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Health information technology tools (eg, patient portals) have the potential to promote engagement, improve patient-provider communication, and enhance clinical outcomes in the management of chronic disorders such as diabetes mellitus (DM).
The aim of this study was to report the findings of a literature review of studies reporting patient portal use by individuals with type 1 or type 2 DM. We examined the association of the patient portal use with DM-related outcomes and identified opportunities for further improvement in DM management.
Electronic literature search was conducted through PubMed and PsycINFO databases. The keywords used were “patient portal*,” “web portal,” “personal health record,” and “diabetes.” Inclusion criteria included (1) published in the past 10 years, (2) used English language, (3) restricted to age ≥18 years, and (4) available in full text.
This review included 6 randomized controlled trials, 16 observational, 4 qualitative, and 4 mixed-methods studies. The results of these studies revealed that 29% to 46% of patients with DM have registered for a portal account, with 27% to 76% of these patients actually using the portal at least once during the study period. Portal use was associated with the following factors: personal traits (eg, sociodemographics, clinical characteristics, health literacy), technology (eg, functionality, usability), and provider engagement. Inconsistent findings were observed regarding the association of patient portal use with DM-related clinical and psychological outcomes.
Barriers to use of the patient portal were identified among patients and providers. Future investigations into strategies that engage both physicians and patients in use of a patient portal to improve patient outcomes are needed.
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions [
Effective diabetes management requires continuous collaboration between individuals and their providers [
Patient portals, often referred to as tethered personal health records (PHRs), provide Web-based platforms for patients’ access to their health information from a health organization’s electronic health record (EHR). Patient portals were widely adopted by health care organizations in the late 1990s and gained greater attention when the Medicare and Medicaid incentive programs for EHR (a.k.a. Meaningful Use) implementation was initiated in 2011 [
Given the continuous increase in the prevalence of diabetes and the increasing development of patient portal applications, a review of the literature on the current use of patient portals in supporting patients with diabetes can be informative. In this review, we identified studies that used qualitative or quantitative methods to describe the state of science in the use of patient portals for diabetes management. Specifically, we evaluated the use of patient portals by patients with diabetes, including the portal functionalities, predictors of portal use, and the effects of portal use on diabetes-related outcomes. These findings provide opportunities for further approaches to improve diabetes management through the use of a patient portal.
Electronic literature searches were conducted through PubMed and PsycINFO databases. Keywords included “patient portal*,” “web portal,” “personal health record,” and “diabetes.” Additional articles were searched by identifying similar articles in PubMed and manually reviewing the bibliography of published papers in relevant articles. The literature search was limited to publications in the English language and peer-reviewed articles, but no restrictions as to the country in which the study was conducted were imposed.
Articles selected were based on the following inclusion criteria: (1) published in the past 10 years (2007-2017), (2) used the English language, (3) study participants were adults (ie, age ≥18 years), and (4) available in full text. Studies using both quantitative and qualitative methods were included in this review. The focus of the selected articles was a patient population of adults with either type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM). Studies were excluded if the portal was designed for parents of children with diabetes.
The initial search from PubMed and PsycINFO retrieved 128 articles after filtering out 11 articles that did not meet the inclusion criteria. We removed 8 duplicates, which reduced the number to 120 articles for review of the title and abstract. The assessment of these 120 articles resulted in a further removal of 74 articles, including 63 that were not relevant, 5 articles that focused on children, and 6 articles that applied mobile apps for diabetes management. Thus, a review of full text was conducted on 46 articles based on the aforementioned inclusion criteria, and 17 were excluded because of the use of stand-alone Web portals that were not connected to any health care organizations, and, in addition, 2 review papers were excluded. We later added 3 additional articles by searching the bibliography of previously published literature reviews. Therefore, a total of 30 articles were included in our study (see
Flow diagram for paper selection process.
Randomized controlled trials examining patient portal for diabetes management.
