Propelled by everything from regulatory requirements to patient centricity, all roads point toward direct communications with patients by radiologists.
The days when radiologists could live in the shadows of the reading room are gone. Now, increasingly, imaging subspecialists of all types are expected to be out in plain sight, interacting directly with patients.
This expectation arises in part from radiology’s sense that it needs to demonstrate ever-greater value in the eyes of customers and payors, something achievable by joining the march to patient-centricity. The need for greater visibility also has its roots in regulatory pressures—the requirements of the federal Meaningful Use program, for instance, in which radiology is financially rewarded for making medical records electronically available to patients and successfully coaxing a sufficient number of those individuals to log on to a patient portal.
Radiology departments and practices are finding it essential to communicate with patients more frequently, facilely, and fully. But in order to have patient interactions and results deliveries that are on par with current expectations, those organizations also are discovering that they must re-engineer comfortably familiar processes and protocols, adopt new ways of working, and even embrace cultural change.
Interactions with patients
Patients today live in a world where people engage in social intercourse about matters both profound and trivial using a variety of electronic communications channels: phones, email, texting, Instant Messaging, Skype, Facebook, Twitter. Significantly, all of this chatter occurs absent the kinds of time delay associated with the sending and receipt of letters via traditional postal mail.
Radiologists like Mark Alfonso, MD, say it is therefore only natural for patients to want to be able to converse with imaging clinicians during preparation for, progress of, or follow-up to an exam. These patients have questions—questions about the study and the results, and they want answers yesterday, if possible.
Alfonso, immediate-past president of Riverside Radiology and Interventional Associates, Inc., in Columbus, Ohio, believes radiologists need to be able to answer those questions as and when they arise. To do that, radiologists need to be more available to and accessible by patients. “The more we are in the position to talk to patients and share information with them, the more empowered those patients will be in the long term,” he says.
Susan D. John, MD, professor and chair, department of diagnostic and interventional imaging, University of Texas Health Science Center at Houston (UTHealth) Medical School and chief of diagnostic and interventional imaging, Memorial Hermann-Texas Medical Center (TMC), contends that the need for radiologists to communicate with patients has always existed but only in recent years has its importance come to the fore.
“PACS and other informatics systems, while responsible for greatly advancing our medical specialty, contributed to making us less accessible to patients by pushing us into remote reading rooms,” she says. “Then, as healthcare shifted more to the integrated delivery system model, we realized that we were going to need to have greater contact with patients to fit in.”
As Chicago-based healthcare attorney W. Kenneth Davis, Jr., JD, sees it, better communication with patients is at bottom a quest by radiologists to gain a better seat at the reimbursement table. “The more that radiologists can drive the process of healthcare delivery—as opposed to merely being along for the ride—the more valuable they become to their hospitals, referrers and payors,” says Davis, a partner in the firm of Katten Muchin Rosenman, LLP. “Radiology practices wishing to survive must provide the highest-quality care. Doing so will help them emerge as the most desirable healthcare-delivery partner possible. One way to become the imaging provider of choice is by improving communications with patients.”
Assuming radiologists need to step up their communications with patients, under what circumstances should such dialogue take place? And who should initiate it: the patient or the radiologist? Some say the radiologist should always be alert to opportunities to take the lead, but only start the conversation when there is bad news to impart. Others say, yes, take the lead, but only if you’ve something encouraging to convey.
N. Reed Dunnick, MD, chair, department of radiology, University of Michigan, believes radiologists need not wait for a patient inquiry before speaking up. However, he believes the good-news/bad-news dichotomy is invalid. “The most critical factor is the importance and complexity of the information to be communicated,” he says.
Still, speaking up to communicate good news is easier than doing so to deliver bad news. That is why many radiologists, when they must relay dismaying information, try to broach the subject as delicately as possible. In her role as chief of the division of breast imaging and co-director of the Cancer Center Breast Care Program at the University of Virginia, Jennifer A. Harvey, MD, FACR, has had ample experience compassionately presenting troubling findings to patients.
