Growth of boutique practice spurs imaging expansion

The Women's Center of St. Francis Hospital on New York's Long Island completed an expansion and renovation in 2005. Planning was guided by the dual objective of providing patients with the highest level of imaging services in the most comfortable, reassuring setting. Various issues arose during this process.

Meeting the needs of our patients was of paramount concern when planning the renovation and expansion. Our goal was to humanize the breast imaging experience by improving patient flow and comfort. The most important consideration was increasing efficiency and decreasing patient waiting time. We also aimed to maximize comfort for patients, staff, and physicians by implementing ergonomic and aesthetic principles in the design of the facility. One challenge was integrating medical needs with architectural requirements. Every effort was made to include staff in problem solving.

We spent a great deal of time with the architects designing the space, the size of the rooms, and the decor. I had visited the Elizabeth Wende Clinic in Rochester, NY, and was inspired by their setup, which emphasized patient flow and comfort.

To create a cheerful, cozy, and upbeat facility, we worked with designers to incorporate a blue and yellow color scheme and added potted silk flowers and bright artwork. The atmosphere is often described as spalike. Chairs in the waiting room are comfortable and nonclinical, similar to those in a typical living room. We provide large private dressing areas, soft gowns to accommodate all sizes, lockers to store valuables, and a patient education room that offers a view of the hospital's beautiful grounds.

PATIENT FLOW

Much thought went into planning the size of the rooms and the flow from one aspect of an appointment to the next. We created two types of waiting rooms. When a patient registers, she is seated in the outer waiting room where she can wait with family or friends. There a technologist greets the patient and invites her into an inner waiting room where she and other patients sit once they've changed into their gowns. The inner waiting room is U-shaped and centered around a technologist's desk so staff can help monitor and direct patient flow.

We have a separate patient education and conference room for privacy, so a physician can talk to a patient and her family about the results of an exam. Nursing staff also use the room to review needle biopsy procedures with patients prior to scheduling, so that a patient knows what to expect when she comes in. This private room is not an exam room. Windows offer views to the outside, and the room gives patients some space to have important conversations in a nonclinical setting.

Before choosing the Hologic digital mammography unit, we conducted site visits to see various machines in operation, read the available literature, and consulted with radiologists across the country. We based our decision on image quality. We also chose the R2 computer-aided detection system, which had the longest proven history of use.

In the changeover to digital mammography, it is critical to be able to compare the new digital images with a patient's former analog (screen-film) images, which may include several years' worth of exams. We spent considerable effort on integrating film and digital mammography, trying to determine the type of reading apparatus necessary to compare the two. We chose an alternator film-viewer to accommodate more volume. To best compare the images, it was important to position the alternator and the digital monitor close to one another.

We already had started performing some breast MR imaging before the digital unit was installed. Breast MR is performed on a 1.5T Siemens Magnetron with an In Vivo 4 channel breast coil, which is soon to be updated. The CADstream software we have used for angiomapping and analysis has been very helpful. We use the ATEC Suros vacuum-assisted biopsy apparatus.

Breast MR has been very helpful in patients who recently have been diagnosed with cancer by needle biopsy; it is also useful for surgical planning. The referral base from our breast surgeons has grown as they become more comfortable with the technology, and we improve our track record of diagnoses. Our MR-guided biopsies have been successful in diagnosing contralateral breast cancers and finding more extensive breast cancers than were originally seen on mammography. We perform breast MR on patients who have a strong family history of breast cancer, have had a difficult mammogram due to breast density, or have multiple findings on ultrasound. Breast MR also is frequently used to screen for recurrence in breast cancer survivors, as well as to monitor therapeutic response.

NEW EQUIPMENT DIGS

The manufacturer of our digital mammography unit provided information about room size, electrical specifications, and ventilation requirements, including temperature and airflow. The digital mammography unit is very heat-sensitive, and we had to install additional air conditioning. We had the same problem in the radiology reading room because the new computers and monitors radiate a lot of heat and require additional cooling. Working with the architects and contractors closely to have more control over ventilation is crucial.

One of the most important considerations in designing a new radiology reading room was to allow a satisfactory transition from analog (screen-film) to digital. The room also had to accommodate the additional computer requirements for PACS, voice recognition, and breast MRI.

