BEYOND TECHNOLOGY ADOPTION: EXPLORING THE IMPACT OF PUBLIC HEALTH EMPLOYEES’ PERCEPTIONS AND USAGE OF PATIENT PORTALS TO ADVANCE DIGITAL HEALTH EQUITY By Helene Franchanita Edwards July, 2025 Director of Dissertation: Dr. Doyle Cummings Major Department: Public Health ABSTRACT Background: Healthcare organizations have been at the forefront of health information technology (HIT), striving to promote health equity and improve access to care. The introduction of electronic health records with patient-centric access has been a game-changer, promising to elevate the quality of care and enhance patient-provider engagement. Among these technological advancements, patient portals provide individuals with secure, unrestricted access to their health information. Several studies have revealed disparities in patient portal adoption across multiple levels, including policy and governance, organizational, and individual levels, which are more pronounced among vulnerable populations who are less likely to achieve optimal health outcomes. There are limited studies assessing the technology acceptance of patient portals in safety net organizations, which provide healthcare services for vulnerable populations. In North Carolina, local health departments (LHDs) promote the health of their respective communities while also organizing and delivering healthcare services to uninsured individuals, Medicaid recipients, and other vulnerable populations. As safety net providers, LHDs play a pivotal role in promoting patient portal utilization among historically marginalized populations and those with limited English proficiency (LEP); therefore, understanding the perspectives of public health professionals on the technology acceptance of patient portals can impact universal adoption. Objective: This study aimed to identify predictors that influence the adoption of patient portals by public health professionals and their recommendations for others to use them. Methods: This quantitative cross-sectional study was conducted among local public health professionals, utilizing a 32-question survey, built in Qualtrics, based on the extended Unified Theory of Acceptance and Use of Technology-2 (UTAUT-2) model to investigate consumer acceptance of patient portals and behavioral intention to use and recommend them. Between February and April 2025, snowball convenience sampling strategies were employed to recruit local public health professionals across North Carolina. The primary theory constructs of performance expectancy, effort expectancy, social influence, and price value were considered independent variables. The dependent variables were behavioral intention to use and intention to recommend patient portals. Age, education, marital status, experience, and residence (urban or rural county) were tested as moderators between the primary theory constructs and behavioral intention to use. The three research questions and six hypotheses were analyzed using descriptive statistical analysis, bivariate analysis (ANOVA and Independent t-tests), and multivariate analysis (multiple regression analyses and Confirmatory Factor Analysis for structural equation modeling). Results: Of the 431 participants, 392 were included in the final analysis. Healthcare providers offered patient portal access to 98.7% (n = 387) of the respondents. Furthermore, 94.4% (n = 370) of the respondents reported having access to patient portals, and 90.8% (n = 356) used their portals within the last 12 months. Performance expectancy (β = .548, C.R. = 11.050, p < 0.001), effort expectancy (β = .303, C.R. = 7.088, p < 0.001), social influence (β = 0.066, C.R. = 2.021, p < 0.043), and price value (β = 0.100, C.R. = 2.905, p < 0.004) were the influential drivers of behavioral intention to use (R2 = 85.3%). Age (β = 0.949, p = 0.008), education (β = 0.959, p = 0.019), experience (β = 0.919, p = 0.007), and residence (β = 0.959, p = 0.029) had moderating effects on the independent variables of the adapted UTAUT-2 model. In addition, behavioral intention to use (β = 0.864, p < 0.001) had a statistically significant impact on intention to recommend (R2 = 74.7%). Conclusion: This study confirmed the valuable impact of healthcare providers promoting patient portals to their patients. Furthermore, performance expectancy, effort expectancy, social influence, and price value were statistically significant predictors of public health professionals’ behavioral intention to use patient portals. Behavioral intention to use and frequency of use of patient portals were statistically significant influential drivers of the intention to recommend patient portals to others. The study’s results suggest that local health departments should focus on strategies associated with these factors to expand health information technology policies, thereby improving population health and reducing barriers to the adoption of patient portals. Future research should be conducted in other contexts and explore additional predictors to develop effective interventions that encourage the adoption and sustained use of patient portals in advancing digital health equity. KEYWORDS Electronic Health Records; Patient Portals; Public Health; UTAUT-2; eHealth; Health Sciences Beyond Technology Adoption: Exploring the Impact of Public Health Employees’ Perceptions and Usage of Patient Portals to Advance Digital Health Equity A Dissertation Presented to the Faculty of the Department of Public Health East Carolina University In Partial Fulfillment of the Requirements for the Degree Doctor of Public Health By: Helene Franchanita Edwards, MS, RD, LDN July 2025 Director of Dissertation: Dr. Doyle Cummings, PharmD Dissertation Committee Members: Dr. O. Elijah Asagbra, PhD, MHA, CPHQ Dr. Cheryl Kovar, PhD, RN, CNS, CPH Dr. Huabin Luo, PhD Dr. Nancy Winterbauer, PhD, MS © 2025, Helene Franchanita Edwards DEDICATION My dissertation is dedicated to my parents, CW5 (retired) Franklin and Helen Edwards. My parents have been my lifelong coaches, guiding me in my personal, academic, and professional endeavors. Growing up as a military dependent, traveling around the world, my parents ensured that I was enriched with historical and cultural experiences of the places where we lived, and they taught me to respect the differences of others. They always provided a stable, loving home environment that fostered physical, mental, and spiritual wellness, nurturing my curiosity to learn more. Emulating my parents' values, my compassion and dedication to public service have led me to a dynamic career in public health. My parents’ unconditional love and support are the cornerstone of my professional and academic achievements. ACKNOWLEDGEMENTS I want to express my deepest gratitude to my East Carolina University academic advisor, Dr. Ruth Litte; Dr. Doyle Cummings, Director of Dissertation; and Dissertation committee members: Dr. O. Elijah Asagbra, PhD, MHA, CPHQ; Dr. Cheryl Kovar, PhD, RN, CNS, CPH; Dr. Huabin Luo, PhD; and Dr. Nancy Winterbauer, PhD, MS for providing guidance and expertise during my DrPH dissertation journey. I am incredibly grateful to Dr. Jorge Tavares, MSc, PhD, for permitting me to replicate the Unified Theory of Acceptance and Use of Technology-2 questions for consumer acceptance of patient portals. This endeavor would not have been possible without the combined efforts of both current and former Hoke County Health Department employees, who assisted me throughout my DrPH journey, researching different perspectives on patient portal adoption and testing survey questions. Words cannot express my gratitude to the North Carolina Association of Local Health Directors for supporting my research and disseminating the survey within their health departments. Special thanks to Region 8 for having the highest number of respondents. I want to extend my sincere thanks to the North Carolina Public Health Association and the Eastern District of North Carolina Public Health Association for disseminating my survey to their members. I am also grateful for my family and friends who have supported me through this fantastic journey. Heartfelt thanks to my parents, Frank and Chrystal, as well as Alena, Aiden, Aniyah, Cary, Jenny, Keyna, Sam, Raymond, Roland, and Donna. Table of Contents TITLE……………………………………………………………………………………………………………………………. i COPYRIGHT…………………………………………………………………………………………………………………. ii DEDICATION……………………………………………………………………………………………………………… iii ACKNOWLEDGEMENTS………………………………………………………………………………………………… iv LIST OF TABLES………………………………………………………………………………………………………….. viii LIST OF FIGURES………………………………………………………………………………………………………….. x Chapter 1: Introduction ............................................................................................................... 1 Background of the Problem ...................................................................................................... 1 Policy & Governance .............................................................................................................. 3 Organizational Level ............................................................................................................... 4 Individual Level ..................................................................................................................... 4 Healthcare Providers’ Perceptions of Patient Portals ................................................................... 5 Role of Public Health .............................................................................................................. 6 Statement of Problem ............................................................................................................... 7 Scope of Study .......................................................................................................................... 7 Research Questions ............................................................................................................... 8 Theoretical framework.......................................................................................................... 9 Significance of Research ......................................................................................................... 10 Limitations ............................................................................................................................ 11 Summary ............................................................................................................................... 12 Operational Definitions .......................................................................................................... 14 Chapter 2: Review of Literature ................................................................................................. 15 Literature Search Strategy...................................................................................................... 15 Review of Literature ............................................................................................................... 16 HIPAA and Health Information Technology ............................................................................. 16 Factors Affecting Patient Portal Usage .................................................................................... 17 Technology Acceptance of Patient Portals................................................................................ 36 Strategies for Optimal Patient Portal Utilization ....................................................................... 44 Technology Acceptance & Intention to Recommend Studies ......................................................... 47 Theoretical Framework .......................................................................................................... 48 Research Conceptual Model: Adapted UTAUT 2 Model ................................................................ 52 Chapter 3 Methodology .............................................................................................................. 