CEO SUMMARY: Should patients be allowed to see their own lab test results when they are available to their physicians? Kaiser Permanente believes so. Since 2005, Kaiser Permanente has given members real-time access to most laboratory test results in their personal health record (PHR) on www.kp.org. In fact, viewing laboratory test results is the single most popular feature on the site and is used by Kaiser Permanente members more often than any other electronic service the plan offers. Patient access to lab test results has also improved patient safety in important ways.
WHEN IT COMES TO GIVING PATIENTS real-time access to their laboratory test results, Kaiser Permanente has a six-year headstart on the federal government’s latest reform of lab test reporting requirements.
Since 2005, Kaiser Permanente members have been able to use the healthcare provider’s online personal health record (PHR) to view most test results at the same time their doctors are viewing these results. My Health Manager, accessed at www.kp.org, takes the PHR to new levels by linking directly to Kaiser Permanente HealthConnect, Kaiser Permanente’s electronic health record (EHR).
Since launching this service six years ago, Kaiser Permanente has found that patients love it. In an exclusive interview with THE DARK REPORT, Kate Christensen, M.D., Medical Director of the Internet Services Group, stated, “Of all the online services Kaiser Permanente offers to its nearly nine million members in eight regions across the nation, online viewing of lab test results is the most popular.”
Christensen noted that more than 60%, or about 3.7 million, of eligible Kaiser Permanente members (aged 13 and over with Internet access) are registered to use the plan’s online service. These members viewed more than 25 million lab test results in 2010 alone.
Kaiser Permanente’s decision to give patients access to their lab tests results was prescient. Just weeks ago, on September 12, the federal Department of Health and Human Services (HHS) published a proposed revision to CLIA rules that would allow all clinical laboratories to send labora- tory test results directly to patients.
The HHS proposal is subject to public comment and revision before it becomes final. The language of HHS’ proposed rule would direct clinical laboratories to provide lab test results to patients or designated personal representatives upon request. This represents a major change to existing CLIA and HIPAA regulations.
Kaiser Permanente’s experience with giving patients access to lab test results affirms that the DHHS proposed rule is a step in the right direction. “Kaiser Permanente has found that making lab tests available to members offers four distinct advantages to health systems,” explained Christensen. “First, it improves patient satisfaction. Second, the service helps Kaiser Permanente retain its members by empowering them to be more knowledgeable healthcare consumers.
Improving Patient Safety
“Third, giving patients real-time access to view their laboratory test results has strengthened the patient-physician relationship in important ways,” commented Christensen. “Fourth, giving patients access to laboratory test results helps avoid the problems that occur when physicians fail to
inform patients about test results. This fourth benefit may be the most important of all, since it improves patient safety and contributes to better patient outcomes.
“Most of our test results can be immediately viewed by the patient,” continued Christensen. “As soon as the results are sent from the laboratory to KP HealthConnect, patients can view them through their online personal health record.
“It is important to understand that certain lab test results are blocked so that the patient cannot view them,” she explained. “California state law mandates that certain lab results must be blocked from the patient. In other cases, the physician needs to have a conversation with the patient about the lab test results.
“In California, state law forbids the release of information in four categories: Malignancy, HIV, infectious hepatitis, and drug abuse,” she said. “Other test results need to be discussed before the patient sees them or they need to be revealed in the context of a physician-patient discussion, such as some of those from genetic testing. Instead of being automatically released, those results can be accessed after the discussion.
“An example of a test result that might be blocked is a diagnosis of cancer,” stated Christensen. “That might be blocked for three to five days, depending on the region. The clinician will use that time to talk to the patient about the result. However, if the clinician does not talk to the patient within the designed time period, then the result in the EHR becomes available to the patient on My Health Manager.
Patient Access Policy
“All patients who can access our patient portal, My Health Manager, can view their results,” Christensen said. “By ‘all’ patients, we mean members over age 13. Parents can set up a proxy access for children. Essentially, Kaiser Permanente’s policy is that all members have access to the information in their electronic health record through their personal health record on www.kp.org. By design, Kaiser Permanente’s EHR is not a system where clinicians decide which patients can get results and which ones cannot.
“The system complies with federal privacy rules under the Health Insurance Portability and Accountability Act (HIPAA),” noted Christensen. “It is designed to meet Kaiser’s goal that all members have access to the data available in their online chart.
“One advantage of giving patients online access to their laboratory test results is that we believe we can eliminate problems caused when physicians do not inform patients about lab test results,” added Christensen.
Failure to Report Lab Results
This problem was highlighted in a study that was published in 2009 by researchers at Weill Cornell Medical College in New York City. Researchers determined that physicians failed to report clinically significant abnormal test results to patients—or to document that they had informed their patients—in one out of every 14 cases of abnormal results.
