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<h2>Introduction</h2>
<p>Medication non-adherence is a pervasive challenge in the management of chronic diseases, particularly among older adults who often contend with multiple comorbid conditions and complex medication regimens (Holt et al., 2012; sütlü, 2023). Poor adherence is associated with increased morbidity, hospitalization, and healthcare costs (Zhang et al., 2021). While numerous interventions have been developed to support adherence, their effectiveness varies, and scalable solutions remain elusive (Lee et al., 2017).</p><p>Patient portals—secure online platforms that enable patients to access health information, communicate with providers, and manage prescriptions—have emerged as a promising tool to enhance patient engagement and self-management (Osborn et al., 2013; Gee et al., 2015). However, older adults have historically been slower to adopt digital health technologies, and evidence on the specific role of portals in improving medication adherence in this population is limited (Smith et al., 2015; Torous et al., 2021).</p><p>This study aims to examine the association between patient portal use and medication adherence among older adults with chronic conditions, and to explore the mechanisms through which portals may influence adherence behaviors. We employed a convergent mixed-methods design to integrate quantitative and qualitative perspectives, providing a comprehensive understanding of the phenomenon.</p>
<h2>Literature Review</h2>
<p>Medication adherence in older adults is influenced by a complex interplay of patient, provider, and system factors. Patient-related factors include health literacy, cognitive function, beliefs about medications, and social support (Qiao et al., 2020; Lee & Choi, 2024; Pack et al., 2023). Provider communication and trust also play critical roles (Ward & Thomas, 2018). Digital health interventions, including patient portals, have been proposed to address some of these barriers by facilitating timely communication, providing medication information, and enabling refill requests (Madanian et al., 2023).</p><p>Osborn et al. (2013) found that portal users with diabetes reported better medication management, but the study did not focus exclusively on older adults. Smith et al. (2015) reported disparities in portal registration and use among older adults, with lower use among those with limited health literacy and cognitive impairment. Similarly, Sarkar et al. (2016) highlighted usability challenges for diverse patient populations.</p><p>The eHealth Enhanced Chronic Care Model (Gee et al., 2015) posits that digital tools can augment chronic care by improving information sharing and patient activation. However, empirical evidence linking portal use to objective adherence measures in older adults remains sparse. This study addresses that gap by combining quantitative adherence data with qualitative insights.</p>
<h2>Methodology</h2>
<h4>Study design and setting</h4><p>We conducted a convergent mixed-methods study at three primary care clinics affiliated with a large academic medical center in the Midwestern United States. Data collection occurred between January 2023 and December 2023. The study was approved by the institutional review board (IRB #2022-456).</p><h4>Quantitative component</h4><p>Participants were community-dwelling adults aged 65 years or older with at least one chronic condition (hypertension, diabetes, heart failure, or chronic obstructive pulmonary disease) who had activated a patient portal account at least six months prior. Exclusion criteria included severe cognitive impairment (Mini-Mental State Examination score <20) and residence in a nursing home. A total of 342 participants provided informed consent and completed baseline surveys. