Abstract
This cohort study among patients with cancer examines changes in the time from posting of test results in the electronic health record to patient viewing in the patient portal before and after implementation of the 21st Century Cures Act.
In April 2021, the 21st Century Cures Act mandated immediate release of all medical test results to patients through electronic portals. At our cancer center, before Cures Act implementation, laboratory test results were automatically released 72 hours after posting in the electronic health record (EHR) (and could be released manually sooner), radiology results were not automatically released (after 72 hours) until 2019, and pathology results were not automatically released. Since implementation, all 3 result types are simultaneously released to the portal when posted in the EHR. While intended to improve information sharing, questions have arisen about consequences for patient well-being and communication. For instance, patients may now learn of a new, recurrent, or progressing cancer before discussion with clinicians.1 This study assessed contemporary patterns of patient and clinician viewing of test results before and after Cures Act implementation.
Methods
This cross-sectional study was approved by the University of Texas Southwestern Medical Center institutional review board with a waiver of informed consent because the research involved no more than minimal risk and could not practically be carried out without a waiver. We followed the STROBE reporting guideline. We identified patients with a cancer diagnosis who received at least 1 laboratory, radiology, or pathology result through the patient portal (Epic MyChart) between January 1, 2017, and December 31, 2022. We extracted information from the reporting database supporting the EHR and the patient portal. We determined time to patient viewing of test results from result availability in the EHR to result release to the portal. Data were analyzed using SAS, version 9.4. Two-sided P < .05 was significant.
Results
Of 5 570 521 test results released to 44 419 patients, 2 706 170 (49%) were viewed (Table). Patients viewed a greater proportion of released radiology (64%) and pathology (64%) results than laboratory results (47%). Black patients (33%) were less likely than Asian (58%) and White (51%) patients to view released results.
Table. Characteristics Associated With Result Reviewing in a Patient Portal and Time to Result Reviewing in the Portal.
| Characteristic | Results released to portal, No. (%)a | Results reviewed by patients in portal, No. (%)a | Time, median (IQR), h | |
|---|---|---|---|---|
| Result release in EHR to patient review | Result release in portal to patient review | |||
| All results | 5 570 521 | 2 706 170 | 50.1 (6.5-139.8) | 6.2 (0.8-51.5) |
| Result type | ||||
| Laboratory | 4 981 615 (89) | 2 327 706 (86) | 49.3 (6.1-138.3) | 6.1 (0.8-50.7) |
| Radiology | 516 684 (9) | 332 401 (12) | 88.6 (15.3-143.2) | 6.2 (0.8-52.1) |
| Pathology | 72 222 (1) | 46 063 (2) | 94.9 (17.7-721.0) | 14.3 (1.0-120.8) |
| Time | ||||
| Before Cures Act | 3 855 660 (69) | 1 732 742 (64) | 77.0 (40.0-153.5) | 6.5 (0.8-61.0) |
| After Cures Act | 1 714 861 (31) | 973 428 (36) | 6.4 (1.0-44.3) | 5.6 (0.8-41.5) |
| Year | ||||
| 2017 | 655 763 (12) | 281 877 (10) | 136.8 (75.9-192.9) | 11.8 (4.9-90.4) |
| 2018 | 797 331 (14) | 334 769 (12) | 138.6 (57.7-186.1) | 7.4 (1.1-77.1) |
| 2019 | 997 182 (18) | 454 020 (17) | 54.0 (38.2-142.0) | 5.2 (0.7-56.6) |
| 2020 | 1 087 701 (20) | 517 671 (19) | 52.7 (28.1-119.1) | 3.7 (0.4-48.5) |
| 2021 | 1 093 579 (20) | 566 106 (21) | 20.4 (2.6-72.4) | 6.2 (0.8-47.7) |
| 2022 | 938 965 (17) | 551 727 (20) | 4.6 (0.7-32.0) | 4.4 (0.7-30.5) |
| Sex | ||||
| Female | 2 566 819 (46) | 1 288 963 (48) | 50.6 (7.0-141.4) | 6.4 (0.8-55.8) |
| Male | 3 003 212 (54) | 1 416 971 (52) | 49.6 (6.2-138.2) | 6.0 (0.8-48.6) |
| Age, y | ||||
| <65 | 2 302 961 (41) | 1 170 571 (43) | 50.0 (5.8-140.6) | 5.4 (0.6-51.9) |
| ≥65 | 3 267 111 (59) | 1 535 384 (57) | 50.1 (7.1-139.2) | 6.8 (1.0-51.2) |
| Raceb | ||||
| Asian | 261 656 (5) | 151 302 (6) | 41.3 (3.3-116.3) | 4.2 (0.6-34.3) |
| Black | 721 247 (13) | 240 123 (9) | 56.1 (10.3-166.1) | 13.4 (1.5-101.6) |
| White | 4 121 204 (74) | 2 097 029 (77) | 49.9 (6.5-138.9) | 5.9 (0.8-48.3) |
| Otherc | 465 965 (8) | 217 501 (8) | 50.9 (7.5-141.9) | 6.6 (0.8-63.1) |
Abbreviation: EHR, electronic health record.
