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September 25, 2006

Eight Keys to Digital Mammography Success
By Beth W. Orenstein
Radiology Today
Vol. 7 No. 19 P. 30

Thinking of taking your mammography practice digital?

Doing so involves a lot more than buying and installing a shiny new digital mammography system.

You also have to think about the technology required to make it work and how it will change your workflow—for both technologists and radiologists.

Here are eight issues that should be part of your decision making and planning.

The first two are fairly straightforward technology issues, says Stephen Archer, director of worldwide marketing of mammography solutions for Kodak’s Health Group. “But they are new to mammography providers that have traditionally performed mammograms on film,” he says.

1. Storage. Film mammograms require lots of physical storage space. Imaging facilities store the films in folders, often with the paper patient records.

“If folks move to digital media, then there will still be lots of storage required. But it’s no longer going to be physical. It’s going to be media storage,” Archer says.

Digital mammograms require quite a bit of data storage capability, he says. The file size of one computed radiography (CR) mammography screening procedure can be as much as 200 megabytes. That would mean an imaging center that does 20 screenings per day must have the capability to store at least 4 gigabytes (4,000 megabytes) of new studies per day.

Angela Hamilton, breast imaging marketing manager for GE Healthcare in the Americas, notes that file size can vary from vendor to vendor as each has various pixel sizes. File size also depends on whether you’re using CR or digital radiography technology. For example, she says, a standard screening with GE’s Senographe is 9 megabytes per view, or 36 megabytes for four views. Its large field of view is 14 megabytes per image, or 56 megabytes for a standard screening study.

Calculating Storage Needs
Whatever you’re using, you must multiply your average file size by how many exams are performed at your site or sites each year to figure out the minimum amount of annual digital storage space you will need, Archer says.

Also, Archer says, you have to consider what happens if your practice increases. Will you continue to have enough storage space?

Realize that you have to store the exams for at least seven years, maybe longer, he says. So you’re not going to free space too readily.

Storing film files is a passive activity, Archer says. “When you put your mammographic films in a filing cabinet, they will stay there unchanged until you pull them out.”

In contrast, storing digital files is an active activity, Archer says. “You have to keep doing backups to keep the files up-to-date and be sure that you can read the media on which you’ve stored them when you go to retrieve them,” he says. That’s why Archer says, “storage is a much more important issue to think about in the digital world than it is in the analog world.”

2. Network bandwidth. “You shouldn’t just assume that all these massive files are going to go whizzing around your network and not cause a problem,” Archer says. How much bandwidth you have will determine how quickly files move and are called up on the workstation. “You need to determine how much bandwidth you need so that your radiologists aren’t sitting around waiting to look at studies,” he says.

Everyone in the department doesn’t necessarily need to understand these technical issues, but you should at least raise the questions and get answers from someone in IT who does, Archer says.

3. Image viewing. By now, many imaging facilities have PACS. Most PACS use 3-megapixel (MP) monitors, which are not FDA-acceptable for viewing digital mammography exams, says Jennifer Conner, director of breast imaging for GE Healthcare. Digital mammography requires high-resolution 5MP monitors, which can be quite expensive, she says.

You will want to consider how many 5MP monitors you need to purchase. To determine that number, you have to consider your workload and what other modalities you read, Conner says.

“A multimodality breast imaging workstation like the one Kodak offers is helpful for facilities that also perform MR/ultrasound breast imaging studies and allows review of general radiology images as well,” Archer says.

Workstations
Also, consider what mammography tools the workstations offer, Conner says. Numerous PACS vendors offer software packages for digital mammography that can affect your productivity level and comfort level, she says.

To make full use of the digital nature of the images, consider workstations that provide easy-to-use image manipulation tools, such as contrast, brightness, image reordering, selection of regions of interest, and magnification. For example, GE’s system offers special function keys that enable the technologists and radiologists to more easily manipulate images.

The ergonomics of reading digital mammography is also different from reading other modalities, Conner says. Consider how you will place the workstations for optimal viewing.

Lighting the room can be another issue as the flat-panel workstations are different from the film boxes to which the radiologists may be accustomed, Conner says.

Also, in the beginning, Archer says, it’s likely that your prior exams still will be on film. You want to think about how you are going to set up the reading room so your radiologists can compare the prior films hanging on light boxes with the digital images on the workstations.

4. Tools for managing patient and image data. While a growing number of imaging facilities have PACS, not all have RIS. Archer and most people in the field suggest that a facility have a RIS in place if it is going to offer digital mammography. It’s cumbersome to have the images on the workstation and the patients’ data on paper. When selecting a RIS, make sure it’s compatible with your PACS, he says. “It would be really inefficient not to have RIS if you have PACS, and an equally important consideration is to make sure the RIS and the PACS work together,” Archer says.

You Need a RIS
When selecting a RIS, Archer says, make sure it provides mammography-specific features such as generating annual exam reminders and customizing patient letters for the required follow-up.

“If you have a RIS mammography module, it will help manage a lot of what is now done on paper,” Conner agrees.

5. Workflow. Converting from film to digital should change your workflow, Archer says. “Don’t introduce digital with exactly what you’re doing now and expect magical results.” Achieving an optimal workflow is going to require redesigning the entire process, he says.

