]) AND (“patient participation”[MeSH] OR patient engagement[Title/Abstract] OR patient satisfaction[Title/Abstract]), which was searched in PubMed. The results from this search were initially screened by reviewing the titles and abstracts, and articles were selected if they met the eligibility criteria. The selected articles were then subject to a full-text review, and the researcher determined whether they should be included in the review based on the eligibility criteria. The reference lists of the eligible articles were also searched for additional articles to ensure a more comprehensive review.
Eligibility Criteria
Studies eligible for inclusion must have been related to patient portals and patient engagement as defined by the researcher. In addition, studies included were required to be available in English and published between 2017 and the end search date of August 8, 2022. A start date of 2017 was selected to obtain recent data. Since patient portals are constantly being re-designed and improved upon, analysis on recent data provides results that are most relevant to the patient portals that patients currently use. Some studies were excluded due to a lack of availability of a full-text article.
Data Extraction and Analysis
The aforementioned steps were completed by one independent researcher. The researcher read the full text, and data was extracted and entered into a spreadsheet. No automation tools were used and no data were missing.
To organize the data, key themes across the studies were identified by the researcher and were categorized into inputs or outputs. Inputs are the components of patient portals that are implemented to establish and facilitate use of the portal, while outputs are the results of patients’ use of the portal. Inputs include portal design, usability, facilitators to use like user instructions or training, and barriers to use of patient portals. Outputs include patient engagement, patient satisfaction, and health outcomes. Tables 1 and 2 provide definitions of these input and output themes as determined by the researcher. All tables to organize data were created in Microsoft
Excel.
Table 1
Input Themes
| Key Terms | Definitions |
| Portal Design | Includes all design-related aspects of the portal, such as portal interface, features like communication and accessing lab reports, and functions |
| Usability | Extent to which a patient portal is able to be operated by patients |
| Facilitators | Factors that enable patients to use the portal, such as training and accessibility |
| Barriers | Factors that hinder portal use or adoption |
Table 2
Output Themes
| Key Terms | Definitions |
| Patient Engagement | Active involvement of patients in their health care, including feelings of empowerment and health self-awareness |
| Patient Satisfaction | Whether patients feel that patient portals enhanced their experience in health care |
| Health Outcomes | The impact of patient portals on clinical indicators, including adherence to medication and not missing appointments |
Risk of Bias
The methods outlined potentially have multiple risks of bias. Only one reviewer performed the systematic review, meaning that there was not another person to check and agree with the selections and exclusions. Therefore, there is potential bias in the selection as the one reviewer could have excluded an article that another reviewer would have included. Additionally, only articles in PubMed, published in English, and published in 2017 or later were included to ensure a current review, which may have excluded some relevant articles. Moreover, articles may have used other terms instead of patient engagement, such as “patient empowerment” and “self-efficacy.” These articles may be relevant but may not have been included by the search criteria.
Results
Study Selection
The search identified 150 papers, which were screened by one researcher. Figure 1 illustrates the screening process, including exclusion criteria (Haddaway et al., 2022). No duplicates were found, and the initial screening of each article’s title and abstract yielded 70 eligible articles. The full-text of the remaining 70 articles were then reviewed for relevance, and 26 articles were included. Seventeen studies were excluded due to lack of access to the full-text article. This was due to database permissions or because the article had been removed from online. Eighteen studies were found to not evaluate patient engagement, patient satisfaction, or health outcomes. Five studies investigated patient characteristics that made patients more likely to use patient portals, which is outside the scope of this review. Four studies did not mention patient portals but analyzed patient engagement. Three additional studies were found through reading citations for a total of 29 eligible studies.
Figure 1
PRISMA flow diagram illustrating screening of studies
Characteristics of Included Studies
The 29 included articles consisted of three systematic reviews, eleven qualitative studies, nine quantitative studies, and six mixed methods studies. The researcher analyzed these articles for key input and output themes. Most articles discussed multiple themes, and the themes described in each of the included studies are shown in Table 3.
