EHR Workflows Contribute to Disparities by Language Preference in Parent Patient Portal Access

Abstract

Background

Identifying patient portals (PP) activation disparities, especially in electronic health record (EHR) activation workflows, can help facilitate equitable health care access.

Objectives

Our study aimed to assess whether the parent/guardian's preferred language was associated with being offered, activating, and using the PP and the methods used to offer activation codes.

Methods

This retrospective cohort study examined PP offer, activation, and usage rates at a large freestanding children's hospital. Patients <12 years old with ambulatory visits from July 1, 2022, to June 30, 2023, without prior active proxy PP accounts were included. The primary independent variable was the self-reported parent/guardian preferred language (English/Spanish). Outcomes included the probability of being offered, overall and by specific offer methods, activation, and usage. Zou's modified multivariate Poisson regression models examined the association between preferred language and offer/activate/use status.

Results

Among 39,578 patients, 85.1% were patients with English as preferred language (PEPL) and 14.9% had Spanish as preferred language (PSPL). PSPL had a lower probability of being offered (adjusted relative risk ratio [aRR]: 0.65, 95% confidence interval [CI]: 0.63–0.67), activated (aRR: 0.72, 95% CI: 0.70–0.75), and used (aRR: 0.68, 95% CI: 0.65–0.72) a PP compared to PEPL. Specifically, PSPL had a lower probability of activating if ever offered via instant activation (aRR: 0.72, 95% CI: 0.69–0.75), parent/guardian with existing account (aRR: 0.73, 95% CI: 0.69–0.76), and had equal probability of activating if ever offered via letter (aRR: 0.42, 95% CI: 0.19–0.94) and clinician-assisted method (aRR: 0.99, 95% CI: 0.86–1.16), compared to PEPL.

Conclusion

PSPL at a large, free-standing pediatric health system had a lower probability of PP offer, activation, and usage than PEPL. Activation methods were not universally effective across language groups, emphasizing the need for equitable workflow optimization. This study highlights an approach to analyzing health disparities in activation workflows to inform targeted interventions to improve equitable PP access.

Keywords

patient portal - health disparities - language - electronic health records - pediatrics

Protection of Human and Animal Subjects

This study was reviewed by the Stanford University Institutional Review Board.

Publication History

Received: 23 April 2025

Accepted: 19 December 2025

Article published online:
22 January 2026

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