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ultidisciplinary Breast Clinic: A Team Effortianne Kane, RN, and Brett T. Parkinson, MD

The coordination of treatment for the newly diagnosed breast cancer patient can bechallenging, especially in a private health care system. The process begins with an effectiveimaging program, built on trust and seamless coordination among breast radiologists,referring clinicians, and treating physicians. Once the imaging component is in place anda multidisciplinary breast conference has been established, the next logical step is to bringthe patient together with a group of medical experts in a clinic setting to discuss her case.This Multidisciplinary Breast Clinic model facilitates direct communication between themultidisciplinary breast conference participants and the patient. In addition to increasingpatient satisfaction, the clinic—if appropriately presented to the community—also has thepotential of directing additional patients into the system for treatment. All medical special-ties involved in the treatment of breast cancer, including many ancillary and supportproviders, come together to consult with the patient in a “one-stop shopping” appointment.The purpose of the clinic is not just to provide a treatment plan but also to educate and offersupport. It also assures the patient that her providers are communicating with one anotherregarding her treatment. This type of service, in addition to being the right thing to do, setsa health care system apart in the competitive cancer care market.Semin Breast Dis 11:31-35 © 2008 Elsevier Inc. All rights reserved.

KEYWORDS multidisciplinary clinic, coordinated care, treatment planning

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s a result of the positive process changes over the lastfew years with focused breast imaging and the suc-

essful multidisciplinary breast conference, Intermoun-ain Healthcare has developed a well-organized, patient-ocused, quality-based breast care program. Please seeccompanying sidebar.

To build on the well-attended, weekly prospective breastonference, the breast care team considered the developmentf a Multidisciplinary Breast Clinic that would provide a fo-um in which the patient could meet with representativesrom all the disciplines involved in her treatment: surgery,adiation oncology, medical oncology, plastic surgery, andenetics. Although the physicians and other health care pro-iders staffing the clinic would not necessarily be the treatinglinicians, they would nonetheless be familiar with the pa-ient’s case. As the clinic would be held immediately after theeekly multidisciplinary conference, the patient would be

nformed of the discussion and any recommendations madeuring the meeting. She would then have the opportunity toose questions to the assembled group of experts. This rep-

anice Beesley Hartvigsen Breast Care Center, Intermountain Medical Cen-ter, Murray, UT.

ddress reprint requests to Dianne Kane, RN, Janice Beesley HartvigsenBreast Care Center, Intermountain Medical Center, 5121 South Cotton-

swood Street, Murray, UT 84157. E-mail: Dianne.Kane@imail.org

092-4450/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.oi:10.1053/j.sembd.2008.04.008

esented a radical departure from the standard care para-igm, with the surgeon traditionally being the one to com-unicate the treatment plan to the patient. In the event theatient had additional nonsurgical questions, which was of-en the case, she would have to make separate appointmentsith the other specialists to discuss her concerns and thisould delay treatment.

esearchlthough the concept of the clinic seemed promising, Inter-ountain Healthcare had no experience in multidisciplinary

ancer clinics. We needed guidance. After an exhaustive in-ernet search and networking with other breast centersround the country, we learned that several cancer centersffered multidisciplinary clinics. Most of these institutionsad developed tumor-specific clinics to assist patients in pre-reatment planning. We sought the advice from an institutionimilar to ours, the Van Elsander Cancer Center at St. Johnealth System in Detroit, Michigan. Like Intermountainealthcare, it is a not-for-profit, multifacility health care sys-

em that draws primarily from a metropolitan area. The ad-inistrators were very attentive, answering our questions

nd freely sharing their experiences with our team. They

ubsequently offered to host a site visit in December 2003.

31

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32 D. Kane and B. T. Parkinson

ite Visit andollow-Up Activities

he site visit consisted of meetings with administrators, phy-icians, and nurses, as well as cancer registry and researchepresentatives. The topics of discussion included differentodels for organizational structure, patient processes, andolitical issues. After the site visit, a steering committee wasrganized to work on the ideas gleaned from the visit. Theteering committee consisted of representation from medicalncology, radiation oncology, surgical oncology, administra-ion, nursing, social work, lymphedema services, patient ac-ount services (registration, billing, and reimbursement per-onnel), transcription services, and medical records. Theandate of the steering committee was to first design and

hen implement a pilot project for a breast cancer clinic to beested the following summer. The committee identified sev-ral tasks that had to be completed before the clinic doorspened.