Table 3
Presence of Input and Output Themes in Included Articles
| Study | Portal Design | Usabili ty | Facilit ators | Barriers | Patient Engage ment | Patient Satisfact ion | Health Outco mes |
| Baldwin et al., 2017 | ✓ | ✓ | ✓ | ||||
| Carini et al., 2021 | ✓ | ✓ | ✓ | ||||
| Collins et al., 2017 | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Coquet et al., 2020 | ✓ | ✓ | |||||
| Cross et al., 2021 | ✓ | ||||||
| Dendere et al., 2019 | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Dumitrascu et al., 2017 | ✓ | ||||||
| Fareed et al., 2022 | ✓ | ||||||
| Graham et al., 2020 | ✓ | ✓ | |||||
| Grossman et al., 2018 | ✓ | ✓ | ✓ | ✓ | |||
| Hefner et al., 2019 | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Kelly et al., 2017 | ✓ | ✓ | ✓ | ✓ | |||
| Kinney and Sankaranarayanan, 2021 | ✓ | ||||||
| Lee et al., 2019 | ✓ | ✓ | |||||
| Lockhart et al., 2019 | ✓ | ✓ | |||||
| Nazi et al., 2018 | ✓ | ✓ | ✓ | ✓ | |||
| Nystrom et al., 2018 | ✓ | ✓ | ✓ | ||||
| Matthews et al., 2022 | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Park et al., 2021 | ✓ | ||||||
| Powell, 2017 | ✓ | ✓ | ✓ | ✓ | |||
| Robinson et al., 2020 | ✓ | ✓ | |||||
| Schember et al, 2022 | ✓ | ||||||
| Schnock et al., 2019 | ✓ | ✓ | |||||
| Shimada et al., 2020 | ✓ | ✓ | ✓ | ||||
| Stewart et al., 2020 | ✓ | ||||||
| Tsai et al., 2019 | ✓ | ✓ | |||||
| Wildenbos et al., 2018 | ✓ | ✓ | ✓ | ✓ | |||
| Wong et al., 2019 | ✓ | ✓ | |||||
| Yen et al., 2018 | ✓ | ✓ |
A summary table of the key findings is provided in Table 4. Twenty-one articles addressed themes in the inputs category. Sixteen articles involved research with portal design and eight articles discussed usability. Facilitators were addressed in 10 articles and barriers to patient portals were discussed in 9 articles.
All 29 studies discussed at least one of the three output themes. Patient engagement was evaluated in 11 articles, patient satisfaction was addressed in 15, and health outcomes were researched in seven.
Table 4
Summary of Key Findings by Theme: Results Table
| Portal Features Messaging via patient portal increases patient engagement (Coquet et al., 2020; Robinson et al., 2020; Shimada et al., 2020)Option for patient-provider communication is seen as important and valuable (Dendere et al., 2019; Grossman et al., 2018; Lockhart et al., 2019; Wildenbros et al., 2018)Checking laboratory test results, care and care team information, medication list, and messaging were most used features (Grossman et al., 2018; Kelly et al., 2017; Schnock et al., 2019; Tsai et al., 2019; Wong et al., 2019) Usability User-centered design and user testing are important (Collins et al., 2017; Nystrom et al., 2018; Yen et al., 2018)Navigation to complete tasks needs improvement (Baldwin et al., 2017; Nazi et al., 2018)Confusing to use interface (Baldwin et al., 2017; Matthews et al., 2022)Consistent user experience across patient portals would increase acceptance (Collins et al., 2017; Wildenbos et al., 2018) Facilitators More training of proper uses and guidelines of patient portals is needed (Carini et al., 2021; Cross et al., 2021; Hefner et al., 2019; Lee et al., 2018; Park et al., 2021; Powell, 2017; Yen et al., 2018) Patients prefer a summary of medical information in nontechnical terms (Dendere et al., 2019; Kelly et al., 2017; Nystrom et al., 2018; Wildenbos et al., 2019) Barriers Worry over security and confidentiality of health information (Carini et al., 2021; Collins et al., 2017; Dendere et al., 2019; Lockhart et al., 2019; Matthews et al., 2022; Nazi et al., 2018; Powell, 2017) Lack of confidence and self-efficacy in using technology (Carini et al., 2021; Hefner et al., 2019; Shimada et al., 2020)No perceived need for technology or disinterest (Carini et al., 2021; Shimada et al., 2020) Patient Engagement Use of portals increased patient engagement (Dendere et al., 2019; Kelly et al., 2017; |
| Park et al., 2021; Powell, 2017; Robinson et al., 2020; Schnock et al., 2019; Stewart et al., 2020) Patient Satisfaction Use of portals increased patient satisfaction (Cross et al., 2021; Fareed et al., 2022; Graham et al., 2020; Kinney and Sankaranarayanan, 2021; Lee et al., 2019; Matthews et al., 2022; Shimada et al., 2020)Improved patient-provider relationship including communication (Kelly et al., 2017; Hefner et al., 2019; Matthews et al., 2022; Powell, 2017; Robinson et al., 2020; Shimada et al., 2020) Health Outcomes Use of portals improved health outcomes (Carini et al., 2021; Coquet et al., 2020; Schember et al., 2022; Tsai et al., 2019)No difference between portal users and nonusers in readmission rates (Dumitrascu et al., 2017) |
