Breast-imaging interpretations by telemedicine? More than a few have said that it couldn’t be done—or, at least, that it couldn’t be done well. The files are too large, the cases too complex. But now the doubters are being proven wrong as a new, carefully thought-through telemedicine innovator specialized in breast imaging has launched from its home base in the New York metropolitan area.
Providing reads by radiologists specialized in breast imaging dispersed around the country, BelleBridge, headquartered in Shelton, Conn., is a high-tech, highly specialized wunderkind. Its radiologists read digital mammograms with or without computer-aided detection (CAD) overlays, as well as images captured with breast ultrasound, breast MRI and tomosynthesis. They are certified by the American Board of Radiology and licensed in all 50 states. And they use PACS, RIS and MQSA management tools to expertly interpret and appropriately manage follow-up exams for both screening and diagnostic exams.
Until now, diagnostic exams have challenged breast telemedicine with difficulties. Diagnostic breast exams, those performed due to suspicion of disease, almost always require real-time collaboration between technologist and radiologist while the patient is still in the imaging suite.
How to bring the two professionals, breast radiologist and technologist, together over the patient when the radiologist is not physically present?
“We have closed that gap utilizing secure, HIPAA-compliant audio-video technology, as well as real-time ultrasound streaming and live conferencing,” explains Elmar A. Davé, BelleBridge co-founder who serves as its chief operating officer. The streaming comes by way of a telemedicine cart, innovated by BelleBridge and registered with the FDA. “These capabilities allow offsite breast radiologists to work with facility technologists just like the two are standing side by side.”
Focus on specialization
Taken together, these developments represent an important breakthrough, Davé adds, because many facilities throughout the United States don’t have access to enough radiologists specialized in breast exams.
“Too often, general radiologists are reading the exams,” he says. “Don’t get me wrong—many general radiologists do an excellent job reading breast studies. But some don’t have the numbers to be qualified by MQSA, which requires the interpretation of at least 960 exams in the prior 24 months.”
At the same time, some generalists are not comfortable reading breast imaging studies, and others are concerned about medical liability. “Breast imagers tend to be less concerned about medical liability,” says Davé. “They feel more confident in what they are doing. BelleBridge’s breast imagers are able to provide credentials as well as confidence regardless of where the patient is located. Any hospital and medical facility that does not have a breast-specialized radiologist on site or simply needs to distribute breast imaging study over-flow can have confidence that their imaging examinations are interpreted by high-quality, dedicated breast radiologists.”
"One of the key differentiators of the BelleBridge model, distinguishing it from conventional teleradiology, is the combination of its breast imaging specific logistics processes and technology,” he adds. “The possibility for a mammography or ultrasound technologist to collaborate with a breast-specialized radiologist via audio/video technology and, as needed, live-stream ultrasound data while the patient is still in the imaging suite is meaningful telemedicine in its purest sense."
Early detection from afar
Then, too, specialized breast expertise is sometimes as critical to cancer screening as it is to cancer diagnostic evaluations. Mammography is the gold standard for screening exams, but close to 40 percent of women have breasts with optically dense tissue. For these patients, it’s useful to do adjunctive breast-screening ultrasound exams, and expert readers are needed to interpret automated breast ultrasound studies.
“Half of cancers are not detected for patients who have dense breasts on mammography,” says Davé, adding that using ultrasound as an adjunct in these cases increases detection rate by about 35 percent.
Meanwhile there are other reasons physicians may have cause to look to telemedicine for breast-imaging proficiency. Local radiologists take vacations, retire and otherwise have less-than-constant availability. Major metropolitan areas find themselves with overflow work, as the demand for reads sometimes exceeds the supply of radiologists. And many facilities don’t need fulltime coverage but could use a half-time or even quarter-time breast specialist.
Technology in the service of care
Is BelleBridge a clinical telemedicine provider that leverages technology or a technology company that happens to work in clinical telemedicine?
Judging by the leadership of its medical advisory board, it’s certainly the former. On the mammography side is László Tabár, MD, FACR, a leading light in the worldwide battle against breast cancer for more than 40 years. On the ultrasound side is A. Thomas Stavros, MD, FACR, who has been working since 1981 to develop and improve high-frequency, hand-held breast ultrasound scanners.
BelleBridge also shopped carefully, with patients and referrers close in mind, when it moved to select its core technology platforms.
“Our partner in image management in PACS is Sectra,” says Davé. “Sectra has a lot of experience in breast imaging and, even including the software that’s used for viewing, they are excellent for breast imaging, which in combination with the breast specific BelleBridge RIS creates unique value.
Capabilities in the cloud
Davé is particularly keen on Sectra PACS’s facilitation of interpretations of images obtained from every major vendor, including breast digital breast tomosynthesis. “In terms of producing hanging protocols and the radiologist or breast imager having everything he or she needs to do breast imaging, it’s integrated into the Sectra viewing software,” he points out. “And even on the front end, for order entry as well as quality-control (QC) work that needs to be done by our operations center, we are able to go into the Sectra PACS environment and do all the QC that needs to be performed in conjunction with our RIS platform.”
Here’s how it works for screening exams. “The examinations are sent and a destination is created from the local facility PACS to the Sectra cloud” he says. “The new and the prior studies are transmitted. Our operations center then will be logged into the Sectra cloud and our RIS, and they will be verifying that the complete studies, the new and the prior examinations, are available.”
Operations center staff then attach any and all relevant patient demographic data, along with prior reports from radiology, pathology and patient history. These will attach to the case and, once receipt of info is verified and completion of work quality-checked, the case is placed on a breast imager’s queue as ready to read.
‘Truly set up for breast’
“Basically, Sectra has all the tools we need right there in a breast-imaging environment,” says Davé. “The archiving is the responsibility of the facility, but we do keep an archive of the screening examinations online for a period of time, as about 10 percent of screens require additional views, and we provide online access to the client to view annotated images.”
Thanks to its clinical excellence and technological visioning, BelleBridge seems well positioned to help lift the state of breast care in the U.S. while holding the line on costs—telemedicine is a tested and proven money saver—without sacrificing on care quality or safety.