OBJECTIVES:

Electronic health records are becoming increasingly common tools for storing and sharing patient health information. Many vendors offer patient “portals” as a way for patients and/or proxies to view test results and communicate with their health care teams. Few researchers have looked at patient portals in the inpatient pediatric population. Our objectives were to describe portal activation and use and factors associated with these end points for hospitalized children.

METHODS:

Retrospective, single-center study of pediatric patients birth through 17 years old who had at least one hospital admission and one or more inpatient diagnostic test performed between January 1, 2018, to December 31, 2018. Portal use was defined as viewing one or more test result. Multivariate logistic regression analyzed the association between patient characteristics and portal account activation and use.

RESULTS:

A total of 5862 patients with 170 685 diagnostic test results were included. A total of 40.9% of patients had an activated account, and 20.3% viewed one or more test result. Factors associated with an increased odds of portal activation and/or use included English as preferred language, white race, commercial insurance, multiple admissions, previous outpatient testing, and having both laboratory and imaging inpatient studies performed.

CONCLUSIONS:

In this study, we highlight the underuse of the patient portal in the inpatient pediatric population, especially for patients whose preferred language is not English, self-identify as multiracial and are publicly insured or uninsured. Concerted efforts to eliminate health care disparities in relation to portal activation are needed.

In the United States, the Health Information Technology for Economic and Clinical Health Act was passed in 2009, identifying engagement of patients and families in their health as a priority.1  In response, many electronic health record (EHR) vendors have created online patient portals (tethered personal health records) to allow patients to access their health information.

Patient portal use is gaining popularity in the inpatient setting, yet relatively few researchers have looked at portal usage in the inpatient pediatric population.210  Hospitalized patients and their families are interested and willing to use patient portals, valuing easy access to test results and improved communication with the health care team.6,11  Additionally, research has revealed an association between portal use and improved health care outcomes.6,12,13  Our objectives were to quantify patient portal activation for pediatric patients hospitalized at an academic medical center in 2018, assess portal use by using inpatient diagnostic test result access, and identify factors associated with portal activation and use. Results from this study may help identify barriers and opportunities to improve portal activation and use.

This was a retrospective study of all pediatric patients from birth through 17 years old who had at least one hospital admission and one or more inpatient diagnostic test(s) performed at our children’s hospital between January 1, 2018, to December 31, 2018. Our 190-bed children’s hospital was located in the Midwest and served a predominately rural and suburban population. It was the state’s only academic medical center, level 1 pediatric trauma center, and level 4 NICU. Patient care areas included the pediatric medical and surgical units, NICU, PICU, and newborn nursery. The study received institutional review board approval.

Our institution implemented the Epic EHR (same used for both outpatient and inpatient) in 2009 and adopted its tethered patient portal (MyChart) in 2010 for use in both the outpatient and inpatient care settings.14  During the study time period, patients and/or proxies were provided with information to set up a MyChart account in their printed discharge instructions, referred to as the “after visit summary” (postvisit summary) in Epic. For inpatients, the instructions contained a toll-free number to call for assistance, a weblink with an activation code, and/or a printed parental access form. Other than English, MyChart instructions were also available in French and Spanish for patients and families who indicated these as their preferred language. A MyChart smartphone app has since been made available, and accounts were accessible on the web. Patients with active accounts at the time of admission had access to their MyChart account during admission. For patients without an account at the time of admission, access was not likely to be available during that admission because setup instructions were not provided until the time of discharge.

During the study time frame, for patients 11 years or younger, parents or legal guardians could activate and manage their child’s account using “proxy access.” Proxy access was defined as a person logging into their own MyChart account and then having the privilege to access another person’s MyChart account. Children age <12 could not have their own login credentials for a MyChart account. At age 12, children could activate their own account with full functionality without parental or guardian consent. From ages 12 to 14, proxy access was restricted to immunization records, asynchronous messaging with the child’s outpatient health care team, and management of medical bills. Starting at age 12, full proxy access rights by the parent or legal guardian required formal committee review and must be based on a qualifying condition in the child such as mental incapacitation or intellectual disability that impacted the ability to make medical decisions. In the current study, there were 84 patients age 12 and older who had proxies with full MyChart access. After patients turned 14, proxy access was no longer routinely allowed.

