The Path to Patient-Centered Radiology

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A young child is being prepared for an imaging procedure when, suddenly, the technologist asks him to name his favorite color. Two minutes later, the examination room lights turn just that shade. A woman has an appointment for a routine mammogram at an outpatient-imaging center, but instead of sitting in a waiting room with oncology patients, she awaits her turn in a separate area reserved for other female patients undergoing the identical procedure. A group of administrators and physicians are deciding on the layout of a new imaging center—but they aren’t doing it alone: A patient advisor participates in the process.

These are just a few iterations of “patient-centered radiology.” Most radiologists have long put referring physicians at the center of their universe; only within a few subspecialties do clinicians ever see patients, and solely in rare cases will radiologists have an opportunity to learn the outcomes of their diagnoses on the patients they image.  However, an overall heightened emphasis on patient centricity, the core objective of the Affordable Care Act, is changing all that, with efforts to implement and conform to a patient-centered radiology model becoming more widespread.

“Patient-centered radiology is now a reality—which is no surprise considering that it’s a key element of the ACR Imaging 3.0” initiative, states James A. Brink, MD, radiologist-in-chief, Massachusetts General Hospital, Boston and Juan M. Tavares Professor of Radiology, Harvard University.

Multiple definitions

Patient-centered radiology may have arrived, but everyone seems to define it differently. For Brink, patient-centered radiology means placing the patient at the center of the healthcare environment, and ensuring that the diagnostic process truly revolves around what care is right for each patient and his or her needs.

James V. Rawson, MD, FACR, Warren Professor and chair, department of radiology and imaging, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, has a similar yet in some ways different take on the concept. Rawson, who also serves as chair of the ACR’s Commission on Patient and Family Centered Care, prefers the term “patient- and family-centered care,” as families are typically as heavily involved in patients’ care as the patients themselves.

Under this umbrella, the radiologist serves as the steward of patient care, partnering with the family to foster collaboration and information-sharing pertaining to responsible diagnostics and treatment. In Rawson’s view, “patient- and family-centered care” also means involving patients and their families in decisions pertaining to the design of the radiology department and the manner in which patients are serviced.

Meanwhile, Jennifer L. Kemp, MD, radiology department chair, Rose Medical Center and a partner with Diversified Radiology, both in Denver, perceives patient-centered radiology as optimizing the patient experience throughout the continuum of radiologic care and assuring patients that clinicians will do all they can to treat them as they would a loved one. This entails “aligning our practices with patients’ needs and best interests,” as well as effectively communicating with patients and their health care providers, so as to empower the former to make more informed decisions regarding their medical care, states Kemp, who also chairs the RSNA’s Patient-Centered Radiology Subcommittee.

However, it is defined, though, patient-centered radiology has implications for, and is clearly impacting, the radiology practice and department in a number of different ways, depending on practitioner and patient parameters. “Patient-centered radiology is very fluid, and what works for one practice” or hospital may not work well for another, Kemp explains.

For example, some practitioners may not be comfortable sharing findings with patients through an online portal without the involvement of their primary care physicians. Likewise, some are wary of verbally revealing study results before patients have left the radiology department, but others are in favor of doing so. Similarly, some clinicians favor online scheduling and/or patient registration; others prefer more traditional, telephone- and paper-based methods.

The radiology care continuum

The evolution of new patient-care protocols exemplifies the effect of patient-centered radiology on practice patterns and departmental culture. Over the past few years, for instance, Massachusetts General Hospital has been developing “care pathways” based on the belief that although a substantial portion of important imaging care occurs prior to and following examinations, radiologists are not providing such care. In keeping with the hospital’s concept of a patient-centered radiology department, Brink says, radiologists leverage their expertise to manage imaging care prior to and following the interpretation, thereby improving patient safety and outcomes and opening doors for more cost-effective care.

Massachusetts General currently utilizes four “care pathways”—one apiece for acute/chronic pneumonia, adenocarcinoma of the lung, CHF/pulmonary edema, and emphysema/COPD—to accomplish this goal; other pathways are on the drawing board. Each pathway melds appropriate ordering, reporting and procedure management with diagnostic clinical support and disease management.

“In the real world, patients don’t say, ‘Put me in the adenocarcinoma pathway,’ or whatever it may be,” Brink says. By using the pathways, he notes, he and his colleagues have a basis for ensuring that the care of every patient is properly managed and that the patient is at the center of decision-making—from determining which procedure an individual should undergo to contributing to disease management.