● Identification of physician leader and definition of role● Determination of medical specialties to staff clinic● Understanding of referral processes and elimination of

barriers that might disrupt them● Identification of appropriate business model● Establishment of physician payment and contract

models● Development of template for electronic medical record● Determination of billing and reimbursement processes● Establishment of transcription and medical record stan-

dards● Determination of patient flow processes● Acquisition of physical space

Although some of these issues were resolved in the initialteering committee meeting, most decisions were made inmaller committees and subsequently presented to the largeream for discussion. A surgical oncologist was selected by theommittee as the physician leader for the project, a well-nown physician in the community who was also medicalirector for Intermountain Healthcare breast cancer services.t was then decided that the clinic would be staffed by aurgeon, radiation oncologist, and medical oncologist. Be-ause of economic and time constraints, it was decided thatadiologists and plastic surgeons—though available for con-ultation at the multidisciplinary conference held just beforehe clinic—would not be on site. However, reconstructiveurgery consultation is provided to all women on an as-eeded basis.There was a great deal of discussion concerning referral

atterns, as several physicians were concerned that patients,fter attending the clinic, might switch physicians. After all,ecause of the rotating staff in the clinic, many patientsould not see their own physicians. And it was certainly

onceivable that some patients might want to switch physi-ians, thus breaking long-established referral patterns. Thisas the greatest challenge for the newly appointed physician

eader whose job it was to assure his medical colleagues that

heir patients would not defect. At the time the clinic ap-ointment is made, patients are told that the consultant phy-icians will in all likelihood not be their treating doctors, inhich case the clinic provides an opportunity for a “secondpinion.” We encourage all participants to return to theireferring clinicians for further evaluation. Of course, patientsre free to choose their providers, so, it is inevitable that someill change physicians based on the clinic experience. How-

ver, we have found this to be rare.The next challenge was selecting a business model for the

nancial operation of the clinic. We ultimately settled on aospital-based model, as it allowed us to bill for up to threehysician consultations and one facility fee per patient. Theospital would contract with the physicians, paying them axed fee for a block of time spent working in the clinic. Theospital would then bill for all professional and technicalees, thus relieving the doctors and their staffs of the respon-ibility of having to deal with billing issues. Details of thehysician contracting are still being worked out, mainlyhere larger physician specialty groups are involved.To assure accurate record keeping and facilitate future out-

omes analyses, the Oncology Clinical Program provided in-ormation system resources in the development of a templateor data collection. This electronic documentation templateould allow us to collect data, beginning with the initialistory and physical, including all events leading to dis-harge. This would be accomplished by using laptop com-uters in the clinic. Moreover, the template would generate aake-home plan for each patient, summarizing the recom-endations of the clinic consultants. In addition, a summary

etter would be generated for referring physicians and otherrimary care providers.The pilot program was scheduled to begin mid-June 2004.

he physician leaders spent the six months preceding thepening of the clinic meeting with various physician groups,ducating them on the purpose of the clinic and encouragingheir participation. Temporary space to house the clinic wascquired. Since the weekly multidisciplinary breast confer-nce was held every Thursday morning from 7:00 until 8:00M, we decided to hold the clinic at 8:30 AM. A surprisingumber of physicians volunteered to staff the clinic, most ofhom were very supportive of the process. During the pilothase, general surgeons with a special interest in breast werehe major source of referrals. However, as time went on, thereast radiologists also became involved in the referral pro-ess.

As the start date of the pilot program approached, thereere still several issues requiring immediate attention. Logis-

ical questions arose, which left unanswered, would prove toe a hindrance in the day-to-day operation of the clinic.

● How would patients be scheduled and by whom?● How would patients be identified in the transcription

and dictation system so that their records could be easilyretrieved? (Most Intermountain Healthcare physiciansuse an electronic medical record.)

● How would the clinic experience be documented? What

would be tracked?

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Multidisciplinary breast clinic model 33

● Who would perform the history and physical?● How would billing and reimbursement be monitored?● Who would function as manager or facilitator, orches-

trating the consultations on clinic day?

