OBJECTIVES:
When it comes to beating breast cancer, everyone agrees: the best way to combat the disease is with early diagnosis via routine mammography. There is also agreement that the quality of the mammography image must always be a primary consideration and that digital mammography is becoming an increasing popular method of choice worldwide. Modifying a busy diagnostic practice is a demanding, expensive process fraught with incredible challenges.
What we need to get started:
Radiologists and administrators today have an ever-expanding wish list of features they are looking for in a digital mammography system, including a comprehensive reporting structure, increased flexibility and ease of use, and a workflow that maximizes the efficiency of the department as well as the level of patient care.
Converting a large, busy mammography department to digital, however, requires a considerable investment in planning by many diverse functions: radiology managers and radiologists, facilities managers, interior designers, technologists, PACS administrators, IT network and storage specialists, clerical supervisors, and others. With sufficient attention to detail and a specific concentration on workflow efficiency, while the migration to a digital environment can be challenging, it can result in improved workflow efficiency.
Choosing a vendor:
Implementing a digital mammography workflow is a demanding task that can exceed the IT resources of even large facilities. In this case, managers might decide to work on the design and implementation of an infrastructure with a vendor, or independent mammography consultant. The latter often recommends appointing a project manager with expertise in purchasing and/or integration of all necessary networking, data and management systems. To prevent outdated tasks and routines hampering the new digital system, and to optimize processes, the consultant might suggest a complete revision of scheduling, examinations and reporting. These advisors, either a responsible vendor or a private consultant, can not only help to maximize digital workflow but also help to evaluate the implementation of digital mammography technology, and to decide on either CR or DR.
A close relationship with a vendor capable of understanding the digital imaging world is critical. The sales and support team must meet frequently with the Information Systems and Radiology personnel in order to configure a site-specific solution for the digital environment. If possible, choose a vendor with which you have a prior relationship, one with a proven track record in PACS systems, large department conversion and digital technology in mammography. The most challenging aspect of the project will be satisfying the needs of a busy breast center that has many varied patients a year. This step-by-step methodology will assist in anticipation of the installation of several digital mammography units of varied uses.
Choosing a workstation:
Choosing the right diagnostic workstation is a critical component of the overall project because the interface that radiologists use has to be intuitive and high speed, and must also provide the highest resolution possible.
The first consideration is the actual value of digital mammography over analog mammography. That makes the biggest difference in a diagnostic practice, then the value of a multimodality workstation or a modality specific one can be considered. With the multimodality workstation, the patient’s complete set of imaging exams are available to review together, allowing the radiologist to make faster and more accurate diagnoses. The diagnosis can often be made while the patient is in the exam room, an enormous comfort to the patients. .
Hanging protocols of the station must cover virtually any configuration that might be desired and should accommodate prior digital or digitized film studies. The available tools must allow for the manipulation of images and studies. Because some radiologists prefer to use the mouse to access tools while others choose to program the keyboard to perform many functions the station should easily accommodate both options. In addition to standard tools, the workstation should be programmed with any number of macros to further expand workstation functionality. The workstation must be able to retrieve reports from HIS and can be linked to voice recognition systems.
For patients having a work-up for an abnormality, the workstation should allow the radiologist to view the screening exam, additional views, ultrasound, and MRI exams at a single site. Radiologists must be able to view studies in progress and annotate the images that need additional views. While logged onto the web tool, technologists viewing these annotations should not have to leave the patient.
Five mega-pixel monitors are needed for mammography, but most general radiology PACS do not have them. An example of a useful system is a multimodality diagnostic workstation for digital mammography built on the IMPAX platform with dual 5 mega-pixel flat-panel monitors. The ability to view color images with a large flat-panel monitor is a good option. However, even that flat panel size does not show some image matrix sizes at full resolution – an automatic zoom and pan tool is essential if large volumes of mammograms are to be read. Rather than install dedicated workstations, centers for screening as well as diagnosis might want to opt for multi-modality breast imaging workstations, which enable reviews of all digital mammograms, as well as MR, ultrasound and other general radiography examinations.
Viewing images:
Patient and image data management and storage:
It is essential to fully integrate the radiology information system (RIS) and picture archive computer system (PACS). Along with the patient’s identification (ID) and examination data, it is now generally understood that a RIS can automate mammography-specific activities, such as blind double reading, sending reminder letters for annual screening, producing customized patient letters for screening and diagnostic examinations and other functions. An integrated RIS/PACS Mammography Workstation offers many reporting and image management options. RIS and PACS should be installed before installation of digital mammography or it should be part of a digital conversion. This is a far more complex task than merely installing the capture device.
The bandwidth:
Computer networks must be able to transmit the very large size of digital mammograms. Internal IT staff, or a network specialist supplied by a contracted vendor, must evaluate an existing network infrastructure and environment and work out what might be needed to produce acceptable image distribution speeds. This is an often-neglected part of an implementation. In a busy screening facility the ability to display a full study, with priors, in a couple of seconds, will test the fastest network; if not addressed up front this aspect can greatly reduce the acceptance of the entire system.
Archiving:
Depending on its capture device, even a small clinical centre, which carries out 20 screenings daily, can generate one terabyte of mammography images within one year. Therefore, the best case scenario would be 25 terabytes of the legally stipulated 25-year image storage. The immediate obvious issue becomes the possible obsolescence of the storage medium and files. A prudent plan must be put in place to migrate data on to current platforms. The failure of such a plan could result in a major cost issue within five to seven years after the first images enter the system. There might be a decided advantage to the use of off-line data centers to manage this type of back-up and migration service.
Managers should factor in an appropriate percentage of growth when coming up with their anticipated storage needs for the immediate future, carefully factoring in the need and increase of diagnostic breast examinations into the storage plans for these files.
When implementing the digital mammography systems it is not always necessary, or even prudent to expand the on sight storage system past the immediate need right away. A decision to outsource image storage to an image management vendor, with retrieval on demand, making a third party responsible for maintaining, backing-up and retrieving archived examinations may be a responsible first step.
SUMMARY
Medical professionals have acknowledged that digital images are at least equivalent to film-based images for identifying breast abnormalities, including cancer. The objective of converting an analogue mammography department to a digital, modern, multi-modality breast center is to allow radiologists to maximize attention devoted to image interpretation while minimizing the effort required to manage a busy workload. In essence, it’s all about the workflow. Indeed, workflow has been an operative phrase for diagnostic efficiency for many years now and it is becoming synonymous with quality patient care.
Dragging ourselves into the future is not always easy and not always cheap but it is worth the effort because of the improved patient outcomes. And so, once again, our attention is where it should be; with the patient.
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