When a patient first enters the facility, she approaches the front desk staff in the main waiting room. The outside waiting room should include varying-sized chairs or benches to accommodate patients and visitors of all sizes. Armchairs are important for patients with limited mobility who may need assistance when getting to a standing position, while bench-style seating (armless) is important as it provides comfort for the overweight patient who may require slightly more room than the standard chair. A waiting room bathroom should be incorporated, as family members tend to accompany and wait for the patient’s visit to be complete. Building codes and specifications will need to be adhered to, to ensure requirements for handicap accessibility are met, for example, a large doorway for wheelchairs, scooters, walkers, or those requiring extra assistance.

Our front reception area went through remodeling to be designed in accordance with HIPAA. It is essential that the check-in process is as private as possible to protect the patients’ protected health information (PHI). Figures 18.4 and 18.5 show the transition of the reception area as the facility adapted to HIPAA regulations. Each receptionist has her own computer and desk, separated from the next receptionist by a glass partition. The partition provides the privacy needed for review of PHI that takes place at check-in (Fig. 18.6).

Aside from the physical design of the outside waiting area, we offer a wide selection of reading materials, as well as herbal teas and decaffeinated coffee, television, and wireless internet for both patients and those who may be accompanying them for the appointment.

Due to the volume of patients we service and the fact that some patients may experience a lengthy visit, the office was designed with two inside patient waiting areas. The asymptomatic screening patients, whether waiting for results or not, have a shorter appointment time, approximately 1 h from check-in to checkout. However, the symptomatic diagnostic patient may be with us for several hours for a complete work-up. The decision of designing two separate waiting areas came from past experience; when all patients shared one waiting area, regardless of appointment type, we found that patients were noticing others would arrive after them and leave before them, and this added additional anxiety to an already stressful appointment. At the earliest opportunity (when further space became available), the decision was made to separate the diagnostic patients and the screening patients. Incorporating the two waiting rooms has turned out to be an excellent decision, as the dynamics of each scenario fit the respective waiting room.

The screening changing area contains 10 changing booths and 72 lockers; the screening waiting room allows seating for 51. A smaller waiting room is adjacent to the large screening waiting room; this room is utilized if a patient requires a smaller setting. The diagnostic changing area has five changing booths and 36 lockers; the diagnostic waiting room is smaller allowing for seating for 34. Both waiting rooms have a fireplace and fish tank to promote a tranquil environment. Decaffeinated coffee and herbal teas are offered for patients, along with reading material (Figs. 18.7 and 18.8).

As with the visitor waiting room, it is important to have comfortable chairs for patients of all sizes. It has been reported that patients with weight issues often do not adhere to screening tests, but if the environment is accommodating, these patients may be more inclined to keep their appointments [4]. Research has shown that obese women have higher mortality rates for breast and cervical cancer [5], and one bad experience may turn a patient away from a lifesaving screening exam.

The main office has ten mammography suites that are centrally located from the two patient waiting rooms. Each room is equipped with a direct ray full field digital mammography (FFDM) unit with attachments and all supplies necessary for the study (Fig. 18.9).

The largest mammography suite has been designated for localization procedures and is also equipped with an examination table used for ductography cannulation (Fig. 18.10).

Utilizing this larger room for interventional procedures is a benefit, as added staff may be needed during the procedure, such as a nurse, in cases where the patient needs extra assistance. Additionally, in each room, a thin client computer is provided for access to the radiology information system (RIS) and picture archiving and communication system (PACS) (Fig. 18.11). The technologist has the ability to review prior reports and images as well as update electronic health information that may be provided during the patient interview portion of the examination.

Each radiologist at our facility has a two-room suite consisting of a reading room and an attached examination and ultrasound room (Fig. 18.12). There is hallway access to both rooms, as well as an inside doorway connecting the two rooms. This allows the patient to be escorted in from the outer hallway and allows the radiologist to enter the examination room from their reading room (Fig. 18.13). Daily, each radiologist has a medical assistant scheduled with them to assist with patient flow.

