Research Article: Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal

Date Published: June 19, 2019

Publisher: Public Library of Science

Author(s): Mary E. Reed, Jie Huang, Richard J. Brand, Romain Neugebauer, Ilana Graetz, John Hsu, Dustin W. Ballard, Richard Grant, Sreeram V. Ramagopalan.


For patients with diabetes, many with multiple complex chronic conditions, using a patient portal can support self-management and coordination of health care services, and may impact the frequency of in-person health care visits.

To examine the impact of portal access on the number of outpatient visits, emergency visits, and preventable hospitalizations.

Observational study comparing patients’ visit rates with and without portal access, using marginal structural modeling with inverse probability weighting estimates to account for potential bias due to confounding and attrition.

Large integrated delivery system which implemented a patient portal (2006–2007).

We examined 165,447 patients with diabetes defined using clinical registries. Our study included both patients with diabetes-only and patients with multiple complex chronic conditions (diabetes plus asthma, congestive artery disease, congestive heart failure, or hypertension).

We examined rates of outpatient office visits, emergency room visits, and preventable hospitalizations (for ambulatory care sensitive conditions).

Access to a patient portal was associated with significantly higher rates of outpatient office visits, in both patients with diabetes only and in patients with multiple complex conditions (p<0.05). In patients with multiple complex chronic conditions, portal use was also associated with significantly fewer emergency room visits (3.9 fewer per 1,000 patients per month, p<0.05) and preventable hospital stays (0.8 fewer per 1,000 patients per month, p<0.05). In patients with only diabetes, the results were directionally consistent but not statistically significantly associated with emergency room visits and preventable hospital stays. Observational study in an integrated delivery system. Access to a patient portal can increase engagement in outpatient visits, potentially addressing unmet clinical needs, and reduce downstream health events that lead to emergency and hospital care, particularly among patients with multiple complex conditions.

Partial Text

Diabetes and other chronic diseases account for significant levels of morbidity and mortality in the United States, with an increasing proportion of patients living with multiple complex chronic conditions [1–3]. Multiple chronic conditions are associated with coordination challenges for both patients and health care providers, often across several clinicians and sites of care [1, 4–7]. This complexity can lead to less than optimal treatment, potentially redundant care, and preventable acute services [1, 7–24]. Patient portal tools that improve patient access to their own health information, support self-management, and help patients communicate asynchronously with providers offer an additional mechanism for delivering high-quality guideline-recommended care that can improve patient health [25, 26].

Among all study patients with diabetes (N = 165,477), 77.4% had multiple chronic conditions (diabetes plus one or more other conditions, Table 1). During the study period 22.3% of all study patients started to use the patient portal (see supplement).

Among patients with diabetes, particularly complex patients with multiple chronic conditions, we examined the association between portal access and office visits and health events as captured by ED visits and hospitalizations. We found that access to a patient portal was associated with engaging in significantly more outpatient office visits. When patients with multiple conditions had access to the portal, however, they were also less likely to have ED visits or preventable hospitalizations, suggesting a reduction in downstream clinical events associated with portal use.

Overall, we found that in patients with diabetes within an integrated delivery system offering a comprehensive patient portal, office visit rates were higher when patients had access to a patient portal compared to when they did not, and that portal access was associated with statistically significantly lower rates of ED visits and preventable hospitalizations in patients with complex chronic conditions. Together with patient partners in this patient-centered study, we interpret these findings as a signal that the portal may be helping to increase engagement in outpatient office visits, a preferable setting to potentially address otherwise unmet clinical needs, and thereby reducing downstream health events that lead to emergency and hospital care.