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SPECIAL REPORT |
1 From the Department of Radiology, University of Arkansas for Medical Sciences, Slot 581, 4301 W Markham, Little Rock, AR 72205-7199 (T.L.A.); the Department of Radiology, Medical College of Virginia, Richmond (E.S.P.); private practice, Women's Imaging Center, Denver, Colo (K.A.M.); and the Department of Radiology, University of California, San Francisco (H.H.). Presented as a refresher course at the 1998 RSNA scientific assembly. Received and accepted May 3, 1999. Address reprint requests to T.L.A.
Index Terms: Radiology and radiologists • Radiology and radiologists, departmental management • Radiology and radiologists, design of radiological facilities
The past 2 decades have witnessed a continuous and increased focus on women's health. Between 1985 and 1988, women's health care was the most rapidly growing area of health care services (1). This trend is predicted to continue as the population's life expectancy is increasing and comprehensive health care to the population of women beyond the reproductive years is emerging. As women became aware of their health care needs, requests for information about issues that affect their health became more important. As a result, there has been more demand for comprehensive women's health care services across the country. Starting with the 1970s, we have witnessed the emergence of women's health care centers. The development of such centers has been recognized as an important service by health care providers. On the average, 63% of all adult surgeries each year is performed on women (1). National statistics suggest that in almost 70% of all households the health care decisions are made for family members by women (1).
In this report, we briefly review the response of the government and the public to the movement for better women's health care; describe a model women's health care center located within an academic center; outline the major areas to be considered in establishing a freestanding, private women's imaging center; and discuss fellowship training in the subspecialty of women's imaging.
THE GOVERNMENT RESPONSE
The movement for better women's health care was boosted by a 1990 government report that highlighted several inequities in women's health care, including (a) failure to adequately include women in research studies; (b) inadequate attention to gender differences in research and clinical services; (c) lack of funding for women's health concerns; (d) lack of access to health care services for women; (e) lack of education on women's health issues, both for the public and for health care professionals; and (f) dearth of women in senior health care professional and scientific positions in our nation's health care and research organizations (2). In the report, it was established that these inequities arose because of the prevailing assumption that causes, treatment, and prevention of diseases are similar for both sexes. This attitude led to inadequate attention given not only to health conditions affecting women but also to the evaluation of gender differences in determining the safety and effectiveness of drugs and medical devices used by women. This deficiency became evident in several studies done by cardiologists, the results of which have since corroborated the concerns of gender inequity (3–6).
In response to the 1990 report, the federal government authorized the creation of centers of excellence in women's health care through the Public Health Service Office on Women's Health. The purpose of these centers was to serve as active forces in their communities and across the nation to address and provide for health care needs of women. This goal was to be accomplished through the integration of high-quality research and training experiences in women's health care in outpatient and inpatient facilities and medical institutions. These activities would be linked with community services and programs in the local areas of each center. This initiative also stipulated that these national models should include a centralized, user-friendly women's health care facility and should use strategies to create a health care system that would operate as "a center without walls." In effect, this facility would serve as a point of triage for departments and resources within the medical institution and the community. This "one-stop shopping center" for deliv
ery of clinical services would focus on the unique needs of women and would include strategies to provide community-based services such as satellite clinics.
Since 1996, 18 centers of excellence in women's health care have been designated (2): (a) Allegheny University Health Sciences, Philadelphia, Pa; (b) Magee Women's Hospital, Pittsburgh, Pa; (c) Ohio State University, Columbus; (d) University of California San Francisco; (e) University of Pennsylvania, Philadelphia; (f) Yale University, New Haven, Conn; (g) Boston University Medical Center, Mass; (h) Indiana University Medical Center, Indianapolis; (i) University of California Los Angeles; (j) University of Maryland at Baltimore; (k) University of Michigan Medical Center, Ann Arbor; (l) Wake Forest University, Winston-Salem, NC; (m) Harvard University, Boston, Mass; (n) Tulane/Xavier University, New Orleans, La; (o) University of Illinois, Chicago; (p) University of Puerto Rico, San Juan; (q) University of Washington, Seattle; and (r) University of Wisconsin, Madison.
In addition to the establishment of the centers of excellence, the government designated Department of Defense funds to be earmarked for breast and ovarian cancer research. Congress also passed the Mammography Quality Standards Act (MQSA) in 1992, which went into effect in 1994. The MQSA requires that all facilities performing mammography must function at a basic or standard level of quality, which is rigorously enforced through annual reviews and inspections (7). This initiative had a tremendous impact on the health care industry and continues to be an example by which other certification procedures are compared.
