Long Article

Transitioning the Radiologist Workflow to Patient-Centered Portal Communication

With the imminent transition to value-based patient-centered care, it has become increasingly critical for the role of radiology and the vital contribution it makes to the diagnostic process to become more visible and valued in the healthcare continuum.1 Many in the field believe the opposite has occurred.1 At stake are staff morale, future role of the profession, funding, research, and students interested in the field. And all of these concerns are significantly influenced by negative perceptions.

What patients want from their radiology exams

When it comes to visibility with patients, a commonly held belief has been that they are not familiar with who or what a radiologist does.2 However, some research has demonstrated that there are patients knowledgeable about the radiologist's role and those patients would prefer to consult with a radiologist instead of their referring physician.2 Some referring physicians agree since they may not be well enough versed in the details of radiology reports to answer questions that fall outside their area of expertise.2

In fact, patients want to hear about their outpatient imaging results as soon as possible.3 An earlier multi-center quality improvement survey revealed patients are only willing to wait a median of three days to get their results given the stress and anxiety induced by not knowing.4,5 Patients reported their intention to make that follow-up call to their physician or the radiologist for test results anywhere from one to five days after their exam, a time frame that was impacted by the individual condition prompting the test.4,5 For those patients who intend to that make the call directly, there may be an online patient portal with direct access to the radiologist waiting.3

Existing tools increase patient engagement

Patient portal use has been on the rise with more than 90 percent of U.S. hospitals providing patients the opportunity to access their medical records online and more than 60 percent allowing patients to send messages to their physicians.3 When these facilities began to notice that a number of patient messages were related to their radiology reports, one large academic children's hospital decided to implement a quality improvement initiative by leveraging their integrated electronic medical record (EMR) system and preexisting built-in online patient portal.3

Although patients were already able to view their radiology exam results through the EMR portal and send messages to the doctor who ordered the test before the new process was implemented, there was no direct messaging capability where the imaging report was accessed due to software limitations.3 To develop a system that would function and accomplish the project's goals within the already existing commercial platform, a team of experts were assembled.3 They included the senior EMR analyst, chair of radiology informatics, lead systems analyst of radiology, and a pediatric radiology fellow.3 When the new messaging system was launched it had five out of seven of the functions planned.3 

Inserting patient communication into the workflow

One functional challenge of the existing messaging system was the lack of ability to send a message directly to the interpreting radiologist.3 Given this, an always accessible pool of radiologists was assembled consisting of 47 radiology fellows and faculty since researchers concluded most of the questions that might be asked by patients could be answered by any radiologist.3 

While sending messages to the inboxes of the entire pool of radiologists prevented messages from sitting around unanswered by any single radiologist who might be away, an individual radiologist could still "claim" the message to avoid duplication of work.3 Once completed, responses were made available to all radiologists in the EMR regardless of what method was used - electronically, forwarded to a referring physician for feedback before replying, or by documenting a phone conversation.3

Patient concerns bring valuable insights

Messages received between October 1, 2017, and July 31, 2018, were included in the 301-day study period and analysis.3 Tracking included both patient and radiologist metrics.3 For patients, how they heard about the message form (social media, blog, portal login page, etc.), preferred means of contact (phone, email, etc.), as well as the number and type of questions asked were recorded.3 Turnaround time from the moment a patient message was received and who responded were the metrics documented for radiologists.3

During the 10-month analysis period, more than 168,000 imaging studies were performed on 69,500 patients.3 More than 83,000 patients visited the patient portal and submitted 88 questions and represented 0.13 percent of patients examined by the radiology department.3 Of the 88 questions, 86 (99 percent) asked about already completed tests.3 

Since the message form for questions was only found where results of completed studies are listed, researchers believe this impacted the number of questions they received (or didn't receive) about future studies.3 The completed studies page is not considered a viable location where patients would think to look for or ask questions about future studies and instead believe the scheduling section would have prompted more pre-imaging exam queries.3

Based on the patient concerns voiced in the 86 questions about already completed exams, availability of results, clarification of results, and requests to view images were found to be the most frequent.3 Insights gained from these metrics included increased patient engagement and indirect feedback on the radiology department itself.3 For example, since 47 percent of the questions focused on getting results and viewing images, the team concluded they could do a better job communicating how and when patients can view their images as well as the time frame for receiving or accessing their test results.3

Skepticism, limitations, and feasibility

After implementation of the new messaging strategy overall perception was positive with 33 of the 47 (70 percent) radiologists having used the system to answer patient questions with a median turnaround time of just over five hours.3 Initially, the team of radiologists who participated in the quality improvement initiative were skeptical voicing concerns about their perceptions of increased workload and the potential for contradicting the referring physician.3 Ultimately, several radiologists reported anecdotal satisfaction over the opportunity presented by the new communication strategy to improve patients' understanding about their radiology test results and therefore their medical situation.3 When patients better understand their situation, they are more likely to make the lifestyle changes that improve their outcomes.3

The pool of radiologists turned out to be one of the biggest limitations of the new system because it amounted to 47 people sharing one email inbox.3 For example, as soon as one radiologist opened a patient message it was marked as read for every radiologist participating in the pool.3 The problem arises when an abdominal imaging study question is initially opened and reviewed by a neuroradiologist.3 Now, unless it occurs to the neuroradiologist to mark the message as unread, it will show up as an already viewed message for everyone else including the abdominal radiologist who will assume there are no questions that need addressed.3 Marking read messages back to unread is not a natural or intuitive part of most workflows and did leave a few unanswered questions.3

Overall the study team reported that creating a digital messaging tool so patients can directly contact and communicate with radiologists through an online portal is feasible with existing commercially available software.3 Moving forward, plans include expanding and upgrading the functionality of the current system.3 

Radiologists look forward to the continued innovation from equipment and system developers to create the simplified and seamlessly connected tools that not only help them make accurate and actionable clinical decisions but that allow the to serve an increasingly valuable role in ensuring patients get the care they need.3

REFERENCES:

  1. Back to Basics in Patient-Centered Care in Radiology. Imaging Technology News https://www.itnonline.com/article/back-basics-patient-centered-care-radiology  Accessed 6/7/2019
  2. Patient-centered Radiology: Where Are We, Where Do We Want to Be, and How Do We Get There?. RSNA Radiology Journal https://pubs.rsna.org/doi/full/10.1148/radiol.2017162056  Accessed 6/7/2019
  3. Direct patient-radiologist communication: Online Patient Portal. Health IT Management https://healthmanagement.org/c/imaging/news/direct-patient-radiologist-communication-online-patient-portal  Accessed 6/7/2019
  4. Waiting for Radiology Test Results: Patient Expectations and Emotional Disutility. Journal of the American College of Cardiology https://www.jacr.org/article/S1546-1440(17)31162-6/fulltext  Accessed 6/7/2019
  5. Radiologists want patients to get test results faster. Reuters https://uk.reuters.com/article/us-radiology-results-timeliness/radiologists-want-patients-to-get-test-results-faster-idUKKBN1DH2R6  Accessed 6/7/2019