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Symposium Review Articles

Patient-centered Radiology

Overview and Opportunities in Cardiothoracic Imaging

Cook, Tessa S. MD, PhD

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Journal of Thoracic Imaging: March 2020 - Volume 35 - Issue 2 - p 79-84
doi: 10.1097/RTI.0000000000000466
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Radiology is unique compared with most other medical specialties in that care can sometimes be delivered without speaking to or touching the patient. As a result, nonprocedural radiologists have become the silent partners in the patient care relationship.1 Patients often confuse the radiologic technologist who guides them through the image acquisition with the board-certified physician radiologist who interprets the examination.2 Unfortunately, the literature on patient and referring physician preferences around who should communicate radiology results to who is inconsistent. A survey of outpatients undergoing computed tomography (CT) and magnetic resonance imaging (MRI) revealed that 63% of patients preferred to receive the results from their physicians rather than from the interpreting radiologist.2 Another survey of a similar patient cohort found that those patients were more concerned with receiving results within a few hours, rather than with which physician (radiologist or referring physician) communicated them.3 Conversely, patients who have had the opportunity to review their images with a radiologist have rated the experience positively.4,5 Other studies surrounding communication of results via patient portals found that most imaging-related questions submitted through the portal relate to obtaining results,6 and that patients like being able to receive results through their online portals.7 However, referring physicians express concern that the release of abnormal results directly to patients could be misinterpreted and cause undue anxiety.8,9 Even radiologists have debated if, when, and how to communicate results directly to patients for more than a decade.10,11

Even though radiologists have increasingly become involved in patient safety, quality improvement, informatics, and advocacy over the past 2 decades,12 they still have to work harder than other medical specialties to deliver patient-centered and family-centered care (PFCC). In the Merit-Based Incentive Payment Program (MIPS), an individual health care provider is considered “patient-facing” if he or she bills Medicare for >100 patient encounters during a designated review period. By this formal definition, and by the stereotype of the specialty as a whole, diagnostic radiologists are considered “nonpatient facing.” However, the announcement of the Commission on Patient- and Family-Centered Care by the American College of Radiology (ACR) in 2015 focused the spotlight on the importance of patient-centered radiology.13,14 Since its inception, the Commission has worked on multiple PFCC projects related to education, economics, quality, advocacy, and informatics, and developed both a PFCC Toolkit and resources to educate radiology residents on PFCC.15 A number of researchers have explored ways to improve how patients interact with radiology services and radiologists, ranging from increasing services and information disseminated via the patient portal to an in-person review of images with a radiologist.6,7,16,17

The subspecialties of radiology offer different opportunities and face different challenges as they strive to deliver patient-centered care. Radiologists practicing interventional radiology, mammography, and pediatric radiology regularly interact with patients (and often their families), in some cases, following them longitudinally surrounding an image-guided intervention.18,19 However, cardiothoracic radiologists have likely experienced fewer opportunities to directly interface with patients. This manuscript reviews the principles of patient-centered care, their application to the practice of cardiothoracic radiology, existing resources for radiologists and patients, and the potential impact of artificial intelligence (AI).


According to the Institute for Patient- and Family-Centered Care, there are 4 core concepts of PFCC: dignity and respect, information sharing, participation, and collaboration.14,20,21 Dignity and respect toward patients, family members, and caregivers should be universal across medical specialties. The remaining 3 principles speak to the idea of shared decision-making between patients and physicians, which, while increasingly recognized as important,22 is less widely practiced in radiology because of the asynchronous nature of care delivery.23–25

Radiologists expect that the physicians ordering the imaging test discuss the need, relevance, and importance of completing it with their patients. However, this discussion may not extend to specific aspects of the examination such as intravenous contrast administration, radiation exposure, claustrophobia, or breath-holding. For these discussions, radiologists are the domain experts, but often do not have the opportunity to directly communicate with patients. Shared decision-making also aligns with the ACR’s Imaging 3.0 initiative that describes how radiologists should be engaged during all aspects of the imaging examination: before, during, and after.26 Recognizing the need for additional training in this area, radiology residency programs are now including the principles of PFCC and their implementation in radiology practice in the clinical curriculum.27,28

Patient interaction can benefit both radiologists and patients. While radiologists participate in the care of a significant number of patients, most of these patients may be unaware of the expertise that a radiologist brings to their care, often assigning the interpretive role to the radiologic technologist who acquires the images.2 By discussing the logistics or results of an imaging examination directly with patients, radiologists can help patients more directly get the information they want, whether it be answers to questions about an upcoming examination or results of a study. Patients may also have a better appreciation for the role of imaging in their care after speaking to a radiologist. Radiology as a specialty continues to face the threat of commoditization: having the opportunity to speak to a radiologist directly may help patients appreciate that all imaging examinations are not created equal.

