Turf Versus Merit: St. Luke's Centralizes Breast Care
Hospitals do not cede turf easily to competitors, even within the collegial environment of a multisite system. That, however, is precisely what had to happen before St. Luke’s Hospital and Health Network, Bethlehem, Pa, could centralize breast care among its four hospitals and six outpatient imaging sites in a regional diagnostic breast-imaging center.
Helene Oplinger
The vision required all sites to continue to offer screening mammography, but all positive screening-mammography patients would be referred to St. Luke’s Regional Breast Imaging Center for further imaging and diagnostics. The task of telling the hospital presidents that this would require removing diagnostic mammograms, breast ultrasounds, and biopsies from their revenue streams—leaving just the screening mammograms—fell to Helene Oplinger, network radiology administrator.
“I think we really have to give credit where credit is due. It was those people, at that level, who looked beyond their own bottom lines to recognize what makes truly outstanding patient care.” —Helene Oplinger, radiology administrator
The big question was whether the patient population, accustomed to ready access to care, would drive an average of 15 minutes to a center of excellence. One year and 15,261 patients later, the new center has reduced the time from screening mammogram to diagnosis to 13.2 days, down from 82 days several years ago. Patients answered the question with a resounding yes. The Vision Oplinger, a former technologist and native of the Lehigh Valley, credited the breast-imaging section’s chief, Joseph Russo, MD, with the vision for a hub-and-spokes model that now serves the six counties in the system’s coverage area. “We were looking at how we delivered care, and it was a little disjointed,” Oplinger says. “We were trying to offer everything at every center where we did mammography.” A goal of the regional center was to offer patients same-day service, if desired. If a patient came in for a diagnostic mammogram and it was positive, she could then go straight to ultrasound and/or biopsy. “We would never be able to offer that service at all of the facilities,” Oplinger notes. The new model required a significant culture shift from the radiologists, who would need to read in near-real time for diagnostic patients. The radiology group carved out a core group of breast-imaging specialists, and St. Luke’s replaced analog with digital mammography machines throughout the system, enabling the radiology group, Progressive Physician Associates, Easton, Pa, to deliver near–real-time readings not only in the regional center, but also for the 30,000 screening studies, Oplinger reports. The bigger paradigm change, however, was convincing referring physicians to allow the center to give the results directly to the patients, bypassing traditional lines of communication between radiology and referring physicians. “Women told us they didn’t want to wait long for results,” Oplinger says. “The goal of the center was to give diagnostic results right there in the center and let the patient know if there was any necessary follow up that had to be done. She wanted the option of having an immediate biopsy or going home and think about it.” St. Luke’s sent letters to referrers explaining the concept and the wish, expressed in focus groups, that patients not find out about a positive screening exam via letter. Oplinger and Russo also met with groups of obstetrician–gynecologists at each hospital campus. “We asked for permission to talk directly to patients so that we could take them from screening through the diagnostic process,” Oplinger recalls. “We also asked them if they had a preference for where they wanted us to refer their patients for biopsy: to a surgeon or to a radiologist.” Many referrers came onboard with the plan, but they insisted that a nurse, not a nonmedical employee, contact patients when a radiologist read a positive screening mammogram. “If additional imaging is required, the radiologist notifies the nurse right away, and the nurse calls the patient before the patient gets the letter in the mail,” Oplinger explains. “That letter causes a lot of anxiety because most women go to the negative right away. Our nurse holds that patient’s hand all the way through the system.”
A water wall softens the reception room at St. Luke's Regional Breast Center.
The nurse schedules the diagnostic mammogram, is present for the biopsy, and if it is positive for cancer, hands the patient off to the surgical nurse or cancer-care nurse. “The women have told us that they really like that there is someone on their side, guiding them through the entire process,” Oplinger says. “Our nurses were just certified by the National Consortium of Breast Centers.” Great Communications The center is hospital owned and operated, and the staff reports up through the director of women’s imaging to Oplinger. With a year of operations under its belt, the center is seeing a definite shift in referring physician behavior. Some recalcitrant referrers continue to insist that they receive results before patients, but others are giving radiologists the green light to perform biopsies as necessary. “Our patients are our best advocates,” Oplinger says. “We have a list. Our nurses know which physicians will let us talk to their patients and which ones won’t. Outstanding communication is what makes the whole thing work.”
St. Luke's Regional Breast Center shares a building with a family practice and physical therapy site owned by the health system.
A robust informatics infrastructure was a prerequisite for the centralized service, Oplinger says. “We couldn’t have pulled this off if we hadn’t already been where we were,” she asserts. In addition to having PACS, the St. Luke’s radiologists use voice-recognition technology and a mammography reporting system. “As soon as radiologists dictate the report, they do their own editing,” Oplinger says. “When they sign the report, it is autofaxed to the referrer.” St. Luke’s also equipped the network of four hospitals and six outpatient imaging centers with 12 Senographe DS and Senographe Essential full-field digital mammography units from General Electric Healthcare, Fairfield, Conn. With the digital mammography units, PACS, the voice-recognition system, and the mammography reporting system integrated, the regional center was ready to launch. “All of those pieces had to tie together for us to be as efficient as we are,” Oplinger says. The time elapsed from a screening study through cancer diagnosis is a key measurement in St. Luke’s performance-improvement studies, Oplinger says. A point of pride, just one year after the center’s debut, is that St. Luke’s time is now at 13.2 days, representing a reduction of 69 days. “The national average, according to what we are told by The Advisory Board, is 20 days for turnaround,” Oplinger reports. “I don’t know that we will be able to get it down much further, because some people want to wait.” There are also the usual pharmacological delays. “Originally, everyone was in his or her own little silo,” Oplinger says. “We’ve proven that if everyone works together, and we leverage technology, the time of anxiety for women is really reduced.” Oplinger worked with the chief of pathology to bring the specimen-diagnosis time down to under two days: A courier takes samples to the hospital twice a day. Same-day availability of results is a strong marketing message that has not been lost on the St. Luke’s marketing/public-relations team. It is taking the story directly to the consumer in a novel marketing campaign that is being played out across the Lehigh Valley on thousands of mini-billboards posted on supermarket shopping carts: same-day availability of mammography results.