53 Study Design .......................................................................................................................... 53 Participants............................................................................................................................ 54 Inclusion Criteria ................................................................................................................. 55 Exclusion Criteria ................................................................................................................ 56 Recruitment ........................................................................................................................... 56 Instrument and Data Collection .............................................................................................. 57 Data Analysis ......................................................................................................................... 64 Measurement Model ............................................................................................................. 66 Summary ............................................................................................................................... 69 Chapter 4 Results....................................................................................................................... 70 Data Examination .................................................................................................................. 70 Data Transformation .......................................................................................................... 71 Sample Description ................................................................................................................ 72 Demographic Information and Access to Patient Portals ............................................................ 72 Patient Portal Utilization ....................................................................................................... 76 Mean Scores for Survey ........................................................................................................ 79 Measurement Model Fit Results .............................................................................................. 81 Reliability............................................................................................................................ 81 Validity ............................................................................................................................... 82 Structural Equation Modeling .................................................................................................... 84 Structural Model Results ........................................................................................................ 87 Survey Mean Scores for the Adapted UTAUT 2 Factors ............................................................ 88 Path Analysis Results ............................................................................................................ 89 Analysis of Moderating Variables in the Model ........................................................................ 91 Moderating Role of Age ........................................................................................................ 92 Moderating Role of Education ............................................................................................... 94 Moderating Role of Marital Status .......................................................................................... 95 Moderating Role of Experience .............................................................................................. 96 Moderating Role of Residence ............................................................................................... 97 Recommending Patient Portals ............................................................................................. 100 Summary ............................................................................................................................. 103 Chapter 5 Discussion ................................................................................................................ 106 Principal Findings ................................................................................................................ 106 Managerial Implications ....................................................................................................... 113 Study Limitations ................................................................................................................. 117 Recommendations for Future Research ................................................................................. 119 Conclusion ........................................................................................................................... 121 References ............................................................................................................................... 122 Appendix A: IRB Approval Letter ............................................................................................ 132 Appendix B: Other Permission Letters ..................................................................................... 134 Appendix C: CEPH Competencies ............................................................................................ 140 Appendix D: Literature Search Strategy ................................................................................... 145 Appendix E: Questionnaire ...................................................................................................... 148 Appendix F: Study Recruitment Items ...................................................................................... 153 Appendix G: Frequency of Patient Portal Usage by Experience and Residence ........................... 158 Appendix H: Reliability and Validity Tables for the Adapted UTAUT 2 Model ........................... 160 Appendix I: Statistical Formulas .............................................................................................. 162 Appendix J: Mean Scores from Adapted UTAUT 2 Survey ........................................................ 163 List of Tables Table 1: Absolute and Incremental Fit Measures of Model Values 68 Table 2: Demographic Characteristics of Respondents and Patient Portal Access 73 Table 3: Professional Roles of Respondents and Patient Portal Access 74 Table 4: Experience of Respondents and Patient Portal Access 75 Table 5: Residence of Respondents and Patient Portal Access 76 Table 6: Frequency of Portal Usage by Demographic Characteristics 77 Table 7: Frequency of Portal Usage by Professional Role 78 Table 8: Frequency of Portal Usage by Experience 78 Table 9: Frequency of Portal Usage by Residence 79 Table 10: Mean Scores of the Patient Portal Acceptance Dimensions 80 Table 11: Scale Reliability Analysis 81 Table 12: Assessment of the Reliability and Validity of the Measurement Model 83 Table 13: Discriminant Validity of the Constructs 84 Table 14: Structural Model Results for Behavioral Intention to Use Patient Portals 88 Table 15: Mean Scores of Adapted UTAUT-2 Factors for Behavioral Intention to Use 89 Table 16: Bivariate Analysis of Age 93 Table 17: Bivariate Analysis of Education 94 Table 18: Bivariate Analysis of Marital Status 95 Table 19: Bivariate Analysis of Experience 97 Table 20: Bivariate Analysis of Residence 98 Table 21a: Moderation Analysis Results 99 Table 21b: Moderation Analysis Results 99 Table 22: Structural Model and Survey Results 100 Table 23: Bivariate Analysis of Patient Portal Usage 103 Table 24: Structural Model Results and Findings Regarding Hypotheses 105 List of Figures Figure 1: Adapted UTAUT-2 Conceptual Model 52 Figure 2: Measurement Items for Patient Portal Usage 58 Figure 3: Measurement of the Adapted UTAUT-2 Model Constructs 59 Figure 4: Measurement Items for Behavioral Intention to Recommend 61 Figure 5: Measurement of Demographics 62 Figure 6: Research Question #1 with Hypotheses 63 Figure 7: Research Question #2 with Hypotheses 64 Figure 8: Research Question #3 with Hypotheses 64 Figure 9: AMOS Model Interface of the Adapted UTAUT-2 Model 85 Chapter 1: Introduction Healthcare organizations have been at the forefront of health information technology (HIT), striving to promote health equity and improve access to care. The introduction of electronic health records with patient-centric access has been a game-changer, promising to elevate the quality of care and enhance patient-provider engagement. Among these technological advancements, patient portals provide individuals with unrestricted access to their electronic health records. However, patients do not fully utilize these patient-centric technologies.1–3 This research aims to analyze the personal usage of patient portals among public health professionals to promote patient engagement within their communities. Promoting health information technology is crucial to improving digital health equity. This chapter provides an overview of the study, including the background of the problem, the research question, the research aims and objectives, the hypotheses, the significance, the limitations, and the operational definitions. Background of the Problem The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 transformed health information technology through the Medicare and Medicaid Electronic Health Record Incentive Programs.2 Under the HITECH Act, healthcare organizations with eligible professionals received financial incentives for purchasing and adopting certified electronic health record technology (CEHRT) that included secure patient portals, facilitating bidirectional communication between providers and patients.2-4 The initial incentive programs evolved into Promoting Interoperability (PI) Programs, which focused on CEHRT measurements to improve patient care quality and health outcomes, ultimately reducing US healthcare spending.2 Without the Meaningful Use (MU) incentives, the aggressive promotion of patient portals within many healthcare organizations diminished.2 2 Patient portals are secure online platforms linked to electronic health records that provide individuals with unlimited access to their health data.1,5 These secure platforms promote health independence by providing patients with access to their health information, including details of their latest medical visits, medications, vaccination records, laboratory results, and a summary of preventive health screenings. Some features of patient portals facilitate patient engagement through secure messaging with healthcare professionals, scheduling appointments, requesting medication refills, sharing health information with others, and identifying educational resources relevant to personal health.6 As healthcare organizations strive to improve health outcomes, bidirectional communication between providers and patients becomes increasingly essential to foster patient empowerment and engagement. During the COVID-19 pandemic, advancements in health information technology were crucial for healthcare organizations to deliver patient care. Consequently, secure HIT online platforms for communication between patients and providers significantly expanded telehealth services, online vaccination scheduling, and other health maintenance visits. In 2020, the Cures Act Final Rule revolutionized access to health-related data for patients and providers by enabling the secure exchange of medical records across smartphone applications. This health technology expansion enabled more individuals to be offered and access their patient portals. The 2022 Health Information Trends Survey VI (HINTS) reported that the nationwide rate of patient portal utilization increased to 57% among individuals who were offered and accessed their patient portals at least once within the year.7 Although more individuals were using patient portals, disparities still exist in portal utilization among vulnerable and historically marginalized populations.2,8,9 3 Since the launch of patient portals, researchers