“The most important thing you can do for the patient is put the findings into perspective,” Harvey says. “I avoid using the word ‘cancer’ unless cancer is likely. If there is a 20% chance of cancer, I will inform the patient there is an 80% chance she is OK. When a biopsy shows cancer, I tell the patient what the size of the tumor is—if, for example, 1 cm, I put that into perspective by indicating that it is about the same size as a pea, and I go one step farther by noting that cancers that size have about a 90% to 95% cure rate.”
Harvey offers that thinking carefully before speaking is essential in these situations: “I’ve found that when you tell a patient he or she has cancer, the patient will remember every word you said. So you have to choose those words very well.”
Well chosen or not, those words of the diagnosis must be conveyed via an appropriate channel. Radiologists prefer communicating bad news in person or by phone. The same holds true for patients, but many—especially younger ones—express a preference to communicate by email. Harvey says email is not a good idea for a discussion of bad findings.
“I am not in favor of communicating findings by email because it does not allow me to gauge the patient’s reaction,” she says. “I need to be able to see or hear the reaction so that I can know what information to convey to keep things in perspective for the patient. I also need to see or hear the reaction so that I can know how to adjust my voice to convey the right emotional support that the patient needs at that moment. Email also is a poor choice for the reason that the meaning of words can be misconstrued since there is no way to inflect them as one would in a face-to-face or over-the-phone conversation.”
Email is acceptable for communicating information about how to prepare for an exam and what to expect during the procedure, as well as for answering some post-procedure questions. “But when you get to diagnosis and the intricacies of imaging procedures, you need two-way communication—in person is best, though not always possible,” she says.
Delegation of communication
A practice model that embraces the idea of radiologists engaging in greater communication with patients is one that presupposes the radiologists possess the requisite skills to be good communicators. Not all radiologists do, and even if they do, they might not have the time to make use of them.
One model is to delegate communications responsibilities to nonradiologists, such as technologists, physician assistants, nurses, and support personnel, John says.
“Delegation depends on the depth of the conversation needed, and that’s something which must be considered from the perspective of the patient,” she explains. “Any communication that involves image interpretation skills must remain with the radiologist because of the level of sophisticated knowledge required to do it. For example, if you’re going be given bad news, from whom would you as a patient most want to receive it? I would want to receive word from the person who knows most about what was seen on the image. While technologists are very knowledgeable, at the end of the day, the essence of being a physician is that you are there to have a conversation with the patient.”
Harvey adds that there are circumstances when it would be appropriate for technologists to enter the conversation. For example, a technologist can respond to a question at the end of the exam about how well the images turned out. “But if a question requires a level of deeper information or if it is likely to lead into an emotional conversation, then it may be better for the radiologist to respond,” she says. “And, if the radiologist is too uncomfortable providing that information, then he or she should consider deferring to the referring physician.”
When less is more
An interesting trend Harvey is noticing is that while patients want more communication, referring physicians seem to want less communication with radiologists. “Referring physicians do not want us calling them on routine matters,” Harvey tells. “For that, they want email. They find that dealing with us by email is much more efficient. If we reach out by phone, it is very possible that the call will be disruptive.”
The referring physicians with whom John is acquainted appear to divide over the question of whether radiologists should have greater interaction with patients. “Some referrers are very supportive of it,” she says. “It can help them improve their workflow by decreasing the number of phone calls they get from patients asking questions about imaging results.”
Stepped-up communication between patient and radiologist also contributes to patients having greater satisfaction with the referring physician, John indicates. “Patients who call their primary care doctor to find out about results can become very unhappy if the doctor doesn’t return the call in what the patient feels is a timely manner,” she says. “That problem might not occur at all if, before the primary care doctor returns the call, the radiologist is there to promptly provide the patient at least some information about the imaging results.”
