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This paper focuses on the barriers that patients have as to why they do not use their electronic patient portal. The literature suggests that the age and socioeconomic status of the individual has a big impact on the use of the electronic portals. A review of the literature showed that all populations have not been represented. This study surveys a broader range of patients including all ages, genders, education and socioeconomic statuses to see what barriers that this broader range of patients has to using their electronic portals. BARRIERS TO THE USE OF ELECTRONIC PATIENT PORTALS 7 Barriers to the Use of Electronic Patient Portals Chapter 1 Introduction Ever since the Affordable Care Act, patient portals are a requirement for health care facilities to get reimbursed. Health care facilities are investing a lot of time and money into these portals, but how many patients with portal access are using them (Lazard, Watkins, Mackert, Xie, Stephens, & Shalev, 2016)? Are patients aware that they have a portal? What are the barriers for the patients that are aware of their portal and are not using them? Background Although the majority of patients are enthusiastic about the use of patient portals, not all patients are actively using the portals or even signed up to use them (Tieu, Sarkar, Schillinger, Ratanawongsa, Lyles, Ralston, & Pasick, 2015). There have been many studies to establish why these portals are not being used since they are so beneficial to patients. Portals allow patients access to past health records, doctor visit summaries, laboratory results and enable them to make or change appointments, communicate monitoring results, and ask or respond to a provider’s question (Tieu et al., 2015). According to Lazard et al. (2016), patient health records or portals can improve patient’s health outcomes by providing patients access to health information thereby allowing them to manage their health on a higher level. Powell’s (2017) literature review showed that many patients are not aware that they have access to a portal. According to Tieu et al. (2015), some of these barriers are related to technology issues. Most patients reported having some access to a computer, whether it is a tablet or smartphone, going to a public facility that offers free access, or using a friend or relative’s computer (Tieu et al., 2015). One common barrier for patients is anxiety and/or problems remembering or establishing usernames and passwords that are required to set up and access portals (Tieu et al., 2015). Some patients do not BARRIERS TO THE USE OF ELECTRONIC PATIENT PORTALS 8 understand the lingo that is used to set up a secure password and username (Tieu et al., 2015). Cafazzo et al. (2012) say that patients often have a hard time navigating the portal or find that the system is slow due to the Internet speed, causing more frustration. Tieu et al. (2017) found that patients with “limited health literacy required 2 additional minutes to complete each task and were more likely to experience each type of navigational barrier” (Tieu et al., 2017, p. e47). Tieu et al. (2017) go on to say that patients with limited health literacy have trouble typing, understanding health acronyms, understanding laboratory tests and medication names. Lazard et al. (2015) did a study that showed that the aesthetics of the portal played an important part in whether patients revisited their portal. Lazard et al (2015) report that even when there are flaws in the portal, patients are more likely to use the portal over a longer period of time when the portal is “visually acceptable” and simple. Lazard et al. (2015) research revealed, “...the visual appeal or aesthetics, has a significant impact on users’ emotional and rational evaluations of e-health applications, especially as regards to the users’ involvement in the application, the application’s perceived usability, the user’ trust in the application, and the application’s credibility.” (Lazard et al., p. e157, paragraph 3, 2015). Another common barrier for patients is the lack of trust in the security of the information that is contained in their portals. The news media often reports on breaches within major companies, which adds to the fear of having their information accessed illegally. Powell’s (2017) literature review showed that patients were concerned about the possibility of their information being obtained by hackers or their passwords being stolen. Tiddy (2015), points out that patient health information is already in electronic format through the use of Electronic Health Records (EHR) in the health care setting, so there is no reason not to take advantage of their portals. Some non-technical barriers associated with patients not using their portals is that patients feel that their health is under control and do not feel a need to report their selfBARRIERS TO THE USE OF ELECTRONIC PATIENT PORTALS 9 monitoring results (Cafazzo et al., 2012). They see that the results are normal and do not want to spend the time and effort to enter them into the portal. Cafazzo et al. (2012) also found that patients reported that it takes them too much time since there was a certain degree of difficulty entering their results into the portal. Tieu et al. (2015) found that patients prefer to speak to their provider on the phone because they like the person-to-person contact and that this is what they have been doing in the past. Patients report that the response time is quicker when they make the phone call over logging in to the portal, which often times has a 48-hour turnaround. Patients often think that the portal is like text messaging and expect a quicker response thereby causing them anxiety and frustration. Patient portals are an important part of the present and future of health care. As time goes on, more patients will be aware of their portal and find it useful. According to Powell (2017), electronic portals have “been found to build trust between the patient and the provider”. Health care facilities can help by informing patients that they have a portal at every opportunity and assisting them with the process. Vendors can help by creating software that is easy to use and visually pleasing. Purpose of Study This study set out to identify the reasons why patients are not using their electronic portals. The literature shows that older patients and lower socioeconomic status are less likely to use portals, but what about the younger population and the upper and middle-class patients? Are they using their portal? Once the barriers are identified, solutions can be provided to offset these barriers and increase electronic portal use. Significance of Study Health care technology is here to stay, and electronic patient portals are a mainstay of health care. If these portals are not being used, the benefits that they provide will be useless. Patient’s BARRIERS TO THE USE OF ELECTRONIC PATIENT PORTALS 10 health can be positively affected by using portals for communication and disease maintenance. Healthier patients lead to better reimbursement. The barriers to using a portal should be identified and rectified so that all patients can reap the positive health benefits. This study can help to identify trends in portal usage when repeated periodically. Research Questions Which patients are using their electronic portals? What are some of the barriers for patients not using their electronic portal? Are younger patients more likely to use electronic portals? Do patients with in a higher education level use their portals? Limitations The sample population may not represent all patient types since access to individuals that do not utilize health care may be limited. This may lead to sicker patients responding to the questionnaire and they tend to be older patients. Time and money do not permit an in-depth interview with each patient so a questionnaire will be used to access the information. The questionnaire will be in a multiple-choice or short answer format that may lead the patient to choose an answer presented on the form even when their choice is not on the list. Patients may not understand the question or not know what an electronic patient portal is. There is a possibility of selection bias in which patients that are aware of portals may respond more than persons who do not know what a portal is. Patients that prefer digital technology over paper may not participate using a paper format. BARRIERS TO THE USE OF ELECTRONIC PATIENT PORTALS 11 Chapter 2 – Review of the Literature Review of the Literature A literature review was performed to identify the research that has already been performed on the subject of barriers to patient portal use and to home in on where more research is needed. The methods used to research, and the findings are presented here. Materials and Methods Identification of articles. A literature review was performed using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar search engine. The research was conducted using combinations of key terms such as barriers, patient, electronic and portal. A research librarian at University of Tennessee Health Science Center was consulted to assist in a thorough search of relevant articles. Inclusion and exclusion criteria. The research was limited to studies done in the years 2014 through 2018 to capture the most current information. Studies done outside of the United States were excluded because the health care system and portals are not known or unlikely to be the same. The eight articles reviewed are from primary sources that exclude articles pertaining to the clinician or clinic employee’s view of patient’s barriers to portal use. Populations Studied The literature review included studies on all patients, but most of the articles focused on the elderly, low income, and minority patients. The participants of most studies were 50 years old and up. Two studies limited their participants to veterans or their

Barriers to Patient Electronic Portal Usage