The Future of Community Outreach: Using Patient Portals to Provide Voter Resources during the Coronavirus Disease 2019 Pandemic

Abstract

Background During the coronavirus disease 2019 (COVID-19) pandemic, there was a concern for the 2020 general election becoming a superspreader event due to in-person voting.

Objectives Our project addressed this concern by disseminating nonpartisan websites detailing safe voter options in the state of North Carolina to prevent community spread of the virus as much as possible.

Methods In this study, patient portals were used to disseminate a Research Electronic Data Capture survey containing embedded links to voter resources including nonpartisan websites discussing voting options. The survey also asked for demographic data and sentiments regarding the resources provided. Quick response (QR) codes with the survey link were also placed in the clinics during the study period.

Results The survey was sent to 14,842 patients who had at least one patient encounter in the past 12 months at one of three General Internal Medicine clinics at Atrium Health Wake Forest Baptist. Survey participation through both the patient portals and QR codes was assessed. Patient sentiments toward the voter resources in regard to (1) interest and (2) perceived helpfulness were collected in the survey. In total, 738 (4.99%) patients filled out the survey. Eighty-seven percent of survey respondents reported that the voter resources were helpful. Significantly more black patients than white (29.3 vs. 18.2, p < 0.05) voiced interest in voter resources. There was no statistical significance across gender or reported comorbidities.

Conclusion Multicultural, underserved, and underinsured patients perceived the most benefit. During public health crises, patient portal messages can be used to bridge information gaps and promote better health outcomes in a timely and effective manner.

Keywords

patient portals - voter registration - social determinants of health - COVID-19 - community outreach

Background and Significance

During the coronavirus disease 2019 (COVID-19) pandemic, in-person voting in the general election had the potential to become an event where COVID-19 could be easily spread on a large scale, known as a “superspreader event (SSE).” By October 1, 2020, almost 1 month before the general election, COVID-19 had infected 7.2 million Americans resulting in 208,000 deaths.[1]

Past outbreaks with highly communicable viruses such as severe acute respiratory syndrome, Middle East respiratory syndrome, and Ebola demonstrated that SSEs were responsible for the severe spike in cases.[2] COVID-19 had a similar community spread in the United States[3] emphasizing the importance of limiting mass gatherings, including voting in person, to prevent the spread of the virus. Several states rescheduled primary elections to mitigate risk;[4] however, the date of the national presidential election could not be changed.[5] [6] In some states, absentee voting (or vote by mail) was extended to all legally registered voters, and options to request an absentee ballot or make changes to one's voter registration electronically had been enacted to reduce foot traffic at typical voter registration sites.[7] Thirty-nine states and Washington, DC, enacted full online voter registration platforms as of March 30, 2020.[8] According to a Pew Research Center survey, 70% of U.S. adults favored allowing any voter to vote by mail if they desired.[9]

Voting is challenging for vulnerable populations, including those with chronic medical conditions. The link between low voter turnout and health has been demonstrated in multiple studies, and low voter turnout has been repeatedly shown to be more than a problem of access and/or participation in voting.[10] [11] [12] A comprehensive review by Brown et al highlighted that lower voting rates are associated with worse self-reported health, especially in the physically, intellectually, and psychologically disabled populations.[10] Furthermore, voting has been linked to social determinants of health, with the same barriers affecting health care access also serving as barriers to voting.[11] [12]

Health care systems have had a unique opportunity to address this gap and educate patients on how to safely vote. Medical organizations have implemented different strategies to enhance voter registration including (1) clinic-based, medical student-driven voter registration drives[13]; (2) medical student-led campaigns providing emergency absentee ballots to hospitalized patients[14]; or (3) larger-scale multi-institutional collaboratives like Vot-ER connecting health care institutions with nonpartisan resources during the 2020 general election.[15] In 2020, Martin et al reported use of voter registration tools in hospitals and medical schools around the country.[15] They offered digital and in-person kits to interested health care organizations that include quick response (QR) codes, badges, and information such as website links and telephone numbers for patients to quickly access information about voter registration and absentee ballots.[15] All of these approaches, however, were limited in scalability and relied on manual effort to have the maximum impact.

Online patient portals, with appropriate patient sign-up, have the potential to directly reach entire patient populations instantly and have not been investigated as a vehicle to promote voter education. Patient portals are online mediums by which health care providers and patients can securely access patient information and communicate directly. Patient portals were built to create easy access to individualized health information as well as develop a secure electronic medium for patient-health care provider communication.[16] Initial concerns that patient portals may exacerbate existing disparities in care have been somewhat addressed by nationwide studies finding that a majority of people have access to the internet via mobile devices.[17] However, it is also true that smartphone ownership does not mean that all smartphone owners can reliably use their phones and data to access patient portals.