One compelling reason to communicate directly with patients is that many seem to prefer it that way. “The radiologist typically understands more about what the images show than does the family doctor who ordered the study, since the radiologist has the high-level expertise in image interpretation,” says Harvey. “If the patient has questions about the results, it is usually much easier for us to give them the information about the implications of that study” than it is for the family physician, who might not even have the images at hand when the patient inquires.
Some referring physicians flatly oppose the notion of radiologists conversing with their patients, John notes. However, she expresses confidence that some of those detractors can be won over. The key is making them feel comfortable about the interaction between radiologist and patient.
Harvey says her organization promotes referring-physician comfort in part by making sure those physicians are apprised whenever University of Virginia radiologists interact with patients. “In the report we send to the referring physician, we make note of our communication with the patient. We disclose that a conversation occurred, and we summarize what was stated. We do this because we are sensitive to the relationship between the physician and the patient. We want to avoid anything that could be construed as disruptive to that relationship.”
Relaying findings via portals
One way radiologists communicate with patients is through an Internet portal. “Many healthcare institutions have created password protected websites for patients to access,” says the University of Michigan’s Dunnick. “This is efficient and effective for simple communications, and it is a relatively inexpensive method.”
One of the requirements of the federal meaningful-use incentive program is to demonstrate that patients access their records electronically, through patient portals, for example. Not all radiology practices have elected to participate in the program, and some that have not are nonetheless forging ahead with efforts to deliver results via patient portals.
As an illustration, John’s radiology department covers a number of Houston-area hospitals, one of which is Memorial Hermann-TMC. Less than a year ago, her department helped Memorial Hermann-TMC expand the hospital’s online portal capabilities to enable Internet-using patients to access radiology records—including images and reports.
“The radiology component of the portal lets patients see their reports 36 hours after we complete them,” John says. “We insisted on that availability delay to give referring physicians time to know before the patients do what the reports contain, since patients will have questions and we want our referring physicians to have adequate opportunity to ready themselves to answer those questions.”
A concern in giving patients electronic access to their radiology reports is that they may not fully understand everything they see or read, which can lead to confusion. Says John, “Some advocate that the way to handle this is to change the way we report. One suggestion is we have a separate report written in layman’s language and only the patient would be able to access that version. I think that will prove impractical. Still, patients may experience anxiety if they are provided information that they are not sure how to interpret, which is another reason why having radiologists accessible and available to communicate with patients is going to be so increasingly important.”
Whether or not a practice participated in the meaningful use program, achieving better communication with patients requires the reengineering of a radiology department’s or practice’s internal policies, processes, and workflow strategies.
“We’ve completely reengineered our workflow and our operations of how we relay information,” Riverside Radiology’s Alfonso says. “Part of that is we internally developed our own workflow product, which allows us to automate a lot of these processes. But it’s been a major development in our practice to accommodate and support the patient, referring physician, and the hospital.”
Patient communications between radiologists and patients also requires a change in culture. “The culture is very important—there is great truth to those phrases ‘culture trumps strategy’ and ‘culture eats strategy for breakfast,’” says Dunnick. “The point is that someone has moved our cheese. Now, as a result, we need patients to be partners in their care and compliant with the recommendations of their providers.”
Harvey insists radiologists may resist this culture change if it is outside their comfort zone. “Our training does not prepare us as well as it perhaps should to know how to communicate with patients,” she says. “If radiologists view patient interaction as an opportunity for education about the meaning of the findings on the study, it will make communication less intimidating.”
Scripting and use of protocols can help radiologists know what to say to the patient in any given situation, says John. “We’ve put in place some general protocols governing patient communications, particularly in our procedural areas. We’ve outlined the kinds of things you should talk to the patient about before the exam begins. For example, we’ve spelled out that you come into the room, wash your hands, introduce yourself, tell the patient about the roles of the accompanying clinicians in the room, ask the patient what brings him or her here today, and assess how much the patient or the patient’s family understands what the study is for.
“During the procedure, our protocols call for confining the conversation to just those things that relate to the procedure. But if the patient or family member is able to see the images while the procedure is underway, the radiologists are free to offer explanatory information, provided they can do that without distracting from the procedure itself.”
