Primary to Imaging to Specialists to Surgery to Rehab – Patient

Visits Primary
Care Provider

  • Patient receives referral to imaging based on diagnosis.
  • Patient reviews imaging type with their PCP.
  • Discusses potential wait times and next steps.

Schedules Imaging

  • Scheduling team calls to coordinate an imaging appointment.
  • Patient is informed of their appointment details.
  • Patient receives a confirmation email or phone call with appointment details, including date, time, location and preparation instruction

Attends
Appointment

  • Patient arrives at the imaging facility and checks in for the scheduled procedure.
  • Patient brings required documentation, such as ID and insurance card.
  • Patient completes necessary paperwork.
  • Technician verifies the patient’s identity and confirms the imaging order.
  • Technician explains the procedure, answers questions and ensures the patient’s comfort.
  • Imaging is performed, and the results are uploaded to the imaging system.

Receives
Results

  • Results are uploaded to Cerner for patient access through the portal, though delays can occur due to variations in dictation systems used across locations.
  • PCP calls patient with test results.

Referred
to Specialist

  • During a follow-up appointment or call, the PCP discusses imaging results with the patient, explaining the necessity of seeing a specialist and outlining the next steps.
  • Patient leaves the PCP’s office with basic information about the referral process, though they may not know the exact specialist or timeline.
  • Phenom notification via text or email provides patient information about their specialist and appointment.
  • Patient must confirm their appointment by clicking the link in the notification that was sent.
  • Patient is contacted to coordinate an appointment with the specialist, considering patient preferences for time and location.
  • Patient is informed about potential wait times, which average 10 days in the Springfield area.
  • Patient, driven by anxiety or uncertainty, may call the PCP’s office during this “black hole” waiting period for updates.
  • Specialist office staff may contact the patient for pre-visit requirements, such as completing forms or conducting lab tests.

Specialist
Appointment

  • Specialist reviews the patient’s symptoms, medical history and diagnostic test results (e.g., imaging, labs).
  • Specialist discusses the diagnosis, surgical options, potential outcomes, risks and benefits with the patient.
  • Surgery is decided as the best course of action.
  • Consultation includes a discussion of the surgery type, procedural details and expected outcomes.
  • Referrals for additional preoperative evaluations (e.g., labs, imaging) are created if required.
  • PCP is copied on notes from the specialist appointment and continues to track progress through the EHR.
  • Follow-ups from staff are triggered at 30 days.

Scheduled
and Prepared for Surgery

  • Scheduling staff call the patient to propose surgery dates and times.
  • Patient provides availability and confirms the schedule.
  • Confirmation is communicated to the patient, primarily via phone.
  • Patient is informed of required preparations, although written or digital confirmations are not consistently provided.
  • Patient is instructed to complete a history and physical (H&P) exam, usually within 30 days of surgery.
  • Patient schedules the H&P exam with their PCP or specialist.
  • Lab work (e.g., blood tests) and imaging (if needed) are completed.
  • Surgery staff contacts the patient 1–2 days before surgery to verify medication schedules, fasting requirements and arrival time.

Completes
Surgery

  • Patient arrives at the designated location within the hospital and checks in at the admission desk.
  • Staff validate the patient’s information, review presurgical requirements and direct the patient to the appropriate presurgical area.
  • Patient provides family contact information for updates through the Mutare system.
  • Family members receive tracking numbers to monitor the patient’s progress via a digital tracking board.
  • In some cases, family members are updated via phone or in-person discussions with the surgeon or medical staff.
  • Surgical team performs the operation and documents the details in the EHR.
  • Surgeon performs the procedure. Realtime updates are provided to family members via the Mutare system or staff communication.
  • Postsurgery, patients are transferred to the postanesthesia care unit (PACU) for monitoring and recovery.
  • Pain management and initial recovery care are initiated.
  •  Discharge instructions are created using the Cerner patient instruction system, tailored to the patient’s surgery and recovery plan.
  • Specialty team provides patient with verbal and written recovery instructions, including:
    • Medication use
    • Wound care
    • Activity restrictions
  • Staff schedule follow-up appointments with specialists and other providers as needed, and document these in the EHR.
  • For outpatient surgeries, staff conduct follow-up calls to monitor the patient’s recovery and address any post-operative questions.
  • Calls include reminders for follow-up appointments and guidance on postoperative care.
  • Patient is instructed to contact their surgeon’s office for ongoing concerns or follow-up care as needed.
  • All follow-up interactions are documented to ensure continuity of care and facilitate any necessary escalations.

