Patient Portals & Open Notes Increase Referral Access by Up to 40%

Does patient portal access make a difference in referral access after a primary care appointment? According to one new study in the Journal of the American Medical Informatics Association (JAMIA), it could.

The study, completed by researchers representing patient advocacy group OpenNotes, also showed that patient access to clinical notes—mandated through the 21st Century Cures Act—also increased the number of closed-loop patient referrals.

Closing the loop on referrals is key to closing care gaps. In a primary care setting, a provider might refer a patient to a specialty provider or a provider who can administer a specialty test. For example, PCPs might refer patients to cardiac stress tests or a dermatologist.

But too often, PCP referrals don’t yield patient follow-up. Although the PCP has referred the patient to the specialist, the patient may not actually access that care for a number of reasons ranging from poor transportation access to simply forgetting about the referral.

This latest study showed that patient access to health information could help curb that issue.

The research group, led by Sigall Bell, MD, director of Patient Safety & Discovery at OpenNotes and an associate professor of Medicine at Harvard Medical School, looked at nearly 13,000 referrals at two academic primary care clinics made between 2018 and 2021.

This timeframe was intentional because it spans before and after the implementation of the information blocking provisions in the Cures Act, Bell and colleagues noted. Those rules went into effect in April 2021.

The team looked at referrals made in a primary care setting for colonoscopy, dermatology, and cardiac stress tests. They stratified patient access into three cohorts: patient portal access plus view of clinical notes; patient portal access with no view of clinical notes; no patient portal access and no view of clinical notes.

By far, the strongest predictor of referral access was tandem patient portal access and open note review, with 61 percent of folks in this bucket accessing referred care. In comparison, 57 percent of folks only logging into the patient portal accessed referred care, and 54 percent of people looking at neither the patient portal nor their clinical notes accessed referred care.

“After controlling for sociodemographic and clinical factors, the odds of a loop closure were 20% higher in tests or referrals for patients with a portal account, and 40% higher in tests or referrals for note readers, compared with those not registered for the patient portal,” Bell, who was lead author on the study, said in a statement.

These findings present just one avenue for healthcare providers to boost patient access to referral care, which is important for early detection of disease and overall better clinical quality measures. Healthcare providers may consider endorsing the patient portal to their patients, even those whom the provider may think would be reticent to use the technology.

Encouraging the use of patient engagement technologies, like the patient portal, should be coupled with different strategies to overcome social determinants of health that often get in the way of healthcare access.

Still, the data is a promising view into the impacts of patient data access, which was enabled by the Cures Act. Groups like OpenNotes have long stressed the importance of open clinical notes, stating that they can lead to more engaged and activated patients.

That doesn’t mean the policy is uncomplicated. For some viewing their clinical notes, it means lab results coming in without the context or counsel of a doctor, which can induce anxiety in patients.

A 2023 JAMA Health Forum article outlined one academic medical center that saw higher patient complaint rates following the implementation of the Cures Act due in part to the influx of patients seeing abnormal test results without hearing from their doctors.

Most experts agree that patient access to clinical notes is, indeed, a good thing but that there should be some caveats. Importantly, providers need to explain to patients that they might be notified of test results before they can be contacted. With that information, patients can decide when it would be best for them to open the test results. In most cases, patients will want to hear from their doctor while opening the test results.

While it would be impossible for clinicians to anticipate the delivery of every test result, explaining to patients how they themselves can view their medical information or wait to be contacted by a clinician could be fruitful.