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Electronic patient portals are increasingly used in health care systems as communication and information-sharing tools and show promise in addressing health care access, quality, and outcomes. However, limited research exists on portal use patterns and practices among diverse patient populations, resulting in the lack of culturally and contextually tailored portal systems for these patients.
This study aimed to summarize existing evidence on the access and use patterns, barriers, and facilitators of patient portals among Chinese Americans, who represent a growing patient population in the United States with unique health care and health technology needs.
The authors conducted a literature search using the PRISMA Protocol for Scoping Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR) for extracting articles published in major databases (MEDLINE, Embase, and PsycINFO) on patient portals and Chinese Americans. Authors independently reviewed the papers during initial screening and full-text review. The studies were analyzed and coded for the study method type, sample population, and main outcomes of interest.
In total, 17 articles were selected for inclusion in the review. The included articles were heterogenous and varied in their study aims, methodologies, sample populations, and outcomes. Major findings identified from the articles include variable patterns of portal access and use among Chinese Americans compared to other racial or ethnic groups, with limited evidence on the specific barriers and facilitators for this group; a preference for cross-sectional quantitative tools such as patient surveys and electronic health record–based data over qualitative or other methodologies; and a pattern of aggregating Chinese American–related data into a larger Asian or Asian American designation.
There is limited research evaluating the use patterns, experiences, and needs of Chinese Americans who access and use patient portal systems. Existing research is heterogeneous, largely cross-sectional, and does not disaggregate Chinese Americans from larger Asian demographics. Future research should be devoted to the specific portal use patterns, preferences, and needs of Chinese Americans to help ensure contextually appropriate and acceptable design and implementation of these digital health tools.
The expansion of health information technology (HIT) has provided patients with tools to proactively access their health information, self-manage chronic conditions, and communicate directly with providers [
Chinese Americans are a population frequently under- or mis-represented in health care, health delivery, and health research [
To improve the effectiveness, acceptability, and use of digital health technologies such as patient portals among diverse communities, a better understanding of the use patterns and practices of the specific communities and their subgroups is needed. This scoping review summarizes the existing evidence on patient portal perceptions, adoption, and use among Chinese Americans, and it highlights gaps and areas for further research on patient portal and digital health technology use among Chinese Americans and other diverse patient populations.
The aim of conducting a scoping review is to identify and broadly describe knowledge and research pertaining to a topic of interest as well as to identify trends, patterns, and gaps in the literature. Scoping reviews are ideal for research areas where the study question is broad or exploratory, there is limited literature on the topic, or study methodologies are diverse [
The review was conducted following the PRISMA Protocol for Scoping Reviews ((Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR) [
US-based studies that described the inclusion and perceptions of Asian Americans (eg, Asians, Asian Americans, Chinese Americans, and Filipinos) toward electronic patient portals were included. Studies that identified Asian Americans only under the heading of “Other” without additional specificity were excluded. Patient portals were defined as web-based platforms that provided access to data from EHRs, including features such as medical histories, visit summaries, medication lists, as well as secure messaging features, access to educational resources, and appointment scheduling [
After duplicates were removed, 1505 articles remained. Titles and abstracts were screened using Covidence software [
PRISMA Flowchart showing the screening and inclusion process of the studies. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
In total, 17 articles were selected for inclusion in the review. A summary of each article, including the study design, sample information (including the level of Asian American population identified in the study), and key findings can be found in
Characteristics of studies that include identifiable data specific to Chinese Americans.
Study | Objective | Research design/tools | Sample population/level of Chinese American granularity and location | Patient portal technology/feature | Relevant results |
Ackerman et al (2017) [ |
To understand the implementation of patient portals in safety net health care systems striving to meet MUa criteria set by the Federal United States government | Mixed methods |
5 California safety net health systems. |
Patient portal (NextGen) implementation strategies and efforts at Site 5 |
Overall: |
Gordon and Hornbrook (2016) [ |
To identify racial or ethnic and age disparities among older patients’ use of patient portals and access to digital technology and devices for email and web-based health care management programs | Quantitative (cross-sectional, administrative data and survey) |
Study 1: English-speaking Chinese (n=6314), non-Hispanic White (n=183,565), Black (n=16,898), Latino (n=12,409), and Filipino (n=11,896) older patients aged 65 to 79 years. |
KPNC internet-based patient portal, kp.org, and other digital health technology and tools (eg, emails, text, computer, smartphones) | Compared to Black, Filipino, and Latino older patients, Chinese and non-Hispanic White older patients were more likely to be registered to use the patient portal and more likely to use portal functions. |
Gordon and Hornbrook (2018) [ |
To assess disparities by race/ethnicity and age on older patients’ ability to engage with online health information and mobile health tools connected to their health system | Quantitative (cross-sectional, survey) |
Stratified random sample of 5420 |
Digital health technology and tools (eg, internet, computer, mobile phone, email, text, social media, apps) | Chinese and non-Hispanic White older patients have higher levels of access to digital tools, experience in performing a variety of web-based tasks, and belief in their ability to seek health information on the internet compared to Black, Latino, and Filipino peers. |
Khoong et al (2020) [ |
To assess predictors of health technology use (eg, language preferences, smartphone ownership, type of clinic for health care) | Quantitative (cross-sectional, survey) | Nonrandom sample of 1027 participants |
Digital health technology and tools for communication with clinicians (eg, email, text, phone apps, web-based health videos, and online health support groups) | Relative to English-speaking survey respondents, individuals who preferred the Chinese language had lower odds of texting or using an app to communicate with their clinician. |
aMU: meaningful use.