Radiologists who do not perform image-guided procedures often get less face time with their patients than some of their colleagues. Research examining the impact of a radiologist consultation clinic and in-person results delivery has shown that patients find the experience valuable, but scaling up these opportunities requires a significant change to the radiologist’s workflow.4,5,29 Nevertheless, the principles of PFCC do not only cover radiologist-patient interactions. Once a patient arrives at an imaging center, the experience of the radiology examination begins at the reception desk, and it continues to the changing rooms, gowned waiting area, imaging or procedure room, and maybe even to the film library. As a result, there are many opportunities to optimize the delivery of patient-centered care in radiology, including remodeling waiting areas to be comfortable, private, and functional, offering child-friendly and family-friendly spaces for pediatric patients, and making sure that patients feel that their privacy is respected throughout their time in the department.30–32

Patients describe a number of challenges particularly related to the information sharing concept, particularly surrounding access to images and reports, and understanding of radiology reports.33,34 Despite significant efforts by the Integrating the Healthcare Enterprise (IHE), and development of image-sharing technology, many patients still find themselves attempting to obtain imaging on discs that they have to transport to another care facility on their own, often encountering issues with disc formats, incorrect studies loaded on discs, and discs getting lost and needing to be reproduced.35 Patients also describe the challenge of understanding their radiology reports, which are conventionally written for an audience of physicians and health care providers. However, research has shown that even online resources written with patients in mind are not always at the recommended fifth-grade reading level.36,37 This persistent challenge is a good reminder to revisit the way in which patient-facing educational materials are developed, and to ensure that radiologists are mindful of the fashion in which they communicate information to patients.


Acknowledging the importance of the patient-centered practice of radiology, there are many opportunities to implement the concepts and principles of PFCC in the domain of cardiothoracic imaging. These opportunities align with the core concepts of information sharing, participation, and collaboration (Fig. 1), and include shared decision-making, direct patient-radiologist communication, periprocedural patient counseling, and electronic resources.

Opportunities for PFCC in cardiothoracic imaging, illustrated by combining the core principles of PFCC21 and the fundamentals of the Imaging 3.0 initiative.26

Shared Decision-Making

Shared decision-making is defined as a joint approach in which patients and physicians share the relevant evidence surrounding a specific question, and patients are supported in considering different options and making informed decisions.38 It is the most recent instantiation of patient-centered care in cardiothoracic imaging practice. In cardiac imaging, radiologists and cardiologists have collaborated around a framework of best practices to include patients in an informed discussion about radiation exposure.39 Shared decision-making is a critical component of lung cancer screening, and has resulted in collaborations between radiologists and pulmonologists, who can both discuss the risks and benefits of screening with patients. Despite being a prerequisite for reimbursement from the Centers for Medicare and Medicaid Services (CMS), one study observing conversations between physicians and patients found that the physicians overwhelmingly recommended the screening with little to no discussion of the associated risks, and rarely gave patients the opportunity to ask questions, express concerns, or participate in the decision.40 In fact, the quality of this “provider-patient communication” is cited as one challenge faced in trying to expand lung cancer screening to high-risk populations in rural America.41 Patient-specific barriers to shared decision-making around lung cancer screening include health literacy, lack of awareness of the option for shared decision-making, and, interestingly, the emphasis of educational materials on the harms and poor outcomes from a diagnosis of lung cancer, rather than the benefits of early detection and treatment.42

