# Assessing the Effects of eHealth Literacy and the Area Deprivation Index on Barriers to Electronic Patient Portal Use for Orthopedic Surgery: Cross-Sectional Observational Study

## TL;DR

This study finds that low eHealth literacy and older age are key barriers to using electronic patient portals for orthopedic surgery, with neighborhood disadvantage playing a smaller role.

## Contribution

The study introduces a novel analysis linking eHealth literacy and neighborhood deprivation to barriers in electronic portal use in orthopedic care.

## Key findings

- 43.2% of patients reported barriers to EPP use, primarily due to preference or technology discomfort.
- Low eHealth literacy and older age were significant predictors of barriers to EPP use.
- Neighborhood deprivation (ADI) did not mediate barriers when adjusting for eHealth literacy.

## Abstract

As electronic patient portals (EPPs) continue to gain popularity and systems transition to online tools for scheduling, communication, and telehealth, patients without access or skills to use these tools may be overlooked.

This study analyzed patient and neighborhood-level factors, including eHealth literacy level and the Area Deprivation Index (ADI), that may limit EPP access for orthopedic surgery.

A cross-sectional, survey-based study was performed at a single urban tertiary academic medical center in the United States across foot and ankle, hand and upper extremity, and orthopedic trauma subspecialty clinics from June 21, 2022, to August 12, 2022. Survey responses (N=287) provided information on sociodemographic characteristics; barriers to EPP use and frequency of EPP use; the eHealth Literacy Scale; and the ADI, which is an address-generated national census measure of neighborhood-level disadvantage. Barriers to EPP use were inductively coded into barrier types, classified as physical access, technology discomfort, or preference. The primary outcome measure was patient-reported barriers to EPP use, which was treated as a binary outcome (1=barrier; 0=no barrier). Bivariate analyses and multivariable binary logistic regressions were performed.

The percentage of patients who self-reported barriers to EPP access was 43.2% (124/287), which related to physical access (13/124, 10.4%), technology discomfort (55/124, 44.3%), and preference (78/124, 63.0%). In the adjusted regressions, only low eHealth literacy and older age predicted barriers to EPP use (low eHealth literacy, adjusted odds ratio [AOR] 1.32, 95% CI 1.13-1.54; P<.001; older age, AOR 1.007, 95% CI 1.003-1.009; P<.001), including barriers of technology discomfort (low eHealth literacy, AOR 1.25, 95% CI 1.11-1.40; P<.001; older age, AOR 1.004, 95% CI 1.002-1.007; P<.001) and preference (low eHealth literacy, AOR 1.33, 95% CI 1.17-1.51; P<.001; older age, AOR 1.004, 95% CI 1.00-1.01; P<.01). Patients with physical access–related barriers as opposed to technology discomfort or preference barriers had the lowest median eHealth literacy scores (17.0, IQR 12.0-14.0 vs 27.0, IQR 16.0-32.0 vs 27.0, IQR 20.0-32.0, respectively) and roughly a quartile higher median ADI (73.0, IQR 41.0-92.0 vs 53.5, IQR 31.2-76.0 vs 58.0, IQR 38.8-83.8, respectively).

Low eHealth literacy was the most significant determinant of overall barriers to EPP use for orthopedic surgery, followed by older age. Neighborhood-level disadvantage as measured through the ADI had no mediating effect on patient-reported barriers to EPP use when adjusting for eHealth literacy level. While patients with physical access barriers had higher ADIs, overall, few patients reported physical access barriers compared to barriers related to technology discomfort or preference. Patient preference for EPP versus non-EPP communications should be documented. Point-of-care screening using the eHealth Literacy Scale may also identify patients who require follow-up outside of the EPP during critical perioperative periods.