Obviously, technologists will no longer have to leave the exam room to process films. Nor will they have to hand the films to the radiologists or put them in their piles to be read. “But getting the processed images to the radiologist could take longer depending on your network bandwidth,” Archer says. So you want to look at each step in the process and determine where you can and should make changes.

Vendors often have specialized teams that can help facilities redesign their workflow and take full advantage of the new efficiencies, Archer says. Third-party consultants can also help redesign the digital department.

6. Disaster recovery plan. Facilities with an existing continuity/disaster recovery plan can add mammography to it. However, if an imaging center doesn’t have a disaster recovery plan, it needs to develop one when it goes digital, Archer says.

“Like any computer system, once you put information into it, you want to be sure to back up that system,” says Hamilton.

Digital mammography systems, including GE’s, likely come with battery backup for short-term recovery, Conner says. “If you had a minor power failure within the hospital or clinic, your exams would be recoverable for the most part.” However, if you had an extended power outage or a disaster such as a flood, a battery backup would not be sufficient. You need a more extensive recovery or back-up plan. Archer adds that film-based departments probably aren’t used to having duplicates, but they become an essential consideration in the digital world.

Host With the Most?
You want to consider whether you need a hosted solution, where the vendor is responsible for maintaining, backing up, and retrieving prior exams and providing business continuity in the event of a disaster, Archer says. Depending on the size and scope of your facility, you may have sufficient IT talent and resources to handle the job on your own.

7. Printing and sharing images. While more facilities are converting to digital mammography, the majority are still film-based, Conner says. So you have to think about how you’re going to share your digital images with those who don’t have digital capabilities, she says.

“You can’t just stick them on the Internet and send them because all physicians, clinics, and hospital departments are not yet ready for digital image files,” Archer agrees.

Archer suggests having a mammography-capable (650 dots per inch) laser printer to share images with referring physicians or surgeons. “Ideally,” he says, “the printer should be able to support output from all imaging modalities.”

When transferring images digitally or in print, you also need to think about HIPAA regulations and security, Archer says. “If you are going to send them electronically, you will need a secure e-mail or something similar.”

8. Training. Finally, Archer says, it is almost certain that if you install a digital solution, technologists and radiologists will need extensive training. “The radiologists are going to need time to learn how to interpret the images that they see on the workstations and the technologists are going to need training to understand how to use the [digital system] and the workstations that go with it.”

Everyone has to understand that it will take time to become proficient with a digital system, he says. “Training is going to be very important [because] no one can afford to make a mistake in obtaining views and reading the images correctly.”

Because procedures are different, moving to a digital world “can sometimes be frustrating for people who are 100% professional and know their jobs very well,” Hamilton says. Still, she says, if you recognize there is a learning curve, if you select a system that is well-designed, and, if you have the support you need from your vendor and/or a third party, much of that anxiety can be reduced.

— Beth W. Orenstein is a freelance medical writer and a regular contributor to Radiology Today. She writes from her home in Northampton, Pa.

Unsure about the impact the change would have on the practice, which performs approximately 50,000 mammograms per year, the center made the transition gradually, installing one Selenia system at its main location in 2004.

The center saw the benefits right away and within three months had installed additional Selenia units—a second one at its main site and one at a satellite center, says Vicki Belmont, administrative director. A fourth has since been installed in the main office as well.

The switch required the center, which was founded in 1981, to buy three 5-megapixel workstations as well as a PACS. It was a hefty investment, Belmont says, but well worth it. Its recall rate dropped nearly immediately by 50%, increasing staff productivity. Performing fewer recalls means the center can operate with two fewer technologists.

“We are able to see more new patients and provide mammography service to more women,” Belmont says.

Equally as important, if not more, Belmont says, is that fewer recalls mean less anxiety for patients.

The conversion has also proven financially beneficial. Most insurance companies reimburse at higher rates for digital than analog mammography and more for complete mammograms than they do for recalls, Belmont says.

Additional savings have been realized by the center not having to buy film, processing chemicals, and cassettes and no longer needing personnel to maintain the processor and supplies.

There were some additional expenses in setting up the digital practice, though. Radiologists needed to be trained to read the digital images—and training was done on site.

Also, the center has found it needs a RIS. “We’re in the process of installing RIS. We have been for about a year,” Belmont says.

The center also needed a recovery plan should it have a power failure or computer crash.

Hologic and the center’s IT staff—one full-time and one part-time employee—were instrumental in helping make the transition go smoothly, Belmont says.

— BWO

The center expects to double its volume with its digital imaging, says Tina Sawycky, director of radiology services. “We’re looking at extending hours, offering more evening appointments, and increasing our radiology staffing,” she says.

Given that its average wait time for a screening mammography is six months, Sawycky expects patients will be pleased.

Preparing for the conversion, the center looked at many issues, including staffing, equipment, training, disaster recovery, and printing.

Perhaps the biggest challenge the center faced in making the conversion was redesigning its reading room. “We had to design a much larger reading room area with the proper lighting and acoustics to optimize the digital workstations for viewing the mammograms and to accommodate the acoustics necessary for voice recognition system,” Sawycky says.

Because most prior exams will be on film, the room had to be designed so its radiologists could read film and digital at the same time, says Juanita Way, director of the Women’s Center. “We plan on analog films for comparison at least for the next three to five years,” she says.

The center is expecting only good things from the update.

“Once you eliminate film, the economies such as improved workflow by the technologists, the radiologists, and the clerical staff are certainly recognized,” Way says.

— BWO