This paper is in the following e-collection/theme issue:

Personal Health Records, Patient-Accessible Electronic Health Records, Patient Portals (538) Participatory Medicine & E-Patients (758)

Published on in Vol 17, No 3 (2015): March

Emergency Physicians’ Views of Direct Notification of Laboratory and Radiology Results to Patients Using the Internet: A Multisite Survey

Emergency Physicians’ Views of Direct Notification of Laboratory and Radiology Results to Patients Using the Internet: A Multisite Survey

Emergency Physicians’ Views of Direct Notification of Laboratory and Radiology Results to Patients Using the Internet: A Multisite Survey

Authors of this article:

Joanne Callen1 Author Orcid Image ;   Traber Davis Giardina2 Author Orcid Image ;   Hardeep Singh2 Author Orcid Image ;   Ling Li1 Author Orcid Image ;   Richard Paoloni3 Author Orcid Image ;   Andrew Georgiou1 Author Orcid Image ;   William B Runciman4 Author Orcid Image ;   Johanna I Westbrook1 Author Orcid Image
Article Authors Cited by (23) Tweetations (17) Metrics

    Original Paper

    1Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia

    2Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX, United States

    3Emergency Department, Concord Repatriation and General Hospital, Sydney, Australia

    4The Joanna Briggs Institute, Department of Anaesthesia and Intensive Care, University of Adelaide, Adelaide, Australia

    *all authors contributed equally

    Corresponding Author:

    Joanne Callen, BA, MPH, PhD

    Centre for Health Systems and Safety Research

    Australian Institute of Health Innovation

    Macquarie University

    Level 6, 75 Talavera Road

    Macquarie University

    Sydney, 2109

    Australia

    Phone: 61 9850 2425

    Fax:61 8088 6234

    Email: joanne.callen@mq.edu.au


    Background: Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions.

    Objective: The aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results.

    Methods: A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification.

    Results: The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61).

    Conclusions: Although patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

    J Med Internet Res 2015;17(3):e60

    doi:10.2196/jmir.3721

    Keywords

    Internet; patient safety; electronic health records; patient empowerment; diagnostic tests; emergency care; radiology 


    Information and communication technology (ICT) is an essential component for facilitating communication between health professionals within and across health care settings [1,2]. Patients are also increasingly using the Internet to communicate with health care providers and access general and personal health information using email and patient portals tied to hospital-based electronic medical records [3-10]. Given the increasing use of ICT to assist communication, any investigation of suboptimal communication between patients and providers should explore ways in which the Internet could improve information exchange. Breakdown in communication has been identified as a common problem with test result follow-up [11-15]. In the emergency department (ED), up to 75% of test results are missed and the potential impact on patient outcomes includes missed cancer diagnoses [16].

    More systematic processes for test result follow-up are needed, including the use of electronic information systems [13,17-20]. It has also been proposed that patient involvement could assist in mitigating missed test results [21-23]. Patients could act as a safety net and be directly notified of their results by the treating clinician transmitting them by email, text messaging (short message service, SMS), letter, or telephone. Alternatively, patients could access test results electronically directly from the laboratory or via a patient portal tied to their hospital electronic medical record (EMR). Physicians would still play a major role in test follow-up and action regarding further treatments, etc. There are moves toward legislating direct notification of tests results in the United States. Since 2004, the Mammography Quality Standards Act has required that a summary of the mammogram report, written in layperson terms, be sent directly to the patient within 30 days [24]. In February 2014, the US Department of Health and Human Services issued a regulation specifying that laboratories must release test reports directly to patients if requested [25].

    Studies have shown that patients support direct notification of normal and abnormal test results [5,21,26-29]. However, studies that have explored physicians’ views have only included primary care practitioners [30-36]. Because the ED is a critical area where results are missed, it is important to gauge physicians’ views on direct notification of test results to patients. There are no published studies of emergency physicians’ opinions of patients’ direct access to test results.

    The aim of this study was to explore emergency physicians’ current practices of abnormal test result notification and their attitudes to direct patient notification of clinically significant abnormal and normal test results.

    Our research questions were 2-fold:

    1. What are emergency physicians’ current practices for patient notification of abnormal test results in terms of methods, timing of, and responsibilities for notification?
    2. What are emergency physicians’ views about direct patient notification of normal and abnormal test results?

    Study Design, Setting, and Population

    A cross-sectional paper-based survey was administered to all senior emergency physicians (site A: n=50; site B: n=39) in the EDs of 2 large public metropolitan teaching hospitals in Australia (Table 1). The sites were selected using convenience sampling. Senior emergency physicians were defined as department directors, specialists in emergency medicine, registrars, and senior medical officers and were included based on their involvement and responsibility in relation to test ordering and test result follow-up. The study was approved by the ethics committees from both hospital study sites and the University of New South Wales, Sydney, Australia.

    Table 1. Characteristics of 2 hospital emergency department (ED) sites.
    CharacteristicsHospital site

    		AB
    Hospital beds, n758543
    Annual inpatient discharges, n83,89845,055
    Annual ED attendances, n61,93935,687
    Annual ED discharges home, n40,71323,019
    Hospitalizations for which the ED is responsible, %25%28%
    ED admission rates, %34%36%

    Survey Instrument

    A survey consisting of 22 closed-ended questions was developed based on literature related to patients’ and physicians’ access to clinical information [34,37]. We pilot-tested the survey face-to-face with 2 senior hospital specialists (1 ED physician and 1 rheumatology specialist) from Australia and 10 US primary care practitioners. Based on their feedback, modifications were made to improve clarity of the survey. Fifteen of the survey questions had 7-point Likert response scales with options ranging from strongly agree to strongly disagree.