have been interested in understanding the low utilization rates nationwide. Initially, healthcare professionals assumed that patients with chronic medical conditions would be eager to use the patient portals; however, underlying barriers have limited portal adoption among high-risk patients.6 Several studies have uncovered multilevel factors contributing to the underutilization of electronic health record patient portals. The barriers and factors affecting patient portal utilization are categorized into three levels: policy, organizational, and individual.8 Furthermore, the factors affecting HIT usage are more noticeable among vulnerable populations who are less likely to achieve optimal health outcomes due to physical, psychological, and social health disparities.9,10 Policy & Governance The implementation of Meaningful Use (MU) incentives for healthcare providers to adopt CEHRT records with bidirectional communication between patients has ignited disparities in patient portal usage.4 To receive financial incentives, healthcare providers recruited at least 5% of their patients, who were more likely to enroll and use the patient portals; therefore, selective portal promotional efforts were utilized to achieve success, which overlooked vulnerable populations.4 As the MU incentives ended, healthcare providers were encouraged to continue promoting universal patient portal enrollment and usage without considering patients’ digital access. Digital access enables individuals to utilize tools and technology for full social participation.8 Furthermore, digital access is a social determinant of health currently disregarded in macro-level policies affecting patient-centric technology adoption nationwide.8 Policies for smartphone ownership can hinder low-income individuals from purchasing and using devices. The lack of home access to high-speed Internet services deters individuals from engaging in 4 health technology services, resulting in limited digital access to navigate and understand online platforms. “Digital redlining” is a form of segregation where Internet service providers choose to install fiber broadband in higher-income communities, thereby overlooking digital access in low- income and rural communities.8 Organizational Level Addressing the organizational factors affecting patient portal utilization is imperative. Many healthcare organizations lack adequate funding to develop the technical and organizational infrastructure necessary to support the advancement of patient-centric technology.8 The most common product usability issues faced by patients and providers usually go unresolved due to limited funding for making changes.3,8 The lack of patient portal promotion in healthcare organizations has led to many individuals reporting a lack of awareness about their healthcare providers’ patient portals.5 Numerous studies examining patient portal usage have identified a “lack of awareness” as a barrier to facilitating the digital divide.2,9,11 Within healthcare organizations, factors such as staffing turnover, lack of reimbursement or financial incentives, healthcare providers’ patient-centric technology acceptance, and workflow designs have impacted the universal adoption of patient portals.12 Individual Level At the individual level, barriers such as computer literacy, health literacy, numeracy, privacy concerns, lack of interest, and lack of internet access have deterred patient portal usage.5 Information technology (IT) sophistication refers to how individuals regularly utilize various information technologies. Furthermore, lower IT sophistication is associated with individuals who do not use patient portals.3 Insufficient numeracy and eHealth literacy skills deter individuals from using patient portals because they cannot understand their health information.4 5 Past societal structural barriers and injustices experienced by historically marginalized populations have eroded the trust of many individuals who are reluctant to use patient portals.8 This distrust exacerbates privacy and security concerns about patient-centric technologies among vulnerable populations.1,8,13 Patient demographic and socioeconomic factors, such as age, gender, race, ethnicity, income, level of education, type of insurance, health conditions, digital access, and frequency of internet usage, impact patient portal utilization.5,8 The non-users of patient portals who were not offered access were more likely to be members of racial minority groups, males, age sixty-five or older, with less than a college degree, unemployed, resident in a rural area, receiving Medicaid, and not having a primary care provider.10 Patient portal users were more likely to be between 18 and 64 years old, female, non-Hispanic White, married, commercially insured, have one or more chronic conditions, have higher eHealth literacy levels, higher educational attainment, and lower healthcare utilization.2,12 Individuals who regularly use computers and other information technology devices are expected to adopt and use patient portals more frequently than those with inadequate digital access and less experience with technology.3,8 Healthcare Providers’ Perceptions of Patient Portals Studies have shown that healthcare providers’ attitudes toward technology, perceived ease of use, and perceived usefulness can contribute to patients' willingness to use patient portals.11 Assessing healthcare providers’ acceptance of technology is vital to supporting and engaging patients through their attitudes, behaviors, and endorsement of health information technology (HIT) services. To protect and secure personal health information in patient portals, healthcare providers must offer patients an invitation via email or text for registration.1 Generally, the front office personnel are the gatekeepers to patient portal invitations; therefore, staff attitudes of 6 resistance or discontent with patient portals undermine any promotional efforts by other healthcare professionals within an organization. Healthcare providers’ acceptance and encouragement of patient portal use are crucial for improving health outcomes.14 Healthcare providers’ perceptions and the offering of patient-centric technology may perpetuate low patient portal utilization rates.10,14 The literature investigating patient portal utilization found that many non-users reported being unaware of the existing patient portal access. Several studies found that 30-40% of individuals reported being unaware of patient portals; furthermore, many of the patients not offered portal access were members of racial minority groups, had a high school diploma or less, and were Medicaid insurance beneficiaries.5,10.11.15 Healthcare providers can positively impact patient portal utilization rates by offering equitable access to portals, promoting their benefits, and educating patients on the use of patient-centric technology. Role of Public Health In North Carolina, local health departments (LHDs) promote the health of their respective communities while also organizing and delivering healthcare services to uninsured individuals, Medicaid recipients, and other vulnerable populations.16,17 As safety net providers, LHDs play a pivotal role in promoting patient portal utilization among historically marginalized populations and those with limited English proficiency (LEP).9 Social determinants of health influence the health status of vulnerable populations; therefore, patient portal utilization may not be a priority without encouragement, resources, education, and support. Unlike most healthcare organizations, where the promotion of EHR patient portals is limited to front-line and medical personnel, LHDs are well-positioned to address the disparities and advocate for universal patient-centric technology use across their comprehensive services. Leveraging the extensive outreach capacity 7 of LHD employees can significantly boost efforts to encourage vulnerable populations to adopt and use patient portals. Statement of Problem Patient portal utilization is crucial for advancing population health outcomes by empowering patients to practice self-management and improving patient-provider engagement.11 Numerous studies have shown that various factors impede the progress of patient portal utilization nationwide.2,8-10 Despite multiple studies investigating the barriers and facilitators of patient portal utilization in primary care and outpatient practices, the literature is limited regarding the dynamics of personal patient portal utilization among healthcare professionals, the “advocates” or “recommenders” of portal adoption in medical practices and safety net organizations.9 Furthermore, understanding personal patient portal usage among healthcare professionals is crucial for reducing health disparities and improving health outcomes. This research examines the factors that influence the use of individual patient portals by local public health professionals, with the aim of promoting patient engagement with health information. Scope of Study Examining the factors contributing to patient portal usage among local public health professionals provides a foundation for exploring alternative approaches to facilitating patient portal utilization within communities. This study aims to identify the primary factors influencing the behavioral intention and actual use of patient portals among employees of local health departments (LHDs). The study's objectives are: 8 1) To examine the influence of performance expectancy, effort expectancy, “social influence”, and price value on the LHD employees’ behavioral intention to use their patient portals. 2) To assess the potential for heterogeneity in behavioral intention to use patient portals by race, age, gender, marital status, educational attainment, professional role, experience, and location. 3) To examine the influential drivers of behavioral intention and the use of behavior in recommending patient portals to new users. Research Questions The following questions guide this research: 1. How do performance expectancy, effort expectancy, social influence, and price value impact the behavioral intention to use patient portals? 2. How do demographic factors and experience levels influence consumers' acceptance and use of patient portals? 3. To what extent do influential drivers of behavioral intention to use impact recommending patient portals to new users? This study is a cross-sectional survey. Before participant recruitment and survey dissemination, the study will be submitted to the East Carolina University and Medical Center Institutional Review Board for review and approval. Convenience sampling strategies will be employed to recruit LHD employees to participate in the “Survey for Local Health Department Employees’ Perceptions of EHR Patient Portals.” The survey invitation will be emailed to North Carolina LHD employees with a Qualtrics survey link. Informed consent will be obtained before participants commence the survey. 9 Theoretical framework The theoretical framework for this study will incorporate the Unified Theory of Acceptance and Use of Technology 2 model (UTAUT-2), which assesses the success of new technologies and their influences on consumer acceptance.18 Incorporating some of the UTAUT- 2 model constructs in this study, the LHD employees are the “consumers,” which will help explain their behavioral intention and usage of patient portals.19 The UTAUT-2 model has been used to examine existing technological products and services, to predict consumer acceptance and use among new users.20 The UTAUT-2 model’s main variables of performance expectancy (perceived usefulness), effort expectancy (perceived ease of use), social influence (perceived belief others want individuals to use), facilitating conditions (perceived belief of organizational or technical support for use), hedonic motivation (perceived enjoyment), price value (costs of purchasing products and services), and habit (perform behavior automatically) act directly on behavioral intention to use, which can predict the use of technology.18 The moderators of UTAUT-2 are age, gender, and experience.18 Since this study investigates patient portal utilization of public health professionals who work continuously with multiple technologies and electronic health records (EHRs), adapted UTAUT-2 model determinants of interest were proposed. In the newly adapted UTAUT-2 model, the determinants were performance expectancy (PE), effort expectancy (EE), social influence (SI), and price value (PV). The adapted UTAUT-2 model requires testing consumer technology acceptance and usage predictors. This study will test the following hypotheses: • Hypothesis 1: Performance expectancy has a positive influence on the behavioral intention to use patient portals. 