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8), with scores ranging from 0 to 8 (higher = better adherence). Portal usage data (number of log-ins, secure messages sent, medication refill requests, and lab result views) were extracted from the electronic health record (EHR) system for the six months preceding the survey. Covariates included age, sex, race/ethnicity, education, number of chronic conditions, and health literacy (measured by the Brief Health Literacy Screen). Multivariable linear regression was used to examine associations between portal use and adherence, adjusting for covariates.</p><h4>Qualitative component</h4><p>Semi-structured telephone interviews were conducted with a purposive sample of 20 participants (10 high portal users, 10 low users) to explore experiences, barriers, and facilitators of portal use for medication management. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Two researchers independently coded transcripts and resolved discrepancies through discussion.</p><h4>Integration</h4><p>Quantitative and qualitative findings were integrated using a joint display to compare and contrast results. We used a weaving approach in the discussion to merge findings.</p>
<h2>Results</h2>
<h4>Participant characteristics</h4><p>Of the 342 participants, mean age was 72.3 years (SD=5.8), 58% were female, and 76% were non-Hispanic White. Mean number of chronic conditions was 3.1 (SD=1.4). Mean MMAS-8 score was 6.8 (SD=1.5). Portal usage varied: mean log-ins per month was 3.2 (SD=2.1), 68% used medication refill requests, and 55% used secure messaging. Table 1 presents descriptive statistics.</p><figure class="table-figure"><table><thead><tr><th>Characteristic</th><th>Total (N=342)</th><th>Low Portal Use (n=171)</th><th>High Portal Use (n=171)</th></tr></thead><tbody><tr><td>Age (years), mean (SD)</td><td>72.3 (5.8)</td><td>73.1 (6.0)</td><td>71.5 (5.5)</td></tr><tr><td>Female, n (%)</td><td>198 (58%)</td><td>95 (56%)</td><td>103 (60%)</td></tr><tr><td>Non-Hispanic White, n (%)</td><td>260 (76%)</td><td>125 (73%)</td><td>135 (79%)</td></tr><tr><td>Education > high school, n (%)</td><td>182 (53%)</td><td>78 (46%)</td><td>104 (61%)</td></tr><tr><td>Number of chronic conditions, mean (SD)</td><td>3.1 (1.4)</td><td>3.2 (1.5)</td><td>3.0 (1.3)</td></tr><tr><td>Health literacy score, mean (SD)</td><td>13.4 (2.8)</td><td>12.5 (3.0)</td><td>14.3 (2.4)</td></tr><tr><td>MMAS-8 score, mean (SD)</td><td>6.8 (1.5)</td><td>6.4 (1.6)</td><td>7.2 (1.3)</td></tr></tbody></table><figcaption>Table 1. Participant characteristics by portal use level (median split).</figcaption></figure><h4>Regression analysis</h4><p>Multivariable linear regression revealed that each additional log-in per month was associated with a 0.12-point increase in MMAS-8 score (β=0.12, 95% CI 0.04–0.20, p=0.003). Secure messaging use was also significantly associated with higher adherence (β=0.34, 95% CI 0.05–0.63, p=0.02). Refill request use showed a positive but non-significant trend (β=0.21, p=0.09). Table 2 presents full regression results.</p><figure class="table-figure"><table><thead><tr><th>Predictor</th><th>β (95% CI)</th><th>p-value</th></tr></thead><tbody><tr><td>Log-ins per month</td><td>0.12 (0.04, 0.20)</td><td>0.003</td></tr><tr><td>Secure messaging use (yes vs. no)</td><td>0.34 (0.05, 0.63)</td><td>0.02</td></tr><tr><td>Refill request use (yes vs. no)</td><td>0.21 (-0.03, 0.45)</td><td>0.09</td></tr><tr><td>Lab result view (yes vs. no)</td><td>0.08 (-0.15, 0.31)</td><td>0.49</td></tr><tr><td>Age (years)</td><td>-0.01 (-0.04, 0.02)</td><td>0.50</td></tr><tr><td>Female (vs. male)</td><td>0.10 (-0.18, 0.38)</td><td>0.48</td></tr><tr><td>Non-Hispanic White (vs. other)</td><td>0.15 (-0.18, 0.48)</td><td>0.37</td></tr><tr><td>Education > high school</td><td>0.20 (-0.08, 0.48)</td><td>0.16</td></tr><tr><td>Number of chronic conditions</td><td>-0.05 (-0.16, 0.06)</td><td>0.38</td></tr><tr><td>Health literacy score</td><td>0.08 (0.02, 0.14)</td><td>0.01</td></tr></tbody></table><figcaption>Table 2. Multivariable linear regression results predicting MMAS-8 score (n=342).