Massachusetts General also has created a tracking system for keeping tabs on significant incidental findings (e.g., a blocked artery discovered during a CT of the lung), so that patients have the opportunity to address a potentially worrisome condition at the earliest possible stage. These findings, Brink observes, may surface in as many as one-third of imaging studies, but often fall through the cracks—particularly in emergency room cases. At Massachusetts General, protocol calls for monitoring incidental findings from emergency room tests over the long term and/or discussing them with patients on the spot. Alternatively, nurses will assess the findings and follow up with patients and their primary care physicians following discharge.

Additionally, the hospital has implemented a pilot clinic in which radiologists confer directly with patients whose condition (e.g., emphysema, liver disease, and heart ailments) warrants regular imaging studies. During meetings with these patients, clinicians review images, explain the implications of any incidental findings and address questions.

“Patient-centered radiology has the potential to change practice patterns, putting patients in the center, ensuring we make good decisions, perform the appropriate imaging tests and optimize care for our patients,” Brink says.

Open communication

When it comes to the way in which patient-centered radiology is influencing culture, “there’s just a lot more openness and fewer communications barriers,” asserts Ella A. Kazarooni, MD, professor of radiology, associate chair for clinical affairs, director of cardiothoracic radiology, and chair of the Radiology Service Excellence Program, University of Michigan, Ann Arbor, Michigan. The organization’s service excellence program encourages communications and accountability by providing every patient with a record of their visit.

Patients undergoing imaging procedures at University of Michigan Health System facilities receive a card at the end of their visit. One side of the card carries a message thanking the individual for “choosing radiology at the University of Michigan.” On the reverse side are the name of the technologist, nurse, employee, or radiologist with whom the patient last spoke at the end of his or her appointment, a list of imaging procedures completed that day, a reminder to feel free to contact the facility with any follow-up questions and an indication of when study results will be available.

The University of Michigan’s patient-centered radiology model also calls for proactive communication with patients when there is a problem—such as an equipment malfunction that would necessitate re-scheduling a procedure. Instead of telling patients the time and date of their new appointment, staff try to find out which alternative slot best suits their schedule and needs. If a patient really wants an appointment the same day, employees attempt to find a later time that works or arrange an appointment at another University of Michigan Health Care site near the individual’s home.

Moreover, the health care system opens lines of communication and maintains a patient-centered focus through patient satisfaction surveys, feedback cards and a patient service recovery program. Patient satisfaction surveys are sent out twice annually, and comment cards—which offer an option for patients who would like to be contacted to share additional feedback to include their contact information—are available in waiting rooms. Members of a patient-centered family group sit in on serious patient incident reviews to provide their insight.

“We are so close to what we do as providers, that we cannot be truly patient-centered unless we get perspective from patients themselves,” Kazerooni notes.

Patient experience

Not surprisingly, the push towards patient-centered radiology has begun to spark changes in the imaging “experience,” a phenomenon sources say touches practice patterns and departmental/practice culture. In University of Michigan Health Care imaging facilities, this means a calmer environment achieved by lowering lights in examination rooms once patients are in proper position, as well as by requesting that staff use slower, softer tones of voice. Patients undergoing MRI examinations are encouraged to distract themselves by donning goggles to enjoy Cinemavision video entertainment. One family- and child-centric waiting room has a miniature MRI scanner children can play with to help them understand what the procedure will be like; they can even perform a mock MRI exam by placing a plush animal toy inside the unit. Similarly, the registration area in the radiology department at

Children’s Hospital of Georgia has been furnished to “look like a kids’ lounge,” Rawson states. On the walls, interactive images that change every 30 seconds replace juvenile-themed artwork. In the examination rooms, youngsters who are being prepared for x-rays or fluoroscopy are asked to name their favorite color; room lights are adjusted accordingly.

“We’ve also upgraded the MRI experience,” Rawson says. “Patients didn’t like the rough, cold surface, so we added a blanket warmer. It’s a small thing, but the better MRI experience has led to increased patient cooperation and better studies.”

Just as significantly, patients are being afforded a voice in the actual design of radiology departments and imaging facilities. University of Michigan Health includes patients and family members in this process.

