I recently received a phone call from my referring clinician in which he requested a change to my radiology report in order to to make it “not so scary” for the patient. Although I have always considered myself a patient-friendly radiologist, in that precise moment I truly felt that times were changing: the patient can now read my report before visiting their doctors through the increasingly available patient portals.
My feeling of uneasiness of such access is shared as a majority of current doctors still do not want patients to have full access to their electronic health records. The general reasoning behind this preference is that it has not yet been proven that such access truly benefits clinical outcomes (Ref 10) and, also, that unregulated access can lead to an increase of unnecessary worrying in patients (Ref 4, 5, 6).
However, a patient’s desire to have such access is overwhelming. A recent study published in the Journal of American College of Radiology illustrated that 79.2 percent of the adult outpatients surveyed prefer to have such access (Ref 1). Many anecdotal stories have also demonstrated potential benefits of granting patients access to full electronic health records, including avoiding medical errors and creating “shared accountability” between caretakers and patients (Ref 7,8).
Although a radiology report is part of a patients medical record it is different from other doctor’s notes, which are often so technical that it is nearly impossible for the patients to directly relate it to their personal experience (like they can with other medical reports from their doctors’ visits or surgeries).
A radiology report typically includes three components:
1. Technique: Technical details on how the pictures are generated. For example, a computed tomography report would include the body part scanned, amount of contrast used, and amount of radiation exposure that occurred.
2. Findings: Descriptions of the abnormalities (or lack of) while utilizing distinct medical jargon. The amount of medical and radiology-specific vocabularies may take a radiologist several years of education to master.
3. Impression: What a radiologist can conclude from what he/she describes in the reports. This is the juiciest part of the report where the art of practicing radiology and medicine manifests itself. Essentially it includes a summarization of the potential diagnoses and the next-step in diagnosis or treatment. This is one of the most important areas of radiology, however, it may also be one of the hardest parts to understand, even to clinicians.
The traditional audience of a radiologist’s report is the patient’s direct caretakers including physicians, nurses, and other healthcare professionals who are familiar with the medical terms. Ideally, the caretakers will then relay the interpretations to the patients in a more digested and filtered fashion. However, now with widespread adaptation of electronic health records (EHRs) and incentives provided by Meaningful Use (MU), the patient is the new audience of radiology reports. Patients not only have access to medical images (e.g. MR, CT, ultrasound, X-rays, etc.), but also the reports containing interpretations of these images by the radiologists.
On one hand, this democratization of access to information empowers the patients; on the other hand, such access challenges the status quo of patient-radiologist communication style and relationship in three main ways:
1. The order of information relay process has changed.
Originally a patient’s anxiety of waiting for an answer, often in life-death situations, has pushed many to attempt to digest the reports themselves before their caretakers have had a chance to filter and understand the information for themselves. A simple Google search on the word “unremarkable” can demonstrate the curiosity and frustration generated from this self-interpretation process. The patients may have done research on the reports extensively and experienced a range of emotions previous to receiving the official and final diagnosis. While a delay in the reports that are experienced by many patients may be viewed negatively as ineffective communication, a recent study has shown that some delay may serve as a beneficial buffer for information transmission between the medical community and the patients. A study done by the Wake Forest radiology team (Ref 1) found that patient’s preferences in receiving reports depended on the level of abnormality reported. They found that if the report showed nearly normal findings, 60.2 % would want immediate access and 28.3 % preferred a 3-day delay; in contrast, these proportions were 47.2 % and 35.8 %, respectively, when the report was seriously abnormal, and 45.3 % and 35.8 % when findings were indeterminate (Ref 11).
Radiologists need not be the first or only party to interpret the images. Due to a nearly universal Picture Archiving and Communication System system, when immediate clinical decisions need to be made many clinicians interpret less sophisticated images themselves even before the radiologists do. The radiologist’s final interpretation simply serves as a reference and quality control. This may result in discrepancies between the preliminary interpretation by the clinicians and the final interpretation by the radiologist which causes confusion and decreases the patient’s confidence in their care process.
2. It is now much easier to challenge the authority of a final report.
It was only months ago when I was invited to join a new international online community of radiologists who re-interpret medical images for a set fee (www.diagnose.me). Such second read services are widely available at academic centers and reputable private radiology groups along with a variety of prices that are attractive both to the patients and the radiologists. Additionally, with cloud computing and many new image-sharing apps/websites, such re-interpretation servicing will only become more prevalent and consumer friendly as we expand into the future. Lately, another interesting phenomenon is crowdsourcing medical diagnostics, which is gaining momentum as patients may now request collective intelligence through platforms such as crowdmed.com to gain further insights into their care process (Ref 11).
3. The knowledge gap is decreasing.
Patients are now not only equipped with powerful search engines such as Google but plenty of interactive websites/Apps are now available for the patients to ask anyone any question they. Such platforms include not only the traditional Q/A platform such as answers.yahoo.com, wiki.answers.com, Quora.com, but also more professional and credible ones such as healthtap.com and www.healthcaremagic.com.
Despite my own discomfort with these changes as a radiologist initially, I advocate patients having access to radiology reports. Outside of the world of medical imaging, the above changes can be extended easily to other areas of medicine given the increasing popularity of telemedicine. More transparency will increase shared accountability in care and transform our healthcare system into a proactive rather than reactive one. However, significant amount of work and creativity are needed to transform the current patient portals into meaningful communication pathways between the providers and the patients, and not just access to unfiltered “scary” words.