Since the nurse navigator was already familiar with most ofhe patients, it was decided that she would serve as clinicacilitator. It would be her responsibility to contact the pa-ients, referred either by their surgeons or sometimes thereast radiologists, and schedule them for clinic. At the timef the pilot, the medical oncologist was responsible for per-orming and documenting the history and physical. Patientsere assigned a number for the dictation system, identifying

hem as breast cancer clinic patients. To avoid confusion, oneeam member from Patient Account Services (PAS) acceptedhe responsibility of tracking billing and reimbursement.

ncoPoliticshe most critical issue involved the OncoPolitics of the clinic.ould the clinic disrupt referral patterns, providing a meanshereby clinic physicians might “steal” others’ patients? Al-

hough there was strong support for the clinic among mosthysicians, some were skeptical. Fortunately, some doctors,efore coming to Intermountain Healthcare, had experiencedhe clinic model at other institutions and were favorably dis-osed to the project. Others were supportive simply becausehey viewed the model as “the right thing to do” for patientare. However, as many physicians in the system were notmployed by Intermountain Healthcare, there was a certainmount of fear that the clinics could potentially interfere withong-established referral patterns, directing patients to em-loyed surgeons and medical oncologists. It was vital, there-ore, that there be strong physician leadership and trust. Thehysician leader stressed that, even though a patient might beeen in the clinic by physicians other than her own, sheould be strongly encouraged to return to her referring cli-icians.

ue Dilligences noted above, the physician leader was the medical director

or breast care services. He was selected, not just for hisnowledge and support of the program, but also for his cred-

bility among his surgical and medical colleagues. He wasesignated as the “go-to” person for the project. He oversawducational sessions for administrators and physicians. Heook advantage of regularly scheduled specialty departmenteetings and tumor conferences to explain the pilot pro-

ram. He also held private meetings with key physicians anddministrators, encouraging their involvement in the plan-ing and the implementation of the clinic. It should be noted

hat much of this work occurred before any formal decisions wereade. It was crucial that physician input and feedback drive the

roject. p

ilots originally planned, the pilot program began in the sum-er of 2004. Two or three patients were scheduled for each

linic. Workflow processes were designed around patientomfort and convenience. The nurse’s role was to track therogress of each patient, directing physicians where theyeeded to be for the next consultation. Each physician wasesponsible for writing a short note, documenting clinical ob-ervations and recommendations for treatment. This informa-ion, recorded on a laptop, was then transcribed into a care plannd subsequently given to the patient on discharge. Each phy-ician was then responsible for dictating a more detailed reportf the clinic visit, which became part of the permanent medicalecord. Dictated notes and reports were also copied and sent toeferring physicians. Much of the record keeping was accom-lished manually during the pilot, as the electronic version wastill under development.

essons Learnedfter the pilot, a debriefing meeting was convened to assess

he strengths and weaknesses of the pilot program. The phy-icians all voiced the same concern: They felt their schedulesere not well planned, as they spent time waiting while pa-

ients were consulting with other specialists. Other minorssues revolved around lost dictations and incomplete billingnformation. As a result of the physician feedback, patientow processes were redesigned, allowing greater flexibility inhysician scheduling. While some were assigned to staff thelinic early first thing in the morning, others were instructedo come after the clinic was well under way. This schedulellowed them to spend more time working in their privateffices, rounding on hospital patients, and less time waitinground the clinic. The clerical issues were easily resolved bylarification of processes for dictation and billing. To simplifyrocedures, laminated pocket cards were designed with dic-ation codes. A billing sheet, with a special column for eachpecialty, was also provided with a user-friendly checklist forhysician fees.We also held a patient focus group, attended by all but one

f the women who participated in the pilot program. Eachatient was asked to complete a 50-question survey. Patientomments, without exception, supported the rationale forroviding the service. The most commonly cited benefits ofhe program included improved coordination of care, in-reased trust by consulting face-to-face with a panel of ex-erts, and patient participation in determining treatment. Itas actually the patient feedback that ultimately persuaded

he oncology administrators to grant funding and eventuallynd a permanent home for the clinic.

mplementationnd Interim Stepsfter physician and patient feedback were analyzed and ap-

ropriate changes were incorporated into the design of the

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34 D. Kane and B. T. Parkinson

linic, the steering committee met again, formally adoptinghe multidisciplinary clinic as the model for breast canceratient care. Before the clinic could actually begin operation,everal tasks still needed to be completed.

