Optimizing Workflow: Creating the Integrated Digital Mammography Facility

Digital mammography deployments are on the rise—fast. The early adoption phase is drawing to a close as facilities large and small that delayed taking the plunge into digital now aggressively invest in the technology. What’s more, the surge is expected to gain momentum over the next decade. In fact, digital mammography volume is projected to increase more than 100 percent in the next 10 years.

The evolving digital mammography market stems from a convergence of several factors. Digital is a demonstrated winner on multiple fronts: clinically and operationally. And PACS integration makes digital mammography a more attractive investment from the workflow and economic perspectives.

Late in 2005, the Digital Mammographic Imaging Screening (DMIST) Trial showed that digital mammography benefits a significant subset of women: patients with dense breasts, pre- or perimenopausal women and women under 50. The mammography subcommittee of the Integrating the Healthcare Enterprise (IHE) intitiative also is facilitating better integration with digital mammography systems and PACS. (More information: www.ihe.net/Mammo/index.cfm) Finally, digital delivers a much more efficient technologist workflow, allowing techs to increase efficiency and focus on patient care. The upshot? Digital mammography is in the eye of a perfect storm.

Full-field digital mammography (FFDM) systems such as GE Healthcare’s Senographe solutions can transform breast imaging, but transitioning to digital mammography is a major undertaking. “Digital mammography represents a protracted and complex process,” confirms Michael Quaranta, regional director for imaging and oncology at Adventist Midwest Health in Chicago. Adventist Midwest is engaged in a fairly aggressive and rapid digital deployment, moving from the decision to implement to deployment in 12 months. Thomas Jefferson University Hospital in Philadelphia, on the other hand, invested a full two years in the digital breast center planning process, says Richard Blob, associate administrator of radiology. The follow-up phase is equally critical, says Quaranta. A well-considered solidification plan can help sites reap the full benefits of digital mammography.

Part of that plan for both facilities was assistance from GE Healthcare Performance Solutions consulting services that analyzed and reconfigured workflow and facilitated change management and training to smooth implementation, enhance user adoption and define a future road map to achieve goals.

The benefits of digital mammography are significant and include increased efficiency, better patient care and enhanced satisfaction among patients, technologists and referring physicians. This month, Health Imaging & IT presents a digital mammography primer to help sites better plan for, implement and optimize FFDM and digital workflow.

Getting started

The decision to deploy digital mammography often stems from a variety of factors. Take for example Thomas Jefferson University Hospital. The hospital embraced the digital concept when it began planning a new breast center in 2005. The decision to invest in digital was based on several factors, including patient throughput, technology and economics, says Blob. Regardless of the reason for converting from analog to digital mammography, appropriate planning is a must.

Adventist Midwest Health emphasizes a strong commitment to state-of-the-art patient care; one of the Midwest region’s four hospitals, Adventist La Grange Memorial Hospital, underscored its commitment by participating in DMIST. After the trial confirmed the benefits of digital mammography, the health system secured funding and began evaluating its digital options.

Adventist Midwest formed an operations committee consisting of the medical director, imaging director, lead technologist, PACS representative, chief operating officer and other key constituents. “We completed traditional due diligence and analyzed all of the quality vendors in the market. We conducted site visits, reviewed images and discussed the technology with radiologists and technologists,” explains Quaranta. The group selected GE Healthcare’s Senographe DS and Senographe Essential digital mammography solutions and developed an implementation plan that would enable it to fully capitalize on the benefits of digital technology.

The implementation addresses the specific needs and goals of each digital mammography site. The first Adventist site to deploy Senographe, DuPage Imaging Center in Hinsdale, Ill., specializes in breast imaging and went live with digital in April. Senographe provides a foundation for growth at the next site; Adventist Midwest Health plans to renovate Westmont MRI into a women’s center with digital mammography, ultrasound and DEXA bone densitometry scanning. Finally, the health system will place two Senographe systems in the women’s center adjacent to its new hospital scheduled to open in November.

The process at Thomas Jefferson University Hospital was fairly similar. The radiology department convened a planning team consisting of the breast management staff, physicists, surgeons and radiologists to investigate and evaluate digital solutions. “This process is time-consuming, but essential. Site visits are necessary to understand the capabilities and nuances of the various products. Experienced users are best-equipped to provide unbiased information about the various options,” notes Blob. Like Adventist Midwest, Thomas Jefferson University Hospital opted for a combination of GE Healthcare’s Senographe DS and Senographe Essential systems.

