|Mary Fran Moliter, administrative director, (left), and Ellen B. Mendelson, MD, director, breast imaging, Northwestern Memorial Hospital, Chicago.|
It may still be 3 years before Northwestern Memorial Hospital unveils its 1 million-square-foot new Prentice Women’s Hospital, but the Lynn Sage Comprehensive Breast Center, which will occupy the fifth floor of the new building, is already gearing up for the move. Fortunately, it has plenty of experience with relocation. Since its inception in 1994, the breast center has grown from two outpatient rooms to an entire floor of the hospital’s 5-year-old Galter Pavilion. Shortly after it made that move, increased patient demand required the center to open an overflow breast screening facility across the street. In 2007, the breast center will move once again when it relocates to the new half-billion-dollar building.
“It’s very exciting,” says Ellen Mendelson, MD, FACR, director, breast imaging, and professor of radiology. “The plans have all been drawn, the ground has been broken, and everyone is looking forward to the completion of the new building.” When it opens, the new women’s health facility will rank as one of the top three maternity centers nationally and will provide a full complement of services for women, including breast disease, genetics, infertility, cardiology, osteoporosis, mental health, gynecologic oncology, and geriatrics. The Lynn Sage Breast Center is currently the Midwest’s largest comprehensive breast center. Seven radiologists work in the breast center with about 38 technologists and 40 support staff. In total, the center has more than 100 employees and sees up to 200 patients a day. More than 50,000 procedures are performed annually.
Most hospitals view breast imaging, particularly mammography, as a loss leader, netting little revenue but still bringing in consumers, who require other services. Even though Northwestern Memorial recognizes the problem of low reimbursement rates for mammography, its administrators understand and support the value of women’s imagingnot only as a critical service for a large segment of the population but also as an indirect contribution to profitability by resulting in other revenue-generating services, such as medical and surgical treatment of cancer. “It’s well recognized that women’s imaging is a critical service and that all the other programs are built around it,” says Mendelson. “All subsequent treatment depends on the initial assessment through imaging.” Northwestern Memorial’s administrators also support the view that women are often the health care consumers for their families and that if a woman becomes committed to a specific service within a hospital, she is likely to bring her family members in for other services.
FFDM Fuels efficiency
Still, recognizing the financial pitfalls of diagnostic mammography, the breast center has focused on efficiency as a means of cost-containment. The hospital’s commitment to the acquisition of full-field digital mammography (FFDM) has contributed to improved throughput and eventually is expected to result in cost savings when the complete conversion from film screen to FFDM occurs. In general, mammography is the last modality to be converted to digital technology, largely because of the low reimbursement rates. The breast center currently has four digital mammography systems and 10 film screen units. When the breast center moves into the new building, it will have nine digital systems.
One of the reasons Northwestern Memorial has been on the forefront of this technology is that it was the first institution in the country to conduct a FDA-approved study involving FFDM. R. Edward Hendrick, PhD, FACR, director, breast imaging research, and a core group of Northwestern Memorial’s radiology and breast center staff in the late 1990s studied more than 700 patients to determine the efficacy of FFDM.1 The breast center is also one of 19 institutions participating in the Digital Mammographic Imaging Screening Trial (DMIST), a study of the American College of Radiology Imaging Network (ACRIN). DMIST is an international study comparing FFDM to film screen mammography.
“Our hospital gave birth to digital technology, which makes everyone here very committed to new technology,” says Robin Loebach, technical manager, breast center. Loebach notes that the technologists and support staff prefer FFDM over film screen mammography because it provides greater efficiencies and fewer lost images. The utilization rate of FFDM is twice as high as film screen mammography. In fact, after a digital system was installed in the overflow screening facility, more than 50% of the patient population at that site is now screened on the device. “I’ve found technologists waiting in line to use the digital system,” says Mendelson. Currently, 35% of all mammographic screenings are digital and this rate continues to climb as staff becomes trained on the new equipment and additional digital systems are added.
To help train technologists and radiologists on FFDM, Northwestern Memorial offers a full-day continuing education program. The course, taught by Hendrick, is offered every other week and includes hands-on training with workstations and covers quality control for physicists and technologists. A large number of clinical cases are presented in both hard-copy and soft-copy format, and radiologists are exposed to the types of image-quality problems and artifacts that can occur in digital imaging.