There was great variability in how individual medical practices reported abnormal test results to patients. Some medical groups met this requirement with close to 100% compliance. But researchers found that some medical groups failed to communicate as many as one in four abnormal test results to their patients.
The findings of this study were published in the Archives of Internal Medicine (June 22, 2009). Lawrence P. Casalino, M.D., who is Chief of the Division of Outcomes Effectiveness Research at Weill Cornell, led a team that analyzed 5,434 patient records from 23 physician practices nationwide.
After the results of this study were published, Christensen wrote to the editors to explain how a patient portal, such as Kaiser Permanente’s My Health Manager on www.kp.org, allows patients to view results regardless of whether physicians report the results to patients or not. The Casalino study also found that having an EHR did not reduce failure-to- inform rates—and even increased them— if the practice did not use good processes to manage test results.
Patients Have Access
In response, Christensen wrote: “The authors missed an opportunity, however, to point out one potential solution—give the patients access to their test results directly, using a personal health record (PHR) directly linked to the EHR.”
In looking back over the success of My Health Manager, Christensen recalled that, in the planning stage, some in Kaiser Permanente were reluctant to let patients see their laboratory test results. “Initially, we heard comments from some physicians and others who thought that doctors would be swamped with phone calls from concerned patients,” she said. “However, once this service went live, the volume of phone calls and emails from concerned patients turned out to be a small and manageable number.
“Another goal was to make it easy for patients to understand their lab test results. Each lab test result posted in the patient’s PHR is explained in plain language,” she said. “If the patient wants to read more about that test in our health encyclopedia, we provide a link in the PHR to an explanation on www.kp.org.
Full Explanations Provided
“Presenting laboratory tests in this manner gives us a teachable moment with the patient,” noted Christensen. “Instead of a nurse simply giving the patient a lab test value over the phone, patients can look up the result online. They can then read more about the lab test and the meaning of their results in our Kaiser health encyclopedia on www.kp.org. In doing so, each member becomes a more informed patient.
“Patients tell us that they are much more informed as a result of this service,” Christensen added. “We know that patients value this feature because they vote with their fingers. Through June of this year, patients used My Health Manager to view more than 15 million test results.”
The numbers at Kaiser Permanente tell a compelling tale. A survey was conducted earlier this year and 91% of members registered to use My Health Manager on www.kp.org said they were satisfied or very satisfied with the website. These findings are reinforced by actual usage data.
During 2010, Kaiser Permanente members logged into My Health Manager more than 62 million times. Lab test results were viewed 25.8 million times. Overwhelmingly, this was the most-used My Health Manager feature.
By comparison, patients used My Health Manager to send 10.7 million email messages to physicians and other providers. Patients also used the website to fill 8.3 million prescriptions and schedule 2.3 million appointments.
“Patients definitely want the information about their diagnostic test results,” she said. “We know that the number of people accessing lab test results has increased steadily and continues to do so. The number of people registering for the patient portal is also rising.
“When patients have the ability to email their doctor, for example, they feel a closer bond with them,” she said. “They also are less likely to change doctors, less likely to leave Kaiser Permanente, and more likely to recommend Kaiser Permanente to others.
Demand for Online Tools
“We are learning that there is a huge demand by consumers for practical tools that allow them to manage their health,” she added. “Not every member is an active user of My Health Manager. However, back in 2005, when access to lab test results was added—along with the ability for members to use the website to email their doctor—there was a sizeable increase in the number of registrations for both of those services.
“Next year, we plan to allow patients to view summaries of hospitalizations, medication history, and immunizations,” Christensen commented.
“When patients have the ability to email their doctor, for example, they feel a closer bond with them,” she said. “They also are less likely to change doctors, less likely to leave Kaiser, and more likely to recommend Kaiser to others.
“More importantly, for patients with such chronic conditions such as diabetes, high cholesterol, or high blood pressure, we see early evidence that emailing their physicians has a positive health impact,” she commented. “We are not sure what the connection is. It could be that the peo- ple who use our online tools are already more engaged in their health. However, it looks like having this kind of access promotes deeper engagement on its own.
“We also have online health programs that offer electronic coaching on such topics as pain, depression, insomnia, and stress,” she said. “Patients fill out a questionnaire, then get personalized instructions, suggestions, and self-care techniques. We find that this service also has big impact on patients, which is another positive result of the online self-management tools on www.kp.org.”
