Fine-Tuning Breast Imaging Workflow
 Michael Trambert, MD
 Michael Trambert, MD—lead radiologist for PACS Reengineering at the Cottage Health System, and the Sansum Clinic in Santa Barbara, Calif.—reads mammography images on an integrated PACS from DR Systems.

2007 could mark the year that mammography turned the corner in terms of achieving efficient breast imaging workflow. More sites are purchasing or planning for digital mammography solutions. Positive clinical study results such as the Digital Mammographic Image Screening Trial (DMIST), new CR-based options, a sharp rise in the number of full-field digital mammography placed and FDA approval of PACS workstations for digital review all fuel interest in digital systems.

Still, digital breast imaging is challenging. There aren’t enough radiologists specialized in mammography; margins are razor thin; transitioning to digital is a challenging process fraught with complex decision such as:

  • Whether or not to digitize prior films
  • Which workstation—a PACS, third-party or single vendor—should be deployed for image review
  • How to develop user-friendly image review processes and reading room configurations

“Transitioning to digital mammography can be painful. Everything changes: image acquisition and review, communication and storage,” says Debra Mitchell, MD, managing partner of Breast Imaging of Oklahoma. This month, Health Imaging & IT visits some digital pioneers to ferret out the secrets to breast imaging workflow success.

PACS pluses

The Sansum Clinic in Santa Barbara, Calif., is a digital mammography pioneer. Its mammography department deployed digital mammography in 2003, replacing five analog rooms with two digital systems. “We decided to convert to digital 100 percent,” says Michael Trambert, MD, lead radiologist for PACS reengineering at the Sansum Clinic and the Cottage Health System. “If the resources are available, complete conversion simplifies the transition, resulting in a clean cutover date to a single digital database, rather than partial conversion that requires two databases: digital and film-based for current exams,” asserts Trambert.

The site did digitize prior analog mammograms, which can eliminate the workflow muddle of maintaining both film and digital archives and the time-consuming process of pulling, hanging and re-filing films. Although some radiologists express hesitation about the image quality of digitized images, Trambert says a good workstation facilitates effective viewing and comparison. The Sansum Clinic uses a simple process for digitization, pulling prior studies for digitization the night before a patient’s scheduled visit. The decision not only enhances radiologists’ workflow, says Trambert, but also improves clinical care as referring physicians can view prior films on the web, including the digitized prior film-based exams, via the clinic’s DR Systems PACS. Current exams have a conclusive voice-clip report attached to the exam at the time of radiologist interpretation, providing immediate results availability for the referring physicians, anywhere anytime over the web.

Sansum Clinic decided to archive digital mammograms and voice-clip reports on PACS from the date of conversion and make exams and immediate voice-clip results available to referring physicians via the web, to allow 100 percent filmless transition to digital mammography. “PACS brings an efficiency benefit to breast surgeons and makes it easier for them to reengineer their workflow. Their front office staff doesn’t need to call us for images or search for films.” Instead, images and reports are available online immediately after the radiologist completes the interpretation.

Over the last two years, the practice has added a third digital mammography system and hopes to transition to PACS review. Trambert has bypassed the third-party workstation for the last 20 months and uses the PACS workstation for mammography interpretation. In the next three to six months, he hopes all of the practice’s remaining eight mammographers will follow suit and convert to PACS review, simplifying workflow and adding efficiency to the system. According to Trambert, PACS review is more efficient than the vendor workstation review. “It used to take about two minutes to read a screening mammogram on the film-based mammoviewer. Now, I’m as fast or slightly faster on the PACS workstation,” Trambert says. In contrast, it took Trambert about three minutes to complete image review on the dedicated digital mammography workstation.

Image review is just one part of the breast imaging workflow equation. Trambert expects other new PACS features to boost efficiency. “We can now follow through on the transition to paperless mammography, with integrated dictation and structured reporting incorporated earlier this year. The next Dominator release will provide a coding grid that will save time by populating the report and quality assurance database, with the option for fully integrated mammography QA available, and further integration with CAD will make CAD available as a toggled hot key,” explains Trambert.

The commitment to digital workflow has paid off at the Sansum Clinic. The site maximizes its digital acquisition units with patient turnaround time in the 15 minute range and about 20,000 studies completed per year.

Telemammography talks

Alan Melton, MD, assistant clinical professor at Columbia University Medical Center in New York City is a pioneer. He reads up to 130 digital mammograms daily at his West Hartford, Conn., home office. Screening mammograms are acquired at Columbia University Medical Center in New York City and transmitted 160 miles to Melton via cable internet. The average case consists of five or six images, about 100 megabytes of data, and takes less than a minute to download, says Melton. Melton uses GE Healthcare Senographe Workstations and Mammography Reporting Systems’ Mammography Reporting System (MRS) to glean maximum efficiency from the approach.

