Best Practices for Patient Engagement
The patient is the center of the healthcare universe, and imaging departments and practices are working ever harder these days to prove patient-centeredness is their No. 1 mission, while the American College of Radiology’s (ACR’s) Imaging 3.0 campaign strives to improve patient engagement
With the help of the folks at ACR, the Health Imaging editorial team collected piles of electronic nominations for the inaugural Patient-Centric Imaging Awards. We were thoroughly impressed with the myriad creative and detailed projects to address the challenges of patient engagement in imaging.
The projects run the gamut from department re-design to communication to image sharing. However, some common themes stand out. Each organization identified and focused on a specific problem at their institution. They engaged multiple stakeholders, including patients, and ensured referring physician buy-in. They measured results and, most importantly, approached their project as a process rather than a product.
Read on to learn more about these projects, as told by the stakeholders themselves.
Cincinnati Children’s Hospital Communicating Difficult NewsCincinnati Children's Hospital main campus.
Background: Radiologists are often tasked with making life-changing diagnoses. In the past, we would dictate a report and call the referring provider. The patient and family would talk with the physician hours or days later and then return to the hospital to initiate therapy.
Objective: The radiology department sought to create a defined process for communicating difficult news directly to a patient or family.
Methods: Difficult news guidelines were created to address the needs of all stakeholders. When radiologists initiate the process, they first contact the referring provider, notify him or her of the findings and ask how the results should be communicated. The ordering provider has the option of in-person communication, phone communication with the radiologist in the room to help answer questions or results delivery by the radiologist.
A non-physician point person is designated to help patients and families by moving them to a multipurpose room if needed, transcribing notes, checking on the patient and interacting with young patients or siblings while results are discussed with parents.
The radiologist or ordering provider reviews the findings with the family, answers questions and discusses the next steps. After the conversation, the radiologist helps to coordinate the agreed upon next steps, including further imaging or admission.
Results: The radiology department implemented the difficult new guidelines. All radiologists, technologists and child life specialists attended or viewed a recorded lecture. All radiologists were required to institute the difficult news process at least one time during the course of the year. If the radiologists did not have an opportunity to employ the process, they were required to undergo simulation-based training. Overall, the program has received positive feedback from families, ordering healthcare providers and radiologists.
East West Health Centers/Invision Sally Jobe Breast Network Knowledge is Power: Increasing Awareness about Personalized Breast Cancer RiskRadiology department staff at Invision Sally Jobe
Background: In 2009, Invision Sally Jobe (ISJ) implemented a process by which breast imaging patients were screened for their lifetime risk to develop breast cancer in order to recommend annual breast MRI screening as an adjunct to mammography. Personal and family history characteristics also were checked to indicate the need for a genetic counseling consultation. Personalized recommendations were communicated to the referring physician via breast imaging reports, but patients were not receiving the information directly.
During 2009, the center saw an increase in breast MRI screening volume and the volume of office visits with its genetic counselor, but the increase was more modest than expected. Additionally, ISJ’s genetic counselor noticed a trend of patients who were unaware of their high risk status and the options available to them, despite this information being communicated to the referring physician via the breast imaging report. At the same time, the idea of direct-to-patient communication about breast density was gaining support in certain states.
Objective: ISJ saw an opportunity to involve patients more extensively in the decision to consider breast MRI screening and/or genetic counseling.
Methods: In the summer of 2010, ISJ created a template letter that could be personalized for each patient. It includes information about the recommendation for genetic counseling, the recommendation for breast MRI screening or both. The language is carefully worded so as not to alarm patients but strong enough to encourage them to take action. A subset of high-risk patients was surveyed and provided feedback on the wording and implications of the letter.
The call to action in the letter is for the patient to schedule a visit with her referring physician to discuss options. This is based on feedback from physicians about the potential for self-referral, as well as the importance of keeping the patient’s physician involved. Referring physicians were educated prior to implementing the direct-to-patient letters to inform them about the new process and review issues related to genetic counseling and breast MRI screening to increase their comfort with discussing these topics with patients.
