Cancer test results shared to portals often viewed by patients before ordering clinicians
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The 21st Century Cures Act aimed to improve patient access to medical test results by requiring their immediate release via electronic portals.
Although this provision has enhanced information sharing and transparency, it has sparked concern about unintended consequences of granting patients immediate access to potentially confusing or alarming information without guidance from the ordering clinician.
This has particularly profound implications in oncology, according to Sheena Bhalla, MD, assistant professor in the division of hematology and oncology at UT Southwestern Medical Center.
“With immediate release of test results, patients are often learning about new or progressing cancer through the portal on their portable devices, at any time of the day, without concurrent clinical interpretation from their care team,” Bhalla told Healio.
Bhalla and colleagues conducted a cross-sectional study to evaluate patterns of patient and clinician viewing of test results before and after implementation of the 21st Century Cures Act in April 2021 to understand its impact on communication about and understanding of cancer diagnoses.
Results showed median time from result posting in the electronic health record to patient viewing in the portal declined considerably after implementation. In addition, the percentage of test results patients viewed prior to the ordering clinician doubled.
Healio spoke with Bhalla about the implications of these findings, as well as how oncologists can provide guidance and support to their patients who access test results on patient portals.
Healio: Can you describe the rationale for this study?
Bhalla: The 21st Century Cures Act mandated the immediate electronic availability of test results to patients. Before implementation, many health systems automatically released results to the patient portal 72 hours after posting in the EHR, although clinicians could manually release sooner. We wanted to better understand this practice change and examine contemporary patterns of patient and clinician viewing of test results since the implementation of the 21st Century Cures Act.
Healio: How did you evaluate patterns of test result viewing?
Bhalla: We identified patients with a cancer diagnosis who received at least one laboratory, radiology or pathology result through our cancer center's patient portal — Epic MyChart — between 2017 and 2022. We extracted information from reporting databases supporting the EHR and patient portal, including time to patient viewing of test results from result availability in the EHR and result release to MyChart. We were particularly interested in characteristics — such as patient demographics and test type — associated with result viewing in the portal, as well as the proportion of results viewed by patients before ordering clinicians.
Healio: Can you summarize your main findings?
Bhalla: Our dataset included more than 5 million test results released to more than 40,000 patients between 2017 and 2022. During this period, patients viewed about 50% of results in the portal, and patients were more likely to review radiology results (64%) and pathology results (64%) than laboratory results (47%).
After implementation of the 21st Century Cures Act, median time from result posting in the EHR to patient viewing in the portal decreased from 77 hours to about 6 hours. Of course, this gives the clinician very little time to review results before the patient views them in the portal.
When we looked at results reviewed by both patients and clinicians — an analysis that included more than 2 million test results — we found the proportion of test results viewed by the patient before the ordering clinician increased from 37% in 2017 to 75% in 2022. This trend was noted among all test result types, including radiology and pathology reports. In 2022, 76% of radiology reports and 58% of pathology reports were viewed by patients before ordering clinicians.
Healio: What are the consequences of patients viewing test results prior to the ordering clinician?
Bhalla: There are advantages when patients can view test results immediately, even if it’s before the ordering clinician. This allows patients to see their results in a timely, efficient manner. This also gives patients time to process results on their own and think about potential questions before meeting with their health care team. On the other hand, there are disadvantages. Patients may have increased anxiety or confusion when viewing abnormal results before the ordering clinician. This may particularly apply to radiology and pathology results, which do not appear as discrete values with reference ranges but as extensive free-text reports that often require a medical background to understand.
Healio: How much of a problem is patient anxiety due to seeing — and potentially not understanding — test results without context from the health care team?
Bhalla: This is becoming common, especially in oncology. In fact, given these concerns, certain states such as Kentucky and California have passed legislation allowing a pause before electronic release of highly sensitive test results.
When clinicians order tests, it’s important to provide anticipatory guidance and set expectations with patients. In my own practice, I let patients know results will be released to the portal automatically, and they often will see results before I do. I share that some patients may prefer to wait to view results, particularly scans and pathology reports, until our visit so I can explain what these findings mean in the context of their particular circumstances. Having this conversation from the start is very helpful for patients and clinical teams. From the health systems perspective, we could optimize existing patient portal interfaces to give users more control over their notification preferences related to sensitive or abnormal results or timing the release of test results during working hours.
Healio: What else can oncologists or hematologists do to help?
Bhalla: Oncologists and hematologists probably order more tests than other medical specialties and are running into these situations routinely. If a medical practice or health system immediately releases test results through the portal, it’s critical to discuss this with patients from the start and set expectations when they will be hearing from the care team about the results — whether it’s through an in-person visit, telehealth visit or phone call. Additionally, further research incorporating patient surveys and focus groups is necessary to better understand patient preferences regarding immediate release of test results — specifically among people with cancer, for whom results are more likely to convey life-changing developments.
Also, reports are designed for clinicians as recipients. Should we begin incorporating more patient-friendly reports in clear, understandable language? Moving forward, ongoing research on this topic may help us identify optimal communication strategies that align with patient preferences, minimize distress, and can be integrated within effective and efficient clinical operations.
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For more information:
Sheena Bhalla, MD, can be reached at UT Southwestern Medical Center, 6202 Harry Hines Blvd., 9th floor, Dallas, TX 75235; email: sheena.bhalla@utsouthwestern.edu.
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