10 • Hypothesis 2: Effort expectancy has a positive influence on the behavioral intention to use patient portals. • Hypothesis 3: Social influence has a positive impact on the behavioral intention to use patient portals. • Hypothesis 4: Price value has a positive influence on the behavioral intention to use portals. • Hypothesis 5: Age, years of experience, marital status, and residence selectively moderate the relationships between the UTAUT-2 model constructs and behavioral intention to use. • Hypothesis 6: Behavioral intention to use portals will positively influence intention to recommend portals to new users. Significance of Research This research is significant because there is a gap in knowledge regarding the dynamics of personal portal utilization among healthcare professionals who are either “advocates” or “recommenders” of portal adoption in medical practices and safety net organizations. This novel study assesses the acceptance and use of electronic health record patient portals by LHD employees, which can help provide alternative approaches to recommending portals to others. In most healthcare organizations, the promotion efforts of patient portals are limited to front-line and medical personnel; however, local health departments are uniquely positioned to facilitate and encourage patient-centric technology use throughout their comprehensive services, such as care coordination, health education classes, supplemental nutrition programs, and various wellness outreach opportunities. The sizable outreach capacity of LHD employees can enhance promotional efforts to encourage vulnerable populations to adopt and use patient portals. The practical implications of this study are that the researcher can identify popularly used portal features, the geographical 11 location of portal usage, the determinants that drive patient portal usage, and the demographic characteristics of non-portal users. Furthermore, these practical implications may serve as the impetus for communities to seek infrastructure grants for broadband Internet services, promoting digital access in underserved areas and enhancing HIT promotional efforts. The study’s findings could help local public health leaders strategize to increase computer skills education for vulnerable populations, provide health literacy and numeracy education classes, and offer instructional tutorial sessions to help individuals learn how to use patient portals. This study aims to address the current research gap in healthcare providers’ perceptions of patient portals and promote innovative strategies for advancing digital health equity. Limitations This study has several limitations. First, this investigation only examines the personal patient portal usage of LHD employees, who do not represent the vulnerable population that the portal is intended to support. Second, quantitative research design has a survey with 32 questions to identify self-reported objective findings about patient portal utilization, which lacks in-depth perspectives. Third, there are biases associated with self-administered online surveys, such as nonresponse and social desirability response biases. The non-probability sampling strategy of convenience sampling will be used to select participants, which limits the applicability of the findings to a broader audience. The disadvantages of convenience sampling include multiple biases, such as sampling, selection, and positivity biases, as well as low external validity.21,22 The study focuses on LHD employees’ technology acceptance based on performance expectancy (PE), effort expectancy (EE), social influence (SI), and price value (PV) responses from an adapted UTAUT-2 model, which fails to investigate all the dimensions. Lastly, this study stops 12 short of examining follow-up patient portal adoption and use rates among vulnerable populations, as recommended by local health department employees. Summary Chapter One introduces the context of the study. The background section describes the history of patient portals, factors affecting patient portal utilization, healthcare providers’ perceptions of portals, and the role of public health. The statement of the problem defines the purpose of the research. The scope section highlights the research objectives, questions, theoretical framework, hypotheses, and methodology. The significance of the research section describes the importance of the research and its implications for public health. The study's limitations are described. The operational definitions are included for reference. Chapter Two will review the existing literature on the background and significance of patient portal utilization. The literature review will demonstrate the importance and relevance of HIT research in public health. The study’s theoretical framework, the adapted UTAUT-2 model, will be explained as the best fit for exploring the LHD employees’ acceptance and usage of patient portals. Chapter Three will explain the study’s methodology and justify the adoption of a quantitative research approach. This section includes the adapted UTAUT-2 model for study and explanation. The study instrument, Survey for Public Health Workforce’s Perceptions of Patient Portals, will be explained. Data collection and statistical analysis will be discussed. Chapter 4 presented the study's results, which addressed the research questions and hypotheses. The chapter will summarize the data examination and transformation conducted before statistical analysis. The descriptive statistical analyses, bivariate analyses, and multivariate analyses will summarize the study’s findings. 13 Chapter 5 discusses the results and interprets the study’s findings. The sections include the principal findings, managerial implications, study limitations, and future research directions. Chapter 5 will end with a conclusion to reiterate the study’s purpose, key findings, and significance. 14 Operational Definitions Healthcare Provider: employees of healthcare organizations who contribute to the medical care services provided at a patient’s visit.14 Public Health Workforce: individuals employed in local health departments. Patient-centric: patient-centered care Health Information National Trends Survey (HINTS): a United States health information self- administered survey mailed to adults > 18 years of age. Computer literacy: basic, nontechnical knowledge of how to use computers, tablets, and smartphone devices.8 Digital literacy: an individual’s ability to find, create, share, and communicate digital content.8 Numeracy: ability to understand and work with numbers.23 Health literacy: the ability to obtain, understand, use, and communicate information to make health-related decisions.24 Chapter 2: Review of Literature The demand for improving the quality of care and health outcomes has spurred a wealth of research on advancing patient-centric technology. However, most published studies on patient portal utilization focus on investigations in primary care and outpatient practices, leaving a significant gap in understanding patient-centric technology use in vulnerable populations. This study aims to fill this gap by exploring the role of LHD employees’ perceptions and use of their patient portals to find alternative approaches to encouraging universal portal adoption and usage. Chapter 2 describes the literature search methods and the synthesis of research discoveries on patient portal utilization, including HIPAA and health information technology, factors affecting use, views of patient-centric technology, strategies for optimal patient portal utilization, and concludes with the study’s theoretical framework. Literature Search Strategy The research topic encompasses several fields of literature, including medicine, nursing, psychology, health information technology, health management, and education. Keywords included, but were not limited to, patient portals, electronic health records, health information technology, utilization, barriers, facilitators, acceptance, emerging adults, safety net, population health, digital health, and rural communities. The literature search utilized PubMed, MEDLINE, CINAHL Plus, EBSCOhost, ProQuest, PsycINFO, and SAGE databases. All searches were limited to documents published in English. Google Scholar was used occasionally for backward reference searching. The sources of information included peer-reviewed journal articles, government statistics, and dissertations. Over 100 articles were identified with relevant information. Most of the articles used in this study were published within the last five years; however, the older articles 16 provided explanations of theoretical frameworks and assessed the progression of health information technology. The literature search for this research topic started in April 2023. (See Appendix D for Literature Search Strategies) Review of Literature Patient-centric technology is a game-changer for enhancing health outcomes and improving the quality of care. Patient portals support patient-provider engagement and promote individual empowerment and patient-centered care; however, they are underutilized. This literature synthesis focuses on factors influencing patient portal usage, disparities in portal use, perceptions of patient-centric technology, strategies for successful utilization, and implications for advancing patient-centric technology. HIPAA and Health Information Technology The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, standardizes the electronic exchange of health information privacy, access, and security.1 The HIPAA Privacy Rule protects individuals receiving healthcare and applies to any healthcare provider, health plan, and healthcare clearinghouse that transmits health data in electronic form for transactions.1 Under the HIPAA Privacy Rule, covered entities are required to protect patients’ identifiable health information from misuse and obtain a patient’s written consent to release it for treatment, payment, healthcare services, or commercial purposes.25 The emergence of the HITECH Act of 2009 modified the HIPAA Privacy Rule to promote patients' access to their electronic health information maintained by covered entities and their business associates.1 The HIPAA Privacy Rule encourages individuals to use their patient portals to access health information whenever possible.1,25 17 The HIPAA Privacy Rule stipulates that patients can access their protected health information in one or more designated record sets (DRSs) maintained by a covered entity.26 DRSs are defined as electronic medical and billing records maintained by or for a covered healthcare provider, including health plan enrollment, payment, adjudication, and claims records, as well as other records used for medical decision-making.26 In 2020, the Office of the National Coordinator for Health Information Technology (ONC) published the Cures Act Final Rule, which increased the availability of health-related data for patients and providers across smartphones by adopting secure, standardized Application Programming Interfaces (APIs).4 The Cures Act Final Rule promises to allow patients access to all electronic health information, expanding the HIPAA right of access policy and certified EHR functionality. 