THE PUBLIC RESPONSE
Medicine in the 1990s is, in a large part, patient driven. As the public became aware of the movement to support women's health care, the need for better care became the focus of attention in the media and publications targeted to women. The public response to the concept of women's health care centers was typified by a survey published in 1997 by Self magazine (8). In that survey, women envisioned that a desirable women's health care center should be a place where all basic health care needs can be met and where all annual screenings and physical examinations are performed by providers with extra training in women's health care. Such a center would also emphasize wellness, prevention, and patient education and would be committed to seeing and treating patients quickly and efficiently, for example, during lunch breaks, in the evenings, and on weekends. The survey results suggested that a desirable women's health care center should have the following characteristics and services: (a) a location of its own; (b) one-stop, state-of-the-art technology; (c) wellness facilities; (d) continuing community education; (e) specialized counselors on staff; (f) alternative therapies; (g) pregnancy-related services; (h) screening and treatment for sexually transmitted diseases; (i) providers with experience or education in women's health care; (j) doctor-patient discussions; (k) female physicians and staff; (l) domestic abuse expertise; (m) strong managerial directions; (n) convenience; and (o) a philosophy committed to empowering patients to take responsibility for their health.
THE CHALLENGE FOR RADIOLOGISTS
As the momentum increases toward offering comprehensive health care for women, radiologists play a crucial role as the primary providers of women's imaging services. The radiology community should respond to the challenge of providing effective service that will complement our primary care colleagues by establishing imaging centers that will be at the core of activity in a women's health care center.
Such patient-focused delivery of care, which crosses departmental organizations, must be expeditious, must be well planned, and must allow for rapid communication of findings to all concerned. A women's imaging center can be integrated into a comprehensive health care center in an academic setting or can be established as a freestanding, private imaging center.
A WOMEN'S HEALTH CARE CENTER IN THE ACADEMIC SETTING
The objectives in planning a women's health care center should include providing comprehensive services by experts in a convenient setting and a patient-focused atmosphere. This health care center can be incorporated on the campus or can be part of a larger, freestanding outpatient center. One such freestanding center is found at the Medical College of Virginia, Richmond, and their experience is outlined here as an example. The center seeks to offer integrated clinical and educational services in a comfortable, user-friendly environment. Patients are the focus of care, and providers from many disciplines come to offer their services. The setting provides an excellent opportunity for linking the expertise offered at the main academic medical campus to the care provided at the women's center.
The success of the women's health care center depends on many factors, including integration of services, dedication and expertise of the staff, sound marketing and outreach to the community, accessibility of location and hours, and re-evaluation with patient feedback (1,9). In the planning and implementation of such a center, soliciting information from potential patients as well as obtaining extensive input from the faculty is important. The establishment of a consumer-based health care advisory council helps maintain valuable contact with the population to be served (1). The women who sit on the council can provide information about the personal needs for women's health care in the community. As programs are planned and developed, the council can provide insight about what would be most used or of interest to consumers.
In line with patient surveys and health care provider and government guidelines, the women's center includes clinical, psychosocial, nutritional, and educational services. Another important planning issue to consider with the larger number of women who work outside the home is the advantage of offering nontraditional clinical hours in the evenings and on Saturdays. Ensuring the safety and accessibility of the site are also important, because educational programs are often ideally planned for evenings.
Among the clinical services offered in the women's center are infertility testing and treatment, adolescent care, obstetric care, perimenopausal care, breast health and care, internal medicine, and a range of psychiatric and counseling services. The center is staffed by physicians from the departments of obstetrics and gynecology, internal medicine, surgery, plastic surgery, psychiatry, genetics, and radiology. A primary presence is maintained daily by faculty from the departments of obstetrics and gynecology, internal medicine, and radiology. Faculty from other services provide scheduled coverage. Nurse practitioners, dieticians, social workers, and counselors provide extensive support to the clinical aspects of the center. Portions of the clinical space are shared, which maximizes an efficient use of space and staff. The design of the center is such that the clinical space is free flowing from one area to the next. Each component and area of the center is patient focused, with all staff understanding clearly and supporting that goal.
Radiology services include general radiography, breast imaging, bone densitometry, and general ultrasonography (US). Radiology services are adjacent to the women's center. The facility design is such that patients who are seen in the women's center for routine gynecologic examination can be scheduled or go to the radiology area for an annual mammographic screening. Similarly, the patient who is examined in the women's health care center and found to have a palpable lesion at physical examination can go immediately to the radiology area for breast imaging. The design of the department allows for separate areas for patient dressing booths and waiting rooms, thus maintaining the women's health focus of the imaging area. The clinical hallways are contiguous, which allows gowned patients to easily go from one area to the next without redressing, reregistering, and so on.
