The Finnish Way: Mammography Screening Saves Lives

Jussi Perkio

Jussi Perkiö, Director, Service Development and Medical Technology, PhD, Hospital Physicist, Suomen Terveystalo Ltd.

The goal of mammography screening is to reduce breast cancer mortality rates by detecting the cancer early enough for efficient treatment to be possible. In Finland, the mortality rates are one of the lowest in the world. One of the reasons is the efficient nationwide screening program.

Finland was the first country in the world to begin a nationwide mammography screening program governed by law in 1987. Beginning with 50-59 y.o. women, the target group was extended to 50-69 y.o. women in 2007. Finland has a high participation rate; almost 90% of the target group undergoes the screening study. Of all the participating women, approx. 3% is recalled to second imaging study and approx. 0.5% is diagnosed with breast cancer and directed to the treatment pathway. Annually, approximately 50 deaths due to breast cancer are prevented by the screening program.

The organizing and funding of mammography screening is the responsibility of more than 300 municipalities. The municipalities typically outsource the screening program as the program is demanding to put up and maintain and not cost-effective to run with low volume of participants. As a result, over 80% of all the nation’s mammography screenings are performed by one operative, a private healthcare service provider, Terveystalo, which has managed to standardize the screening process and obtain large enough volume to maintain very high quality – both clinical and operational quality as well as experienced quality – with low cost.

One of the key points in the process is the utilization of digital technology to allow the primary screening images to be read by specialist radiologists anywhere. This not only promotes equality by putting all the women to be screened in equal position regardless of their location, but also ensures that the specialist radiologists get to screen enough mammograms to maintain high quality in their expertise.

As for the digital imaging technology, it does not necessarily mean FFDM. While it is highly likely that FFDM will be the method of choice in the future, Terveystalo currently uses CR technology for the most part due to its flexibility, cost-effectiveness, and high-enough image quality. Due to advances in detector screen development, the image quality vs. dose levels have met Finnish requirements. Also, tomosynthesis, an inherently FFDM application, is so far not included in the screening process. To meet national requirements, Terveystalo has a technical quality assurance protocol in place, routinely measuring and documenting the whole imaging chain.

From the information technology point-of-view, the backbone of the common nationwide process is a fast and secure nationwide information system. Although screening data cannot be mixed with patient data, the systems, e.g. PACS, can serve both groups simultaneously.

The other key points for the efficient screening process are the high level of standardization and continuous improvement. Apart from the service provider, the process has three important stakeholders:

  • Municipalities: appreciate clear contract models, see-through pricing, and reliable and on-demand reporting
  • Women to be screened: value flexibility in the scheduling of the imaging study, comfortable and competent imaging study, and clear results without delay
  • The national authority responsible for planning and evaluating national cancer screening programs: expect to get the data concerning invitations and findings to further evaluate the statistics, develop the screening program and guiding also political decision-making in the field.

The screening process has to be designed to provide all these and be flexible enough to allow municipality- and consumer-dependent modifications.

Based on experiences in Finland, an efficient mammography screening process is not easy to set up and maintain. However, by combining reliable technology with both medical and process expertise, the results are excellent.

CR: Alive and Well in a Digital World

Heidi McIntosh, Marketing Manager, X-ray Solutions, Carestream

Heidi McIntosh, Marketing Manager, X-ray Solutions, Carestream

I recently spoke with Radiology Today about computed radiography (CR) and how it is still being used widely throughout the world. Many people figured once digital radiography (DR) systems were intact they would replace and eventually phase out computed radiography (CR) from the imaging world. Well, they were wrong. In a world gone digital, it’s hard to imagine using equipment that doesn’t fit the trend, but when it comes to imaging there’s still a need for CR. The change in the use of CR is evident in the United States. It is slowly declining and being replaced by DR systems in many imaging facilities. However, the technology is not going away anytime soon—it’s simply found a new market for itself.

CR is moving to smaller facilities worldwide as well as in emerging markets. This is because the systems are easy to use and deliver significant advantages—such as affordable conversion—to facilities moving from film-based systems to digital. The need for this technology in smaller facilities worldwide in areas such as India, China, the Middle East, Russia, South America, and Africa, will keep CR around for quite a while thanks to their exponential growth.

For these lower volume facilities and clinics, CR is more practical than moving to DR because they don’t have the need for it. Their workflow is much less than hospitals or large imaging facilities that would benefit more by going digital. Many are on a limited budget and even though the cost of DR systems has dropped considerably, CR will always be the more affordable option.