26 Factors Affecting Patient Portal Usage The Health Communication and Informatics Research Branch (HCIRB) of the Division of Cancer Control and Population Services (DCCPS) developed and administered the Health Information National Trends Survey (HINTS) in 2002-2003 to investigate cancer and health- related information.27 HINTS, a cross-sectional, nationally representative survey, collects data from US non-institutionalized adults.27 The HINTS data has provided valuable information about the evolving trends in health communication and health information technology by measuring health information-seeking behaviors, healthcare use and access, and technology use and access of survey participants.27 Furthermore, HINTS enabled researchers to test new health communication and information technology theories, determining factors and barriers to patient portal utilization. This literature synthesis comprises several studies that utilized secondary data from HINTS for their findings on health information technology, serving as a precursor for future studies. 18 Demographic & Socioeconomic Factors Anthony et al. (2018) utilized the 2017 HINTS 5 Cycle 1 to examine the characteristics of individuals who do not use patient portals. They found that 63% of insured adults who had a healthcare visit in the previous 12 months reported not using their patient portal, and over half reported not being offered access by their HCP or insurer.8 The nonusers who were not offered access were more likely to be male, members of racial minority groups, over 65 years of age, have less than a college degree, be unemployed, reside in a rural area, have Medicaid, and not have a regular healthcare provider.8 The nonusers who were offered access to their patient portals reported the following reasons for nonuse: reported a technological barrier, did not have internet access, did not have an online medical record, and privacy concerns.8 The study recommended that HCPs discuss the importance of offering the patient portal to “all” patients to prevent disparities in portal usage.8 The endorsement and communication of healthcare providers regarding patient engagement and care management would promote the use of these services among vulnerable patients. Additionally, healthcare providers must inform individuals that HIPAA safeguards patient portal usage to alleviate privacy concerns. Demographic and socioeconomic factors affect the utilization of patient-centric technologies. Mahmood et al. (2019) used 2017 HINTS 5 Cycle 1 data to assess the association between having a regular provider (65.3%) and access to the patient portal (29%).7 Andersen’s behavioral model was used to identify control variables that influence access to healthcare services. The researchers found that individuals who accessed patient portals were between 35 and 49 years of age, females, non-Hispanic Whites, never smokers, had some college education, had an annual household income >$75,000, had health insurance, had IT devices (tablet, computer, and smartphone), lived in an urban location, self-reported excellent or perfect health, and had two or more chronic medical conditions.7 Mahmood et al. found a significant association 19 between having a regular healthcare provider and access to the patient portal.7 Additionally, participants who accessed their patient portals were actively engaged in their healthcare by reviewing test results, securely messaging healthcare providers, scheduling appointments, requesting medication refills, and completing forms or paperwork related to their healthcare.7 In conclusion, having a regular healthcare provider increases the likelihood of patient portal utilization. El-Toukhy et al. (2020) utilized data from the 2017-18 HINTS 5 Cycles 1 and 2 to investigate the relationship between patient characteristics and levels of patient portal use, as well as the factors that facilitated its use. They also explored the relationship between individual user characteristics and the functionalities of patient portals.28 El Toukhy et al. found that 76.9% of the participants’ HCPs maintained EHRs, but only 47.2% reported being offered access to the patient portal.28 The researchers found that accessing patient portals was associated with internet access and device ownership, and that demographics and socioeconomic factors also influenced access to and use of patient portals.28 The female respondents were more likely to report that HCPs offered them access to patient portals than males.28Also, individuals with lower educational attainment were less likely to report that their providers offered them access to the patient portals.28 HCPs encouraged the use of patient portals more among females than males, with females reporting significantly higher patient portal usage. Individuals with limited English proficiency or those who are uninsured were less likely to have reported accessing their patient portals within the last year.28 In this study, the researchers found that respondents’ knowledge of patient portal functionality varied, with laboratory test results being the most popular known function and clinical notes being the least known.28 Individuals aged 60 years and older were more likely to 20 use the patient portal to refill medications.28 In contrast, individuals 18-39 years were more likely to use the patient portal to message their healthcare provider and make decisions.28 The researchers did not identify differences in patient portal access and use by race and ethnicity; however, they discovered differences in gender, educational attainment, and language proficiency.28 This study indicated that having a regular healthcare provider was associated with patient portal access, facilitators of use, and actual usage.28 Aggressive efforts should be directed toward the universal promotion of patient portals and their functionalities to underserved populations. Limited English Proficiency Effective communication between providers and patients is essential for understanding health information. However, using patient portals can be challenging for individuals with limited English proficiency, who may struggle to understand health information. Azevedo et al. (2022) conducted a study to demonstrate how the communication of health information differs for second language (SL) patients and to explore the potential benefits of SL use.29 The researchers proposed that SL users may exhibit weaker emotional reactions to content presented in English compared to their native language; furthermore, this distancing may impact their understanding, decision-making, and responses to health risks.29 SL use may influence attitudes toward and intentions to perform behaviors that address risk because these processes are manifested by risk perception, numeracy, and memory of the risk information.29 Azevedo et al. tested risk perception, numeracy, and memory of risk information using a simulated EHR patient portal with diagnostic test results in English from fictional patients.29 Azevedo et al. found that SL participants with higher or lower numeracy had a flatter slope for positive and negative emotional responses than English participants.29 The memory accuracy did not differ between English and SL participants.29 Affective distancing ensures dependency on 21 deliberative processes related to risk perception; therefore, SL participants reported a greater perceived risk as the objective risk increased in the scenarios than English participants.29 Also, SL participants reported greater behavioral intention and attitudes towards taking medications as the objective risk rose than English participants.29 This study stresses that SL users trust analytical, deliberative decision-making processes of health information.29 Using culturally and linguistically appropriate services (CLAS) during clinical visits and in communications via EHR patient portals to ensure health equity for SL users. Disparities Bhavsar et al. (2019) utilized the 2019 HINTS 5 Cycle 3 to investigate the differences in access to and use of patient portals among rural and urban respondents in the United States.30 The secondary data included 467 of the 4293 respondents who reported residing in rural areas.30 The researchers found that rural respondents were less likely to have had their healthcare providers offer access to a patient portal within the last 12 months.30 Furthermore, living in rural communities was associated with lower odds of using a patient portal in the last 12 months.30 Expanding broadband Internet services in rural areas should be lobbied with local governments to advance digital health equity. Using data from six cycles of HINTS (2014, 2017-2020, 2022), Richwine (2023) investigated the progress in patient engagement with electronic health technology and identified racial or ethnic disparities in access to patient portals.31 The measures of this study included the respondents' survey responses to being offered portal access by a healthcare professional, being encouraged by the HCP to use the portal, assessing their experience with the patient portal, and using the patient portal's functionalities.31 The study population comprised 22,266 diverse patients.31 22 In 2022, Richwine found increased racial and ethnic diversity among portal users; however, Black and Hispanic respondents reported being offered access and encouraged to use patient portals by their healthcare providers at significantly lower rates than White respondents.31 Most of the sample consisted of college-educated individuals who lived in urban areas, were covered by health insurance, and had access to the Internet.31 Also, Richwine found that Black and Hispanic respondents accessed a patient portal at significantly lower rates than White respondents. In contrast, there were no disparities in the use of patient portals among the respondents who accessed them, and they reported that health information was easy to understand.31 Black and Hispanic respondents who accessed a portal were more likely to download health information to a device than White respondents.31 (p. 5) Incorporating universal access policies and promoting patient-practitioner trust can help reduce disparities in patient portal access and use. Casacchia et al. (2022) conducted a cross-sectional analysis to examine the socioeconomic factors, comorbid conditions, and healthcare utilization among patients who used patient portals and assessed portal functions most often. The study included 178,720 patients who met the inclusion criteria; however, only 32% of these patients were portal users.2 Casacchia et al. found that the patient portal users were likely to be 18 to 64 years of age, female, non- Hispanic White, married, commercially insured, have more medical conditions, have a median household income of $51,250, have higher education attainment ( >college degree), and have lower healthcare utilization.2(p1056-1057) In this study, sending messages and viewing test results were the most frequently used patient portal functions.2 Casacchia et al. discussed the significance of disparities associated with patient portal utilization arising from healthcare providers' introduction of patient portals, individual comfort levels with technology, the lack of 23 broadband Internet access, and the digital divide among historically marginalized populations.2 This study highlighted the importance of marketing patient portals to vulnerable populations and the need for policy changes to improve digital access. Ukoha et al. (2019) conducted a retrospective cohort study investigating patient portal use during pregnancy and any disparities related to patient demographics or clinical characteristics.32 The study participants were 3,450 women who received prenatal care at an academic medical center between 2014 and 2016.32 The researchers found that 2530 participants were enrolled in the patient portal, and 72.09% of the enrollees were active portal users.32 Ukoha et al. found no difference in portal enrollment by maternal race and ethnicity; however, women with public insurance, late enrollment in prenatal care, and high-risk pregnancies were less likely to enroll in