Breast Imaging Workstations: Why Multimodality Is a Must

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The Merge Mammo workstation features the ability to simultaneously display mammography, MRI and/or ultrasound studies for viewing or manipulation at one workstation. Displayed on the left monitor is a mammogram showing a solid mass on the left breast and on the right monitor an ultrasound of the same mass.

Breast imaging workstations are a whole new breed of animal these days. Becoming extinct are the single-vendor workstation solutions in favor of more flexible multimodality, multi-vendor workstations that allow radiologists to efficiently read digital mammography, ultrasound, breast MRI, and CT images in one place as well as read remotely to cover a variety of imaging sites.

In the early days of digital mammography, image review options were very limited. Digital pioneers paired the digital acquisition unit with the mammography vendor’s workstation. This approach does work, but in a fair share of cases, it may not be ideal. The digital mammography vendor often differs from the PACS vendor, which means the facility needs to develop interfaces between the workstation and PACS. In addition, RIS/PACS workstation integration may be an issue.

Some sites have found the cost of vendor workstations hard to swallow. In other cases, the site is a hybrid environment with an array of acquisition units. It can be difficult or impossible to read one vendor’s mammogram on a second vendor’s workstation, which creates workflow and logistics challenges. And finally, breast imaging is a multimodality specialty; in many cases, radiologists need to review ultrasound, MRI and mammography studies to provide a complete diagnosis. And reading efficiency is a must these days.

The past several years, however, have delivered a new breed of options. In addition to vendor workstations, digital mammography facilities can install third-party or PACS review stations approved for digital mammography interpretation. This option brings a number of advantages. For starters, the systems are built to handle multi-vendor, multimodality images, which delivers workflow and efficiency improvements as radiologists can use a single workstation as their primary review station for digital mammograms and multimodality studies. The approach also facilitates remote reading, a key consideration for multi-site operations. Third-party systems also can deliver economic benefits. The initial cost of the breast imaging workstation may be lower, and the site may be able to trim the total number of workstations because the breast review station can be used to read multiple types of images—not just mammograms.

The open model

Digital mammography can be a challenging transition. Early adopters, like Doshi Diagnostic in New York City, encountered several roadblocks. One of the challenges, says Lyle Backenroth, CIO of the 48-site imaging center group, was the limitations posed by vendor workstations. The practice, which started deploying digital mammography in 2003, is a mixed acquisition environment that uses digital mammography systems from two different vendors. The hitch is reading one vendor’s study on the second vendor’s workstation. In some cases, radiologists had to move between two workstations to review a single case, complicating workflow and reducing efficiency.

Four years ago, the practice began looking for new workstations and decided to deploy Carestream Health Kodak Carestream Mammography Workstations, eventually equipping its centers with 35 mammography workstations for its 45 radiologists. “This model provides flexibility. Our digital acquisition units produce different file sizes and use different DICOM tags. The Carestream workstation can interact with mammograms from both vendors,” says Backenroth. The practice developed a variety of hanging protocols to address the array of studies and priors. That is, there is a protocol for each possible permutation of current study and prior exam. “It took some effort on the part of the IT and PACS teams, but it cuts down on the total number of workstations and saves workflow steps because radiologists don’t need to move between workstations to interpret multi-vendor patient exams. The Carestream workstation lets them concentrate on reading.” What’s more, the new system allows radiologists to share digital images with colleagues for consultation.

In addition, the workstation is a multimodality solution, so radiologists can rely on the same workstation for all types of work, from digital mammography, to CT, breast MRI and even scintimammography images if they are in DICOM format, which reduces total workstation costs and keeps radiologists focused on their primary duty—interpreting imaging exams—rather than shifting from one station to the next to read studies. 