Like many institutions that have started acquiring FFDM, Northwestern Memorial’s Breast Center struggles with supporting both a digital and film screen environment (see story, page 18). The breast center has gradually replaced film screen units with digital systems but has done this at a cautious pace due to the high cost and to allow for a smooth transition. But at the same time it becomes challenging for radiologists to conduct studies involving both digital and analog images. “It can be very tricky for radiologists reading images if you have a patient who in 2001 had an analog examination, came back in 2003 and had a digital mammogram, and then in 2003 had an analog mammogram because there were no digital systems free at that time,” says Mendelson. Eventually, as the breast center acquires more digital systems, it will be able to avoid this problem by having every patient screened digitally.
Patient feedback concerning FFDM has also been extremely positive primarily because of the faster turnaround. “We eliminate about 10 minutes of patient wait time that used to occur waiting for the film to be developed,” says Loebach. “Any time you add extra waiting for a patient who is already anxious and apprehensive, you increase their stress level, which is not good.”
The interior layout of the new breast center was also designed for the comfort of patients. One of the challenges was to take the breast center’s high-volume service and humanize it, so patients would feel more comfortable. “We’ve had times when there were 20 to 30 women in the waiting room, which is overwhelming for patients,” says Loebach. To respect patients’ privacy and ease their anxieties, Mendelson, Loebach, and other breast center staff developed a unique design that incorporates nine pods, which will be run almost like small units. Each of these pods will have its own waiting and dressing areas. “Our goal is to take an uncomfortable procedure like mammography and try to make it as comfortable as possible for the patient,” says Loebach.
The breast center also will have similar dedicated locations for ultrasound patients and a large interventional suite for patients undergoing breast procedures. Space has been allocated on the floor of the breast center for a magnetic resonance imaging scanner. “Our MR utilization has increased significantly, particularly due to our consulting practice, so having this technology within our center makes a lot of sense,” says Mendelson. The new breast center will also have a medical oncology and surgical area for breast cancer patients. Since the building will house a full range of women’s health services, breast patients will also have access to genetic counseling, OB/GYN ultrasound, general ultrasound, and bone densitometry, as well as general medicine and imaging.
In designing the new breast center, one of the most important aspects has been allocating space based on projected growth. Loebach, who has worked for the breast center for 10 years, notes that the biggest change she has seen is the continued increase in demand for services. Because FFDM is more efficient and takes up less space, she adds that the new facility will eventually be able to treat even greater numbers of patients. “Even though the digital technology is more expensive, ultimately we will be reaping financial benefits as far as throughput is concerned,” says Loebach.
Mendelson points out that the full integration of women’s health services will also create greater efficiencies through improved communication and work flow. For a number of years, the breast center has recognized that the best way to provide breast care, whether it involves benign or malignant conditions, is
by using an interdepartmental team. Meetings involving all specialties are held weekly to discuss current cases. Outcomes data, related to service standards, such as patient satisfaction, patient wait time, and “availability of next appointment,” are closely assessed to ensure that the breast care team maintains its commitment of providing patient-focused care. Financial outcomes data are also studied, particularly with attention given to some of the procedures that are more profitable for the department, such as ultrasound, MRI, and various interventional procedures.
A Larger Umbrella
According to Loebach, one of the reasons plans have progressed so smoothly with the development of the new Prentice Women’s Hospital is that Northwestern Memorial’s administration several years ago created a Women’s Division, which served to integrate all of the women’s health care services under one umbrella. Unlike many hospital breast centers that have direct reporting relationships with either radiology or obstetrics/gynecology, Northwestern Memorial’s breast center reports directly to the senior vice president of the Women’s Division. “It stands to reason that we should be part of the Women’s Division because breast imaging is a service that all women need,” says Loebach.
A collaborative working environment with employees committed to patient care has created a strong culture within the breast center that attracts highly skilled radiologists, technologists, nurses, and support staff. At a time when radiologists and technologists are in short supply, the breast center has experienced extremely low employee turnover. “Employees here really want to make a commitment to women’s health care, so we’re fortunate to have such a dedicated and experienced staff,” says Loebach. “In return, we like to reward them by offering alternative work arrangements such as flex scheduling.” This focus on employee needs has contributed to the breast center’s excellent reputation as an employer.
