January 2017

Door to the Future?
By Jeannette Sabatini
Radiology Today
Vol. 18 No. 1 P. 20

Patient portals may open a path to a more direct role in patient care for radiologists.

Patient portals allow patients to view their personal health care information, get feedback on that information, and do other clerical tasks, but they can't help a patient prove his worth in his workplace. They can, however, help radiologists prove theirs, and that is good news in a coming age of value-based care. Radiologists will be able to leverage patient portals as a means to improve and add value to patient care—as well as their position within health care—by interacting with patients who use them, a duty that is now most often handled by referring clinicians. Yet, in order for that opportunity to open up, radiologists will need to work with their clinical and IT colleagues and vendors to discuss issues such as technology, management, content, and communication to guarantee the implementation of portals that patients will actually use.

"Radiology reports and images are key to care for many patients in myriad scenarios. These reports are often released to patients shortly after they get their scans, and easy access via portals and apps adds a convenience factor for patients. However, beyond mere convenience, we should look at this as an opportunity to communicate with and educate the patient and to be available to the patient who may have questions and concerns," says Rasu Shrestha, MD, MBA, chief innovation officer at the University of Pittsburgh Medical Center (UPMC) and executive vice president at UPMC Enterprises, the commercialization arm of this integrated health care provider and insurer. "As we propagate principles of value-based care, engaging patients more directly in their care, ensuring better compliance, improving satisfaction, and addressing needs that may contribute to better outcomes may all become critical aspects of the 'new norm' for radiologists."

Clouds in the Forecast
Patient portals are empowering patients to access their own data from EMRs and other clinical information systems, such as imaging and labs, Shrestha explains. They also are enabling patients to receive e-mails and reminders, make appointments, refill prescriptions, and pay bills.

Yet, "the ability to even access radiologic images on portals varies," says Eric Rice, chief technology officer at Mach7 Technologies. "Many of the portals and image sharing solutions in the marketplace right now can only handle the standard radiology images. A robust solution … that can manage/display any piece of unstructured clinical data, including any type of image, document, video, and more, is what is needed," he explains.

At Stanford Children's Health in Palo Alto, California, patients still get their images on a DVD or CD, "but we are working to change that," says Safwan Halabi, MD, a pediatric radiologist and director of imaging informatics at the facility. "We are still utilizing solid media to store and distribute imaging right now, but we are moving toward a cloud-based solution."

That solution is provided by cloud image management vendor Ambra Health. "Ambra's cloud is the keystone technology we are using for everything from CD ingestion to developing electronic portals for not only patients but [also] our referring hospitals and physicians that refer patients to us," Halabi says. "Access to the cloud solution allows our physicians to upload patient images and view those images on any web browser without worrying about installing programs or image viewers on their computer."

"Cloud technology is the key to succeeding at value-based care," says Morris Panner, JD, CEO of Ambra Health. "As value-based care becomes a bigger force in American health care, radiologists need to develop a business model that reflects their contribution in that new world. As radiology moves from fee-for-service, which has been a very successful business model, to value-based care, patient portals and flexible cloud-based approaches to imaging are the technical lifeline for the modern radiologist."

Panner believes cloud technology will facilitate data access, which will free radiologists from a system that ties him or her down in the reading room. "Cloud technology breaks down the silos of the on-site PACS and the on-site storage architecture that keeps radiologists isolated from patients and other physicians."

Professionals need to work in a secure environment, however. "The cloud allows me to collaborate over the internet in a secure environment," says Kevin W. McEnery, MD, a professor of radiology and director of innovation in imaging informatics at Houston's M.D. Anderson Cancer Center.

Panner adds, "Users want to make sure they are secure and compliant."

Engaging Patients?
Many portals already provide a means for patients to access their data on a mobile device, including the Mach7 Clinical Portal, which can run on any HTML5-compliant browser, such as a smartphone, laptop, or tablet, Rice says. Likewise, in October 2016, Westmed Medical Group in Kirkland, Washington, reported that it has partnered with Bridge Patient Portal and adopted the new mHealth App Platform developed by Medical Web Experts that will allow patients easy access to all information from an iOS or Android device, according to a Westmed release. The portal and the app interface with the GE Centricity Business and EMR products that existed at Westmed. Centricity 360's Case Exchange and Centricity 360 Physician/Patient Access are applications that allow users to securely login and share patient images and documents with other users.

At present, radiologists do not have a leading role in interacting with patients who view portals; yet, when value-based care hits, those who are comfortable in isolation will need to come out from it, professionals agree. "Patients still heavily rely on the primary care provider to communicate the significance of clinical test results and to clarify results," McEnery says.

But that role won't stand, Shrestha says: "Today, there's a minimal interaction between a radiologist and a patient, but this will change."

Fortunately, Panner says, most radiologists appreciate the need for patient engagement. "Many believe that the more engaged patients are, the better off they are," he says. "Patient engagement dramatically reduces bad outcomes and readmissions as patients take a more proactive role in their own care."

Nevertheless, some radiologists are not ready to bring patients into the loop of care, Halabi explains. "There is one camp that wants to maintain the 'doctors' doctor' relationship, where radiologists are reporting and interacting with referring providers, but I think that there is another camp that realizes that staying in the reading room and not interacting with patients may not be beneficial or add value to patient care or the practice of radiology."

In addition, some patients hesitate to use portals because they'd rather not get involved. "There are other patients that say, 'Just tell me everything that is going on and/or I need to do,'" he says. "I am seeing a shift to more patients that would prefer to have all their medical information, including images, available to empower their medical decision-making."