Many of these facilities have opted for a budget-friendly system that integrates CR imaging with a “mini-PACS,” such as Carestream’s Image Suite Software. These systems deliver an affordable and convenient platform that allows staff members to capture, view, store, and output digital images. Mini-PACS can also provide specialized digital measuring tools and other features that can save time and help improve accuracy when interpreting images.

Converting to DR isn’t necessary for everyone but it definitely has its benefits for those considering the switch. The big one being related to dose reduction. It’s no secret that DR detectors, with cesium iodide scintillators, use less radiation than CR machines and are capable of limiting dosage. Dose management is a hot topic right now and will continue to be for a long time. But for many facilities throughout the world, the switch to digital is not possible, and reliable, efficient X-ray systems are still needed. Both DR and CR have their advantages, but one thing is for sure: regardless of DR’s growing popularity, CR will be sticking around for quite a while.

Where do you see CR heading in the future? Do you think the technology has longevity? Or, will DR eventually phase out CR systems around the world?

Using Multidisciplinary Teams to Achieve Dose Reduction

Dr. Marc Zins, Department of Radiology, Hôpital Saint-Joseph

Dr. Marc Zins, Department of Radiology, Hôpital Saint-Joseph. He is also a member of Carestream’s Advisory Group, a collective of medical professionals that advises the company on healthcare IT trends.

The radiologists who conduct CT and interventional radiology with fluoroscopic guidance examinations are in a position where dose reduction is of the utmost importance. Presently, less than 40% of medical imaging examinations are CT and CAT scans, but they account for about 95% of radiation dose among these exams.

A multi-disciplinary dose team is a necessity if successful dose reduction is to be achieved. I have learned this through personal experience, starting back in 2010 when my hospital put a dose reduction plan into practice using a dose tacking system and then had to redesign the plan after it did not work as well as we would have liked it to in the beginning.

From October 2010 – October 2012, we had what we called a retrospective approach to dose reduction. The advantage that this provided was that it allowed us to get a glimpse of any malpractice taking place and ways in which to make corrections. The drawbacks of this approach outweighed the advantages, which forced us to examine the protocol all together. These disadvantages included a lack of collective implication, data only being shared between the Radiologist Safety officer and the department’s chairman with no implications on the technologists or other radiologists, and no sustained communication among the small team.

Since 2010, we had metrics at the end of each month and conductive results that showed the way we used our two CT scan units, such as which examinations used the highest dose in the month. To better explain, we used the tracking system from 2010-2012 only with a retrospective approach, meaning at the end of the month, the radiation safety officer and myself would analyze results to increase our knowledge about the usage of our CT system and how it relates to dose.

We changed this approach at the end of 2012. Our first step was to install dedicated screens that inform the technologists about the dose being delivered to the patient in real time. Our next step was to officially create a multi-disciplinary dose team, which included the following members:

  • Radiation Safety Officer (technologist, involved since 2010)
  • Chief CT technologist (was missing from 2010-2012 because our data results were not involved in the daily practice)
  • Radiologist (dedicated to newer physics and competencies)
  • A middle-manager technologist (helps with logistics, communications, meetings, etc.)

The advantages of creating this multi-disciplinary team have been numerous. The quality of the communication throughout the department has improved immensely. We are better organized and have implemented new processes and protocols that have improved efficiency. For example, with the diagnosis of a pulmonary embolism, it has been much easier to communicate from the chief technologist through the radiologist, receive feedback about the protocol, and implement a new protocol (if necessary) for the next exam.

While the advantages have been numerous, there remain some challenges when it comes to dose reduction. Ultimately, the best way to reduce dose is to decrease the volume of imaging examinations a person has in their lifetime. In the meantime, there are other valuable tactics. Any examination using radiation should be justified and using dedicated instructions, new technologies, and following the good practices guidelines can lead to only administering these justified examinations.

Using the multi-disciplinary team, it has become easier to sustain quality time, and better communicate metrics of the dose tracking solution in CT units. There is a great deal of research dedicated to reducing dose, which will improve new technologies using advanced iterative reconstruction, allowing exams to possibly take 10 or 20 seconds in data reconstruction compared to a normal CT. In the next five to 10 years, that time may decrease even more, become available in daily practices, and ultimately allow for a much lower dose for the patient.