Authors, country | Study aims, design, and level of evidence | Sample and retention | Patient portal features | Intervention | Outcomes (portal related) | Findings |
van Vugt et al (2016) [ |
2-group study, 6-month randomized controlled trial (RCT) to study the uptake and effects of e-Vita with a self-management support program (SSP) and personalized coaching for patients (Ps) with type 2 diabetes mellitus (T2DM); Evidence: Grade A | N=132; males: 59.1%; white: 91%; age: 67.9 (SD 10.4) years; body mass index (BMI): 30.2 (SD 5.2); glycated hemoglobin (HbA1c): 6.6%; retention: Coaching group (CG): 43.9%; noncoaching group (NCG): 59.1% | e-Vita (diabetes mellitus [DM]-specific) by VU University Medical Center allows Ps to access diabetes education; access data from electronic medical records (EMRs) of primary care physicians (PCPs); receive messages from providers; receive SSP | CG (n=66): Personal health record (PHR)+SSP+coaching; NCG (n=66): PHR+SSP | HbA1c, BMI, systolic blood pressure (SBP), diastolic blood pressure (DBP), cholesterol, diabetes self-care, diabetes-related distress, and PHR and SSP use | Intention-to-treat (ITT) was applied. PHRs were assessed by 128 Ps, of which 59 Ps never returned to the PHR. The use declined over time. The SSP was used by 5 Ps in the CG and 1 patient in the NCG group, 3 of whom asked a coach for feedback. Ps recently diagnosed actively used the SSP; no differences were observed on outcome measures between baseline (BSL) and 6 months for the 2 groups. |
Tang et al (2013) [ |
2-group study, 12-month RCT to evaluate an Web-based disease management system by Ps with uncontrolled T2DM; Evidence: Grade A | N=415; Intervention (Int) vs Control (Con): males: 58.9% vs 61%; white: 60% vs 58%; age: 54 (SD 10.7) vs 53.5 (SD 10.2) years; weight: 215.3 (SD 49.4) vs 218.4 (SD 51.3) pounds; HbA1c: 9.24 (SD 1.59) vs 9.28 (SD 1.74); Retention: 87% | Web-based diabetes management system (DM specific) by Palo Alto Medical Foundation allows Ps to monitor glucose remotely; view summary report; document nutrition and exercise; record insulin; communicate with the health team; receive advice; personalized education | Int (n=202): access to Web-based disease management system for diabetes; Con (n=213): usual care | HbA1c, BP, low-density lipoprotein (LDL), health care utilization, diabetes knowledge, diabetes treatment satisfaction, and depression screening | ITT was applied. Int had reduced HbA1c at 6 months (−1.32% Int vs −0.66 Con, |
Fonda et al (2009) [ |
2-group study, 12-month RCT to examine changes in Problem Areas in Diabetes (PAID), and its association with use of an internet-based diabetes care management (IBCM) program; Evidence: Grade A | N=104; males: 99%; white: 76.7%; age: 60.9 (SD 10.3) years; HbA1c: 9.9 (SD 0.9%); Retention not reported | IBCM (DM specific) by VA Boston Healthcare System allows Ps to transmit BP and glucose data from devices; view BP and glucose data; message care managers; access diabetes education | Int (n=52): access to the IBCM program; Con (n=52): usual care | Diabetes distress (PAID), and pattern of usage | The decline in PAID score was significant for sustained users of the portal but not for nonusers in the Int group. Sustained users (n=27) had lower PAID scores at baseline. |
McCarrier et al (2009) [ |
2-group study, 12-month RCT to test whether a diabetes case management program can improve glycemic control and self-efficacy in adults with T1DM; Evidence: Grade A | N=77; males: 67.5%; white: 96.1%; age: 37.3 (SD 8.09) years; HbA1c: 8%; Retention: 83% | Web-based program (DM specific) by University of Washington (UW) General Internal Medicine Clinic allows Ps to view EHR data; upload glucose readings; enter medication, nutrition, and exercise; create action plans; access education | Int (n=41): usual care+Web-based case management program; Con (n=36): usual care | HbA1c, diabetes-related self-efficacy, and usage | ITT was applied. A nonsignificant decrease in HbA1c in the Int compared with the Con group (−0.48%, 95% CI −1.22 to 0.27) between groups. The Int group had an increase in self-efficacy compared with the Con group (95% CI 0.01 to 0.59, |
Ralston et al (2009) [ |
2-group study, 12-month RCT to test Web-based care management of glycemic control using a shared EMR in Ps with T2DM; Evidence: Grade A | N=83; Int vs Con: females: 47.6% vs 51.2%; white: 89.7% vs 73% ( |