the patient portal.32 The factors associated with patient portal enrollment were nulliparity and having more than eight prescription medications at the first prenatal care visit.32 In this study, nulliparity was a significant predictor of active portal use.32 Tsai et al. (2019) conducted a retrospective analysis of patient portal usage to determine the characteristics of portal users. The dataset subset consisted of 505,503 patients; however, only 21.6% of these patients had portal accounts.33 The researchers found that the patient portal users were older and more likely to be female.33 Furthermore, Tsai et al. discovered differences in healthcare utilization between active portal users and those without portal accounts. Nonusers had fewer outpatient visits per month but more monthly emergency room visits than active portal users, which resulted in increased healthcare expenditures.33 This study demonstrated that digital health disparities affect the healthcare utilization of individuals. MacEwan et al. (2022) conducted a study to assess patient portal use by device, mobile application, or computer online website, and geographic location. The following geographic 24 comparators defined the location: proximity to a medical center offering portal access, urban/rural classification, and degree of digital distress (“lack of internet access and/or devices to use the internet”).34 The study included 172,979 active portal users, with 68.1% of participants using desktops and 31.9% using mobile devices.34 The researchers found that geographic location was the determining factor of portal use; patients who lived within the medical center county, urban counties, and counties with digital distress in <25th percentile were more likely to be active portal users.34 The patients’ geographic location influenced the type of device for portal access. The researchers found that mobile portal users tended to live closer to a medical center and in counties with digital distress above the 25th percentile.34 Healthcare providers should offer mobile and desktop patient portal formats to individuals to promote digital health equity. Liu et al. (2022) conducted a cross-sectional study to investigate the characteristics of active patient portal users and assess utilization among users in a rural academic primary care clinic. In this cohort study of 28,028 patients, Liu et al. found that 82% of patients used the portal, and active users were more likely to be female, between 41 and 65 years of age, and non- smokers.35 The study revealed disparities in portal use. Nonusers were patients who were typically males, active smokers, older patients, underweight, obese, and had chronic illnesses.35 The findings for portal use frequency showed that the average patient logged onto the portal 25 times per year and sent and received six messages to the clinic.35 Liu et al. emphasized that the availability of high-speed internet access and the expansion of smartphone use enabled patients residing farther away from the clinic to communicate with their healthcare team through the patient portal.35 Healthcare providers should continue to mitigate patient barriers to portal use through education, resources, and support, encouraging sustainable portal usage among all patients. 25 Individual Barriers Turner et al. (2020) conducted a cross-sectional study using the 2019 HINTS 5 Cycle 3 to assess the prevalence of barriers to patient portal adoption among nonadopters and examine the association between nonadopter characteristics and reported obstacles. The sample included 4815 survey respondents, with over half of the individuals not using patient portals.36 Turner et al. found that the predominant barriers to patient portal adoption included a preference for in-person communication, a perceived lack of need for the patient portal, low computer literacy, individuals' reported lack of access to patient portals, no Internet access, privacy concerns, difficulty logging in to portals, and the presence of multiple patient portals.36(p 5) The researcher found that females, older individuals, those with chronic conditions, those with a regular healthcare provider, and those with an income of less than $20,000 were more likely to indicate a preference for in-person communication.36 (p.5) Hispanic individuals reported not needing a patient portal.36 Individuals with chronic conditions, older adults, those with lower educational attainment, and households with incomes of less than $75,000 were significantly more likely to report low computer literacy.36 The nonadopters were more likely to be male, of black race, or Hispanic ethnicity, have lower educational attainment, lower income, live in rural communities, be unmarried, uninsured, without a regular provider, and have a lower quality of care health rating compared to individuals using patient portals.36 These findings should motivate healthcare providers to incorporate alternative approaches to bolster patient portal usage among diverse populations. Altinay (2023) employed the UTAUT model to investigate the factors influencing patient portal usage and enhancing patient engagement with health information. This study used cross- sectional national survey data from the 2020 HINTS 5 Cycle 4, which had 3,865 respondents.37 The UTAUT model was used to interpret data that could predict continued patient portal use and 26 examine the impact of demographic variables and types of health insurance on patient portal nonadopters.37 Since the UTAUT model was not widely used to investigate post-adoptive health technologies, Altinay introduced additional dimensions pertinent to healthcare, thereby improving the consistency of the model’s predictability.37 The dimensions included were “poor perceived health,” “type of insurance coverage,” “past interaction with health-related data via an electronic device,” and “frequency of provider visits” to evaluate nonadopters of patient portals.37 “Frequency of provider visits” was considered a facilitating and moderating variable in the UTAUT model because more frequent provider visits demonstrate increased healthcare needs.37 Altinay found that “continued use of patient portals’ was associated with respondents' “perceived ease of use,” “past interaction with health-related data via an electronic device,” “frequency of provider visits,” and “poor perceived health.”37 Race/ethnicity was not significantly associated with specific reasons for not using patient portals; however, Non- Hispanic White respondents were 2.3 times more likely to report a lack of need for patient portals than other racial or ethnic groups.37 (p.804) The increasing age of respondents was associated with a decreased level of computer literacy.37 In this study, male respondents reported a greater likelihood of not accessing patient portals due to a lack of Internet access and a perceived lack of need for patient portals.37 Altinay found that Medicare respondents reported not using patient portals due to a lack of Internet access and lower computer literacy. Due to privacy concerns, a higher proportion of Medicaid respondents were non-adopters of the patient portal.37 Identifying the predictors of underutilization of patient portals enables healthcare providers to implement targeted improvement strategies. 27 Assessing a patient's capacity to use the patient portal can provide insight into their readiness to use other health information technology tools, such as telehealth. McAlearney et al. (2021) examined and tested factors related to patients’ capacity to use a patient portal.38 Using the Engagement Capacity Framework, which encompasses self-efficacy, resources, willingness, and capabilities, the researchers mapped data responses from 698 hospitalized patients who completed the survey items of a large-scale pragmatic randomized controlled trial of patient portal use.38 The study findings showed that patients with limited resources, lower capabilities, lower willingness, and lower overall capacity to use portals were less likely to use patient portals.38 Conversely, individuals with lower perceived self-efficacy used patient portals more often.38 McAlearney et al. found that patients with higher household incomes across all three capacity level scores used patient portals more frequently, along with sicker patients.38 As healthcare approaches more virtual care options, vulnerable populations are at greater risk of health technology disparities; therefore, universal patient portal access and training are paramount to improving health outcomes. Asagbra et al. conducted a novel study investigating how varying levels of information technology (IT) sophistication were associated with individual patient portal usage. IT sophistication refers to the extent of an individual's regular use of various information technologies, including computers, tablets, the internet, smartphones, and social media.9 The researchers used a cross-sectional survey to assess IT sophistication and patient portal usage of 565 individuals.9 The researchers found that individuals with low IT sophistication were less likely to activate or use their patient portals than individuals with high IT sophistication.9 Furthermore, an individual’s technical skills could hinder their ability to activate and use a patient portal. The study reaffirms that healthcare providers should promote the use of patient 28 portals and offer support resources to individuals with limited experience in information technology. Digital Divide Zhong et al. (2020) conducted a study to investigate the characteristics of primary care patients using different patient portal functions and the impact on their clinical care. The research design was a retrospective, observational study with 17,580 nonusers and 4,312 users.39 To measure the impact on clinical care, the researchers evaluated rates of office visits, categorized as "arrived," "canceled," or "no-show," as well as the number of telephone encounters per quarter.39 Zhong et al. found that nonusers of the patient portals were more likely to be of Hispanic or Black race, males, unmarried, from an insurance type other than Blue Cross Blue Shield, with a high baseline active problem number (APN), and a high baseline no-show rate.39 Conversely, the researchers found that patients >30 years of age with a high baseline telephone encounter rate were more likely to use the patient portal.39 The mean portal log-in rate was 6.85 log-ins per user per quarter, and the most popular portal functions were messaging, laboratory services, appointments, and medication management. Zhong et al. found no differences between office visit rates and telephone encounter rates for non-users, and the rates for users remained unchanged after the adoption of portals. However, the no-show appointment rates were lower for portal users.39 The digital divide between historically marginalized populations is evident in patient portal adoption and active usage; therefore, identifying the barriers that deter usage is crucial to increasing universal patient portal utilization. Arcury et al. (2017) integrated two theoretical frameworks, the Technology Acceptance Model (TAM) and the Person-Environment Interaction Model, to determine modifiable factors affecting patient portal usage among older adults (over 55 years old) who received care at clinics 29 that predominantly served vulnerable populations.40 The study participants, 200 ethnically diverse patients, completed questionnaires and were recruited from one urban and two rural clinics.40 The study included 41 participants who reported using their patient portals and had the following characteristics: 37.5% were white, 9.2% were minority participants, 47.1% had higher education attainment, 25.4% were in worse health, 50.9% had adequate health literacy scores, 6.3% lived in rural areas, and 29.8% were married.40(p.6) Arcury et al. found that computer literacy, Internet access, and device ownership were predictors of patient portal utilization. The study found that 70.7% of users use their portal at least