The radiology services area is highly efficient and productive. Technologists, clerical staff, and physicians operate as a team, with the patient as the focal point. Technologists oversee clerical and file room staff, ensuring that patients move quickly from the reception area into the clinical area and verifying that reports are completed, signed, and sent. The crossing over of duties enhances the quality of the entire operation and improves the utilization of staff. Technologists can teach patients breast self-examination on request. They also provide patients with explanations of the procedures and are available to answer patient questions. Within this productive framework, it is important to make the patient feel that she is not being rushed through, that her questions are being answered, and that she is being provided with the quality of services that she seeks and deserves.
A key concept of the women's center is the emphasis on health maintenance, disease prevention, and changing health risk behaviors. Because of this emphasis, one of the fundamental components of the program is increasing the regular utilization of screening mammography. Locating the mammography area within or contiguous with a women's health care center readily increases the volume of women who undergo screening on a regular basis. Physician referral for screening mammography is another important incentive to increasing utilization of this procedure (10). Full-time staffing by a breast imager ensures that diagnostic mammography can be directed and performed at any time and that a more comprehensive approach to patient care is provided.
A comprehensive radiology service provides additional procedures beyond screening mammography. Breast US can be performed at the same time if needed, and the patient leaves the radiology area with the results of her study. A full range of breast interventional procedures is also offered, including stereotactic breast biopsy, cyst aspiration, fine-needle aspiration biopsy, US-guided core biopsy, galactography, and needle localization. Patients with mammographically detected abnormalities that require percutaneous biopsy are informed of the findings and are scheduled for the procedure. At the same time, the referring physician is consulted regarding the recommendation. The results of the biopsy are conveyed by the radiologist directly to the patient as well as to her physician. Patients with malignant diagnoses are told the results in person instead of being called on the phone. The radiologist spends time explaining the next step and may even set up the appointment with the surgical oncologist for patients who require a surgical consultation, so that the care is complete. The surgical oncologist may see the patients in the center if they wish. This rapid response to the patient with an abnormality greatly expedites her care and alleviates much of the anxiety associated with waiting for the various steps in the process.
A computerized database is used for reporting mammography results and for the medical audit required by the MQSA. The computerized patient reporting and tracking database for mammography patients is used to generate recall letters to patients. The use of such reminders is advantageous in improving the regular utilization of screening mammography by women (11). The marketing of the breast imaging services to the community has enhanced the growth of the radiology practice and has created an additional referral source to the women's center. Self-referred patients for screening mammography often make their first visit to the entire outpatient center through their mammography appointment. Patients with a positive experience in this setting may seek referral to a primary care physician or gynecologist in the center and use other services offered by the main academic medical campus.
A FREESTANDING, PRIVATE WOMEN'S IMAGING CENTER
Despite today's managed care environment, outpatient women's imaging centers are flourishing. Creating a successful solo women's radiology practice can be one of the most difficult yet satisfying ventures in which a radiologist can be involved. The subspecialty of women's imaging naturally affords many opportunities because of its relatively low-cost equipment and its feasibility for being provided in an outpatient facility.
A women's imaging center is, by definition, multimodality, and such a center should provide radiologic examinations for the entire woman. It cannot focus on a single modality such as mammography or be organ-specific and provide, for example, only breast examinations. A women's imaging center is a comprehensive center that can be tailored for the outpatient or inpatient setting. Services that can easily be offered in an outpatient setting include mammography, US, stereotactic and US-guided breast biopsy, and bone densitometry.
An integrated approach to patient care is necessary from the moment the patient walks through the door. Optimally, all necessary services are provided on site during the same patient visit. For example, abnormal results at mammography may lead the radiologist to obtain spot compression views, followed by US to evaluate a suspected solid mass, and then imaging-guided biopsy. The entire process may take 30–40 minutes, with the histologic results being made available the next day. Similarly, a woman with abnormal uterine bleeding may be scheduled for both pelvic US and sonohysterography if indicated. The patient should hand-carry or send in advance any necessary previous imaging studies so as not to delay the workup further.