Web-based diabetes support program (DM specific) by UW General Internal Medicine Clinic allows Ps to access EHR data; communicate with providers; send glucose readings; enter exercise, diet, and medication data; access education | Int (n=42): usual care+Web-based case management program; Con (n=41): usual care | GHb, total cholesterol, SBP, DBP, health care utilization, and usage | ITT was applied. More change in GHb among the Int group compared with the Con group at 12 months (change −0.7%, |
Grant et al (2008) [ |
2-group study, 12-month RCT to evaluate the impact of a PHR for T2DM; Evidence: Grade A | N=244; Int vs Con: females: 43% vs 56% ( |
Patient Gateway by Partners Health care system allows Ps to update registration information; send messages; confirm appointments; request prescription refills; access DM modules | Int (n=126): access to a DM-specific PHR (ie, review mediations, and access decision support and care plans); Con (n=118): non-DM-specific PHR | HbA1c, BP, and LDL | ITT was applied. More Ps in the Int group had DM treatment adjusted compared with the Con group (53% vs 15%; |
Qualitative or mixed methods studies on patient portal for diabetes management.
Authors, country | Study aim | Study design | Sample | Portal features | Measures or questions | Findings |
Sieverink et al (2014) [ |
To explore factors associated with diffusion of a personal health record (PHR) for patients with type 2 diabetes mellitus (T2DM) in primary health care workers | Semistructured interview with primary care nurses: qualitative | N=11 | e-Vita (diabetes mellitus [DM]-specific) by the Diabetes Center in Zwolle allows patients (Ps) to access diabetes education; access electronic health record (EMR) data; receive messages from providers | What are the reasons for using a PHR?; What training do you receive?; How to embed PHR in your daily routine?; What are the barriers and facilitators for embedding PHR in daily routine?; What are your expectations? | Practice nurses indicated barriers for using a PHR: lack of integration with work routines, time constraints, and experience usability problems. |
Osborn et al (2013) [ |
To understand Ps with T2DM who use MyHealthAtVanderbilt (MHAV) and reasons for use and nonuse, how users are using a portal to manage medications, and explore ideas for functionality improvement | Focus groups and medical chart review: mixed methods | N=75; females: 67%; white: 63%; age: 56.9 (SD 8.8) years | MHAV by Vanderbilt University Medical Center (VUMC) allows Ps to access EHR data; message providers; manage appointments; assess risks; access education | Do you use MHAV or not? How and why?; What could be added to MHAV to help manage medications?; What do you think about an email reminder to refill or dose reminders? | Users were more likely to be white, have higher incomes, and be privately insured. Reasons for nonuse: unaware of the portal (n=3), no access to a computer (n=3), and helped by a family member (n=1). Users used the portal to request prescription refills and view medication list, and Ps were enthusiastic about the idea of adding refill reminder functionality, alerting providers to fill or refill nonadherence, and providing side effects and interactions. |
Wade-Vuturo, et al (2013) [ |
To explore how Ps with T2DM use and benefit from secure messaging within a patient portal | Focus group and patient survey: mixed methods | N=54; females: 65%; white: 76%; age: 57.1 (SD 8.4) years; body mass index (BMI): 34.4 (10.2); HbA1c: 7.0 (SD 1.4) | MHAV by VUMC allows Ps to access EHR data; message providers; manage appointments; assess risks; access education | HbA1c, self-reported frequency of use, benefits and barriers to use messaging | Greater use of messaging to schedule an appointment was associated with patients’ glycemic control ( |
Urowitz et al (2012) [ |
To evaluate the experience of Ps with T1DM or T2DM and providers using a Web-based diabetes management portal | Telephone interview and open-ended questionnaire: qualitative | Ps (n=17); females: 53%; providers (n=64) | Patient portal by the Waterloo Wellington Local Health Integration Network allows Ps to access DM education; access EHR data | Telephone interview with Ps and open-ended questionnaires with providers | 17 Ps were interviewed. Facilitators of disease management: increase awareness of their disease, access to educational information, and promote behavior change. Barriers to portal use: poor usability, not useful, challenges with physician engagement, and lack of understanding. Recommendations for portal improvements: more Web-based tutorial about the portal content, improve usability. |
