Patient and clinician perceptions of the immediate release of electronic health information

Addressing language barriers in access to genetic testing under the United States 21st Century Cures Act

The Final Rule of the 21st Century Cures Act ("Cures") in the United States, which healthcare professionals (HCPs) were required to comply with starting in 2021, transformed clinical care by providing patients with immediate electronic access to their medical records. This often included the option to view their genetic testing results before discussing them with HCPs. "Cures" overarching goal was to enhance healthcare access and empower patients. However, a crucial limitation within the implementation of this legislation is the absence of language concordance in the dissemination of test results. While immediate access to test results may be a significant advancement, these results are predominantly offered in English, creating a formidable barrier for patients with limited English proficiency (LEP), exacerbating healthcare inequities. Consequently, this has the potential for misinterpretations, misdiagnoses, and inappropriate medical interventions. There is an urgent need to provide accessible, culturally sensitive, and language concordant genetic testing and counseling services, especially as results may also carry a direct impact on family members' medical management. This paper underscores the importance of recognizing that the issue extends beyond the availability of genetic testing results; it exemplifies a broader systemic challenge that disenfranchises patients with LEP, limiting their ability to comprehend and engage effectively with their healthcare. This paper advocates for the role of genetic counselors in developing and implementing solutions that bridge the language gap and promote equitable access to genetic healthcare. By leveraging our advocacy skills, genetic counselors can contribute to positive changes that benefit patients with LEP, ensuring that the promise of "Cures" is realized for patients of all linguistic backgrounds.

Timing and Method of Patient-Provider Communication for Abnormal Hepatocellular Carcinoma Screening Results in Cirrhosis

PURPOSE

Patients with cirrhosis undergo frequent abdominal imaging including semiannual hepatocellular carcinoma (HCC) screening, with results released immediately via the patient portal. We characterized time from patient review to patient-provider communication (PPC) for patients with abnormal liver imaging results.

METHODS

We identified patients with cirrhosis enrolled in the patient portal with a new abnormal liver lesion (LI-RADS, LR) on ambulatory liver ultrasound (US) or multiphasic computed tomography/magnetic resonance imaging. Imaging findings were grouped into low-risk (US-2, LR-2), intermediate-risk (US-3, LR-3), and high-risk (LR-4, LR-5, LR-M, LR-TIV) results. We extracted three date-time events from the electronic health record, including result release to the patient, patient review of the result, and result-related PPC. We compared communication methods and the median time with PPC after patient review of results between groups.

RESULTS

The cohort included 133 patients (median age, 62 years, 56% male) with 34 (25.6%) low-risk, 61 (45.9%) intermediate-risk, and 38 (28.6%) high-risk results. PPC for high-risk results was predominantly via telephone calls (60.5%), whereas portal messages were most commonly used for low- and intermediate-risk results (61.8% and 45.9%, respectively; P < .001). For patients who reviewed their result on the portal, most (79.3%) reviewed the result before PPC, among whom the median time between review and PPC was 55.8 (IQR, 22.0-219.0), 167 (IQR, 42.7-324.0), and 47.3 (IQR, 25.8-78.8) hours for low-, intermediate-, and high-risk results, respectively (P = .02).

CONCLUSION

Portal-based review of abnormal imaging results by patients before provider communication is common, including results concerning a new HCC diagnosis. Further studies are needed to evaluate patient-reported outcomes, such as psychological distress, associated with this method of disclosing cancer-related results.

Patient and Family Perceptions of Real-Time Access to Electronic Health Information: A Social Media Survey

OBJECTIVE

 This study seeks to understand pediatric rheumatology patients' and caregivers' utilization and perceptions of immediate access to their electronic health information (EHI) via patient portals.

METHODS

 An anonymous, 23-question Qualtrics survey was distributed via social media to patients and families with pediatric rheumatic diseases. The survey link and Quick Response (QR) code were posted on disease-specific Facebook accounts. Descriptive statistics were used with a thematic content analysis performed on free-text responses.

