Positive tests - hard to reach patients

robert bell rmsbell200 at YAHOO.COM
Tue Mar 10 17:14:51 UTC 2015


Wow, what a great reply. 

Beautifully expresses all the complexity of medicine and the challenges to reduce error against a relentless sea of obstacles that helps create error.

Also speaks to the difficulty of patient communication and Portals being adequately evaluated prior to introduction.

Well done Michael Bruno.

Rob B

Sent from my iPad

On Mar 10, 2015, at 6:38 AM, "Bruno, Michael" <mbruno at HMC.PSU.EDU <mailto:mbruno at HMC.PSU.EDU>> wrote:

> Thanks, Tim,
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> It’s great to hear from a fellow “Quality Officer” in a medical practice.  I’m also a quality officer, for a large academic department of Radiology.  This particular issue, of communicating effectively with our patients, is near & dear to my heart.  I’d like to briefly share our own experience in alerting a subset of patients to their test results, an experience which surprised me and my team here and may surprise others on this listerv as well.  We were surprised to encounter a population of patients who were remarkably disengaged, and who weren’t particularly receptive to hearing from us with their test results.  This was quite the opposite of what we expected.
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> In the practice of modern radiology, we encounter a good many unexpected findings—items of varying importance that are turned up on imaging tests that need to be followed up (often after a suitable delay to allow us to better characterize them).  While such findings need to eventually be addressed clinically, they are not the immediate reason for the patient coming to the doctor or undergoing their imaging test.  We dutifully report all of these “incidental” findings to the ordering physician—phoning them when the surprise is a critical one—and trusting them to read our written report when it is not.  As a corollary, there’s quite a bit of pressure to make our reports timely and clear, and these days our formal, signed final reports are predominately delivered electronically through the EMR in a matter of minutes, although providers outside of our center may still get their radiology reports via fax or even through the regular mail.  The issue is particularly problematic for us in Radiology where Radiology intersects the Emergency Department.  We invest a lot of resources to the E.D., and most of our final, written reports on E.D. patients are delivered literally within minutes, plus we always have someone (a faculty member, resident trainee, or both) physically stationed in the E.D. itself to provide immediate availability for consultation.   
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> That’s all well and good for the acute findings, i.e., those addressing the clinical question that brought the patient into the E.D., but it tends not to work all that well for those incidental findings unrelated to the immediate problem and that require a medium to long-term follow up—follow-up which is outside of the purview of the E.D.  In such cases, it falls to the patient’s primary care physician (if there is one) to follow up on the incidental findings, and it’s almost useless for us to even alert the E.D. physician to those findings.  In many cases when we report the findings to the ED physician the patient still isn’t even told of them by that E.D. physician.  Rather, patients are directed to sign a form at the time of their discharge from the E.D. in which they promise to “follow-up with PCP.”  This promise to follow up is generally little more than a charade.  From the patient’s standpoint, they often feel that they’ve (1) just SEEN a doctor, and (2) been SCANNED from top to bottom, and therefore they should be “all good.”  At least until their next acute problem arises and they return once more to the E.D.  In a handful of cases, depending on the nature of those incidental findings, that is a very dangerous complacency.  Their PCP, if they even have one, may never learn they were even seen in the E.D., much less that there were CT or x-ray findings from that E.D. visit which will need to be worked up or at least followed.  So you see the problem.
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> To address this, we’ve developed a “failsafe” plan to alert the patients directly to their incidental findings requiring follow-up, and to encourage them to obtain the recommended follow-up with their PCP.  We also direct them to our Dept. of Family & Community Medicine in the event they don’t have a PCP (which is unfortunately a fairly frequent situation in the E.D. population).  We do so by mailing them a letter.  This is an unusual type of direct communication for Radiologists.  In the U.S., we Radiologists have traditionally been the “doctor’s doctor,” communicating our findings and opinions only with the referring physician, who then relays our impressions to the patient (who, in turn, generally assumes that it was their own doctor who interpreted their CT scans and generated the diagnostic opinions).  