Communication

Direct Reporting to Patients and Patient Portals

The written radiology report has largely been a private communication between the radiologist and the referring physician. Although patients have never been legally denied access to their medical records, barriers to their access have been constructed, whether for fear of delivering records into the hands of a plaintiff’s attorneys, over concerns that patients will find errors or admissions of uncertainty in reports and lose confidence in radiologists, or for fear it will start to shift the lopsided balance of the physician-patient relationship away from the physician. Until the passage of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which explicitly guarantees patients the right to their own health information, little consideration was given to increasing transparency in reporting. Since then, it has become progressively more common for radiologists to communicate results of diagnostic imaging examinations directly to patients. This trend has been fueled by a number of factors, including a national healthcare organization initiative (The Joint Commission National Safety Goals), various judicial rulings, professional society guidelines (American College of Radiology Practice Parameter for Communication of Diagnostic Imaging Findings [ACR PPCDIF]), the modish philosophy of patient-centered care, consumerism, and entrepreneurial radiology practice. Perhaps the most important driver of the trend toward direct reporting is the Mammography Quality Standards Act (MQSA), a federal mandate passed on October 27, 1992, as a result of efforts to encourage greater access to quality mammography. A provision therein mandates that “a summary of the written report shall be sent directly to the patient in terms easily understood by a lay person.” Furthermore, “facilities must provide a summary of the results of the mammographic examination written in lay terms to all patients within 30 days.” Although MQSA is perhaps the most significant legal mechanism enshrining the practice of greater transparency in radiology, the most significant practical tool has been patient use of online portals, which are electronic applications managed by healthcare providers that give patients access to their medical records through the Internet. The development and spread of online portals can be traced to advances in information technology and to initiatives such as patient-centered care, which encourage patients to more actively engage in their own healthcare decisions. The Joint Commission explicitly encourages patients to participate actively in their own healthcare through patient portals and has accordingly required hospitals to encourage patients to use them; to this end, in order to be in compliance with federal mandates for meaningful use of the electronic health records (EHRs), hospitals must prove that a minimum of 5% of their patients are using web-based access to their medical records. Although some critics of online patient portals have suggested that their use will prompt a greater number of phone calls directly to radiologists to discuss findings in their reports, early experience has not shown this to be the case.

Although advances in information technology, illustrated by the proliferation of web portals, is partly responsible for improvements in communications between radiologists and patients, a synergism of multiple external forces has driven radiology departments in recent years to improve the quality of their services. Although clinicians have long valued clarity, pertinence, and brevity in the written radiology report, new technologies in electronic data transmission have created an expectation of prompt reporting of findings. In this vein, ACR PPCDIF section I states that “quality patient care can only be achieved when study results are conveyed in a timely fashion to those responsible for treatment decisions.” Especially at clinics at tertiary care centers to which many patients travel long distances for their appointments, it has become a common practice for patients to schedule their clinic appointments with their doctors within hours of their imaging examinations, thus placing greater pressure on the radiologist to communicate findings immediately.

Just as electronic data transmission has fueled tougher, if not qualitatively better, standards for timeliness of reporting, the quality of the radiology report has also come under greater scrutiny through increased patient access to reports via web-based portals. Studies show that patients are more critical than physicians of typographical errors, grammatical errors, sensitive topics, word selection, clarity, and overall organization. Inconsistencies such as right/left transposition and oversights such as failing to amend the default macro are common pitfalls, and while another physician who better understands the context of such errors might easily forgive them, these sorts of mistakes can be viewed by a patient as careless. A patient who sees an error-laden and disorganized report may lose confidence in the radiologist or even in the institution. The inevitable extrapolation that a sloppy report is the product of a harried, detached specialist understandably undermines confidence in the radiologist’s work. Accordingly, serious medicolegal liability can result from patients’ access to reports that contain such inaccuracies; plaintiff’s attorneys may exploit a report with uncorrected errors and inconsistencies to portray the radiologist as inattentive and uncaring. The heightened expectations of quality incurred by greater transparency in reporting must be balanced against demands for greater productivity.