Internal quality control processes ensure that letters match the recommendations made by the radiologist in the breast imaging report. This reduces the chance of a patient surprising a referring physician with a question about a recommendation of which the physician was completely unaware.
In November 2010, ISJ began sending personalized letters to patients. Between 600 and 700 letters are mailed per month.
Results: The overall volume of breast MRI screening exams at ISJ increased 47 percent in 2011 vs. 2010. The volume of genetic counseling consultations increased 25 percent in 2011 vs. 2010. In 2011, ISJ collected approximately 10 case reports where breast MRI screening and/or results from a genetic counseling session led to the diagnosis of a breast cancer that would likely have been missed without those interventions.
Through the systematic breast cancer risk assessment process, ISJ identifies approximately 3 percent of its breast imaging patients as annual breast MRI screening candidates and approximately 9 percent as candidates for genetic counseling. The process reaches about 7,400 patients annually.
ISJ has submitted an IRB application for a clinical research study to further analyze the effect of the direct-to-patient letters on compliance with risk-related recommendations, as well as the clinical outcomes for patients who receive the letters.
Georgia Regents Medical Center Implementing of Patient-and Family-Centered Care Practices in RadiologyMammography workstation at Georgia Regents Medical Center
Background: In the past, radiology primarily focused on daily workflow demands. Planning and construction decisions, including new imaging equipment selections, were made without the input of those who stood to be the most affected—our patients. Not surprisingly, patient satisfaction scores were low. Mammography ratings fell in the 40th percentile range.
Objective: The radiology department sought to increase value for patients and their families by incorporating patient- and family-centered principles into its daily operations and put the patient and family in the center of the care model.
Methods: In 2001, the project started with mammography. An interdisciplinary design team that included patients was formed to renovate mammography and improve the patient experience. Some patients had their screening mammograms at our institute; some were breast cancer survivors; others never had gotten mammograms.
The mammography experience was re-designed from a patient and family perspective and emphasized bringing value to the patient. Every step from registration to mammography to biopsy to recovery was re-evaluated from this perspective.
The multi-iterative process occurred over months and was complete when all stakeholders signed off on the proposal. Since the 2001 renovation, all other equipment installations and renovations in radiology include patient advisors at the design table. Our patients have become our partners.
With improved access to mammography, we addressed other barriers for our patients. Grant funding was obtained to encourage and support mammograms for indigent patients. A “Walk-in” Friday program for employees was created on the first Friday of every month, allowing employees to arrive unannounced and be screened immediately.
Results: Our embracing of patient- and family-centered care principles and bringing patients into the discussions has had many benefits for patients as well as the department. Our mammography backlog was eliminated while our volume and patient satisfaction scores increased. Our patient satisfaction scores in mammography jumped more than 30 points and surpassed the 90th percentile, which has been sustained. In other sections of radiology, patient satisfaction scores also increased and generally average in the 90th percentile range or above. Other results include:
Radiology has served as a training site for patient- and family-centered care;
Radiology took a leading role in patient satisfaction and developed web training tools used by all departments (see www.xtranormal.com/watch/14111056/physician-orientation-to-hcahps);
- Radiology became the only department with two members (one faculty and one resident member) on the enterprise-wide Quality Operations Council;
- Decrease in contrast extravasations;
- Reduction in patient falls;
- Positive impact on our mammography patients; and
- Faculty members have lectured nationally on patient- and family-centered care
Given our annual volume and the number of pieces of equipment we have replaced, we estimate that more than one million patients have been positively impacted by radiology’s implementation of patient- and family-centered care.
Radiology Ltd., Tucson, Ariz. Clinical Review & Protocol ProcessRadiology Ltd., Tucson, Ariz.
Background: Despite an extensive footprint, high degree of technical sophistication and 75-year history, our nine-site, physician-owned practice faced challenges similar to every other imaging center. Patients were becoming increasingly impatient, a finding confirmed by observation and patient surveys showing room for improvement in two areas: wait time and explanation of the exam.
Objective: Radiology Ltd. sought to identify and address the root causes of lengthy patient wait times and the lack of satisfaction with exam explanation.
