Breast informatics drives health system's quality efforts

Tracking information about workflow, payment, and outcomes has never been more important for breast imaging centers. Some clinical and technical data collection has long been mandated by the Mammography Quality Standards Act, and new recommendations by the Institute of Medicine could require centers to step up their efforts.

But regulatory demands are not the only reason for breast centers to make the most of what information systems have to offer.

That data - properly mined - can help administrators maximize throughput, set and meet performance goals, and better understand how their centers really work, said Terry Macarol, a mammography systems specialist at Advocate Health Care in Oak Brook, IL.

"We have to find ways to be more efficient," Macarol said. "Costs are going up, and reimbursement is going down - it's flat at best. It's becoming harder to make ends meet at breast centers. It is important to know if improvements are occurring in your operations, and the only way to know is to track the data."

Collecting, analyzing, and disseminating that information - to radiologists, administrators, technologists, and insurers - is a key component of Macarol's job at Advocate, the largest independent delivery network in the greater Chicago area.

Advocate's 200 sites of care, which includes hospitals and clinics, have 21 sites that deliver mammography services. These include seven comprehensive breast centers, three diagnostic centers, and 11 screening centers. Screening and diagnostic mammography volume totaled 163,500 exams in 2004, or about 10% of Advocate's total medical imaging volume.

Two of its 58 mammography units are full-field digital systems, and Macarol expects to purchase seven more digital units this year. Ninety radiologists and 145 technologists work in the mammography sites, using 17 computer-aided detection units.

All sites are connected with a mammography information system that incorporates results reporting, quality assurance and quality control for MQSA, and an array of auditing modules to assess referral patterns, personnel performance, and practice and pathology outcomes. Developed by PenRad Technologies of Plymouth, MN, the system is one of several such software products tailored for mammography practices.

PenRad allows users to log on at any of Advocate's mammography sites to obtain information about a patient's screening exam or biopsy, regardless of which facility performed the work.

"The information is all shared and secure," Macarol said. "There's no need to call and ask for a report to be faxed. If it weren't for this type of software, I would not be able to compile these statistics on a monthly basis."

Macarol tracks everything from costs to quality assurance and outcomes. She knows how much it costs to the penny to provide a mammography exam at any one of the 21 Advocate sites. She evaluates how appointment availability and scheduling backlog for screening and diagnostic mammography, as well as for stereotactic and ultrasound-guided biopsy.

She uses PenRad to track scheduling volume by day, time, and mammography unit. One of the most telling pieces of information a breast center can compile is procedure volume.

"We look at the systemwide average per month and on a per-site basis," she said. "We look at the top three months and at the top and bottom performing sites. Are we reaching appointment capacity per site? This information helps us set averages per site and determine facilities that are above and below the average, as well as which sites may need to adjust staffing, hours of operation, or additional equipment and facilities. We're constantly looking at the data from as many angles as possible."

Financial tracking is also critical. Macarol compiles data on gross revenues per procedure. Such information is useful when it comes time to update budgets or justify new personnel and equipment.

Clinical quality assurance data, another key component of the information system tracking, includes positive predictive values, and patient recall rates. Three, six, and 12-month follow-up rates are compiled for each site and for each radiologist. Follow-up recommendations are categorized by modality as well as by physician along with the ratio of breast ultrasound exams to diagnostic mammograms.

A related statistic is turnaround time (TAT). Advocate sets both short-term and long-term TAT goals for screening mammography exams. At year-end, Macarol makes several assessments:

• whether short-term TAT goals were met for any month

• average monthly TAT in terms of hours

• best reported TAT, and in which month

• longest reported TAT, and in which month

• sites that performed better than, or below than, the TAT average

"We don't always meet our goals," she said. "But our team works hard to reach them. My boss's favorite statement is, 'If you can't measure it or monitor it, you can't manage it.'"

Data tracking is part of a comprehensive process improvement program at Advocate, and Macarol is a firm adherent of the principles of PDSA: plan, do, study, act. One aim she cited is reduction of patient cycle time - the journey from screening to biopsy. Mean cycle times are tracked per site, an average set is calculated, and then outlier sites are evaluated.

At least as important as collecting data is disseminating it effectively.

"If you are trying to justify purchasing a $450,000 digital mammography unit, you need to tailor your presentation accordingly," Macarol said. "If you're talking to financial staff and administrators, show how revenues will pay for the equipment in terms of efficiencies, turnaround time, or staffing. If you are talking with physicians, address how this will benefit their patients. And if you are talking to your own staff, show a little of both - the big picture."