bIT: information technology.
cEHR: electronic health record.
dKPNC: Kaiser Permanente Northern California
Characteristics of studies with aggregated Asian American data.
Study | Objective | Research design | Sample population/ level of Chinese American granularity and location | Focus | Relevant results |
Ahlers-Schmidt and Nguyen (2013) [ |
To obtain parents’ feedback and intention to use patient portals for their children’s health records and concerns post the facilitated learning session | Quantitative (cross-sectional, survey) | Parents of patients. (N=65) |
University of Kansas Pediatric Clinic’s eClinical Works, an electronic medical record with a patient portal | Most parents did not know about the patient portal before the study demonstration. |
Dalrymple et al (2018) [ |
To assess parents’ use of the internet for health information and parents’ awareness of digital health technologies to obtain health information |
Quantitative (cross-sectional, survey) |
Total sample population of parents or adult caregivers of children and adolescents, N=270 |
Internet and patient portal | Most patients reported having access to the internet and using the internet to seek general and health information. |
Foster and Krasowski (2019) [ |
To assess patient portal usage by EDa patients at an academic medical center using patient portal activation rates and rates of accessing diagnostic test results on patient portals | Quantitative (retrospective cohort, EHRb, and administrative data) | 25,361 unique ED patients identified via EHR patient portal records |
UIHCc patient portal (MyChart), connected to EPIC EHR system | Highest rates of using the patient portal to view laboratory and radiology results were observed for younger female, proxies, Asian, and White patients. |
Goel et al (2011) [ |
To examine the enrollment in and use of patient portal at an academic medical center by race/ethnicity, gender, and age | Quantitative (cross-sectional, EHR and administrative data) |
Patients enrolled in the patient portal system, N=7088 |
Northwestern Medical Faculty Foundation’s EHR patient portal | Significant disparities in patient portal enrollment by race/ethnicity were observed, but not by age or gender. |
Graetz et al (2016) [ |
To assess sociodemograp |
Quantitative (cross-sectional, survey) |
Total study participants from KPNCd, N=1041 |
Internet and email | Asian and Black respondents were more likely to rarely or never to use the internet (45.4% and 45.6%, respectively) compared to their White respondents. |
Ketterer et al (2013) [ |
To identify predictors of patient portal enrollment and activation among a pediatric primary care population | Quantitative (cross-sectional, EHR and administrative data) |
Total sample population N=84,015 |
Patient portal site, MyNemours | Adjusted odds of portal enrollment were lower for Asian respondents compared to White respondents. |
Lyles et al (2013) [ |
To understand how patient-provider relationships influence patients’ use of online patient portals and secure messaging | Quantitative (cross-sectional, survey) | Surveyed patients DISTANCEe |
KPNC’s internet-based patient portal, kp.org | White and Latino individuals with higher trust in the providers were more likely to register on the patient portal. |
Lyles et al (2016) [ |
To determine whether racial/ethnic minority patients’ use of the patient portal’s medication refill function has changed over time compared to White patients | Quantitative (EHR and administrative data) |
White (58%); |
KPNC’s internet-based patient portal, kp.org | Asian were not less likely to exclusively use refill functions than other ethnic groups. |
Miles et al (2016) [ |
To measure and evaluate the frequency at which patients use the patient portal to view online radiology reports | Quantitative (cross-sectional, EHR and administrative data) |
UW’sf patient portal system, UW eCare web portal | Asian respondents were more likely than White patients to view their radiology reports. |
|
Patel et al (2011) [ |
