Analog & Digital: The Mammography Workflow Primer

Workflow is the key driver of digital mammography investment. When implementing digital, be sure to analyze all aspects of the workflow efficiency equation - not just digital acquisition systems, but also human resources and scheduling patterns and ancillary systems such as workstations, reporting systems and CAD.

Efficient workflow is critical in mammography. From a financial perspective, mammography is notoriously under-reimbursed. The site that fails to implement optimal practices could go out of business. There is also the patient care element; women are nervous and want results - fast. Breast imaging centers across the country are turning to digital mammography for a variety of reasons, increasingly for the potential boosts in workflow efficiency. "The ability to manipulate images digitally reduces callbacks, which improves workflow and patient satisfaction," sums Sharon Chambers, site supervisor at Sarasota Memorial Health System (Sarasota, Fla.). Digital streamlines CAD with CAD images available at the click of a button and the extra mammogram digitization process completely bypassed.

Developing efficient digital workflow processes is a delicate operation; factors in the workflow equation include staffing processes and patterns as well as the digital mammography solution, information systems and workstations. Prior analog films are a reality, so sites need to develop a plan for handling comparisons, and image-viewing ergonomics can make or break the entire arrangement. Can radiologists efficiently and comfortably read analog and digital mammograms as well as multi-modality images?

It's no surprise that optimal digital workflow is a work in progress for many facilities. Still, a comprehensive evaluation of all phases of the mammography process can reveal a number of ways that sites can move closer to the promise of digital workflow.

  • Start with a thorough digital vision, from acquisition through display and archiving, and involve all key players, including radiologists, technologists, facility IT staff and even experts in refining workflow.
  • Develop efficient staffing assignments, scheduling and reporting patterns and processes.
  • Implement processes and systems to simplify analog to digital image reading and multi-modality and multi-vendor digital comparisons.

Conquering the dual environment

Many facilities using digital mammography operate in a dual environment with both analog and digital equipment, which can create workflow challenges. Take for example, Beth Israel Deaconness Medical Center in Boston. The center has operated in a dual environment since 2002 with GE Healthcare and Hologic Inc.'s analog systems as well as GE's Senographe and Fischer Imaging's SenoScan digital solutions and iCAD's SecondLook CAD system.

"The dual environment is a challenge," confirms Janet Baum, MD, director of breast imaging at Beth Israel Deaconness. It's difficult to compare analog and digital mammograms, and in facilities with systems by multiple vendors, radiologists need to learn to comfortably read on different mammography systems and workstations (unless they utilize multimodality workstations).

"Digital systems are not interchangeable, so we try to keep our patients, especially screening patients, on one digital acquisition system," explains Baum. The center aims to smooth workflow with written protocols outlining what studies should be completed in specific locations. For example, if a patient requires a repeat study, a protocol should specify whether the repeat should be repeated on the same digital unit or an analog system. "The six-month follow-up is a problem," Baum notes. "We try to leave decisions up to the interpreting physicians and ask them to put recommendations in the report."

Elizabeth Wende Breast Clinic (Rochester, N.Y.) reports a similar situation. The facility primarily utilizes analog mammography systems by Hologic, GE and Siemens as well as R2 Technology's ImageChecker CAD. The clinic is headed in the digital direction with Fischer, GE, Hologic and Sectra digital mammography systems and a planned installation of a Sectra PACS. Currently, Elizabeth Wende Breast Clinic does not schedule patients by specific digital or analog units; however, Business Manager Tess Wade indicates that the clinic expects to schedule patients by unit in the future as it further implements digital mammography. This could aid workflow by limiting comparisons among mammograms generated by various digital systems.

In the interim, the high-volume mammography center undertook a workflow analysis and redesign plan to facilitate streamlined workflow and better serve its 350 daily patients (250 screening and 100 diagnostic, which ads up to 75,000 studies in 2004). The breast clinic contracted with Eastman Kodak Co.'s Professional Services Group to develop a workflow improvement plan. "We used on open book for patient scheduling to accommodate patients and referring physicians," Wade explains. "This created huge swings in volume and backed up both technologists and radiologists."

A pair of Kodak consultants hosted a two-day planning session with clinic staff to list problems and solutions, eventually reorganizing workflow. The redesign resulted in implementation of a target number of maximum patient daily appointments, development of 'urgent work-in' criteria for diagnostic patients to limit the number of work-ins and elimination of screening work-ins. "This has evened out patient volume and actually increased patient flow. Every month our volume is growing by an additional 500 to 750 patients," says Wade.