Going live

The multi-year planning effort at Thomas Jefferson University Hospital laid the groundwork for an extremely smooth implementation early this year. “We closed the former breast center on a Thursday and re-opened as an all-digital site the following Tuesday,” says Blob. The new, full-service diagnostic center is equipped with four digital mammography units and six GE Seno Advantage Image Review Workstations, enabling the center’s radiologists to interpret offsite screening mammograms as well as onsite diagnostic mammograms, along with two ultrasound rooms and biopsy equipment.

Adventist Midwest Health took a slightly different approach to the review process. The healthcare systems’ radiologists read digital studies from PACS workstations. A number of factors contributed to the decision. “PACS workstations equipped with 5 megapixel [MP] monitors [mandatory for reading digital mammograms] are sophisticated enough for digital mammography interpretation. Interpreting digital mammograms from a PACS workstation is the wave of the future,” predicts Sandra Mueller, technical manager at DuPage Imaging Center. “Although [dedicated] vendor workstations such as GE’s Seno Advantage Image Review Workstation are very good, there are some advantages to the PACS option,” adds Mueller.

The final preparatory step centered on IT infrastructure. Prior to deploying the FFDM systems, Adventist Midwest Health beefed up its storage capacity to handle digital mammography studies. The health system also upgraded its high-speed network to Gigabit lines to ensure rapid transmission of digital files across sites.

The lifestyle change

The next step in the conversion process is deployment. DuPage Imaging center installed three Senographe systems in April. The facility realized that the conversion represented significant workflow changes. “Radiologists can be very efficient with analog mammography, but technologists are not as efficient as they can be in the analog environment because of tasks like film developing and CAD processing. Converting to digital [workflow] shifts the clogs to a different spot,” explains Mueller. Technologist workflow improves in the digital world. A study published last year in the American Journal of Roentgenology shows digital mammography saves technologists time—35 percent—with digital mammograms completed in about 14 minutes compared to about 21.5 minutes for screen film. Other factors must be considered too, such as individual facility learning curves, radiologists’ learning curves, training and whether they are working in a blended analog-digital environment. Conversely, digital mammography may slow radiologists because the studies can take longer to read, especially early in the implementation process as radiologists transition from analog to digital review. It is key to maximize radiologists’ interpretive efficiencies through complementing workflow.

DuPage Imaging Center proactively addressed the learning curve phase for the entire department during implemenation by reducing its capacity for a short time. The site cut its screening schedule in half for the first week after going live and reduced its diagnostic schedule by half for the first month following deployment. The site also decided to add a temporary radiologist to its staff, and hopes to grow from two to 2.5 FTEs this year. “The vision is to grow the business, so adding another radiologist would address that need as well as facilitating the conversion to digital,” notes Mueller.

Thomas Jefferson University Hospital also halved its schedule for the first few weeks after installing its digital mammography systems and gradually increased to a full schedule with improved throughput and patient capacity. The hospital also prepped technologists for the digital conversion by installing a digital unit for learning purposes before going live. “This helps familiarize the techs with the equipment before seeing the first patients,” explains Blob.

“Digital can be challenging for radiologists because it takes longer to read each mammogram during the early part of the deployment process,” Mueller says. “Conversely, techs are speeding up during this stage. This can be stressful for the radiologists as they try to keep up with their workload.”

The same study that showed technologists are more productive with digital proved that FFDM initially increases radiologist interpretation time—2.3 minutes vs. 1.4 minutes for screen film—but after radiologists master the nuances of digital and the site builds a library of digital priors, the department will realize the true benefits of digital.

The good news is that the adjustment process is finite. “We anticipate a several-month learning curve before radiologist throughput reaches pre-digital levels,” states Quaranta. Sites that continue to evaluate workflow as radiologists master the technology may realize additional or more rapid workflow gains.

Thomas Jefferson  University Hospital has nearly passed the magic six-month mark, when digital becomes comfortable for radiologists. “We have seen an increase in throughput,” reports Blob, “and we continue to massage the schedule to maximize our resources.”

The digital workflow analysis

The debate: To digitize or not
The efficiency of soft-copy mammography interpretation hinges on  the ease of reading comparison views. “The longer radiologists live in both worlds, the longer it takes to streamline the digital mammography workflow,” explains Sandra Mueller, technical manager of DuPage Imaging Center in Hinsdale, Ill.

One solution to accelerate the transition to a primarily digital environment is to digitize prior mammograms to enable digital-to-digital comparisons, rather than the more cumbersome analog-to-digital comparisons. But there are downsides to this model. DuPage Imaging Center decided against digitizing priors because of radiologist preference and concerns about cost and it being labor intensive. Digitization would have required a dedicated FTE, says Mueller. In addition, if quality does not meet radiologists’ criteria, the prior film mammogram is still required. 

