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White Paper
Designing the Ideal Findings Management Process
Summary
How better patient and provider communications can increase follow-up care.
Whitepaper | Spencer Cross, MBA | Ty Williams
Mr. Cross leads product strategy and development for Change Healthcare’s Digital Experience business.
Mr. Williams is an agile product designer and user experience researcher with a background in product design and business development management for tech startups.
As the name suggests, “incidental findings” are medical findings that are unintentionally discovered during radiological evaluation for an unrelated medical condition. For decades, radiologists reported incidental findings to the patient’s referring physician, who then made the decision as to whether the patient required notification or additional care.
This communication flow has always been problematic, in part because it was never intended to be a closed-loop process. Radiologists are not typically aware of whether follow-up care or patient notification has occurred. In addition, most referring physicians struggle with an overwhelming caseload, which increases the likelihood that test results can be inadvertently overlooked.
Recently, jurisdictions have implemented new regulations requiring radiologists to directly notify patients about their incidental findings. For example, Act 112 in Pennsylvania requires outpatient diagnostic imaging services to notify patients and referring physicians about any significant abnormality within a 20-day time frame.
In reaction to these new laws, some physician groups have expressed concerns that patients might not understand or may misinterpret test results they receive directly. They argue that misinterpreted results will increase patient anxiety and lead to unnecessary testing, further straining an overloaded healthcare system. Despite these fears, legislation centered on improving transparency is on the rise. Proponents believe that patients have the right to know their own medical information, and that giving patients access to this information will help them advocate for better care.
Uncovering Workflow Pain Points
To understand how incidental findings can best be addressed, managed, and communicated to referring physicians and their patients, Change Healthcare conducted multiple rounds of primary research involving empathy interviewing and prototype testing. The research centered on a medium-sized radiology practice’s interaction and communication with referring physicians and patients. Our user experience researchers conducted 60 interview and prototype testing sessions with radiologists, referring physicians, administrators, and patients. The team assessed each group’s pain points and communication needs for incidental findings management.
Radiologists Want to Protect Their Physician Relationships
We found that radiologists are primarily concerned with protecting their relationships with referring physicians. They worry that communicating with patients directly will negatively impact their valuable relationships, chiefly due to timing issues. The radiologists believed that referring physicians would not want them to notify patients about any incidental findings, as patients might besiege their doctor’s office with questions before the physician had fully digested the report.
As a result, radiologists favor a communication flow that allows the referring physician ample time to review the radiology report before patients are notified. Radiologists also believe that physician notifications are more effective if they are sent with or linked to the original report. Urgent significant findings should be communicated by phone, but others can wait for email delivery.
Physicians Want Contextualized Results Within Their Workflow
As the radiologists expected, our research reveals that referring physicians do feel they are operating over capacity. As a result, however, referring physicians are far more appreciative of direct patient communication than radiologists tend to believe. They are appreciative of the idea of radiologists notifying patients in the case of non-urgent incidental findings. They also support patients becoming more proactive in pursuing follow-up care.
Referring physicians want fast, seamless access to a patient’s personal health information (PHI) within the notification of incidental findings. As radiology centers and provider practices often use different patient identification frameworks, quick patient identification is of primary importance.
The ability to conveniently receive, interpret, and assess reports is critical for referring physicians. In the case of incidental findings, they want to be able to understand the seriousness of the radiologist’s recommendation and the associated protocol for patient follow-up—without needing to call for clarification.
Notably, many referring physicians say that integration within their existing system is a prerequisite for active engagement with a new system. Provider offices are wary about adopting a separate alert system for incidental findings, as physicians already face cluttered inboxes. They are sensitive to any administrative processes that can contribute to physician burnout.
Up to two-thirds of patients whose radiology reports advise follow-up care for incidental imaging findings do not receive care.1
Patients Want Clear, Caring Communications with Explicit Next Steps
The radiology patients we interviewed differed in their opinions, but they all shared one priority: the desire for knowledge. Patients believe they have the right to be informed about any reports regarding their own bodies and well being in a timely manner. Patients want to be told about any findings as soon as their report is generated and sent to their physician. While some patients wanted only an overview, others preferred to read the full details of their report.
We found that patients expect to be informed of any findings by the physician who ordered the exam. They value the ability to have a conversation with their physician and ask questions about incidental findings. Despite this expectation, patients generally welcome additional information, explanations, and next-step directions from the radiology facility as well.