RESULTS

 The survey received 253 eligible responses. Nearly 48% of participants reported accessing their electronic patient portal >12 times in the last year, while only 0.4% (one respondent) reported accessing it zero times and 8% reported accessing it 1 to 2 times. Following a medical appointment, 45% reported regularly accessing their portal the same day as their appointment, 36% when they get an alert for new results, and 0.8% only in response to a healthcare provider message. About 98% use the patient portal to access laboratory results, 98% provider notes, 80% healthcare provider messages, 64% imaging results, 53% appointments, and 28% medications. Thematic content analysis found that respondents use the portal for coordination of care and to advocate for themselves or their child. The emotional impact of access to EHI without provider explanation was variable by respondent, with some reporting increased worry and some less worry. Many respondents (18%) found value in posting results to social media sites for help in interpretation.

CONCLUSION

 This study demonstrates pediatric rheumatology patients' and caregivers' strong portal engagement and expectation for immediate access to EHI through the patient portal. Although some did report that access to EHI without provider input can increase worry or anxiety, families perceive the patient portal as a tool for self-advocacy and engagement in care, leading to a stronger sense of their role as a member of the care team.

Timing of Liver Imaging Result Release Is Associated with Patients with Cirrhosis Reviewing Results Prior to Providers

BACKGROUND

 Patients with cirrhosis are at high risk for developing hepatocellular carcinoma (HCC), warranting receipt of semiannual surveillance imaging with the potential to identify abnormal liver lesions. Since the implementation of the 21st Century Cures Act's Information Blocking provision, test results are immediately released to patients through the patient portal. There is an increasing trend of patients reviewing their results before their providers.

OBJECTIVE

 We aimed to determine whether the date and time characteristics of when the result is released to the electronic health record (EHR) are associated with patients reviewing results before providers.

METHODS

 In patients with cirrhosis undergoing ambulatory liver imaging, the date-time characteristics of when the result was released to providers in the EHR were categorized as outside regular work hours for holidays, weekends, or outside normal business hours. Logistic regression was used to determine the relationship between results released to the EHR outside work hours and whether the patient or provider was the first to review the result.

RESULTS

 We identified 850 imaging studies from 401 patients with a median age of 62 (interquartile range [IQR]: 53-69) years. Patient time to result review was shorter or equivalent to their providers for 57% of the results. A total of 170 (20.0%) of results were released outside regular work hours. There was an increased odds of the patient reviewing the result before providers for results released outside regular work hours (adjusted odds ratio [aOR] = 1.54, 95% CI: 1.08-2.20).

CONCLUSION

 HCC screening results released to the EHR outside regular work hours is associated with patients reviewing these results before providers.

Helping patients navigate the immediate release of medical records: MedEd, a novel patient engagement technology

BACKGROUND

Through online health portals, patients receive complex medical reports without interpretation from their healthcare provider. This study evaluated the usability of MedEd, a patient engagement tool providing definitions of medical terminology in breast pathology and radiology reports.

METHODS

Individuals who underwent a normal screening mammogram were invited to complete semi-structured interviews where they downloaded MedEd and discussed their download experience. Acceptability, appropriateness, and feasibility of MedEd were evaluated.

RESULTS

143 individuals were invited to participate, and 14 semi-structured interviews were completed. Participants reported ease of downloading and navigating MedEd with concerns about privacy and others' abilities to download. Participants demonstrated high acceptability (mean 4.48/5, SD 0.95), appropriateness (mean 4.66/5, SD 0.83), and feasibility (mean 4.48/5, SD 1.04) scores.

CONCLUSION

Participants expressed excitement for future use of MedEd and provided suggestions for improvements. Next steps include evaluating comprehension of real breast reports while using MedEd and expanding patient access.

Patient discourses on real-time access to test results via hospital portals: a discourse analysis of semistructured interviews with Dutch patients

OBJECTIVE

Real-time access to test results on patient portals can have advantages and disadvantages for patients. It confronts patients with a complicated decision, namely whether to consult results before the medical consultation. To gain a deep understanding of patients' decision-making processes, we unravelled three discourses about real-time access to test results, each of which articulates a different set of values, assumptions and arguments. Our research question was what patient discourses on real-time access to test results can be distinguished?

DESIGN

We conducted discourse analysis on 28 semistructured interviews.

SETTING

Interviews were conducted with patients who had (no) experience with real-time access to test results. Our participants were treated in different hospitals, and therefore, used different portals since Dutch hospitals can choose from suppliers for their patient portals.

PARTICIPANTS

Patients with experience (n=15) and without experience (n=13) of real-time access to test results on a patient portal.

