BackgroundOlder adults are increasingly accessing information and communicating using patient-facing portals available through their providers’ electronic health record (EHR). Most theories of technology acceptance and use suggest that patients’ overall satisfaction with care should be independent of their chosen level of portal engagement. However, achieving expected benefits of portal use depends on demonstrated support from providers to meet these expectations. This is especially true among older adults, who may require more guidance. However, little is known about whether misalignment of expectations around technology-facilitated care is associated with lower perceptions of care quality. ObjectiveThe aims of this study were to analyze whether older adults’ assessment of primary care quality differs across levels of patient portal engagement and whether perceptions of how well their provider uses the EHR to support care moderates this relationship. MethodsWe conducted a cross-sectional survey analysis of 158 older adults over the age of 65 (average age 71.4 years) across Michigan using a 13-measure composite of self-assessed health care quality. Portal use was categorized as none, moderate (use of 1-3 functionalities), or extensive (use of 4-7 functionalities). EHR value perception was measured by asking respondents how they felt their doctor’s EHR use improved the patient–provider relationship. ResultsModerate portal users, compared to those who were extensive users, had lower estimated care quality (–0.214 on 4-point scale; P=.03). Differences between extensive portal users and nonportal users were not significant. Quality perception was only particularly low among moderate portal users with low EHR value perception; those with high EHR value perception rated quality similarly to other portal user groups. ConclusionsOlder adults who are moderate portal users are the least satisfied with their care, and the most sensitive to perceptions of how well their provider uses the EHR to support the relationship. Encouraging portal use without compromising perceptions of quality requires thinking beyond patient-focused education. Achieving value from use of patient-facing technologies with older adults is contingent upon matched organizational investments that support technology-enabled care delivery. Providers and staff need policies and practices that demonstrate technology adeptness. Older adults may need more tailored signaling and accommodation for technology to be maximally impactful.