The influence of patient portals on users' decision making is insufficiently investigated: A systematic methodological review

Background: Patient portals are considered valuable conduits for supporting patients' self-management. However, it is unknown why they often fail to impact on health care processes and outcomes. This may be due to a scarcity of robust studies focusing on the steps that are required to induce improvement: users need to effectively interact with the portal (step 1) in order to receive information (step 2), which might influence their decision-making (step 3). We aimed to explore this potential knowledge gap by investigating to what extent each step has been investigated for patient portals, and explore the methodological approaches used. Methods: We performed a systematic literature review using Coiera's information value chain as a guiding theoretical framework. We searched MEDLINE and Scopus by combining terms related to patient portals and evaluation methodologies. Two reviewers selected relevant papers through duplicate screening, and one extracted data from the included papers. Results: We included 115 articles. The large majority (n=104) evaluated aspects related to interaction with patient portals (step 1). Usage was most often assessed (n=61), mainly by analysing system interaction data (n=50), with most authors considering participants as active users if they logged in at least once. Overall usability (n=57) was commonly assessed through non-validated questionnaires (n=44). Step 2 (information received) was investigated in 58 studies, primarily by analysing interaction data to evaluate usage of specific system functionalities (n=34). Eleven studies explicitly assessed the influence of patient portals on patients' and clinicians' decisions (step 3). Conclusions: Whereas interaction with patient portals has been extensively studied, their influence on users' decision-making remains under-investigated. Methodological approaches to evaluating usage and usability of portals showed room for improvement. To unlock the potential of patient portals, more (robust) research should focus on better understanding the complex process of how portals lead to improved health and care.