Patients also appreciate communication followup that reflects the urgency of the situation. They appreciate communication via their individuallypreferred channels (i.e. text, email, phone). More than anything, patients want to feel as if their health is a priority for a referring physician who will take responsibility for their care and communicate about any necessary treatments.
Lifting the Veil of Uncertainty
Both radiologists and referring physicians are troubled by the current state of incidental findings reporting—most notably, the inability to track completed and pending steps throughout the process.
The radiologists we interviewed do not have visibility into whether their recommendations are followed or even seen. Although critical findings necessitate immediate contact with the ordering physician, the radiologists can only assume that reports for nonurgent findings are appropriately addressed.
Radiologists do not know if their patients were ever informed about their findings by the referring physician, and they have no way of knowing if their patients received follow-up care within the recommended timeframe. This uncertainty creates a sense of anxiety, as they cannot prevent patients from “falling through the cracks.”
Referring physicians also face challenges throughout the incidental findings reporting and communication process, as they often experience immense difficulty making direct contact with reporting radiologists to inquire about details of the report. Referring physicians can easily become trapped in extended phone-tag sessions as they attempt to get in touch with the right radiologist.
Using Design Thinking to Orchestrate a Better Workflow
As the industry examines the current state of incidental findings reporting and debates the transition of notification responsibilities, the needs of all parties—radiologists, referring physicians, and patients—should be thoughtfully addressed. New system designs aim to lift the veil of uncertainty for radiologists, reduce the administrative burden for referring physicians, and empower patients to advocate for themselves.
New system designs aim to lift the veil of uncertainty for radiologists, reduce the administrative burden for referring physicians, and empower patients to advocate for themselves.
After the initial feedback rounds, our researchers applied their findings to a rigorous reassessment of the ideal reporting workflow. They tested a wide variety of provider- and patient-facing communications, including landing pages, emails, and multi-option tracking buttons to confirm message receipt and/or intended actions.
We discovered that referring physicians greatly prefer communications which help to facilitate the patient/provider conversation. When radiology reports are embedded in the message, referring physicians are more likely to fully understand the report summary. Referring physicians also appreciate receiving additional information regarding the patient’s results—such as the clinical significance of common findings, follow-up protocol timing, or a comparison to the patient’s past results—to help rapidly contextualize the recommendation. The inclusion of free text fields helps referring physicians quickly respond to radiologists with any questions.
The researchers also conducted iterative prototype testing and review rounds on the content, tone, and language of patient-facing notifications. Trialed designs redefined the patient’s call to action and accounted for patients’ varying responses.
Researchers learned that direct communication from the patient’s radiologist is generally wellreceived but requires very delicate and precise execution. As patients are not used to receiving specific communication from secondary medical providers, such messages can be cause for alarm. Simple, precise wording works best, especially when coupled with clear directions for next steps.
Exploring patient acknowledgment interactions may facilitate escalation workflow for unresponsive recipients, prompting patients to engage in self-advocacy. We also found that including the referring physician’s contact information within the communication mobilizes patients to take the next step. Data trends of qualitative patient feedback indicate that when consumers believe their physicians care about their wellbeing, they are more empowered to seek the appropriate follow-up care.
Improving Patient Outcomes with Closed-Loop Reporting
Our primary research results contributed to the development and design of Change Healthcare’s Digital Patient Experience Manager platform. The platform uses integrated clinical and financial data to personalize patient communications and align automated messaging with the patient’s individual care journey.
The platform’s Patient Follow Up service streamlines the incidental findings reporting process from notification through follow-up care management with closed-loop communication and collaborative transparency that serves the best interest of all patients and practices. Radiologists can automate patient notifications of incidental findings via the communication method each patient prefers. As the service integrates directly into a practice’s radiology information system (RIS), radiologists can work seamlessly within their existing workflow.
Patient Follow Up supports prompt attention to incidental findings, as it tracks the referring provider’s and patient’s responses to the initial notification. The service monitors scheduled exams to help ensure the patient has an appointment for follow-up testing, and it continues to communicate with the patient until follow-up care is complete.
Implementing a trackable incidental findings notification process helps both radiology and physician practices reduce risk, increase scheduling volume, and improve patient satisfaction. Most importantly, however, a closed-loop reporting management system can have a significantly positive impact on patient outcomes—which is ultimately healthcare’s foundational goal.