To the authors' knowledge, no studies have investigated the use of a patient portal to provide education on electronic voter registration and absentee ballot information. No published studies have evaluated whether the patient portal or in-person QR code scanning is more effective for patient engagement or assessed patient perceptions on receiving voter information from their medical provider.

This project aimed to educate the community regarding safe voting options to prevent the spread of the virus while encouraging patients to vote. To support efforts to combat pandemic-generated risks and inequities in voting and expand research into health care delivery-based Voter Registration Programs, we implemented an intervention to evaluate the efficiency of patient portals and QR codes in disseminating information to patients regarding voting protocols that followed Centers for Disease Control and Prevention (CDC) guidelines for social distancing and assess patient preferences for receiving this information from their health care providers.

Objectives

Our objective was to assess the efficacy of QR codes and electronic patient portals in disseminating health-focused voting options prior to the 2020 General Election in North Carolina and to prevent the spread of COVID-19 through education on safe voting practices.

Methods

Atrium Health Wake Forest Baptist (AHWFB) is an academic learning health system with a central 885-bed tertiary care hospital in Winston-Salem and four network community hospitals. In total, the AHWFB Network encompasses more than 232 primary and specialty care clinics with 1.98 million outpatient visits annually.[18] The electronic health record (EHR) used by the main campus and several affiliated sites is 2021 EpicCare (Epic Systems).

Patients from three general internal medicine clinics were included in this study. One clinic primarily includes patients of internal medicine faculty members and is identified as “faculty clinic.” The other two clinics have a majority of patients seen by resident physicians and are identified as “resident clinics.” The breakdown of providers for resident clinic encounters were as follows: 60% resident physicians, 13% faculty physicians, 11% nurse practitioners, and 12% physician assistants.

The resident clinics have approximately 30,000 patient encounters per year staffed by 115 internal medicine resident physicians, 11 faculty physicians, and 4 advanced practice providers. The faculty clinic has approximately 19,000 patient encounters per year seen by 11 faculty physicians and one nurse practitioner. The resident clinics include the Downtown Health Plaza (DHP) and the Internal Medicine—Janeway Tower Clinic (OPD). The DHP clinic is a standalone clinic in the downtown area serving Winston-Salem, NC, and the greater Forsyth County community. The OPD clinic is a hospital-based clinic at AHWFB. The faculty clinic, University Internal Medicine—Country Club Clinic (UIM), is a standalone clinic in Winston-Salem. [Table 1] depicts the demographic characteristics of these clinics.

Table 1 Demographic data of the active patient population and survey respondents divided by clinic

	Active clinic patients (prior 12 mo)			Survey respondents
	Faculty clinic	Resident clinics	p-Value	Faculty clinic	Resident clinics	p-Value
	(N = 8,120)	(N = 11,308)		(N = 609)	(N = 129)
Age (y)			<0.001			<0.001
18–24	225 (2.8%)	680 (6.0%)		2 (0.3%)	1 (0.8%)
25–34	535 (6.6%)	1,412 (12.5%)		17 (2.8%)	10 (7.8%)
35–44	814 (10.0%)	1,764 (15.6%)		42 (6.9%)	10 (7.8%)
45–54	1,301 (16.0%)	2,459 (21.7%)		66 (10.8%)	27 (20.9%)
55–64	1,858 (22.9%)	2,962 (26.2%)		144 (23.6%)	37 (28.7%)
65–74	1,886 (23.2%)	1,459 (12.9%)		226 (37.1%)	35 (27.1%)
75 or older	1,501 (18.5%)	572 (5.1%)		112 (18.4%)	9 (7.0%)
Gender			0.778			0.817
Female	4,768 (58.7%)	6,664 (58.9%)		365 (59.9%)	79 (61.2%)
Male	3,352 (41.3%)	4,644 (41.1%)		238 (39.1%)	48 (37.2%)
[a]Other				1 (0.2%)	0 (0%)
[a]Prefer not to answer				5 (0.8%)	2 (1.6%)
Race			<0.001			<0.001
White	6,753 (83.2%)	2,774 (24.5%)		535 (87.8%)	79 (61.2%)
Black	969 (11.9%)	6,291 (55.6%)		39 (6.4%)	36 (27.9%)
Asian	187 (2.3%)	115 (1.0%)		7 (1.1%)	2 (1.6%)
Hispanic or Latino	0 (0%)	3 (0.0%)		11 (1.8%)	6 (4.7%)
Native American	12 (0.1%)	32 (0.3%)		3 (0.5%)	0 (0%)
Other	181 (2.2%)	2,071 (18.3%)		14 (2.3%)	6 (4.7%)
[a]Comorbidities			<0.001			<0.001
≥1	4,783 (58.9%)	6,999 (61.9%)		326 (53.5%)	93 (72.1%)
None	3,337 (41.1%)	4,309 (38.1%)		283 (46.5%)	36 (27.9%)
Insurance			<0.001
Commercial insurance	4,479 (55.2%)	2,106 (18.6%)
Medicare/Medicaid	3,157 (38.9%)	5,724 (50.6%)
Self-pay	213 (2.6%)	2,408 (21.3%)
Other government	45 (0.6%)	321 (2.8%)
Worker's comp/liability	226 (2.8%)	749 (6.6%)