Specialization is a necessary part of a women's imaging center. Examinations are interpreted and procedures are performed either by radiologists trained in women's imaging or a group of radiologists trained in various subspecialties, such as breast imaging, body imaging, or interventional radiology, who work together to optimize patient care. The radiologist may often coordinate the patient's care. He or she informs the requesting practitioner of the results, offers to provide imaging-guided biopsy when appropriate, talks with other specialists, and discusses the overall plan of management with the patient before she leaves the imaging center. For a small percentage of women, a radiologist may serve as the patient's only physician. In these cases, a targeted clinical history is obtained followed by a clinical breast examination and a breast biopsy when necessary. The patient is given the pathology results if malignancy is found. Further care is coordinated with a breast disease treatment team, which may include the breast surgeon, radiation oncologist, medical oncologist, and plastic surgeon when necessary.
Many details must be considered when a private imaging center is started, including performing a market survey; developing a business plan, including a mission statement; developing a medical plan; acquiring necessary insurance contracts, equipment, and licenses; developing a market strategy; and preparing financial statements and summaries.
Performing a market survey is paramount for establishing a new practice. Selecting a good geographic location for a private practice clinic can make the difference between success and failure. This step should not be delegated to "marketing professionals," who base their decisions on demographics, regional costs, and limited surveys. Rather, the radiologist should do the homework to find out where potential referring physicians and competing services are located. Familiarity with the different patterns of referral in the community can be helpful, since they can be very difficult to change. Radiologists interested in starting a private imaging center should talk to many providers to ascertain which doctors need these services. They should learn about the competition and determine how services can be offered that are different from those provided by other imaging centers or offices. For example, if many obstetricians do their own office US examinations, find those who do not and target marketing efforts to them.
In any successful business plan, the originators must first develop a mission statement that is unique to the practice. An example would be "to develop a freestanding center to provide high-quality, comprehensive, outpatient radiology imaging for women." The mission statement serves as a template to follow in developing the practice, informs others about the services to be provided, and helps maintain the focus of the practice. The first mission statement may be revised over time, but it is a necessary and useful starting point. It should describe how the services differ from those of the competition, such as provision of comprehensive services under one roof, rather than requiring patients to go to various centers to complete their workup; provision of same-day results; or use of the latest in state-of-the-art technology.
A medical plan should be developed in parallel to the business plan. Insurance contracts must be obtained 1 year in advance of the start date. It may be advantageous to consider joining an independent practice association, which already has negotiated contracts with many insurance carriers, or to negotiate different reimbursement rates. Another strategy might be to convince insurance companies that the planned services are going to attract new members and keep existing members happy. When successful, it can be a win-win situation.
In deciding what equipment to acquire, research is needed to determine which companies have the best reputation for performance and service. Prices are typically competitive. Final decisions should be made only after consultation with other radiologists and technologists about their experiences. Individuals found through company reference lists are usually not very objective, since only satisfied consumers are kept on such lists. Another factor in equipment choice is anticipated technologic advancements in the next 5 years. For example, if digital mammography is expected to have a prominent role in screening, it may be worth spending a little extra for a machine that can be upgraded to digital capability. Lease versus purchase options should be investigated. Usual lease options include a straight lease, a 10% buy out, and a $1 buy out. If capital is available, it usually costs less to purchase the equipment outright. An accountant should be involved in these decisions, because there are significant tax ramifications in either decision.
Special licenses may be necessary before the imaging center can be operational and the contracts are signed. The building space chosen should allow medical use, use of radiation, and storage of blood products. A physicist who is approved by the Food and Drug Administration (FDA) for mammography inspection should be chosen once the machines are installed. Accreditation procedures should be fulfilled to obtain preliminary FDA/MQSA mammography accreditation and American College of Radiology (ACR) or American Institute of Ultrasound Medicine accreditation for US.
A strong marketing strategy needs to be developed. Key providers should be identified: internists, obstetricians, gynecologists, surgeons, and family practitioners. It is important to know that identified potential providers are planning to refer patients to the center. This information is especially crucial at the beginning, when a small number of physicians will constitute a large percentage of the imaging center's referral base.
For mammography, most insurance companies give their patients the option to self-refer. This opens opportunities to appeal directly to patients through teaching seminars, advertising, and word-of-mouth. Providing amenities such as private dressing rooms, soft robes, and herbal teas may distinguish an imaging center from others when a patient has a choice of mammography centers.
The financial statement presented will depend on the source of capital. There are many financial resources available. If the center is affiliated with a hospital, the hospital may cover the cost of development. This will mean, of course, that the hospital will own all or some of the center, depending on the amount of investment. Venture capital firms and public market funds are other sources of financing. With a solo venture, it may be possible to procure a commercial bank loan or Small Business Administration loan. Obtaining a government grant may be an option if there are plans to provide services to an underserved population.