Input Themes
Portal design was addressed in 16 articles with communication between providers and patients via patient portal being the most prevalent theme. In multiple studies, it was observed that patients valued communication with providers above all other features of the portal (Dendere et al., 2019; Grossman et al., 2018; Lockhart et al., 2019; Wildenbros et al., 2018). It has also been shown that messaging increases patient engagement (Coquet et al., 2020; Robinson et al., 2020; Shimada et al., 2020). Instead of calling the office and waiting for a doctor to return the call, patients can send a text message or email through the patient portal and receive a prompt response, making provider and patient communication fast and easy (Hefner et al., 2019). Moreover, five studies advocate for patient portal interfaces that aid patients in understanding their health data and are designed to be user-centered (Baldwin et al., 2017; Collins et al., 2017; Nazi et al., 2018; Nystrom et al., 2018; Matthews et al., 2022). Additionally, in five articles, it was observed that checking laboratory test results, care and care team information, medication list, and messaging were the most used patient portal features (Grossman et al., 2018; Kelly et al., 2017; Schnock et al., 2019; Tsai et al., 2019; Wong et al., 2019).
Eight articles discussed usability with the majority having predominantly unfavorable findings. Articles stressed the importance of a user-centered approach and performing user testing to determine effectiveness of the patient portal (Collins et al., 2017; Nystrom et al., 2018;
Yen et al., 2018). Many patients found the portal interfaces to be confusing (Baldwin et al., 2017; Matthews et al., 2022) and that the navigation to complete tasks needed improvement (Baldwin et al., 2017; Nazi et al., 2018). Other studies mentioned that if patients see multiple providers having a consistent user experience across patient portals would make patients more amenable to adopting portals (Collins et al., 2017; Wildenbos et al., 2018).
The most frequently mentioned facilitator across the ten studies that mentioned facilitators was that there needs to be more instruction and guidelines on the use of patient portals (Carini et al., 2021; Cross et al., 2021; Hefner et al., 2019; Lee et al., 2018; Park et al., 2021; Powell, 2017; Yen et al., 2018). In terms of messaging, patients were unsure when to send messages and what appropriate content of messages would be. Many worried about providers answering messages without being uncompensated and expressed uncertainty about what ‘non-urgent’ message means (Hefner et al., 2019). Another important facilitator is accessibility measures, such as providing nontechnical explanations for results and care plans (Dendere et al.,
2019; Kelly et al., 2017; Nystrom et al., 2018; Wildenbos et al., 2019).
Barriers to patient portal use and adoption were identified in nine articles. The most prevalent concern about patient portals is about security and confidentiality of their health information, which is mentioned in seven articles(Carini et al., 2021; Collins et al., 2017;
Dendere et al., 2019; Lockhart et al., 2019; Matthews et al., 2022; Nazi et al., 2018; Powell, 2017). Other studies describe a lack of knowledge of medical terminology or technology (Carini et al., 2021; Hefner et al., 2019; Shimada et al., 2020). Furthermore, there are issues with technology that range from insufficient knowledge on navigating to missing usernames and passwords to a disinterest in using technology (Carini et al., 2021; Shimada et al., 2020).
Output Themes
Patient engagement was investigated in 11 articles, and Table 5 shows the terms each article used to define or operationalize the concept. Many articles showed that the use of patient portals increased patient engagement (Dendere et al., 2019; Kelly et al., 2017; Park et al., 2021;
Powell, 2017; Robinson et al., 2020; Schnock et al., 2019; Stewart et al., 2020). Park et al. determined a causal relationship between patient portal use and increased self-efficacy and confidence in obtaining health information (2021). One study showed an association between portal use and patient activation (Schnock et al., 2019), while two articles demonstrate the increase in patient engagement because of messaging (Robinson et al., 2020; Shimada et al., 2020). Four articles describe facilitators and barriers to implementing a successful patient portal that engages patients (Collins et al., 2018, Nazi et al., 2018; Nystrom et al., 2018; Powell, 2017).