Wade says it's possible to improve combined analog-digital workflow. Elizabeth Wende Breast Clinic has 'digital techs,' who complete the lion's share of the clinic's 50 to 60 daily digital mammograms. This develops a digital skill set that can be shared among the group as digital ramps up.

The multi-site environment

Digital mammography enables telemammography, and more multi-site breast imaging centers are taking advantage of this option. Take for example Sarasota Memorial Health System, which is equipped with four Fischer Imaging SenoScan digital systems at three outpatient screening centers and one comprehensive breast center. "All screening images are interpreted at one location. This improves radiologists' efficiency. We're able to send images to a second Fischer workstation to expedite processes or solicit a second opinion," says Sarasota's Chambers. A new T1 network supports offsite reading by enabling efficient transfer of mammograms from site to site.

Tucson Breast Center (Tucson, Ariz.) touts a 45-minute turnaround time for its five telemammography sites. A patient care assistant who staffs the reading room hand-delivers faxed telemammography referrals to the reading radiologist, so he can retrieve images on his workstation. A web reporting system completes the circle, enabling the center to report back to other sites in the 45 minute window.

Staffing matters

Tucson Breast Center completes 120 mammograms daily with GE Healthcare's Senographe 2000D and Senographe 2000DS digital mammography systems - doubling the throughput of the three analog rooms the systems replaced in 2001. The center achieves its high throughput and patient satisfaction with smart staffing choices.

Two patient care assistants complete patient histories. Two technologists work each mammography room, with one tech handling the acquisition station and one tech positioning the patient. "We don't mandate a volume in each room. This allows techs to spend more time with a patient if needed," explains Director Lisa Labbe. Nevertheless, the site completes an average of three mammograms every 10 minutes.

The center's 1.5 FTE radiologists manage to keep pace with both technical and human assistance. Another patient care assistant works the reading room, entering all negative reports into a template on the IDX ImageCast Mammography Administration Module.

Sometimes it's appropriate for techs to assume additional responsibilities that may traditionally fall on radiologists' plates. This can relieve the radiologists' workflow burden and keep throughput humming. For example, Tucson Breast Center has approved its technologists to work up calcifications, asymmetries and suspicious cases with cone down compressions and diagnostic mammograms. "This reduces interruptions to radiologists while they are reading and decreases callbacks and wait time," sums Labbe.

But how do you get the ball rolling? The early days of a digital implementation can be a workflow challenge. Sarasota's Chambers says facilities should allow additional time in the schedule during the implementation phase, adjusting the schedule as radiologists and technologists master the digital learning curve to gradually work toward a goal such as 10- or 15-minute appointments.

Streamlined CAD

Facilities using digital mammography agree digital streamlines CAD, enabling breast centers to offer CAD with minimal workflow impact. Lipman says CAD integrates into the digital workflow with the push of a button, allowing the center to handle microcalcifications and suspicious areas seriously, yet slowing down reading by a few seconds. David points out that CAD can boost workflow by helping radiologists reach a decision faster. 

Souped up mammo reporting

"We are under federal mandate to provide a quick turnaround, so we have to look at all [workflow] processes," states Mari David, director of Torrance Memorial Breast Diagnostic Center (Torrance, Calif.). The Torrance Center undertook a SWOT (strengths, weaknesses, opportunities and threats) analysis when it entered the digital environment in January 2004 with the installation of two Hologic Selenia digital mammography systems.

One result of the analysis was to incorporate a templated tracking sheet to use with its Mammography Reporting Systems MRS reporting system. The radiologist fills in a tracking sheet that contains demographic information, history, findings and recommendations and serves as the groundwork for the report. "This facilitates concise, specific reporting," explains David.

The current system relies on a transcriptionist to complete the report.  However, David anticipates additional workflow gains and elimination of the transcription middleman with the implementation of touchscreen Tablet PCs. When the touchscreen technology is deployed, radiologists will input directly into the template.

Southern Ohio Medical Center (Portsmouth, Ohio) relies on a variety of technologies - Mammography Reporting Systems' MRS, two Hologic Selenia digital mammography systems, R2 Technology's ImageChecker CAD and Agfa's IMPAX PACS - to facilitate digital workflow at its breast center.