RESULTS

We identified three discourses: (1) real-time access as a source of stress, which highlighted how real-time access could cause stress due to the complexity of deciding whether to access test results, the incomprehensibility of medical language and the urge to repeatedly check if test results were available, (2) anxiety reduction through real-time access showed how real-time access can reduce stress by reducing waiting times and (3) real-time access for self-management showed how real-time access can give patients an opportunity for self-management because they can make informed decisions and are better prepared for the medical consultation.

CONCLUSION

Our study shows the plurality in opinions on real-time access, which helps in forming different strategies to inform and support patients in order to realise optimal use of real-time access.

Immediate Access to Radiology Reports: Perspectives on X Before and After the Cures Act Information Blocking Provision

OBJECTIVE

The 21st Century Cures Act's information blocking provision mandates that patients have immediate access to their electronic health information, including radiology reports. We evaluated public opinions surrounding this policy on X, a microblogging platform with over 400 million users.

METHODS

We retrieved 27,522 posts related to radiology reports from October 5, 2020, through October 4, 2021. One reviewer performed initial screening for relevant posts. Two reviewers categorized user type and post theme(s) using a predefined coding system. Posts were grouped as "pre-Cures" (6 months before information blocking) and "post-Cures" (6 months after). Descriptive statistics and χ2 tests were performed.

RESULTS

Among 1,155 final posts, 1,028 unique users were identified (64% patients, 11% non-radiologist physicians, 4% radiologists). X activity increased, with 40% (n = 462) pre-Cures and 60% (n = 693) post-Cures. Early result notification before referring providers was the only theme that significantly increased post-Cures (+3%, P = .001). Common negative themes were frustration (33%), anxiety (27%), and delay (20%). Common positive themes were gratitude for radiologists (52%) and autonomy (21%). Of posts expressing opinions on early access, 84% favored and 16% opposed it, with decreased preference between study periods (P = .006). More patients than physicians preferred early access (92% versus 40%, P < .0001).

DISCUSSION

X activity increased after the information blocking provision, partly due to conversation about early notification. Despite negative experiences with reports, most users preferred early access. Although the Cures Act is a positive step toward open access, work remains to improve patients' engagement with their radiology results.

Information transparency with immediate release: Oncology clinician and patient perceptions

INTRODUCTION

As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients. In this study, we sought to evaluate clinician and patient perceptions regarding this immediate release.

METHODS

After surveying 33 clinicians and 30 patients, semi-structured interviews were conducted with a subset of the initial sample, comprising 8 clinicians and 12 patients. Open-ended questions explored clinicians' and patients' perceptions of immediate release of EHI and how they adjusted to this change.

RESULTS

Ten themes were identified: Interpreting Results, Strategies for Patient Interaction, Patient Experiences, Communication Strategies, Provider Limitations, Provider Experiences, Health Information Interfaces, Barriers to Patient Understanding, Types of Results, and Changes due to Immediate Release. Interviews demonstrated differences in perceived patient distress and comprehension, emphasizing the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.

CONCLUSIONS

Clinicians and patients have unique insights on the role of immediate release. Understanding these perspectives will help improve communication and develop patient-centered tools (glossaries, summary pages, additional resources) to aid patient understanding of complex medical information.

Impact of a switch to immediate release on the patient viewing of diagnostic test results in an online portal at an academic medical center

Patient portals allow patients to access their personal health information. The 21st Century Cures Act in the United States sought to eliminate 'information blocking', requiring timely release upon request of electronic health information including diagnostic test results. Some health systems, including the one in the present study, chose a systematic switch to immediate release of all or nearly all diagnostic test results to patient portals as part of compliance with the Cures Act. Our primary objective was to study changes in the time to view test results by patients before and after implementation of Cures Act-related changes. This retrospective pre-post study included data from two 10-month time periods before and after implementation of Cures Act-related changes at an academic medical center. The study included all patients (adult and pediatric) with diagnostic testing (laboratory and imaging) performed in the outpatient, inpatient, or emergency department settings. Between February 9, 2020 and December 9, 2021, there was a total of 3 809 397 diagnostic tests from 204 605 unique patients (3 320 423 tests for adult patients; 488 974 for pediatric patients). Overall, 56.5% (115 627) of patients were female, 84.1% (172 048) white, and 96.5% (197 517) preferred English as primary language. The odds of viewing test results within 1 and 30 days after portal release increased monthly throughout both time periods before and after the Cures Act for all patients. The rate of increase was significantly higher after implementation only in the subgroup of tests belonging to adult patients with active MyChart accounts. Immediate release shifted a higher proportion of result/report release to weekends (3.2% pre-Cures vs 15.3% post-Cures), although patient viewing patterns by day of week and time of day were similar before and after immediate release changes. The switch to immediate release of diagnostic test results to the patient portal resulted in a higher fraction of results viewed within 1 day across outpatient, inpatient, and emergency department settings.