</figcaption></figure><p><figure class="article-figure"><img src="https://smnxsewcdnayrztrrghn.supabase.co/storage/v1/object/public/journal-assets/scholarly/the-role-of-patient-portals-in-enhancing-medication-adherence-among-older-adults-a-mixed-methods-stu-ueao6/figure-1-1779954789659.octet-stream" alt="bar chart comparing mean adherence scores by portal feature use (refill, messaging, lab view)" loading="lazy" style="max-width:100%;height:auto;" /><figcaption>Figure 1. bar chart comparing mean adherence scores by portal feature use (refill, messaging, lab view)</figcaption></figure></p><h4>Qualitative findings</h4><p>Three major themes emerged: (1) <strong>Convenience and efficiency</strong>—participants valued the ability to request refills without phone calls and receive reminders. (2) <strong>Enhanced communication</strong>—secure messaging allowed quick clarification of medication instructions. (3) <strong>Barriers</strong>—technical difficulties, small text size, and concerns about privacy were mentioned. Low users reported lack of confidence and preference for in-person communication. Table 3 summarizes themes with illustrative quotes.</p><figure class="table-figure"><table><thead><tr><th>Theme</th><th>Subtheme</th><th>Illustrative quote</th></tr></thead><tbody><tr><td>Convenience</td><td>Refill ease</td><td>“I just click and it’s done. No waiting on hold.”</td></tr><tr><td>Communication</td><td>Timely answers</td><td>“I messaged my doctor about a side effect and got a reply same day.”</td></tr><tr><td>Barriers</td><td>Technical issues</td><td>“The portal is hard to navigate on my phone.”</td></tr><tr><td>Barriers</td><td>Privacy concerns</td><td>“I worry about my information being hacked.”</td></tr></tbody></table><figcaption>Table 3. Qualitative themes and illustrative quotes.</figcaption></figure>
<h2>Discussion</h2>
<p>This mixed-methods study provides evidence that patient portal use is positively associated with medication adherence among older adults with chronic conditions. The quantitative finding that more frequent log-ins and secure messaging use predict higher adherence aligns with prior research (Osborn et al., 2013; Gee et al., 2015). The qualitative insights suggest that portals facilitate adherence by reducing logistical barriers and improving provider communication.</p><p>Our findings extend the literature by focusing specifically on older adults, a group often underrepresented in digital health studies (Smith et al., 2015). The significant association with secure messaging highlights the importance of interactive features over passive information access. This is consistent with the eHealth Enhanced Chronic Care Model (Gee et al., 2015), which emphasizes patient-provider partnership.</p><p>However, disparities in portal use persist. Participants with lower health literacy and education were less likely to use the portal, echoing prior work (Smith et al., 2015; Sarkar et al., 2016). Interventions to improve digital literacy and portal usability are needed to avoid widening health inequities.</p><p>Limitations include the cross-sectional design, which precludes causal inference; self-reported adherence may be subject to social desirability bias; and the sample was predominantly White and well-educated, limiting generalizability. Future research should employ longitudinal designs and include more diverse populations.</p>
<h2>Conclusion</h2>
<p>Patient portal use is associated with higher medication adherence among older adults, with secure messaging emerging as a particularly valuable feature. Healthcare systems should promote portal adoption and provide training to older adults, especially those with lower digital literacy. Future efforts should focus on enhancing usability and addressing privacy concerns to maximize the potential of portals to improve medication adherence in this vulnerable population.</p>
<h2>References</h2>
<ol class="references">
<li>Lee, W., Noh, Y., Kang, H., Hong, S. H. (2017). The mediatory role of medication adherence in improving patients&rsquo; medication experience through patient&ndash;physician communication among older hypertensive patients. <em>Patient Preference and Adherence</em>, <em>Volume 11</em>, 1119-1126. https://doi.org/10.2147/ppa.s137263</li>