Direct Patient-Radiologist Communication

Direct communication between patients and radiologists is a component of shared decision-making but also has an independent role in cardiothoracic PFCC. Although the literature on cardiothoracic radiologists conveying results to patients is sparse, the literature from the mid-late 1990s suggests that patients have a strong preference to get their results from radiologists.43–45 More recent literature is mixed, although some studies have still shown that patients find value in speaking directly to a radiologist about their imaging test results.16,46 In addition, patients and patient advocates anecdotally describe not only their desire to speak to a radiologist directly, but also their experience that this is not easily accomplished currently.33

To afford patients the opportunity to speak directly to a radiologist about their imaging, Barbosa and Novak47 described their experience with a thoracic imaging reading room embedded within the outpatient pulmonology clinic of a tertiary academic medical center. Referring physicians from pulmonology, thoracic surgery, and oncology consulted the radiologists in the embedded reading room and had an overwhelmingly positive opinion of the availability of radiologists and the ease of consultation. They also described the positive impact of this real-time consultation on patient care. In some instances, patients accompanied referring physicians to the reading room to view their images and ask questions of the radiologist directly. Both the radiologist assigned to the embedded reading room and the other radiologists on the schedule shared a common worklist, enabling the embedded radiologist to have discussions with patients and referring physicians without being penalized by a growing worklist. A related study from Pahade and colleagues described offering patients the opportunity to review their images directly with a radiologist after an abdominal imaging examination. The authors of that study found that nearly all patients given the opportunity to review their results with the interpreting radiologist found it useful and would choose to do so again in the future.5

Periprocedural Patient Counseling

Cardiac imaging examinations sometimes involve medication administration before or during imaging to create or elicit specific physiological conditions. At our institution, patients who undergo cardiac CT angiography or stress cardiac MRI are met by a radiologist who explains the procedure and risk factors before imaging and administration of medications such as sublingual nitroglycerin for coronary vasodilation, beta-blockers for heart rate control, or adenosine or regadenoson for cardiac stress imaging. This interaction gives patients the opportunity to ask questions and enables the radiologist to allay concerns and provide information and clarification. Medication administration warrants some detailed evaluation of patients’ history, current medications, and allergies, to identify potential contraindications. It also behooves the radiologist to discuss potential side effects of the medication, such as headache after sublingual nitroglycerin administration. Patients sometimes request to review their imaging at the conclusion of a coronary CT angiogram, in order to prepare for a conversation with their cardiologists.

A conversation between the cardiothoracic radiologist and the patient, during which the potential discomfort of the upcoming examination is acknowledged and discussed, may help the patient to be as comfortable as possible during imaging, or may lead to the selection of an alternate modality. For example, claustrophobia and the need for repeated breath-holds can prevent patients from getting or completing diagnostic imaging, particularly for longer examinations such as cardiac MRI.48 In contrast, patients who are unable to or uncomfortable with running on a treadmill can be offered nonexercise stress testing alternatives. Direct patient communication and education can decrease the anxiety associated with an unfamiliar test and increase the likelihood that a patient will successfully complete the examination.

Electronic Resources

Additional resources within radiology can be leveraged to deliver patient-centered care in cardiothoracic imaging. Patient-friendly summaries of the ACR Appropriateness Criteria are being developed and published,49 with topics that include routine chest radiography, workup for suspected pulmonary embolism, coronary calcium scoring, and planning for transcatheter aortic valve replacement.50–53 informs patients about imaging for both screening and diagnosis, describes specific imaging tests for both adult and pediatric patients, and even educates patients about radiation safety.54,55

Tools to help patients better understand their radiology reports can also be useful in working toward the PFCC concept of information sharing. Oh et al56 developed a report annotation tool called PORTER (the Patient-Oriented Radiology Reporter) that generates a hyperlinked, annotated version of a patient’s radiology report using a customized glossary of terms and annotations. An example of a chest CT report annotated using PORTER is shown in Figure 2.

Example of a chest CT report for a patient with sarcoidosis annotated using PORTER. Terms are hyperlinked with definitions. The mouseover shows the definition of the term “lymphadenopathy.”