^a This was an option given to our patient at the time of intake for any clinic visit. It is an open option.

An online Research Electronic Data Capture survey was designed to provide awareness of safe, healthy voting options in North Carolina during the pandemic via embedded links in the survey provided based on patient responses to the survey questions. The survey assessed patients' preferred voting method and perception of resource helpfulness. A survey snapshot is provided in [Fig. 1]. A link to the survey is provided in [Supplementary Appendix A] (available in the online version). The survey ascertained basic demographic data including age, gender, race, ethnicity, and self-reported comorbidities. The list of selectable comorbidities was based on the CDC's description of patients at the highest risk of poor outcomes if infected with COVID-19.[19] Nonpartisan voter information was provided via links to state websites, including the North Carolina Department of Motor Vehicles (NC DMV),[20] NC Board of Election Voter Search,[21] NC Voter Information website,[22] and the NC Ballottrax website[23] (links available in [Supplementary Appendix A], available in the online version). These links provided guidance regarding voter registration, absentee request, absentee tracking, and information about the general elections. Specific candidate views or preferences were neither provided nor obtained.

Fig. 1 This is a screenshot of part of the survey provided to patients. The screenshot displays how the survey both provides links to voter resources and collects data on preferred voting methods.

The survey with the embedded voter resources was distributed by a link sent in an EHR patient portal message and through posters with QR codes placed in noticeable locations in the resident clinics. However, we were unable to display the QR codes in the faculty clinics. The QR code, when scanned by a smartphone using the provided instructions, opened a link to an identical but separate online survey which allowed us to distinguish it from the portal link survey entries. These posters were prominently displayed on September, 30th 2020 and were present until election day. [Fig. 2] displays a sample of the flyer with the QR code. This project was discussed and approved by unanimous consensus during a General Internal Medicine section meeting prior to implementation.

Fig. 2 An example of the QR code posted in the clinics.

Patient demographic data and data regarding medical comorbidities were extracted for each of the participating clinics via the EHR databases. Patients were messaged with the survey via the patient portal if they had (1) attended any one of the clinics in the prior 12 months up to the time of the initiation of the study and (2) if they had an active patient portal established. “Active” status is defined as a patient using an initiation link and creating an account but does not necessarily imply consistent use.

Patient demographics and survey response data were summarized using standard descriptive statistics, including frequencies and proportions. Chi-square tests were used to compare clinic populations in terms of patient demographics and presence of comorbidities. Chi-square tests were also used to determine associations between patient demographics and the outcome (1) interest and (2) helpfulness of the intervention. Multivariate logistic regression was performed to assess the outcome interest and helpfulness, adjusted for clinic, race, age, gender, and comorbidity level. Statistical tests were two sided, and α level of 0.05 was used to determine statistical significance. Multivariate statistical analyses were completed using R statistical software, version 3.6.1.

Results

In the 12 months period prior to study initiation, 19,380 patients had 48,489 patient encounters in the participating clinics. In total, 14,842 patients (77%) had active patient portals in the study clinics and received the survey via the EHR patient portal (6,781 in the resident clinics and 8,061 in the faculty clinic). Seven hundred thirty-eight (4.99%) surveys were completed. In total, 3,078 patient encounters occurred in the residency clinics where the QR codes were posted during the study period. One survey was completed via the QR code (0.03%). The faculty clinic had 2,039 patient encounters during the study period.