Once a MyChart account was activated, examples of outpatient functionality available to patients included the ability to schedule appointments, view laboratory test results and imaging narrative reports (referred to collectively as “diagnostic test results”), renew prescriptions, access postvisit summaries, view medical documentation, send asynchronous messages to their health care providers, and complete medical history registration forms. Inpatient functionality included viewing diagnostic test results, postvisit summaries, and discharge summaries.

Diagnostic test results could be released into MyChart by two main mechanisms. Authorized health care providers who have ordered these tests could release the results “manually,” at which time the results were immediately available for the patient or proxy to view. If not manually released, the results (normal and abnormal) “autoreleased” according to a specific schedule. Most common laboratory tests autoreleased at 3:00 am on a business day after a full business day delay (eg, a result finalized on Tuesday autoreleased on Thursday assuming no intervening holidays; or a result finalized on Friday autoreleased on Tuesday). Anatomic pathology, imaging narrative reports, genetic tests, and sexually transmitted infection testing autoreleased typically with a 4-business day delay. HIV test results did not release to MyChart to comply with state law on counseling of patients on positive HIV results. Compared with the outpatient setting, the workflow to manually release results was more involved for inpatient encounters, requiring additional steps for the provider. Therefore, the vast majority of inpatient test results were autoreleased.15 

Epic Reporting Workbench (RWB) was used to retrieve the data. RWB was a tool within Epic that can run reports to retrieve specific retrospective data such as diagnostic test orders.15  For tests results, RWB was able to determine if the patient had an active MyChart account and whether the patient and/or proxy viewed test results. RWB does not differentiate who (patient or proxy) accessed a specific test result, discharge summary, or postvisit summary from inpatient encounters, because this specific information is not captured in Epic.

For patients hospitalized at any point during 2018, activation was defined as having an activated portal account (registered by using an activation code) as of January 1, 2020 (allowing for at least a full year from inpatient admission). Activation may have occurred before or during hospitalization or after discharge. Activation rate was defined as the percentage of patients with active accounts at the time of data review. Use was defined as whether the patient and/or proxy viewed any diagnostic test result performed during hospital admission(s) in 2018 as of January 1, 2020. Use rate was defined as the percentage of patients and/or proxies who viewed at least 1 laboratory and/or imaging test result performed during the hospitalization(s) at the time of data review.

The combined data were subcategorized by the patient’s age, sex (male or female), self-identified race, self-identified preferred language, insurance status, previous hospitalization, whether both laboratory tests and imaging studies were performed during hospitalization(s) in 2018, whether there were one or more ICU admission(s) in 2018, and whether outpatient diagnostic tests were performed in 2018. Race was categorized as white or multiracial (included African American, American Indian or Alaska Native, Asian American, Hispanic or Latino, mixed race, Native Hawaiian or Pacific Islander, other, unknown, and declined), language was categorized as English or non-English (included a total of 75 other languages with the 6 most common other than English being Spanish, Arabic, French, Chinese, Swahili, and Vietnamese), and insurance was categorized as commercial payer or public payer or uninsured.

Data were also analyzed by testing category. Laboratory tests were categorized as anatomic pathology (including surgical biopsies and resections), chemistry, genetic, hematology, and microbiology. Imaging tests were categorized as computerized tomography scan, MRI, radiograph and other.

We employed univariate comparisons using Fisher’s exact test for categorical variables. We also performed multivariate logistic regression analysis to determine the association between patient medical and demographic characteristics and end points of patient portal activation and use. Statistical analyses were performed by using SPSS (SPSS Inc, Chicago, IL).

The study population consisted of 5862 unique patients who were hospitalized in 2018 and had either laboratory test(s), imaging test(s), and/or both performed during the hospitalization (for reference, a total of 7442 pediatric patients were hospitalized in 2018, including those without any inpatient diagnostic testing performed during hospitalization). Of the 5862 patients, 4940 (84.2%) self-identified as white, 5608 (95.1%) indicated English as preferred language, and 2799 (47.7%) had public insurance (Medicaid or Medicare) or were uninsured (Table 1).

