NURS 630 Week 2 Evidence-Based Project Part 1: Discovery Example

Evidence-Based Project Part 1, Discovery: Unequal Use of the Patient Portal During Hospitalization and a Nurse-Led Bedside Portal Coaching Program

Introduction

Since the 21st Century Cures Act information blocking rule took effect in 2021, hospitalized patients in the United States can see their clinicians' notes and their test results in the patient portal, usually as soon as they are signed. For many patients this has changed what it means to be in the hospital: a person can read the morning's potassium level before the nurse mentions it, or read the surgeon's note while waiting to be discharged. For other patients, nothing has changed at all, because they have never activated a portal account or do not know how to use one from a hospital bed. This paper describes the discovery phase of an evidence-based project that grew from my INFO 668 project on portal adoption: the problem of unequal portal use during hospitalization at a composite 300-bed community hospital, its impact on care, the rationale for a nurse-led solution, the stakeholders involved and the project's link to national quality frameworks.

The Problem

At Lakeside Regional Medical Center, only 38% of adult inpatients had an active portal account at admission over the last twelve months, and fewer than half of those logged in during their stay. Use was lowest among patients aged 75 and older, patients whose preferred language was Spanish and patients covered by Medicaid. Nurses on the medical-surgical units report that patients regularly ask what their results mean, or ask for a printed copy of a note, without knowing that both are available on a phone at the bedside.

The pattern at Lakeside mirrors published research. Cool et al. (2025) studied 43,588 adults hospitalized at an academic medical center between 2021 and 2023 and found that only 31.0% had an active portal account during their stay; of those, 54.0% logged in while hospitalized, and 62% of those who logged in viewed clinician notes. Patients who were older, Black, male, non-English speaking, covered by Medicaid or from out of state were less likely to have an active account. Bain et al. (2025) examined 58,801 surgical admissions over five years at another academic center and found that patients logged in during 49% of admissions but viewed a note in only 10%; immediate release of results and notes was associated with more logins and more viewing, and use fell with age and was lower among Spanish speakers, patients with noncommercial insurance and Black and Hispanic patients. Redelman-Sidi et al. (2026) found the same pattern at a cancer hospital: among 28,386 hospitalized patients, Black patients, single patients and Medicaid recipients were 32%, 20% and 21% less likely to log in at least once. The Cures Act gave every patient the same right to see their record, but the hospital decides who actually gets to use it.

Impact on Patient Care, Delivery and Outcomes

Portal access during a stay is not only a convenience. In two children's hospitals, Luke et al. (2026) studied 40,371 hospitalized patients and found that those whose families used the portal before hospitalization had lower odds of critical care admission and shorter lengths of stay, with no difference in readmissions; families who were Black, publicly insured, spoke a language other than English or lived in lower-opportunity neighborhoods were less likely to activate or use the portal. The design cannot show that portal use caused these outcomes, but it raises the possibility that unequal access compounds existing disparities. Access can also improve safety. When Kieren et al. (2026) gave 25 parents on a pediatric oncology service real-time access to notes on a bedside tablet, every parent read at least one note, most found the notes understandable and useful for tracking plans, and five parents identified possible inaccuracies, of which most were confirmed safety concerns, including a medication error. For care delivery, patients who can read their own results arrive at discharge with fewer surprises and more specific questions, which may shorten discharge teaching and reduce calls after discharge.

Project Rationale

The gap in portal use is usually treated as an IT or registration problem, solved by handing patients an activation code. I believe it is a nursing problem. Nurses are with patients more hours than anyone else, they already teach patients about medications and discharge plans, and they can see which patients are struggling with technology. Alla et al. (2026) found that when medical students trained 33 patients on an adult inpatient floor to use the portal, most reported better communication with their care team and a better understanding of their medications. A nurse-led approach builds on that finding by making portal coaching part of admission and discharge teaching, offered in the patient's preferred language and with a hospital tablet for those without a smartphone. The project's intervention, a bedside portal coaching program delivered by trained unit nurses and portal champions, will be developed in the next three parts. In outline, the admitting nurse would ask every patient about portal access as part of the admission database, offer activation on the patient's phone or a unit tablet, and show the patient where to find results, notes and the medication list. A second, shorter session at discharge would show the patient how to message the care team and find the after-visit summary. Patients who prefer not to use the portal would be recorded as declining, so that the gap the project measures reflects choice rather than missed opportunity.

Key Stakeholders

Link to National Quality Frameworks

The project reflects two QSEN graduate competencies. Under informatics, it uses information technology to support patient engagement and safe care, and under patient-centered care, it removes barriers to patients' participation in decisions by giving them access to their own information in an understandable form. It also reflects the CMS Promoting Interoperability program, the successor to Meaningful Use, whose provider-to-patient exchange objective measures whether patients are given timely electronic access to their health information. Offering access is not the same as enabling use, and a hospital can satisfy the measure while many of its patients never open the portal. The project aims to close that gap.

Conclusion

The Cures Act made patients' records open during hospitalization, but at Lakeside and in the published research, that openness reaches some patients far more than others. Because portal use during a stay may support safety and engagement, and because the gaps follow lines of age, race, language and insurance, unequal use is a problem of care, not only of technology. Nurses are well placed to solve it through bedside coaching. The next part of this project will synthesize the evidence on inpatient portal use and its effects.

References

Alla, S., Kukreja, R., Harrison, G., Royal, S., & Markus-Rodden, M. (2026). Effect of patient portal utilization on patient experience among hospitalized adult patients on an orthopedic surgical unit. CIN: Computers, Informatics, Nursing, 44(1). https://doi.org/10.1097/CIN.0000000000001311

Bain, A. P., Heslin, R., Matthews, L., Ji, H., Moore, C. B., Higashi, R. T., Louissaint, J., McDonald, S. A., Navar, A. M., Willett, D., Steitz, B. D., & Turer, R. W. (2025). Patient portal use among admitted surgical patients following the 21st Century Cures Act. JAMA Surgery, 160(10), 1082-1090. https://doi.org/10.1001/jamasurg.2025.2799

Cool, J. A., Zhang, C., Yang, J., Herzig, S. J., & Roches, C. D. (2025). Hospitalized patient portal access in the post-information blocking rule era. Journal of Hospital Medicine, 20(12), 1290-1296. https://doi.org/10.1002/jhm.70093

Kieren, M. Q., Lee-Miller, C., Smith, C. A., Brown, R., Limjoco, J. J., McArdle, K., Uhing, A., Veit, A., & Kelly, M. M. (2026). Parent experiences accessing inpatient clinical notes on a pediatric oncology service. Hospital Pediatrics, 16(6), 536-543. https://doi.org/10.1542/hpeds.2025-008530

Luke, M. J., Zhu, Y., Wolk, C. B., Menko, S. G., Capriola, D., Fuller, K., Scribano, P. V., Bonafide, C. P., & Vasan, A. (2026). Patient portal use and care utilization among hospitalized children. Hospital Pediatrics. Advance online publication. https://doi.org/10.1542/hpeds.2026-009398

Redelman-Sidi, Y., White, C., Seier, K., Lipitz-Snyderman, A., Dawson, J. P., Kuperman, G., Polubriaginof, F. C. G., & Chimonas, S. (2026). Disparities in cancer patients' portal usage during hospitalizations. Applied Clinical Informatics, 17(4), 844-853. https://doi.org/10.1055/a-2961-1034