JMIR Publications

ABSTRACT

Background:

Patient portals have become essential infrastructure for healthcare delivery following the 21st Century Cures Act, yet adoption remains inequitable. Understanding demographic and geographic determinants of portal activation is critical for addressing digital health disparities, particularly among neurology patients who face unique access barriers.

Objective:

We examined the demographic, geographic, and neighborhood-level factors associated with patient portal activation among neurology patients at multiple geographic scales in the Washington, DC metropolitan area.

Methods:

We conducted a retrospective cohort study of 72,417 adult neurology patients seen at two academic medical centers sharing an electronic health record in Washington, DC (February 2021–February 2026). We examined portal activation using multivariable logistic regression and geographic analysis at four nested scales: the metropolitan catchment area, DC’s eight wards, individual census tracts (via geocoded patient addresses), and individual DC residents.

Results:

Portal activation was 64.7% overall. Activation varied by race/ethnicity (Non-Hispanic White 76.1%, Non-Hispanic Black 57.0%, Non-Hispanic Asian 57.6%, Hispanic 55.0%) and geography (DC Ward 2: 82.0% vs. Ward 7: 48.0%). Ward-level educational attainment (r = 0.948), broadband access (r = 0.889), and income (r = 0.811) were strongly correlated with activation. Within individual wards, Non-Hispanic White patients activated at 84–91% while Non-Hispanic Black patients activated at 48–64%, demonstrating that neighborhood resources alone do not explain disparities.

Conclusions:

Patient portal activation is shaped by demographic, socioeconomic, and geographic factors operating at multiple levels. Persistent within-ward racial disparities indicate that neighborhood resources alone do not explain the digital divide. Geographically targeted interventions must be paired with culturally tailored approaches to achieve digital health equity.