TABLE 1

Activation and Use of the Patient Portal for the Patient Population that Had Any Inpatient Diagnostic Test(s) Performed

Number of Unique PatientsaActive MyChart AccountaInactive MyChart AccountaActivation Significance PbViewed versus Not Viewed Significance Pc
At Least 1 Result Viewed, %No Results Viewed, %
Overall 5862 20.3 20.6 59.1 N/A N/A 
Female 2786 19.7 20.8 59.5 .54 .30 
Male 3076 20.8 20.5 58.7 .54 .30 
No outpatient studies in 2018 3744 15.8 19.0 65.2 <.0001 <.0001 
Outpatient studies in 2018 2118 28.0 23.7 48.3 <.0001 <.0001 
Only 1 admission in 2018 4329 19.0 21.8 59.2 <.0001 <.0001 
2 or more admissions in 2018 1533 25.9 22.7 51.4 <.0001 <.0001 
Only laboratory or imaging done in 2018 4623 16.1 19.8 64.1 <.0001 <.0001 
Both laboratory and imaging done in 2018 1239 36.9 27.4 35.7 <.0001 <.0001 
Preferred language not English 254 5.9 7.5 86.6 <.0001 <.0001 
Preferred language English 5608 20.9 21.3 57.8 <.0001 <.0001 
Public insurance or uninsured 2799 14.5 14.0 71.5 <.0001 <.0001 
Commercial insurance 3063 25.6 26.7 47.7 <.0001 <.0001 
Self-declared multiraciald 922 27.9 11.0 72.1 <.0001 <.0001 
Self-declared race white 4940 44.1 22.2 55.9 <.0001 <.0001 
0–11 y old at time of testing 4269 36.4 15.5 63.6 <.0001 <.0001 
12–17 y old at time of testing 1593 42.6 22.0 57.4 <.0001 <.0001 
No ICU admission in 2018e 1796 39.4 18.6 60.6 .0004 .0017 
ICU admission(s) in 2018e 4066 44.3 22.2 55.7 .0004 .0017 
Number of Unique PatientsaActive MyChart AccountaInactive MyChart AccountaActivation Significance PbViewed versus Not Viewed Significance Pc
At Least 1 Result Viewed, %No Results Viewed, %
Overall 5862 20.3 20.6 59.1 N/A N/A 
Female 2786 19.7 20.8 59.5 .54 .30 
Male 3076 20.8 20.5 58.7 .54 .30 
No outpatient studies in 2018 3744 15.8 19.0 65.2 <.0001 <.0001 
Outpatient studies in 2018 2118 28.0 23.7 48.3 <.0001 <.0001 
Only 1 admission in 2018 4329 19.0 21.8 59.2 <.0001 <.0001 
2 or more admissions in 2018 1533 25.9 22.7 51.4 <.0001 <.0001 
Only laboratory or imaging done in 2018 4623 16.1 19.8 64.1 <.0001 <.0001 
Both laboratory and imaging done in 2018 1239 36.9 27.4 35.7 <.0001 <.0001 
Preferred language not English 254 5.9 7.5 86.6 <.0001 <.0001 
Preferred language English 5608 20.9 21.3 57.8 <.0001 <.0001 
Public insurance or uninsured 2799 14.5 14.0 71.5 <.0001 <.0001 
Commercial insurance 3063 25.6 26.7 47.7 <.0001 <.0001 
Self-declared multiraciald 922 27.9 11.0 72.1 <.0001 <.0001 
Self-declared race white 4940 44.1 22.2 55.9 <.0001 <.0001 
0–11 y old at time of testing 4269 36.4 15.5 63.6 <.0001 <.0001 
12–17 y old at time of testing 1593 42.6 22.0 57.4 <.0001 <.0001 
No ICU admission in 2018e 1796 39.4 18.6 60.6 .0004 .0017 
ICU admission(s) in 2018e 4066 44.3 22.2 55.7 .0004 .0017 

N/A, not applicable.

a

For each row of data, the number of unique patients is the denominator for percentage calculations in that row. The category of patients with active MyChart accounts is subdivided into those who had viewed at least 1 inpatient diagnostic test result in the patient portal and those who had not viewed any inpatient test result in the portal.

