Making Medical Imaging Transparent

This article appears in the March 2012 issue of HealthLeaders magazine.

Within the next five years, experts believe that patients will have—or will come to expect—near immediate Internet access to medical imaging as part of their personal medical records.

That push toward more access to imaging has caused some trepidation within healthcare circles as primary care physicians, radiologists, administrative staff, and even healthcare economists try to determine how it will alter the physician-patient relationship, what new demands and constraints it will place on physicians, and how it will impact the use and cost of expensive medical imaging. 

David S. Mendelson, MD, FACR, chief of clinical informatics at Mount Sinai Medical Center in New York City, says improving patient access to imaging is something that all physicians—including radiologists—should embrace.

"The intent is to push for more appropriate imaging. The goal is, through easier accessibility you reduce redundant imaging," says Mendelson, who serves on the Radiology Informatics Committee of the Radiological Society of North America.

"You need the right information available when you're evaluating a patient. One reason there is 'inappropriate' imaging is lack of access to prior exams," he says. "You can spin a variety of clinical stories where someone wants the images or the results, or frequently both, and they aren't available and the only answer is to repeat the exam. That is costly, and in the case where there is ionizing radiation—CT is a common example—there is an extra radiation dose. And there is clearly a parallel drive right now to reduce radiation exposure to patients and use only as necessary."

Mendelson is also the principal investigator for the RSNA Image Share network, which offers patients Internet access to their medical imaging through a secure portal. The pilot project has enrolled patients at the Mount Sinai Medical Center, the University of California–San Francisco, and University of Maryland Medical Center in Baltimore. The Mayo Clinic in Rochester, MN, and the University of Chicago Medical Center will soon enroll patients.

The Image Share network all but eliminates the need for patients or attending medical professionals to travel to their physicians' offices to request or retrieve compact discs containing their medical imaging—which is the cumbersome and standard method of delivery at most healthcare facilities right now.

"The patients who have embraced Image Share are very positive about the expediency of using the Internet to replace a whole set of manual processes," Mendelson says. "This is not instantaneous gratification, but it is relatively quick and convenient. It cuts through a lot of manual processes." 

Nagging doubts
Mendelson says there is growing support for improving patient access to all medical records, including imaging. However, he and other healthcare leaders concede that issues remain to be solved.

A paper about a survey released in December for the OpenNotes medical record pilot project that was initiated by Beth Israel Deaconess Medical Center in Boston found that patients were overwhelmingly interested in accessing their doctors' notes, but physicians were less receptive.

There also are concerns about utilization. Will facilitating patient access to their medical records increase their demand for more services and procedures, including costly CT scans, MRIs, and other imaging that may not otherwise be warranted?

"That is the question of the hour, and it remains to be seen," Walker says. "A lot of times we underestimate how resourceful patients are. Certainly knowledge is power in other arenas, so you could argue it either way. I can't deny the possibility but I hope the preponderance of evidence will be that people use this information well."

Steven P. Cohen, MD, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, has studied the overuse of medical imaging in spine care, which he says often adds little value but adds significant costs. He says it's critical that increased patient access to medical records does not lead to more inappropriate imaging.

"The use of imaging does not seem to affect decision-making or improve outcomes in the large majority of individuals," he says. "So while I think that patients have a right to know the results of tests done on them, I don't think they should be the ones who decide on whether they are indicated—unless they are paying for them."

Ted Eytan, MD, MS, MPH, a director for the Permanente Federation at Kaiser Permanente, says facilitating patient access to their medical imaging will help to educate the patient and demystify the technology. "What will happen now is they will start to understand the limits of imaging," he says.

"Sometimes these imaging reports come back and do not reduce the uncertainty that the patient has, and the patient thinks, 'Why did I spend two hours in a box if this was not a justifiable expense that didn't change the condition?'" Eytan says. "Especially if they are going to pay for this, they are going to ask questions: 'Why are we doing this?'"