The idea for our “Failsafe” program came from the Joint Commission NPSG about involving patients in their own care as a specific safety strategy—and it puts the patient in the middle of the communication chain between us and their PCP.  When we proposed the idea of having Radiologists send letters directly to patients – letters addressed to specific patients and signed by a specific Radiologist(!) – with the purpose alerting patients to abnormal findings on their scans without any intermediary physician there to explain the findings, it raised a lot of eyebrows, not least among the Radiologists themselves.  Many worried that the clinical physicians would not appreciate our getting between them and their patients, and others were worried that patients would call us incessantly with questions and consume too much time, destroying our RVU-based productivity.  We also worried that receiving a Failsafe letter would be unduly frightening for patients.  But none of these concerns turned out to actually be a problem.  Our faculty physicians were very receptive to Failsafe, and they universally appreciated the added measure of safety for their patients that the new program provided.  If anything, they wanted to see the program expanded.  And very few calls from patients came to us.
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> Our Failsafe letter does not attempt to explain the findings or their significance to the patients.  Rather, it merely alerts them that “their Radiologist” found something on their scan requiring follow-up, and urges them to see their doctor to discuss the findings (or call the Family Medicine office to arrange a follow up if they don’t have their own PCP).  We have so far limited the program to E.D. patients, based on the rationale above, and currently we send out about 6 – 8 letters per week, and have been doing so for about three years now.   But when I phoned bunches of these patients to see what their reaction to the letter had been, and to ascertain whether it had achieved its intended purpose, I discovered that patients were fairly uniformly disregarding the letters.  Most never even returned my calls.  Those who did seemed completely unconcerned and none even asked me what the findings we were pursuing were!  They simply did not care to know—they were feeling well, and they were not receptive to any potentially worrying information.  Far from being frightened by the letters, they were not even concerned when the letter was followed up by some doctor (me) phoning them repeatedly, leaving multiple voicemails and messages with their family members at home and co-workers at their places of employment.  It was clear that these patients could not care less about our findings, our letter, or whatever it was I may have had to say to them on the phone.  In short, we encountered a large group of patients who were so unconcerned and unfrightened about their test results that nothing we tried could frighten or concern them!
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> This situation was essentially 180 degrees diametrically the opposite of what we had expected—which was that patients would be highly invested in the results of their studies, that they would be anxious to learn what their imaging showed, and would be pressing their physicians for answers.  We expected the phones to be ringing constantly once the first batch of letters went out.  What we found instead was that, at least for the population seeking their medical care in the E.D., with a few notable exceptions, our patients were pretty much un-engaged with their own care beyond the acute episode of care.
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> We have been struggling with this patient engagement issue and are now working toward developing more effective ways to augment our program and try to reach these patients.  But I would suggest, based on our experience, that merely sending patients the results of their lab tests by mail is simply NOT going to be adequate across the board.  Some patients are turning out to be very hard to reach.
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> All the best,
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> <image002.png>
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> Michael A. Bruno, M.D., F.A.C.R.
> Professor of Radiology & Medicine
> Director of Quality Services & Patient Safety
> The Milton S. Hershey Medical Center
> Penn State College of Medicine
> 500 University Drive, Mail Code H-066
> Hershey, PA  17033
> 
> Phone: (717) 531-8703
> Fax:      (717) 531-5596
> 
> e-mail:  <mailto:mbruno at hmc.psu.edu>mbruno at hmc.psu.edu <mailto:mbruno at hmc.psu.edu>
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> From: Timothy Stevenson [mailto:Timothy.Stevenson at SSWAHS.NSW.GOV.AU <mailto:Timothy.Stevenson at SSWAHS.NSW.GOV.AU>] 
> Sent: Monday, March 09, 2015 4:50 PM
> To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [IMPROVEDX] FW: [IMPROVEDX] Positive tests
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