Resident clinics had 20% more uninsured patients compared with faculty clinics (21.9vs. 1.8%; p-value < 0.05) and 45% more patients of color (57 vs. 12%; p-value < 0.05). A majority of survey respondents identified as white (87.8% at the resident clinics and 61.2% at the faculty clinic, p < 0.05). In total, 72.1% of survey respondents from the resident clinics reported at least one high-risk comorbidity associated with poor outcomes from COVID-19 infection compared with 53.5% from the faculty clinics (p < 0.05). The gender of the survey respondents was not significantly different among the participating clinics.

[Table 2] portrays the degree of interest in the voter resources stratified by the demographic data. Interest was evaluated using the following yes/no question: “Would you be interested in learning how to update your voter registration online and/or request an absentee ballot?” In total, 18.8% (N = 139/738) of survey respondents were interested in receiving information about absentee voting and/or voter registration. In total, 25.6% (N = 33/129) of patients in the resident clinics were interested compared with 17.1% (N = 106/619) of patients in the faculty clinic (p < 0.05). Interest was also statistically significant across races with 29.3% of black patients being interested in voter resources compared with 18.2% of white patients (p < 0.05). Gender and reported comorbidities were not statistically significantly associated with interest.

Table 2 Outcome of “interest” compared by demographic data

	Interested	Not interested	p-Value
	(N = 138)	(N = 610)
Clinic			<0.05
Faculty clinic	106 (17.1%)	513 (82.9%)
Resident clinic	33 (25.4%)	97 (74.6%)
Age (y)			0.06
18–24	1 (33.3%)	2 (66.7%)
25–34	10 (37%)	17 (63%)
35–44	14 (26.9%)	38 (73.1%)
45–54	21 (22.6%)	72 (77.4%)
55–64	36 (19.9%)	145 (80.1%)
65–74	34 (15%)	227 (85%)
75 or older	23 (23.5%)	98 (76.5%)
Gender			0.59
Female	81 (18.2%)	364 (81.8%)
Male	57 (19.8%)	231 (80.2%)
Race			<0.05
White	112 (18.2%)	505 (81.8%)
Black	22 (29.3%)	53 (70.7%)
Asian	3 (33.3%)	6 (66.7%)
Hispanic or Latino	1 (5.9%)	16 (94.1%)
Native American	1 (33.3%)	2 (66.7%)
Other	0 (0%)	28 (100%)
Reported comorbidities			0.61
≥1	82 (19.2%)	345 (80.8%)
None	57 (17.7%)	265 (82.3%)

Note: “Interest” was surveyed using the following yes/no question: “Would you be interested in learning how to update your voter registration online and/or request an absentee ballot?”

[Table 3] portrays the degree of perceived helpfulness of the voter resources in relation to the demographic data. In total, 69.9% (N = 516/738) of survey respondents answered the optional question on the helpfulness of the voter information provided. Although 18.8% of all survey respondents were initially interested in voter information, 62.5% (323/516) of survey respondents who rated the helpfulness of the information found the resources to be “extremely” or “very” helpful. In total, 24.2% (125/516) found the resources to be “moderately” or “slightly helpful,” and 13.2% (68/516) did not feel that the resources were helpful. Women were significantly more interested in receiving voting information than men (90% of women vs. 82% of men; p-value < 0.05). There were no significant differences in race or reported comorbidities.

Table 3 Observing the outcome of “helpfulness” compared by demographic data

	Extremely—very helpful	Moderately—slightly helpful	Not at all helpful	p-Value
	(N = 323)	(N = 125)	(N = 68)
Clinic
Faculty clinic	249 (59.85%)	105 (25.24%)	62 (14.90%)	<0.05
Resident clinic	74 (74%)	20 (20%)	6 (6%)
Age (y)
18–24	0 (0%)	0 (0%)	3 (100%)	0.14
25–34	11 (61.11%)	6 (33.33%)	1 (5.55%)
35–44	27 (72.97%)	8 (21.62%)	2 (5.40%)
45–54	48 (64.86%)	16 (21.62%)	10 (13.51%)
55–64	84 (71.79%)	20 (17.09%)	13 (11.11%)
65–74	94 (54.97%)	52 (30.41%)	25 (14.62%)
75 or older	57 (62.64%)	20 (21.98%)	14 (15.38%)
Gender
Female	194 (65.54%)	72 (24.32%)	30 (10.13%)	<0.05
Male	123 (58.29%)	51 (24.17%)	37 (17.53%)
Race
White	261 (61.84%)	106 (25.11%)	55 (13.03%)	0.083
Black	46 (76.66%)	9 (15%)	5 (8.33%)
Asian	4 (50%)	2 (25%)	2 (25%)
Hispanic or Latino	8 (72.72%)	1 (9.09%)	2 (18.18%)
Native American	1 (50%)	0 (0%)	1 (50%)
Other	3 (23.076%)	7 (53.84%)	3 (23.07%)
Reported comorbidities
≥1	187 (62.54%)	71 (23.74%)	41 (13.71%)	0.89
None	136 (62.67%)	54 (24.88%)	27 (12.44%)