Impact of the Immediate Release of Clinical Information Rules on Health Care Delivery to Patients With Cancer

PURPOSE

The 21st Century Cures Act mandates the immediate release of clinical information (IRCI) to patients. Immediate sharing of sensitive test results to patients with cancer might have serious unintended consequences for patients and providers.

METHODS

A 22-question REDCap survey was designed by the Association of American Cancer Institutes Physician Clinical Leadership Initiative Steering Committee to explore oncology providers' opinions on IRCI policy implementation. It was administered twice in 2021 with a 3-month interval. A third survey with a single question seeking providers' opinions about their adaptation to the IRCI mandate was administered 1 year later to those who had responded to the earlier surveys. The data were analyzed using descriptive statistics such as chi-squared or Fisher's exact tests for categorical variables. The survey was sent to all Association of American Cancer Institutes cancer center members. In the first or second administration, 167 practitioners answered the survey; 31 responded to the third survey.

RESULTS

Three quarters of the providers did not favor the new requirement for IRCI and 62% encountered questions from patients about results being sent to them without provider interpretation. Only half of the hospitals had a plan in place to deal with the new IRCI requirements. A third survey, for longitudinal follow-up, indicated a more favorable trend toward adoption of IRCI.

CONCLUSION

IRCI for patients with cancer was perceived negatively by academic oncology providers after its implementation. It was viewed to be associated with higher levels of patient anxiety and complaints about the care delivered. Providers preferred to discuss test results with patients before release.

Perspectives of Patients About Immediate Access to Test Results Through an Online Patient Portal

Importance

The 21st Century Cures Act Final Rule mandates the immediate electronic availability of test results to patients, likely empowering them to better manage their health. Concerns remain about unintended effects of releasing abnormal test results to patients.

Objective

To assess patient and caregiver attitudes and preferences related to receiving immediately released test results through an online patient portal.

Design, Setting, and Participants

This large, multisite survey study was conducted at 4 geographically distributed academic medical centers in the US using an instrument adapted from validated surveys. The survey was delivered in May 2022 to adult patients and care partners who had accessed test results via an online patient portal account between April 5, 2021, and April 4, 2022.

Exposures

Access to test results via a patient portal between April 5, 2021, and April 4, 2022.

Main Outcomes and Measures

Responses to questions related to demographics, test type and result, reaction to result, notification experience and future preferences, and effect on health and well-being were aggregated. To evaluate characteristics associated with patient worry, logistic regression and pooled random-effects models were used to assess level of worry as a function of whether test results were perceived by patients as normal or not normal and whether patients were precounseled.

Results

Of 43 380 surveys delivered, there were 8139 respondents (18.8%). Most respondents were female (5129 [63.0%]) and spoke English as their primary language (7690 [94.5%]). The median age was 64 years (IQR, 50-72 years). Most respondents (7520 of 7859 [95.7%]), including 2337 of 2453 individuals (95.3%) who received nonnormal results, preferred to immediately receive test results through the portal. Few respondents (411 of 5473 [7.5%]) reported that reviewing results before they were contacted by a health care practitioner increased worry, though increased worry was more common among respondents who received abnormal results (403 of 2442 [16.5%]) than those whose results were normal (294 of 5918 [5.0%]). The result of the pooled model for worry as a function of test result normality was statistically significant (odds ratio [OR], 2.71; 99% CI, 1.96-3.74), suggesting an association between worry and nonnormal results. The result of the pooled model evaluating the association between worry and precounseling was not significant (OR, 0.70; 99% CI, 0.31-1.59).

Conclusions and Relevance

In this multisite survey study of patient attitudes and preferences toward receiving immediately released test results via a patient portal, most respondents preferred to receive test results via the patient portal despite viewing results prior to discussion with a health care professional. This preference persisted among patients with nonnormal results.