Highlights of AHRA 2013 with Marianne Matthews of Imaging Economics

Marianne Matthews, Editor in Chief of Imaging Economics, stopped by our booth on the last day of AHRA to wrap up the key topics of interest from the show. Matthews starts off by talking about quality and the real issues that surround it, such as how providers are going to be measured and meet the CMS mandates. Other key topics Matthews discussed were patient safety and the new tracking tools for radiation dose along with patient satisfaction and how that ties into the consumerization of imaging.

Matthews also offered insights on what she believed were to come for RSNA 2013. Not only does she see further expansion on these topics but we’ll also hear a lot about information technology (IT) and reimbursement.

Hear more of what Marianne Matthews had to say:

AHRA 2013: Gillette Children’s Specialty HC Provides Insight on Carestream Products

Jenny Severud, Lead Technologist of Out-Patient X-ray at Gillette Children’s Specialty HC, sat down with Don Thompson to discuss dose management and the use of the DRX-Revolution in her pediatric facility. In the video Severud discusses how Carestream’s cesium detectors allow technologists to use lower techniques to help lower dose, which is an important factor in medical imaging. She also talks about the new 2530C detector and commends the maneuverability of being able to efficiently get under the patient in a small, limited area.

Severud also discusses the fully automatic DRX-Evolution room at the Gillette facility and how the auto-centering and auto-positioning is her favorite feature.

Optimize Image Quality and Accelerate Work Processes with WLAN Systems

Guenther Hefler

Gunther Hefler, XRS Product Specialist, Europe, Carestream

The German translation of this post can be found following the English version.

At the 94th German Radiology Congress 2013 in Hamburg, I had the opportunity of giving a talk during X-ray technician training about technological advances. The subject of my talk was “WLAN in intensive care” and the feedback I received afterwards was very positive. Among other things, the aim was to present Carestream Health as an innovative manufacturer of WLAN-based systems, such as the newly launched DRX-Revolution.

After the talk, several delegates came to our stand to see a demonstration of DRX-Revolution and during those two days we gave over 70 live demonstrations which, without exception, were very well received by customers.

Here is a brief summary of the talk:

In addition to their established use in existing conventional X-ray equipment and completely direct digital radiography systems, the market launch of mobile wireless WLAN detectors in cassette format in 2009 has created new and interesting possible applications in bedside X-ray diagnostics in intensive care.

The technical requirement for the efficient use of these detectors is two separate WLAN connections. Connection 1 guarantees CSH_Revolutionimage transmission and internal systems communication between the detector and the X-ray equipment console. Connection 2 takes over communication between the hospital’s network and the console. A DICOM modality work list is continually retrieved from RIS. This WLAN connection also allows previous images to be displayed through DICOM query/retrieve and up-to-date X-ray images to be despatched in PACS.

This approach ensures that the image is displayed directly at the bedside within a few seconds of the image being acquired. After the user carries out quality control and releases the image, it takes around 20 seconds for the up-to-date X-ray images to be available on the hospital network. As well as complete digital systems from leading manufactures, there are also digital retrofit solutions available for most analogue mobile equipment.

All in all, the clinical use of the WLAN links described leads to considerable improvement and acceleration in work processes in intensive care. The time between X-ray creation and their availability is reduced considerably in comparison with imaging plate technology. Further advantages include optimal image quality with a lower dose combined with a reduced workload for staff.

German Translation:

Anläßlich des 94. Deutschen Röntgenkongresses 2013 in Hamburg hatte ich die Möglichkeit als Referent im Rahmen der MTRA- Fortbildung im Bereich Technolgiefortschritte, einen Vortrag mit dem Thema „ WLAN auf Intensivstation zu halten. Die Resonanz auf meinen Beitrag war sehr positiv. Ziel war unter anderem Carestream Health als innovativen Hersteller von WLAN- basierten Systemen, wie zum Beispiel des neu markeingeführten DRX Revolution, darzustellen.

Sehr viele der Teilnehmer kamen nach diesem Vortrag auf unseren Stand, um sich unser DRX Revolution demonstrieren zu lassen. Wir hatten während der 2 Tage insgesamt mehr als 70 Live-Demonstrationen mit durchwegs beigeisterten Kunden.

