Running head: REASONS FOR NOT USING THE PATIENT PORTAL

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Patient portal engagement at a pediatric office:
Reasons why individuals are not using the portal.

Sherry DelGrosso, MSN, RN, LNC
Edinboro and Clarion Universities of Pennsylvania Consortium

A DNP research project submitted to Clarion and Edinboro Universities in partial fulfillment of
the requirements for the Doctor of Nursing Practice Degree
May 2019

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Acknowledgments

The scholarly information presented in this DNP project is the result of meaningful
collaboration and partnership between people for whom I am eternally grateful. In addition to
their passion, time, and expertise, their leadership, mentorship, and guidance afforded me
significant growth, both personally and professionally. I want to acknowledge the following for
their tremendous contributions to my academic journey with the Edinboro and Clarion
Universities consortium. My advisor, Dr. Colleen Bessetti-Barrett, committee chair, Dr. Meg
Larson, and committee members, Dr. Jill Rodgers, Dr. Monty McAdoo, community expert, Dr.
Harry Greenspun, and the Edinboro IRB committee, you are my academic village of support. I
appreciate each of you and your distinctive role in my terminal degree. To Patti Shontz,
Stephanie Zilhaver, Jessica Albert, and all of the support staff at both universities, it is your hard
work and contributions to the daily operations of the program, which allows students to
seamlessly progress throughout the program. To my DNP cohort/colleagues, your responses to
weekly assignments and discussions brought breadth and depth to my nursing career. Your
support, laughter, emails, calls, texts, and genuine friendships will remain for years to come. To
the members of our unofficial group, “the DNP’sters” – you hold a special place in my heart.
This study was made possible because of the collaboration of Dr. Rakesh Chopra, his
fantastic staff, and the study participants. I am honored and humbled to have worked with all of
you. To my colleague and dear friend, Dr. Alyssa Todaro-Brooks, I appreciate our friendship and
the time and expertise that you and Shravya Raju provided with the statistical analyses of this
project. To Shelley Rapp-Link and all of my friends, thank you for your support and
encouragement. You are amazing, and life is beautiful because of all of you.
To my former patients, families, students, colleagues, and acquaintances, you have
contributed to my growth as a nurse over the last twenty-seven years.
To my siblings and family, especially my mother, Diane, your love, support, and prayers
continue to give me strength in all that I do. To my dad, Kelly, as you watch over me from
Heaven, I feel your presence every day. Mom and dad, I love you both so much and know that
my determination, compassion, and desire to make a difference come from you. Thank you.
To my husband, Michael, I truly appreciate your support and encouragement during this
journey, as you know how much I enjoy academia and life-long learning. I love you. To my
beautiful daughter, Sofia, thank you for being my study partner, biggest cheerleader, and the
reason that I find strength every day to do all that I do. You are my shining star, and I am so
proud of you. When I was tired or struggled to manage a variety of challenges, it was you, baby
girl, who kept me going. You are my compass for much of what I do. I am in awe of your
strength, determination, passion for the arts, and your commitment to the piano and Tae Kwon
Do. I love you with all of my heart and soul and look forward to your very bright future. I am
honored to be your mother.
To God and the daily Blessings, I humbly utilize my gifts and talents to enthusiastically
make a difference in the lives of those around me. It is through faith, love, community, prayer,
and all those in my life that I enter the next phase in my life.

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Dedication
This study is dedicated to all those who have positively influenced my life, especially my
dear friend, Polly Decker-Barbosa. Although you were only on this earth for 53 years, you loved
and lived every day to the fullest. Thank you for your strong faith, unconditional love, sincere
friendship, and generous heart. I know that you are in Heaven watching over me. I feel your
warmth, presence, and protection every day. Thank you, Polly. I love and miss you dearly.

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TABLE OF CONTENTS
TITLE PAGE……………………………………………………………………………………………………..1
ACKNOWLEDGEMENTS…………………………………………………………………………………...2
DEDICATION……………………………………………………………………………………………………3
TABLE OF CONTENTS………………………………………………………………………………………4
ABSTRACT……………………………………………………………………………………………………….5
CHAPTER I: THE PROBLEM…………………………………………………………………………6-13
Context of the Problem…………………………………………………………………………….6-9
Statement of the Problem……………………………………………………………………………9
Theoretical Framework………………………………………………………………………………9
Significance of the Problem……………………………………………………………………9-10
Need for the Study.………………………………………………………………………………10-11
Research Questions…………………………………………………………………………………..11
Hypotheses.……………………………………………………………………………………………...11
Definition of Terms……………………………………………………………………………...11-12
Assumptions and Limitations of the Study…………………………………………….12-13
Summary………………………………………………………………………………………………….13
CHAPTER II: REVIEW OF THE LITERATURE………………………………………………14-18
Information Literacy……………………………………………………………………………14-16
Theoretical Framework……………………………………………………………………….16-18
Review of Common Themes……………………………………………………………………...18
CHAPTER III: METHODOLOGY…………………………………………………………………..19-27
Research Design……………………………………………………………………………………….19
Setting/Sample……………………………………………………………………………………20-21
Recruitment Process……………………………………………………………………………21-23
Instrumentation and Data Collection Methodology……………………………….23-24
Survey Development…………………………………………………………………………...25-27
Ethical Considerations……………………………………………………………………………...27
CHAPTER IV: RESULTS……………………………………………………………………………..28-39
Sample Selection Process and Sample Size Calculation………………………….28-29
Survey Responses and Tables………………………………………………………………29-37
Discussion…………………………………………………………………………………………..37-38
CHAPTER V: SUMMARY, CONCLUSION, AND RECOMMENDATIONS……………39-42
Summary…………………………………………………………………………………………………39
Limitations of the Study………………………………………………………………………39-40
Conclusion……………………………………………………………………………………………….40
Recommendations/Future Research……………………………………………………40-42
REFERENCES……………………………………………………………………………………………43-45
APPENDICES…………………………………………………………………………………………….46-52

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Abstract

This descriptive study explores the reasons individuals bringing their child(ren) to the pediatric
office are not using the patient portal. There was negligible use of the patient portal as shown by
a retrospective review of data usage reports via the eClinicalWorks software. Additionally, staff
reported that they still answered many calls for information (immunization records, lab results,
medication refills, appointment scheduling, and care-related questions), all of which were easily
obtained through the portal. The objective of this study is to determine the reasons why
individuals bringing the child(ren) to a rural pediatric practice in Central Pennsylvania are not
using the patient portal. The scope of the survey is broad, as overall knowledge of the patient
portal and its capabilities is assumed to be low based on current usage data. A convenience
sample of individuals was pursued. The survey questions focused on the potential contributing
factors to the individual’s lack of portal usage. Demographic data were obtained as part of the
survey to identify the characteristics of the participants. The results revealed that the lack of
patient portal usage/engagement would be responsive to change with some practice planning and
education.

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Chapter 1

Introduction
Portal is a term, commonly synonymous with a gateway for a World Wide Web. It is the
initial site for individuals to connect to the Web or to visit as an anchor site (TechTarget, (n.d.).
There are various types of portals, including general and niche portals. Patient portals are an
example of a niche portal.
Patient portals not only provide access to parts of the individual’s health records, but also
offer services such as customized educational materials, messaging, prescription requests,
and appointment scheduling. U.S. healthcare organizations are using patient portals more
and more as a way to provide patients with partial access to their health records while
complying with the “meaningful use” of the Health Information Technology policy
released by the Federal Government (Nambisan, 2017).
Direct access allows individuals to be proactive in their healthcare, while the centralized
records system facilitates operational efficiencies within the provider’s office (Ahlers-Schmidt &
Nguyen, 2013). This is noteworthy as “Pediatricians in the United States are caring for children
with mounting rates of chronic disease and complex medical needs” (Ray, Bogen, Mehrata &
Miller, 2015, p. 622). To assist with managing the growing number of patients, many
pediatricians are increasingly using patient portals within their practice. However, studies
examining the adoption rates of patient portals have reported limited adoption and use by
individuals, especially among the medically underserved population (Nambisan, 2017).
The objective of this study is to generate findings to determine the reasons why
individuals are not using the patient portal at a pediatric office in rural, central Pennsylvania.