Although the legal implications of greater transparency deserve serious consideration, initial concerns that increased patient access to reports would increase the frequency of malpractice suits by effectively handing over a “blank check” to the trial lawyers has not translated into higher legal costs for most institutions. Acceptance of accountability, in fact, appears to mitigate patients’ negative feelings. In 2001, the University of Michigan Health System (UMHS) adopted transparency and disclosure as its comprehensive claims management model, offering patients “the facts, a sincere apology, a commitment to prevent the error from recurring, and fair compensation” for harmful medical errors. The UMHS experience with error disclosure and transparency with patients and their families showed a decrease in the number of filed lawsuits, decreased time from claim to resolution, lower costs of compensation, and a reduction in legal costs. However, there is perhaps no stronger argument for reporting results of all radiologic examinations directly to patients than the byproduct of MQSA. Since the passage of the act, lawsuits alleging delay in communication of significant findings on mammography have been virtually eliminated.

The traditional method of communication of test results to the patient, which is for the referring physician to call or speak in person with the patient, is still preferred by most patients. In addition to understanding patients’ preferences of how and which physicians relay examination results, it is important to consider how physicians might interact with patients and which physicians are most qualified to do so. To this end, the Radiological Society of North America (RSNA) campaign Radiology Cares promotes patient-centered culture within a radiology practice by assisting radiologists in becoming more comfortable with interacting with patients. However, even if radiologists were to receive training to minimize their discomfort in discussing results with patients, systems do not currently exist to accommodate this change in the workflow. Besides the overwhelming operational complexities of systematizing radiologist-patient interactions, any theoretical benefits could scarcely justify the expense incurred by loss of radiologist manpower. A radiologist’s breadth of training would need to expand considerably to ensure he or she was qualified to answer any questions a patient might ask about the management of a problem uncovered by the radiologic exam. Furthermore, radiologists would, in addition to producing the written radiology report, also need to document what advice they rendered, which would incur both a significant time drain and additional legal implications. Besides these logistical complications, serious underlying ethical questions arise when considering whether to more systematically integrate the radiologist into the patient experience. In other words, the gradual shift toward the practice of unrestricted and immediate patient access to radiology reports through portals raises the question of to whom the report is, and should be, directed: the patient, the referring physician, or the medicolegal record.

Although one might look to MQSA for guidance on this issue, the precedent of directly reporting results of screening mammography to patients is not analogous, because MQSA was a federal mandate and not a unilateral move by the radiology community to encroach upon the domain of the referring physician. A few progressive radiology practices have taken the step of giving patients preliminary results of their examinations on site before they leave the imaging center. A few groups who do provide this service give the patient the option to receive preliminary results. Referring physicians who request that the patient not be given preliminary results on site may do so for a variety of reasons. Many referring physicians maintain that it is their privilege and duty to relay results to their patients; a few do it for disingenuous financial purposes, but many do so because they believe their knowledge of the patient’s problems, health history, and other ancillary studies best qualifies them to discuss the findings. Another criticism that referring physicians have of direct reporting by radiologists is that the patient may call the office to discuss the radiologic examination findings before the referring physician has even received the report. A simple solution to prevent the patient from viewing the results of his or her examination before the referring physician has had a chance to read the report is to impose an embargo of several days before the patient can gain access. The exception to this is mammography results (which the radiologist is legally bound to provide to the patient within a specific time frame). Furthermore, the complexity of the examination can tip the balance on the question of who is best qualified to explain the results to the patient. In either case, the medical professional must strike a balance between creating unneeded patient anxiety over observations that are likely to be incidental, benign, or of no clinical significance and alerting the patient of the need for follow-up on a finding that has a small risk of being a cancer. Adherence to guidelines published in the ACR white papers on incidental findings on computed tomography (CT) and following the guidance provided through clinical decision support (CDS) offer some degree of medicolegal protection on this front.

