Breast Imaging Workflow: Imaging and IT Bring Better Diagnosis

Hologic's Selenia digital mammography system

When you factor together the one million women turning 40 every year, growing awareness of the importance of early detection for breast cancer and surging interest in digital mammography based on its validation by the National Cancer Society's Digital Mammographic Imaging Screening Trial (DMIST) — breast imaging is top of mind and the market is exploding. Everything on the spectrum from digital mammography and breast MRI to automated report generation and easier-to-use workstations are helping facilities meet the growing demand.

Preparing for digital mammo

Raleigh Radiology in Raleigh, N.C., is an outpatient imaging center that brought on digital mammography when it moved to a new location on October 2005. PACS Administrator Sabrina Johnson worked with Hologic when the center went live with digital mammography. When making the switch, the center was able to cut its mammography rooms in half, from four to two. "I was skeptical when Hologic said we could do as many patients in just two rooms, but we are pretty close to that." Mammograms are done every 15 minutes from 7 a.m. to 7 p.m., Monday through Thursday.

Radiologists read images on a Hologic SecurViewDX workstation. Images come up in hanging protocol in a continuous flow, and the radiologist marks them as read when done interpreting. "At first it took more time because everything looks different and there are more tools. But now they can read faster than they could with film," Johnson says. They are constantly reminded of the difference now that they are digital thanks to the worklist. Radiologists read all their screenings in one session and all their diagnostic exams in another. "It's easier for them when broken down into smaller sessions," he says.

Once a mammogram is finished, it is sent to CAD, the soft-copy workstation, and PACS. "The radiologists never have to pull from PACS, so there's no delay in retrieval." If the physician makes annotations, he or she can click a button, and they are automatically sent back to PACS as an overlay.

Switching to digital was a big transition, Johnson says. "The workflow was totally different, but Hologic offered training and provided resources." She highly recommends taking advantage of vendor training. And, "if you're going to [install] anything digital, trace out your workflow before it actually happens. Play out a mock workflow, and talk with your vendor about that. Let them meet the needs of your workflow."

Scheduling, scheduling, scheduling

The hardest part of maintaining a good workflow is scheduling, says Andrew Gitschlag, administrative director of Knoxville Comprehensive Breast Center in Knoxville, Tenn. And although digital mammography offers many benefits, it takes longer to read digital images, says Kamilia F. Kozlowski, MD, medical director. "You have to be careful how you schedule screenings and diagnostic mammograms," she says. "You can end up with a backflow rate of clinicians, and you can't speed that up. Seeing the patient has not been expedited in any way."

The center uses Hologic's mammography image management solutions (MIMS) mini-PACS and PACS 1, a PACS software that was tailored to the center's needs, says Gitschlag. Kozlowski is in the process of linking disparate systems to eliminate double entry of patient data. "Integration has been good on some of the vendors, but for some of the others, it's a little harder because of the proprietary nature of their products."

Two coordinators help drive the workflow. One follows the patients, the other follows the doctor, Gitschlag explains. The coordinators make sure the doctors are reading the patient who has been waiting the longest, let patients know how long they will wait to see the doctor, and work with technologists so that the radiologist knows the best angle and approach for a study.

Enhanced and improved productivity

Closely managing mammography reports was a priority at the Breast Center at Southern Ohio Medical Center in Portsmouth that installed Mammography Reporting System's MRS reporting system for exam results reporting for all breast-related procedures and letter generation.

As established patients enter the center, the office staff prints a history sheet, and the technologist checks the information with them, explains supervisor Robin Dixon. After a screening mammogram, the radiologist can use one of several templates to create a report right in MRS. Radiologists can mark the studies as read and they are archived to PACS. Coming soon will be a new workstation that will allow the radiologists to use voice recognition to create reports.

The system also lets users link exams together. For example, if a patient has a diagnostic mammogram and then a breast ultrasound, the patient information for the first study can be applied to the second. "The information is already there for the technologist, and she doesn't have to input anything but what she sees on the study. That's a little bit of time savings."

Performing imaging studies efficiently, while ensuring quality, is a top priority for Lake Forest, Calif.-based InSight Health Corp.'s 115 imaging centers located across the country. That's why InSight recently selected the MergeMammo workstation from Merge eMed, a Merge Healthcare company, for one of its facilities, Encino (Calif.) Diagnostic Imaging Center, with plans to expand to more. The key factors in making this decision were flexibility, cost, and the ability to integrate with their Merge PACS, according to Gregg C. Daversa, vice president, technical services. And, opting for MergeMammo, based on the I-ReadMammo work≠station from Cedara software, also a Merge Healthcare company, was a vendor-neutral solution, allowing radiologists to view mammography images with other modalities when necessary.