Robin Dixon, breast center supervisor, explains the value of MRS. "Radiologists are able to do all of their reporting in the system. Reports are available to referring physicians as soon as the radiologists finalize them. Diagnostics are usually available within two hours, and screenings are turned around in six to eight hours."

Dixon offers a checklist of features to look for in reporting systems.

  • Make sure the system is user-friendly. Page tabs eliminate flipping through multiple pages to reach a certain page.
  • The system should recall standard views based on the procedure.
  • Items requiring diagnosis, such as incisions and bumps, should come up automatically for the radiologist.
  • The system should accept priors from other facilities.

Workstation wonders

Multi-modality, multi-vendor workstations hold some promise as a means to streamline digital reading, particularly in multi-vendor sites. Full system integration is key to streamlined workflow, and multi-modality, multi-vendor workstations can ease some of the pain (and workflow disruptions) of disjointed digital environments. For example, multi-vendor workstations may overcome the differences in image appearance among mammograms generated by various vendors' units.

Northwestern University Medical School in Chicago plans to open an all-digital women's hospital in 2007. The medical center hopes to reduce technical glitches at the new hospital by requiring that all equipment designated for the new site function in the current hospital for six months. The hospital is testing multiple systems, including GE and Siemens digital mammography systems and an Agfa IMPAX MA3000 workstation.

"It's not plug and play [between two digital systems]," explains Eric Berns, PhD, research assistant professor, department of radiology at Northwestern. When the department attempted to push GE images to the Siemens system, it encountered image quality problems, requiring Siemens to backtrack and install a GE look-up table on their workstation. Berns believes that Agfa has overcome this challenge by incorporating the various look-up tables on the workstation. Consequently, Berns was able to install the MA3000 and have radiologists reading on the workstations within a few hours.

Inger Bjarke, applications specialist with Alfa, Kommun and Landsting, a PACS installation and education consulting firm in Malmo, Sweden, points out, "Radiologists must read screening mammograms very fast." Bjarke recommends Cedara Software's I-ReadMammo workstation, which offers one-click image activation to clients seeking a digital mammography workstation.
How can sites avoid connectivity challenges that can negatively impact workflow? Berns recommends:

  • Have vendors set up new systems in the background before going live. Insist that together they make it work.
  • Check image quality.
  • Verify PACS communication. Go beyond send and receive, and check functional tools like overlays and annotations.
  • Solicit the radiologists' input. Make sure they're satisfied with the user interface, image quality and performance.

To digitize or not

One of the primary questions confronting facilities as they plan for and implement digital mammography is whether or not to digitize prior analog studies to ease comparison. That is, comparing digital to digital is less cumbersome than comparing digital to analog. "It's a struggle to look at a mammogram on a workstation and another on a film alternator. Plus, you need people power to hang prior studies," sums Robert Lipman, MD, staff radiologist at Straub Clinic and Hospital in Honolulu.

Straub Clinic uses R2's DigitalNow program to digitize mammograms acquired on a Hologic Selenia digital mammography system and store them on a Fuji Synapse PACS. The clinic plans to use the system for comparison rather than primary interpretation.

Other sites are less enthusiastic about digitizing. Insiders at Tucson Breast Center, which has been digital since 2001, recommend sites 'tough it out' rather than digitize analog films. Labbe claims, "You really only need one to two years of priors for most patients." During the first year of digital mammography, Tucson Breast Center relied on patient care assistants to hang two year's prior films on one of two mammography viewers in the reading room. By the second year, a small viewbox replaced one of the viewers. Four years into digital, Tucson still sees film; however, the numbers have dropped to a level where radiologists can hang their own priors, as many patients have several years of digital priors.

Tucson Breast Center aims to further boost workflow and cut film costs when it deploys Fuji Synapse PACS later this year. Currently, the site prints film for surgeons, a task that should be eliminated with PACS, says Labbe. He adds, "An upgrade to the GE DS workstation will allow us to accept other vendors' digital images on CD and download them to our workstations. This also will reduce the number of films to compare."

Advice from the digital trenches

Digital systems can be implemented to boost mammography workflow. Facilities that plan for and implement digital acquisition devices with workflow in their crosshairs can up the odds of a smooth transition and reap the benefits of digital workflow in minimal time.