Although diagnostic imaging examinations are usually ordered by physicians or other healthcare providers with the expectation that the examination will answer a clinical question, issues with direct reporting also arise when patients are self-referred or referred by a third party, such as by a prospective employer or an insurer. In these cases, a direct communication between the radiologist and patient is necessary; on this point, the ACR PPCDIF states,

Interpreting physicians should recognize that performing imaging studies on self-referred patients establishes a doctor-patient relationship that includes responsibility for communicating the results of imaging studies directly to the patient and arranging for appropriate follow-up.

Although sometimes the pretest probability of a serious disorder is low, and the examination is ordered only with the intent to reassure the patient that a serious medical condition does not exist, the ACR PPCDIF says,

Regardless of the source of the referral, the interpreting physician has an ethical responsibility to ensure communication of unexpected or serious findings to the patient. Therefore, in certain situations the interpreting physician may feel it is appropriate to communicate the findings directly to the patient.

Nonroutine Communication

Although direct reporting and patient portals deal with more routine communications between radiologists and patients, there are circumstances in which the duty of the radiologist extends beyond interpretation, dictation, and signature of the final report. Findings on medical imaging examinations that demand immediate medical attention place moral and legal obligations on the radiologist to make direct contact with a patient. The ACR PPCDIF states that the following situations may warrant nonroutine communication:

• 1.

  Findings that suggest a need for immediate or urgent intervention. Generally, these cases may occur in the emergency and surgical departments or critical care units and may include such findings as pneumothorax, pneumoperitoneum, or a significantly misplaced line or tube. Other urgent conditions typically included in “critical values” categories in most healthcare institutions would also be included in this group.

• 2.

  Findings that are discrepant with a preceding interpretation of the same examination and where failure to act may adversely affect patient health. These cases may occur when the final interpretation is discrepant with a preliminary report or when significant discrepancies are encountered upon subsequent review of a study after a final report has been submitted.

• 3.

  Findings that the interpreting physician reasonably believes may be seriously adverse to the patient’s health and may not require immediate attention but, if not acted on, may worsen over time and possibly result in an adverse patient outcome. For example, acute infectious processes, possible malignant lesions, or other unexpected findings that may impact patient care if not treated in a timely fashion would fall into this category. This may be particularly applicable when there is a potential break in the continuity of care (such as can occur in emergency department encounters or the outpatient setting) that is unexpected by the treating or referring physician.

In situations where nonroutine communication is necessary, logistical obstacles often arise. Berlin noted that contacting the referring physician concerning urgent or unexpected findings is not always possible; offices may be closed by the time the study is interpreted; phone calls are answered by an answering machine; the patient may receive medical care from more than one physician or at a clinic with rotating physicians or physician extenders; or the name of the ordering physician may not be listed. Although they demand greater time and effort, in these instances it is appropriate for the radiologist to disclose the results of the examination directly to the patient. This duty to disclose has since been reiterated in revisions of the ACR Practice Parameter for Communication, and adherence to these guidelines reduces the chance of malpractice litigation and reinforces quality medical care. The ACR and judicial rulings clearly indicate that it is incumbent upon radiologists to relay significant findings to referring physicians, and this duty has been increasingly extended to include a duty to inform patients as well.

In addition to nonroutine and direct communication with patients, communications that are not part of the final report but are important for medical and legal purposes may be documented by way of digital “sticky notes.” Examples include preliminary reports by residents; documentation of communication of emergent findings in emergency department, trauma, or critical care patients before the examination is viewed in its entirety and a final report submitted; two-way communication with technologists; flagging cases for performance improvement and quality measures; and posting memos to radiologist associates that supplemental information pertinent to the case is available.