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Background of the Problem
With the continued focus on personal health records, patient portals, portal engagement
(usage), patient-centered care, and the management of one’s health, features of the patient portal
are rather compelling. Various studies have reported patient portal benefits such as improved
communication between the provider and patient, greater responsibility for one's wellness and
disease management, convenience with use (i.e., the portal can be accessed and used 24/7 ), and
decreased call volumes and wait times with the provider and patient. Combine these aspects with
the fact that approximately 68% of adults in the United States have a smartphone and 45% of
adults have a tablet (Yen, Walker, Smith, Zhou, Menser, McAlearney, 2017), non-usage remains
a challenge.
According to Showell (2017), barriers can interfere with various aspects of portal
adoption by individuals, including the choice to start using the portal; continued use of the portal;
and the various barriers encountered at different phases of portal adoption. A solid understanding
of the barriers is vital to understand why individuals are not using the patient portal within a
healthcare setting.
The patient portal can be an effective means to facilitate self-management for individuals
and the health of their child(ren). However, not all individuals are utilizing this electronic
resource (Powell & Myers, 2018). Perceived barriers commonly cited by individuals for not
using the patient portal begin with difficulty accessing the patient portal. This may be due to
password, computer, or server problems. Some individuals forget the password; have too many
passwords to remember; encounter problems with the screen freezing, or the inability to access
the portal the first time they try to sign-in. The combination of frustration with the portal and
busy schedules may contribute to individuals not coming back to the patient portal to try again

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(Powell & Myers, 2018). Others report that the portal features are not beneficial; they did not
know that the portal features existed, or did not have access to disease-specific information to
better understand their child(ren)'s health issues. Some users prefer to interact with the staff
member or the provider versus a portal; others favor talking on the phone; and even some wish to
ask providers a question in person (Powell & Myers, 2018).
Population demographics may significantly influence patient portal adoption as disclosed
in an article from the Journal of the American Board of Family Medicine.
The researchers found that patients who were male, non-white, Hispanic, Spanishspeaking, and lower-income were less likely to adopt patient portals than their female,
white, and higher-income cohorts. Uninsured patients or those insured through Medicare
or Medicaid were also less likely to adopt patient portals than patients with private
insurance (Heath, 2016, para. 3).
Provider-specific barriers to portal promotion within the organization include obstacles
such as staff not having time to assist individuals with sign-in procedures or teaching the various
aspects of the portal to encourage future use; reimbursement concerns, including integrating the
portal into the payment structure; and, administrative difficulties (Powell & Myers, 2018). At the
center of this study is the effort to understand the reasons why portal usage remains negligible at
the pediatric practice in rural, central Pennsylvania.
The theoretical model serving as the foundation for this study is The Technology
Acceptance Model (TAM). Application of the model is most significant with its relevance in
forecasting and describing the end users’ reactions to health information technology such as the
patient portal (Holden & Karsh, 2010).

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Variables of the Technology Acceptance Model (TAM) support the scope of this study as
it addresses health information technology broad themes such as behavior, usage, intention,
attitude, perceived ease of use (PEOU), perceived usefulness (PU), perceived behavior control
(PBC), and behavioral benefits (including normative and control beliefs) with information
technology (Holden & Karsh, 2010).
The creators of the model maintain that to increase usage, providers must know what the
individuals’ intentions are to use the technology. TAM has been applied to survey development
questions with the goals of not only identifying the end users future intentions to use the
technology but to give the organization information to direct factors to promote acceptance and
use of the technology.

The Statement of the Problem
Pediatric medicine is projected to benefit from the use of telehealth technology (e.g.,
portals) by improving patient access to care in medically underserved rural areas. This
technology also extends the reach of pediatric subspecialists at academic and tertiary medical
centers to patients and colleagues in more distant community hospitals and clinics (Utidjian &
Abramson, 2016). The objective of this study is to identify the reasons why individuals are not
using the patient portal at a pediatric office in rural, central Pennsylvania.

Significance of the Problem
Patient portals provide access to medical information and allow individuals enhanced
communication with their providers while promoting self-management practices. As several
studies have established the benefits of the patient portal within the adult population, less is

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known about whether parents/legal guardians perceive electronic tools as helpful in managing
their child(ren)'s health care (Britto, Hesse, Kamdar, & Munafo, 2013).
Based on the results of a national survey in conjunction with the C.S. Mott Children’s
Hospital National Poll on Children’s Health (NPCH), pediatric providers may find that roughly
half of their parents have positive perceptions about utilizing patient portals while the other half
of parents may choose not to engage in portals (Clark, Costello, Gebremariam, & Dombkowski,
2015). Even when providers make considerable attempts to promote portal use among parents
and offer technical support, it is likely that they will need to continue to offer support to foster
portal engagement (Clark, Costello, Gebremariam, & Dombkowski, 2015). Further highlighting
the challenge of individuals adopting patient portals into their daily lives is the 2017 Government
Accountability Office (GAO) report underlining ninety-percent of providers offer patient portal
access, with less than one-third integrating the tool and even less reporting regular use (Heath,
2018, para. 4).
For this reason alone, it is imperative for pediatricians to identify the barriers that keep
individuals within their practice from using the portal.

Need for the Study

Patient portals grant individuals access to personal medical data, while presenting
opportunities to improve knowledge, competence, productivity, and engagement in health care
(Ancker, Snezana, Osorio, Cole, Silver, Kaushal, 2015).
Developments with the Health Information Technology for Economic and Clinical Health
Act (HITECH) are aimed at facilitating improvement in the delivery of health care by
incentivizing the implementation of electronic health records (EHR). “In stage 1, health care

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professionals must demonstrate meaningful use by providing patients with timely online access
to their health information” (Lanzo, Taeger, Huston-Paterson, Tomaszewski, Trent, 2016, p.
S18).
Once promised to revolutionize health care, patient portals have yet to reach their
potential of improving communication and partnership between patients and clinicians. This
study aims to identify the factors affecting the low patient portal engagement within a pediatric
practice in rural, central Pennsylvania.

Research Question
The research question guiding this study: What are the reasons why individuals are not
using the patient portal at a pediatric office in rural, central Pennsylvania?

Hypotheses

The research (directional) hypothesis for this study:


Null hypothesis (Ho): Individual lack of awareness about the patient portal is not a
primary factor for low patient portal usage



Alternative hypothesis (HA): Individual lack of awareness about the existence of the
patient portal is the primary factor for low patient portal usage.

Definition of Terms
The word engagement “describes everything from patient portals to social media
strategies, from tracking vitals with wearables to patients actively participating in their health
and wellness" (Noteboon, 2015, para. 3). Patient engagement combines the patient's knowledge,
skills, ability, and willingness to manage one’s health (Noteboon, 2015).

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“A patient portal is a secure online website that gives patients convenient, 24-hour
access to personal health information from anywhere with an Internet connection. Using a secure
username and password, patients can view health information” (HealthIT.gov, (n.d.), para. 1).
Some patient portals also allow the user to securely message the provider; request prescription
refills; schedule non-urgent appointments; update contact information; make payments;
download and complete forms; and view educational materials (HealthIT.gov,(n.d.), para. 2).

The individual (participant) in this study is identified as the person bringing the
child(ren) to the appointment the day the survey is completed. This may include, but may not be
limited to the following titles: parents, grandparents, legal guardians, aunts, uncles, friends,
sibling over 18 years of age, or other.