Walker agrees that cost-shifting will make for more discriminating patients. "The incentives are going to be different, so it seems like a well-informed patient could spend money more wisely as patients are spending more out of pocket," Walker says.

"And it certainly seems logical to have patient eyes on what is going on with care so that they could head off some errors early if a patient spots something wrong. It would provide opportunities for patients to say, 'I don't need a test. I already had it, and here are the test results right here,'" she says.

Image maker makeover
Increasing patients' access to medical imaging will also raise the profiles of radiologists—many of whom now have little, if any, contact with patients.

Mendelson acknowledges that some radiologists probably got into the subspecialty specifically to avoid patient interaction. That will have to change, he says, "and I believe that change may be a good thing.

"This will raise awareness of the profession to the general patient community," Mendelson says. "One of the pushes of our professional societies over the last few years is to let the patients know who we are. A lot of patients are not fully aware of who radiologists are or that we are even physicians. This is a way of raising awareness."

That higher profile will also carry some new responsibilities, Mendelson says, including "making yourself available and spending time that you don't spend today more directly encountering the patients. But perhaps in the big picture, that is a good thing." 

Eytan says that more direct contact with patients will make radiologists better physicians.

"Radiology is a service profession. In this new era, they may not yet realize how valuable their service will be to the actual patient," Eytan says. "In the past they were serving other doctors, but I think they understand quite well what the future is."

Eytan compares increasing patient access to imaging to that of opening laboratory records to patient review. Similar concerns were raised at the time, but that access is now part of standard operating procedure at most healthcare systems and has cast a new appreciation from patients on the value of pathology and other lab services. He says medical imaging will see the same growth in stature from patients. 

"I would tell radiologists that this is going to help the people you serve understand just how much you contribute to their care. It's going to make you look great," he says. "And the second thing is, if you never do it, you'll never know how much better your care can be because you'll keep talking in this arcane language, things will keep falling through the cracks, and you won't learn how to be a better radiologist."

Mendelson says that the increased visibility of radiologists carries "a lot of positive ramifications" that could help the profession in its pitched battles against reimbursement cuts from the federal government.

"There is the generic good will between patients and physicians," he says. "Secondarily, patients might become more appreciative of their radiologists and assertive toward their politicians to make sure that radiologists are treated reasonably."

Dumb down the data
Mendelson says he is not overly concerned that radiologists might have to alter the case notes they provide for imaging in electronic medical records to account for patient access.

"We believe patients are entitled to see their reports, but it will be a balancing act," he says. In the long run, he says the process will improve communication and efficiency.

"As more patients leverage seeing their results, will there be a feedback loop? Where will  radiologists get more demand on their time to deal with patients? Will they find ways to rephrase things to generate fewer questions? That may well happen. But I wouldn't call it 'dumbing down' as much as finding the appropriate phrasing."

As an additional safeguard—at least initially—the RSNA Image Share network has a 72-hour delay on releasing new medical images to the patient until results and images can be communicated to the referring physicians. The delay was designed in part to protect patients from potentially devastating or confusing news without a ready interpretation of the data.

Mendelson acknowledges that the program designers knew such a delay would be controversial "because there were times when people needed these things instantaneously."

However, he says, the system designers also were being pragmatic.

"When we set this up initially we knew that we couldn't do everything in one fell swoop perfectly. We had to set priorities," he says. "The 72 hours was something that we recognized would require further refinement. We wanted to get the programming right for moving images around first. Now we can come back and revisit things that need to be a little more granular."

For Eytan, patient access to medical imaging is inevitable and part of the greater move toward access and transparency in healthcare delivery. Rather than debating the pros and cons of that patient access, Eytan says physicians should spend their time trying to make it work.

"It's not the 'if,' it's the 'how,'" he says. "This should be done, and the 'how,' I have learned, is everyone needs to be involved. The subspecialty of radiology is very important so this should not be done without their involvement. If we allow them to be involved, they will do a great job with primary care doctors to make this happen."

This article appears in the March 2012 issue of HealthLeaders magazine.

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