Mayberry et al (2011) [ |
To examine the role of health literacy, numeracy, and computer literacy on usage of a patient Web portal (PWP) in Ps with T2DM | Focus group and patient survey: mixed methods | N=75; females: 68%; white: 47%; age: 56.9 (SD 8.8) years | MHAV by VUMC allows Ps to access DM education; access EHR data | Health literacy, numeracy, computer literacy, self-report usage of PWP and health information technology (HIT) | Lower health literacy was associated with less use of a computer for searching diabetes medications or treatments, but not usage of a PWP. Numeracy and computer literacy were not associated with PWP use. Family members’ support facilitated Ps usage of both PWP. |
Bryce et al (2008) [ |
To rate the potential or actual usefulness of 15 features of a Web-based portal for diabetes management | Focus group and patient survey: mixed methods | Preportal group (n=21) vs portal-user group (n=18): nonwhite: 33% vs 22%; age: 53 (SD 13) vs 55 (SD 11) years | HealthTrak by University of Pittsburgh Medical Center (UPMC) allows Ps to access EMR data; schedule appointments; message providers; access education; logbooks | The study asked how the portal affected management of diabetes, Ps’ experiences in using the portal and communicating with physicians | Features rated most favorably were: calculator to estimate blood glucose control (74%), appointment reminder (74%), email to health team (74%), personal tracking logs (69%), and scheduling (69%). More patients from the preportal group than the portal-users group favored personal logs ( |
Zickmund et al (2008) [ |
To examine the impact of the provider-patient relationship on interest in using the patient portal | Focus group: qualitative | N=39; white: 72%; males: 52%; age: 54 (SD 12) | HealthTrak by UPMC allows Ps to access EMR data; schedule appointments; message providers; access education; logbooks | Topics included the relationships with providers, and feedback on the patient portal | Interest in the portal was linked to dissatisfaction with provider responsiveness, unable to obtain medical information, and logistical problems. Disinterest in the portal was linked to satisfaction with the provider communication, difficulty in using the portal, and fear of losing connections with providers. No patient identified email communication through the portal was helpful |
Hess et al (2007) [ |
To assess the impact of HealthTrak on patient-provider communication during September 2004-January 2007 | Focus groups: qualitative | N=39; males: 51%; white: 72%; age: 54 (SD 12) years | HealthTrak by UPMC allows Ps to access EMR data; schedule appointments; message providers; access education; logbooks | Discussion around living with diabetes, desired information about diabetes, current sources of information about diabetes, doctor-patient communication, and reaction to the portal | The number of patient visits or telephone calls received did not change, but the number of HealthTrak messages increased. Participants felt that the system enhanced communication. Having access to laboratory tests was preferred. They became frustrated when test results were not released, or messages were not answered by providers. |
The quality of the reviewed studies that used quantitative methods was assessed using the evidence grading system developed by the American Diabetes Association. An evidence grade of A, B, C, or E is assigned depending on the quality of the evidence. A grade A evidence is considered optimal because it is derived from large, well-designed clinical trials or meta-analyses; it is estimated to have the best chance to improve outcomes when applying the treatment to the appropriate population. Grade B ratings indicate supporting evidence from well-conducted cohort studies or case-control studies. Grade C ratings indicate supporting evidence from poorly controlled or uncontrolled studies. A separate category E is applied to papers reporting expert opinions or clinical experience when there is no evidence from clinical trials.