Methods: As practice leadership examined the issues, we realized inefficiencies were increasing the amount of time technologists spent solving issues instead of scanning patients. Techs did not have enough time to review procedures in full detail to ensure every patient’s exam was performed on the day and time originally scheduled. The investigation also revealed patients often required rescheduling because reports or labs were not received, wasting valuable time and casting a cloud over the patient experience.
Armed with these insights, Radiology Ltd. devised a multi-faceted plan consisting of workflow changes, technology tools and an innovative mindset. Three distinct, related undertakings included: a clinical review project, a new protocol process and a patient portal.
The clinical review project partnered several seasoned techs with the scheduling team to establish a procedure that all CT, MR and PET patients’ records would be reviewed at scheduling to ensure the right data were collected.
The same techs also initiated a new protocoling process and scheduled the appointment, ensured all relevant data were included in the file and sent the file to the radiologist. The radiologist then dictated the protocol as a report. At the time of the procedure, the tech reads the report and follows the protocol. Because the technologists no longer had to research or protocol exams, exams started on time and the techs had more time to spend with the patient and explain procedures.
Patient satisfaction increased as delays and issues were diminished. Many patient surveys expressed appreciation for the explanation of the exam and the timeliness of the appointment.
Finally, a patient portal rolled out in August 2012 allowing patients to pre-register and access results, which has reduced registration time and helped techs stay on schedule.
Results: With seasoned techs pre-screening all CT, MR and PET patients, more patients arrive ready for their procedures. The project is no longer a special initiative but simply a Radiology Ltd. best practice.
Each month, more than 20,000 patient records are reviewed to collect data that would have resulted in a postponed or delayed appointment. The patient protocol process delivered internal efficiencies, freeing up techs to spend as much time as possible with patients. The patient portal expedites patient check in and has reduced check-in times from 15 minutes to one to two minutes.
Radiology Ltd. plans to enhance the project with social media and text messaging for appointment reminders to continue to optimize workflow and increase patient engagement and satisfaction.
University of Maryland Medical Center & University of California, San Francisco RSNA Image ShareAt UCSF, an average of 119 patients enroll in Image Share every month, and approximately 60 new patients sign up weekly at the University of Maryland Medical Center.
Background: As one of the primary diagnostic tools of modern medicine, medical images constitute a key component of the patient’s health record. However, sharing images with patients and healthcare providers when they are outside the healthcare enterprise remains a challenge.
Objective: The RSNA Image Share network pilot project is a five-site endeavor funded by the National Institute of Biomedical Imaging and Bioengineering (NIBIB). It is designed to establish basic infrastructure to promote the exchange of images across broad geographic areas within the U.S. and test the hypothesis that patients can successfully control storage and distribution of imaging exams and reports using an electronic personal health record (ePHR) account. The five participating sites are Mayo Clinic in Rochester, Minn.; The Mount Sinai Medical Center in New York City; University of California, San Francisco (UCSF); University of Chicago Medical Center and University of Maryland Medical Center in Baltimore.
Methods: The project established the image-enabled personal health record, tested and validated the standards-based technical component and tested and evaluated a clearinghouse in the workflow. The objectives included a secure and user-friendly image-sharing solution that was a satisfactory alternative or superior substitute to the conventional physical CD.
Results: The pilot sites calculated monthly rates of patient enrollment and surveyed patients and physicians on:
- Perceived benefits/utility of patient-controlled ePHRs;
- Importance of health record privacy;
- Baseline computer, Internet and social media usage;
- Satisfaction using the Image Share system;
- Satisfaction with the Image Share system’s security; and
- Whether difficulty with access to CD or the Image Share system led to repeat imaging
A total of 1,383 patients, accounting for 5,807 imaging exams, have participated in the pilot project. The patient survey revealed an average satisfaction score of 1.5 (1 most—5 least satisfied), and 95 percent of patients felt the tool was very important or important. Two percent of patients underwent repeat imaging because their physicians had difficulty accessing the system.
At UCSF, an average of 119 patients enroll in Image Share every month, and approximately 60 new patients sign up weekly at the University of Maryland Medical Center.