The radiologist reading room reflects the current modern, ergonomic design for the digital era. Due to the sedentary nature of the digital reading room, it is crucial that ergonomics be addressed to minimize eyestrain, lower back strain, carpel tunnel syndrome, and fatigue [6]. Each radiologist’s office is equipped with a lumbar-supportive chair and a height adjustable desk that can be used for seated or standing reading (Figs. 18.14 and 18.15).

Two 5 megapixel monitors can be height adjusted and tilted for optimal viewing to minimize neck strain. Each room has overhead fluorescent lighting, but when interpreting digital mammograms, it is not used due to the reflective glare on the monitors. Instead, ambient lighting (with a low-wattage bulb) that is located behind the monitors is used. Each radiologist has an ergonomic keyboard and mouse allowing for their hand and wrist to be neutrally positioned. A programmable gaming mouse is used and programmed so that with slight hand movement, the reading protocol can be advanced and CAD can be applied.

The ultrasound room attached to the reading room allows for an efficient workflow for the radiologist. This room is used for clinical breast examination, handheld ultrasound, and clinically guided procedures such as cyst aspirations, antegrade ductography injection, FNAC, and core biopsy. In addition to this attached room, there is an overflow ultrasound/examination room that is shared amongst the radiologists if needed on a busy day. This allows the radiologist to see their next patient without waiting for the turnover and cleaning of the room just used. The combination of having an individual suite and a medical assistant assigned to help maintain adequate patient flow is an important aspect in the design of our facility.

In 2008, our facility became 100 % digital and since then has been converting to a paperless, chartless environment. Our facility uses an electronic proprietary RIS (Avairis). This system is closely integrated with our PACS system (Sectra). The two systems, using bidirectional Health Level 7 (HL7) messaging, have allowed us to follow and manage all aspects of our patients’ visits electronically, as well as maintain an electronic chart for each patient.

Our operation has gone through many changes over the years, and it is important to describe the progression that has brought us to the present functionality. Originally, during the time of film-screen mammography, PACS was solely used to view the new digital images as we began to implement FFDM. As the years progressed, our Information Technology (IT) department and PACS administrators have integrated PACS closely with the RIS. Prior patient information has been added into the patients’ record on PACS to ensure that all information on a patient is directly available to the radiologist. In the transition from film screen to digital, film images have been digitized into PACS. Additionally, all radiology reports have been tied into the exams in PACS and can be viewed directly alongside the images. Personal and family history and prior needle or surgical biopsy information are also now included in PACS and can easily be viewed by the radiologist while reviewing a case. Changes such as these have allowed the radiologists to read all examinations from their own workstations within their own offices.

Today, when a patient schedules an appointment, a message (made possible with HL7) containing appointment information is sent to PACS. PACS performs an automatic “pre-fetch” of prior images from archive the night before the appointment. All prior images will be available for the radiologist to review and compare with the current examination.

During the appointment, PACS will send an HL7 message to the RIS when the radiologist has completed reading the examination. Immediately after screening examinations are interpreted and marked by the radiologists as normal, a message is sent to the RIS, the patient result letter is automatically printed, and the date of the next appointment is set for the patient. Once the letter is printed, the medical assistant knows that the patient’s visit is complete and can then give the patient her results. At the same time, the report is also automatically sent to the patient’s referring physicians, and the name of the reading radiologist is sent to the billing program in the RIS and charges are posted.

When a radiologist needs additional imaging, they will mark either “finding” or “assessment” on the exam in PACS. If “assessment” is marked, this is a request for extra mammographic images to be performed. A message is automatically sent to the RIS where an extra view/exam is created on the “dashboard” (which will be explained in the next section) and is available for the technologist. The process will repeat itself until the patient is marked as normal. If “finding” is marked, which means the additional mammographic views are obtained and the radiologist is still concerned about the area of investigation, a message is automatically sent to the RIS to create a new exam for an ultrasound, and the patient will present on the ultrasound “dashboard” for the sonographers or the radiologist, converting the exam to a diagnostic appointment.