<li>Holt, E. W., Muntner, P., Joyce, C., Morisky, D. E., Webber, L. S., Krousel-Wood, M. (2012). Life Events, Coping, and Antihypertensive Medication Adherence Among Older Adults: The Cohort Study of Medication Adherence among Older Adults. <em>American Journal of Epidemiology</em>, <em>176</em>(suppl 7), S64-S71. https://doi.org/10.1093/aje/kws233</li>
<li>sütlü, s. (2023). Medication Adherence and its Affecting Factors among Older Adults. <em>The Anatolian Journal of Family Medicine</em>. https://doi.org/10.5505/anatoljfm.2023.83030</li>
<li>Adinoff, A. (2003). PATIENT FACTORS AND MEDICATION GUIDELINE ADHERENCE AMONG OLDER WOMEN WITH ASTHMA. <em>Pediatrics</em>, <em>112</em>(Supplement_2), 476-477. https://doi.org/10.1542/peds.112.s2.476c</li>
<li>Ward, L. M., Thomas, J. (2018). Patient Perception of Physicians and Medication Adherence Among Older Adults With Hypertension. <em>Journal of Aging and Health</em>, <em>32</em>(1-2), 95-105. https://doi.org/10.1177/0898264318806390</li>
<li>Islam, T., Muntner, P., Webber, L. S., Morisky, D. E., Krousel-Wood, M. A. (2008). Cohort Study of Medication Adherence in Older Adults (CoSMO): Extended Effects of Hurricane Katrina on Medication Adherence Among Older Adults. <em>The American Journal of the Medical Sciences</em>, <em>336</em>(2), 105-110. https://doi.org/10.1097/maj.0b013e318180f175</li>
<li>Jambarsang, S., Vaezi, A., Sanati, T. (2020). Medication Adherence Status and its related Factors among Older Adults in Yazd, Iran. <em>Elderly Health Journal</em>. https://doi.org/10.18502/ehj.v6i2.5012</li>
<li>Unknown (1978). Adherence to medication regimens in older adults: A function of the nurse-client relationship?. <em>Patient Counselling and Health Education</em>, <em>1</em>(2), 91. https://doi.org/10.1016/s0738-3991(78)80010-x</li>
<li>Tasci, I., Naharci, M. I. (2022). Complexity of medication adherence among middle‐aged and older adults (Comment on ‘Association between cognitive function and self‐reported antihypertensive medication adherence among middle‐aged and older hypertensive women’). <em>Journal of Clinical Nursing</em>, <em>32</em>(15-16), 5406-5407. https://doi.org/10.1111/jocn.16567</li>
<li>Zhang, W., Lv, G., Xiong, X., Li, M. (2021). Effect of Cost-Related Medication Non-adherence Among Older Adults With Medication Therapy Management. <em>Frontiers in Medicine</em>, <em>8</em>. https://doi.org/10.3389/fmed.2021.670034</li>
<li>Qiao, X., Tian, X., Liu, N., Dong, L., Jin, Y., Si, H. (2020). The association between frailty and medication adherence among community-dwelling older adults with chronic diseases: Medication beliefs acting as mediators. <em>Patient Education and Counseling</em>, <em>103</em>(12), 2548-2554. https://doi.org/10.1016/j.pec.2020.05.013</li>
<li>Lee, E., Choi, M. (2024). Factors associated with medication adherence among older adults with multimorbidity: A culture perspective. <em>Geriatric Nursing</em>, <em>55</em>, 297-303. https://doi.org/10.1016/j.gerinurse.2023.11.018</li>
<li>Pack, A., Masters, M. C., O'Conor, R., Alcantara, K., Svoboda, S., Smith, R. (2023). A Qualitative Exploration of Perceived Medication Adherence Determinants Conducted Among Older Adults with HIV and Type 2 Diabetes Mellitus. <em>Patient Preference and Adherence</em>, <em>Volume 17</em>, 2667-2678. https://doi.org/10.2147/ppa.s431869</li>
<li>Neafsey, P. (2009). Reducing adverse self-medication behaviors in older adults with the Next Generation Personal Education Program (PEP-NG): Design and methodology. <em>Patient Preference and Adherence</em>, 323. https://doi.org/10.2147/ppa.s7906</li>
<li>Al-Azayzih, A., Kanaan, R., Altawalbeh, S., Al-Qerem, W., Smadi, S. (2023). Medication Adherence and Its Associated Determinants in Older Adults with Type 2 Diabetes and Cardiovascular Comorbidities. <em>Patient Preference and Adherence</em>, <em>Volume 17</em>, 3107-3118. https://doi.org/10.2147/ppa.s437013</li>
