Background: Digital determinants of health (DDoH), including access to technological tools, digital health literacy, and internet access, function independently as barriers to health. Assessment for DDoH is not routine within most healthcare systems, although addressing DDoH could help mitigate differential health outcomes and the digital divide.
Objective: To assess the role of individual-level factors of DDoH on patient enrollment in and use of the patient portal.
Methods: A multi-modal, cross-sectional survey was developed and deployed to 11,424 individuals based on preferred mode and language documented within the Electronic Medical Record. Based on the Technology Acceptance Model, enrollment in the patient portal and intent to use the patient portal were the outcomes of interest. Perceived usefulness and ease of use were assessed to determine construct validity, and exploratory investigations included individual-level DDoH, including internet and device access, availability of technological support, medical complexity and symptom burden, individual relationship with the healthcare system, and digital health literacy. Counts (n) and proportions (%) were used to describe response categories and unadjusted and adjusted odds ratios are reported.
Results: This study included 1,850 respondents (11,424 invited; 16.2% response rate) who were majority female (58.3%), White (77.2%), and an average age of 63 years. In validation of the Technology Acceptance Model, measures of perceived ease of use (i.e., using the patient portal will require a lot of mental effort, patient portal will be very easy to use) and perceived usefulness (i.e., usefulness of the patient portal to send and receive messages with providers, schedule appointments, refill medications) were positively associated with both enrollment in and intent to use the patient portal. Within adjusted models, perceived ease of use and perceived usefulness constructs in addition to constructs of digital health literacy, knowing what health resources are available on the internet (aOR=3.5, 95% CI 1.8-6.6), portal ease of use (aOR=2.8, 95% CI 1.6, 5.0), and portal usefulness (aOR=2.4, 95% CI 1.4, 4.2) were significantly associated with patient portal enrollment. Other factors associated with patient portal enrollment and intent to use included being comfortable reading and speaking English, reported use of the internet to surf the web or to send / receive emails, home internet access, and access to technology devices (computer, tablet, smartphone, etc.).
Conclusions: Assessing for and addressing individual-level DDoH, including digital health literacy, access to digital tools and technologies, and support of the relational aspects between patients, social support systems, and healthcare providers could help mitigate and reduce disparities in health. By focusing efforts to assess for and address individual-level DDoH, we have an opportunity to improve digitally driven healthcare delivery outcomes like access and experience, and structural outcomes like bias built within algorithms created with incomplete representation across communities.