In an article published online in August, “Kaiser Electronic Health Records Connect a Fragmented System,” Rob Unitan, M.D., a Kaiser Permanente physician and specialist in pulmonology and emergency medicine, wrote about a diabetes patient who used Kaiser Permanente’s PHR to her benefit. She established regular contact with her care team by emailing her blood glucose results two to three times per week. She also took diabetes management classes. Over time, this patient lost 33 pounds and cut her blood sugar from 142 to the high 90s. She could not have achieved this result without the support she received from her care team, including the ability to stay in touch with them online, he wrote.
Step Forward in Patient Care
For Christensen, the two-way communication that is delivered by My Health Manager on www.kp.org represents a step forward in patient care. “Delivering information to patients in this way is so much different than how it was when I started working as a general internist in 1984,” she recalled. “At that time, physicians were less accessible to patients.
“Now, it is easier for patients to communicate with physicians,” observed Christensen. “We are more open and reachable. There is a better partnership with patients. Plus, we have more tools— such as My Health Manager—to keep patients engaged in these self-care activities. Today, there are more touch points between health systems and patients.
“For hospitals, health systems, and clinical laboratories considering what Kaiser Permanente has accomplished with its on-line PHR, I would recommend that they act confidently and provide patients with as many lab test results as can be done safely and legally,” she stated. “Patients are way ahead of most providers in terms of their comfort with getting this information electronically.”
THE DARK REPORT observes that Kaiser Permanente’s success with its My Health Manger is an important milestone for the laboratory medicine profession. For more than six years, Kaiser Permanente has delivered real-time access to most laboratory test results for millions of patients.
Throughout this time, Kaiser Permanente has gained several important insights. Patients are not only enthusiastic about having access to this part of their electronic health record, but it motivates them to take active steps to improve their personal health outcomes. These are both notable developments and should encourage other clinical laboratories to similarly develop ways to give their own patients fuller access to lab test results.
These are significant findings, given the sheer scale of the patient population utilizing KP HealthConnect on a regular basis. Kaiser Permanente’s comprehensive health information system is considered one of the nation’s most advanced electronic health records available. It securely connects 8.9 million people to their health care teams, their personal information, and the latest medical knowledge, leveraging the integrated approaches to health care available only at Kaiser Permanente.
Another lesson gained from the experience at Kaiser Permanente is that a substantial number of patients are eager to use a personal health record to monitor their healthcare. Pathologists and clinical laboratory managers may want to study Kaiser Permanente’s success with digital personal health records as the basis for developing a clinical and business strategy at their respective lab organizations. With more integration of healthcare informatics and clinical care predicted, that would be a timely management action by clinical labs.
Kaiser’s Lab Test Reporting Differs Slightly From HHS Proposal on Lab Test Results
IN SEPTEMBER, A PROPOSED NEW RULE that would allow all clinical laboratories to send lab test results directly to patients was published by the federal Department of Health and Human Services (HHS). The HHS proposal is subject to comments and revision before it becomes final.
The proposal is slightly different from the system Kaiser Permanente uses, said Kate Christensen, M.D., Kaiser Permanente’s Medical Director of the Internet Services Group. “HHS is talking about having laboratories send laboratory test results to patients. That’s not what we do,” she said.
“Kaiser Permanente has its own laboratories that transmit test results electronically to the patients’ electronic health record (EHR), which are immediately populated on patients’ personal health record on www.kp.org. My Health Manager is the health plan’s patient portal on www.kp.org and provides selective access to the EHR,” she said. “For the most part, when the lab sends the results to KP HealthConnect, patients can look at those results at the same time the doctor gets them.
“But it’s important to note that patients are looking in their own personal health record,” she added. “The laboratory does not send clinical information directly to members.
“Rather, Kaiser Permanente opens a patient’s EHR so that they can look at it, print it, graph the results, or store the results,” noted Christensen. “Soon members will be able to download their EHR and send it to another doctor if they want.
“In certain ways, our system may work better than what the HHS is suggesting because the results are provided to the patient in the context of their overall care,” Christensen explained. “There are other parts of the EHR that they can see along with the test results.
“For example, there is a list of their diag- noses,” she continued. “Soon, they will be able to see their lab results related to each diagnosis. Currently it is listed as data and it is embedded with encyclopedia content that explains the results. Also, the physicians can write a note in the EHR commenting about the lab test results.”
Top 10 Features of Kaiser’s Digital Health Record System
CURRENTLY, PATIENTS AT KAISER PERMANENTE can use their personal health record (PHR) for a wide variety of purposes.
Kaiser Permanente provided this list of the 10 features that are most popular with its members. At the top of the list, and widely popular by a significant margin, is access to laboratory test results.
- Test Results
- E-mail My Doctor
- Prescription Refill
- Facility Directory
- Past Visit Information
- Health Encyclopedia
- Medical Staff Directory
- Act for a Family Member
- My Prescriptions
Source: Kaiser Permanente, Oakland, California, 2011.