  • Look at the entire systems and processes, including paperwork and documentation, says Torrance Memorial's David.
  • Use human resources efficiently and effectively. The right people should be doing the job. Techs should not perform clerical work. Evaluate duties and processes regularly as needs evolve during a digital implementation.
  • Involve your facility IT staff from the beginning, says Chambers. The department can assist with planning for network, archiving and integration needs.
  • Consider contracting with an outside company for auditing, report generation and patient communication, continues Chambers. Software can handle these tasks, but doesn't replace multiple FTEs to staff the software.
  • Cross-training staff keeps them challenged and happy, says Labbe. And cross-training can aid workflow during all-too-frequent transition times.
  • Talk to and educate radiologists, technologists and clerical staff prior to the transition, says Dixon.  This may allow sites to anticipate and prevent some challenges.

Musts for Mammography Reading Room Design

The mammography reading room configuration can make or break digital workflow. Janet Baum, MD, director of breast imaging at Beth Israel Deaconness Medical Center, offers a few pointers.

  • Place viewboxes at a right angle to the workstation for simplified comparison of prior analog and current digital studies.
  • Install height-adjustable tables and chairs to accommodate readers of different heights.
  • Light control is crucial; lighting should be controllable, preferably from the workstation.
  • Elimination of paper patient histories can improve workflow. This can be achieved via scanning or electronic input into PACS.
  • Computers and alternators generate a great deal of heat. Improved ventilation or cooling systems can increase comfort, which could translate into productivity gains.

Smooth Sailing: Optimizing Analog

For many facilities, film remains the medium for mammography. They may cling to film for financial or technical reasons. Nevertheless, it remains critical to streamline workflow to stay afloat in the mammography world.

X-Ray Associates of New Mexico (Albuquerque) has demonstrated that analog and efficient are not mutually exclusive concepts. Director of Mammography Michael Linver, MD, says, "We've learned to be efficient with analog, so we don't have to install digital." The center performs 30,000 to 35,000 mammograms annually on eight Siemens Mammomat analog systems and relies on R2 Technology's ImageChecker for CAD. Linver manages to read an impressive 60 to 80 screening mammograms an hour with a reading assistant.

The site is a model of mammography efficiency for two reasons, says Linver. In the 1990s, Linver designed a new breast center with workflow at its core, and the site employs technical aides to boost efficiency. He estimates that mammography became two to three times more efficient when X-Ray Associates opened the new center.

Designing for workflow

Linver carefully considered mammography workflow before opening a new breast center in 2000. "I figured out who was going where and designed the building to cut down on extra motion," he says. The new site offers two back-to-back screening rooms; each has a pair of dressing rooms to facilitate a constant flow of patients in and out of the screening rooms. One tech images patients, and a tech aide runs the film through a CAD processor and then to the reading room for pre-hanging. Techs and patients have separate hallways to facilitate efficiency; patients can't interrupt techs or aides as they walk from one part of the building to another. The set up allows X-Ray Associates to comfortably schedule 15-minute exams.

The reading room emphasizes workflow. Linver and his colleagues read in a closed room without a phone or other interruptions. A tech aide pre-hangs the film and sits with the radiologist as he reads, taking notes and filling out forms, so that the radiologist's eyes never leave the film. Linver confirms, "It's important to use ancillary help for relatively menial tasks Radiologists need to buy into efficiency and do what they are paid to do. This means not hanging films themselves."

X-Ray Associates completely separates screening and diagnostic patients with different waiting rooms and reading schedules. Linver claims, "This arrangement benefits patients, and it boosts workflow." The practice's two radiologists divide work with one completing diagnostic workups in the morning and then switching to screening mammography, interventional procedures, bone scans and ultrasounds in the afternoon. The site also incorporates a diagnostic consultation room. Linver explains, "This keeps diagnostic rooms busy. If I need to talk to a patient, we move to the consultation room [instead of tying up the mammography room]."

Linver points out that CAD can be an economic boon and workflow gain, helping the bottom line and workflow by eliminating double reading but increasing clinical accuracy.

Patient care counts

X-Ray Associates proves that efficiency and patient care can go hand in hand. Linver admits he rarely talks to screening patients, but he has instructed techs to tell all patients that he reads mammograms within one day. He also offers to call patients personally with results. "This takes 15 to 20 minutes at the end of the day and instills a sense of patient loyalty," Linver explains.


Digital mammography may be the wave of the future; however, analog remains the right choice for many sites. Analog facilities can reap workflow gains with a well-designed space and implementation of efficient processes.