Informal Communication

Radiologists’ work does not just involve cases in which the radiologist is officially consulted. In fact, radiologists are commonly asked by their nonradiologist colleagues to render curbside consults, which often take the form of an outside examination that is rendered for unofficial review; in these cases, the examination technique and quality are not controlled by the consulted radiologist; the viewing conditions may be less than optimal; and the clinical information may be incomplete. Many practices do not have a mechanism for the radiologist to document the communication from these encounters, and consequently these situations are replete with (legal) traps for the radiologist. The ACR Practice Parameter II.C.3. states,

Informal communications carry inherent risk, and frequently the ordering physician’s/health care provider’s documentation of the informal consultation may be the only written record of the communication. Interpreting physicians who provide consultations of this nature in the spirit of improving patient care are encouraged to document those interpretations. A system for reporting outside studies is encouraged.

Commercial vendors have developed systems to archive data from varied sources and integrate these studies with the institution’s picture archiving and communication system (PACS). With a system in place, reports can be generated, accurate and timely communication can be documented for optimal patient care and for legal protection, and codes can be applied for billing of second-read consultations.

Costs of Poor Communication

Lack of effective communication, whether formal or nonroutine, can have serious consequences in both human and financial terms. Data on the medical implications of poor communication has been collected by the Joint Commission, a not-for-profit organization founded in 1951 that evaluates, inspects, and accredits healthcare organizations in the United States. Since 2002, the organization has published an annual list of National Patient Safety Goals, and improvement in communication among caregivers has been on the list every year. Communication is the primary root cause of serious injury or death related to a delay in treatment; the second largest contributor to sentinel events arising from op/postop complications, transfer-related events, unintended retention of foreign objects, and wrong-site, wrong-patient, wrong-procedure incidents; and the third leading root cause overall. Aside from the material harm to the patient, the financial costs of poor communications can also be significant as a result of prolonged length of hospital stays, more expensive and/or prolonged care, lower reimbursement, lower patient satisfaction scores, and damaged institutional reputation. Inefficiencies in communication waste an estimated $12 billion a year, according to Agarwal, and increased length of stay accounted for more than 50% of that amount.

The Physicians Insurers Association of America, an association of physician- and dentist-owned or operated medical malpractice liability insurance companies, has also collected information on the legal implications of poor communications in radiology. In a survey of its 56 member companies in 1997, in which it collected data on more than 150,000 claims, communications errors were the fourth most frequent primary complaint against radiologists. In 10% of claims, the radiologist failed to send the report to the appropriate physician or patient, and in another 10% the delivery of the report was delayed and “directly affected the outcome of the case 75% of the time.” However, the most significant breakdown in communication in almost 60% of the claims occurred when the radiologist did not notify the appropriate referring physician of “urgent or significant unexpected findings.” The Healthcare Information and Management Systems Society (HIMSS) reported that in 2009, 75% of malpractice cases at Yale-New Haven Medical Center are communication related. These statistics underscore the serious moral, legal, and financial imperatives of efficient formal and informal communications.

Key Steps in Communication

A helpful framework for considering an effective communication process in radiology is critical to quality care. Thomas H. Berquist, editor-in-chief of the American Journal of Radiology in 2009, described four major steps in the process of communication:

• 1.

  The first step pertains to the appropriate imaging examination to answer the clinical question posed by the ordering physician. Appropriateness criteria based on evidence should be readily available to the referring physician when selecting the optimal imaging examination, but the choice of exam or technique of the examination may be modified by pertinent clinical information that may not have been provided to the radiologist.

• 2.

  Berquist’s second step in good communication pertains to “a shared responsibility among the referring physician, patient, and radiologist to be certain the patient understands the examination and any potential risks.” Situations in which a patient refuses a scheduled examination because the risk of the examination was not explained in advance, or in which the patient could not undergo the examination because he or she was not adequately informed of the necessary preparation for the examination, can largely be avoided.

• 3.

  The third step involves effective communication between the radiologist and technologist to ensure that the correct views, imaging planes, or sequences are obtained to maximize the likelihood that the examination will be of good diagnostic quality.

• 4.

