Cures Act Presents Clinician Burden Challenges, EHR Inbox Volume

Implementation of 21st Century Cures Act patient data access mandates led to a twofold increase in EHR inbox volume, according to a research letter published in JAMA Network Open that draws clinician burden concerns.

The 21st Century Cures Act mandates that patients have immediate electronic access to test results, medication lists, and clinical notes. While the requirement aims to boost patient engagement, it has been met with some skepticism.

Before the Cures Act, many institutions would delay the release of information to the patient portal when it was considered to be highly sensitive. The immediate release of health information to the patient portal presents the opportunity for patients to view the information before their clinicians, which can lead to misinterpretation.

A cross-sectional study examined health results released to the patient portal between January 2020 and April 2021 at Vanderbilt University Medical Center (VUMC). Historically, VUMC has released testing results to its patient portal, My Health At Vanderbilt (MHAV), based on tiered intervals according to test sensitivity and complexity. Cures Act compliance at VUMC began on January 20, 2021.

The researchers found that the implementation of Cures Act requirements led to a significant increase in the number of patients who viewed test results before their clinicians.

Among tests categorized to be released with a delay before January 20, 2021, patients viewed 10.4 percent of results before clinicians. After the implementation of Cures Act requirements, patients viewed 40.3 percent of the same kinds of test results before their clinicians.

The researchers found that this increase in patients accessing their test results prior to their clinician led to a large jump in EHR inbox message volume.

In particular, the volume of daily messages sent by patients within six hours of reviewing a test released after any delay changed from a median of 77.5 messages before the transition to Cures Act compliance to 146 messages after the transition.

The study authors noted that while the Cures Act’s patient data access requirements aim to improve the patient experience, this benefit could be overshadowed by patient well-being and clinician burden concerns.

“Additional consideration of the timing of test result release to patients and clinicians is necessary to ensure that results are made available to patients while maintaining the opportunity for clinicians to apply their expertise and interpretation,” the study authors wrote.

The researchers noted that this study has several limitations, including the fact that they conducted the research at a single academic medical center, which limits the applicability of the findings to other health systems.

They also pointed out that the study measured changes in the number of patient-initiated messages relative to the timing of result review without further analysis of message content.

“Additional research is necessary to assess patient and physician perceptions of reviewing immediately released test results,” they concluded.

This study adds to the growing literature of clinician burden related to EHR use.

A recent study published in JAMA Network Open revealed that medical and primary care physicians’ EHR inbox message volume increased over the course of the COVID-19 pandemic despite fewer patients receiving care.

Over the course of the first 15 months of the COVID-19 pandemic, the average total messages per day increased from 45.0 to 46.0 messages per day for primary care physicians.

Medical physicians, or physicians who are not surgeons and who do not practice primary care, also saw an increase in messages from 29.3 to 32.0 per day. 

Surgical physicians experienced the greatest uptick in EHR inbox messages during this time period, jumping from 16.6 to 23.3 messages per day.

Patient-originated messages also increased during the first 15 months of COVID-19. Specifically, patient medical advice requests (PMARs) increased from an average of 1.8 to 3.9 messages per day for primary care physicians; from 1.0 to 2.2 messages per day for medical physicians; and from 0.4 to 1.1 messages per day for surgical physicians.