Patient Portals: What You Need to Know Before Launching

This is part two in our series on radiology patient portals. Part one covered why portals are good for business and patients.

Have you considered providing patients with their radiology records online, but something is holding you back?

“Don’t be reluctant,” said Steven L. Mendelsohn, MD, president and medical director of Zwanger-Pesiri Radiology on Long Island in New York. Launching its portal in March 2012, Mendelsohn found it empowered patients, demonstrating the radiologists’ quality and value. “Patients are becoming drivers of medical care. We as radiologists need to document and show our patients that we’re an important part,” he said.

Numerous studies show that patients want their medical information, and the transition to providing it online can be uneventful if planned and managed carefully, said Curtis Langlotz, MD, PhD, professor of radiology and vice chair for informatics at the University of Pennsylvania. His hospital system conducted a pilot study in early 2012, rolling out the portal completely mid-year.

When only certain services shared medical results on the Memorial Sloan Kettering Cancer Center (MSKCC) portal, patients requested the same from those services still offline. “Everyone was happier when we went full institution,” said David Artz, MD, medical director of information systems at MSKCC.

Implementation considerations

Consider the portal from an enterprise level, not just the radiology portion, said Cristine C. Kao, global marketing director of Carestream Health Inc. From a patient perspective, the value is in being able to pay bills and schedule appointments, as well as seeing medical history. Looking at patients as consumers can change an institution’s perspective.

Before installing it, you’ll need to discuss and negotiate it with others in your institution, said Artz. A well-constructed pilot study can do wonders in convincing hesitant staff members that it’s worthwhile. “At any institution you have folks who run the gamut: some who want it yesterday, and some who think bad things will happen,” he said. MSKCC’s radiology portal went live in July, 2013, but they ran large pilot studies starting early 2012, and the portal was already active for other departments.

A pilot does more than give naysayer staff members evidence that the program works. With a working prototype, patient usability testing helps tweak assumptions and functionality.

Educating office staff about the portal

Once the portal is nearing completion, you’ll need to train the office staff on its use and helping patients enroll. Patients will question whether the portal is secure and whether they can manage each family member’s information. “Educating your front desk staff is critical for success,” said Kao. The front or nursing staff, not the radiologists, usually takes on the management and patient education role.

Many who have implemented a portal say there was no increase in IT support needed after the portal went live. Staff time previously spent copying reports and images transitioned to spending time educating patients about sign-up and portal use. At MSKCC, the only additional IT calls they received were enrollment-related questions about forgotten passwords, for example, said Diana Garcia, MSKCC’s patient portal operations manager.

MSKCC surveyed nurses about their time involvement with the lab report portal, and found no increase. “If patients don’t access the information online, they’ll call the office,” Artz said, adding that it’s more efficient for patients and staff to have the portal.

Educating patients about the portal

The most effective way MSKCC found to get patients signed up for the portal was to print the information on the patient’s appointment reminder page, since they usually see multiple specialists, Garcia said. The reminder includes a unique enrollment ID if the patient hasn’t signed up yet. Other marketing material includes signage, brochures and business cards with instructions and explanations, plus the nursing staff talks to patients about it.

For patients already signed up, Partners HealthCare in Boston lists details instructions online, including explanations like “pending results” mean the results aren’t available to the doctor or online, so not to contact the doctor’s office. It explains that some tests are available immediately, some are delayed a few days, and also lists which results are blocked from the site.

Other education methods include embedding a short video in the portal explaining how it works, as well as a list of frequently asked questions and answers.

Educating doctors about the portal

The University of Pennsylvania’s medical center prepared radiologists and referring providers through multiple channels, reminding radiologists that their reports would likely be viewed by patients, and training referring providers how to embargo a result, said Langlotz. Though response has ultimately been positive, some referring physicians had to be convinced of its benefit. The pilot study helped with that.

When Zwanger-Pesiri Radiology activated its portal in March 2012, a few referring doctors were upset about the change. They didn’t want the patients to get their results online, and didn’t want patients calling their offices to discuss the results before the referring doctors were ready to do so. In response, Mendelsohn told them to use the reports to their advantage, saying, “I understand you’re not ready to talk to the patient. Explain to them ahead of time that you’ll get the results but won’t be ready to discuss it for a week, when the other results are in.” Referring doctors routinely thank him for putting the results online because it’s one additional check in case the report gets misplaced or forgotten at their office.

Should you list radiologist contact information?

Some radiologists fear giving patients portal access, with concern that patients will disrupt the workflow when calling for more information. “These fears were unfounded,” Mendelsohn said, adding that his practice lists the radiologist’s direct extension on the report, and they get very few patient calls.

Facilities have different philosophies, though. “The ones that offer their own radiology department phone number are the ones who want to be in front of the patients,” said Kao. “I think it’s based on the strategy of the facility in terms of how they want to engage with the patient.”

