Building an Efficient, Effective Women’s Imaging Service
Ask providers of women’s imaging services why they stick with the niche, in spite of declining reimbursement and the risk of malpractice suits, and the answer you’ll get is a simple one: patient interaction. It’s the ability to work directly with patients in potentially life-changing ways that continues to attract talented radiologists to the subspecialty, and that’s also the factor that makes mammography the unseen backbone of an imaging practice. Women have a unique opportunity to get to know their radiologists, and women are more likely to return to those radiologists for their other imaging needs. Kerry Chandler, MD, director of the breast-imaging section at Wake Radiology, Raleigh, North Carolina, says, “There’s a lot of satisfaction in it. You have a lot of interaction with patients, more so than in other subspecialty areas, and you can do something where you’re making a definite difference. You can see it and know about it. It’s not the most well-reimbursed imaging modality in radiology, and the malpractice issue has been a problem, but all in all, the positives outweigh the negatives.” Tina Hodge, RT(R), manager of breast imaging at the Montgomery Breast Center in Alabama, describes the business of providing women’s imaging as “investing in their influence.” She says, “We know that we can offer good services to women, who will, we hope, direct their families’ care back to the center.” That notion is seconded by Stephen Feig, MD, director of breast imaging at the UC Irvine Breast Health Center (UCIBHC) in California, who adds that women who receive their breast imaging in a hospital setting are more likely to return there for any further treatment that might be needed. “Breast imaging is good public relations,” he says. “It draws patients to the medical center. Although we may lose money on it, the hospital will gain downstream revenues from patients who are there for breast surgery, breast radiation therapy, oncology, and even pathology, because we’re there.” Throughput Counts Clearly, there are strong business reasons for both hospitals and OICs to invest in building high-quality women’s imaging services. To keep the doors open despite low reimbursement, there also is a compelling need to construct an efficient patient flow. The process begins with scheduling; Montgomery Breast Center’s patients are sent reminder letters two months in advance, and if they haven’t scheduled exams by a month after they were due for mammograms, another reminder is sent. UCIBHC sends reminder cards, while Wake Radiology sends yearly reminder letters and allows patients to request appointment times through its Web site. “Mammography is one of the few areas where we can let the patient initiate the scheduling,” Chandler explains. At UCIBHC, 15 to 20 minutes are allotted for a screening exam, while diagnostic time slots run up to 45 minutes; at Wake Radiology, screening patients are assigned five-minute slots, while 20 to 30 minutes are allotted for a diagnostic exam. Feig explains that because UCIBHC still uses analog mammography at one of its three sites, patient throughput can take slightly longer there. “We try to take as much of the preregistration and demographic information as we can when the patients call to schedule, so when they get here, we can avoid backups at the front desk,” he notes. Wake Radiology uses what Chandler calls a subwaiting area as an intermediate space between the front waiting room and the mammography suite; patients who have already changed into their gowns wait in the second room until it’s time for their exams. “We got them robes that aren’t skimpy so that they wouldn’t feel uncomfortable waiting in them,” Chandler says. “They could wear them to the mall. Now, the technologists aren’t always tied up helping patients undress and dealing with clerical issues.” Freeing the technologists to focus on the exams themselves has enabled the center to reduce total patient time for screening mammography to an average of 13 minutes.
Similarly, UCIBHC’s center has been designed for optimal flow for both patients and technologists. “When you design a center, you want to make sure there’s as little walking time as possible for the technologists, and you don’t want the patient to have to backtrack. It’s a natural flow: registration desk to dressing room, dressing room to exam, and then out,” Feig says. Wake Radiology employs a specially trained group of staff members who are entrusted with calling women to notify them of a suspicious finding on a screening mammogram and to schedule the patient for diagnostic work-up. “They’re trained in how to talk to people, and we look for a certain type of person who can be empathetic and reassuring,” Chandler says. Wake Radiology has other protocols in place as well: “We don’t call anybody on Friday about abnormal screening results because we don’t want them staying anxious all weekend about their mammograms,” she continues. “Those who need to come back we schedule for the same day or a day after; if the recall time is over a day, I’m notified, and we reschedule some less-urgent screening mammograms.” Feig also emphasizes the importance of knowing how to discuss results with patients. “It’s important to handle that properly,” he says. “We speak to the diagnostic patients directly; it’s not a very cost-effective way to do things, but the patients really like it. If I see something suspicious, I’ll talk to the patient and let her know she needs a biopsy, but I won’t mention the word cancer.” At UCIBHC, same-day results are available for patients with digital images who were examined in the morning; for those with film images, or whose exams were performed in the afternoon, results go out the next day. If a mammogram has a suspicious finding, “We have a staff member who is trained to talk to the patient, and that person lets her know that most of the time, it’s nothing serious,” Feig says. Patients are scheduled for follow-up care, and results are tracked so that the center knows which have returned and which still need their diagnostic studies. Montgomery Breast Center also offers same-day results, when possible, “so patients can come