Table 5
Patient Engagement Defined or Operationalized
| Study | Defined or Operationalized As |
| Collins et al., 2017 | Patient empowerment and engagement |
| Dendere et al., 2019 | Active involvement of patients in health care |
| Kelly et al., 2017 | Active patient and public involvement in health and healthcare |
| Nazi et al., 2018 | Data on patient utilization of portal over 10 years |
| Nystrom et al., 2018 | Focus groups and user testing on portal design |
| Park et al., 2021 | Self-efficacy and self-management of health care |
| Powell, 2017 | Patient engagement, feelings of empowerment, self-management of health care |
| Robinson et al., 2020 | Survey on self-efficacy and disease self-management |
| Schnock et al., 2019 | Survey to measure patient activation |
| Shimada et al., 2020 | Use of secure messaging |
| Stewart et al., 2020 | User feedback on feelings of engagement via interviews |
Patient satisfaction was studied in 15 articles, and Table 6 shows the terms each article used to define or operationalize the concept. Kinney and Sankaranarayanan defined patient satisfaction as positive feelings about “care team interaction, atmosphere, and instruction effectiveness” (2021). Other articles agreed that provider-patient communication and interaction were indicators of patient satisfaction. Notably, many patients stated that portals improved the overall patient-provider relationship especially in regards to communication (Kelly et al., 2017; Hefner et al., 2019; Matthews et al., 2022; Powell, 2017; Robinson et al., 2020; Shimada et al., 2020). Likewise, patients explained that they repeated themselves less during the appointment and saved time with scheduling (Graham et al., 2020). Three articles described features of patient portals that patients feel would aid in satisfaction (Baldwin et al., 2017; Grossman et al., 2018; Lockhart et al., 2019; Nazi et al., 2018; Wildenbos et al., 2018; Wong et al., 2019). The majority of articles showed that the use of portals increased patient satisfaction with their health care experience (Cross et al., 2021; Fareed et al., 2022; Graham et al., 2020; Kinney and
Sankaranarayanan, 2021; Lee et al., 2019; Matthews et al., 2022; Shimada et al., 2020).
Table 6
Patient Satisfaction Defined or Operationalized
| Study | Defined or Operationalized As |
| Baldwin et al., 2017 | Increased use of patient portals |
| Cross et al., 2021 | Perception of improved provider-patient interaction |
| Fareed et al., 2022 | Satisfaction survey on health care experience |
| Graham et al., 2020 | Satisfaction survey about portal perceptions |
| Grossman et al., 2018 | User feedback on portal perceptions |
| Hefner et al., 2019 | Perceptions of messaging via portal |
| Kelly et al., 2017 | Qualitative data |
| Kinney and Sankaranarayanan, 2021 | User feedback on portal perceptions |
| Lee et al., 2019 | Content and ease of access to patient data via survey |
| Lockhart et al., 2019 | Improve communication and access to care via survey |
| Matthews et al., 2022 | Qualitative interviews on portal perceptions |
| Nazi et al., 2018 | User feedback on portal design and function |
| Powell, 2017 | Perception of improved provider-patient interaction |
| Wildenbos et al., 2018 | Satisfaction survey on portal features |
| Wong et al., 2019 | Satisfaction survey |
Health outcomes as a result of patient portals were investigated in seven studies. Most articles found an association between the use of patient portals and improved health outcomes (Carini et al., 2021; Coquet et al., 2020; Dendere et al., 2019; Graham et al., 2020; Schember et al., 2022; Tsai et al., 2019). Health outcomes included decreased appointments missed and increased medication adherence (Dendere et al., 2019; Graham et al., 2020; Schember et al., 2022). Tsai et al., 2019 showed that patients who used the portal had less ER visits in comparison to nonusers, while Schember et al., 2022 showed that reminders to use medication increased retention of medication use and viral suppression of HIV as a result. Despite these conclusions, there is at least one article that showed no difference between portal users and nonusers in their 30-day readmission rates (Dumitrascu et al., 2017).