At MSKCC, reports do not include the department phone number, nor the physician’s direct line. “We thought about doing it, but technically it wasn’t easy and we didn’t necessarily want to encourage it,” said David Panicek, MD, vice chair for clinical affairs at MSKCC’s radiology department. That said, they’re happy to talk with patients and answer any calls coming through the main switchboard. Since the radiology portal went live in July 2013, there’s been no difference in the number or type of patient calls Panicek received, which are general questions and not about the reports.

When to release reports

Determining the best time to release reports to patients is another philosophical issue each facility must determine. Carestream’s MyVue portal program allows administrators to set the parameters for when to make a report available, and this is built into custom software as well.

“Some want patients to have access to reports immediately. Some want the referring physician to explain the report first,” Kao said. “There are a lot of different controls based on how you want to engage your patient.” With MyVue, patients can share their results with others by sending a link. The cloud-based system does not require the viewer to have specific software. The patient can decide whether to release their entire history or just one specific image or report when sharing their results with another physician or family member.

Zwanger-Pesiri, which built their portal in-house, initially had a three day delay to give the referring doctor time to read the report and contact the patient. Mendelsohn later decreased that to a one day delay, out of concern for proactive patients who might face a weekend without results, or if their doctors were out of town. The change from three to one day led to no negative feedback. Now the facility provides results available the instant the report is signed.

“Many patients now are literally in their car looking, pulling them up on their mobile device from (the study) 15 minutes earlier,” Mendelsohn said. If the report isn’t yet available, likely it will be by the time the patient gets home.

Though their patients may get the results directly from the portal, they understand that the referring doctor is seeing other patients and they’re busy. “In reality, patients don’t expect their doctors to drop everything. The patient has their results,” said Mendelsohn.

MSKCC went the longer route, with a four business day delay for results, to allow the treating physician to address any issues, said Artz. They debated allowing a physician to manually release the report, but this was extra work for the physicians and not all results would get to the patients.

They chose that period because it’s the same as the current CMS definition of meaningful use of electronic health records. That requirement says that patients should have timely electronic access to their health information within four business days of it being available to the eligible professional. While MSKCC shows laboratory tumor markers in real time, they had additional concern with radiology, because they didn’t want the portal to be the initial source of bad news.

Reports at Penn are available after a three day delay, but the ordering provider can embargo the result, said Langlotz.

Report language

Another physician concern is that patients won’t understand what the radiology report means. Yet again, each facility has its own approach.

At Zwanger-Pesiri, Mendelsohn heard these concerns, and his response was to tell the radiologists to put the reports in clear, understandable English. “The quality of their reports has increased tremendously,” he said. “We don’t need to have technobabble in our reports, like esoteric information on pulse sequences. That’s radiologists trying to show off how smart they are. Even the specialists don’t know what they’re talking about.”

Separate from the pending radiology portal, the MSKCC staff began changing their reports in 2009 to make them more uniform. They wanted this project complete before the radiology portal went live in 2013. As a closed system hospital with entirely employed staff, including 100 clinical radiologists, 40 radiology residents and 35 fellows, they wanted to devise a common nomenclature for uniform descriptions and probabilities, so reports could be compared to each other.

“They were very concerned that it be standardized before we went online,” Artz said. Only reports from 2009 and later, which meet these requirements, are available to patients online.

The reports are now more clinically relevant and patient-friendly, said Panicek. They devised standardized templates, structured according to different organs. They also developed integrated reports for patients who have several tests in less than a month. Sometimes the reports are conflicting, where one says a nodule is benign and another says it’s malignant. Prior to this, the clinician was told to work it out, but now the radiologist reading the final report looks at the results and gives his or her opinion.

“Sometimes these tumors aren’t hot on a PET scan, and rather than say it’s not hot, and the clinician say it’s not a tumor, we say we wouldn’t expect it to be hot in that type of exam,” Panicek said. The integrated imaging summary is on the bottom of the final report.

MSKCC also made a standardized lexicon with five levels of certainty, so when they used “consistent with” they mean more than 90 percent certain. If “unlikely” they mean less than 10 percent, and those keys are printed at the bottom of every report so the patient also knows what it means.

The portal inspired MSKCC radiology staff to see what else they could improve on their reports, and they added a clinical statement on top. This was a combination of the requisition from the referring physician along with additional information the radiologist thought was pertinent from the records or discussion with other doctors.

As a result of patient focus groups on report language, they changed certain terms like “history: terminal cancer,” Panicek said. “Who wants to read that? We’re all terminal,” he said. They also eliminated words like “gross” as in “no gross disease evidence” because patients didn’t like it.

While most radiology reports don’t include patient education, MSKCC provides outside references. They include links to radiologinfo.org on the results page, said Garcia, and similar lab results link for those reports, so patients can learn more about test types and results. She said patients do click on these links.

“Our philosophy is that more information to the patient is never a bad idea,” said Artz.