The synergy between PACS and the diagnostic mammography workstation can play a key role in the transition to digital mammography. Medical University of South Carolina (MUSC) in Charleston, an Agfa HealthCare Impax PACS site, decided to deploy Agfa Impax MA 3000 diagnostic mammography display station in conjunction with its transition to digital mammography in 2004. The similarities between the PACS review station and the diagnostic mammography station streamlined the orientation process because radiologists were already familiar with the user interface, says Director of Breast Imaging Tommy Pope, MD. “Another advantage is the ability to seamlessly interact with sub-specialty images on the mammography station.” The multimodality model not only helps radiologists diagnose breast imaging patients but also allows physicians who aren’t dedicated breast imagers to review other studies at a single workstation.

Solis Women’s Health, a newly constructed breast care center in Austin, Texas, aimed for solid RIS/PACS integration when it opened its doors early this year. The center paired Sectra PACS with an IDS5/ mammography review station and three IDS5/ review stations for techs with its digital mammography system. “We felt it was important to have RIS/PACS integration, and we knew Sectra integrated with our Eclipsys RIS,” explains COO Bonnie Lankford. Scalability was another consideration. The new center did not require a PACS geared for a full-blown radiology department. At the same time, the scalable system can accommodate future organizational growth. The Sectra workstation will allow the practice to incorporate other digital mammography vendors in the future, and it provides a solid platform for remote review if the practice opens other facilities.

Get ready…

Similarly, Radiology Associates of Albuquerque (RAA) in New Mexico employed a best-of-breed approach to its digital mammography acquisition system and workstation pairing, opting to combine a vendor acquisition system with Sectra IDS5/ dedicated mammography review workstations when it deployed digital mammography in 2004. The practice feeds multimodality images, including digital mammography, breast MR, CT and ultrasound, into the Sectra workstation. “Everything is in one place, which has a significant impact on workflow and efficiency,” says RAA President Gary Wood, MD.

The practice began setting the stage for digital one year before installing the new equipment. The practice decided to bypass the hybrid environment that combines analog and digital systems and implement digital ‘cold turkey.’ The first step entailed digitization of priors acquired six to 10 months before implementation. This step speeds workflow and produces priors sufficient for most cases; occasionally the radiologist can pull film if the digitized prior is unsatisfactory, says Wood. “If the site can afford to digitize prior mammograms, it is well worth the effort,” says Kandace Farmer, MD, breast radiologist with Solis Women’s Health, “because it simplifies the transition to digital.” Like RAA, Solis digitizes all priors, but maintains a viewbox for the occasional calcification that is not well-seen on a digitized mammogram.

Every site wrangles with the decision to digitize prior mammograms. On the plus side, it can minimize or eliminate the workflow and ergonomic burden of the hybrid analog/digital environment, where radiologists must compare a prior analog mammogram to a current digital study. On the other hand, says Pope of MUSC, digitizing is somewhat laborious, not inexpensive and requires additional digital storage. MUSC did not digitize prior mammograms and set its digital workstations across from an alternator where prior film images are reviewed; radiologists turn back and forth between the digital and analog images. The approach is less efficient than all-digital review. And the configuration is an ergonomic burden compared to an all-digital review model or the ideal hybrid arrangement with analog and digital images placed at a 90-degree angle. Three years after deploying digital, Pope estimates that 60 to 70 percent of patients return with a prior digital exam and predicts that the hybrid era could come to a close in another year.

Remote reading challenges

When Zwanger-Pesiri Radiology, an eight-site imaging practice in Massapequa, N.Y., deployed digital mammography in 2003, it opted for a pair of vendor workstations. The approach sufficed in the early days of digital, but as the practice expanded digital acquisition units into additional sites, it ran into several challenges.

“There were connectivity, efficiency and workflow issues,” says Medical Director Steven Mendelsohn, MD. For example, the practice could not feed digitally acquired mammograms from an acquisition unit at one site to a reading workstation at a remote site; however, it wasn’t practical or affordable to place a dedicated mammographer at lower volume sites. “We found that the vendor workstation impeded the flow of images between offices; multiple radiologists could not review the same studies,” says Mendelsohn. The growing radiology practice decided to search for another solution. After considering various options, the practice decided to implement Merge Healthcare MergeMammo softcopy review workstations. “The [relatively low] cost of this system got us in the door, but we’ve found the benefits far surpass cost,” shares CIO Matt Dewey.