We reviewed 30 studies focusing on 13 different portals from 3 countries—10 from the United States, 2 from the Netherlands, and 1 from Canada. Of these 13 portals, 5 were designed for patients with diabetes and functioned as a component in Web-based diabetes management programs. These 5 DM-specific patient portals were from the Palo Alto Medical Foundation, VA Boston Healthcare System, University of Washington General Internal Medicine Clinic, the VU University Medical Center, and the Diamuraal of the Netherlands. Almost half of the included studies (n=13) focused on patients with T2DM, 1 on patients with T1DM, 6 included both types, and 10 did not specify.
Of all the studies included, 6 [
There were 16 observational studies [
Qualitative methods were used in 4 studies [
Features offered in patient portals varied across systems. Most portals allowed patients to access a component of the EHR data (eg, visit summary, medical history, physical examination results, lab results), receive general health education, request prescription refills, and communicate with health care providers. In the DM-specific portals, patients were able to perform more activities such as wirelessly uploading their blood glucose readings assessed via home-monitoring devices [
The percentage of patients with diabetes who registered for a portal account ranged from 29% to 46% [
Patients logged on to portals for various tasks. Of all included studies, 1 study identified viewing laboratory results as the most frequently used feature, followed by requests for medication refills, sending and reading messages, and making appointments [
Significant differences between portal users and nonusers have been identified. Portal users were more likely to be younger [
The impact of DM-specific patient portals on glycemic control was investigated in 5 RCTs. Of these, 4 targeted patients with T2DM and yielded inconsistent results. Tang et al randomized 415 patients to either the usual care group or the intervention group. The results demonstrated reductions in HbA1c in the intervention group, where patients had access to a Web-based diabetes management system, compared with that of the usual care group (−1.32% vs −0.66%,
There were 3 observational studies that used data from EHR as well as an audit of portal registration and usage to examine the association of portal use with glycemic control. Of these 3 studies, 2 studies focused on single features (ie, secure messaging, Web-based medication refill). The 5-year retrospective cohort study conducted by Shimada et al in 111,686 veterans demonstrated that patients with HbA1c ≥7% at baseline tended to achieve HbA1c <7% with 2 (odds ratio [OR] 1.24, 95% CI 1.14 to 1.34) or more (OR 1.28, 95% CI 1.12 to 1.45) years of messaging use. Use of Web-based medication refills was not associated with changes in glycemic control [
In addition to glycemic control, researchers also explored other diabetes-related physiological outcomes. The RCT by Tang et al found that patients who had Web-based access to the diabetes management system had better control of LDL, but not BP or weight, when compared with patients in the usual care group at 12 months (
Several studies also assessed changes in psychological measures, including diabetes-related distress and self-efficacy for managing diabetes. Data on diabetes-related distress as measured by the Problem Areas in Diabetes (PAID) questionnaire were reported in 4 studies. Of these studies, 1 study using an RCT design found a lower distress score in the intervention group (n=202) compared with the usual care group (n=213, 0.6, SD 0.8, vs 1.0, SD 1.0,
Self-efficacy between groups was assessed in 2 studies. In an RCT by McCarrier et al (n=77 patients with T1DM), the intervention group had a significant increase in diabetes-related self-efficacy compared with the control group (
There were 8 studies that evaluated patient portals by applying qualitative methods—6 used focus groups, 1 used face-to-face interviews, and 1 used telephone interviews. Qualitative responses revealed that patients favored features that allowed them to view summaries, request prescription refills, receive reminders for medical appointments, access laboratory results, and communicate with providers [
Patients who never used the portal provided the following reasons for not requesting a log-in: unawareness of the existence of the portal, no use of computers, family members as delegates, slow response from physicians or nurses, and poor usability of the portal [
This literature review reports on the current evidence on EHR portal use in the clinical management of patients with diabetes. The 13 patient portals that were represented in the 30 studies showed wide variability in features examined and provided across portals, evaluated diabetes outcomes, and whether the technology resources were applied in combination with a disease management program for diabetes. These variabilities increased the difficulty of performing a meta-analysis and generating any conclusions about the effectiveness of patient portals for diabetes management. In our review of the RCTs, we found inconsistent findings regarding the effect of the portal use on diabetes outcomes. Observational correlational studies also yielded mixed findings regarding the association between portal use and diabetes outcomes. However, we were able to identify that the patient portal, which leverages strong patient-centered principles (eg, DM education, tailored feedback on patient’s DM-related health data), performed better in improving patient outcomes. The DM-specific portals enabled patients to receive personalized education, send blood glucose readings, and obtain individualized feedback from the health team.