The financial summary is a breakdown of how the money will be used. Projecting cash flow is a skill equivalent to writing a grant proposal in academic medicine. Every dollar going out and every dollar coming in should be anticipated before opening the clinic doors. As a general rule, the money needed should be overestimated by 50%. Payment for services cannot be expected for at least 3 months because of the delays in receiving insurance reimbursements. Start-up costs should be the first column in any financial summary. These costs include every item and its cost of purchase needed on site before opening (eg, capital medical equipment, building expenses, furniture, telephone system). Operating costs are the ongoing expenses necessary to continue operations after the doors open (eg, payroll, film and medical supplies, advertising). These expenses must be projected until the anticipated break-even point. If meticulous attention is paid to all these details, there is an increased likelihood of success in a private imaging center.
THE SUBSPECIALTY OF WOMEN'S IMAGING
The concept of a women's imaging subspecialty in radiology was formalized in 1993 when Thurmond and Jones (12) suggested the combination of multiple disciplines to consolidate services on women's health care to include bone density studies (12,13). In 1997, Thurmond (14) conducted a study that showed that graduates of fellowship programs in radiology that incorporated some element of women's imaging in their training experienced a 100% employment rate, compared with an 86% employment rate for graduates in all radiology fellowships in general for the same period. Although to our knowledge no recent studies have been reported to track these developments, the increasing number of women's health care courses and the initiatives being offered in both the educational and research arenas are testimonials that this trend will continue to rise.
To meet the need for specialized training in women's imaging, the Society for the Advancement of Women's Imaging (SAWI) recommended guidelines for fellowship training in women's imaging at its annual meeting in December 1998. Proposed requirements for a women's imaging fellowship program include (a) a board-certified radiologist as the program director; (b) interdisciplinary conferences in obstetrics, gynecology, and breast diseases; and (c) access to imaging devices relevant to the practice of women's imaging such as mammography, general radiography with fluoroscopy, US, computed tomography (CT), magnetic resonance (MR) imaging, and interventional radiology.
In addition to the above requirements, the women's imaging fellow should learn the indications, alternatives, risks, benefits, strengths, and limitations of different radiologic techniques as they relate to infertility, pregnancy, gynecologic disease, breast disease, and osteoporosis. The following number of procedures were proposed as a minimum core of examinations to be incorporated in a fellow's learning experience: mammography, 500; breast sonography, 200; pelvic sonography, 300; obstetric US screening, 300; obstetric US-targeted, 25; pelvic MR imaging, 25; percutaneous breast procedures, 25; hysterosalpingography, 25; and sonohysterography, 25.
A women's imaging fellow will most likely be involved in more procedures with a wider variety than those proposed by SAWI. In addition, in some instances, the fellow may be trained at multiple sites to gain the required experience and expertise. Thus, it is recommended that a log be kept to document a fellow's experience with the above procedures. In addition, SAWI recommended that the fellowship program require 40 hours of didactic lectures or focused case reviews, including coverage of the ACR appropriateness criteria for women's imaging. An environment that promotes and provides research opportunities for the fellow was also highly recommended.
As of November 1998, 14 such fellowship programs have been listed by SAWI. It is recognized, however, that many more institutions offer a women's imaging fellowship in various combinations other than that outlined above.
CONCLUSIONS
Disease-specific medical practice such as women's health care emphasizes the need for a harmonious integrated approach among medical subspecialties. As the population of women in midlife increases, there is growing need for high-quality women's health care services that provide comprehensive, efficient care in a single setting. This concept requires rethinking the traditional departmental organization, becoming patient-focused, and bringing various specialists together. It also demands the inclusion of modern diagnostic and therapeutic technologies into clinical practice and clear and open communication among patients, physicians, and providers as a team. The radiologist becomes an important member of such a team.
To be effective practitioners, radiologists specializing in women's imaging need proficiency in many different modalities, including mammography, US, CT, MR imaging, hysterosalpingography, and bone densitometry. Emerging procedures such as imaging-guided therapy make radiologists aware that the skills required for this subspecialty are changing, demanding continuous training and education. The women's imager is a consultant, who solves problems by choosing the radiologic test that renders the most information. Knowledge of radiology is supplemented by the understanding of clinical problems and by sensitivity to patient needs.
As momentum toward better care for women gathers, radiologists are poised at a vantage point to be key players through the creation of women's imaging centers. There are important practical concerns that must be considered when planning and operating an imaging center, whether it be an independent clinic or integrated into a larger women's health care center. With foresight and purpose, a women's imaging center can be the cohesive force that makes the enterprise of a comprehensive women's health care center a reality.
References
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