Since starting the telemammography project in the spring of 2005, Melton and Columbia have refined processes to boost workflow. For example, Melton found that the medical center’s dictation system slowed workflow. “It shouldn’t take longer to dictate a report than it does to interpret images,” asserts Melton. So the radiologist worked with MRS to create structured report templates. “I don’t touch the keyboard except to load the patient,” says Melton. His turnaround rates are among the best. “I can have the report dictated and uploaded by the time the patient is in the dressing room,” Melton says. Most cases see a 24-hour turnaround.

Some cases, however, require workflow adjustments. Recalls, for example are faxed to the medical center, and Melton calls, emails and faxes reports for emergency cases that clearly show cancer. If Melton finds an abnormality on a patient with prior film mammograms, he dictates, but does not finalize, the report in MRS and faxes Columbia so an on-site radiologist can pull the film mammogram and compare the current and prior studies.

The batch-screening/telemammography undertaking is ultra-efficient, says Melton. “I’m not disturbed with phone calls, physician conferences or requests to review ultrasound studies, so I can go through cases accurately and rapidly.” Another boon? Melton’s recall rate sits at 7.1 percent compared to a national average in the 13 to 16 percent range.

Digital workflow realized

Breast Imaging of Oklahoma in Oklahoma City, Okla., embraced digital mammography when the center opened it doors nearly five years ago. The independent, private practice is an all-digital comprehensive breast center offering ultrasound, stereotactic biopsy and MRI and equipped with PACS, four GE Healthcare Senographe 2000D digital mammography systems, one Senographe DS and a mammography information management system from MagView. In addition to its primary site, the practice also includes two satellite clinics that transmit digital screening studies via a T1 line. Daily mammography volume fluctuates between 140 and 170 studies.

Breast Imaging of Oklahoma and the surrounding area has been digital for several years, so the practice is over the hurdle of transition and the challenges of hybrid analog/digital mammography. “We rarely use viewboxes anymore,” says Mitchell. The center did operate a hybrid review environment when it first opened as it opted not to digitize priors. “Four years ago, digitizing priors represented a tremendous PACS burden. It would have tripled or quadrupled our archive in the first year,” says Mitchell. “Now storage is cheaper, so sites should assess the cost and value of digitizing prior studies when they implement digital mammography.”

Breast Imaging of Oklahoma constantly analyzes workflow, combing through systems and practices to find areas that can be improved. For example, the center decided to dedicate one mammographer to screening mammograms only every day. This approach makes it possible for the screening mammographer to read 70 to 100 cases daily, Mitchell says.

At the technologist level, DICOM worklist helps the center streamline its screening flow. MagView talks to the acquisition equipment and pre-populates the record, which decreases the risk of workflow-busting errors. Every night, the system pushes prior images for the next day’s patients to the GE Centricity PACS review station, so radiologists can easily access prior images.

On the reporting end, the center taps into MagView’s customizable tools to meet radiologists’ preferences and deliver 24-hour report turnaround. Some physicians use voice recognition and others rely on traditional dictation and transcription; however, all use point-and-click normal templates to sign and release normal reports.

The challenge on the diagnostic side, says Director of Technical Operations Kathy Tucker, is to keep patients on track and moving through their exams. Tucker designed the center’s scheduling template to leave open slots for callback procedures, thus building in capacity for diagnostic studies. 

New American Cancer Society guidelines for following high-risk patients present another workflow challenge. Now the society recommends high-risk patients receive annual MRIs and screening mammograms, so breast imaging centers, particularly those with high-risk programs, are seeing significant increases in MRI volume. “It is a challenge to accommodate the volume,” confirms Mitchell. Tucker helped radiologists handle the reporting aspect of its high-risk program by setting up a genetics module within MagView to streamline high-risk reporting. Still, MRI acquisition time is lengthy, which can impact workflow; the center may add a second breast MRI scanner to handle the increased demand for scans. Breast Imaging of Oklahoma has seen its MRI volume increase nearly 50 percent since the new guidelines came out in March 2007.

Surviving the digital transition

Encino Diagnostic Imaging in Encino Calif., is a multi-modality imaging center in a very competitive market. The center deployed digital mammography early in 2006 and has a breast imaging volume of 40 patients daily for mammography and breast ultrasound. The practice uses the Merge Healthcare MergeMammo workstation to review digital mammography and breast ultrasound studies.