“There are important things that we may not see because, while we have all been patients, we have a bias,” Kazerooni states. “We say, ‘Okay, we need “x” number of square feet of rooms laid out in “x” way,’ but is that going to feel right to patients? Is the flow—the way people walk through—going to be comfortable? This is about much more than paint colors and decorating.”

The health system is presently building an outpatient facility that will provide CT, ultrasound, x-ray and mammography services. Patient feedback has indicated that routine mammography patients may not be comfortable coming into contact with oncology patients. Consequently, the idea of a separate entrance for mammography services or a different hallway through which mammography patients can enter examination rooms is being considered.

For its part, the Georgia Regents Health System has responded to comments about privacy from mammography and women’s health patients. Discussions between patients, their families and radiologists and surgeons can be held in a private space that is also used as a women’s health education area. This has alleviated patients’ expressed concern about the need to make follow-up appointments to review study findings and next steps.

More changes afoot

This is all the tip of the iceberg, interviewees attest. In the near future, the advent of patient-centered radiology in all its guises will give rise to changes in informatics platforms. To deliver on the patient-centered radiology promise, clinicians will be looking for prompt delivery of images to PACS, along with all comparison examinations and a comprehensive cadre of information from referrers.

In an ideal scenario, sources say, image-sharing software will allow easy access to prior studies completed at other facilities, improving the patient focus by reducing overutilization and the administration of unnecessary radiation

exposure. Radiologists will have automated access to electronic medical records (EMRs), along with software tools for “pre-mining” such records to obtain the appropriate history and facilitate actionable reporting.

“With more patient access to information through portals, presented in a language they understand, patients will come to understand radiology’s role in their care and will feel more empowered to have a say in it,” Rawson observes. This will occur, also, as reports come to include both medical verbiage for physicians and lay language that patients can easily comprehend when reviewing reports accessed via portals and EMRs, according to Kazerooni.

Patient-centered radiology not only has the power to alter departmental culture, practice patterns and informatics platforms; it also will likely alter the way in which radiologists are paid.   As Kemp puts it, “Health care’s new economics require providers to transition from volume-based to value-based care.” On the payment front, this may mean shifting the practice paradigm from transactional to consultative and focusing on outcomes as well as interpretation.

“Radiology groups as part of ACOs will engage actively in the design and implementation of non-traditional systems service lines aimed at adding differentiated value [to larger health organizations],” Kemp says, an important element of which will be patient-centered care. “These lines may include utilization management and decision support, IT leadership and quality and safety assurance.” These service lines will be tailored to the needs of integrated care entities, supported by performance metrics, and could become an important source of non-clinical revenue, she believes.

Moreover, patient satisfaction scores will be tied to reimbursement. “The easiest way to improve those scores is to engage patients, find out what their values are, and try to give them” what they want in terms of the experience, at least, Rawson asserts. “The asking part is very important, because in every project we have done, we have been consistently wrong about what patients want, and we have stopped guessing. Those warm MRI blankets were not at the top of our list, but they turned out to be a huge patient satisfaction factor and are now in multiple procedure areas.”

Certain subspecialties within radiology can serve as models as radiology seeks to become more patient centered. Brink deems mammography, interventional radiology and pediatrics three key examples. “When kids come into the radiology department, they’re accompanied by their family, and things are explained to family members and kids in the most helpful way,” he says. “In interventional radiology, relationships with patients are built as studies are done. This can be carried over to other types of practice.”

Kemp concurs, adding that radiologists can take a leaf from other clinicians’ book by becoming more accessible to patients, including the sharing of test results immediately if asked (via a meeting with patients or a telephone conversation). She already does so, and provides her direct telephone number to patients and their physicians. The RSNA’s Patient-Centered Radiology Subcommittee is working on avenues to encourage these exchanges.

The ACR’s recently formed commission on patient experience is developing resources intended to help radiology professionals provide and document patient- and family-centered care. “Our work will help enhance radiologists’ understanding of, and participation in, new practice and payment models that promote patient-centered care,” Rawson says.

Patient-centered radiology, indisputedly, is a moving target. Health care reform and an increasingly engaged base of patients who want to better understand their disease—and imaging options—will continue to change how patient-centered radiology is defined and delivered moving forward. Clinicians, practices and hospitals interested in demonstrating their value will need to factor in the patient perspective if they are to flourish in an increasingly challenging health care environment.

Julie Ritzer Ross is a contributing writer for Radiology Business Journal.