"With digital mammography, InSight knew that it would get improved productivity and workflow," says Daversa. "With only one film screen mammography system, we knew we were not meeting our capacity or offering the best for our patients. Now, our centers can perform more procedures each day in less time. Once our technologist captures the images, she can view the images immediately for quality, which has reduced the need for patients to have additional imaging procedures and more radiation exposure." In addition, Daversa says, using the MergeMammo workstation allows the interpreting radiologist to correlate the mammography images with other images from other modalities, such as ultrasound, at one workstation at the same time. The radiologist can place digital marks on the images and communicate to the technologist's workstation if additional imaging is needed. "The ability to perform more studies in less time has allowed InSight to grow its business and reduce the patient backlog; however, getting to the point of committing to convert entirely from film to digital took a well-thought-out plan implemented by a multidisciplinary team," says Daversa.

"Many women typically wait two to four weeks to have a screening or diagnostic mammogram, which can be very stressful for some women who may have concerns. With the increased efficiency of digital mammography, InSight has reduced waiting time, which means they get critical life-saving answers faster," says Daversa.

MRI answers the demand

When Breast Care Specialists in Atlanta implemented breast MRI from Aurora Imaging Technology in July 2005, they experienced changes they weren't expecting, says Christine Murphy, MD, medical director. "When starting with a new modality, our concern was, ëWhat will it take to pay the loan?'" The real concern wound up being the thought that they might need a second MR system. "Within six months, we were doing 10 [studies] a day because of need," Murphy says.

With this kind of volume for a practice with two radiologists and three surgeons, the challenge became finding trained technologists. "It's a very specific training issue. You need somebody who knows breast imaging first. You need a mammo tech who is top of the line and wants to learn MR." The practice has five technologists on staff and two working with MRI at any one time. "They are all mammographers first," says Murphy. "They understand positioning, the patients, the location of things within the breast, and then they learned MRI."

The practice exclusively sees patients with a medical problem related to their breasts. They installed MRI for staging new cancers and to follow up on high-risk patients, Murphy says. Because all patients have a pressing medical issue, they are triaged based on their symptoms. The goal is to offer and complete every necessary procedure in one day, which requires complex scheduling since that can include a mammogram, ultrasound, physical exam, time with a radiologist, and an MRI consult with a surgeon. "We try, in about a three-hour time span, to do all imaging and sometimes needle aspirations and even biopsies," she says. A flow manager determines which modality has the shortest wait. "There is a wait between each procedure, but when they leave here, they are all done" with all procedures. "As we're doing one image, we're determining if they need something else."

The incidence of breast cancer has been increasing over the past several years, Murphy says. "I think the need for an expedient diagnosis is increasing. You can't do a mammogram and send the results in a letter two weeks later." At the practice, all mammograms are read while the patient is there, and she can take her results letter with her when she leaves. Unlike imaging centers, patients are referred to the practice for consult and workup as the clinicians deem necessary. "Referring physicians love the fact that we take the patient and run with the process," she says. "They know if they send their patients here, they don't have to worry. They don't have to get the radiology report and act on it. We act on our own reports."

That helps with doing Breast Imaging and Reporting Data System (BIRADS) also, according to Murphy. "They are easy to track because almost all the biopsies are done by us."

Herself diagnosed with breast cancer in January 2005, Murphy knows how important it is that a patient's time is well spent at her practice. "We are constantly improving. We are never comfortable with our workflow. We are always trying to speed up. The trick is to juggle who's in what queue at any one time. The most important thing is quality imaging and quality care and ensuring that the time they spend here is very worthwhile to them."

Mammo function through RIS

Watauga Medical Center in Boone, N.C., recently went live with Kodak's CARE≠STREAM RIS and is getting ready to install PACS. The hospital chose a HIS that did not have a radiology module, says Brandie Foster, director of imaging, so she began a PACS search that led her to Kodak's RIS. "It had the mammography functionality we needed, so we didn't need a separate mammo system."

The facility will stay with analog mammography for the time being. All mammograms are double read. They are hung, and the first radiologist goes into the documentation window within the RIS and gives his impressions and moves on to the next film. Later in the day, the second radiologist reads the films and dictates a report.

Watauga schedules about 28 screenings a day that are performed in the outpatient imaging center and eight to 10 diagnostic mammograms a day, says Chastity McGuire, PACS/RIS administrator. Referring physicians have a report from the screening within one or two days. Diagnostic patients usually can undergo further testing the same day, if necessary.

The facility uses a centralized scheduling system rather than the RIS, but they are interfaced so that the schedule is updated in real time. Screenings are scheduled for every 15 to 20 minutes, and diagnostic visits about every hour, which helps with setting aside time for further testing. "We also can compress the schedule and add more slots in. We also will devote an extra technologist to help," says Foster.
Screening patients come in, fill out paperwork, and usually don't have to wait more than five to 10 minutes. As soon as the procedure is finished, they can leave. All diagnostic patients get results before they leave, but still aren't there much more than 20 minutes.

With the RIS, all documentation is in one system. Now, staff doesn't have to log into a separate system to enter patient information. It also has eliminated double data entry. Plus, the system's mammo≠graphy module is designed for automated reporting to help with creating patient letters customized based primarily on the BIRADS levels selected. Letters to referring physicians and patient appointment reminders also can be generated and tracked. Available reports include MQSA basic audit data, initial diagnosis statistics, patient follow-up, and patient statistics.