On that note, radiologists are among the professionals with questions concerning the content of patient portals. Rice suggests: "Patient portals should provide access to engage the patients, from structured patient demographics including medications, allergies, clinical history, and lab reports to unstructured imaging data and reports from departments such as radiology, cardiology, dermatology, and more. A true patient portal should not be focused on a single department or only the structured data from an EMR but rather consolidate the PHR [personal health record] across all departments, which includes both structured and unstructured clinical data."

"A lot of it is unknown territory," Halabi says, referring to content decisions. "Some clinicians want to protect the patient and not reveal everything that is happening in real time, and then there is a whole side of medicine—particularly the younger generation of physicians—that thinks everything should be released to empower the patient. These types of decisions require thoughtful discussion and an institutional buy-in."

Halabi says, although many health care organizations are developing content strategies that include medical imaging, sharing any imaging content is raising concerns at some facilities. "There is a fear that we are going to get inundated with phone calls, that clinicians are going to have to do more work, and [that there will be] discrepancies over calls on imaging and how clinicians handle them," he notes. "There are very sensitive issues that need to be worked out. The goal is to provide the highest level of care while respecting the rights and preferences of patients and providers."

"A potential negative impact includes patient worry induced by a positive finding that either does not require follow-up—renal cyst, [unidentified bright objects], etc—or may or may not require follow-up depending on the clinical condition of the patient," offers Chris Deible, MD, PhD, medical director of radiology informatics at UPMC. "This may lead to extra time in follow-up discussions with referring physicians to explain findings they otherwise would not have mentioned or, alternatively, may lead to additional exams or follow-up."

To reach solutions to such issues, radiologists and other disciplines must work together, suggests Halabi, whose facility hosts multidisciplinary and informatics meetings on patient portals. "There is a significant range of opinions," he says. "Every specialty is represented. We have a very strong electronic health record group and clinical informatics group. We have learned that technology doesn't drive the solution or the strategy; it's clinicians that understand the technology that can make the biggest impact on health care delivery."

Beyond Access
"With the shift to value-based reimbursements, there will likely be a greater integration of reports and images with a greater proportion of multimedia reports or alternative report delivery mechanisms available to assist both the clinician and the patient in better understanding the status of their disease process—informed by ordered imaging studies," McEnery says. "It is reasonable to expect that vendors will develop clinical content support applications, hosted by patient portals, which will help the patients understand the results of their examination."

Radiologists and their facilities also should consider the promotional value of portals, Halabi says. "Going to a value-based proposition, I think patients will flock to those types of centers that provide the tools to empower them."

Rice adds, "As insurance plans are moving to higher deductible plans, patients are putting more thought into where and by whom medical procedures are performed. Patients are beginning to shop. As patients shop, choosing a health care facility that offers digital access to their PHR may be a factor in the patient's decision process. Having access to their PHR may enable a more meaningful treatment discussion with their local general practitioner or with a specialist across the country. The ability to share medical data with family caregivers who live in a distant city is important for patients to feel supported with treatment plan decisions. Even the ability to simply share a baby ultrasound with distant family can have a huge positive impact on the patient experience. As the patient population continues to grow in an age of technology, PHR access will be a necessity for the business success of health care facilities."

"Adopting innovation is really the challenge," Panner adds. "Like so many other industries, if you fall behind, you are going to have trouble competing."

Meaningful use places requirements on patient portal use, as well. "Meaningful use requires eligible providers to provide a portal through which patients can view medical records. It is required that 50% of patients be granted access to the portal, and 5% of patients actually access EHR data in those reports," Deible explains.

Facilities have concerns that they will do a lot of work to establish patient portals that patients won't even use, yet studies out of the University of Washington revealed that "patients are reading their reports, including the detailed findings, sometimes even before their ordering physicians read them," explains Christoph Lee, MD, MSHS, an associate professor of radiology and adjunct associate professor of health services at the University of Washington. "We were surprised to see that more than one-half of patients were viewing their radiology reports through their patient portals, which is more frequent than their actual clinical visit notes. This is important to highlight as, historically, the audience for our reports have been the referring physicians."

The cross-sectional study, done in 2014, assessed 129,419 patients who had online patient portal access in the University of Washington health system in 2014. "By looking at associated sociodemographic characteristics, we found that traditionally underrepresented and vulnerable populations [eg, racial/ethnic minorities and the elderly] are the least likely to access their radiology reports, potentially leading to lower patient engagement in care," Lee says. "Overall, this analysis has serious implications for what we report, how we phrase our findings, and who we should be directing our communication towards."

Since the study, many more patients in the health system have access to radiology reports, laboratory reports, and clinical visit notes," Lee says. "We are beginning to see some more direct communication from patients regarding their imaging findings."

"Beyond access, some patient portals are enabling data to be shared via secure web technologies. Sharing capabilities of the consolidated PHR can provide health care providers the complete medical history for a patient," Rice explains. "For years, our industry had the desire for an ATM-like card to access the patient's complete medical record. The day is quickly approaching where we may simply leapfrog that card and enable patients with their mobile devices to transfer medical records."

"With advances in technology and evolving needs for patients, it is critical for institutions to ensure that access to patient data gets easier, that patients have access to more data, and that this data is presented in a meaningful way, so as to inform and engage the patient," Shrestha says. "An informed patient is a compliant patient. This can directly lead to better care outcomes."

— Jeannette Sabatini is a freelance writer based in Malvern, Pennsylvania.