Thomas Jefferson University Hospital in Philadelphia also decided against digitization, with radiologists citing image quality concerns. Instead of focusing on digitizing priors, the center and GE Healthcare consulting services developed a plan to improve the radiologists’ efficiencies in an analog-digital reading environment.

“We’ve had some very challenging technical implementations in the past, and our techs adapted to the changes. It’s been a pleasure to implement Senographe because the techs are so excited about the technology,” says Mueller. Tech excitement stems from a few factors. For starters, a screening mammogram takes sub-five minutes to complete. Patients are amazed at the speed of the visit, says Mueller.

The speed is one factor in the appeal of digital. The other major gain is image quality. “Image quality is amazing. We knew that digital image quality would be better than analog quality, but it didn’t hit home until we compared images,” says Mueller. In fact, technologists no longer use the site’s remaining analog rooms and instead steer all patients to the digital suites because the speed and image quality is far superior to the analog equipment.

Adventist Midwest Health realized additional workflow benefits by tapping into GE Healthcare’s consulting services. “GE offers objective data and experience including Lean/Six Sigma analysis tools, which helped us analyze workflow with real numbers. We were definitely surprised with the results,” states Mueller.

GE consulting helped the healthcare system detect time-consuming processes that did not add value to patient care. For example, prior to the GE analysis, technologists delivered diagnostic mammograms to the radiologists and waited for instructions. Now, a single clinical coordinator serves as the point-person between radiologists and techs, which frees remaining staff to focus on patient care and other duties. 

Thomas Jefferson University Hospital engaged GE Healthcare’s consulting team during its planning stage. During the six- to eight-week process, the team—using Lean/Six Sigma methodologies—analyzed current analog workflow processes to eliminate tasks that don’t add clinical value and re-allocated essential tasks to maximize technologist and radiologist efficiencies. “Planning is what makes digital mammography work,” says Blob, “but not everything is the same at each site. It’s important to re-evaluate processes on a regular basis.”

Re-evaluation is particularly important during the first six months following deployment to ensure user needs are being met and goals are being met.

Going forward in the digital world

Digital mammography is a journey rather than a destination, and the most successful sites approach digital as a process that is continually refined as needs change. Thomas Jefferson University Hospital schedules weekly breast imaging workflow meetings with key stakeholders to continuously refine workflow. Adventist Midwest Health’s digital mammography operations committee plans to continue to meet on a regular weekly basis during both the short and long term. The purpose of continued regular meetings, says Quaranta, is to hardwire changes and address any challenges. In addition, the healthcare system plans to monitor progress through various metrics including efficiency and patient satisfaction.

Mammography transformed

Digital mammography systems have the potential to reinvent breast imaging. Digital yields improvements on multiple fronts, including workflow, efficiency and patient care. The hitch with digital is its complexity. Digital mammography does represent a lifestyle change. To succeed, facilities need to understand all aspects of the transition to digital, develop a robust plan for the conversion and tap into outside expertise like GE Healthcare’s consulting services so they are primed to reap the full advantages of digital mammography technology and image management.

Making Images Flow
Digital mammography transforms the breast imaging process and can deliver improved efficiency and better patient care and service. But the conversion from analog to digital mammography can be tricky. One of the most significant challenges associated with deploying digital mammography is image management. In fact, a thorough and robust image management plan boosts the odds of a successful implementation.

Thomas Jefferson University Hospital in Philadelphia analyzed its current image informatics infrastructure—including image storage, transfer and display systems, during its two-year digital mammography planning process.

 One image management consideration is archival of digital mammograms. Study sizes at Thomas Jefferson University Hospital range from 8 to 50 megabytes (MB). The facility deployed digital mammography to coincide with a new PACS installation, which helped minimize informatics adjustments.

Peter Natale, informatics administrator at Thomas Jefferson University Hospital, calculated the digital mammography portion of the new archive using 50 MB as the average file size, multiplying the file size by annual case load and adding 10 percent. He also factored in future growth in digital mammography volume into its archive by applying the previous year’s growth rates to the archive forecast for the next two to five years.

Other informatics considerations include network capacity and integration of client workstations. The new breast imaging center is located in a building adjacent to Thomas Jefferson University Hospital; the sites are linked by a gigabit network.

Although there are some consistencies among sites as far as digital mammography image management, every institution is unique. It’s critical to develop a site-specific image management plan that addresses key questions including:

  • PACS mammography workstation vs. dedicated workstation
  • Electronic methods of communication to eliminate paper—among radiologists and technologists
  • Image routing and storage to support existing network and infrastructure
  • Systems integration and configuration—PACS, HIS, RIS, dictation/reporting system
Addressing IT issues proactively lays the groundwork for a successful digital mammography deployment.