The reading room was set up to accommodate the new technology and designed to give the radiologist a comfortable reading environment. We researched ergonomic furniture and installed a computer table that can be raised or lowered so that reading can be done while sitting or standing. Another consideration was lighting. Older viewbox technology requires absolute darkness for reading, while computer screens require some light. We installed dimmer switches and arranged the computers to minimize glare.

Given the choice, patients prefer digital to film. When our digital mammography unit was installed, however, we maintained the film unit for four to six months to avoid glitches or interruptions in service. There were one or two days initially when the digital unit was down. We have since stopped using the analog unit.

At the same time we went digital, we also integrated our ultrasound system with PACS, acquired voice recognition software, and saw breast MR take off. The challenge was to learn the new software for each system. To accommodate, we realized that we had to decrease the number of patients scheduled per day, and each radiologist was given uninterrupted time to learn software for each new implementation. I recommend allowing plenty of time to learn software. The learning curve may slow you down initially as far as patient volume but will ultimately enable a seamless transition. We find it very important to continually offer in-service training for all staff as new technology is implemented so everyone becomes fully conversant in the technology and can answer patients' questions.

When technology changes, billing codes change. You must have all the new codes well in place, with their charges, before you begin the new procedures. We have a medical record coder who reviews our charts internally. The professional component is billed by an outside agency linked to our system. To improve patient throughput, we eliminated all but one form-the medical history form that is completed by patients and reviewed by a technologist. We've hired additional schedulers to handle the phones and film management. Both the coder and physician billing agency perform a daily code audit. Billing issues are resolved promptly and overseen by the center's business manager.

BOUTIQUE PRACTICE

In many ways, the Women's Center is a boutique practice. We experienced 22% growth in 2005 due to our expanded technological capabilities and the hiring of a part-time physician. We enhanced our marketing campaign with a new brochure, newspaper ads, a mailing to referring physicians, a large banner at a high-traffic area, a feature on a local television show, and community outreach via lectures and events.

Presently, the center sees screening and diagnostic patients in a 45% to 36% ratio, respectively. All diagnostic patients receive a workup on the spot with a physician present to supervise the exam. Screening patients are given an option at the time of scheduling to have a same-day workup. If they want an appointment sooner, they may come to the center without a physician present the day of the study. The patient is informed that there is a possibility of being recalled for additional views and/or an ultrasound. Those studies are read within one to two days of the exam, and all patients receive a phone call from the staff, as well as a letter regarding their outcome.

The majority of screening patients prefer to have their appointment when a physician is present and the full workup can be completed the day of the study. This includes any additional views and/or ultrasound. The patient obtains the results the same day.

The wait to be screened is about one month. We have one full-time and one part-time (three days per week) dedicated breast imagers. Another radiologist doubles at the center for one or two days a week. Our geographic area has no lack of breast imagers, but it took quite a while to find our recent part-time hire because of the particular work schedule. The nationwide shortage of breast imagers is less severe here, but it still made our search difficult.

One big challenge is the shortage of good ultrasound technologists who are interested in and enjoy doing breast exams. We have two technologists who split their time for the week, and we're looking to hire an additional part-time technologist. This is a critical need, as we have found ultrasound to be an important tool in the breast workup. Many patients and physicians request this exam as part of the workup, even for a screening patient with dense breasts.

In addition to breast care, the center offers bone densitometry of the lumbar spine, hip, and forearm using a Hologic QDR-4500 fanbeam x-ray bone densitometer, which is slated to be updated soon. It also provides a full range of ultrasound, including pelvic, abdominal, and thyroid. In today's busy world, the patients appreciate the option of having three or four exams in one day.

The Women's Center is accredited by the American College of Radiology and the FDA. For more information, visit http://stfrancisheartcenter.chsli.org.

Dr. Dintenfass is director of the Women's Center of St. Francis Hospital in Old Brookville, NY.

Consider technical specs in design

Transition to digital can be a time-consuming process

My advice to any facility planning a state-of-the-art women's center is to carefully consider all the technology requirements such as ventilation and electrical needs.

The transition to digital imaging and voice recognition is also a time-consuming learning process for the radiologists and technologists. Initially, you have to adjust the scheduling of patients to allow for additional time requirements.

When setting up the reading area, attention to ergonomics and comfort is essential. Several manufacturers offer special computer desks and chairs that can improve the radiologist's reading life. -ND