in for a screening, and we can do everything (all the way up to a biopsy) during that same visit,” Hodge says. Biopsy results are returned within 24 hours. “We bring the patient back the next day to go over the results, and then, we help her go to the next level,” Hodge explains. “We make all the appointments for her.” Hodge plays the role often filled by a nurse navigator, facilitating this process for the patient. All three centers emphasize the importance of building personal relationships with patients. “We always talk to the patients who come back personally, unless we call the physician and that person specifically wants to talk to the patient,” Chandler says. “We think you need face-to-face communication. It’s time consuming, but it really is worth it. The patients never forget it.” Reading-room Workflow The conversion from analog to digital mammography continues to create workflow hiccups in the reading room as breast imagers find ways to adapt to the necessary evil of switching back and forth between film and workstation reading. At UCIBHC, one of two screening centers uses analog mammography. “We have digital mammography in the diagnostic center and one of the screening centers, but at the other, our volume has not been sufficient for the hospital to purchase digital equipment,” Feig explains. “We have a higher proportion of diagnostic and consultation work because we practice in an area where there are a lot of freestanding imaging centers.” Analog prior studies are pulled in advance, and the current studies are read the day after the study is performed, with voice recognition ensuring that the reports are ready immediately. Wake Radiology’s mammography equipment is all digital, but dealing with prior studies on film can often lead to delays in turnaround time. “With film prior studies, I want to see every single one the patient ever had,” Chandler says. “We try to look at as many prior mammograms as possible before we decide that a patient’s current mammogram is abnormal and she needs to return for more images. Prior mammograms performed in our own community are easy to obtain. If a patient has had mammograms performed out of our state, however, we may wait a week or so to get these studies for comparison before reading her current mammogram.” Likewise, the Montgomery Breast Center opened its doors seven years ago with digital equipment, and it uses a courier to retrieve analog prior studies within the community. “If the prior studies are out of town, we try to get somebody to go get those as well,” Hodge says. When analog prior studies are needed for comparison, Wake Radiology has the film jackets sent along with the current study to the reading area, where they are read on a viewbox. In the reading room, Chandler dictates her report to a staff member. “I have an assistant; all she does is enter what I say into the computer, and the second she does that, a report is generated with my name on it, and she signs that,” she says. “I can’t make it any quicker. The second I sit down and start reading, the report is generated. I haven’t found a reporting system I’m very happy with for diagnostics yet, so I just go ahead and dictate.” Because UCIBHC is part of an academic center, residents play a big role in its reading process, Feig explains. “The residents look at the screening cases, I review them with them, and then they dictate them,” he says. “We can easily get through 30 cases in an hour, but the residents have to review the exams first, and they do the dictation.” Computer-aided detection is used at each of the three centers, though its overall contribution to sensitivity remains a matter of some debate. Hodge says that Montgomery Breast Center’s two radiologists appreciate what the software tool brings to the process. “There are times when it will show you things you know are benign, but there are times when it also picks up really subtle abnormalities,” she says. Chandler says that she likes the tool as well. “It’s good as a second reader. I find that it does make me take a second look at certain calcifications. Rarely do I ever call something back based on computer-aided detection, but sometimes it catches things I already don’t like, and that’s a kind of confirmation.” Feig adds that computer-aided detection does not help every reader equally. “The people computer-aided detection will help the most are the least experienced people,” he says. “It’s excellent for calcifications, but it’s not as good for masses; that’s just the limitation of it right now.” When Mammography Is Not Enough Breast imaging entails more than mammography, and depending on the location, scope, and affiliation of the practice, a range of modalities and technologies may be employed. The most frequently used are ultrasound and MRI, used as complementary exams when mammography alone is inadequate. For women whom the center has identified as high risk, Wake Radiology will “nudge the referring physician to consider breast MRI,” Chandler says. “We think it’s a decision the patient and the referring physician need to make together, but we do bring it up as something to think about. We don’t recommend it, however, unless the patient has dense breasts and some kind of risk factor.” UCIBHC is rolling out a new template for its patient letters (explaining results in lay terms for a patient’s records) in which MRI is recommended for high-risk women. “We recommend that they consider it,” Feig says. “We don’t want to recommend it outright because the referring physicians may be sensitive to it, or the patient’s insurance may not pay for it, but we include a sentence about how the patient should consider breast MRI because she’s high risk.” For patients with palpable lumps that are not visible on a screening mammogram, ultrasound is a reliable option. “We always go to ultrasound,” Feig says. He explains that when a referring physician writes an order, most of the time, that order is for breast imaging (not mammography alone), so there’s no reimbursement risk in imaging a patient with ultrasound on the spot, if needed. Chandler concurs, saying, “If we can’t see it on mammography, of course we’re going to do an ultrasound and look for it there; then, where