Pathology and diagnostic imaging reports

While there are benefits to patients having immediate access to their results, such as better-informed discussions with their GP and the ability to self-manage chronic conditions, there are some scenarios GPs will need to consider: 

• an unexpected abnormal result that might indicate a serious health problem that was previously unknown and unsuspected 

• a normal result that requires patient follow up  

• patient misinterpretation of results (both normal and abnormal) 

• an anxious patient requesting an urgent appointment to discuss their results 

There is a risk patients could experience undue distress by viewing sensitive or abnormal results in an unsupported environment. 

Patients may misinterpret their results, which could lead to patients not seeking follow up care for a result that appears normal.  

There could also be an increased demand for appointments and enquiries by patients who are concerned and seeking an explanation of their results. 

It remains important to discuss with patients why a test is being requested and what the results may mean. GPs should also consider: 

• providing a clear plan for when and how the patient should expect to hear from them for both a normal or abnormal result and the urgency of any follow up care required.  

• reviewing their systems and processes to ensure results are reviewed and patients are notified in a timely manner. GPs could consider notifying patients of results that do not require follow up. 

• assisting patients to understand the test being requested and how to interpret their results, GPs can direct patients to trusted information sources such as the Pathology Tests Explained website  

• encouraging and booking a review appointment in advance for tests that may have a significant result. The RACGP’s Standards for general practice (5^th edition) advises, ‘It is best practice to inform patients of clinically significant results in person, so the patient can ask questions and receive advice from the GP. When an in-person consultation is not possible, consider whether the use of telehealth platforms is appropriate to convey this information.’

The obligation to follow up test results rests with the requester of the test.

GPs may have access to view reports of investigations requested by other practitioners, subject to any access controls the patient may have set and there are benefits to this including improved coordination of care, reduce duplication of testing and better-informed clinical decision making.  

See the RACGP’s position statement Testing initiated by other health care clinicians for further advice.  
 

If your patient requests for their test results not to be uploaded, you can do this via your practice software by checking the ‘Do not send reports to My Health Record’ tick box when requesting the investigation. 
 
Alternatively, patients can mark a tick box on the paper request form to request the report is not uploaded to My Heath Record, or the request can simply be written as a note on the form.  

Test results will not be uploaded to a patient’s My Health Record where existing State or Territory legislation prohibits the disclosure of sensitive information without the patient’s express consent. Information about which reports are covered by this in different States and Territories is available here. 

If a test result has already been uploaded to a patient’s My Health Record patients can apply access controls to remove the document, restrict access, or hide it from view. Information on privacy and access controls can be found here. 

While patient consent is not required to share reports to My Health Record, it is considered good clinical practice to advise a patient and their authorised/nominated representatives that their test reports will be uploaded, particularly if this information might be considered sensitive.

Patients need to be provided with the option to not have a report uploaded.

It is important patients, and their carers understand the importance of discussing their results with their GP. Patients may need support in understanding that they are in control of the information shared to their My Health Record by setting access controls or choosing not to have their reports uploaded. 

The Australian Digital Health Agency has created a consumer factsheet explaining these changes. 

Practices can communicate information on pathology and diagnostic imaging report uploads to My Health Record by:

• including information in existing practice documents such as the practice privacy policy and patient registration forms
• adding details to the practice website, patient newsletters and social media channels

The RACGP has developed a Privacy policy template for general practices to adapt, to meet their obligations under the Australian Privacy Principles (APPs). The template should be used as a guide and it is important each practice adapts its content to their individual procedures.  

When a request is created from a patient record within your CIS, an eRequest is automatically sent to the selected pathology provider. A paper request form is printed at the same time. The paper request form contains a barcode that can be scanned by the pathology provider, and patients can choose to attend a different provider should they wish to do so.

If you would like to begin using eRequesting, you must first ensure t your practice is using a compatible CIS and that your preferred pathology providers can receive eRequests. The next step is to contact your preferred pathology providers to have eRequesting set up between your system and theirs. Once the functionality has been switched on, eRequesting happens automatically.

All pathology reports, whether paper-based or generated via eRequesting functionality, will always be sent directly to the requesting GP using the existing processes in place.

The Australian Digital Health Agency's Pathology and diagnostic imaging providers uploading to My Health Record webpage contains an up-to-date list of the general practice CISs and providers able to participate in eRequesting.

• My Health Record online training (you will need to set up an account to log in)
• Better and Faster Access to health information 
• Consumer factsheet - Your pathology and radiology reports in My Health Record