once a month, and 48.8% of portal users utilize at least four portal features.40(p.7) The study participants who received care at the rural clinics did not utilize at least four patient portal features nor positively perceive patient portal attributes.40 This study confirmed that digital access is a social determinant of health. Policies to address digital health disparities, such as Internet access in rural and low-income areas, computer skills training for older adults, education, and resources to improve health technology advancements, are needed to increase universal patient portal utilization. Tuan et al. (2022) conducted a five-year, retrospective study to examine patient portal utilization in 18 family medical clinics. They analyzed patients' time and portal feature use patterns and identified user characteristics. The study participants included 74,147 patients who had online portal accounts, and the portal users were more likely to be female, younger, non- Hispanic white, have commercial insurance, and have a chronic illness.41 Tuan et al. found that 95.7% of the participants had access to the patient portal during the study period; however, the high portal access rate was skewed by 25.9% of those users, accounting for more than half of the total portal access time.41(p.561) 30 In this retrospective study, the popular patient portal features were messaging, health information management, billing/insurance, and resource/education. Patients over> 65 used the resource/education feature more than younger patients.41 The researchers found that minority patients were less likely to use online features in messaging and health information management domains.41 Individuals living in areas with greater Internet access and higher education attainment levels were more likely to use messaging features.41 The researcher found that participants residing in lower-income areas spent more time viewing and using the health information management and billing/insurance domains.41 HCPs should continue encouraging patients to use portals, but educate them on the various features. Addressing the digital divide challenges can improve and sustain patient portal utilization. Health Literacy Individuals with low health literacy often struggle to find and effectively utilize health information. Mackert et al. (2016) investigated whether health literacy is associated with patients' use of health information technology tools, including fitness and nutrition apps, activity trackers, and patient portals.24 Furthermore, the researchers investigated whether health literacy was associated with patients’ perceived ease of use and usefulness of HIT tools.24 The study comprised 4,974 adults who completed the Newest Vital Sign measure of health literacy and indicated their use of HIT tools.24(p.4) In this study, 2,087 adults had used a patient portal, with 1,883 participants having adequate health literacy scores compared to 204 participants with low health literacy scores.24(p.5) Mackert et al. found that adequate health literacy scores were significantly associated with greater perceived ease of use and perceived usefulness across all HIT tools, especially patient portals.24(p.9). This study highlighted the importance of developing HIT tools that consumers with lower health literacy levels can use to improve and sustain continued patient portal usage. 31 The Technology Acceptance Model (TAM) guided a study assessing patient portal satisfaction. Wong et al. (2019) hypothesized that health literacy, computer literacy, and HIT usage correlated with patient portal satisfaction.42 The researchers developed a survey comprising three validated instruments: the End-User Computing Satisfaction (EUCS) survey, the Computer Attitude Measure (CAM), and the Brief Health Literacy Screen (BHLS). The study included 5880 participants who met the study criteria, with the following results: 87% were satisfied with the patient portal, 86% had computer literacy, and 95% had high health literacy scores.42(p.459) The study participants frequently used portals for messaging, labs, appointments, medications, and immunization functions.42 (p.459) Wong et al. found that computer and health literacy were attributed to high satisfaction levels in patient portals.32(p.459) Assessing patient satisfaction with patient portals effectively improves the functionality and usability of portals for increasing usage among individuals with lower computer and health literacy levels. High eHealth literacy scores in older adults with chronic conditions were associated with greater patient portal use, as these individuals can access health information from electronic sources and apply the knowledge gained to address health issues.15 In contrast, Wright et al. found that eHealth literacy was not a predictor of patient portal usage among diverse 340 emerging adults (ages 18-29) at two universities.15 Over half of the emerging adults reported using at least one portal feature.15 In this study of emerging adults, the factors associated with higher use of clinical portal features included being Asian or Hispanic, having higher scores in patient engagement, and having more healthcare encounters in the six months.15 The researchers concluded that emerging adults are familiar with the internet and online information sources but do not seek health information; therefore, eHealth literacy is not a driver for using portals.15 32 HCPs should continue to recommend patient portals to emerging adults in concurrence with improving their eHealth literacy skills for preventive health management. Self-Efficacy Park et al. (2020) conducted a secondary data analysis using 2017 HINTS 5 Cycle 1 to examine the causal relationship between patient portal usage and patients’ self-efficacy in obtaining health information and performing self-care. The study’s sample included 1,003 of the 3,198 respondents who self-reported using a patient portal.43 The characteristics of portal users were more likely to be <65 years of age, females, White, married, non-Hispanic, with higher household income, higher educational attainment, and covered by employer-provided insurance.43 Furthermore, the researchers categorized patient portal usage behavior for the 1,003 users as follows: 49% reported using portals 1-2 times, 31% reported using portals 3-5 times, 10% reported using them 6-9 times, and 9% reported using them >10 times within the past 12 months.43 (p. 6) Of the 1,823 respondents who were not encouraged by their healthcare providers to use the patient portal, approximately 10% used it at least once without their endorsement.43 Park et al. found that more respondents with positive self-efficacy outcomes were recommended to use portals by their healthcare providers.43 The study demonstrated that increased patient portal usage has a causal effect on self-efficacy in obtaining health information.43 The researchers defined the causal effect as an indicator that as respondents increased their patient portal usage intensity to a higher tier, they became more confident in obtaining health information.43 The staggeringly high number of nonusers suggested that many individuals were not encouraged by their healthcare providers to use the patient portals, which negatively impacted their self-efficacy. Healthcare providers’ endorsement has a significant influence on patient portal utilization. 33 A study conducted by Agrawal et al. (2021) used secondary data collected by the 2019 HINTS 5 Cycle 3 to examine the system determinants and patient characteristics that influence the level of patients’ portal use. The researchers employed an extended version of the Patient Technology Acceptance Model (PTAM), incorporating additional relevant patient characteristics—health conditions, issue involvement, preventive health behaviors, and caregiving status — to investigate their effects on the adoption and use of patient portals.44 The sample size consisted of 2100 respondents. Agrawal et al. found that performance expectancy was statistically significant for higher patient portal use, whereas the effort expectancy construct was positive but not statistically significant.44 The researchers discovered that perceived behavioral control, health knowledge, caregiving status, issue involvement, chronic conditions, preventive health behavior, and issue involvement were statistically significant drivers of higher levels of patient portal use.44 Issue involvement signifies individuals’ self-management of health and motivation to make health- related decisions. Additionally, Agrawal et al. found that patients’ chronic conditions had greater “issue involvement,” which significantly increased the magnitude of patient portal use.44 The study recommended that the significance of perceived behavioral control should motivate healthcare providers to develop high-quality training modules and end-user support services to increase patient portal utilization.44 Privacy & Security Concerns Kisekka et al. (2021) employed the Theory of Planned Behavior (TPB) model to investigate the obstacles, including privacy and security concerns, that deter individuals from using patient portals. The TPB model suggests that the intention to engage in a specific behavior is guided by attitude toward the behavior, subjective norms, and perceived behavioral control. Therefore, the researchers hypothesized and tested the TPB determinants of privacy awareness, 34 security awareness, perceived benefits, and perceived support.45 The study included 836 survey respondents.45 Kisekka et al. found that attitude was the strongest predictor of intention to use patient portals, followed by subjective norms and perceived behavioral control.45 Privacy and security concerns negatively impact attitudes toward patient portal usage, while the perceived benefits and support strengthen these attitudes. Perceived support had a statistically significant relationship with subjective norm and perceived behavioral control.45 This study showed that privacy and security concerns can deter individuals from using patient portals. Furthermore, HCPs can mitigate privacy and security concerns by educating individuals about HIPAA and the safeguards in place to protect personal health information. Many healthcare organizations and providers face challenges with sustaining patient portal usage. Moqbel et al. (2022) conducted a study using the cognitive dissonance theory (CDT) to examine the role of healthcare provider encouragement and patients’ security concerns in influencing continuous use intention and deep structure usage among portal users. This study confirmed that healthcare providers’ encouragement helped increase the continuous use intention and deep structure use of portals in 177 patients; however, security concerns hindered them.46 Moqbel et al. found that the social influence of CDT helped reduce the negative impact of security concerns on portal use; therefore, healthcare providers' encouragement and addressing of security concerns alleviated patients’ apprehension.46 Healthcare providers should address portal security concerns during the HIT promotion and provide resources and support for patients' sustained use. Psychological Factors Fatehi et al. (2020) investigated the psychological and demographic factors associated with patient portal usage among people seeking musculoskeletal specialty care. In this study, 35 4676 patients completed a survey about patient portal usage, which included additional questions to measure depression symptoms (Patient Health Questionnaire-2, PHQ-2) and anxiety symptoms (General Anxiety Disorder-2, GAD-2).47 Fatehi et al. found that the patient portal users were associated with fewer symptoms of depression and anxiety, were younger, were English-speaking patients, were patients visiting a back or neck care team, and had a higher number of completed visits.472081) This innovative study featured a psychological screening for healthcare providers to identify behavioral factors that impede patient portal utilization. The findings also revealed other