The pediatric patient is the patient (birth to 18 years of age) under the care and medical
supervision at the pediatric practice and the child(ren) visiting the office the day the survey is
completed.

Assumptions of this study include:


Pediatricians, physician assistants, nurses, medical assistants, and other staff members
will positively promote the participation in the study



Individuals bringing the children to the office will want to participate in the survey to
identify the reasons why they are not using the patient portal



The survey results will provide a foundation for practice changes and educational
interventions with the aim of increasing patient portal usage

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Limitations of this study include:


It is a single-site study



Individuals completing the survey may not be representative of the population and end
users of the portal



Sample size may not readily generalize to broader pediatric populations



The timeframe to collect survey data may not be sufficient and may not account for
seasonal differences in the number of visits to the practice (e.g., summer versus fall
volumes)



The use of only paper-based surveys may have impacted the sample size as a more
significant number of participants may have been achieved through the use of an
electronic survey posted on the pediatric practice website



Some participants selected more than one answer when they should have only chosen one
answer per question

Summary of the Problem
The patient portal use within the pediatric practice is negligible despite its existence since
2014. Individuals still routinely call the office to request immunization records, lab results,
medication refills, schedule appointments, and ask care-related questions. All of these concerns
can be addressed via the patient portal. The objective is to generate findings to determine the
reasons why individuals are not using the patient portal at a pediatric practice in rural, central
Pennsylvania.

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Chapter 2
In the review of the literature, the following areas of research were addressed: portals,
patient portals, the benefits of patient portals, and why individuals do not use portals (potential
barriers), all of which will serve as the foundation for this study.
Web portal. A web portal is a term, generally synonymous with a gateway, for a World
Wide Web and is the initial site for individuals to connect to the Web or to visit as an anchor site.
There are general and niche (specialized) portals (TechTarget, (n.d.), para. 1). Patient portals are
an example of a niche portal.
Patient portal. The patient portal not only provides access to parts of the individual's
health records, but also offer services such as customized educational materials, messaging,
prescription requests, and appointment scheduling (Nambisan, 2017). Healthcare organizations
in the United States are increasingly using patient portals as a means to provide patients with
partial access to their health records and thereby comply with the “meaningful use” of Health
Information Technology policy issued by the U.S. Federal Government. For these reasons alone,
the use of patient portals continues to expand, and sustained momentum is crucial.
Patient portal perceived benefits. The patient portal may influence care delivery for
individuals and ease access to services, which may have a positive impact on satisfaction as well
as the way the individual seeks care for their child(ren).
Patient portals allow individuals access to personal account information and health
records in an asynchronous (self-service) matter providing direct access to patient registration,
scheduling, past medical and surgical history, medications, immunizations, laboratory and
radiology reports, health and wellness education, messages to and from the practice, as well as
appointment reminders (Ahlers-Schmidt & Nguyen, 2013).

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In addition to the perceived benefits by patients, providers also share positive attributes of
the patient portals: reports of uncomplicated integration of the portals into the daily workflow
and processes; more effective and efficient communication with the patients via the messaging
center of the portal; decreased reliance on and loss of paper forms; increased access to patient
information during operating and non-operating hours; and more in-depth discussions and
appointments as a result of the patient reviewing test results and other data prior to meeting with
the provider (Powell & Myers, 2018).
Patient portal perceived barriers. Twiddy (2015) identifies various barriers to remove
if a practice wants to enhance portal use: the providers’ self-limiting perceptions and barriers to
their own portal use and practices; concerns with practice economics and portal use (i.e., lack of
reimbursement for communication time via the portal); staff barriers and biases to portal use;
patient resistance to portals; technological limitations; and security and privacy concerns with
technology.
Each potential barrier is explored in detail, beginning with the physicians themselves.
Although studies have revealed that portals can enhance and simplify interactions and treatments
with patients, some physicians are not easily persuaded of the portal’s value or have questions
and apprehensions about the technology itself. Some physicians are concerned about the volume
of emails, and the time it will take to answer with portal messaging (Twiddy, 2015).
A second potential barrier for the providers focus on the economics of patient portals.
“Other than receiving meaningful use incentive payments and avoiding penalties, providers do
not receive direct reimbursement for their time for using the portal” (Twiddy, 2015, p. 28). Some
providers worry that answering secure messages may result in decreased revenue because of the

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operational efficiencies achieved through the portal instead of meeting appointment capacity
(Twiddy, 2015).
As addressed by providers, integrating a portal can be somewhat disruptive to the practice
and requires staff to manage increased quantities of online messages; changes in their daily
practices, the office systems, and various processes (Twiddy, 2015).
Another consideration with patient portals is “the researcher and the pediatric practice
need to take into account sociodemographic data, clinical information, attitudes toward
telemedicine (and patient portals), perceived advantages of the patient portal, fears, and
willingness to use the patient portal” (Russo, Campagna, Ferretti, Agricola, Pandolfi, Carloni, . .
. Tozzi, 2017, p. 17).

Theoretical framework
Serving as a framework for this study is The Technology Acceptance Model (TAM),
which addresses the explanation of end users’ reaction of health information technology such as
patient portals (Holden & Karsh, 2010). This model has applicability for the pediatric practice
staff in this study and the individuals (end users) of the portal who have the authority to manage
the child(ren)’s health care.
Variables of the Technology Acceptance Model (TAM) support the scope of this study as
the model addresses critical factors related to health technology (patient portals): behavior, use,
behavioral intention, attitude, perceived ease of use (PEOU), perceived usefulness (PU),
perceived behavior control (PBC), and behavioral benefits (including normative beliefs, control
beliefs) with information technology. The following are TAM-specific definitions to ground the
reader with the terminology presented with the model (Holden & Karsh, 2010):

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

Behavior: the action (specific or general) of interest



Use (USE): specific behavior performed by individuals concerning information technology
(e.g., patient portals)



Behavioral intention (BI): an individual’s motivation or willingness to engage in the target
behavior (e.g., use the patient portal)



Attitude (ATT): an individual’s evaluation of the target behavior (e.g., good/bad,
harmful/beneficial, pleasant/unpleasant)



Perceived ease of use (PEOU): an individual’s perception that using an IT system (i.e.,
patient portal) will be free of effort or require minimal effort



Perceived usefulness (PU): an individual’s perception that using an information technology
system (e.g., patient portal) will enrich job performance



Image (output quality): real or perceived attributes of information technology (e.g., patient
portal) that influence its perceived worth



Perceived behavior control (PBC): an individual’s perception of how easy or difficult it is to
perform the target behavior (self-efficacy that can be experienced with the use of the patient
portal), the circumstances that inhibit or facilitate the use of the portal (facilitating
conditions), or the amount of influence one has over performing the behavior (controllability)



Behavioral beliefs (normative and control beliefs): an individual’s perceptions about positive
and negative outcomes of using the portal, specific groups or people who encourage or
discourage portal use, and specific components that make the portal engagement simple
The Technology Acceptance Model (TAM) is the "gold standard" (Holden & Karsh,

2010, p. 159) when considering acceptance and reactions to information technology in a variety
of industries, and is gaining widespread acceptance in healthcare.