When radiologists are asked to increase their interactions with patients, most respond by saying they would welcome the opportunity to do so but are at a loss for how to incorporate meaningful conversations with patients into already long clinical days.34 Outside of mammography, the diagnostic radiology workflow in its current form is not designed to support long or frequent departures from the reading worklist for any reason. Radiologists feel responsible for all patients on the worklist, and spending additional time with some subset of patients in person (acknowledging that they are equally responsible for those patients also) may cause consternation. As such, these conversations currently rely entirely on the personal sacrifice of the radiologist, who must extend his or her shift (without additional compensation) to finish the cases on the list. While most physicians chose their profession with at least some sense of selflessness and altruism, radiology practices do not have mechanisms to support their diagnosticians spending time talking to patients. In the future, the transition from volume-based to value-based care under MIPS will gradually increase the proportion of reimbursement that is tied to quality measures, as opposed to strictly relative value units (RVUs).57 This may lead to a shift in priorities and a corresponding modification of practice patterns that enable more radiologist-patient communication.

Rawson and colleagues describe the importance of multiple strategies toward successful implementation of the principles of PFCC in a radiology practice: leadership commitment, engagement of all stakeholders (including patients, family members, radiologists, and radiology staff), training, incremental change, and early and frequent check-ins with stakeholders.30,31 As burnout is increasingly recognized as growing in prevalence among radiologists, consideration should be given to studies showing that involving health care professionals in decision-making and acknowledging the importance of non–RVU-generating activities increase overall job satisfaction and mitigate burnout.58 Implementing PFCC principles in a radiology practice requires more non–RVU-generating activities and could be implemented in order to give radiologists more control over their workday, decrease their isolation, and also provide valuable information and education to patients visiting the practice. Again, enabling radiologists to meet with patients should not come at the expense of penalizing them for not keeping up with cases on a worklist. The latter would only decrease the likelihood that radiologists would embrace the principles of PFCC.

Acknowledging the challenges of taking time away from the worklist and the reading room imposed by the modern radiology workflow, how can radiologists realistically carve out time to have meaningful conversations with patients? Depending on the nature of the conversation, a few minutes may be appropriate, for example, when educating patients on what to expect from an upcoming coronary CT angiogram or stress cardiac MRI, or when ensuring that medications (such as beta-blockers or adenosine) are safe to administer before imaging. However, there may be situations wherein a radiologist has to convey difficult news, such as after a high-grade lesion is identified on coronary CTA or a condition is identified that carries a risk of sudden cardiac-related death and requires placement of a defibrillator. In these instances, the conversation may require more detailed knowledge of the patient’s history and risk factors and may require more than a short amount of time. In these instances, if the radiology practice has made it a policy to communicate with patients after these kinds of examinations, it becomes the radiologist’s responsibility to have the conversation and answer the patient’s questions. However, as mentioned previously, this policy should have been created to enable the radiologist to conduct the discussion appropriately without the pressure of a growing worklist.


Exactly how AI will transform the practice of radiology remains uncertain.59 While a great deal of effort is focused on developing findings detection tools that work on images, AI could impact all aspects of radiology workflow.60 If tasks such as intelligent data mining of the EMR (for relevant patient history and workup), protocol determination, and asynchronous communication with ordering physicians could be automated (with or without AI), radiologists may be able to evolve their workflow to include appointments with patients to review imaging and answer related questions. Multiple groups have presented AI-powered approaches toward automatic identification of follow-up recommendations.61–63 Although these are yet to permeate the clinical workflow, they offer the potential for radiologists to take a more active role in ensuring that patients complete the recommended follow-up, either by contacting referring physicians or even patients to discuss the recommendation and next steps.64


While radiologists have traditionally been known as the doctors’ doctors, they have simultaneously (though in some cases, invisibly) delivered care to patients as their physicians. Following the guidance from the ACR’s Imaging 3.0 initiative and the resources from the Commission on Patient- and Family-Centered Care, radiologists have the opportunity to increase their visibility and improve the care experience for their patients. Applying the principles of dignity and respect, information sharing, participation, and collaboration to the practice of cardiothoracic radiology gives patients the opportunity to participate in shared decision-making around imaging, particularly for lung cancer screening and considerations surrounding radiation exposure. Many additional opportunities exist to help patients speak directly to radiologists both before and after imaging, to not only discuss specific aspects of an imaging examination but the impact of that imaging on next steps in the patient’s care. Implementing the principles of PFCC in a radiology department or practice requires the participation and engagement of all stakeholders, including patients.


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patient-centered radiology; patient-centered radiology; patient- and family centered care; cardiothoracic imaging

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