This reputation and the scale of the construction project have caught the attention of hospitals throughout the United States. Many institutions send staff to tour the breast center, as well as other services within the Women’s Division, to learn how to develop similar programs. Loebach is quick to point out that one of the comments visitors make is how committed the breast center staff is to patient care. “At our center, we see as many as two to four new cancers a day, which is a lot. But at the same time, our staff knows that we’re seeing it at earlier stages and that the prognosis and treatment are generally quite effective,” Loebach says. “Our employees are committed because they know they can make a difference in a patient’s life.”
FFDM and IHE Work Flow
|David Channin, MD|
It is not surprising that breast center administrators are usually advocates of full-field digital mammography (FFDM). This new technology has the ability to bring efficiency to a service that is usually considered a money-losing operation for most hospitals. By improving throughput, FFDM can potentially increase productivity, thereby minimizing costs. The hope is that a much greater number of patients can be studied in the same time using FFDM compared to film screen mammography.
The problem, according to David Channin, MD, chief of imaging informatics, Northwestern Memorial Hospital, Chicago, is that FFDM systems are many times more expensive than film screen systems. In order to achieve a positive return on investment, Channin says, “You would have to do three or four times as many cases as you currently do on film screen units.” This has not yet been attained by Northwestern Memorial’s Lynn Sage Comprehensive Breast Center, as well as many other institutions’ breast centers, for several reasons.
When considering which FFDM system to purchase, most radiologists are concerned primarily with the physics and efficacy of the devices. Although these are important considerations, Channin stresses that the purchasers also need to be knowledgeable about the informatics related to acquiring the devices, which involve the following issues: connectivity, integration, usability, and efficiency.
A major challenge facing all digital mammography users is that digital mammography systems do not yet fully support the Integrating the Healthcare Enterprise (IHE) initiative scheduled work flow. In other words, these digital modalities do not support integration into a picture archiving and communications system (PACS)-driven work flow. “What happens is what I call the ‘push’ model,” says Channin. “After acquiring studies on a modality, we then have to push them to the mammography workstation and then have to push them again to the PACS for storage.” He adds that the real problem occurs when the hospital has multiple digital systems and the mammogram must be pushed to all the workstations. Then subsequent mammograms are pushed through the system in a similar fashion, which obviously is slow and inefficient. Complicating matters is the fact that rather than building mammography functionality into PACS, the manufacturers have created stand-alone workstations for mammography that prevent an integrated system. According to Channin, their PACS vendor’s next software release will include integration of PACS and mammography. The FFDM unit eventually will support more of the IHE integration profiles as well so work-flow improvements will eventually be seen.
The manufacturers’ products also have proprietary postprocessing systems for images, which create another integration issue, according to Channin. Some vendors claim the PACS workstations are approved only to display their own mammography workstation images and this is not always spelled out until after the purchase is made. “Physicians need to be aware of this and should be sure that their purchase agreements have a clause stating that the equipment will support multiple vendors’ mammography images,” says Channin. “Buyers of digital equipment must communicate to their vendors that they need IHE work flow.”
A decision facing many hospitals is whether to replace the majority of their film screen mammography machines all at once or whether to replace them gradually as the breast center has been doing. When Northwestern Memorial opened its new main building in 1999, it replaced all of its imaging equipment with digital systems except for mammography. Because the technology is so costly, most hospitals prefer purchasing the units gradually. Yet this can be complicated when a patient’s file contains an assortment of digital and film screen mammograms. “Some hospitals may find that the best solution is to start dedicating a portion of the capital budget to digital mammography and then 2 or 3 years later buy five machines all at once and switch over completely,” says Channin.
Research has yet to demonstrate that digital mammography has the ability to increase work-flow efficiency while delivering adequate clinical quality. But at the same time, hospital breast centers that have begun adopting the technology need to pay attention to the informatics in acquiring this technology. “It’s all about market-driven engineering,” stresses Channin. “If the buyers are educated about these issues, they can communicate their needs to the vendors, who will then in turn make the necessary adjustments.”
Carol Daus is a contributing writer for Decisions in Axis Imaging News.