Foster and her staff also focus on providing individual attention for their patients. "You've got to have that side of it. If we're not having to worry about processing films, pulling folders, and other administrative tasks, that gives us a few extra minutes to be customer-service oriented."

Watauga is seeing an annual increase of about 5 percent in breast imaging patients. In response, they've trained an additional technologist. As the demand arises, they add extra resources where needed. "The media has done a great job of educating women that digital is the way to go," Foster says. So, a lot of the changes and plans are driven by patient demand. "Our dream is digital," she says, and hopes that will be the case within the next year. "That will free up a lot of paper processes," and having already streamlined one system, Foster says going into the digital realm will be very easy.

Single system for single entry

Debra Mitchell, MD, radiologist and director of Breast Imaging of Oklahoma in Edmund, sees an increase in patient volume of about 7 percent a year. She and her colleagues see 80 to 90 patients a day at their main location and another 50 to 60 patients a day at two satellite locations. "The number of women in the breast screening age group is increasing — every year about 1 million women turn 40 years old," she says.

Growing awareness of breast cancer and early detection also results in an increase in utilization of mammography. However, the increases in patient volume, in utilization and in the types of breast imaging are not met with a corresponding increase in breast imaging radiologists. It's a critical shortage. We need two right now." And every day she gets a phone call, fax, or letter from someone looking for a breast imaging radiologist.

The three-and-a-half-year-old freestanding imaging center is comprised of physicians who came from the University of Oklahoma's medical center. "There was and is some continuity because we were not creating the wheel — we were repeating parts of the wheel." They imitated the workflow there, which also was completely digital. The practice uses digital mammography and ultrasound equipment from GE Healthcare.

Images from the satellites come in on T1 lines. "We have multiple workstations, and our PACS allows us to distribute our images to the different workstations, and then we have three physicians working every day," says Mitchell. Her philosophy to manage the workload is "divide and conquer."

Mitchell uses a single system for scheduling, billing, transcription, and other functions. With everything working off a single system, only single entry is required. Most demographic data are obtained over the phone with initial scheduling. Then, when the patient comes in, only minor corrections are needed. "Some information the patient has to fill out every time, but as much as possible, we try to correct rather than repeat," she says.

Mammography brings with it some perpetual business for annual screenings. "Each year, our percentage of return patients is greater. But, if we open posts, there will be new patients." That demand forces Mitchell to think about workflow all the time. "We are constantly evaluating it and trying to improve it. It's a never-ending process to maintain high quality, improve efficiency, and maintain human touch and compassion."

Toward more personal care

Nagi F. Khouri, MD, director of breast imaging at The Johns Hopkins Outpatient Center in Baltimore, Md., also uses digital mammography equipment from GE Healthcare and is keenly aware of the need for quality care and patient satisfaction. In recent years, the facility has devoted its resources to improving its customer service. "Improving your workflow does not happen by chance," he says. "You have to think the process through, decide that you're going to prioritize patient care and satisfaction, and then look at whether you're doing a good job or need to improve." To improve, you should talk to coworkers, look for solutions, and execute, he adds.

The right solution depends on the facility and the patient population. At the main, inner-city location, the local population is not highly educated and does not reliably show up for exams, Khouri says. The high no-show rate allows the center to fit in diagnostic patients on short notice and provide all the necessary procedures. Another group of patients drive long distances for imaging procedures. "We don't think it would be fair to send them home and bring them back for another image another day." Anything that needs to be done is done right then and there, he says. That, however, has a negative impact on workflow.

At its suburban location, patients are more reliable, so it's a very different situation, Khouri says. "Every facility has its own environment, and you have to adapt to that. Think about your patient population. What is it that would achieve high satisfaction? How can you modify the practice to suit the needs of the physicians as well as those of the women. That can be variable."

Screening patients have two pictures of each breast taken. The technologist checks for quality, and the patient can leave. The images are electronically sorted and transmitted to a physician for reading. Typically, five to 10 women of 100 will need to come back for additional images. "A mechanism has to be put in place so that as soon as the films are read, the patient is notified. Unfortunately, certain practices don't have room to bring them back the following week, Khouri says. A four-week wait is a long interval for a panicked patient. "Good flow is to try and accommodate callbacks within a reasonable period of time. Everybody has to define what reasonable is."

For diagnostic patients whose images present enough evidence for an ultrasound or even a biopsy, the facility should have the capability to do those procedures right away, Khouri says. Ninety to 95 percent of the time his staff can perform a needle or stereotactic biopsy at the time of the visit. "If they have cancer on the biopsy, we will arrange for them to see a surgeon within 48 hours. That's not because we have vacancies — we'll create slots even if there are no slots."


There are an abundance of methods that can improve breast imaging workflow. "Every facility is uniquely different in how patients proceed through the breast center," says Knoxville Comprehensive Breast Center's Kozlowski. "We constantly monitor how the patient flows and look for ways to expedite their stay without compromising imaging quality and services needed for a patient. It's always a work in progress."