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The following databases were used in the inquiry for the research question development:
Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Medline, and
general searches via the Penn State University, Clarion University, and Edinboro University
libraries (General and Advanced Search Categories), Google, Google Scholar, and Google
Images. Keywords in the search included: patient portal, telehealth, telemedicine, pediatrics,
parents, perceptions, and education with Boolean phrases (and, or) and MeSH terms (patient
portals, pediatrics, barriers, engagement, and meaningful use). Domestic and international
studies and sources published in the English language from the past nine years (2009-2018) were
examined with broad content type (e.g., journals, articles, books). Full online text articles, peer
and scholarly reviews within the medical, nursing, social work, and public health disciplines
were included while researching the common themes:


Populations: parents, providers, families of children, pediatricians



Interventions: journals, interviews (in-person and phone), questionnaires, surveys, descriptive
articles



Comparisons: surveys, attitudes toward telehealth/patient portals



Outcome variables: patient portal use; demographics, technology profile, usability



Study types: descriptive, action, qualitative, retrospective
The review of literature demonstrated the need and context for this study by providing

definitions, various benefits, and barriers associated with patient portals. The theoretical
framework provided structure to the objective of generating findings to determine the reasons
why individuals were not using the patient portal at a pediatric office in rural, central
Pennsylvania.

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Chapter 3
Methodology
The objective of this study was to generate findings to determine the reasons why
individuals were not been using the patient portal at a pediatric office in rural, central
Pennsylvania. A convenience sample of individuals was approached regarding the study. The
paper survey, completed by each participant, had a total of eight (8) questions, focusing on
aspects of the patient portal, reasons for not using the portal, and finally, demographic
information. See Appendix C: Patient Portal Survey, as it served as the tool to generate the study
findings.

Research Design
This descriptive study explored the reasons individuals bringing their child(ren) to a
pediatric office had not been using the patient portal. A retrospective review of patient portal
usage was obtained using the eClinicalWorks software. Data were collected regarding the
practice call volume and the reasons individuals were calling the office (during operating and
non-operating hours).

Research Question
The research question guiding this study: What are the reasons why individuals are not
using the patient portal at a pediatric office in rural, central Pennsylvania?

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Setting
The setting for this descriptive study was a pediatrics office in rural, central
Pennsylvania. The practice has estimated call volumes of 40,000 – 50,000 annually with a
significantly higher number of calls between October and March and in August with back-toschool appointments.
Additional practice-related information includes estimated 30,000 patient visits per year;
payer mix of 65% Medicaid, 35% commercial health insurance, and 5% cash or self-pay. The
racial and ethnic categories were primarily Caucasian with 1% Asian & African American
(Chopra, personal communication, 2017).
As to a further itemization of the call volumes, categorical estimates of calls include:


35% requested appointments



25% left messages for the office staff or providers with updates



15% sought medical advice or symptom management



15% requested prescription refill(s)



8% asked questions regarding billing and account matters



2% requested directions to the office, inquired about office hours or other
administrative matters

Sample and Recruitment Process
Sample. A convenience sample of individuals bringing the child(ren) to the practice was
approached to participate in the survey. Inclusion criteria for the participants of the survey:
individuals (>18 years of age) with child(ren) (newborn to 18 years of age); English-speaking
and reading, and individuals who have not used the patient portal to date. Exclusion criteria for

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the participants of the survey: individuals (< 18 years of age bringing children to the practice;
patients >19 years of age; non-English speaking and reading, and individuals who have used the
patient portal to date.
Recruitment process. The timeframe for approaching potential participants, obtaining
consent, and survey completion began November 1, 2018, with a terminal date of January 31,
2019. The flyers for the study (Appendix A) were posted in the waiting area, hallways, and the
restrooms before the start of the study. The co-investigator conducted an informative session
with the medical, nursing, and general staff before the launch to share the background of the
study, allow for question and answers, and to reinforce their role in promoting the study by
directing individuals to the flyers.
Starting November 1, 2018, recruitment began after the check-in procedure was
completed with the office staff; the child(ren) had height and weight measurements, vital signs
recorded, and the individual bringing the child(ren) to the practice discussed the reason(s) or
chief complaint for the visit. All confidential steps and documentation were completed within the
exam room while the co-investigator remained in the hallway. The medical assistant notified the
co-investigator when she could enter the exam room to approach the individual regarding study
participation and to obtain informed consent if all inclusion criteria were met. The coinvestigator discussed the purpose of the study and asked the individual if he or she had used the
patient portal to date. Only individuals stating that they had not used the patient portal were
further approached about study participation. Next, the co-investigator reviewed the consent and
allowed time for the individual to ask questions before determining if he or she wanted to
participate in the survey. If the participant stated that he or she wanted to participate in the study,

REASONS FOR NOT USING THE PATIENT PORTAL

22

the Edinboro University Informed Consent form was reviewed, signed, and dated before the start
of the paper survey. The informed consent and paper survey remained separate during the study.
The co-investigator directed the participant to the survey, asked if there were any
questions, and then exited the room to give the individual privacy to complete the survey. The
co-investigator remained outside the exam room to offer support or answer questions the
individual might have during the completion process. The individual placed the completed
survey in the envelope that was provided by the co-investigator. The envelope was sealed and
hand-delivered by the participant and placed into the secured lock-box at the checkout area of the
practice. The staff member located at the checkout area thanked the individual for his or her
participation in the survey. The study took place during regular business hours, 0900 – 1800
Monday through Friday.
Instrumentation
Utilization of flyers (See Appendix A) in the waiting room and various areas within the
practice were posted to promote the survey and its purpose. After the confidential check-in
process, the co-investigator approached individuals in the exam rooms to participate in the
survey. The eight-question paper survey focused on questions to address why the individuals
were not using the patient portal as well as demographic data collection. (See Appendix C:
Patient Portal Survey).
Data Collection
The Edinboro University Consent to Participate form was utilized for purposes of the
survey. Only the co-investigator (DNP Student) obtained consent before the survey completion.
The co-investigator approached the individuals by stating, “Hello, my name is Sherry
DelGrosso. I am a registered nurse and a DNP student with Edinboro and Clarion Universities.

REASONS FOR NOT USING THE PATIENT PORTAL

23

I am working with Dr. Chopra to learn more about portal usage within the practice. Have you
ever used the patient portal?”
If the individual affirmed, “Yes,” to prior portal usage, the co-investigator thanked the
individual for using the patient portal and encourage continued use with the following statement,
“Thank you for using the patient portal. Please continue to use this valuable tool. If you have any
questions about the portal, please ask any staff member to assist you. At this time, we are
interested in learning from individuals who have not used the patient portal to date. Thank you
for your time.”
If the individual stated, “No,” to the question about prior portal usage, the co-investigator
stated: “As someone who has not used the portal, would you be willing to participate in a fiveminute voluntary paper survey?” With a verbal commitment to participate in the study, the
individual was directed to the Edinboro University Consent to Participate form. The consent
form was read and reviewed with the individual. The following script was utilized to conclude
the consent process (prior to the individual providing his or her signature and date). “Thank you
for considering participating in this brief, paper-based survey. Your signature acknowledges the
following."









I had a chance to ask questions about the study.
My questions were answered to my satisfaction.
I realize that being part of this study is my choice (voluntary).
I will receive no preferential treatment because of participation or non-participation.
I have not used the patient portal to date.
I am 18 years of age or older.
The child(ren) at today’s appointment are newborn to 18 years of age.
I can read and speak English.

Following the completion of the consent process, the individual handed the signed consent to
the co-investigator. Only the co-investigator had access to the individual’s identity through the
signature of the Consent to Participate in the Survey (See Appendix B: Consent to Participate in

REASONS FOR NOT USING THE PATIENT PORTAL

24

Survey). The consent was placed in a secured lock box within the pediatrician’s office. The
survey data was stored and secured in a lock box within the practice, and the co-investigator only
accessed the box. The door to the office was locked at all times. With the possibility of future
publication or presentation, no personally identifiable information was shared.
Before exiting the exam room, the co-investigator asked the individual if there were any
questions about the survey or in general. If there were no questions, the co-investigator thanked
the participant for his or her time and exited the room. If there were questions, the coinvestigator answered the questions to the satisfaction of the participant. Once the individual
verbally acknowledged that all questions were satisfactorily answered, the co-investigator left the
room and remained in the hallway to serve as a resource for the participant to answer additional
questions. At no time did the co-investigator have to return to the room to answer additional
questions.
The individual completed the survey in the privacy of the exam room before the provider
entered the room. The first portion of the survey included questions about the portal with the
collection of individual demographic data of the person completing the survey. (See Appendix C:
Patient Portal Survey).
If a confidentiality breach had occurred, the committee, Dr. Chopra, and the Edinboro
University IRB would have been immediately notified, and appropriate next-steps followed,
including the use of the Edinboro University Unanticipated Problem Report form located in
Appendix D.