to go next really depends on the physical exam. Even if the ultrasound appears negative, we can decide to biopsy a lump based on the physical exam.” Emerging modalities play a role as well. Montgomery Breast Center has embraced breast-specific gamma imaging (BSGI) and elastography, going so far as to participate in a recent study of the modality. “Anything breast related, we’re doing,” Hodge says. “Our radiologists do a lot of research; they go to a lot of breast meetings and stay very current with what’s going on and what the buzz is. Our administrator watched BSGI for a couple of years and decided it was definitely something she wanted here.” Like Montgomery Breast Center, Wake Radiology offers BSGI, and the center participated in an elastography trial for a year and a half. “We don’t make new modalities part of our usual work-up until we’re absolutely convinced they have utility,” Chandler says. “We haven’t relied on elastography until the recent past. We had our own ideas about it, but we wanted to see data.” She notes that elastograms have proven challenging for technologists because the pressure on the breast has to be just right and must remain consistent. BSGI, by contrast, has become a go-to test for patients who aren’t eligible for breast MRI. “Our referring physicians seem to like BSGI a lot these days,” she says. “With insurers getting more stringent about breast MRI, they’re asking for it more and more.” At the two practice-affiliated breast centers, a range of complementary women’s imaging services also are offered. Wake Radiology has uterine-fibroid embolization, hysterography, bone densitometry, and pelvic ultrasound. Montgomery Breast Center also performs bone densitometry, and Hodge notes that offering these ancillary services and alternative breast-imaging modalities can help compensate for mammography’s relatively low reimbursement. Community Effort In the event of a cancer diagnosis, it’s critical to ensure that patients receive the care that they need as promptly as possible; as breast surgeons, oncologists, and other members of the patient’s future care team join the process, what began as a simple screening mammogram evolves into a community effort. Montgomery Breast Center is attached to a cancer center, so medical oncologists and radiation oncologists are part of the staff available to patients from the breast center. The center also has relationships with breast surgeons to whom it regularly refers. “It’s definitely a team approach,” Hodge says. New cases of breast cancer are discussed at a pretreatment conference, during which all the members of a patient’s care team, from oncologists to radiologists to pathologists, come together to discuss the best approach. The center once employed a nurse navigator, but its financial situation meant that it could not support her. “Because of reimbursement being the way it is, we were unable to keep her,” Hodge says. “It’s just not something that’s reimbursed.” At UCIBHC, surgeons and medical oncologists confer with breast-imaging radiologists throughout the day; weekly, multidisciplinary tumor boards enforce the collaborative approach. “It’s easy because we are all located in a single multidisciplinary breast center. It’s a situation many places don’t have the good fortune to have,” Feig says. “We’re there when the other clinicians look at the patients, so we can work them up at the same time. We review the images with the clinicians at our workstations. It’s not a very cost-effective system, but it’s good for patient care.” In Raleigh, similar weekly tumor boards at Rex Hospital bring together breast surgeons, oncologists, radiation therapists, and pathologists. “Problem cases are presented and discussed at the conference,” Chandler says. “We share a building with our own radiation-oncology practice, and there is a medical-oncology practice in the building, but this practice is not part of Wake Radiology. These practices often share patients, making it easy for us to assist in providing care to their patients.” Marketing and Outreach Because women’s imaging can be the linchpin of a practice or hospital’s overall business, patient-targeted marketing is of particular importance, and all three centers advertise to patients in local markets while maintaining referring-physician outreach. “We’ve run ads about our breast MRI in Orange Coast magazine and a few others, and that’s been very helpful,” Feig says. “We also just hired a marketing person to go out to physicians’ offices and talk about breast MRI, and we’re interested to see whether that works well.” Montgomery Breast Center advertises to patients in the local newspaper, and the center has branched out further to advertise on the Web and to sponsor an educational site, breastcancertv.net. “It’s very helpful for patients with questions. Several physicians in town have put videos on there about what to expect if you’re going through radiation therapy, breast biopsy, and so on,” Hodge says. Wake Radiology also advertises in local newspapers and magazines, and it adds local medical publications to the list. “People pick them up here and there, and they do make an impact. We also sponsor things like public radio and local television shows, and we sponsor a lot of charity events that help to get our name out there in front of the public,” Chandler says. Marketing representatives visit referring physicians’ offices to discuss the modalities offered, and Wake Radiology’s radiologists will even meet with referrers to touch base on customer service. “The best way to market a women’s imaging practice is to take good care of your patients and to communicate well with them,” Chandler says. “That’s what they, and their referring physicians, appreciate.” Additional Reading - The Cosmetic Frontier: BOTOX and Beyond Cat Vasko is associate editor of Radiology Business Journal.
“We always talk to the patients who come back personally, unless we call the physician and that person specifically wants to talk to the patient. We think you need face-to-face communication. It’s time consuming, but it really is worth it. The patients never forget it.”
—Kerry Chandler, MD, director, breast imaging section,
Wake Radiology, Raleigh, NC