Discussion
Principal Findings
One key finding of this study was that patient portal design needs to prioritize communication between patients and providers. Patients value this connection and feel more engaged in their care when they have access to communication systems (Coquet et al., 2020;
Dendere et al., 2019; Grossman et al., 2018; Lockhart et al., 2019; Robinson et al., 2020;
Shimada et al., 2020; Wildenbros et al., 2018). With this finding also comes drawbacks. Providers are already overburdened and fatigued, and if more patients start actively messaging providers, physician burnout will only increase. In order to prevent this, proper education around using patient portals is necessary for both patients and providers.
This leads to the second major finding, which is that patients need to be trained on the instructions on how to use the patient portal and guidelines on best practices of using the messaging feature (Carini et al., 2021; Cross et al., 2021; Hefner et al., 2019; Lee et al., 2018; Park et al., 2021; Powell, 2017; Yen et al., 2018). Providing instructions should educate patients on the available features and aid in navigating the portal to access these features. Guidelines on messaging expectations would ensure that patients don’t overuse or underuse the feature. It’s important to clarify instances when a patient should use the portal instead of making an appointment or calling because this would alleviate patient uncertainties as well as reduce the volume of calls a provider receives.
The third crucial finding is that while studies find that patient portals increase patient engagement and satisfaction, there is still need for improvement. In surveys and interviews, patients often mentioned a desire for nontechnical explanations for health data and for patient portals to be more user-friendly. It is important to take this feedback into account when designing portal interfaces (Baldwin et al., 2017; Collins et al., 2017; Dendere et al., 2019; Kelly et al., 2017; Matthews et al., 2022; Nazi et al., 2018; Nystrom et al., 2018; Wildenbos et al., 2019; Yen et al., 2018). In regards to barriers to adoption, the most prevalent one is worry over security and confidentiality (Carini et al., 2021; Collins et al., 2017; Dendere et al., 2019; Lockhart et al., 2019; Matthews et al., 2022; Nazi et al., 2018; Powell, 2017). This is a concern that can be addressed by developers or an organization’s security team to assure patients that their health data is secure.
Future Directions
Through this systematic review, there were some areas that had limited articles. There was an abundance of literature on messaging, but limited articles on other portal features like laboratory results or care plan information. More research on how to make these areas more accessible and less technical should be conducted as these are two of the most accessed portal features.
Furthermore, most articles studied the use of portals on patient engagement. While this is valuable information, the merit in researching use of portals depends on how use is measured. One article measured portal use as if the patient had an account (Schember et al., 2022). This is misleading because patients may have opened an account but did not actually use the portal.
Similarly, the measure of patient engagement or satisfaction varied amongst articles.
Many used survey responses or interviews to measure patient engagement and satisfaction (Cross et al., 2021; Fareed et al., 2022; Graham et al., 2020; Grossman et al., 2018; Hefner et al., 2019; Kinney and Sankaranarayanan, 2021; Lee et al., 2019; Lockhart et al., 2019; Matthews et al.,
2022; Nystrom et al., 2018; Robinson et al., 2020; Schnock et al., 2019; Stewart et al., 2020; Wildenbos et al., 2018; Wong et al., 2019). Surveys and user feedback is valuable if the participants are unbiased and aware of scales. If a participant is rating their feelings of engagement from one to ten, they must have a reference of what each number means; otherwise, one patient’s response of eight may be equivalent to another patient’s response of six. Another drawback of surveys and user feedback is that patients may not feel comfortable sharing negative feedback, which can potentially skew data to more positive conclusions. Therefore, studies with objective measurements of patient engagement should also be conducted.
Ultimately, future research should focus on addressing these concerns and more to determine more factors and best practices that are essential for successful implementation of patient portals. Developers should use research to design an optimal patient portal, and government officials can implement policy to ensure that designs that cater to patients are created.
Limitations
There were several limitations with this review. Despite the numerous initial search results, the articles chosen often had minimal diversity in the sample and a small sample size. This means that the results of these studies may not be generalizable to other populations. In addition, there is no standardized definition or measure of patient engagement. This makes it difficult to synthesize data across articles, limiting reviews to summarizing key findings. Finally, the categorization of themes across the included articles is subjective. There is overlap in the themes identified and other researchers may select different themes and categorize data differently.
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