REASONS FOR NOT USING THE PATIENT PORTAL

25

Survey Development
The survey developed for this single-site study was a result of general searches regarding
“barriers to patient portal engagement” which were explored and discussed in chapter two. The
survey instrument most closely examined was that from Ancker, Snezana, Osorio, Cole, Silver,
Kaushal (2015). The instrumentation included questions about potential correlates of portal use
in four categories (demographics, health issues, technology use and attitudes, and patient
activation). The survey by Ronda, Dijkhorst-Oei, & Rutten (2014), regarding patient portal usage
among patients with diabetes mellitus, and an industry review of patient portal preferences from
IndustryView in 2014 were also explored. The following table provides the reader with the unit
of analysis for this study:
Name of the population
Subgroup for comparison

Sources for data
Sample population
Inclusion criteria

Exclusion criteria

Timeframe

Individuals: the person bringing the child(ren) to the office the
day the survey is completed.
All individuals who meet the inclusion and exclusion criteria;
who voluntarily agreed to participate in the survey and signed the
disclaimer were included in the study. No subgroups.
Patient portal usage via eClinicalWorks software, data provided
by the lead physician, Dr. Chopra; the survey
A convenience sample from Nov. 1, 2018, to Jan 31, 2019.
Inclusion criteria for the participants of the survey: individuals
(>18 years of age) with child(ren) (newborn to 18 years of age);
English-speaking/reading; individuals who had not used the
patient portal to date.
Individuals (parent/legal guardian) less than 18 years of age;
patients >19 years of age; individuals who had used the patient
portal in the past.
November 1, 2018, to January 31, 2019.

REASONS FOR NOT USING THE PATIENT PORTAL

26

The detailed variables for the patient portal survey
Variable Name

Variable
Description
-Yes
-No
-Unsure
-Did not know the
portal exists
-Do not know how to
access the portal
-Unsure how to signin
-Do not understand
how it functions
-Perceived lack of
time
-Do not see the value
or benefit of using
-No access to
technology
-Prefer to call the
office
-Medical data privacy
concerns
-Other
-Home computer
-Home tablet
-Work computer
-Work tablet
-Public computer
-Cell/mobile phone
-Do not have access
-Other
-Small group
instruction
-One-on-one
demonstration
-Web-based
instruction
-Pamphlet or Handout
-Learn on my own
-Other

Data Source

Individual’s age of the
person bringing the
child(ren) to the office
and completing the
survey

Years of age

Self-report via
the survey

Gender

-Male
-Female
-Other
-Parent
-Step-parent
-Foster-parent
-Legal or -Appointed
Guardian
-Grandparent
-Sibling > 18 yrs.
-Friend
-Other
-Seldom
-Sometimes
-Often
-Always

Self-report via
the survey

Patient portal usage
prior to study date
Factors that prevent
individuals from using
the patient portal?

The technology the
individual will most
likely use to access the
patient portal

Primary preference for
future educational
models to learn about
patient portal

Title of the individual
bringing the child(ren)
to the pediatrics office
and completing the
survey

How often the
individual completing
the survey is the
person who brings the
child(ren) to the office

Potential
participant
answer
Self-report via
the survey

Self-report via
the survey

Self-report via
the survey

Self-report via
the survey

Self-report via
the survey

Possible Range of
Value
1= Yes
2= No
3=Unsure
1=Did not know the
portal exists
2=Do not know how to
access the portal
3=Unsure how to signin
4=Do not understand
how it functions
5=Perceived lack of
time
6=Do not see the value
or benefit of using
7=No access to
technology
8=Prefer to call the
office
9=Medical data
privacy concerns
10=Other
1=Home computer
2=Home tablet
3=Work computer
4=Work tablet
5=Public computer
6=Cell/mobile phone
7=Do not have access
8=Other
1=Small group
instruction
2=One-on-one
demonstration
3=Web-based
instruction
4=Pamphlet or
Handout
5=Learn on my own
6=Other
1. 18-25
2. 26 – 35
3. 36 – 45
4. 46 – 55
5. 56 – 65
6. 66 – 75
7. 75+
1= female
2 =male
3=other
1=Parent
2=Step-parent
3=Foster-parent
4=Legal/Appointed
Guardian
5=Grandparent
6=Sibling > 18 yrs old
7=Friend
8=Other
1=Seldom
2-Sometimes
3=Often
4=Always

Level of
Measurement
Inclusion criteria

Percentage

Timeframe for
Collection
During the recruitment
of potential participants
for the study
During data collection
via the survey

Percentage

During data collection
via the survey

Percentage

During data collection
via the survey

Percentage

During data collection
via the survey

Percentage

During data collection
via the survey

Percentage

During data collection
via the survey

Percentage

During data collection
via the survey

REASONS FOR NOT USING THE PATIENT PORTAL

27

Ethical Considerations
Approval from The Edinboro University of Pennsylvania Institutional Review Board was
obtained. The lead pediatrician, Dr. Chopra, initially provided a verbal agreement and
commitment to the project and then subsequently furnished a Letter of Permission to the coinvestigator to work with the practice and conduct the survey to determine the reasons why
individuals were not using the patient portal. There were no other Institutional Review Boards to
collaborate with during the study, as the study took place at a single-site (private practice). The
potential risks to the participants were minimal. According to Rid, Abdoler, Roberson, Pine, &
Wendler (2014),
The probability and magnitude of harm or discomfort anticipated in the research were no
more significant than those ordinarily encountered in daily life using the patient portal as
long as the participants met the inclusion criteria and followed the study protocol (p.
391).
General benefits of study participation may include personal satisfaction, the individual
learning the definition of the patient portal, recognition that the practice has a patient portal, the
discovery of potential uses and benefits of the portal, and appreciation of personal contribution to
the pediatric practice and healthcare in general.

REASONS FOR NOT USING THE PATIENT PORTAL

28

Chapter 4
Results
Prior to sharing the results, it is imperative to review the research question guiding this
study: What are the reasons why individuals are not using the patient portal at a pediatric office
in rural, central Pennsylvania? The survey results will be used by the lead pediatrician to guide
future patient portal educational endeavors to increase portal usage within the practice.