Now, digital mammography is geographically seamless at the practice. If a tech acquires a diagnostic mammogram at one site, she can buzz a radiologist at the primary mammography interpretation clinic to immediately determine if additional views are needed, which enhances patient care and boosts efficiency. The benefits extend beyond real-time review. Zwanger-Pesiri Radiology loaded Merge software onto tech workstations, so techs can print images without interrupting radiologists at their review stations. The software also features a shared database, so all information—including hanging protocols and patient merges (such as name changes)—travels with the user or patient. On some systems, a patient name must be changed on each individual workstation if she changes her name. Finally, the softcopy review station allows users to read multimodality, multi-vendor images. “Radiologists can read MRI, ultrasound, CT and x-ray images on the mammo station, which means we don’t have to interrupt workflow to read other modality studies,” explains Mendelsohn. And users can read studies acquired on any vendor’s digital mammography acquisition system, providing the site with greater flexibility as it expands its digital mammography base. In addition, it simplifies and speeds workflow by making it easy to access priors regardless of the acquisition unit.

Efficiency and versatility provided by the software model does require a fairly substantial hardware backbone, says Dewey. “MergeMammo is fairly intense. It’s important to equip the workstation with robust RAM.” Zwanger-Pesiri Radiology uses Dell Precision workstations with 4 gigabytes (GB) of RAM and 5 megapixel (MP) displays.

Solving breast MRI challenges

Although it is not nearly as widely used as mammography, breast MRI presents parallel reading challenges. That is, the radiologist may prefer or require multimodality images, or the vendor workstation may be inhospitable. “When we first started performing breast MRI, I would complete all post-processing at the magnet workstation. It was really cumbersome,” recalls Bernadette Redd, MD, MRI radiologist with X-ray Associates in Albuquerque, N.M. To complicate the situation, it was difficult to compare studies obtained on different vendors’ systems. Fortunately for Redd, the advent of breast MRI coincided with the rise of 3D post-processing, and in 2002 X-ray Associates invested in TeraRecon’s

“I use AquariusNET for every breast MRI study,” says Redd, “It readily receives images from multiple types of MRI scanners and incorporates very rapid post-processing.” In fact, Redd says she can provide an interpretation within five minutes of an on-site study and within 20 minutes of an off-site exam. The 3D workstation also accepts multimodality images, including digital mammograms, enabling Redd to obtain a more comprehensive picture of the patient at a single workstation. 


Advice from the field
Digital mammography is on the radar for many sites across the country. Today’s buyers have far more choice and flexibility in their deployment and workstation selection than early adopters. Pairing a PACS workstation engineered for digital mammography with a digital acquisition system can deliver critical benefits including improved workflow and efficiency; multimodality, multi-vendor and remote review capabilities and streamlined integration between the workstation, PACS, RIS and digital acquisition unit. Evaluating the various digital options can be an all-encompassing undertaking. Pioneers offer their advice to facilitate the process.
  • “Look at all of the workstations you can,” says Pope. Site visits should follow the initial investigations. Finally, bring the top system candidates to the home site and see how each interfaces with PACS and the mammography acquisition system.
  • “Determine what’s most important to the site,” says Lankford. Image quality and resolution, integration, cost and workflow and efficiency are common priorities.
  • It isn’t necessary to commit to the vendor’s workstation. Compare overall cost and functionality of several systems. Dewey recommends those in the market for new systems get a separate price for the acquisition unit and the workstation, and then ask the vendor for competitive bids for the workstation component.
  • Be sure to evaluate all systems from a medical perspective, says Backenroth. “Radiologists have to be happy with image quality, tools and the user interface.”
  • On the IT level, ensure that the workstation integrates well with the network, imaging modalities and PACS. “Validate and verify,” sums Backenroth.
  • Assess the workstation’s functionality and versatility and determine if it can read multi-vendor and multimodality images. Is multi-vendor image review streamlined? Does the workstation support CAD? Does the system facilitate remote review?