● Formally present the concept to administration andphysician groups

● Begin discussions on quality assurance and outcomesreporting

● Obtain permanent space for the clinic● Structure an operational budget for expenses● Define staff duties, then post positions● Formalize physician contracting and reimbursement● Complete development of the electronic medial record● Begin logistical planning (staffing, supplies and sched-

ules, etc)

An eight-month timeline was established, with an antici-ated opening date of June 2005. Although certain compo-ents of the program fell together easily, such as the hiring oflinic staff and acquisition of leased office space, there were aew issues that were not so easily resolved.

arrierhe major obstacle in implementing the multidisciplinarylinic was the financial component. If reimbursement wereenerous enough to win physician support and participation,he resulting proforma would likely be negative, secondary tohe additional operational and nonphysician professional ex-enses. This potentially could be a tough sell to administra-ion. However, if the Multidisciplinary Breast Clinic wereiewed as part of the breast cancer “system,” taking into ac-ount both downstream and incremental revenue when non-ntermountain Healthcare patients stay within the system forheir care, the clinic would indeed be profitable. Downstreamevenue tracking must be by ICD-9 codes, not diagnosis-elated groups. Incremental revenue tracking would mostfficiently be accomplished by medical record number of allon-Intermountain Healthcare patients.To fully capture the profitability of the multidisciplinary

reast clinic, a downstream revenue analysis was conductedo assess the clinic’s financial impact. The analysis looked atet operating income from cancer treatment in the followingreas: surgery, radiation, pathology, infusion services, imag-ng, and laboratory. The analysis only included technicalharges on hospital-based procedures to avoid counting rev-nue that was not directly received by the hospital. Conse-uently, many treatments commonly performed in physi-ian’s offices such as chemotherapy and hormone therapyere not included in the analysis.The downstream revenue analysis compared the total net

evenue per patient of those who attended the multidisci-linary clinic with those who did not. This approach waselected to demonstrate the revenue differences between thewo groups without having to calculate the hypotheticalumber of patients who would have left the Intermountainystem, but stayed because of the clinic. Those who attended

he multidisciplinary clinic had an average net operating in- d

ome per patient of $5115 (n � 103), while those who didot attend the clinic only averaged $2933 (n � 173) peratient. This represents a statistically significant difference of2182 (P � 0.0145) and an expected revenue of $224,699.he adjusted analysis for early versus late stage cancer foundimilar results (an expected revenue of $225,930).

The results of the downstream revenue analysis show in-reased net operating income for patients who attended theultidisciplinary breast clinic. This increase in revenue is

ikely due to a mixture of lower out migration rates and moreomprehensive care for multidisciplinary clinic patients.hile this method of analysis has some limitations, it does

how positive financial implications for having a multidisci-linary clinic.

utcome Measuresntermountain Healthcare is recognized internationally for itsophisticated data collection and outcomes research. Sincehe infrastructure for clinical research was already in place,e elected to analyze three aspects of the breast program:

linical outcomes, patient satisfaction, and financial impact.ur approach to outcome analysis was to compare two

roups of breast cancer patients—those who attended clinicnd those who did not.

● Clinical Outcomes: time to initiation of care, which isdefined as the length of time between tissue diagnosisand initial therapeutic surgery.

● Patient Satisfaction: a modified version of the 50-ques-tion survey from the pilot program, isolating three areasfor investigation: overall perception of care, quality ofinformation and education, and effectiveness of care co-ordination.

● Financial impact: Net Operating Income for cost percase in both groups—attenders and nonattenders.

mplementationhe multidisciplinary breast clinic at LDS Hospital became

ully functional July 2005. Held every Thursday morningmmediately after tumor conference, it has become increas-ngly popular among both providers and patients. In fact, therovider participant list has expanded to include physiciansrom other health care systems. The number of ancillary staffontinues to grow as well. An occupational therapist is nown site to assess each patient’s risk of lymphedema and dis-uss strategies for prevention. A social worker is also availableo address psychosocial and financial concerns. A geneticsounselor consults with each patient, but focuses on thoseho present with a high-risk pedigree. To accommodate thisuch activity on clinic day, the admission process has

hanged so that now patients are preadmitted. Two part-timeomen’s health nurse practitioners (NP) have been hired to

onduct preclinic telephone interviews the day before clinic.t that time, they record the patient history and pedigree.hen the patient does arrive at clinic the next day, she un-