factors that influenced patient portal utilization, such as geographic location and differences in medical conditions, which could prompt healthcare providers to adjust their marketing strategies and allocate additional resources to enhance patient portal utilization. Organizational Barriers Niazkhani et al. (2020) conducted a systematic review to identify the association between the types of barriers to adopting and using patient portals experienced by patients, providers, and caregivers and to analyze their magnitude in chronic disease care. The researchers employed the Personal Health Record Adoption Model (PHRAM) and the UTAUT model to identify barriers associated with patient portal utilization, as determined in 60 studies.48 Niazkhani et al. found that other key factors related to health status, computer literacy, preference for direct communication, and personal coping strategies deterred patients from using patient portals.48 The factors affecting the adoption and use of patient-centric health technologies in healthcare organizations included healthcare providers’ lack of interest or resistance to adopting patient portals due to increased workloads, inadequate reimbursement, and insufficient patient user training.48 The technological barriers for patients and providers included concerns over the privacy and security of information, patient caregivers’ access to their information, 36 interoperability with electronic health records, and a lack of customized features for chronic conditions.48 This study stressed the importance of healthcare organizations planning and re- designing workflows before promoting and implementing EHR patient portals. Technology Acceptance of Patient Portals The HITECH Meaningful Use incentives were dissolved several years ago, leaving healthcare providers to promote Health Information Technology to their patients to improve healthcare quality and outcomes while simultaneously striving to reduce healthcare costs. Investing in Health Information Technology (HIT), with a focus on patient portal adoption and usage, offers several advantages for both providers and patients. Clinically integrated networks (CINs) and health insurance plans provide incentives to healthcare organizations to improve the quality of care metrics for individuals with chronic conditions.49 Accepting HIT by healthcare providers and patients is crucial for facilitating the equitable adoption and use of patient portals. Several theoretical framework models were implemented in research to investigate the acceptance of health information technology among healthcare providers and patients. Healthcare Providers’ Perceptions In a cross-sectional study, Yousef et al. incorporated an adapted UTAUT model to investigate the predictors of healthcare providers' (HCPs') acceptance of personal health records, using the behavioral intention to recommend them to patients. In this study, the researchers sought to understand the perspectives of healthcare professionals (HCPs) on patient-centric technology and its potential influence on patient adoption. Therefore, HCPs from various disciplines completed a 51-item self-administered survey.14 The study included 246 HCP surveys, and the findings were as follows: 91.5% of the HCPs were aware of the EHR patient portal, 86.6% of HCPs had an account, 82.1% used the portal, and 80.5% of the HCPs recommended it to patients.14 Yousef et al. found that “performance expectancy” and “attitude” 37 were significantly associated with behavioral intention to recommend PHRs to patients.14 In conclusion, the HCPs' endorsement of patient portals led to 58.7% of patients using them.50 Miller et al. conducted a qualitative study to investigate how administrators, clinic staff, and healthcare providers (HCPs) who provide care to low-income adults viewed patient portals.51 In this study, 20 healthcare professionals were interviewed about their views on potential benefits, areas of concern, and hopes for the future of patient portal utilization. The participants viewed the implementation of patient portals as “mandated technologies rarely used by older adults and another workplace job task.”51 The participants categorized the potential disadvantages of the portals as threats to practice, patients, and systems. The threats to practice included concerns about being inundated with numerous portal messages, restructuring workflows to ensure portal coverage, reduced office visits with healthcare providers, and liability concerns related to communicating health information.51 Patient portal utilization was a threat to patients, causing patient confusion and anxiety, alienating older patients, and expanding health disparities.51 The participants viewed portal usage as a threat to the system because of potential data entry errors, system failures, and privacy concerns.51 Conversely, the researchers found that participants viewed office efficiency, patient or caregiver access to health information, and information sharing with other healthcare professionals as potential benefits of the portals.51 The participants commented that the low uptake of portals discourages healthcare professionals from using them to communicate with patients.51 Furthermore, participants who provided services to vulnerable patients perceived portal utilization as a burden for individuals with lower educational attainment levels, a lack of home internet access, and limited computer literacy.51 This study confirmed the importance of 38 technology acceptance among healthcare providers and patients for facilitating patient portals as a healthcare information technology (HIT) to provide value to care and improve quality. Janssen et al. conducted a qualitative study using the UTAUT framework to understand healthcare teams’ experiences with using a patient portal and investigate the barriers and facilitators that promote continued use. The researchers identified nine themes aligned with the four UTAUT model constructs through post-launch interviews with 11 healthcare professionals.52 Under the performance expectancy determinant, participants provided positive feedback on the experience design, which described how the intended functionality influenced the use of the portal; however, they had concerns about the technical reliability.52 For the effort expectancy determinant, participants emphasized that the portal should be integrated into the daily clinic workflow and that it would improve patient and caregiver efficiency.52 The researchers found that the participants expressed positive patient feedback and recommended others to use portals as a social influence determinant.52 The participants were pleased with the portal’s integration with other systems under the facilitating condition determinant. However, they were concerned about technical and implementation support when the portal was universally offered to all patients.52 The participants expressed that technical issues could deter some patients and caregivers from continuing to use portals. Healthcare professionals view patient portal utilization as beneficial for both patients and caregivers.52 An improved workflow, along with adequate technical and implementation support, would encourage and sustain the use of the portal among patients and providers. Patients’ Perceptions Yousef et al. used the UTAUT model to explore the predictors of patient intention to use patient portals. The study included 261 adult patients who completed a cross-sectional survey to assess the intention to use portals.50 The researchers found that performance expectancy, effort 39 expectancy, and positive attitude were associated with behavioral intention to use the patient portal.50 Furthermore, this study confirmed that individuals will use patient portals if they are beneficial and easy to use. Yousef et al. found that social influences, such as healthcare provider endorsement of portals, did not impact patients’ adoption of portals.50 Others may influence attitudes, such as friends, family members, healthcare providers, and other healthcare professionals; therefore, promoting patient portals can encourage positive attitudes that lead to portal adoption.50 This study did not assess the participants' actual usage of patient portals to confirm technology acceptance. Velverthi et al. investigated the behavioral intentions of emerging adults aged 19-29 regarding the adoption and use of patient portals.10 The researchers integrated the Technology Acceptance Model, Perceived Risk Theory, and Personal Innovativeness into the survey administered to university students.10 The study sample included 164 completed survey responses, with 64.6% of the participants having no experience with patient portals and 34.8% having prior knowledge.10 The study findings showed that participants perceived higher levels of risk negatively influenced their perceived ease of use, perceived usefulness, and behavioral intentions to use patient portals.10 The researchers found that perceived ease of use did not motivate emerging adults to adopt or utilize patient portals; however, a positive correlation was observed between perceived usefulness and behavioral intentions to use portals among the study participants.10 Higher levels of personal innovativeness were associated with individuals who take risks and find portals easy to use and beneficial.5 Patient portal promotion strategies should be tailored to various groups to maximize adoption and usage. Healthcare providers should discuss the portal's privacy and security features with all patients to alleviate perceived risks 40 Hoogenbosch et al. conducted a cross-sectional study in university hospital clinics to investigate the prevalence of portal use and the characteristics of patients who used and did not use portals. The original UTAUT model was employed to examine the acceptance of HIT technology among 439 participants.11 The study found that 32.1% of portal users, 32.2% of non- users, and 36.6% were unaware of portals.11 Being chronically ill and having higher eHealth literacy scores were predictors of portal use.11 Conversely, Hoogenbosch et al. found that the “effort expectancy” and “performance expectancy” constructs of UTAUT significantly influenced portal use among both aware users and nonusers, regardless of health status and eHealth literacy.11 Most of the users reported satisfaction with using the portals.11 This study emphasized the importance of promoting patient portals to individuals during medical visits, assessing the eHealth literacy skills of patients to increase the adoption and use of these portals. Ordaz et al. conducted a qualitative study of Black Americans' primary care experiences to explore the use and perceived value of patient portals. The study employed an inductive theme analysis based on eight remote focus group interviews with 29 Black American patients, aged 30-60 years, who regularly accessed portals.53 The theme of “Optimization of care” described the value of patient portals as a mechanism to keep providers and patients informed and organized. The participants emphasized that portals facilitated communication with the healthcare team, allowing them to review medical histories before appointments, check medical test results, integrate portals into their treatment, and reduce the number of appointments.53 “Patient empowerment” was another theme that helped participants view educational resources, document health concerns on the portals to reduce in-person anxieties, reciprocity in patient- provider communication of medical treatment plans, and the ability to share portal information with family members.53 41 The theme of “Patient-Provider Communication” was discussed. The participants found that patient portals enhance their interactions with their healthcare team, thus increasing their engagement with providers.53 The participants valued the provider's response time and thoroughness; however, they were concerned about receiving delayed, confusing, and terse messages from providers.53 The last theme of the focus group interviews, “