Sample Selection Process
Before launching the study, the ideal sample size was calculated using the online
Qualtrics tool, Ideal Sample Size Calculator (2019). The following numbers were entered into
the calculator to determine the ideal sample size: The estimated practice population of 7500
patients, the proposed confidence level (95%), and the margin of error (10%). The calculated
ideal sample size was ninety-five participants for this study. The ideal calculated sample size
criterion was met as ninety-six surveys were used in the study and data analysis as displayed in
table one.
Table 1. Calculation of Ideal Sample Size
Calculation Ideal Sample Size
Confidence level = 95%
Population size = 7500
Margin of Error = 10%
Calculated Ideal Sample Size = 95
Per DataStar (2019), an identified ‘confidence level’ qualifies a statistical statement by
expressing the probability that the observed result cannot be explained merely by sampling error.
The 95% confidence level means that there is 95% likelihood that the difference is valid and not

REASONS FOR NOT USING THE PATIENT PORTAL

29

just an oddity of the sampling. With a small sample size of 50 respondents, a 14% margin of
error is conventional, whereas 100 respondents typically yield a 10% margin of error. The
margin of error reveals the imprecision fundamental in survey data (Hunter, 2019). A 10%
margin of error was applied for the sample size calculation in this study.
A convenience sample of individuals bringing the child(ren) to the practice was
approached to participate in the study. Of the 126 individuals approached to participate in the
study, n=100 (79.37%) affirmed they had not used the patient portal to date, while n=20
(15.87%) affirmed they had used the patient portal. The participation response was strong with
only n=6 (4.76%) declining to participate in the study. Reasons cited for not participating in the
survey included: four individuals stated they were not interested in participation and provided no
explanation; one individual stated “My spouse takes care of this” and the other individual said, “I
am the grandmother and know nothing about the portal.”
Table two addresses the total number of individuals approached to participate in the
study. Twenty individuals who used the patient portal before the study were not eligible to
participate in the study, while six individuals chose not to participate in the study. Thus, the coinvestigator had 100 individuals who met inclusion criteria for the study.
Table 2. Patient portal usage prior to study

Patient portal usage prior to study
Variable
Yes
No
Declined Participation
Total
N=number of respondents

N
%
20 15.87%
100 79.37%
6
4.76%
126 100.0%

REASONS FOR NOT USING THE PATIENT PORTAL

30

The N=100 served as the foundation for the study as it represents the individuals who met
inclusion criteria and agreed to participate in the study (e.g., the number of respondents).
Informed consents were obtained from these individuals and surveys were provided to each
participant per the guidelines outlined in Chapter three. The response rate was strong with
ninety-seven surveys being returned to the lock box. After initial review by the co-investigator,
one survey was removed from the study due to partial survey completion. Ninety-six surveys
were utilized for data entry and analysis.
The participants completed an eight-question survey (See Appendix C). After the consent
was obtained, the survey was distributed to the individual. Overall, the questions focused on
determining if the individual had set up a patient portal account for the child(ren); what
prevented the individual from using the patient portal, as well as the individual's preference for
learning to use the portal in the future. Select demographic information was collected regarding
the individual’s age, gender, relationship to the child(ren), and how often s(he) brought the child
to the pediatric office.
Table three details the results from the survey with the questions, number of respondents,
number of responses and , and corresponding percentages. The findings were supportive of the
research hypothesis:
HA: Individual lack of awareness about the existence of the patient portal is the primary factor
for low patient portal usage. Survey question two revealed that 50% of the responses revealed
that participants did not know that the patient portal existed.

REASONS FOR NOT USING THE PATIENT PORTAL

31

Notes
Please refer to page 33 for all survey questions, number of respondents, number of responses,
and percentages as displayed in Table three.


Questions one, four, five, six, seven, and eight asked the participant to provide one
answer per survey question
o N = number of respondents



Questions two and three asked the participant to provide all answers that applied to the
survey question
o n = number of responses per variable

REASONS FOR NOT USING THE PATIENT PORTAL

32

Table 3. Patient portal survey responses
Q1: Do you have a patient portal account? (Select one answer)
Yes
No
Unsure
Total
Q2: What prevents you from using the patient portal? (Select all answers that apply)
Did not know it exists
Do not know how to access
Unsure how to sign in
Do not understand how it functions
Perceived lack of time
Do not see value or benefit of using
No access to technology
Prefer to call into the office
Medical data privacy concerns
Other (Specify)
Total
Q3: Which technology are you most likely to access the patient portal? (Select all answers that apply)
Home computer
Home tablet
Work computer
Work tablet
Public computer (school, library)
Cell/mobile phone
Do not have access to technology
Other
Total
Q4: What is your PRIMARY preference for learning how to use the patient portal in the future? (Select one answer)
Small group instruction
One-on-One Demonstration
Web-based instruction
Pamphlet/Handout
Learn on my own
Other
Total
Q5: What is your current age in years? (Select one answer)
18-25
26-35
36-45
46-55
56-65
66-75
76+
Total
Q6: What is your gender? (Select one answer)
Female
Male
Other
Total
Q7: What is your relationship to the child(ren) with you today? (Select one answer)
Parent
Step-parent
Foster-parent
Grandparent
Legal or Appointed Guardian
Sibling (18+ years of age)
Friend
Other (specify) - Aunt
Total
Q8: How often are you the person bringing the child(ren) to the pediatric office? (Select one answer)
Seldom
Sometimes
Often
Always
Total

N = number of respondents

n = number of responses per variable

N
18
63
15
96
n
59
11
9
1

%
18.8%
65.6%
15.6%
100.0%
%
50.0%
9.3%
7.6%
0.8%

12

10.2%

2
0
16
1
7
118
n
35
22
8
2
1
88
0
1
157
N
5
9
17
32
48
3
114
N
15
45
28
4
2
2
0
96
N
80
16
0
96
N
89
1
0
4
1
0
0
1
96
N
2
8
17
69
96

1.7%
0.0%
13.6%
0.8%
5.9%
100.0%
%
22.3%
14.0%
5.1%
1.3%
0.6%
56.1%
0.0%
0.6%
100.0%
%
4.4%
7.9%
14.9%
28.1%
42.1%
2.6%
100.0%
%
15.6%
46.9%
29.2%
4.2%
2.1%
2.1%
0.0%
100.0%
%
83.3%
16.7%
0.0%
100.0%
%
92.7%
1.0%
0.0%
4.2%
1.0%
0.0%
0.0%
1.0%
100.0%
%
2.1%
8.3%
17.7%
71.9%
100.0%

REASONS FOR NOT USING THE PATIENT PORTAL

33

The survey data presented in Table three was further analyzed using the Chi-square test
to determine if there was a statistically significant association between the patient portal account
and the following variables: age, gender, and the relationship of the participant to the child.
Cross-tabulations were conducted using SPSS software with questions one, five, six, and seven
serving as the data source for evaluation. With all cross-tabulations, p < .05 represents a
statistically significant relationship between the two variables.
The following served as the foundation for the case summaries for the Chi-square tests:
Ninety-six surveys were utilized, and no surveys were missing from the data set. Of the ninetysix surveys, 63 (65.6%) individuals revealed that they did not have a patient portal, 18 (18.8%)
stated they did have a patient portal account and have not used it, while 15 (15.6%) were unsure
if they had a patient portal account.
Table five denotes the cross-tabulation between the patient portal account and the age
range of the participants completing the survey. The p-value of 0.954 indicated that there was no
statistically significant association between the patient portal account and the age range of the
participant completing the survey.
Table 5. Existence of a patient portal account and age range of participant
Age range (in years) of participant completing the survey
Do you have a
patient portal account?

Pearson Chi-Square

Yes
No
Unsure
Total
p-value

18-25
2
11
3
16

26-35
9
27
8
44

36-45 46-55 56-65 66-75
6
1
0
0
19
2
2
2
4
0
0
0
29
3
2
2

0.954

Table six details the cross-tabulation of the patient portal account and the gender of the
participants completing the survey. The p-value of 0.928 revealed no statistically significant

76+
0
0
0
0

REASONS FOR NOT USING THE PATIENT PORTAL

34

association between the patient portal account and the gender of the participant completing the
survey.
Table 6. Existence of a patient portal account and gender of the participant

Do you have a
patient portal?

Gender of the participant
Female
Male
Other
15
3
0
53
10
0
12
3
0
80
16
0

Yes
No
Unsure
Total
p-value

Pearson ChiSquare

0.928

Other variables that were cross-tabulated included the patient portal account and the
relationship of the participant to the child(ren) brought to the pediatric office as displayed in
Table seven.
Table 7. Existence of a patient portal account and the participant relationship to the
child(ren)
Relationship of the participant to the child(ren)
Parent

Do you have a patient
portal?