Although we observed more favorable outcomes associated with using the DM-specific portals, the effect sizes in the studies reviewed were small. This may be due to several challenges associated with the use of patient portals. The design of the majority of the patient portals currently available was not patient-centered, meaning that features provided do not align with patient expectations, and in many cases were not evidence based. For a self-management intervention to be effective, appropriate theories of engagement and implementation should be in place to support the evidence-based intervention. For example, to ensure the effective application of a system, the system needs to provide a complete feedback loop, which consists of multiple components that include monitoring and transmission of patient status, data interpretation in comparison with personalized goals, adjustment of treatment regimen based on patient status, timely communication with individualized recommendations, and repetitiveness of this cycle [
The current state of low engagement by patients in portal use may interfere with the ability to achieve meaningful clinical benefits. Initial high log-in rates followed by a rapid decline in portal use suggest that multifaceted barriers prevent patients from engaging in the long-term use of patient portals. These barriers are technology-related (eg, functionality, usability), patient-related (eg, access to the internet or a computer, low health literacy, perceived usefulness, sociodemographic and clinical characteristics), and provider-related (eg, provider engagement).
A recently published review indicated that endorsement from providers was one of the most influential factors that contributed to patients’ accepting the portal and using it as a tool for diabetes self-management [
There were several noted limitations of this review. First, our findings lacked sufficient quality evidence; the results of this review are not well-supported by level A evidence, with the majority of studies graded as the B or C level. It is no longer feasible to randomly assign patients to either portal use or nonuse group as individuals have the right to access their health information, but studies could consider examining different designs or additional features, given the necessary health information included in the portal. Second, this literature review only included studies explicitly concerned with patient portals and diabetes, studies evaluating patient portals for multiple chronic disease management that may include diabetes were not included. Finally, only 1 person was involved in the selection of the studies for inclusion in our review. Future studies should consider using a multiple-rater approach for study evaluation and data extraction.
In conclusion, this review identified several opportunities that could potentially improve diabetes outcomes through a patient portal. Because the majority of the studies examined the overall effect of patient portals, future investigations should consider investigating single features to understand the contribution of each component and understand which component is more influential than others in helping patients manage their diabetes. Moreover, a conceptual framework is needed to standardize an approach to guide the design and evaluation of patient portals. Specifically, functionalities need to be specified to provide guidance on system requirements for patient portal developers. Moreover, a set of evaluation metrics needs to be developed for the evaluation of patient portals to enable them to be compared and ranked. To further improve diabetes outcomes, continued investigation of strategies that could potentially enhance the implementation of the patient portal (eg, portal design, implementation strategy) may enable the patient portal to reach its fullest potential in supporting diabetes management and increasing patient engagement. At the same time, physicians’ perceptions of portal use need to be assessed, and potential barriers need to be addressed to foster physicians’ engagement in patient portals.
Observational studies examining patient portals for diabetes management.
body mass index
blood pressure
chronic care model
diastolic blood pressure
diabetes mellitus
electronic medical record
electronic health record
glycohemoglobin
glycated hemoglobin
low-density lipoprotein
Problem Areas in Diabetes
personal health record
randomized controlled trial
systolic blood pressure
The authors would like to thank Mary Lou Klem for assistance in determining the search terms for study identification.
None declared.