Nearly six in 10 Americans have been offered access to a patient portal. Fewer than four in 10 have actually logged in and used one in the past year. That gap — between being handed a credential and doing anything with it — is the central problem in digital patient engagement right now, and it has not closed nearly as fast as portal rollout itself. Health systems spent the better part of a decade satisfying meaningful-use requirements to stand up portals. The harder problem is getting patients to open them, understand what they find, and act on it — without burying clinicians in a new channel of unstructured work.

Two forces have pushed this issue into sharper focus. First, the federal information-blocking rule under the 21st Century Cures Act, which took effect April 5, 2021, forced nearly every hospital and clinic to release clinical notes, lab results, and other health information to patients electronically, without delay, largely by default — often described informally as an “open notes” mandate, even though ONC and the OpenNotes research initiative are technically distinct efforts. Second, the volume of patient messages flowing back through portals has surged, adding to clinician workload in a way that is now measurable and, in some specialties, tied to burnout. This piece looks at where portal adoption and activation actually stand, what the rule changed, what it costs clinicians, who is being left out, and what the research says drives sustained use.

Adoption Has Grown Steadily; Activation Has Lagged Behind It

The Office of the National Coordinator for Health IT (ONC) has tracked patient portal access and use since 2014 through the National Cancer Institute’s Health Information National Trends Survey (HINTS). The trend line shows real progress on access, paired with a persistently smaller number of patients who actually use it:

  • 2014: about 42% of individuals were offered portal access; roughly 25% accessed it.
  • 2017: about 51% offered; roughly 27% accessed.
  • 2019: about 58% offered; roughly 37% accessed.
  • 2020: about 59% offered; roughly 38% accessed at least once that year.

Later ONC survey data suggests the pandemic accelerated both numbers, with reported portal use climbing to roughly 57% by 2022 in some survey estimates — though methodologies and question wording differ across survey years enough that comparisons should be treated as directional rather than exact. Consistent across nearly every year measured is the same pattern: a meaningful share of patients offered a portal never open it, and among those who do, most log in only a handful of times.

What “Activation” Actually Looks Like

Among patients ONC found had portal access in 2020, use was concentrated at the low end of frequency: roughly a quarter logged in only once or twice in the entire year, another fifth logged in three to five times, and fewer than one in five reached six or more log-ins — the threshold researchers generally treat as a marker of sustained engagement rather than one-off curiosity after a visit. Even within the population that activates an account, a large share treats it as an occasional lookup tool rather than a routine part of managing their care. That distinction matters for anyone measuring “engagement” using account-creation or one-time-login numbers alone — those figures can look strong while genuine, repeated use remains thin.

One variable stands out consistently in the ONC data as associated with higher activation: whether a clinician or health plan actively told the patient to use the portal. In the 2020 ONC data brief, patients encouraged to use their portal by a health care provider reported accessing it at roughly 71% versus roughly 48% among those not encouraged — a spread of more than 20 percentage points attributable, at least in part, to a single sentence during a visit. That is a low-cost intervention relative to the platform investment itself, and one several health systems have leaned on more deliberately.

The Information-Blocking Rule’s Effect on What’s in the Portal

Before April 2021, what patients could see through a portal was largely up to the health system: lab results after some delay, visit summaries, maybe a partial problem list. Clinical notes — the physician’s actual narrative of the visit, assessment, and reasoning — were rarely shared as a matter of course. The Cures Act information-blocking rule changed that by default. As of April 5, 2021, providers are required, with narrow exceptions, to give patients electronic access to eight core clinical data classes “without delay” — including progress notes, discharge summaries, consultation notes, and imaging and lab results as they are finalized, not on a lag. A second phase, effective October 6, 2022, broadened the requirement to the entirety of the electronic health information in a patient’s designated record set as defined under HIPAA.