Yes
No
Unsure
Total

17
58
14
89

Step
parent

0
0
1
1

Fosterparent

0
0
0
0

Grandparent

1
3
0
4

Legal
Guardian

0
1
0
1

Sibling
(18+)

Friend

Other

0
0
0
0

0
1
0
1

0
0
0
0

Other = aunt (indicated by the participant in the survey)

p-value
Pearson Chi-Square

0.513

The p-value of 0.513 revealed that there was no statistically significant association
between the patient portal account and the relationship of the participant to the child(ren).

REASONS FOR NOT USING THE PATIENT PORTAL

35

Since the above analyses did not bare statistical significance in the association between
the patient portal account and the age, gender, or relationship of the participant to the child,
further evaluation was conducted to aid future educational interventions to increase patient portal
usage within the practice. Cross-tabulations were conducted using the SPSS software with
survey question five as it related to the reported age range (in years) of the individual completing
the survey and the answers provided in question two, which addressed factors that prevented the
participants from using the patient portal, specifically “didn’t know that the patient portal
existed” and communication preference of “calling the office. ”
Table eight revealed that there was no statistically significant association between the two
variables as evidenced by the p-value of 0.221.
Table 8: Participant age range and knowledge of the existence of the patient portal
Age range of the
participant

Did not know the
patient portal existed

18-25
26-35
36-45
46-55
56-65
66-75
76+
Total

12
24
16
3
2
2
0
59
p-value

Pearson Chi-Square

0.221

With the results from Table eight not revealing a statistically significant association
between the two variables, the next analysis included the age range of the participant and the
cross-tabulation from survey question two, where the individuals indicated they “Preferred to

REASONS FOR NOT USING THE PATIENT PORTAL

36

call into the office.” Table nine revealed that there was no statistically significant association
between the variables as evidenced by the p-value of 0.910.
Table 9. Participant age range and preference to call into the office

18-25
26-35
36-45
46-55
56-65
66-75
76+
Total

Prefer to
call into the
office (n)
3
8
5
0
0
0
0
16

Pearson ChiSquare

p-value
0.910

Age Range of the
Participant

Lastly, the Chi-square test was conducted on the participant age range and survey
question three, “Which technology are you most likely to access the patient portal?” The choice
“cell/mobile phone” was the leading answer to this question. Table 10 provides the results of this
cross-tabulation with a p-value = 0.009, which shared a higher statistical significant association
between any two variables reviewed.

REASONS FOR NOT USING THE PATIENT PORTAL

37

Table 10. Participant age ranged and preferred technology to access the portal

Age Range of the
Participant
18-25
26-35
36-45
46-55
56-65
66-75
76+
Total
Pearson Chi-Square

Cell phone:
preferred
technology for
patient portal
access (n)
16
41
26
1
2
2
0
88
p-value
0.009

Discussion
The survey answers provided insight into the research question: “What are the reasons
why individuals are not using the patient portal at a pediatric office in rural, central
Pennsylvania?” Survey question two shared valuable information regarding the factors that
prevented the participants from using the patient portal. Fifty percent of the responses per
variable indicated that the survey participants “did not know that the patient portal existed;”
10.2% of the responses per variable specified “perceived lack of time” to be a factor, and 9.3%
of the responses per variable listed “did not know how to access the portal.” Additionally, 13.6%
of the responses per variable revealed that participants “preferred to call into the office” to
handle matters. These findings offered clarity as to the barriers contributing to the low patient
portal usage. Other noteworthy findings revealed the cell/mobile phone as the technology most
likely to be utilized to access the patient portal in the future, followed by the home computer.
Future educational interventions can be tailored with the top learning preferences as identified by

REASONS FOR NOT USING THE PATIENT PORTAL

38

the participants: learn on my own with the use of a pamphlet or handout and web-based
instruction. In closing, the female parent between the ages of 26-35 and 36-45 years of age was
the profile of the individual always bringing the child(ren) to the pediatric office.

REASONS FOR NOT USING THE PATIENT PORTAL

39

Chapter 5
Summary, Conclusion, and Recommendations
Summary
The study provided valuable information as to the reasons why individuals were not
using the patient portal at a pediatric office in rural, central Pennsylvania. Question two outlined
valuable elements that were preventing the participants from using the patient portal. There was
no statistically significant association between the patient portal account and the following
variables: age, gender, and the relationship of the person to the child. Also, statistical
significance lacked with age range and factors preventing the individual from using the patient
portal, the preference to call into the office for care-related matters, and the use of a cell/mobile
phone as the technology most likely to be accessed in the future by the participants to use the
patient portal.

Limitations
Limitations that may have influenced the findings and conclusions include the following
elements: it was a single-site study; individuals completing the survey may not be representative
of the larger population and/or the end users of the patient portal; the small sample size may not
readily generalize to broader pediatric populations in other rural and metropolitan areas; the
timeframe to collect survey data may not have been sufficient and may not account for seasonal
differences in the number of visits to the practice (e.g., summer versus fall volumes); the use of
only paper-based surveys may have impacted the sample size as a more significant number of
participants may have been achieved through the use of an electronic survey posted on the

REASONS FOR NOT USING THE PATIENT PORTAL

40

pediatric practice website; and lastly, some participants selected more than one answer when
they should have chosen only one answer per question.

Conclusion
The survey confirmed the directional hypothesis for this study as the individuals lacked
awareness about the existence of the patient portal. It was the primary variable for low
patient portal usage. Continued efforts will be needed to ensure that patient portal usage
increases over time.

Recommendations
The results of the survey revealed that the lack of patient portal usage/engagement may
well be responsive to change with some practice planning and possible educational interventions.
First, strong leadership is necessary. Specifically, strong project leaders will be needed to
coordinate marketing and educational efforts. The pediatric office will need to work closely with
the marketing team and project leader to tailor the patient portal engagement campaign.
Marketing materials in the form of pamphlets, handouts, and web-based instruction will need to
address the fundamental factors preventing the individuals from using the patient portal while
ensuring that the portal is mobile compatible, user-friendly, and supports the individuals' desire
to utilize the patient portal more efficiently than calling into the office. Personnel (either within
the office or sub-contracted with the patient portal vendor customer service team) will need to be
deployed during the marketing campaign with the anticipated surge in patient portal account
registration to support the individuals. Patient portal software or other technologies may be
needed to capture patient portal usage rates and other variables during the marketing campaign in

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41

order to analyze key trends in usage, technology complications, and consumer feedback about
the portal.
Educational materials and marketing campaigns need to be clear and aesthetically
pleasing. Future educational interventions and marketing campaigns will need to target a variety
of populations to alert the individuals bringing the child(ren) to the pediatric practice of the
existence of the patient portal and how to access it. Because the individuals preferred to call into
the office and perceived “lack of time” as barriers to using the patient portal, strategic and
operational plans need to be developed and executed to support the individuals as they transition
to the patient portal as the primary means to request immunization records, lab results,
medication refills, schedule appointments and ask care-related questions, all of which may now
be managed via the patient portal. Step-by-step instructions for patient portal access,
troubleshooting, and frequently asked questions need to be provided using paper and electronic
formats. Studies will need to be reviewed and utilized to effectively share healthcare information
with such a broad audience.
Participants indicated that they plan to use their cell phones for future patient portal
access. Thus, the project leader must ensure portal compatibility with mobile devices. It must be
user-friendly and efficient for the individuals to decrease the calls to the office. Otherwise, portal
engagement will remain low. Organizational policies and practices will need to be updated
accordingly while reflecting all standards of care and regulations. As telehealth technologies
grow within the practice, the patient portal will need to support the continuous flow of
information across the electronic medical record, the patient portal mobile app, and the
computer-based platform.

