Online scheduling portals promote care continuity – but may widen gaps in access

A wide-ranging JAMA study showed that early adopters of direct scheduling were more often young, white and commercially insured.
By Kat Jercich
09:24 AM

Online patient portals are an increasingly popular way for health systems to allow appointment scheduling, with many major electronic health record vendors offering them as an option.

But a study of more than 134,000 completed primary care visits published this past week in the Journal of the American Medical Association found that early adopters of direct scheduling – as opposed to making appointments with clinic staff via the telephone or in person –  were more likely to be young, white and commercially insured.

"To the extent these differences persist as direct scheduling is used more widely, this service may widen socioeconomic disparities in primary care access," wrote the researchers.


Direct scheduling can offer patients an option to make appointments at their own convenience, outside of business hours. Small-scale studies also suggest that direct scheduling may be associated with lower no-show rates.

By January 2018, as researchers write, a large Boston-area academic medical center had implemented direct scheduling in 17 adult primary care centers. The team used EHR data to identify the characteristics of more than 62,000 patients who sought appointments with 140 primary care physicians between March 1, 2017 and March 1, 2019.

Among those patients, 5,020 used direct scheduling during the study period. These adopters, compared with nonadopters, were more likely to be younger and white. They were also more likely to have commercial insurance, more comorbidities and higher prior utilization.

Most directly scheduled visits were done with the patient's own primary care physician. They were less likely to be billed at the highest complexity level.  

"We also found evidence that patients might find direct scheduling more convenient than usual scheduling: Most directly scheduled visits were scheduled during usual business hours, when patients could have called the office, yet chose to schedule online," wrote the researchers.

The results suggest, according to the study, that direct scheduling may contribute to continuity and access, which are associated in turn with better health outcomes and lower costs.

At the same time, the research team warned, "our findings raise the possibility that direct scheduling might contribute to disparities in primary care access."

They noted that they restricted the sample to patients who had enrolled in the portal. Prior research has shown that patients of color are less likely to enroll in patient portals in the first place. Half of primary care patients across the larger health systems were active portal users, and these users were more often women, English-speaking, and white.

"Even among patients with portal access, those who are socioeconomically disadvantaged are less likely to use the technology," they wrote.


Patient portals and online scheduling technology have been found to offer financial benefits and improve efficiency and engagement, and to lower no-show rates.

But some patients say they're clunky, and complain of confusing interface design and too much time investment for setup. They also often complain of having a different portal for every provider, and suffer from so-called "multi-portalitis."

And, as the JAMA study notes, the disproportionate use of direct scheduling by younger white patients could "crowd out visit access" for older patients and those of color – who may have historically decreased access to primary care.


"Direct scheduling is intended to improve patient convenience while reducing administrative burden for practices," wrote the researchers. "This offering may have additional benefits, especially in the primary care setting, such as promoting continuity with one’s usual primary care physician." 

"Conversely, direct scheduling might worsen disparities in access to care via the so-called digital divide," they added.

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Healthcare IT News is a HIMSS Media publication.

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