    A detailed description of the design and development of the survey instrument is included in the paper on primary care physicians’ attitudes to directly releasing results to patients [38]. An identical survey was used in both studies. Questions included: current practices and institutional policies for patient notification of abnormal test results (timing, methods, and responsibilities), attitudes toward direct notification of normal and abnormal results, possible physician concerns including lack of patient expertise in interpreting results, previous experiences with missed abnormal test results by themselves or others, patient care decision-making attitudes, and participant demographic details.

    For the purposes of the study, direct notification was defined as the automatic release of test results directly to the patient regardless of whether or not the ordering physician had reviewed the results. Direct notification could be achieved by mail, telephone, fax, SMS text message, or by patients accessing their EMR using a patient portal. Abnormal test results were defined for this study as clinically significant abnormal results. This includes those that are not immediately life-threatening but required short-term follow-up; for example, newly elevated glucose blood levels or a chest x-ray with a new shadow.

    Data Collection

    The survey was self-administered by emergency physicians at the 2 study hospitals between July 1 and September 30, 2012. The survey took each physician approximately 15 minutes to complete. After obtaining staff rosters, researchers approached each ED physician from the study population and asked them to participate in the study. Each physician was informed of the confidential nature of the results and each survey contained a participant information sheet outlining the nature of the study and that completion of the survey implied consent. The survey was left with the ED physician and they were asked to place the completed survey in a dedicated secure box in the ED secretary’s office. The researchers returned at the end of each week to collect the completed surveys and follow-up with nonrespondents. Those physicians who had failed to complete the survey were reminded and given another survey if the previous one had been mislaid.

    Statistical Analysis

    Data were analyzed using SPSS version 21.0 (IBM Corp, Armonk, NY, USA) and descriptive statistics calculated. For ease of interpretation, we recoded the dependent variable responses into dichotomous categories. For descriptive analyses and logistic regression, the responses of agree, moderately agree, or strongly agree and disagree, moderately disagree, and strongly disagree were collapsed into agree and disagree, respectively. The category of neither agree nor disagree was retained for descriptive analyses.

    We used logistic regression to identify predictors related to emergency physicians’ comfort with direct notification of abnormal test results to patients and their agreement with direct notification of normal test results. Exact methods for logistic regression models were adopted because the sample size of the study was too small for asymptotic methods [39]. The category of neither agree nor disagree was excluded for logistic regression because the number of physicians who responded to this category was small and exact analysis for an ordinal logistic regression model was not available computationally. Two exact logistic regression models were developed using a stepwise forward selection of covariate method [39]. To avoid overfitting the models, we included no more than 2 explanatory variables in each model [40]. We included only variables that were clinically relevant as possible predictors. Predictors in the final models were considered significant at the P<.05 level. Odds ratios and their 95% confidence intervals were presented for the predictors included in the final models. The regression analysis was generated using SAS/STAT version 9.3 (SAS Institute, Inc, Cary, NC, USA).


    Characteristics of Respondents

    A total of 89 emergency physicians were invited to complete the survey and 61 complied giving an overall response rate of 69% (61/89) (Table 2). The response rate for hospital A was 74% (37/50) and for hospital B was 62% (24/39).

    Table 2. Characteristics of emergency physicians from the 2 study hospitals (N=61).
    Participant characteristicsTotal, n (%)
    Gender

    		Female30 (49)

    		Male31 (51)
    Age (years)

    		20-2920 (33)

    		30-3917 (28)

    		40-4916 (26)

    		50-595 (8)

    		60-693 (5)
    Positiona

    		Senior emergency physician21 (34)

    		Registrar25 (41)

    		SRMO15 (25)
    Years in practice

    		<525 (41)

    		5-1012 (20)

    		11-1510 (16)

    		16-204 (7)

    		>2110 (16)

    a Senior emergency physicians are board certified specialists in emergency medicine; registrars and senior resident medical officers (SRMOs) are physicians in senior fellowship or residency positions.

    Emergency Physicians’ Attitudes Toward and Concerns About Direct Notification of Test Results

    Approximately half of the emergency physicians (54%, 33/61) were not comfortable with patients receiving direct notification of abnormal results, although a similar proportion (57%, 35/61) agreed with direct notification of normal results (Table 3). Most (57%, 35/61) agreed that overall a direct notification system would reduce the number of patients lost to follow-up. Physicians’ major concerns relating to direct notification of abnormal results were confusion (92%, 56/61), lack of expertise necessary to interpret test results (90%, 55/61), and patient anxiety (85%, 52/61). Most also expressed concerns that the patient may seek information that could be unreliable (57%, 35/61). Most physicians were not concerned that direct notification would interfere with the practice of medicine (90%, 55/61) or increase their workload (92%, 56/61). The majority of physicians disagreed with releasing abnormal results directly to patients for human immunodeficiency virus (HIV) (84%, 51/61), cancer screening (84%, 51/61), and chest x-rays (59%, 36/61). Tests which most thought suitable for direct notification were lipid profile (64%), blood glucose (59%), and urinalysis (57%). Approximately half the respondents felt comfortable with releasing abnormal complete blood counts (49%, 30/61), thyroid function tests (48%, 29/61), and electrolytes (44%, 27/61) directly to patients (Table 3).

    Emergency Physicians’ Current Practices and Responsibilities for Direct Notification of Abnormal Results

    Most respondents agreed (75%, 46/61) that there were standard policies and procedures for notification of abnormal results in their EDs (Table 4). However, there were mixed responses regarding who should be responsible for notifying patients of results with some physicians (43%, 26/60) stating that it was not always clear who should notify patients of abnormal results. The majority agreed that the ordering physician (or their assigned delegate) should be solely responsible for notifying patients (65%, 39/60) and the majority also agreed that the primary care provider should be responsible for following up abnormal results regardless of who ordered the test (65%, 39/60). Emergency physicians’ practices in relation to methods of patient notification of abnormal test results varied with respondents stating that they always (47%, 25/53) or sometimes (43%, 23/53) phoned the patient. The majority of emergency physicians indicated that they never emailed (100%, 44/44), never faxed (91%, 40/44), and never waited for the patient to contact them (91%, 40/44) regarding abnormal results. In relation to decision making, most respondents (58%, 35/60) thought that they shared responsibility with the patient for deciding on treatments.

    Table 3. Emergency physicians’ attitudes toward direct notification.
    Opinions and concerns about direct notification of test results to patientsScale, n (%)n (%)

    		Agree/yesNeither agree or disagreeDisagree/no
    Attitudes to direct notification of test results to patients (n=61)




    		I am comfortable with patients receiving direct notification of abnormal test results24 (39)4 (7)33 (54)

    		Do you agree that there should be direct patient notification of normal results?35 (57)8 (13)18 (30)

    		Overall, a direct notification system would reduce the number of patients lost to follow-up35 (57)13 (21)13 (21)

    		Overall, a direct notification system would reduce physician workload19 (32)15 (25)26 (43)
    Concerns regarding direct notification of abnormal test resultsato patients (n=61)

    		Patient anxiety about test results52 (85)
    		9 (15)

    		Patient confusion about test results56 (92)
    		5 (8)

    		Patients lack expertise necessary to interpret the results55 (90)
    		6 (10)

    		Patient may seek unreliable information35 (57)
    		26 (43)

    		Patient may seek care without consulting their primary care provider29 (48)
    		32 (53)

    		Interferes with the practice of medicine6 (10)
    		55 (90)

    		Physician workload increase5 (8)
    		56 (92)

    		I have no concerns2 (3)
    		59 (97)
    If direct notification became the norm, which abnormal test resultsawould you be comfortable with releasing directly to patients (n=61)

    		Complete blood count30 (49)
    		31 (51)

    		Electrolyte panel27 (44)
    		34 (56)

    		Blood glucose36 (59)
    		25 (41)

    		Chest x-ray25 (41)
    		36 (59)

    		Lipid profile (TC, HDL, LDL, TG)39 (64)
    		22 (36)

    		Thyroid blood tests (TSH, T4, TPO)29 (48)
    		32 (53)

    		HIV10 (16)
    		51 (84)

    		Urinalysis35 (57)
    		26 (43)

    		Cancer screening tests (eg, mammography, PAP smear)10 (16)
    		51 (84)
    Please specify at what time interval, after the result became available, would you be comfortable with direct notification of abnormal test resultsato patients (n=60)b

    		24 hours


    		31 (52)

    		48 hours


    		16 (27)

    		7 days


    		5 (8)

    		14 days


    		0 (0)

    		30 days


    		1 (2)

    		Other


    		7 (12)

    a Abnormal test results are clinically significant abnormal results such as newly elevated blood glucose or chest x-ray with new shadow.

    b One missing response.

    Table 4. Emergency physicians’ current practices and responsibilities for direct notification of abnormal results.a
    Emergency physicians’ current practices and responsibilities for direct notification of abnormal resultsn (%)Scale, n (%)


    		AlwaysSometimesNever
    As part of your usual practice when do you (or staff delegated by you) typically notify patients of abnormal test results? (n=61)

    		<24 hours50 (82)



    		24 hours-1 week11 (18)



    		>1 week0 (0)


    In my practice, there are standardized policies and procedures for notification of abnormal test results (n=61)

    		Agree46 (75)



    		Neither agree nor disagree7 (12)



    		Disagree8 (13)


    The physician who ordered the test or their assigned delegate should be solely responsible for notifying patients of abnormal test results (n=60)

    		Agree39 (65)



    		Neither agree nor disagree0 (0)



    		Disagree21 (35)


    The assigned primary care provider for the care of the patient should always be responsible for following up abnormal test results regardless of who ordered the test (n=60)

    		Agree39 (65)



    		Neither agree nor disagree2 (3)



    		Disagree19 (32)


    It is not always clear who should notify patients of abnormal test results (n=60)

    		Agree26 (43)



    		Neither agree nor disagree9 (15)



    		Disagree25 (42)


    When it comes to make decision about my patients’ care, I am most comfortable when (n=60)

    		I make the decision about treatment0 (0)



    		I make the final decision but consider the patient’s opinion22 (37)



    		The patient and I share responsibility for deciding treatment35 (5)



    		The patient makes the final decision but considers my opinion3 (5)



    		The patient makes the final selection with little input from me0 (0)


    Once you have seen an abnormal test result how do you (or staff delegated by you) notify patients?b

    		Phone
    		25 (47)23 (4)5 (9)

    		Email
    		0 (0)0 (0)44 (100)

    		Fax
    		1 (2)3 (7)40 (91)

    		Letter
    		3 (7)23 (50)20 (44)

    		Wait until next appointment
    		0 (0)5 (12)38 (88)

    		Schedule a follow-up appointment
    		3 (7)14 (32)27 (61)

    		Wait for the patient to contact you
    		1 (2)3 (7)40 (91)

    a Abnormal test results are clinically significant abnormal results such as newly elevated blood glucose or chest x-ray with new shadow.

    b Not all respondents answered each question.

    Emergency Physicians’ Experiences With Missed Test Results

    In the previous 12 months, 21% (13/61) of emergency physicians said they had missed an abnormal result which led to delayed patient care, although half said they did not know whether they had missed a result or not (51%, 31/61). When asked if their colleagues had missed an abnormal result, a higher proportion responded yes (44%, 27/61). Participants reported radiology results to be the most frequently missed (38%, 23/61) followed by microbiology (13%, 8/61) and chemistry (13%, 8/61).

    Results From Exact Logistic Regression Models

    The final exact logistic regression model showed that emergency physicians who were not concerned about whether patients might seek unreliable information were 4 times more likely to be comfortable with direct notification of abnormal test results than those who were not concerned about this issue (OR 4.56, 95% CI 1.04-24.30). If direct notification became the norm, physicians would feel more comfortable with releasing abnormal test results on blood glucose than on other test results (OR 15.74, 95% CI 2.84-171.16).

    Emergency physicians’ agreement on whether a direct notification system would reduce physician workload was the main factor associated with agreement on direct patient notification of normal test results. Those who agreed that a direct notification system would reduce physician workload were more likely to agree with a direct patient notification of normal results than those who disagreed that it would reduce workloads (OR 5.72, 95% CI 1.14-39.76). Those who were neutral about this issue were more likely to agree on direction notification than those who disagreed, but this difference was not statistically significant (OR 3.84, 95% CI 0.72-27.81).

    Table 5. Logistic regression exploring predictors of emergency physician comfort with direct patient notification of abnormal test results and agreement with patient notification of normal test results.
    ParameterOR (95% CI)P
    Feel comfortable with patients receiving direct notification of abnormal test resultsa


    		Concerned that patients may seek unreliable information
    		.04

    		No (reference)4.56 (1.04-24.30)

    		Yes

    Feel comfortable with releasing abnormal test results on blood glucose, if direct notification became the norm<.001

    		Yes15.74 (2.84-171.16)

    		No (reference)


    		Agree that there should be direct patient notification of normal results

    Overall, a direct notification system would reduce physician workload.03

    		Agree5.72 (1.14-39.76).003

    		Neutral3.84 (0.72-27.81).14

    		Disagree (reference)

    a Abnormal test results are clinically significant abnormal results such as newly elevated blood glucose or chest x-ray with new shadow.


    Principal Results

    Although most emergency physicians in our study thought that a direct test notification system would reduce the number of patients lost to follow-up, just over half did not support direct notification of abnormal test results. The main concerns expressed were that it would result in patient anxiety and confusion, and that patients lacked the necessary expertise to interpret test results. Physicians were more likely to be comfortable with direct notification of abnormal test results if they were not concerned about whether patients might seek potentially unreliable information. However, the majority of emergency physicians in our study were comfortable with direct notification of normal test results and they were more likely to be supportive if they thought this would reduce their workload. Approximately 1 in 5 respondents reported missing results in the previous 12 months, whereas half did not know whether they had or not. Radiology results were cited as the most frequently missed. There were diverse responses regarding who should be responsible for notifying patients of abnormal results with a number of respondents stating that this was not always clear.

    Two key results from our study, which have not been previously published, focus attention on the unique ED environment, where physicians normally have no continuing relationship with their patients. Most respondents in our study notified patients of abnormal test results via telephone, sometimes they used a letter, and email was never used. ED physicians also showed mixed views regarding who was responsible for notifying the patient of an abnormal result. Lines of responsibility for test notification seem unclear because the majority of respondents in our study thought the physician who ordered the test should be responsible, but the majority also agreed that the primary care provider was responsible as well. These new findings underscore the need to design test notification systems to suit the ED context.

    Limitations

    The data were collected from senior emergency physicians from 2 EDs. Emergency physicians from regional and smaller hospitals and junior emergency physicians may have different attitudes. We did not include a question in the survey about the possible responsibility of laboratories (pathology or imaging) with regard to notifying patients of test results, which meant we did not garner emergency physicians’ opinions on this. Qualitative interviews with emergency physicians, laboratory personnel, and information technology staff could have elicited richer information on barriers and facilitators to patients having direct access to their test results.

    Comparison With Prior Work

    Overview

    Studies have shown that patients overwhelmingly support direct notification of their test results [5,9,21,26-29] and when given access to their hospital medical records via a patient portal, test results are often cited as the most frequently accessed information [41-43]. One study surveyed 304 ED patients regarding their use of the Internet and found that the majority were willing to view laboratory results via the Internet [44]. However, when physicians are asked their views of direct notification, they often perceive barriers [5,32,34,36,45]. In contrast to the generally negative opinions from surveys and qualitative studies asking physicians for their views, pilot studies trialing patients’ electronic access to their EMR have reported positive attitudes from physicians [30,31,33,35,46,47]. An example is the positive findings reported from the Open Notes project [31,37,48].

    Physicians’ Concerns About Patients’ Anxiety if Results Are Directly Notified

    Physicians’ perceived concerns about direct access to test results raising anxiety levels of patients is an often reported issue [32,34,45,49] and was also a finding from our study. However, studies which measured whether patients’ access to medical records and test results caused undue anxiety found no increase in their anxiety levels [23,35,50-52] and have reported positive outcomes for patients. A systematic review to determine the effect of providing patients with access to their medical records, although not specifically reporting on test results, concluded overall that access reduced or had no effect on patient anxiety [53].

    Physicians’ Concerns About Patients’ Lack of Clinical Knowledge if Results Are Directly Notified

    A concern expressed by emergency physicians in our study was that patients lacked the necessary expertise or knowledge to interpret test results; emergency physicians were more likely to be comfortable with release of abnormal results if they were not concerned about patients seeking potentially unreliable information. A pilot study exploring patient access to electronic laboratory results via a patient portal attempted to address this issue by providing easily accessible test result reference information for patients [33]. Each test result had an information button with a hyperlink to general reference information about the result, and they reported that patients in 1 primary practice who viewed results also viewed reference information in 50% of cases [33]. Other studies have reported patients’ lack of understanding and confusion when receiving written histopathology reports following endoscopy [54] and mammography [55], which underscores the need to provide further background/reference information to patients to enhance comprehension of the test result report.

    Physicians’ Concerns About the Timing of Reporting Results Directly to Patients

    Timing of release of information was identified as important in our study with the majority of emergency physicians indicating that they would prefer a 48-hour delay for release of abnormal results to allow them time to contact the patient first. Patients have indicated that timeliness of notification of test results is important [28,29,54,55] and this was taken into account in the Wald et al pilot study [33], as an expert panel of clinicians identified the set of results for direct release and their timing rules (immediate release or a 2-day embargo).

    Physicians’ Concerns About Direct Notification of Abnormal Results

    Our study found whether a result is normal or abnormal is an issue for physicians in relation to reporting test results directly to patients. Most emergency physicians were not comfortable with releasing results that might have a significant emotional impact on patients, such as abnormal HIV, mammography, and PAP smears. This finding is supported by results from a survey of primary care physicians by Sung et al [32], which indicated physicians were significantly more interested in reporting normal rather than abnormal results (P<.001). That study found that the level of interest in direct reporting of results declined progressively depending on the perceived emotional impact of the result on the patient, from low (dual energy x-ray absorptiometry scan) to intermediate (genital herpes testing) to high (breast biopsy) (P<.001) [32].

    Physicians’ Concerns Regarding Direct Notification of Radiology Results

    Radiology result follow-up remains a vulnerable area [15,56,57]. Although allowing patients direct access to certain radiology results is gaining some support from radiologists [56], some have expressed concerns about imaging results raising patients’ anxiety because the terms used would be unfamiliar and there might be too many requests from patients to meet with radiologists to seek further information and explain the test results [45]. If direct online reporting was instituted, mixed views from physicians and radiologists about how much information patients should have (ie, the full report versus just the conclusions) have been reported [45]. Our study found similar equivocal results in relation to patients’ direct access to radiology reports: the majority were not comfortable with patients directly accessing abnormal chest x-rays (although 41% agreed), and the majority (83%) also did not agree with patients being sent abnormal cancer screening tests such as mammography and PAP smear results. In our study, physicians reported that radiology was the most frequently missed test result; if there is no process of systematic feedback to physicians regarding missed results it is difficult to understand how they learn about test results which they, or a colleague, have missed [58-60].

    Physicians’ Views Regarding Workload if Results are Directly Notified to Patients

    Any intervention introduced into the emergency care context must weigh up the potential impact on the workload of busy emergency clinicians. Our study found that the majority of emergency physicians were not concerned that direct notification of results to patients would increase their workload. In relation to direct notification of normal test results, they were more likely to agree with the process if they believed it would reduce their workload. Other studies have supported this finding [30,32,61].

    Physicians’ Views Regarding Responsibility for Test Result Follow-Up

    Our study showed that there were mixed views regarding responsibility for notifying patients of abnormal results with a lack of clarity regarding the responsibilities of the ordering physician and the primary care provider. Results pending are particularly prevalent for discharged patients from the ED who often have a short stay. Responsibility for follow-up of results, which may or may not be listed on the ED discharge summary, is impacted by unclear lines of responsibility for follow-up between local medical officers and hospital doctors, combined with emergency physicians’ lack of a continuing relationship with the patient [14,19,62,63]. Electronic discharge summaries can play a role in improving information transfer between hospital and community settings. However, critical information can still be missing [64,65]. Others studies have made recommendations for test follow-up responsibility and these need to be assessed to ensure they apply in the ED context [14,66]. The issue of whether patients’ direct access to test results challenges the physicians’ role as an information gatekeeper has been raised by some [30,49]. However, the majority of emergency physicians in our study did not think that direct notification would interfere with the practice of medicine, so concerns regarding physician role adjustments may be overstated.

    How Emergency Physicians Currently Communicate Abnormal Results to Patients

    Our study found that most ED physicians notified patients about abnormal test results by telephone. Other studies have shown that patients prefer a direct phone call from the physician for abnormal results [22,26,29,67]; however, studies of email communications between patients and physicians for result notification have also reported positive experiences from patients [28,68]. Physicians still express some concerns, such as managing clinical issues by email and integrating email into office work processes [4].

    Conclusions

    Future work needs to determine if direct notification of test results to patients leads to improved follow-up of abnormal results. Methods of ensuring patients can access test results directly, including secure Web-based patient portals with drill-down capabilities providing test descriptions and result interpretations need to be evaluated in terms of patient outcomes, cost, and patient usability across socioeconomic groups. Implications of patients “pulling” results from a laboratory information system using a patient portal tied to a hospital-based EMR versus test results being “pushed” automatically to patients needs evaluation.

    The fast-paced ED environment presents a number of unique challenges for test result follow-up. Although notification of test results to ED patients has promise, it is important to ensure that methods for direct notification suit the environment and work practices of ED clinicians and laboratories and meet patient needs. Efforts should be directed toward establishing a clear set of recommendations regarding which test results should be directly notified to which patients, methods of notification, and the timing of notification. Emergency physicians’ concerns regarding anxiety, confusion, and lack of patients’ expertise to interpret results should be addressed in order to promote wider test results access to patients.

    Acknowledgments

    We would like to acknowledge the contributions of Louise Robertson, Michael Stewart, Julie Li, George Touli, and Elia Vecellio. This study is part of an Australian Research Council Discovery Project Grant (DP120100297) to investigate whether technology can make communication in complex systems safer and more efficient.

    Dr Giardina is supported by the VA Health Services Research postdoctoral fellowship through the VA Office of Academic Affiliations. Dr Singh is supported by the VA Health Services Research and Development Service (CRE 12-033; Presidential Early Career Award for Scientists and Engineers USA 14-274), the VA National Center for Patient Safety and the Agency for Health Care Research and Quality (R01HS022087). This work is also supported in part by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413).

    Authors' Contributions

    JC, HS, TG, AG, RP, WR, LL, and JW designed the study. JC, AG, and WR obtained research funding. JC, HS, TG, LL, AG, RP, WR, and JW supervised conduct of the study and data collection. JC, AG, RP, LL, and JW undertook recruitment of participating hospitals and clinicians and managed the data, including quality control. JC, AG, JW, and LL provided statistical advice and analyzed the data. JC drafted the manuscript. All authors contributed substantially to its revision and all authors approve the final version of the manuscript submitted. JC takes responsibility for the paper as a whole.

    Conflicts of Interest

    None declared.

    1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Centrury. Washington, DC: National Academy Press; 2001.
    2. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003 Jun 19;348(25):2526-2534. [CrossRef] [Medline]
    3. Hobbs J, Wald J, Jagannath YS, Kittler A, Pizziferri L, Volk LA, et al. Opportunities to enhance patient and physician e-mail contact. Int J Med Inform 2003 Apr;70(1):1-9. [Medline]
    4. Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J Med Internet Res 2003;5(2):e9 [FREE Full text] [CrossRef] [Medline]
    5. Hassol A, Walker JM, Kidder D, Rokita K, Young D, Pierdon S, et al. Patient experiences and attitudes about access to a patient electronic health care record and linked web messaging. J Am Med Inform Assoc 2004;11(6):505-513 [FREE Full text] [CrossRef] [Medline]
    6. Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Aff (Millwood) 2010 Jul;29(7):1370-1375 [FREE Full text] [CrossRef] [Medline]
    7. Ralston JD, Rutter CM, Carrell D, Hecht J, Rubanowice D, Simon GE. Patient use of secure electronic messaging within a shared medical record: a cross-sectional study. J Gen Intern Med 2009 Mar;24(3):349-355 [FREE Full text] [CrossRef] [Medline]
    8. Lin CT, Wittevrongel L, Moore L, Beaty BL, Ross SE. An Internet-based patient-provider communication system: randomized controlled trial. J Med Internet Res 2005 Aug;7(4):e47 [FREE Full text] [CrossRef] [Medline]
    9. Haun JN, Lind JD, Shimada SL, Martin TL, Gosline RM, Antinori N, et al. Evaluating user experiences of the secure messaging tool on the Veterans Affairs' patient portal system. J Med Internet Res 2014;16(3):e75 [FREE Full text] [CrossRef] [Medline]
    10. Hanberger L, Ludvigsson J, Nordfeldt S. Use of a web 2.0 portal to improve education and communication in young patients with families: randomized controlled trial. J Med Internet Res 2013;15(8):e175 [FREE Full text] [CrossRef] [Medline]
    11. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006 Oct 3;145(7):488-496. [Medline]
    12. Matheny ME, Gandhi TK, Orav EJ, Ladak-Merchant Z, Bates DW, Kuperman GJ, et al. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med 2007 Nov 12;167(20):2233-2239. [CrossRef] [Medline]
    13. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. Arch Intern Med 2004 Nov 8;164(20):2223-2228. [CrossRef] [Medline]
    14. Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf 2010 May;36(5):226-232. [Medline]
    15. Callen JL, Westbrook JI, Georgiou A, Li J. Failure to follow-up test results for ambulatory patients: a systematic review. J Gen Intern Med 2012 Oct;27(10):1334-1348 [FREE Full text] [CrossRef] [Medline]
    16. Callen J, Georgiou A, Li J, Westbrook JI. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf 2011 Feb;20(2):194-199 [FREE Full text] [CrossRef] [Medline]
    17. Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc 2007;14(4):459-466 [FREE Full text] [CrossRef] [Medline]
    18. Singh H, Thomas EJ, Sittig DF, Wilson L, Espadas D, Khan MM, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med 2010 Mar;123(3):238-244 [FREE Full text] [CrossRef] [Medline]
    19. Roy CL, Rothschild JM, Dighe AS, Schiff GD, Graydon-Baker E, Lenoci-Edwards J, et al. An initiative to improve the management of clinically significant test results in a large health care network. Jt Comm J Qual Patient Saf 2013 Nov;39(11):517-527. [Medline]
    20. Georgiou A, Hordern A, Dimigen M, Zogovic B, Callen J, Schlaphoff G, et al. Effective notification of important non-urgent radiology results: a qualitative study of challenges and potential solutions. J Med Imaging Radiat Oncol 2014 Jun;58(3):291-297. [CrossRef] [Medline]
    21. Meza JP, Webster DS. Patient preferences for laboratory test results notification. Am J Manag Care 2000 Dec;6(12):1297-1300 [FREE Full text] [Medline]
    22. Grimes GC, Reis MD, Budati G, Gupta M, Forjuoh SN. Patient preferences and physician practices for laboratory test results notification. J Am Board Fam Med 2009;22(6):670-676 [FREE Full text] [CrossRef] [Medline]
    23. Spodik M, Goldman J, Merli K, Walker C, Alpini B, Kastenberg D. Providing an endoscopy report to patients after a procedure: a low-cost intervention with high returns. Gastrointest Endosc 2008 Jan;67(1):103-111. [CrossRef] [Medline]
    24. US Department of Health & Human Services. 2004. Mammography Quality Standards Act (MQSA)   URL: http:/​/www.​fda.gov/​Radiation-EmittingProducts/​MammographyQualityStandardsActandProgram/​Regulations/​ucm110823.​htm [accessed 2015-02-03] [WebCite Cache]
    25. Federal Register: The Daily Journal of the United States Government. 2014. CLIA Program and HIPAA Privacy Rule; Patients' Access to Test Reports   URL: https:/​/www.​federalregister.gov/​articles/​2014/​02/​06/​2014-02280/​clia-program-and-hipaa-privacy-rule-patients-access-to-test-reports [accessed 2015-02-03] [WebCite Cache]
    26. Baldwin DM, Quintela J, Duclos C, Staton EW, Pace WD. Patient preferences for notification of normal laboratory test results: a report from the ASIPS Collaborative. BMC Fam Pract 2005 Mar 8;6(1):11 [FREE Full text] [CrossRef] [Medline]
    27. Keren R, Muret-Wagstaff S, Goldmann DA, Mandl KD. Notifying emergency department patients of negative test results: pitfalls of passive communication. Pediatr Emerg Care 2003 Aug;19(4):226-230. [Medline]
    28. Couchman GR, Forjuoh SN, Rascoe TG, Reis MD, Koehler B, van Walsum KL. E-mail communications in primary care: what are patients' expectations for specific test results? Int J Med Inform 2005 Jan;74(1):21-30. [CrossRef] [Medline]
    29. Leekha S, Thomas KG, Chaudhry R, Thomas MR. Patient preferences for and satisfaction with methods of communicating test results in a primary care practice. Jt Comm J Qual Patient Saf 2009 Oct;35(10):497-501. [Medline]
    30. Earnest MA, Ross SE, Wittevrongel L, Moore LA, Lin CT. Use of a patient-accessible electronic medical record in a practice for congestive heart failure: patient and physician experiences. J Am Med Inform Assoc 2004;11(5):410-417 [FREE Full text] [CrossRef] [Medline]
    31. Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012 Oct 2;157(7):461-470 [FREE Full text] [CrossRef] [Medline]
    32. Sung S, Forman-Hoffman V, Wilson MC, Cram P. Direct reporting of laboratory test results to patients by mail to enhance patient safety. J Gen Intern Med 2006 Oct;21(10):1075-1078 [FREE Full text] [CrossRef] [Medline]
    33. Wald JS, Burk K, Gardner K, Feygin R, Nelson E, Epstein M, et al. Sharing electronic laboratory results in a patient portal--a feasibility pilot. Stud Health Technol Inform 2007;129(Pt 1):18-22. [Medline]
    34. Ross SE, Todd J, Moore LA, Beaty BL, Wittevrongel L, Lin CT. Expectations of patients and physicians regarding patient-accessible medical records. J Med Internet Res 2005;7(2):e13 [FREE Full text] [CrossRef] [Medline]
    35. Bartlett C, Simpson K, Turner AN. Patient access to complex chronic disease records on the Internet. BMC Med Inform Decis Mak 2012;12:87 [FREE Full text] [CrossRef] [Medline]
    36. Kittler AF, Carlson GL, Harris C, Lippincott M, Pizziferri L, Volk LA, et al. Primary care physician attitudes towards using a secure web-based portal designed to facilitate electronic communication with patients. Inform Prim Care 2004;12(3):129-138. [Medline]
    37. Walker J, Leveille SG, Ngo L, Vodicka E, Darer JD, Dhanireddy S, et al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med 2011 Dec 20;155(12):811-819 [FREE Full text] [CrossRef] [Medline]
    38. Giardina TD, Callen J, Georgiou A, Westbrook JI, Greisinger A, Esquivel A, et al. Releasing Test Results Directly to Patients: A Multisite Survey of Physician Perspectives. Patient Education and Counseling 2015 Feb:1. [CrossRef]
    39. Hosmer DWS, Lemeshow S, Sturdivant S. Applied Logistic Regression. 3rd edition. Hoboken, NJ: Wiley; 2013.
    40. Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996 Dec;49(12):1373-1379. [Medline]
    41. Ralston JD, Carrell D, Reid R, Anderson M, Moran M, Hereford J. Patient web services integrated with a shared medical record: patient use and satisfaction. J Am Med Inform Assoc 2007;14(6):798-806 [FREE Full text] [CrossRef] [Medline]
    42. Weingart SN, Rind D, Tofias Z, Sands DZ. Who uses the patient internet portal? The PatientSite experience. J Am Med Inform Assoc 2006;13(1):91-95 [FREE Full text] [CrossRef] [Medline]
    43. Cimino JJ, Patel VL, Kushniruk AW. What do patients do with access to their medical records? Stud Health Technol Inform 2001;84(Pt 2):1440-1444. [Medline]
    44. Bond MC, Klemt R, Merlis J, Kopinski JE, Hirshon JM. Computer access and Internet use by urban and suburban emergency department customers. J Emerg Med 2012 Jul;43(1):159-165. [CrossRef] [Medline]
    45. Johnson AJ, Frankel RM, Williams LS, Glover S, Easterling D. Patient access to radiology reports: what do physicians think? J Am Coll Radiol 2010 Apr;7(4):281-289. [CrossRef] [Medline]
    46. Nordfeldt S, Ängarne-Lindberg T, Berterö C. To use or not to use--practitioners' perceptions of an open web portal for young patients with diabetes. J Med Internet Res 2012;14(6):e154 [FREE Full text] [CrossRef] [Medline]
    47. Nordqvist C, Hanberger L, Timpka T, Nordfeldt S. Health professionals' attitudes towards using a Web 2.0 portal for child and adolescent diabetes care: qualitative study. J Med Internet Res 2009;11(2):e12 [FREE Full text] [CrossRef] [Medline]
    48. Delbanco T, Walker J, Darer JD, Elmore JG, Feldman HJ, Leveille SG, et al. Open notes: doctors and patients signing on. Ann Intern Med 2010 Jul 20;153(2):121-125. [CrossRef] [Medline]
    49. Davis GT, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA 2011 Dec 14;306(22):2502-2503. [CrossRef] [Medline]
    50. Gravis G, Protière C, Eisinger F, Boher JM, Tarpin C, Coso D, et al. Full access to medical records does not modify anxiety in cancer patients: results of a randomized study. Cancer 2011 Oct 15;117(20):4796-4804 [FREE Full text] [CrossRef] [Medline]
    51. Wiljer D, Leonard KJ, Urowitz S, Apatu E, Massey C, Quartey NK, et al. The anxious wait: assessing the impact of patient accessible EHRs for breast cancer patients. BMC Med Inform Decis Mak 2010;10:46 [FREE Full text] [CrossRef] [Medline]
    52. Wiljer D, Urowitz S, Apatu E, Leonard K, Quartey NK, Catton P. Understanding the support needs of patients accessing test results online. PHRs offer great promise, but support issues must be addressed to ensure appropriate access. J Healthc Inf Manag 2010;24(1):57-63. [Medline]
    53. Davis GT, Menon S, Parrish DE, Sittig DF, Singh H. Patient access to medical records and healthcare outcomes: a systematic review. J Am Med Inform Assoc 2014;21(4):737-741. [CrossRef] [Medline]
    54. Karnieli-Miller O, Adler A, Merdler L, Rosenfeld L, Eidelman S. Written notification of test results: meanings, comprehension and implication on patients' health behavior. Patient Educ Couns 2009 Sep;76(3):341-347. [CrossRef] [Medline]
    55. Dolan NC, Feinglass J, Priyanath A, Haviley C, Sorensen AV, Venta LA. Measuring satisfaction with mammography results reporting. J Gen Intern Med 2001 Mar;16(3):157-162 [FREE Full text] [Medline]
    56. Berlin L. Communicating results of all outpatient radiologic examinations directly to patients: the time has come. AJR Am J Roentgenol 2009 Mar;192(3):571-573. [CrossRef] [Medline]
    57. Singh H, Thomas EJ, Mani S, Sittig D, Arora H, Espadas D, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med 2009 Sep 28;169(17):1578-1586 [FREE Full text] [CrossRef] [Medline]
    58. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med 2008 May;121(5 Suppl):S38-S42. [CrossRef] [Medline]
    59. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008 May;121(5 Suppl):S2-23. [CrossRef] [Medline]
    60. Croskerry P. The feedback sanction. Acad Emerg Med 2000 Nov;7(11):1232-1238. [Medline]
    61. Liederman EM, Morefield CS. Web messaging: a new tool for patient-physician communication. J Am Med Inform Assoc 2003;10(3):260-270 [FREE Full text] [CrossRef] [Medline]
    62. Greenes DS, Fleisher GR, Kohane I. Potential impact of a computerized system to report late-arriving laboratory results in the emergency department. Pediatr Emerg Care 2000 Oct;16(5):313-315. [Medline]
    63. Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007 Feb;49(2):196-205. [CrossRef] [Medline]
    64. O'Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, et al. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med 2009 Apr;4(4):219-225. [CrossRef] [Medline]
    65. Callen JL, Alderton M, McIntosh J. Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. Int J Med Inform 2008 Sep;77(9):613-620. [CrossRef] [Medline]
    66. Schiff GD. Eight questions for getting beyond "getting results". Jt Comm J Qual Patient Saf 2010 May;36(5):224-225. [Medline]
    67. Fazili J, Ilagan M, Phipps E, Braitman LE, Levine GM. How gastroenterologists inform patients of results after lower endoscopy. Am J Gastroenterol 2001 Jul;96(7):2086-2092. [CrossRef] [Medline]
    68. Houston TK, Sands DZ, Jenckes MW, Ford DE. Experiences of patients who were early adopters of electronic communication with their physician: satisfaction, benefits, and concerns. Am J Manag Care 2004 Sep;10(9):601-608 [FREE Full text] [Medline]

    ‎
    ED: emergency department
    EMR: electronic medical record
    ICT: information and communication technology

    Edited by G Eysenbach; submitted 22.07.14; peer-reviewed by M Wong, F Kammerer; comments to author 16.10.14; revised version received 15.12.14; accepted 21.01.15; published 04.03.15

    Copyright

    ©Joanne Callen, Traber Davis Giardina, Hardeep Singh, Ling Li, Richard Paoloni, Andrew Georgiou, William B Runciman, Johanna I Westbrook. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.03.2015.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.