The practical result has been the near-simultaneous arrival of “open notes” across the industry — not because a single open-notes mandate exists in the way it is sometimes described, but because information-blocking penalties made the old practice of withholding notes indefensible for most organizations. Research from the OpenNotes initiative, based at Beth Israel Deaconess Medical Center and predating the federal rule by nearly a decade of pilot data, has consistently found that a large majority of patients who read their notes report better understanding of their health and care plan, without the broad increases in alarm or confusion some clinicians worried about. That research helped build the case for the rule, even though the rule itself was written primarily to prohibit information blocking rather than to codify the OpenNotes program specifically.

An Uneven Transition for Clinicians

The rule’s rollout was not uniformly smooth. Clinicians in sensitive specialties — oncology, mental health, and pediatrics among them — raised concerns about patients encountering serious diagnoses, prognosis language, or safety-related documentation in a note before a clinician could discuss it directly. ONC’s rule includes exceptions covering situations such as a reasonable belief that access could cause substantial harm, but applying those exceptions correctly, case by case, has required new judgment calls that were not previously a routine part of documentation. Surveys of clinicians who have worked under open notes longer, including physicians at early OpenNotes pilot sites, tend to report that early anxiety decreases with experience, and that many adapt by writing more plainly — cutting unexplained abbreviations and softening language a patient might read as judgmental — rather than by omitting clinically important detail. Whether that holds at newly mandated sites with less runway to adjust is still being studied.

The Message Volume Problem: Portals Shifted Work, Not Just Access

If information blocking answered “can the patient see it,” a separate and less resolved question is what happens once patients can also write back. Secure messaging is one of the oldest portal features, but its volume changed sharply during the pandemic and, notably, has not receded the way telephone call volume has. National EHR usage data reported by the American Medical Association found that patient portal messages continued climbing well after the acute phase of the pandemic passed, even as phone call volume stabilized — meaning portals did not just add a new channel, they became the growing one.

That shift lands squarely on clinicians, largely outside scheduled visit time. Multiple EHR-log studies published during this period have found that answering patient messages, along with other inbox work, is associated with time spent on the record system outside standard work hours — sometimes called “pajama time” — and, in some specialty-specific analyses, with measurably higher burnout risk among physicians receiving the highest message volumes. The causal direction is not fully settled — burned-out clinicians may also generate or attract more messages — but the association has been consistent enough across settings to draw attention from medical societies and health system operations leaders.

Why This Complicates the Engagement Conversation

The tension is not hypothetical: the same portal features that plausibly increase engagement — easy messaging, visible notes and results that prompt follow-up questions — are the ones adding to clinician workload with the least new reimbursement or staffing behind them. Some health systems have responded with billing codes for time-intensive message responses, message-triage staffing (nurses or medical assistants handling routine messages before they reach a physician), or templated responses for common questions. Others have piloted software-assisted drafting tools to reduce the time cost of each reply, though evidence on quality, accuracy, and patient acceptance remains early and should not be treated as settled at this stage.

Equity and the Digital Divide in Portal Use

Averages obscure a persistent and well-documented split in who actually uses portals. Survey data collected before and through the pandemic has repeatedly found lower portal access and use among adults 65 and older, Black and Hispanic patients relative to White patients, people with lower household income, and people without a college degree — even after accounting for whether access was offered. Some of this reflects a straightforward infrastructure problem: broadband is not evenly distributed, and lower-income households are disproportionately likely to lack a reliable home connection, limiting portal use to whatever can be done on a smartphone data plan, if that.

Some of it reflects design and literacy barriers separate from connectivity. Usability research on portals used by older adults and patients with lower health literacy has found that navigation problems often trace back to unfamiliar medical terminology and interfaces that assume comfort with both computers and clinical language — two separate literacies a single login screen tends to assume rather than accommodate. Language access is a related gap: portals built primarily in English, without in-line translation, functionally exclude patients who are not fluent in English even when they have both a device and an account.

