Study Shows Digital Divide Among Patients with Diabetes

Released jointly by UCSF and Kaiser Permanente

People with limited education and in certain racial/ ethnic minority groups are less likely to use an internet- based patient portal to interact with their health care system, according to a new study from researchers at the University of California, San Francisco and the Kaiser Permanente Division of Research in Oakland, CA.

The team investigated the use of Kaiser’s state-of-the-art internet-based patient portal,, among more than 14,000 English-speaking adults with diabetes who are part of the Diabetes Study of Northern California (DISTANCE) -- making it the largest observational study to assess use of a patient portal among diabetes patients in the United States.

Internet-based patient portals allow patients to access their health information, including their diagnostic test results, to perform health-related tasks such as making medical appointments and requesting refills of prescription medications, and to interact with providers through secure email messages. Such patient portals are considered a core component of “meaningful use” of health information technology under federal health reform legislation, and will be rapidly implemented across U.S. health care settings in the coming years.

Researchers found that those with limited education were less likely to perform the initial step of requesting a password for Similarly, fewer African-American and Latino participants in the study logged on to the secure patient portal, compared to non-Hispanic White and Asian participants.

Findings appear in the Journal of the American Medical Informatics Association and are available online.

Urmimala Sarkar, MD, MPHUrmimala Sarkar, MD, MPH

“We found that the very groups most affected by diabetes -- those with limited education and African-American and Latino populations -- were less likely to access the internet-based patient portal. As health systems increasingly rely on the internet, it is critical that disadvantaged groups not fall farther behind. In fact, we should find ways to use the internet to close the gap,” said Urmimala Sarkar, MD, MPH, lead author of the study.

Sarkar is with the UCSF Center for Vulnerable Populations and the UCSF Division of General Internal Medicine at San Francisco General Hospital. In a prior study of the same cohort, published in 2010 in the Journal of Health Communication, available online, the investigators found similar disparities in use of the patient portal between those with limited health literacy compared to those with adequate health literacy, regardless of race/ethnicity.

“This study suggests that outreach to vulnerable groups, improving internet access, a user-friendly interface using plain language and specific training on use of the patient portal may be useful as more health systems adopt technological approaches like ours,” said Andrew J. Karter, PhD, principal investigator of the DISTANCE Study and senior research scientist at the Kaiser Permanente Division of Research in Oakland, CA.

Investigators used administrative records to assess patient portal registration and use. Patients reported their race, ethnicity, and educational attainment in a survey. The researchers found that:

  • 40 percent requested a password for the patient portal. Of these, 70 percent logged on to the patient portal one or more times.
  • Compared to college graduates, those without a high school diploma were about half as likely to log on the patient portal one or more times.
  • Compared to Asian and Non-Hispanic White participants, African-American and Latino participants were about half as likely to log on the patient portal one or more times.

Data collection and analyses for this study was conducted by the NIH-funded DISTANCE study, which enrolled an ethnically-stratified, random sample of patients from the Kaiser Permanente Northern California Diabetes Registry. The overarching aim of DISTANCE is to investigate ethnic and educational disparities in diabetes-related behaviors, processes of care and health outcomes.

Dean Schillinger, MD, of the UCSF Center for Vulnerable Populations and UCSF Division of General Internal Medicine at San Francisco General Hospital, is senior co-author. He also is director of the California Diabetes Program, a federally-funded program that is administered by UCSF for the California Department of Public Health.

Co-authors include Andrew J. Karter; Jennifer Y. Liu, MPH and Howard H. Moffet, MPH, Division of Research, Kaiser Permanente Northern California; and Nancy E. Adler, PhD, UCSF Center for Health and Community.

Funds were provided by the National Institute of Diabetes, Digestive and Kidney Diseases, the National Institute of Child Health and Human Development, and the National Center for Research Resources. Sarkar is supported by the Agency for Healthcare Research and Quality. Schillinger is supported by a grant from Agency for Healthcare Research and Quality and a NIH Clinical and Translational Science Award.

About UCSF
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large. It seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 500-plus staff is working on more than 250 epidemiological and health services research projects.

About Kaiser Permanente
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America's leading health care providers and not-for-profit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services to improve the health of our members and the communities we serve. We currently serve 8.6 million members in nine states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: