Abstract

Summary: Many health care organizations release test results to outpatients through an online patient portal. However, there are no reports in the literature about the immediate release of online test results to patients who are in the hospital. We report an experience with a patient’s family member who reviewed online test results in the intensive care unit (ICU) and the divergent opinions of care team members about how this information affected the patient’s care.
Keywords: EHR, medical transparency, patient portal, access to data, HIT, patient engagement.
Citation: Sprague J, Pell J, Lin CT. Divergent care team opinions about online release of test results to an ICU patient. J Participat Med. 2013 Jun 12; 5:e24.
Published: June 12, 2013.
Competing Interests: The authors have declared that no competing interests exist.

Introduction

The University of Colorado Hospital deployed its electronic health record in 1994 and began offering an online patient portal to improve communication in 2001. The portal was initially deployed in primary care clinics and was eventually adopted by all specialty clinics. Patients may choose to use the portal to communicate with physicians and clinic staff about clinical questions, appointments, prescriptions, and referrals.

Patient satisfaction and perceptions of quality of care improved after the portal was implemented, and physician satisfaction with the portal was neutral to positive.[1] Test results were released immediately through the portal to a limited number of clinic outpatients in a controlled study.[2][3] Compared to patients who did not use the portal, those who used it had higher rates of adherence to therapy and greater trust in their physicians.[2] Additionally, patients described the usefulness of this tool for continuity of care: for example, one patient lost his luggage when traveling, and was able to obtain replacement prescriptions by showing his online medical record to a local urgent care doctor.

In 2008, the University of Colorado Hospital began to offer online access to test results through the portal to all patients in the hospital system, which included 50 primary care and specialty clinics with ≥600,000 patient visits per year. More than 1 million test results have been released online in the past 4 years. There are currently ≥35,000 active patient portal accounts.

Although online test results were released immediately to patients during the controlled study,[2][3] a more conservative approach was taken for institution-wide release of results in response to physician and organization feedback. Borrowing heavily from release rules developed by others,[4] the rules are as follows:

1. All blood test results are released immediately, with the exception of qualitative HIV and genetic tests, which are never shown online.
2. All radiology reports are released immediately, with the exception of those from CT, MRI, and PET scans, which are released 7 days after the report is delivered electronically to the ordering physician.
3. All pathology reports are released 14 days after the report is delivered electronically to the ordering physician.
4. At their discretion, physicians may elect to release results sooner than stipulated by the rules above.

Hospital inpatients are not explicitly offered portal access. However, a clinic outpatient who already has portal access can view inpatient results online both during and after a hospitalization.

We describe the mixed reactions of health care providers to a situation in which a patient’s wife reviewed immediately available inpatient test results online during her husband’s ICU stay.

Case Presentation

A middle-aged man became critically ill and developed significant complications after surgery, resulting in an extended stay in the ICU. He required blood pressure support with intravenous medications, mechanical ventilation, and dialysis for renal failure. Throughout his stay, his wife was continuously at his bedside, very attentive to management decisions about his care. Because the patient had signed up for portal access as an outpatient, he and his wife had immediate access to his online laboratory results and radiology reports.

The patient’s wife used her own laptop and the hospital’s guest wireless network to access the portal and view her husband’s results. Often, she saw his results before any of his nurses or physicians. New results often prompted prolonged discussions with various members of the care team. For example, she monitored her husband’s arterial blood gas results very closely, and she used internet resources to help her interpret the results. (Arterial blood gasses are drawn frequently in patients with respiratory and renal failure.) She deduced at one point that her husband had a respiratory acidosis and suggested that her husband’s ventilator settings be changed immediately to correct it. She perceived that the care team did not act quickly enough in response to the results and that her husband’s care was consequently compromised.

She also followed his serum creatinine, a marker of kidney function and part of a blood chemistry panel, very closely. After he started dialysis, she interpreted the decrease in his serum creatinine as signifying improvement in his kidney function, even though it fell because of effective dialysis. She was distraught to learn that his kidney function had not actually improved.

We interviewed two ICU nurses and the physician who cared for the patient and interacted with his wife while he was in the ICU.

One nurse felt that immediate access to online test results hurt the patient’s overall care. He felt that he was pulled away from his clinical duties to interpret medical data for the patient’s wife. He also thought that the patient’s wife misinterpreted the significance of many of the lab results and that she would have been less frustrated if she did not have immediate access to them.

A second nurse acknowledged that this was a particularly difficult situation, but she felt very differently. She felt that educating the patient’s wife about test results was part of providing emotional and practical support to the family, that it fell completely within the scope of her nursing practice. This nurse felt that the wife’s access to the results prompted meaningful discussions of issues that may not otherwise have surfaced. “She [the patient’s wife] might have actually caught something we missed.”

The patient’s physician shared his belief that patients and families should not have immediate online access to their test results. He felt that test results are not intended for lay audiences and that immediate access to them only distracts physicians and nurses from providing timely, high-quality care.

Discussion

This case raises questions about the ethical, social, and legal aspects of a transparent electronic medical record in the ICU setting. If patient-centered care implies information transparency and the ability of patients to see their test results, are we then obligated to be transparent in real time? Are the principles of transparency and excellent patient care mutually exclusive?

A consistent theme that arises during discussions with hospital nurses, physicians, and administrators is that patient-centered care requires information transparency, regardless of the acuity of the care setting. Our organization has made other, similar patient-centered adjustments to care, including removing visiting hour restrictions and allowing families to be present during cardiac resuscitation. We believe that transparency is not a barrier to excellent care.

Nonetheless, this case does point out that inpatients and outpatients may not be considered to be the same when it comes to immediate online release of test results. Certainly, care providers within our organization had varied opinions about the value and timing of online release. At the very least, it would seem necessary to train nurses, physicians, and patients on how to handle this information in a way that ensures cooperative relationships and positive outcomes.

Conclusions

In this case of an ICU patient, the immediate online release of test results caused unintended frustration and friction between his wife and one of his nurses. Another ICU nurse found discussion of the husband’s test results to be positive and helpful, however. Online test result release is becoming more common in the outpatient setting, but it is relatively new in the inpatient setting and care team member opinions about its value vary. Organizations planning immediate online release of test results to inpatients should consider educating care team members and patients about what to expect and how to best use this information.

Acknowledgement

The authors thank Esther Langmack, MD for editorial assistance in the preparation of the manuscript.

References

1. Lin C, Wittevrongel L, Moore L, Beaty B, Ross, S. An internet-based patient-provider communication system: a randomized controlled trial. J Med Internet Res. 2005 Aug 5;7(4):e47. ↩
2. Earnest M, Ross S, Wittevrongel L, Moore L, Lin C. 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 Sep-Oct;11(5):410-7. ↩
3. Ross S, Moore L, Earnest M, Wittevrongel L, Lin C. Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: a randomized trial. J Med Internet Res. 2004 May 14;6(2):e12. ↩
4. Halamka J, Mandl K, Tang P. Early Experiences with Personal Health Records. J Am Med Inform Assoc. 2008 Jan-Feb; 15(1): 1-7. ↩

Copyright: © 2013 Jonathan Sprague, Jonathan Pell, CT Lin. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.