None of this is fixed simply by expanding who is offered an account, since the ONC data already shows a meaningful gap between being offered access and using it even among patients who are online. Closing it appears to require some combination of affordable broadband, interfaces built for lower digital and health literacy, multilingual support, and continued availability of non-portal paths — phone calls, mailed after-visit summaries, in-person help at check-in — for patients who cannot or do not want to engage digitally. Treating the portal as the only front door risks concentrating access problems on the same populations that already face the most barriers to care.

What Actually Drives Meaningful Engagement

Pulling together the adoption and activation data with what usability and behavioral research has found, a few factors show up repeatedly as associated with patients moving from “has an account” to “uses it routinely”:

  • Provider endorsement. As the ONC figures above show, a clinician or care team member explicitly recommending the portal — ideally at the point of care, not just in onboarding paperwork — correlates with substantially higher use.
  • Personalized onboarding and training. Research on personal health record use has found that one-on-one or small-group training, rather than a generic tutorial, correlates with more frequent subsequent use, particularly among patients with lower baseline technology comfort.
  • Perceived usefulness tied to an actual need. Patients managing a chronic condition, awaiting a test result, or coordinating care across specialists have a concrete reason to log back in; patients without an active clinical concern have little pull to return.
  • Trust that the information will be understandable and current. Open notes appear to reinforce this when implemented well — but only if the notes and results are actually current, complete, and reasonably free of unexplained jargon.
  • Low friction at every step. Password resets, multi-portal fragmentation across different providers, and clunky mobile experiences remain commonly cited reasons patients disengage even after an initial login.

None of these are novel insights specific to health care — they mirror general findings about technology adoption in other consumer contexts — but they are worth restating because portal engagement strategy has often defaulted to expanding access rather than addressing the second-order barriers that determine whether access converts into use.

The Bottom Line

Patient portals have gone from a niche meaningful-use checkbox to a default channel most patients are at least nominally offered. What they have not yet become, for a meaningful share of the population, is a routine tool patients actually use to manage their health. The information-blocking rule has made the portal’s contents more complete and immediate, which appears to be improving patient understanding where it has been studied — but it has also added a message workload that clinicians and health systems are still figuring out how to staff and pay for. Underneath both trends sits a durable equity gap: the patients with the most to gain from easy access to their own health information — those managing chronic disease, coordinating multiple specialists, or facing language and literacy barriers — are disproportionately the same patients least likely to be using a portal today. Closing the adoption-to-activation gap equitably looks less like a technology problem at this point and more like an operations, staffing, and design problem layered on top of technology that, in most cases, already exists.

Frequently Asked Questions

What is the difference between patient portal adoption and activation?

Adoption typically refers to whether a patient has been offered and has access to a portal account. Activation refers to whether the patient actually logs in and uses it. ONC survey data has consistently shown a substantial gap between the two — access offered runs well ahead of the share of patients who log in even once a year, let alone regularly.

Did the information-blocking rule require open notes for all patients?

Not exactly. The rule, part of the 21st Century Cures Act and effective April 5, 2021, prohibits health systems from unreasonably blocking electronic access to clinical information, including notes, with narrow exceptions. It is often described informally as an open-notes mandate because its practical effect was to make routine note-sharing the default, but it is legally distinct from the separate OpenNotes research and advocacy initiative.

Why are clinicians receiving more patient portal messages than before?

Message volume through portals rose sharply during the COVID-19 pandemic and, unlike phone call volume, has largely stayed elevated rather than returning to prior levels. Easier access to clinicians via secure messaging, combined with more visible test results and notes prompting follow-up questions, appears to be driving sustained growth in inbox work.

Who is least likely to use a patient portal?

Survey data has repeatedly found lower portal use among adults 65 and older, Black and Hispanic patients relative to White patients, people with lower household income, and people without a college degree, even when portal access has been offered. Broadband access, device availability, health literacy, and language barriers all contribute to this gap.

Does reading clinical notes actually help patients?

Research from the OpenNotes initiative has found that a large majority of patients who read their notes report better understanding of their health condition and care plan, and does not find that broad note access meaningfully increases patient worry or confusion, though individual reactions vary and sensitive diagnoses require careful communication regardless of portal access.