ergoes a brief physical examination by the NP. She is then

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Development of the JBH Breast Care Center 35

eady to consult with the physicians and other ancillary careroviders. The total time in the clinic for the patient is ap-roximately 2 to 2.5 hours. The breast clinic can now com-ortably accommodate four patients per 4-hour block.ecord keeping is electronic.Since the introduction of the pilot program, we have

earned that patients are more likely to attend clinic if they arentroduced to the concept shortly after diagnosis, before sur-ery or other treatments have been initiated. The nurse nav-gator, the Intermountain Healthcare representative respon-ible for guiding the patient through the treatment process,as been especially effective in explaining the clinic concepto patients. Often, however, the newly diagnosed patient firstearns about the clinic from the breast radiologist. We haveound that this is actually the most effective means of recruit-ng patients for the clinic. Since the majority of Intermoun-ain Healthcare cancer patients undergo imaging-guidedather than open surgical biopsy for diagnosis, it is usuallyhe radiologist who informs the patient of her biopsy results.ealizing the importance of that exchange and its potential

or setting the tone for the rest of the patient’s treatmentxperience, the lead radiologist developed “talking points” touide the radiologists through the process. In addition toffering suggestions on how to most sensitively explain theiagnosis, the talking points encourage the radiologist to in-roduce the concept of coordinated care. The radiologist in-orms the patient that her case will be discussed at the mul-idisciplinary conference by a group of experts. And then,tressing that the patient herself is part of the decision-mak-ng process, she is told that she can meet with the “team”ace-to-face in the clinic setting. It is at this point that theatient is referred to the nurse navigator. For patients outsidef the Intermountain Healthcare system, primary care pro-

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lso provided brochures to health care providers throughouthe Salt Lake City area.

The multidisciplinary breast clinic is now a well-estab-ished part of the Oncology Clinical Program. Clinic space atntermountain Healthcare’s new flagship facility in the Can-er Center opened in February 2007 and hosts a breast clinicvery Thursday. The success of the breast clinic created aeliable template for additional tumor types. Physicians fromther specialties have already begun clinics for thoracic, liver/ancreas, prostate, neuro, and sarcoma, and a head and necklinic is under development. The multidisciplinary clinicodel is also being adopted in other areas of the state where

ntermountain Healthcare has cancer treatment facilities.We feel that this multidisciplinary care model, from diag-

osis to treatment, sets us apart from other health care sys-ems that offer cancer services. Research documents thatultidisciplinary care is one of the “Must Have Attributes”

hat patients seek when choosing their cancer care (2005,dvisory Board Company). Moreover, it is the right thing too, enabling patients to feel included in the decision-makingrocess. Although the process that brought these clinics toruition has been long and arduous, beginning with the cre-tion of dedicated diagnostic breast imaging centers and cul-inating in coordinated care, it has been well worth the

ffort. We are encouraged that, at least for breast cancer, weave been successful in coordinating the care of our patients.heir praise for the program is heartwarming. Most of themave indicated that the coordinated care provided by theultidisciplinary conference and clinic has been the most

ffective means of support during the time of diagnosis andreatment. Intermountain Healthcare’s next challenge was toot just improve the breast program, but to make this type ofomprehensive, coordinated care available to all our cancer

iders and surgeons are often the source of referrals. We have patients.

he Janice Beesley Hartvigsen Breastare Center at Intermountain Medicalenter: The Path from Vision to Realization

rett T. Parkinson, MD

rustrated by a lack of coordination of services for breastpatients with breast problems, a group of concerned phy-

icians and administrators at LDS Hospital (LDSH) in Saltake City, Utah, formed a task force and instituted regular

ntermountain Healthcare Breast Center, Murray, UT.ddress reprint requests to Brett Parkinson, MD, Intermountain Healthcare

Breast Center, 5121 South, Murray, UT 84157. E-mail: Brett.Parkinson@

eetings to address the problem in early 1997. Althoughhere was uniform agreement that the care rendered by indi-idual physicians was excellent, there was concern that theverall process was too slow and fragmented. In addition,here was a lack of communication among diagnosingnd treating physicians, resulting in some patients “fallinghrough the cracks.” Patients themselves were concerned thatheir doctors were not communicating with one another,eaving them to wonder if anyone was actually taking overall

esponsibility for their care.