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The pediatric practice, project leader, and marketing team will need to review studies for
the effectiveness of delivering healthcare information to individuals to ensure health and
computer literacy skills. Programs and incentives may need to be instituted to encourage the
individuals to sign-up and use the patient portal. One example may include entering new and
experienced patient portal account users into drawings and awarding weekly, monthly, and
yearly prizes for patient portal usage. Continued efforts, surveys, and studies will be needed to
ensure that patient portal usage is increasing over time.

Future Research
Prospective research should include additional qualitative studies to systematically
address the patient portal engagement and variables affecting the usage within the pediatric
practice after this study. It will also be beneficial to have convenience sampling or mixedmethods approaches to assess the impact of the marketing campaign as it pertains to the ongoing
process improvement measures with the patient portal engagement. Additionally, a review of
select sub-populations (ADHD, asthma, and pediatric obesity) within the practice may afford the
opportunity to address the impact the patient portal usage may be having on health outcomes,
patient and family knowledge as it relates to the care of the patient, as well as the impact the
patient portal usage may be having on care metrics (cost, quality, and safety).
Future studies may include additional pediatric and adult practices, hospitals, and health
care systems within other rural and metropolitan areas to increase healthcare partnerships and
sharing of valuable information to promote patient portal engagement.

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43

References
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Ancker, J. S., Osorio, S. N., Cheriff, A., Cole, C. L., Silver, M., & Kaushal, R. (2015). Patient activation
and use of an electronic patient portal. Informatics for Health & Social Care, 40(3), 254-266.
Britto, Maria T., Hesse, E. A., Kamdar, O. J., & Munafo, J. K. (2013). Parents' perceptions of a patient
portal for managing their child's chronic illness. The Journal of Pediatrics 163(1), 280-281.e2.
Chopra R. (personal communication, 2017-2018), Practice information, and other data to-date.
Clark, S. J., Costello, L. E., Gebremariam, A., & Dombkowski, K. J. (2015). A national survey of parent
perspectives on use of patient portals for their children's health care. Applied Clinical
Informatics, 6(1), 110.
DataStar (2018). “What every researcher should know about statistical significance.” Survey Star.
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eClincialWorks V11. (2018), [Computer software]. Portal usage statistics to-date
Heath, S. (2016, September 16). Patient portal adoption hinges on unique demographic barriers.
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Heath, S. (2018, May 15). What are the top barriers to patient portal adoption, use? Retrieved from:
https://patientengagementhit.com/tag/patient-portal-adoption
HealthIT.gov (n.d.). What is a patient portal? Retrieved from: https://www.healthit.gov/faq/whatpatient-portal

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Holden, R. J., & Karsh, B. (2010). The Technology Acceptance Model (TAM): Its past and its future in
health care. Journal of Biomedical Informatics, 43, 159-172. Retrieved from https://ac.elscdn.com/S1532046409000963/1-s2.0-S1532046409000963-main.pdf?_tid=e8baf4a7-a99f-40d19f2b-f8c5b5ea7211&acdnat=1530123741_64fdd1da04b0303cba25e3612765b13f
Hunter, Pamela (2019). “Margin of error and confidence levels made simple.” ISixSigma, Retrieved
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underserved. International Journal of Medical Informatics, 102, 62-70.
Noteboon, M. R. (2015, May 1). What does "patient engagement" really mean? Retrieved from
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Powell, K. R., & Myers, C. R. (2018). Electronic patient portals: Patient and provider perceptions. Online Journal of Nursing Informatics, 22(1).
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strategies for subspecialty care: Recommendations from rural pediatricians. Telemedicine and eHealth, 622-630.
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Appendix A: Flyer Promoting the Survey

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Appendix B: Consent to Participate in Survey Edinboro University Consent
EDINBORO UNIVERSITY OF PENNSYLVANIA
Edinboro, Pennsylvania
CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Title of Study: Patient Portal Engagement at a Pediatric Office: Reasons Why Individuals are
Not Using the Portal.
Principal Investigator: Dr. Meg Larson
Co-investigator: Sherry DelGrosso, MSN, RN, LNC
Introduction
The study, Patient Portal Engagement at a Pediatric Office: Reasons Why Individuals are not
using the Portal, is being conducted at Dr. Chopra’s office, 1224 7th Avenue Altoona, PA
(Blair County).
“A patient portal is a secure online website that gives patients convenient, 24-hour access to
personal health information from anywhere with an Internet connection. Using a secure
username and password, patients can view health information” (HealthIT.gov, (n.d.), para. 1).
Some patient portals also allow the user to securely message the provider; request prescription
refills; schedule non-urgent appointments; update contact information; make payments;
download and complete forms; and view educational materials (HealthIT.gov,( n.d.), para. 2).




You are being asked by Sherry DelGrosso, MSN, RN, LNC (co-investigator) to be in a
research study.
You should understand that this study involves research. This consent describes your
role as a participant in the study.
In this study, you will complete a brief paper survey, which has a total of eight (8)
patient portal and demographic questions.

Purpose of the Study
The purpose of the study (through the brief paper-survey) is to explore the reasons
individuals bringing their child(ren) to the pediatric office are not using the patient portal.
What Will Happen During the Study?
Only individuals stating that they have not used the patient portal to date will be approached
further about survey completion.
The survey will focus on:
 Reasons why the individuals are not using the portal
 Primary preference for learning how to use the patient portal in the future
 Demographic data collection

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What Are the Possible Risks or Discomforts?
The potential risks to the participants are minimal. The co-investigator will be available to
answer any questions; address any issues and work with the participant to decrease
frustration or any concerns.
What Are the Possible Benefits of Being in This Study?
 General benefits may include, but not be limited to personal satisfaction and general
appreciation of personal contribution to the pediatric practice and healthcare in
general.
 The study-specific benefits to the participants may include an understanding of the
patient portal (definition), its benefits and how to access the portal in the future for key
requested information (immunization records, lab results, request for medication
refills, messages (questions) to the provider for care and follow up.
Are Other Treatments Available?
You may choose not to participate in the patient portal study, as it is voluntary.
How Will the Data Collected Be Kept Confidential?
 You should know that your name will be kept as confidential as possible, within local,
state and federal laws.
 Completed surveys will be stored in a sealed envelope and stored in a secured lockbox
within the pediatric practice.
 The signed consent form and the completed survey may be reviewed by the Edinboro
University Institutional Review Board (IRB), if necessary.
 The results of this study may be shared in aggregate form at a meeting or in a journal,
but your name or individual results or information will not be revealed.
What Happens If I Have More Questions?
 Sherry DelGrosso will answer your questions about the research study at 814.944.8784
or in person at the time of survey completion.
 If you have a question about your rights as a research participant that you need to
discuss with someone, you can call the Edinboro University Institutional Review Board
at (814) 732-2856 or at irb-chair@edinboro.edu.
What Will Happen If You Decide Not To Be in the Study?
 Your participation is strictly voluntary
 The survey will be conducted within the exam room after the children have completed the
check-in process, had height and weight measurements, vital signs, discussed the reason(s)
for the visit with the medical assistant (chief complaint), and all confidential steps and
documentation have been completed within the exam room
 You may choose to quit at any time without any penalty, retribution, or repercussion.
 You will not be given preferential treatment or have your appointment time advanced
as a result of participation or non-participation

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SUBJECT’S STATEMENT
 I had the opportunity to ask questions about the study.
 My questions were answered to my satisfaction.
 I realize that being part of this study is my choice (voluntary).
 I received no preferential treatment because of participation or non-participation.
 I have not used the patient portal to date.
 I am 18 years of age or older.
 The child(ren) at today’s appointment are newborn to 18 years of age.
 I can read and speak English.
SUBJECT’S SIGNATURE
Rev. 09/04/14

DATE

REASONS FOR NOT USING THE PATIENT PORTAL
Appendix C: Patient Portal Survey

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REASONS FOR NOT USING THE PATIENT PORTAL
Appendix D: Edinboro University Unanticipated Problem Report

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