All respondents were required to answer a question regarding the likelihood of voting absentee during the pandemic. In total, 69.4% (512/738) of survey respondents answered that they would be “likely” or “very likely” to vote absentee. In total, 19% (139/738) of survey patients answered an optional question on preferred voting method. In total, 48.2% (67/139) of this subgroup planned to vote absentee followed by early voting at 37.4% (52/139) and voting in person on election day at 14.4% (20/139).

Further statistical analysis was performed on the 19% (139/738) of survey respondents who showed initial interest in voter resources. Resident clinic patients were more interested in voter resources (25.4 vs. 17.1%; p < 0.05). Black patients were also more interested in voter resources (29.3% of black patients vs. 21% of patients of other races, p < 0.05). Gender and presence of comorbidities did not affect interest. Patients who were interested in voter resources were 3.4 times more likely to find them helpful (p < 0.05) and to report planning to vote absentee (65 vs. 46%; p < .05).

Discussion

The 2020 national general election had potential to be a SSE during the COVID-19 pandemic. This project aimed to educate the community regarding safe voting options to prevent spread of the virus while encouraging patients to vote. We were able to reach 77% of all patients that came through the clinic in a calendar year via EHR patient portal messaging. As a means of distributing information, this was an effective approach to reaching out to the community for this public health initiative.

Of individuals who completed the survey, the majority found the information to be helpful suggesting this information was well received by our patients and could be a means of providing similar public health and voting information to at-risk populations. This study did not involve individualization based on patient demographics and included a nonpartisan message applicable to all patients. However, as noted in previous studies, patient portals do have the potential to provide individualized medical instruction and education based on structured data connected to the patient's chart.[24] [25] [26] [27]

To be effective in dissemination of information, patient portals must be active and functional. One meta-analysis demonstrated that mean adoption rates for patient portal hovered around 52% with “real-world experiments” having a much lower adoption rate of 23%.[28] Patient portal adoption rates also vary by patient demographics and socioeconomic factors with patients who are female, white, and commercially insured having higher odds of using their patient portal.[29] Within our own community, 77% of eligible patients had an active patient portal reflective of high usage in our patient population. However, there were large discrepancies between faculty and resident clinics (86.4% active and 36.8% active, respectively). This may be due to differences in patient populations in the clinics. Nevertheless, efforts to aid with the adoption of patient portals could widen the power of population health initiatives such as this one.

This study involved two methods of distribution, and there were stark contrasts in effectiveness. Prominently posted QR codes were not effective in our community in distributing the voter resources and survey compared with EHR patient portal messaging. This is similar to previous studies for passive survey delivery methods such as QR codes.[30] Studies during the COVID-19 pandemic evaluated required QR code utilization as part of the clinic visit and showed successful usage by patients around 90%.[31] However, accessing our QR code was not a required step in the patient visit. Poll research has suggested that up to 85% of adults in the United States have smartphones with only slight variations due to socioeconomic factors.[32] This would decrease the potential concern for lack of smartphone access being a limiting factor for QR code usage, even in lower socioeconomic communities.

The analysis of the main study outcome of perceived interest in voter resources showed novel findings compared with the literature. After controlling for clinic and demographic data, race was a statistically significant variable with black patients expressing higher interest in voter information (29% of Black patients were interested compared with 18% of White patients and 9% who identified as “Other”). A factor that did not play a role was the reported presence of comorbidities identified by the CDC as having a higher risk of morbidity/mortality with COVID-19. The fact that the presence of comorbidities did not play a role in interest or perception of helpfulness fits with previous research showing that the presence of multimorbidity alone is not enough to influence behavior toward more health conscious and/or less risky health behavior.[33] Gender did not play a role in interest but women did report an increase in perceived helpfulness which is in line with national trends for voting.[34]

A subset of patients from the resident clinics were more interested in the resources provided and found them more helpful. As noted in [Table 1], these clinics are significantly different in terms of race, medical comorbidities, and insurance with a much larger proportion of the population at the resident clinics with government insurance or no insurance (72.5 vs. 40.5% at the faculty clinic). Resident clinics at our institution also have more culturally diverse patients with greater comorbidities and barriers to care.

