WatchMe: Utilizing Digital Tools to Improve Patient Education, Satisfaction and Attendance in the Echo Stress Laboratory

PROJECT LEAD(S):

Aimee Camano MSN FNP-C

William Bradley DNP

EXECUTIVE SPONSOR(S):

Isaac Kwan - Cardiac Sonographer, Supervisor

Dr. Kirsten Fleischmann -  Associate Chief of Cardiology, Ambulatory Operations

Monet Strachan - Technical and Quality Director, Adult Echocardiography

Dr. Mike Salerno – Echo Laboratory  Chief Medical Director, Cardiology

ABSTRACT  

Heart disease remains the leading cause of mortality in the United States affecting both men and women (Centers for Disease Control and Prevention, 2024). At UCSF, a range of cardiac stress tests – including Treadmill Stress Echo, Stress EKG Test, Supine Bicycle Stress Echo, Dobutamine Stress Test and Tilt Table Testing – are essential diagnostic tools for preventing heart attack and progression of cardiovascular diseases. However, these tests currently face a scheduling wait time of 1-2 weeks, with daily patient cancellations, reschedules and no-shows at 10.2% contributing to an estimated annual revenue loss of $1,861,779. 

The primary causes of missed appointments leading to revenue loss include patient refusal, inability to follow instructions when holding beta blockers due to limited understanding of the tests, inappropriately ordered test due to acute disease conditions such as musculoskeletal limitations and uncontrolled hypertension. To address these challenges, developing a digital education tool partnering with Mytonomy, a contracted media company, tailored specifically for UCSF echo procedures and digitally updating our stress laboratories by placing television sets in the waiting room and individual stress rooms will improve patient education, satisfaction, and reduce missed appointments. This tool will be integrated in the Echo Lab website and embedded within the Epic system, allowing providers and patient care teams to shared decision making by providing real-time educational resources with patients at the point of care. This informative and collaborative approach to ordering tests, encourages patients engagement thereby increasing the chance of patients showing up for the appointment. In the primary setting, a systematic review by Coronado-Vasquez et al., shows  strong evidence supporting use of decision aids in improving knowledge, risk and patient satisfaction in their plan of care (2020). 

Following implementation, a targeted campaign: WatchMe is designed to raise awareness about the digital platform available to the UCSF community. The  impact will be measured by analyzing Epic data and Press Ganey Patient Satisfaction scores in six months post-intervention. By enhancing patient education and provider support, WatchMe aims to improve clinical accessibility, reduce delays in critical cardiac testing necessary for early diagnosis and treatment of heart disease, and mitigate revenue loss- ultimately advancing patient care and operational efficiency at UCSF.

TEAM 

Aimee Camano MSN FNP-C- Nurse Practitioner

William Bradley DNP, ACNP Nurse Practitioner

PROBLEM  

Over the past six months, the UCSF Parnassus Echocardiography (Echo) Lab has experienced a 10.2% daily average  patient cancellations, reschedules, or no-shows. This trend has adversely affected scheduling efficiency, revenue, and patient satisfaction. As of February 14, 2025, the average wait time for stress testing appointments is 1-2 weeks. In a similar internal study done at the UCSF Radiology Unit by Anthony et al. (2022), the initial no show rate was at 18.1%,  after calling patients two- to four days prior to scheduled appointment, the rate decreased to 4.3%. Currently, the echo lab is sending calls and text messages prior to appointment and the no show rate from August 19, 2024 to February 14, 2025, a total of 122 working days remains at 10.2%.

A significant contributor to these missed appointments includes orders that do not correlate to patient’s physical condition prior to testing such as mobility limitations, uncontrolled hypertension and receiving beta blocker treatment. Moreover, patients' limited understanding of procedures, leading to unmet expectations and test changes, is reflected in the 2025 PressGaney score of 94.3% for staff's explanations. Consequently, more time is needed to describe the procedures leading to increased waiting time in registration,shown at 92.91% (PressGaney, 2025). These factors lead to delays, rescheduling, or cancellations, thereby impacting future scheduling availability and revenue. Overall, the likelihood to recommend stress testing is at 55th percentile with a decrease in trend since 2021 (PressGaney, 2025). 