Scheduled for Outpatient
Rehabilitation

  • Staff reach out to patient to initiate the scheduling process.
  • Phone calls are made during business hours using contact numbers provided in the referral.
  • Voicemail messages include instructions to call back along with relevant clinic hours.
  • Staff secure an initial appointment for the patient in the scheduling system.
  • Confirmation details, including time, location and therapist, are shared with the patient.
  • Automated systems generate reminders 48 hours prior to appointments via email or phone.
  • Reminder content includes appointment date, time and a checklist of required items (e.g., insurance card, previous reports).
  • Future appointments are scheduled based on the treatment plan.
  • Patient confirms or adjusts follow-up dates during therapy sessions or subsequent calls.

Attends
Outpatient Rehab

  • The rehabilitation center contacts the patient to schedule therapy sessions.
  • Therapists conduct an evaluation of the patient’s condition, mobility and postsurgical needs.
  • Therapy sessions involve exercises and activities tailored to the patient’s recovery plan.
  • Progress and updates are documented in the EHR and shared with the specialist and PCP.
  • Therapists monitor patient progress and adjust the plan as necessary.
  • The rehabilitation team assesses the patient’s recovery against established benchmarks.
View Technology Map

Step

Technology/Touchpoints
Visits Primary
Care Provider
  • FollowMyHealth®
Schedules Imaging
  • Cerner Scheduling Module
  • Phone
Attends
Appointment
  • Cerner
  • Imaging System
    • Philips PACS
    • MagView
    • 3Mensio
    • Circle 42
Receives
Results
  • Cerner
  • FollowMyHealth® Portal
Referred
to Specialist
  • Cerner
  • Phenom
  • Phone
  • Email
Specialist
Appointment
  • Cerner Millennium
  • Phenom
Scheduled
and Prepared for Surgery
  • Cerner Millennium Scheduling Module
  • Phone
Completes
Surgery
  • Cerner Millennium
  • Mutare
  • Phone
Scheduled for Outpatient
Rehabilitation
  • Cerner
  • Physician Office Systems (Integrated Platforms)
  • Manual Scanning Systems
  • Scheduling System
  • Insurance Verification Tools (Integrated with Scheduling System)
  • WebPT
Attends
Outpatient Rehab
  • Cerner Millennium
  • Rehabilitation Scheduling System (Unspecified Name)