b

Fisher’s exact test for number of patients with activated MyChart accounts compared with number of patients who had not activated MyChart accounts.

c

Fisher’s exact test for number of patients who had viewed at least 1 inpatient diagnostic test result compared with number of patients who had not viewed any inpatient test result.

d

Multiracial is composed of Hispanic (n = 252, activation rate 27.6%, view rate 12.5%), African American (n = 353, activation rate 18.5%, view rate 6.8%), Asian American (n = 175, activation rate 51.4%, view rate 22.3%), and other (n = 142, activation rate 36.1%, view rate 17.5%).

e

ICU included neonatal and PICUs.

Overall, 40.9% of patients had an active MyChart account as of January 1, 2020 (Table 1). Of these, 14.0% had an activated MyChart account before their initial (or only) admission in 2018; an additional 7.5% activated during their initial (or only) admission in 2018 or within 5 days of discharge. Factors associated with higher MyChart activation rates included outpatient studies performed in 2018, multiple hospital admissions in 2018, one or more ICU admissions (neonatal and/or pediatric) in 2018, performance of both laboratory testing and imaging during hospitalization(s) in 2018, English as preferred language, commercial insurance, self-declared race as white, and age 12 to 17 years (all P < .001; Table 1, Fig 1A). On multiple logistic regression analysis, outpatient studies, performance of both inpatient laboratory and imaging studies, English as preferred language, commercial insurance, self-declared race as white, age of 12 to 17 years, and ICU admission were significantly associated with increased odds of MyChart account activation (adjusted odds ratios presented in Table 2).

FIGURE 1

MyChart activation (A) and use rates (B) by percentage of patients by subcategories. Analysis restricted to population of patients who had 1 or more diagnostic tests (laboratory and/or imaging) performed during hospitalization in 2018. Use was assessed by rates of viewing results for at least 1 inpatient diagnostic test ordered during hospitalization.

FIGURE 1

MyChart activation (A) and use rates (B) by percentage of patients by subcategories. Analysis restricted to population of patients who had 1 or more diagnostic tests (laboratory and/or imaging) performed during hospitalization in 2018. Use was assessed by rates of viewing results for at least 1 inpatient diagnostic test ordered during hospitalization.

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TABLE 2

Factors Affecting the Odds of MyChart Activation and Use (Viewing of Inpatient Diagnostic Test Results) in Pediatric Inpatients

VariableActivationUse
Adjusted OR (95% CI)aPaAdjusted OR (95% CI)aPa
Female sex 1.00 (0.98–1.03) .87 1.00 (0.98–1.02) .87 
Outpatient studies in 2018 1.16 (1.13–1.19) <.001 1.11 (1.09–1.14) <.001 
Multiple admissions in 2018 1.01 (0.98–1.04) .59 1.06 (1.04–1.09) <.001 
Both laboratories and imaging performed in 2018 1.37 (1.33–1.42) <.001 1.23 (1.19–1.23) <.001 
Preferred language English 1.14 (1.07–1.21) <.001 1.06 (1.01–1.12) .027 
Commercial insurance 1.21 (1.18–1.24) <.001 1.08 (1.06–1.10) <.001 
Self-declared race white 1.11 (1.07–1.15) <.001 1.05 (1.05–1.12) <.001 
0–11 y oldb 0.90 (0.88–0.93) <.001 0.91 (0.89–0.93) <.001 
No ICU admission in 2018c 0.92 (0.90–0.95) <.001 0.95 (0.92–0.97) <.001 
VariableActivationUse
Adjusted OR (95% CI)aPaAdjusted OR (95% CI)aPa
Female sex 1.00 (0.98–1.03) .87 1.00 (0.98–1.02) .87 
Outpatient studies in 2018 1.16 (1.13–1.19) <.001 1.11 (1.09–1.14) <.001 
Multiple admissions in 2018 1.01 (0.98–1.04) .59 1.06 (1.04–1.09) <.001 
Both laboratories and imaging performed in 2018 1.37 (1.33–1.42) <.001 1.23 (1.19–1.23) <.001 
Preferred language English 1.14 (1.07–1.21) <.001 1.06 (1.01–1.12) .027 
Commercial insurance 1.21 (1.18–1.24) <.001 1.08 (1.06–1.10) <.001 
Self-declared race white 1.11 (1.07–1.15) <.001 1.05 (1.05–1.12) <.001 
0–11 y oldb 0.90 (0.88–0.93) <.001 0.91 (0.89–0.93) <.001 
No ICU admission in 2018c 0.92 (0.90–0.95) <.001 0.95 (0.92–0.97) <.001 