The imaging center digitized prior film studies to prep for the transition to digital. “It’s time-consuming to pull film priors. With our volume, we knew our radiologists couldn’t handle the additional work associated with comparing digital and film mammograms,” says Medical Director Pamela Hilpert, MD. Another reason to digitize, says Hilpert, is office size. The combination of a mammo viewer and digital review systems can make for a tight office.

The adjustment to digital mammography remains a work in progress one year after implementing digital mammography. “Our productivity has not reached the analog point,” says Hilpert. For starters, it can take radiologists six months to a year or longer to adjust to digital review. In addition, the center does not use a worklist for screening mammograms, so radiologists must load each patient’s file individually.

Still, digital mammography offers critical benefits over analog mammography. As DMIST demonstrates, digital mammography can provide better results for certain patients, it also serves as the foundation for future applications like breast tomosynthesis. And finally, for sites like Encino Diagnostic Imaging that operate in a very competitive market, digital mammography differentiates a provider from its competition.

Words of wisdom

Digital mammography may be one of the toughest transitions in the radiology business. Learning from the experiences of others can help newbies—or facilities still struggling—streamline the process. Sites prepping to take the plunge (or just looking to improve workflow) should:

Carefully assess the PACS workstation situation. “Images should come over read-ready,” says Trambert. Work with the digital mammography vendor and make it an acceptance requirement that images arrive on the PACS ready to read, properly windowed and leveled. 

Invest in training for radiologists and technologists. It streamlines the transition and helps sites maximize investments in staff and acquisition and IT systems.

Workstations should be configured to minimize or eliminate interruptions to the screening mammographer. If a site decides on the dedicated workstation route, buy two to provide flexibility and avoid interruptions. Another option is to read exams directly off PACS workstations, with at least two workstations appointed with the FDA-required 5 megapixel monitors. This configuration allows sheltering of the screening mammographer, with another radiologist fielding the “additional view” workflow interruptions on a different PACS workstation, says Trambert.

Beef up the network and lay the groundwork for efficient reading. Digital mammography files can be large, so be sure to know the size of files from your systems. A gigabit network is warranted.

Ad hoc choosing and opening a digital mammography exam with a comparison study can eat up 15 seconds, even at gigabit network speeds. Reading exams off of a worklist with preloading expedites this workflow with immediate image access and no delays. 

“During the evaluation process, if two vendors offer equivalent image quality and one provides smaller-sized files, go with the smaller files,” recommends Trambert.

Ergonomics counts. Mammographers need to use image review systems to minimize key strokes and maximize interpretation time. Melton combines Dragon Dictation commands and structured reporting to slash reporting time.

Images and results should be available online. Efficiency gets a major boost because referring physicians no longer need to call the imaging center and ask them to hunt down results. Sansum Clinic has experienced a six-fold drop in these calls for results since providing online images and results.

Look for flexibility and customization in reporting systems. Some radiologists prefer voice recognition; others want structured reporting and some stick to traditional dictation and transcription. Providing options can accelerate the transition to digital because radiologists aren’t forced to adapt to additional new systems.


Workflow at the End of the Analog Era
The Betty Puskar Breast Center in Morgantown, W. Va., has reached the end of analog mammography. The breast center and satellite clinic plan to swap five Siemens Medical Solutions Mammomat Nova systems for digital acquisition and review solutions early in 2008. Currently, the center completes 1,700 procedures monthly including mammography, breast ultrasound, stereotactic biopsy and DEXA scans. “We’ll be able to handle more patients with fewer units after we deploy digital,” says Breast Care Coordinator Alice Belmont. The move is well-timed as the center has outgrown its space.

As the center phases out analog mammography, it is investing in systems and processes to streamline the transition. For example, the breast center plans to continue to use the MagView mammography information management system after it deploys digital. “The system contains all procedures including biopsies, breast MRI and ultrasound studies, which facilitates quality assurance, productivity and repeat analysis.”

Each room at Betty Puskar Beast Center contains a laptop. MagView interfaces with the registration system, so files are pre-populated with patient demographics to save technologist time and minimize errors. In addition, the system merges radiologists’ findings into a report for referring physicians and patient letter. “The system can address every angle of the mammography process,” sums Belmont.

Belmont expects to use the current analog workflow as a foundation for digital processes, refining workflow with workflow maps developed in collaboration with the center’s digital vendor.

The move to digital is well-timed. The breast center can benefit from the experiences of pioneers and implement solid digital workflow from day one.