Percentages may not total to 100 due to rounding.
We recorded self-reported race as documented in the electronic health record. This demographic variable was included in the analysis because it has been associated with health behaviors.
Includes American Indian, Hawaiian Pacific Islander, and participants with multiple races or unknown racial information.
After Cures Act implementation, median time from result posting in the EHR to patient viewing in the portal decreased from 77.0 hours (IQR, 40.0-153.5 hours) to 6.4 hours (IQR, 1.0-44.3 hours), although considerable decrease was observed before the Cures Act. The proportion of test results viewed by patients before ordering clinicians increased from 37% in 2017 to 75% in 2022 (P < .001), with the greatest increase for radiology results (Figure).
Figure. Proportion of Test Results Viewed by Patients Before Ordering Clinicians.
Discussion
Over 6 years, we observed a shortening interval between medical test result availability and viewing by patients. This decrease began before the Cures Act, which may reflect developments such as increased use of portable devices2 and automated posting of radiology results. After the Cures Act, 75% of test results were viewed by patients before the ordering clinician, almost double the views in 2017.
How patients with cancer receive test results has implications for practice quality. Most patients prefer to receive test results immediately through the portal.3 However, patients also report increased anxiety when receiving abnormal results this way. 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. While patients tend to want immediate access to blood test results, most prefer delayed release of radiology and pathology reports,4 the tests most likely to convey life-changing developments such as new or progressive cancer. Recognizing these concerns, Kentucky and California have passed legislation allowing a pause before electronic release of highly sensitive test results, and other states may follow.5,6
Study strengths include the large sample size, focus on oncology, period spanning Cures Act implementation, and categorization of test results by type. Limitations include the single-center setting, lack of clinical context for tests (eg, whether a pathology result conveyed an initial cancer diagnosis), and reliance on inbox accessing to define clinician result reviewing, which does not account for viewing by other personnel or through other EHR channels.
Data Sharing Statement
References
- 1.Bellizzi KM. “You’ve got mail”—receiving bad news through a patient portal. JAMA Oncol. 2023;9(6):757-758. doi: 10.1001/jamaoncol.2023.0422 [DOI] [PubMed] [Google Scholar]
- 2.Pho KK, Lu R, Gates S, et al. Mobile device applications for electronic patient portals in oncology. JCO Clin Cancer Inform. 2019;3:1-8. doi: 10.1200/CCI.18.00094 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Steitz BD, Turer RW, Lin CT, et al. Perspectives of patients about immediate access to test results through an online patient portal. JAMA Netw Open. 2023;6(3):e233572. doi: 10.1001/jamanetworkopen.2023.3572 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Hulter P, Langendoen W, Pluut B, et al. Patients’ choices regarding online access to laboratory, radiology and pathology test results on a hospital patient portal. PLoS One. 2023;18(2):e0280768. doi: 10.1371/journal.pone.0280768 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Arnold SM, Allison CL, Bernard P. Tempering the 21st Century Cures Act: physicians, policy advocacy, and Kentucky’s solution. JCO Oncol Pract. 2022;18(9):603-605. doi: 10.1200/OP.22.00254 [DOI] [PubMed] [Google Scholar]
- 6.Gerber DE. Taking it to the states: adapting information blocking legislation to oncology. J Clin Oncol. 2023;41(27):4348-4351. doi: 10.1200/JCO.23.01108 [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Data Sharing Statement