CI, confidence interval; OR, odds ratio.

a

OR >1.0 indicates increased odds of MyChart account activation. Analysis uses multivariate logistic regression analysis.

b

Relative to 12 to 17 y old, where patient has ability to activate own account.

c

ICU included neonatal and PICUs.

In total, 170 685 inpatient diagnostic tests (laboratory and imaging combined) were performed, and 20.3% of patients and/or proxies viewed at least one inpatient diagnostic test result as of January 1, 2020. Factors associated with higher use rates were the same as for overall MyChart activation rates (Table 1, Fig 1B). It is notable that for some of the factors associated with low use rates, lack of having an active MyChart account alone accounts for differences in use rates (Table 1). On multiple logistic regression analysis, factors associated with increased odds of viewing an inpatient diagnostic test result and MyChart account activation were the same with the exception of multiple admissions, which significantly increased odds of viewing an inpatient diagnostic test result but not for MyChart account activation (adjusted odds ratios presented in Table 2).

Overall, the percentage of inpatient diagnostic tests (n = 170 685) viewed were highest for MRI narrative reports (27.8%) and genetic tests (19.1%) and lowest for chemistry tests (7.3%) (Fig 2). For inpatient laboratory tests, the more specialized genetic and anatomic pathology testing were viewed at significantly higher rates compared with the higher volume chemistry, hematology, and microbiology tests (P < .001 for each comparison; Fig 2A). For inpatient imaging, MRI narrative report use rate was significantly higher than the aggregate of other imaging tests (P < .001; Fig 2B).

FIGURE 2

Percent of all inpatient laboratory results (A) and imaging results (B) viewed in the patient portal, subdivided by category of diagnostic testing. Analysis restricted to population of patients who had 1 or more diagnostic tests (laboratory and/or imaging) performed during hospitalization in 2018. CT, computed tomography.

FIGURE 2

Percent of all inpatient laboratory results (A) and imaging results (B) viewed in the patient portal, subdivided by category of diagnostic testing. Analysis restricted to population of patients who had 1 or more diagnostic tests (laboratory and/or imaging) performed during hospitalization in 2018. CT, computed tomography.

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In our study, we found that portal activation and use was lowest for patients whose preferred language was not English, self-identified as multiracial, and were publicly insured or uninsured. Increased portal activation and use was associated with multiple hospital admissions, ICU admission(s), previous outpatient testing, older age, and having both laboratory and imaging tests performed during hospitalization(s) in the study year. Overall, the percentage of patients with active accounts was 40.9%, and use rates were even lower.

Compared with reports that described targeted intervention to enhance patient portal use, our rates of activation and use were low.2,7,8,10  Kelly et al8  reported 90% of parents of hospitalized children logged into their patient portal. In their study, hospital issued tablets and Internet access were provided at admission with explanation of usage by the bedside nurse.8  Burke et al2  reported a 93% activation rate for patients undergoing congenital heart surgery. During hospitalization, patients and/or families were given login information and taught how to login by a nurse practitioner.2  In another study of hospitalized children, 80% of families used the patient portal.10  Families were provided a computer tablet, brief orientation to the portal, and contact information for one-on-one support during admission.10  In contrast, in a study in which researchers used similar recruitment strategies as our institution in an outpatient setting, only 27.9% of families of children opened an account, and of those, less than half used the portal within 3 months of registration.4 