Step

Pain Points
Visits Primary
Care Provider
  • Access to diagnosis and referral information is delayed and not easily available.
  • Delays in ability to schedule an imaging appointment.
Schedules Imaging
  • Lack of overall availability options for a timely appointment that aligns with schedules.
  • Scheduling relies heavily on phone-based communication with patients, which are time-consuming, and missed calls or voicemails prolong the process.
  • Calls that notify of patient appointments vs. coordinate to schedule one
  • Appointments that are scheduled without coordination do not work for the patient’s schedule.
  • No automated system exists for sending appointment confirmations or reminders resulting in delays or missing confirmations.
  • Critical details about fasting, attire or medication restrictions are prone to being misunderstood or forgotten because they are provided verbally without written follow-up.
Attends
Appointment
  • The need to provide the same patient information upon arrival despite sharing it in earlier appointments.
  • Misunderstanding or forgetting requirements (e.g., the need to fast) for the imaging appointment requires rescheduling or potentially alters the results.
Receives
Results
  • Reports are transmitted to PCPs, but there is no automatic notification system for patients, leaving them dependent on PCP communication for updates.
  • Delays in the availability of finalized reports with PCPs impact patient care.
  • Patients often experience confusion or anxiety due to delayed communication, leading to increased calls to providers and dissatisfaction .
  • Despite its availability, portal engagement is approximately 10%, limiting its effectiveness for providing updates or enabling communication.
  • Patients cannot directly access radiology images; only written reports are viewable in the portal.
Referred
to Specialist
  • The manual nature of referral coordination slows down the patient transition process, leading to delays in specialist appointments and potential dissatisfaction among patients.
  • Sometimes a match with a specialist may not align with a patient’s insurance or other preferences based on missed information within the automated system.
  • Communication with patients relies on fragmented tools, such as phone calls or inconsistent chatbot notifications, leaving patients anxious during the “black hole” waiting period.
  • Texts and emails to patients are frequently undeliverable due to outdated patient information, requiring manual follow-ups by referral staff.
  • Some patients experience technical issues or lack the digital literacy to effectively interact with automated systems.
  • Manual handling of pre-visit steps, such as lab work or form submission, increases the likelihood of missed or incomplete preparation.
Specialist
Appointment
  • Specialists often encounter inefficiencies when accessing patient information due to the fragmentation of systems and data, which can come through in a patient appointment.
  • Length of time to get into a specialist and have surgery can be a long during an anxious time.
  • Specialists and PCPs may not always be on the same page, which can cause confusion and distrust.
Scheduled
and Prepared for Surgery
  • Scheduling team contacts patients via phone to finalize surgery details, which is time-intensive and dependent on patient availability.
  • Chatbots are referenced as available but not effectively integrated into the scheduling process for streamlining patient communication.
  • Patients are informed about surgery details primarily via phone, without automated digital follow-ups or reminders. This limits patient engagement and increases reliance on memory.
  • Patients must manually schedule H&P exams, often resulting in delays and lastminute adjustments.
  • Verbal-only communication creates challenges in ensuring patients retain and follow instructions. Without written or digital reminders, compliance rates are inconsistent.
Completes
Surgery
  • Patients unfamiliar with digital platforms rely on paper instructions, which are prone to loss or misunderstanding. Lack of portal usage contributes to incomplete recovery compliance.
  • Allow patients to check in using a mobile app before arriving at the hospital.
  • Patients receive conflicting instructions on when to arrive for surgery.
  • Patients may not meet their surgeons preoperatively.
  • Missed follow up appointments.
  • The discharge systems used at the hospital do not offer seamless translation capabilities, making it difficult to provide clear instructions for patients who do not speak English.
Scheduled for Outpatient
Rehabilitation
  • On average, patients wait up to 10 days for specialist referrals or rehabilitation scheduling, creating a “black hole” experience. This uncertainty increases anxiety and leads to repeated inquiries.
  • Staff must digitize physical referrals, increasing the time needed to process each referral.
  • Many patients do not recognize the hospital’s phone number or are unavailable during business hours.
Attends
Outpatient Rehab
  • The automated system sends reminders that are sometimes mistaken for other healthcare appointments, particularly when patients have multiple engagements. This leads to no-shows or confusion about scheduled times.

Step

Thinking

Feeling

Quotes
Visits Primary
Care Provider

“I wasn’t expecting this. I hope it’s not a cause for concern.”

“I want to get this handled as soon as I can to see if something is wrong.”

Anxious

Overwhelmed

 N/A
Schedules Imaging

“We keep playing phone tag. Will I ever get an appointment?”

“How can I rearrange my schedule to make this work?”

“What do I need to do and remember? I should probably write this down.”

Preoccupied

Frustrated

 N/A
Attends
Appointment

“I hope I have all the information.”

“Why do I have to fill this out again?”

“I hope everything is OK.”

Nervous

 N/A
Receives
Results

“When am I going to get my results?”

“Where can I access them? Maybe I should call and check.”

Anxious

“Patients see their results before their provider does, and they panic because they don’t understand what they mean.”

“We get a lot of calls from anxious patients saying, ‘Why hasn’t my provider called me yet? ”
Referred
to Specialist

“This is scary.”

“How soon can I get in?”

“Is this the best specialist for this?”

Scared

Overwhelmed

Apprehensive

“Patients get really mad about that, which they should. We don’t even get an appointment back for 10 days from another organization.”

“There’s no patient-facing interface where they can see the status of their referral. They’re just waiting.”

“There’s no interface between Phenom and TouchWorks—our team has to manually enter every referral.”
Specialist
Appointment

“Am I in good hands?”

“What are the next steps?”

Anxious

 N/A
Scheduled
and Prepared for Surgery

“This is taking so much time.”

“There is so much to remember and do to get ready for surgery.”

“Why do I have to do this?”

Overwhelmed

Nervous

“ Sometimes patients wait until the very last second to schedule their history and physical, and then we’re scrambling to squeeze them in.”

“ Some surgeons give instructions over the phone, but patients don’t always understand—one might say, ‘I didn’t eat anything, just a breakfast sandwich,’ and now they can’t have surgery.”
Completes
Surgery

“What will my recovery be like?”

“I hope I can get back to my normal life soon.”

“Was it effective?”

Hopeful

Curious

 N/A
Scheduled for Outpatient
Rehabilitation

“This is time-consuming and a mess.”

