Taking Charge of FFDM Workflow

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Radiographic mammography can be difficult to interpret, and radiologists who read mammograms rely on prior studies to guide them. Many women wisely comply with the recommendation to have this lifesaving study annually, so radiologists are often doing a difficult job within a tight timeline because they must review many mammograms, including the relevant prior studies. Going digital can be fairly traumatic under these circumstances.

It was trying enough for radiologists at Maryland’s University Medical Center in Baltimore to attempt to dig in their heels when the hospital converted overnight from film to digital mammography six months ago, according to Reuben Mezrich, MD, PhD, FACR, professor and chair of the department of radiology at the University’s School of Medicine. The radiologists argued that the task was difficult enough without the added burden of switching to a new technology that was achingly slow, compared with reading film, Mezrich adds.

He says that, at the time, he agreed with them, but he assured them that, with perseverance, it would get better. That has happened, he adds, although reading film is probably still faster than soft-copy interpretation.

Add to the digital switch the imposition of voice recognition for reporting and the radiologists faced a double whammy in disruption of their routines when the conversion to digital operations was undertaken, Mezrich acknowledges.

Nonetheless, the advantages have outweighed the disadvantages, he says, adding that he doubts that any of the radiologists would now choose to turn back the clock.

New Breast Center

Mezrich was named radiology chair at Maryland five years ago. He says that he’s been pushing for digital mammography all along, but the time wasn’t really right until six months ago, when the hospital opened The Breast Center, a brand-new facility at a location in the main hospital building. Its predecessor had been in a nearby building, Mezrich says.

The new center was a chance for a clean break from the film world and was designed to be digital from the outset. Once it opened, there was no changing course back to film, no matter how much the radiologists might have wished for it. “We went full bore,” Mezrich says.

Much of the difficulty of adapting to digital operations for the radiologists was simply the change in process, Mezrich says. “The hardest thing has been the workflow—and happily, they have done it well,” he adds. “There has been a learning curve. There was a little push back and concern.”

Accustomed to looking at film, the radiologists suddenly found themselves having to call up images on the workstation and adjust and manipulate them. This took added time. “We tried to throttle back the volume, but the demand was there. The hours got longer. It was the flow, learning what to do next, not having to ask. It was doing it over and over again. The [interpretation] rate took six months to come back up again,” Mezrich says.

For one thing, seeing the images electronically meant that some breast structures no longer “jumped out anymore,” Mezrich says. For another, the electronic images were much more detailed—“enormously better,” as Mezrich puts it—than film. That sheer amount of detail also slowed down the radiologists. “You go through a period when you start to overcall a little bit,” he says.

The problems were like those faced by other radiologists when the hospital first adopted PACS use in the late 1990s, Mezrich says. “It was a change, and you could read a chest x-ray on film in a fraction of the time it took on a workstation.” Mezrich says that the facility’s workstations are sluggish, compared to moving the eyes from one piece of film to the next.

Mezrich FFDM Workflow Checklist

  • Switch analog for digital mammography machines.
  • Convert film hangers to digitizers.
  • Digitize all prior studies.
  • Read from PACS monitors only.
  • Expect a six-month lag in throughput while radiologists adapt.
  • Don't look back.

While the amount of electronic data in a mammographic screening study is on the small side, compared with a multislice CT file, it still amounts to a fair amount of information to process, at up to 40MB per study, Mezrich says. Processing this much information leaves the radiologists waiting on the workstations. This is a key point of frustration with the electronic conversion for the radiologists, but one that Mezrich says will go away as the mammography software is improved.

“The workstations are not a finished process,”