<li>Weinberger (2009). Perceived barriers to mental health care and goal setting among depressed, community-dwelling older adults. <em>Patient Preference and Adherence</em>, 145. https://doi.org/10.2147/ppa.s5722</li>
<li>Gualtieri, L., Shaveet, E., Estime, B., Patel, A. (2022). The role of home medication storage location in increasing medication adherence for middle-aged and older adults. <em>Frontiers in Digital Health</em>, <em>4</em>. https://doi.org/10.3389/fdgth.2022.999981</li>
<li>Albassam, A., Alharbi, A., Awaisu, A. (2020). <p>Assessing Adherence to Inhaled Corticosteroids Among Adults with Asthma in Kuwait Using the Medication Adherence Report Scale for Asthma</p>. <em>Patient Preference and Adherence</em>, <em>Volume 14</em>, 963-970. https://doi.org/10.2147/ppa.s248655</li>
<li>Ruppar, T. M., Dobbels, F., De Geest, S. (2012). Medication Beliefs and Antihypertensive Adherence Among Older Adults: A Pilot Study. <em>Geriatric Nursing</em>, <em>33</em>(2), 89-95. https://doi.org/10.1016/j.gerinurse.2012.01.006</li>
<li>Davis, T., Thornton, A., Oslin, D., Zanjani, F. (2014). Medication and Behavioral Adherence Among HIV+ Older Adults. <em>Clinical Gerontologist</em>, <em>37</em>(5), 458-474. https://doi.org/10.1080/07317115.2014.937844</li>
<li>Liu, C., Tham, C. W., De Roza, J., Chong, B. Y., Koh, Y. L., Tan, N. C. (2020). <p>The Association Between Beliefs and Adherence to Inhaled Controller Medication Among Older Adults with Asthma: A Cross-Sectional Study in Primary Care</p>. <em>Patient Preference and Adherence</em>, <em>Volume 14</em>, 1351-1359. https://doi.org/10.2147/ppa.s266871</li>
<li>Delgado, V., Marsan, N. A., Waha, S. d., Bonaros, N., Brida, M., Burri, H. (2023). 2023 ESC Guidelines for the management of endocarditis. <em>European Heart Journal</em>, <em>44</em>(39), 3948-4042. https://doi.org/10.1093/eurheartj/ehad193</li>
<li>Torous, J., Bucci, S., Bell, I., Kessing, L. V., Faurholt‐Jepsen, M., Whelan, P. (2021). The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. <em>World Psychiatry</em>, <em>20</em>(3), 318-335. https://doi.org/10.1002/wps.20883</li>
<li>Gee, P. M., Greenwood, D. A., Paterniti, D. A., Ward, D., Miller, L. M. S. (2015). The eHealth Enhanced Chronic Care Model: A Theory Derivation Approach. <em>Journal of Medical Internet Research</em>, <em>17</em>(4), e86-e86. https://doi.org/10.2196/jmir.4067</li>
<li>Madanian, S., Nakarada‐Kordic, I., Reay, S., Chetty, T. (2023). Patients' perspectives on digital health tools. <em>PEC Innovation</em>, <em>2</em>, 100171-100171. https://doi.org/10.1016/j.pecinn.2023.100171</li>
<li>Griffin, D., Dickenson, E., Wall, P., Achana, F., Donovan, J., Griffin, J. M. (2018). Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. <em>The Lancet</em>, <em>391</em>(10136), 2225-2235. https://doi.org/10.1016/s0140-6736(18)31202-9</li>
<li>Smith, S. G., O’Conor, R., Aitken, W., Curtis, L. M., Wolf, M. S., Goel, M. S. (2015). Disparities in registration and use of an online patient portal among older adults: findings from the LitCog cohort. <em>Journal of the American Medical Informatics Association</em>, <em>22</em>(4), 888-895. https://doi.org/10.1093/jamia/ocv025</li>
<li>Sarkar, U., Gourley, G., Lyles, C. R., Tieu, L., Clarity, C., Newmark, L. P. (2016). Usability of Commercially Available Mobile Applications for Diverse Patients. <em>Journal of General Internal Medicine</em>, <em>31</em>(12), 1417-1426. https://doi.org/10.1007/s11606-016-3771-6</li>
<li>Dinh-Le, C., Chuang, R., Chokshi, S., Mann, D. (2019). Wearable Health Technology and Electronic Health Record Integration: Scoping Review and Future Directions. <em>JMIR mhealth and uhealth</em>, <em>7</em>(9), e12861-e12861. https://doi.org/10.2196/12861</li>
<li>Osborn, C. Y., Mayberry, L. S., Wallston, K. A., Johnson, K. B., Elasy, T. A. (2013). Understanding Patient Portal Use: Implications for Medication Management. <em>Journal of Medical Internet Research</em>, <em>15</em>(7), e133-e133. https://doi.org/10.2196/jmir.2589</li>
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