To determine low-income, ethnically diverse consumers’ attitudes and beliefs toward HIEg and use of HIE via PHRsh and to identify factors that impact consumers’ support for providers’ use of HIE and their own personal use of PHRs | Quantitative (cross-sectional, survey) |
BHIXi’s patients |
EHRs, internet, HIE, and PHRs | Compared to other racial/ethnic groups in the study, Asian Americans indicated lower levels of support for HIE (48%) and lower levels of potential PHR usage (67%). |
Sarkar et al (2010) [ |
To examine whether use of an internet-based patient portal differed between English-speaking patients with limited health literacy and English-speaking patients with adequate health literacy | Quantitative (cross-sectional, survey) |
Total of 14,201 surveyed participants from DISTANCE study |
KPNC’s internet-based patient portal, kp.org | Study did not find increased risk of not signing onto the patient portal for Asian Americans compared to African American, Latino, and Filipino respondents. |
Sarkar et al (2011) [ |
To examine portal use habits via the frequency at which participants requested a password for the patient portal, the proportion of participants who activated their accounts by changing the default password, and the proportion of participants who login to their accounts using their personal, customized password | Quantitative (cross-sectional, EHR and administrative data ) |
Total of 14,201 surveyed participants from DISTANCE Study |
KPNC’s internet-based patient portal, kp.org | Asian American (53%) and White (51%) participants were more likely than their African American (31%), Latino (34%), and Filipino (32) counterparts to request a password for the internet-based patient portal and to login to the patient portal after requesting a password. |
Tieu et al (2017) [ |
To measure participants’ satisfaction with use of patient portal | Mixed methods (cross-sectional, usability testing and survey) |
Total of 25 English-speaking (23 patients and 2 caregivers) participants. African American (n=9, 36%); White (n=6, 24%); Hispanic (n=2, 8%); |
RFPC’sj patient portal, MYSFHEALTH | Participants with limited health literacy, including Asian and Pacific Islander patients were more likely to need assistance navigating the patient portal. |
aED: emergency department.
bEHR: electronic health record.
cUIHC: University of Iowa Hospitals and Clinics.
dKPNC: Kaiser Permanente Northern California.
eDISTANCE: Diabetes Study of North California.
fUW: University of Washington.
gHIE: health information exchange.
hPHRs: personal health records.
iBHIX: Brooklyn Health Information Exchange.
jRFPC: Richard H. Fine People’s Clinic.
The included articles varied in terms of the study methodology, sample population, data collection methodology, and geographic area within the United States. Among these, 10 were from populations in California [
Overall, the articles described heterogenous results among varied patient populations, health conditions, and care settings. Few clear themes emerged and results specific to Asian American subgroups such as Chinese Americans were not identified. In general, the authors were able to identify the following major themes and trends from the results.
Chinese Americans demonstrate variable patterns of patient portal access and use as compared to other demographics, particularly racial or ethnic groups; exploration of the specific contexts of use, including barriers and facilitators, is limited.
Most studies employed cross-sectional, quantitative tools to assess patient portal use patterns and practices, including patient surveys and EHR-based data that measure portal activity (eg, logins and click-throughs); neither longitudinal nor significant qualitative research studies were conducted to validate or further explore nuances in findings specific to Chinese Americans.
Despite the heterogeneity of the populations included in AAPI designation, studies exploring patient portals do not disaggregate Asian and Asian American study populations into Chinese Americans and other subgroups.