“At the end of the exam, the radiologist gives either a preliminary report or tells the patient that it will be X number of hours or days before he or she can expect to hear back from us with a formal report,” John continues. “The radiologist also asks if the patient has any questions and invites him or her to talk over any concerns about what happened with the exam.”
Expect more communication
With more direct patient communications on the horizon, be advised: Scripts and protocols have their limitations. “You cannot always anticipate what a patient’s questions are going to be, what his or her concerns are going to be, what findings are going to crop up,” John says. “Generally, communications with patients need to be personalized to the patient’s needs and abilities. Although having a script to deal with certain common questions, such as incidental findings, can be a very useful tool, ultimately the conversations will be different for each, individual patient.”
John explains that the scripts and protocols used in her organization were developed by the department’s subspecialty divisions individually. “We are a very subspecialized department,” she says. “Each section has different practice patterns. Because they are different, each section is responsible for developing its own patient-communication protocols. And because each is independently responsible, some sections have more fully developed protocols than others. In every section the scripts and protocols work well; however, they continue to be a work in progress.”
Radiologists whose departments and practices have striven to enhance their interactions with patients say that good communication begets more communication. “We are already seeing more questions from patients,” Dunnick says. “Patients are becoming more sophisticated and want to know about false positive or negative examinations. We should welcome the opportunity to have these discussions. Not only will the patients be better informed, but they are likely to be more compliant and appreciate the contributions of many physicians to their care.”
Alphonso believes that is exactly right. “Patient-radiologist communications will continue to evolve,” he says. “I can foresee the day when patients will have even more options for communicating with us, and we with them. By no means have we reached the endpoint in this movement. If anything, we’re just at the beginning.”
Rich Smith is a contributing writer for Radiology Business Journal.
The Patient Portal: Opening the Door to Direct Radiologist-Patient Communications
Online question-asking forums are useful tools for encouraging and facilitating communication with patients.
The University of Texas’s Department of Diagnostic and Interventional Imaging takes this approach with its “Ask the Imaging Expert” website [http://www.utradiology.com/]. The service is offered at no charge to all Internet users with a question related to one of four major subspecialty areas of imaging: breast, head/neck/spine, pediatrics, and bone and joint.
After arriving at the website’s homepage, visitors’ are directed to a bright red navigation bar near the top of the page. The navigation bar allows users to connect to the four subspecialty sections, where they will find a box containing a list of commonly asked questions. For, example, at the breast-imaging page, the topic list includes mammograms, breast ultrasound, breast biopsy, and more. Adjacent to each topic is a tally of the questions asked about it.
The radiology department’s designated expert provides answers to each question. Although presented in forum style, only the designated expert is able to respond to the question—and no one else may comment on the answer.
Each of the subpages prominently features a red button that, when clicked, whisks users to a page containing a fill-out form that allows them to ask questions of their own.
“There are faster and more personal ways for us to interact with patients than our ‘Ask the Expert’ system, but it does offer value in that it provides one more way for patients who are computer-savvy to receive good quality information from us,” says Susan D. John, MD, professor and chairman, department of diagnostic and interventional imaging, University of Texas Health Science Center, Houston.
The system cost little to set up, operate, and promote, John allows. Use, however, has been less robust than she had hoped when it first was conceived several years ago. Still, she is confident that it will grow into a popular avenue of communication.
“The most challenging aspect is building awareness among patients that they can ask questions of us this way,” John says. “We advertise it through our service lines, clinics and imaging sites. We also have run ads on Google. If the hospital approves, we plan next to include our ’Ask the Imaging Expert’ web address on the thank-you cards and other printed materials we give our patients at the end of an appointment.”
Soliciting online questions is only part of the work the “Ask the Imaging Expert” website is designed to do. It also serves to drive questions submitted by phone or fax, since those contact numbers are published in large text. The department’s Houston street address is also easy to find. Visitors can connect with the radiology team’s Facebook page and other social-media platforms.