  Berquist’s fourth step to good communication provides for alternatives to routine communication in cases where a delay can result in inappropriate, ineffective, or delayed treatment of significant findings. As telephone contact is not always successful, radiologists must use alternative methods to make contact and document confirmation that a responsible healthcare provider has received a report of the findings.

Critical Test Results Management

Critical test results management (CTRM) is an area in which closed-loop communication has become essential. Critical results include findings such as pneumoperitoneum, pneumothorax, and a significantly misplaced tube, which are findings from tests and diagnostic procedures that fall significantly outside the normal range and may indicate life-threatening situations. The radiologist’s objective, therefore, is to provide the designated caregiver with the test results within a specific window of time so that the patient can begin treatment. Underscoring the particular importance of swift and accurate communication in relaying these findings to the appropriate individuals, The Joint Commission (an accreditation organization) and the American College of Radiology (ACR) have developed guidelines for communication of these time-sensitive findings. The Joint Commission requires hospitals to implement procedures for reporting critical results and evaluating the effectiveness of the procedures, although definitions of critical results and the acceptable length of time for a report to reach an actionable provider are left to each healthcare institution. There are no national standards for reporting time of critical results, and the definition of a critical result remains the discretion of each institution. One method adopted by some institutions to stratify abnormal findings is to color-code alerts, analogous to the Department of Homeland Security threat levels. Red alert signifies an immediate life-threatening condition, requiring notification of a caregiver within 60 minutes. Orange alert applies to conditions that, if not treated urgently, may increase morbidity and mortality, for example, acute diverticulitis. A yellow alert designation applies to conditions that do not require urgent attention or action but may lead to increased morbidity/mortality, such as a small pulmonary nodule. Recognizing the labor-intensive process of finding an actionable individual and its negative impact on radiologist productivity, vendors have developed automated solutions to CTRM. Current communication methods such as landline telephone, mobile telephone, fax, email, text messaging, and instant messaging have increased the options for communication, but none guarantee that the message has been received and understood by the intended individual.

The ACR’s IT Reference Guide for the Practicing Radiologist states the following:

It is important for each participant in patient care to know that information sent has been successfully received and understood by the intended recipient. This is called “closed-loop communication” because the information is first sent out on one leg of a hypothetical loop to its intended recipient, and then a message returns back to the originator, confirming that the information was received. Confirmation of receipt and understanding is easy when communication is synchronous (i.e., both participants involved in the communication physically participate in the activity at the same time via telephone, online meeting, etc.), but when communication is asynchronous (e.g., e-mail) and separates participants in space and time, confirmation of successful communication may be more difficult. Additionally, permanent documentation of successful and timely communication is often critical for medicolegal and quality assurance activities, despite the challenges of asynchronous communication.

CTRM solutions use advanced technologies to streamline communication between parties and document verification of receipt of critical test results (CTRs). Berlin strongly cautions that:

Once a radiologist decides that a finding needs a telephone report, he or she must continue efforts to reach the referring physician or an acceptable alternate to complete the communication. Terminating attempts at communication because the referring physician is not easily available…places the radiologist in greater medical and legal jeopardy than not having attempted to telephone in the first place.

Escalation tools built into automated systems bypass the inefficient process of humans trying to contact the clinician by alternative methods or finding an alternate clinician responsible for the patient’s care. Automating the process of closed-loop communication has many benefits: improved patient safety, savings of time and resources, and more precise documentation. Messages are tracked and stored in compliance with ACR PPCDIF II.C.2.c, which recommends that:

…non-routine communications be handled in a manner most likely to reach the attention of the treating or ordering physician/health care provider in time to provide the most benefit to the patient. …There are other forms of communication that provide documentation of receipt that may also suffice to demonstrate that the communication has been delivered and acknowledged.

Automated closed-loop systems, which document confirmation that the message was received, ensure compliance with Joint Commission and ACR guidelines for communication of CTRs, thus lowering the risk of liability. Time stamps on communications facilitate monitoring of organizational compliance and quality performance.