Similar to our study, several studies have revealed that portal activation and use are lowest in underrepresented minorities and those with public insurance.4,1517  The largest disparity in our study was seen for patients whose preferred language was not English, with rates of portal activation and use >3 times lower than those for patients with English as a preferred language. This may relate to availability of MyChart instructions only in English, French, and Spanish. Arabic, Chinese, Swahili, and Vietnamese were the most common non-English languages encountered in our pediatric population that did not have printed patient instructions in the preferred language. In addition, portal interfaces are not available in multiple languages, including the MyChart interface, which is only available in English. Higher rates of account activation and use rates were seen in patients with multiple admissions, both laboratory and imaging tests performed during hospitalization, and diagnostic tests performed in the outpatient setting. This is consistent with other studies in which researchers report higher rates of portal uptake in patients with more outpatient clinic visits and health care issues.4,5,18 

By category, genetic testing was viewed at the highest rates, despite many genetic test results having a long turnaround time before results are available. For imaging, MRI narrative reports were viewed most often compared with all other imaging categories combined. The format in which laboratory test results are viewable may be a limiting factor. MyChart presents every unique laboratory order (including panels such as the 8-test basic metabolic panel) as a discrete entry.15  For inpatients with many laboratory and/or imaging test results, viewing can thus become time-consuming for patients and/or proxies. This may influence viewers to focus on a manageable subset of specific diagnostic tests perceived of as greatest interest, such as MRI, genetic tests, and surgical biopsy results, as seen in our patients. Health care literacy of the patient and family may also be an important factor, as shown in other studies.3,19 

For ongoing use after discharge, patients and/or proxies must have access to telecommunication technologies including affordable, high-speed Internet. Multiple studies have revealed that portal use is lower in those without access to broadband Internet.20,21  In our state, almost 96% of the population has access to a broadband connection.22  Although access is relatively broad across the state, Internet speed and affordability are overall poor. Our state has the second slowest average download speed nationwide, and only 18.5% of our population has access to low-priced Internet plans (costing $60 or less per month) compared with 51.5% nationally.14  We were unable to determine rates of individual telecommunications access, but this is an important factor that requires additional study.

The patient portal must be functional for patients and/or proxies during the hospitalization. In the studies previously discussed, all used portals were designed to be used in real time and included various features such as daily agenda, photographs of the health care team, test results, and patient photographs.2,8,10  Our patients frequently wait a full business day for test results because of institutional rules regarding timing of test result release to the patient’s account, limiting the utility of the result for the patient. In a study by Kelly et al8  using MyChart Bedside, a tablet-based app that allows patients to be actively engaged in their care during the hospitalization, test results were released approximately every 90 minutes during daytime hours, yet many parents requested results to be updated more quickly. MyChart Bedside was not available at our institution and may not be an available feature within an institution’s EHR license without additional expense. Researchers have shown that secure messaging of the health care team is one of the most frequently used and liked functions by parents; this is a portal feature heavily used in our hospital outpatient network but was not an available inpatient feature.6,8,9 

In the United States, a federal mandate known as the Cures Act will, among its provisions, mandate that health systems release all diagnostic test results and notes to patients as soon as they are available.23  There are limited exceptions, such a psychotherapy notes or individual cases, in which release of diagnostic test results may result in harm to the patient. This Act was set to take effect November 2, 2020, but has been delayed. The data in the current study indicate that there is room for improvement in engaging patients across different ages and demographics in use of patient portals.

Our study is limited by the fact it was performed at a single institution that serves a predominately white rural and suburban population and may not be applicable to urban institutions with a more diverse patient population. In addition, we were unable to distinguish patient from proxy usage.

In hospitalized children, the lowest rates of portal activation and use were seen in patients whose preferred language was not English, were multiracial, and were publicly insured or uninsured. Repeated health care use was associated with higher portal activation and use. Additional research should focus on strategies to eliminate disparities.

Ms Greene performed data analysis and drafted the initial manuscript; Dr Krasowski conceptualized and designed the study, performed data analysis, assisted with drafting the initial manuscript, created the figures and tables, and reviewed and revised the manuscript; Dr Wood conceptualized and designed the study and drafted the initial manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Wood has a financial relationship with McGraw Hill Professionals. She receives royalties for a pediatric board review textbook she coedited. The work presented was not influenced by that relationship. Drs Krasowski and Ms Greene have indicated they have no financial relationships relevant to this article to disclose.