Frustrated

“Patients tell us, ‘I’ll just look it up on Follow My Health,’ but we have to say, ‘Sorry, we’re not in that system.”

“There’s no way for patients to self-schedule, so we play phone tag.”
Attends
Outpatient Rehab

“How much longer will I need to do this?”

“I’m feeling better.”

“I’m ready to get back to my life.”

Optimistic

Accomplished

 N/A

Step

Opportunities
Visits Primary
Care Provider
  • Enable the opportunity for scheduling imaging appointments in-office before patients leave the appointment
  • Make diagnostic information and next steps easily and quickly accessible in the patient portal.
Schedules Imaging
  • A self-scheduling portal for patients to choose time slots based on their availability will empower patients and reduce the no-show rate.
  • Automate patient reminders using text messages or chatbots with interactive confirmation features.
  • Email guidelines with fasting, attire and medication restrictions.
  • Interactive patient preparation tool. Patients can input their procedure type, and the tool provides customized preparation steps with visual aids, reminders and FAQ.
  • Consolidate all patient communication (calls, texts, emails) into one platform.
Attends
Appointment
  • Enable patients to confirm appointments, upload necessary documents and complete intake forms via the app.
  • Biometric and contactless check-in. Patients can use facial recognition, fingerprint scanning or QR codes via a mobile app to check in, confirm appointments and complete necessary documentation upon arrival.
  • Offer a virtual assistant to guide patients through the check-in and imaging process.
Receives
Results
  • Notify patients of results via the patient portal immediately after finalization.
  • Implement a multichannel notification system that delivers imaging results in real-time to patients and providers.
  • Use an AI-driven system to automatically suggest follow-up appointments based on results.
Referred
to Specialist

• A unified patient engagement platform consolidates notifications, scheduling, check-ins, results and follow-up interactions into a single interface.

• Use automation to track and notify patients about pre-visit requirements.

• Provide prefilled appointment information cards, which can be handed to patients during their PCP visit to set expectations, reducing anxiety and unnecessary followup calls.

• Use API integrations to instantly validate insurance network compatibility.

• Provide a scheduling tool that syncs with specialist calendars and patient availability.

• Use AI to guide patients through appointment confirmations or rescheduling via chat.

• Use automation to track and notify patients about pre-visit requirements.

• Provide patients with pre-visit preparation kits. These kits can include forms, FAQ and checklists to ensure patients are fully prepared, reducing no-shows or delays.
Specialist
Appointment
  • Expand telehealth capabilities for specialist consultations to improve timeliness of appointments.
  • Introduce real-time note sharing during specialist visits. This verbal summary ensures patients leave with a clear understanding of the visit, reducing followup questions.
  • Expand communication channels and/or create better governance around existing channels to improve coordination between PCPs and specialists.
  • Create a digital tool that maps out the entire patient journey from surgery to rehabilitation to help patients understand next steps.
Scheduled
and Prepared for Surgery
  • Develop a mobile app or chatbot that acts as a virtual assistant for presurgical preparation and/or provides preoperative instructions
  • Create a patient self-scheduling portal.
Completes
Surgery
  • Expand Mutare’s functionality to provide real-time updates on expected surgery start times and delays.
  • Introduce pre-translated discharge templates in the Cerner and Cranes systems for common surgeries.
  • Attach QR codes to printed discharge instructions that link to detailed, multilingual digital guides.
  • Develop a mobile app that tracks patient recovery and provides postsurgical support.
  • Implement AI-driven chatbots to manage appointment scheduling and rescheduling.
  • Use visual aids (e.g., diagrams, charts) to clarify recovery instructions in the discharge packet.
Scheduled for Outpatient
Rehabilitation
  • Allow patients to schedule a callback time through an automated system.
  • Allow patients to customize their reminder preferences, including frequency and format (text, email or call).
  • Sync therapy appointments with FollowMyHealth for unified scheduling.
  • Enable rescheduling through text messages for missed appointments.
  • Create a patient-facing portal that integrates scheduling, therapy details and session feedback.
  • Provide a one-page guide outlining the steps to schedule
Attends
Outpatient Rehab
  • Create a patient-facing portal that integrates scheduling, therapy details and session feedback.
  • Add a referral confirmation stamp or label to physical paperwork given to patients.
  • Provide a one-page guide outlining the steps to schedule therapy sessions, including FAQ.
  • Create a checklist outlining therapy milestones tailored to the patient’s recovery plan.
  • Send post-rehabilitation feedback forms to patients.
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