However questions reach the department, John says, the first eyes to see them usually belong to an experienced radiology nurse who drafts responses and forwards those to the most appropriate radiologist for review and approval. The reviewing radiologist can accept, as is, make changes, or reject en toto and craft completely original answers.
Because of the generalized nature of these questions, answers can be given and shared publicly without fear of running afoul of the rules about privacy (questions are posted to the forums anonymously).
Most “Ask the Imaging Expert” users are individuals curious about radiology in general or are prospective patients contemplating having a procedure done but wanting more information about it before making any commitments, John says. Relatively few users appear to be existing patients with follow-up questions about recently completed procedures.
“Questions often pertain to how much radiation the person will be exposed to if he or she undergoes a certain procedure,” John says, “or whether that procedure is really the most proper one.”
The Legal Implications of Patient Communications
The rewards of communicating more with patients are potentially sizeable. But with those rewards come risks—legal risks in particular. These risks fall into two categories. The first is tort liability, says W. Kenneth Davis, Jr., a partner in the Chicago law firm of Katten Muchin Rosenman, LLP.
Davis warns that something as seemingly innocuous as communicating study results can strip radiologists of a layer of shielding they formerly enjoyed against liability. Discussing results with patients can qualify as providing direct care and thus can shift the radiologist’s status from that of consulting physician to treating physician.
“By virtue of taking over more of the care continuum, you become responsible for more,” he explains. “You pick up obligations that expose you to risks you didn’t have before, but that the treating physicians have always had.”
Tort liability, however, likely will not attach if the communication was both reasonable and effective. That means the patient understood the communication and felt it was conveyed in a considerate way, Davis explains. “You must always strive for clear, concise communications with patients,” he tells. “If the patient does not understand a communication, he or she might do things inconsistent with what you intended to convey and could end up being harmed because of that misunderstanding.”
Do not underestimate the importance of conveying considerately. “Studies have time and again shown that you can reduce your risk of being sued simply by treating patients with kindness,” says Davis. “The kinder you treat them, especially when giving them bad news, the lower your risk of them turning around and suing you.”
The second risk category revolves around privacy and confidentiality breaches. The riskiest communication where privacy is concerned is one that involves diagnostic information on paper slipped inside an envelope, sealed, and transmitted by U.S. mail or overnight courier.
“What we now call ‘snail mail’ can be very problematic, because you cannot control who in the intended recipient’s household will intercept and read it, let alone whether it will even arrive at the intended recipient’s home or be mistakenly delivered to someone next door or across town,” says Davis. “For those reasons, many radiology enterprises have moved completely away from ‘snail mail’ when it comes to communicating results or asking for protected health information.”
Only slightly less risky is email, and for essentially the same reasons that surface mail is risky—there is no guarantee it will be delivered to the right person or seen by only the right person in the event it arrives at the right address. Davis says there is a way to make email less risky.
“Many of my radiology clients in just the last year have switched from conventional email to encrypted email,” he says. “When an encrypted email is sent, the recipient receives a link to the sender’s system and must log into that system to read the actual email message. This approach prevents viruses from forwarding email to unauthorized recipients. It also prevents someone who may have access to the recipient’s emails—such as a spouse or coworker—from opening and reading it.”
The risk is much more manageable when communication occurs by telephone. Still, phone conversations may pose liability threats because the radiologist cannot be 100% sure the person he or she called and intended to speak with is in fact that same person, unless the radiologist is familiar with his or her voice from prior encounters, says Davis.
Ordinarily, one of the least risky channels of communication is the password-protected, secure-encryption online portal. Barring attacks by sophisticated hackers and absenting other foreseeable acts beyond the reasonable control of the portal operator, no one but the patient is likely to be able to see the content of communication between him or her and the radiologist, says Davis.
Least risky of all, says Davis, is the face-to-face conversation that takes place far from prying eyes and ears. “Either the exam room or the radiologist’s private office are ideal for this purpose,” he says.