Brown et al demonstrated that patients with increased barriers to care related to social determinants of health also have increased difficulties with voting and are less likely to vote.[10] [35] In comparison, strong “social capital” or “the networks of relationships among people who work in a particular society” may positively influence voting rates in general.[10] If the “social capital” or social network prioritizes voting, then the individual within that network will more likely prioritize voting.[10] Social capital is such a strong element in voter turnout that it has been shown to directly conflict with a well-documented deterrent, chronic health conditions. In one study of patients with several different comorbidities, cancer patients were significantly more likely to report voting than patients with other chronic comorbidities.[36] Cancer survivors also formed 40 times more support groups than heart disease sufferers, and it has been suggested that cancer patients are more likely to join advocacy groups with focuses on voting, ultimately leading to higher voter turnout.[36] Social networks that discuss voting and the political process promote higher participation in voting even when controlled for well-established barriers such as chronic comorbidities and socioeconomics.[10] [36] Our resident clinics notably have more developed social networks that collectively promote efforts to unite and elevate the community. Social capital potentially contributed to higher interest in voter resources in our resident clinics. Furthermore, our study demonstrated an opportunity for the health system to build on existing social capital and integrate itself into patients' social networks to encourage voting participation. Future research could explore the impact of trusted health care organizations in promoting voter resources, perhaps even when the threat of a global pandemic does not insert additional barriers to voting processes.

Limitations

Limitations of the study include the significant patient population (23%) who did not have an active patient portal account and an unknown number of patients who had ongoing access but were not actively using accounts. The subset of the clinic population with an active patient portal was also significantly different from the general clinic population in regard to race. Another limitation was the passive nature of the QR code links in the clinic, which were not included in the patient intake process prior to this project, likely leading to decreased response volumes. We were unable to fully measure QR code utilization among all three clinics given inability to post-QR codes in the faculty clinic. We also were unable to do baseline studies of whether our patient population felt competent with using QR codes with their phones. Finally, the limited number of survey respondents made it difficult to have enough statistical power to make statistical analysis/claims within racial and socioeconomic groups.

Conclusion

In our study, the multicultural, underserved, and underinsured patients perceived the most benefit from dissemination of safe voter practices through the EHR patient portal during the COVID-19 pandemic. This study showed effective outreach to this large at-risk population of patients through the patient portal. Patients were interested in hearing about voting resources within the context of their health care. During health crises, patient portal messages can be used to promote public health initiatives in a timely and effective manner.

Clinical Relevance Statement

Our study demonstrates that electronic patient portals can be used for department/institution-wide population health initiatives specifically aiding multicultural, underserved, and underinsured patients in our community. These initiatives can also include providing general aid with civil duties such as voting in the general election and be well received by the public.

Multiple-Choice Questions

1. Which of the following mediums has NOT been studied in-depth as a means of providing voter information to patients?

   • QR code-linked initiatives

   • Electronic patient portals

   • Voter registration drives

   • Inpatient emergency absentee ballot initiatives

   Correct Answer: The correct answer is option b. The other three options have all been studied in the past. This is the first study that has evaluated as the potential for electronic patient portals in providing voter resources.

2. Which well-documented network of relationships plays a direct role in voting habits/patterns as well as perception of the medical community?

   • Socioeconomics

   • Economic capital

   • Social capital

   • Ethical egoism

   Correct Answer: The correct answer is option c. Social capital has been shown to play a strong role on voter element and in someways surpass the effect that personal health or socioeconomics can have on voter turnout.

Conflict of Interest

A.D. serves as an EHR Consultant for the AAMC CORE program. A.D. and M.F. are the coinventors of WHIRL, which is licensed to Illumicare, Inc. A.D., M.F., and Wake Forest University Health Sciences have an ownership interest in the WHIRL application. D.M. and A.D. are the coinventors of mPATH. D.M., A.D., and Wake Forest University Health Sciences have equity in Digital Health Navigation, which has licensed mPATH. This research study does not involve or overlap with any of the above conflicts of interest. The other authors declare that they have no conflicts of interest in this research.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by Wake Forest University Health Sciences Institutional Review Board.

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Publication History

Received: 03 October 2022

Accepted: 23 January 2023

Article published online:
19 April 2023