TARGET

The primary beneficiaries of this project are patients aged 18 to 90 scheduled for cardiology stress testing. Our goal is to reduce missed testing opportunities from 10.2% to less than 5% within six months by improving access to educational resources while fostering collaborative decision making when test ordering. Data will be collected by tracking no-shows, cancellations, and rescheduled tests, aiming to enhance outpatient and inpatient access to cardiac stress testing. Furthermore, the echo lab team seeks to improve patient satisfaction by decreasing the wait time in registration and improve likelihood to recommend.

Table 1. Collected Data from 8/19/24- 02/14/25

Table 2. Cost of Studies 2025 - Average Cost of Procedures Billed  $5,881

 Table 3. RETURN ON INVESTMENT (ROI) – $857,879

 GAPS

Due to time constraints during clinic visits, patients often struggle to comprehend and visualize the procedures. The current age for stress testing is over 65 years old, with diverse educational backgrounds and language proficiencies. Providing educational videos in multiple languages with clear visual demonstrations will enhance equity and accessibility for all patients.

 INTERVENTION 

 Developing a digital educational tool by partnering with Mytonomy focusing on UCSF-specific echo procedures such as Treadmill Stress Echo, Treadmill Only, Supine Bicycle Stress Echo, Dobutamine Stress Test, and Tilt Table Testing. Existing educational guidelines and protocols will enhance accuracy in creating videos available in the following platforms: Epic system (while ordering), MyChart for patient access, and UCSF Echocardiology website. Once the videos are produced, a robust campaign (WatchMe) emphasizing ease of access to multiple clinic sites within UCSF will start and continue until the 6^th month. Utilizing a multi-channel communication through emails, intranet, posters and creating events in major outpatient clinics in UCSF to hold Q&A sessions while showing videos of our stress laboratory.  A digital upgrade to install television and other electronic devices (IPAD) will then be utilized at the exercise lab to show the video to patients. At this stage data collection will commence to document missed opportunities and patient satisfaction for comparison. 

PROPOSED EHR MODIFICATIONS

• Integration of Video Links: Incorporate video links into stress testing order forms within the Epic system which will then be available in MyChart for patients to view.
• Enhanced Ordering Process: Add prompts to provide real-time information to providers and patients regarding the ordered tests.
• Updated Online Resources: Revise the UCSF Echo Lab website to include access to frequently asked questions and educational materials.
• Update the digital tools at the echo lab with television sets and other digital tools (IPAD).

SUSTAINABILITY and SCALING

 The videos wil be available to UCSF with Mytonomy licensing for two years. Since the video links will be automatically embedded in the EPIC system when orders are placed, all providers including care teams have access to this digital educational tool, strengthening shared decision making and engagement in the testing modality. The project can scale up to all exercise labs in the UCSF system including remote sites. Team meetings will be held monthly to address barriers, successes and adjust strategies to sustain momentum. The same model can be replicated in multiple procedural areas within the UCSF system to improve missed opportunities for testing. Furthermore, potential research opportunities in measuring exercise capacity with digital tools to improve exercise time will be available in the future. 

 Table 4. BUDGET - Projected Cost $50,000

References

Anthony, R., Fleischman, K., Bradley, W., Chao, C., Lee, S., Greenway, J. (2022). Myocardial Perfusion Study No Show Rate.

Coronado-Vázquez, V., Canet-Fajas, C., Delgado-Marroquín, M. T., Magallón-Botaya, R., Romero-Martín, M., & Gómez-Salgado, J. (2020). Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review. Medicine, 99(32), e21389. https://doi.org/10.1097/MD.0000000000021389

Centers for Disease Control and Prevention. (2024, October 24.). Heart Disease Facts. https://www.cdc.gov/heart-disease/data-research/facts-stats/index.html

 PressGaney. UCSF Echo Lab Parnassus. (2025, February 21).  Breakout Scorecard.