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,” he says. “The manufacturers put tremendous research and effort into the imaging modalities,” and the equivalent work is now being done for the workstations. Mezrich says that the breast center has experimented with several workstations from different vendors, and is now in the process of evaluating workstations from two vendors, including the Synapse mammography workstation from Fujifilm, Stamford, Conn. He says that the concern over sluggishness will end as engineers adapt the workstations to handle larger datasets, which he foresees as taking a year or so. One PACS Only From the outset, Mezrich says, the Maryland radiology department has held steady in its demand that all digital mammography is to be accessed through the single radiology PACS, not through a separate mammography miniPACS, as pushed by some vendors. “We didn’t want another PACS that rides on our main PACS,” Mezrich says. “We integrated everything. It works just fine.” Another decision that Mezrich and his colleagues made was that all mammographic prior studies would be digitized and put on the PACS. The department didn’t want radiologists glancing from workstation screens to film viewboxes, as is often the procedure when prior studies stay on film, Mezrich says. Having all the breast center’s images on the hospital’s single PACS, where any radiologist could refer to them, fit into Maryland’s integration goal, Mezrich says. Today, when a mammography patient who has undergone earlier screenings at the hospital returns, her three most recent prior studies are pulled from film jackets and digitized before the new examination so that radiologists have the previous images on the PACS, Mezrich says. If the woman is a new patient, she is asked to bring any film prior studies that she has with her. These are then digitized, and the film copies are returned to her. Mezrich says that getting the priors and getting them digitized is so important that the department has added three employees just to complete the task. “We converted film hangers, too, but we still added more people,” he says. “This will pass, but right now, it’s a big hiccup.” It will pass because, increasingly, patients will have their prior studies on the PACS, and the need to digitize film will fall. Everything will be on the PACS, and the radiologists will be able to do their interpretations more quickly. All breast-imaging modalities will be integrated, including MRI, ultrasound, and radiography. This is the advantage that the hospital sought by having a single PACS. Patient Volumes Mezrich says that the breast center now is conducting 30 to 40 screening mammograms daily. One of the big advantages of digital mammography is that throughput per machine increases because the images can be verified and adjusted or retaken much more quickly in digital format than with an analog system. With film, the technologist must leave the patient and wait for film to be developed before checking the image. The time needed for the digital image to appear on the technologist’s screen at the modality is about 7 seconds, Mezrich says. It is not necessary to leave the patient. Mezrich adds that the breast center has yet to take full advantage of the improved throughput because of the bottleneck at the workstations. “We expect that we will put more patients through, but we’re not ready for it yet,” he says. The department has 55 radiologists on staff, but only three are assigned to the breast center; Mezrich says, “At our site, we’re a little short-handed.” Despite this, the breast center tries to complete the report on each mammogram within 24 hours. If an anomaly turns up on the mammogram, the patient is routed to further diagnostic study. “If you think it’s a cyst, you do an ultrasound,” Mezrich says. “If it is a cyst, then you’re done; you don’t have cancer. If it’s not a cyst, then you do a biopsy or a fine-needle aspiration.” Under various conditions, many other examinations might be done, especially MRI, Mezrich adds. “There’s a whole hierarchical approach to working up lesions.” One thing that the breast center tries to avoid is telling the patient to come back in six months to see if, or how, a lesion may have developed. “You’re not going to be any smarter in six months, so do it now,” Mezrich says. Despite the difficulties of converting to digital mammography, Mezrich says that the advantages have made the effort more than worthwhile in terms of integration, accuracy, processing speed for the patient, and availability of the studies on the PACS. There has even been the advantage of allowing the radiologists to work from home. Mezrich says that the hospital has put a special monitor into one radiologist’s home to allow her to work half-time from home while she cares for a newborn. The other half of her schedule is spent in the breast center. In the radiology department, four other radiologists are working half-time from home as well, Mezrich notes, saying that he expects the number to grow. He says the flexibility of working from home has been beneficial. “We have people who take call from home. You get more continuous service. It’s better care for the patient, not worse care,” he says. He also says that working from home keeps radiologists from drifting to other jobs, such as those with teleradiology coverage services, where working from home is the rule. Moving Target When it comes to the future of breast care, Mezrich is mindful that the whole effort to detect breast cancer is a moving target. Within a year, the hospital will add a tomosynthesis component to its breast cancer detection effort, he says. He also foresees MRI and nuclear medicine having wider impact. “I think image-guided therapy will become more important,” he says. As far as screening for breast cancer is concerned, Mezrich says that he’s hopeful that a blood test will be found that is similar to the prostate-specific antigen test used now to detect prostate cancer. “Call it an MSA,” he says. “Then we’ll do an MRI as the next step. We don’t have this yet, but my optimism suggests it will happen.”