Digital Mammography Workflow: Lessons Learned at The Elizabeth Wende Breast Clinic

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The Elizabeth Wende Breast Clinic (EWBC) in Rochester, N.Y., was an early adopter of full field digital mammography (FFDM), CAD, breast imaging workstations and PACS to manage its comprehensive breast care practice that images 350 women every day. The facility has fine-tuned its workflow through trial and error - and is leading the call for better connectivity solutions to seek to unite valuable diagnostic information from disparate vendors' FFDM systems, workstations and PACS - to enable better patient care.

The challenges of mammography have been well documented. The combined stressors produced by insufficient reimbursement, ever-increasing workloads, innate flaws in the means of detection and the precision required in reading these critically important exams increase the intensity of these endeavors. As recent studies have indicated, breast cancer deaths have declined thanks to earlier detection enabled by excellence in breast imaging.

Yet while earlier and better detection of breast cancer is, for sure, saving lives, many breast imaging centers are "killing" themselves in integrating all of the current elements of the analog and digital imaging world to continue to improve breast cancer detection and advance care.

When they entered the realm of digital mammography in November 2002, little did the staff of The Elizabeth Wende Breast Clinic anticipate how dramatic a shift would occur in their work patterns or how demanding the problems with connectivity between systems would become. Three years after the installation of their first digital mammography unit, they have realized that their experience is invaluable to share in hopes of reducing the headaches for colleagues who are following in their digital footsteps. As leaders in this field, they are dedicated to participating with vendors, governmental agencies such as the FDA, professional organizations and fellow clinicians to improve and enhance the technical aspects of digital mammography.

EWBC was founded in 1976 as the nation's first free-standing mammography and breast imaging center devoted to the detection of breast disease. Typically this busy radiology practice performs 350 mammographic studies per day, including both screening and diagnostic exams. The clinical patient work pattern involves "double reads" by two physicians for each exam coupled with computer-assisted detection (CAD) software. Some 70 percent of their patients prefer to wait in the Clinic for the results of their exams which can include ultrasound, additional mammographic views and core biopsies that are performed during the same appointment rather than requiring patients to return at a later date. This approach is designed to reduce their patients' apprehension that comes from waiting for additional testing to be performed.

Stamatia Destounis, MD, staff radiologist at EWBC and a clinical associate professor at the University of Rochester Medical Center, explains that for patients who are being worked up for an abnormal mammogram, the physician will follow that patient throughout the process. Therefore, as a physician, she doesn't necessarily sit all day in a darkened room to read images in batches. She may go to do an ultrasound scan and a core biopsy and then return to read other mammograms.

Besides the issues produced by their patient-centric work pattern, EWBC radiologists straddle analog and digital worlds with some full-screen analog and digital imaging units. They are attempting to maximize the number of patients who are scanned on the digital units, and they don't plan to purchase more analog machines. This situation means that with any given patient, they may need to review both films and soft-copy versions of newer images. Comparison may be hampered because the image size may be different, the level of image contrast does not match and there can be annotation challenges that make it more difficult for physicians to communicate needed additional views to the technologist.

Destounis says that it takes longer to read a digital image than film screen because there are more ways to manipulate the image data produced by FFDM. Digital images can be windowed and leveled, zoomed in on, and physicians can examine the images in several different ways. She relates that all the radiologists experienced a learning curve and that they have increased their efficiency as they became more comfortable with the technology.

"In all honesty, I have to say that digital mammography has helped us see