Only 4 studies [
This represents a finding in the data across studies, with some demonstrating lower rates of use and others demonstrating higher rates and rates comparable to White patients. In a study on the use of the Northwestern Medical Faculty Foundation’s electronic patient portal [
Identified studies provided limited evidence on the barriers faced by Chinese Americans in using patient portals. For individuals, the main reported barrier was language congruency with the portal or related technologies, or English language proficiency. In a mixed methods study evaluating the implementation of meaningful use at community health centers in California, Ackerman et al [
Identified community and structural barriers were largely related to clinic-level resources and included the clinical staff’s ability to support patients’ engagement in patient portal technology and the paucity of language-congruent support services. In their rapid ethnography with clinical staff in safety net hospital–affiliated practices, Ackerman et al [
Among the 17 studies, 8 employed survey-based, numeric (eg, Likert scale) data collection tools disseminated using either digital tools (eg, email) or in person. Survey question areas ranged from portal familiarity and general perspectives to personal experiences, feature preferences, and self-reporting of details on use habits [
Of the 17 studies included in this review, only 4 specifically disaggregate or discuss Chinese Americans [
This scoping review highlights the extremely limited research on the use patterns, experiences, and needs of Chinese Americans who access and use patient portal systems for their health care. The identified studies were heterogenous in their approaches and outcomes, making generalizable trends in the data difficult to identify, although we were able to identify some patterns in the research methodologies and data collection tools across studies. By and large, the existing studies have focused on the identification of varying portal use patterns among racial, ethnic, and other demographics, and their correlative predictors such as age, primary language, or health literacy. Overall, the studies obtained mixed findings regarding the rates of portal usage by Chinese Americans when compared to other populations, with some indicating lower rates of portal adoption and use when compared to White patients and others finding comparable rates. We were unable to identify trends more granularly in terms of portal access within Chinese American subgroups (eg, women, geographic populations) due to limitations in the available data. We identified individual- and system-level factors that contributed to use patterns, as well as barriers to access and usage. Relevant individual-level factors included English language proficiency and language congruency with portal technology; health literacy; perceived usability and usefulness of the technology; and trust in provider relationships, privacy, and confidentiality. Relevant system-level factors included clinical resource and capacity limitations, and access to digital tools such as email and the internet. Studies tended to be cross-sectional and quantitative in nature, with minimal exploration of longitudinal trends in use patterns or practices, qualitative aspects, or correlation with health outcomes. Finally, we identified a pattern of data aggregation practices that tended to combine and compare Asian Americans as a larger demographic group to other racial or ethnic groups, rather than identifying data at the level of Chinese Americans or other subgroups. This practice had the effect of generalizing learning across Asian Americans, thus providing limited insight into the experiences of Asian subgroups of different ethnicities, languages, and religious affiliations, among other factors.
To our knowledge, this is the first study to evaluate the patient portal use patterns and needs of Chinese Americans. Prior research has explored various features of patient portal activity, use, and experience in other clinical contexts, including among Black and Latinx communities and vulnerable populations such as the older people and those with disabilities [
The findings of this study have important implications for the design and deployment of patient portals and other digital health tools (eg, EHRs, mobile health apps) as well as for the study of health technology usage among Chinese Americans, Asian subgroups, and other diverse or vulnerable patient populations. Overall, there is need for a more granular study focusing on the use of digital health technology by diverse communities to elucidate key differences in their needs, preferences, and constraints. Participatory design frameworks that incorporate diverse stakeholders to identify and address specific needs, preferences, and concerns regarding health care technologies can help inform more effective and sustainable implementation of these tools in clinical practice. Frameworks and methodologies that explicitly address digital health disparities and digital health equity, such as the equity-centered design framework [
There are several limitations to this study. We included only major databases (PubMed and Embase) and did not include unpublished or gray literature. We also limited our inclusion criteria to articles published only in English, excluding Chinese language biomedical databases such as the China National Knowledge Infrastructure. We further included only those articles focusing on populations in the United States. These criteria were established to ensure a focused review of our target community of interest, namely Chinese Americans, engaging with relatively similar health care delivery models and HIT technology. However, this may have resulted in the exclusion of relevant articles, particularly those published in Chinese language journals. Additionally, although the term “patient portal” included in our search string is broadly used, our search may have missed studies that incorporated portals, portal-like systems (eg, PHRs), or portal features without explicitly identifying them. We attempted to address this by performing a series of web-based searches (Google) and manual searches to identify articles using variable terms that could meet our inclusion criteria. Finally, our study did not systematically evaluate the quality of the data presented in the included studies beyond an assessment of the study design and the level of racial or ethnic granularity among Asian Americans; moreover, we did not evaluate the bias in these studies. Future areas of research may include expanded language contexts and further quality and bias evaluations.
There is limited research dedicated to understanding the use patterns, experiences, and needs of Chinese Americans who access and use patient portal systems for their health care. Most of the research in this area focuses on disparities in use and access across the aggregated racial and ethnic demographic of Asian Americans, potentially obscuring important differences among and between the diverse and heterogeneous populations that comprise this designation. Studies are also overwhelmingly quantitative, focused on surveys and administrative data from portal systems, and they lack longitudinal data. Future research should focus specifically on Chinese Americans and prioritize performing more detailed longitudinal and qualitative evaluations to understand why specific communities of patients access and use portals in the ways that they do. A broader understanding of the diversity of health technology users in general can help ensure that these tools are applicable and acceptable to all patients, including the most vulnerable, and do not contribute to disparities in health access, equity, or outcomes.
Ovid MEDLINE search strategy.
Asian Americans and Pacific Islanders
Diabetes Study of Northern California
electronic health record
health information exchange
health information technology
personal health record
This publication is supported by the National Institute on Minority Health and Health Disparities-National Institutes of Health (grant U54MD000538). The views expressed are those of the authors and do not necessarily represent the official position of the funding organization.
None declared.