Hier die  Kurzfassung des Vortrags:

Mit der Markteinführung mobiler kabelloser WLAN-Detektoren in Kassettenformat im Jahr 2009 haben sich neben dem etablierten Einsatz in bestehenden konventionellen Röntgenanlagen und voll digitalen Direktradiographiesystemen auch neue interessante Anwendungsmöglichkeiten im Bereich der bettseitigen Röntgendiagnostik auf Intensivstation ergeben. Technische Voraussetzung für den effizienten Einsatz dieser Detektoren sind zwei separate W-LAN Verbindungen. Verbindung 1 gewährleistet die Bildübertragung und interne Systemkommunikation zwischen Detektor und der am Röntgengerät befindlichen Konsole. Verbindung 2 übernimmt die Kommunikation zwischen Kliniknetzwerk und der Konsole. Über diese W-LAN Verbindung wird kontinuierlich eine DICOM Modality Worklist aus dem RIS abgerufen. Die Anzeige der Voraufnahmen über DICOM Query/Retrieve und der Versand der aktuellen Röntgenbilder ins PACS sind ebenfalls möglich. Diese Vorgehensweise gewährleistet die Bildanzeige direkt am Krankenbett innerhalb weniger Sekunden nach der Bildakquisition. Nach Durchführung der Qualitätskontrolle und der Freigabe des Bildes durch den Anwender stehen die aktuellen Röntgenbilder nach ca. 20 Sekunden im klinischen Netzwerk zur Verfügung. Neben digitalen Komplettsystemen der führenden Hersteller sind auch digitale Nachrüstlösungen für die meisten analogen Mobilgeräte verfügbar. In Summe führt der klinische Einsatz der  beschriebenen W-LAN Anbindungen zur einer deutlichen Verbesserung und Beschleunigung der Arbeitsabläufe auf Intensivstation. Die Zeitspanne zwischen Erstellung und Verfügbarkeit der Röntgenaufnahmen wird im Vergleich zur Speicherfolientechnologie deutlich verringert. Optimale Bildqualität bei geringerer Dosis in Verbindung mit reduzierter Arbeitsbelastung des Personals sind weitere Vorteile.

AHRA 2013: Thoughts on the DRX-Revolution

In this video Anthony Aukes, Radiology Manager at Carle Foundation Hospital, reviews the Carestream DRX-Revolution Mobile X-ray System after seeing it at AHRA 2013. Aukes talks about how the life of any tech at an imaging facility is always fast paced and busy, but the built in features on the portable helps enhance their workflow and make their life much easier.

This year we showcased our new 2530C detector, which is something Aukes feels has a place in the hospitals’ NICU department. Being able to capture and review images quickly allows radiologists to show physicians what they’re looking for without any detrimental impact to patient care.

When discussing converting rooms to DR, Aukes emphasized the “do more with less” motto many healthcare facilities face today and how to stay on the leading edge of technology. The DRX-1 system allows them to upgrade exam rooms to newer technology with lower dose and better image quality without having the expense of replacing a whole room.

Key Trends in Healthcare from AHRA 2013: IT and Big Data

Opening day of AHRA 2013 focused a lot on IT and big data. We sat down with Cat Vasko, Editor of Digital Media at ImagingBiz, to discuss these and other key trends from throughout the day including does reduction and outcomes management.

In the video, Vasko discusses the need for advanced data analytics tools to move forward in radiology and medical imaging. She also talks dose reduction and how IT is necessary to do the cumulative dose tracking and analysis that is needed in the field to enhance patient safety. This is because technologists cannot achieve the same results from a chest CT and a chest X-ray without having the data to analyze.

Looking ahead to RSNA 2013, Vasko offers her predictions on key topics to be seen, placing emphasis on integration between different IT systems and modalities. She believes radiology departments can’t move forward and do the necessary analytical work without easy integration between all these systems.

Why Should Radiologists Be Mobile Friendly?

Cristen Bolan, Executive Editor, Applied Radiology

Cristen Bolan, MS, Executive Editor,  Applied Radiology

Radiologists should be mobile friendly. Have you heard that? As soon as someone tells you what you should be, you don’t want to be it, even when you already are. Most radiologists have already thrown out those archaic flip phones and all-thumbs Blackberrys and graduated on to the much sleeker, interactive interface of smartphones. Is it a sign of higher intelligence or just a new shiny thing in the corner? Visually, it may be eye candy, too tempting for a visual junky to pass up. But is it too personal; something you wouldn’t bring into the workplace…or would you?

The biggest reason radiologists should be mobile friendly is because their referring physicians are.

Physicians and other clinicians are using their personal devices, like iPads, iPhones, and Androids, to access patient information from anywhere, anytime. In a recent survey, primary care and internal medicine physicians indicated a strong preference for electronic health record (EHR) usability on their mobile devices.1  In the same survey, 83% of respondents reported they would immediately use mobile EHR functionalities to update patient charts, check labs, and order medications if available to them via their current EHR.1

Mobile-device medicine, ie, the use of mobile devices to deliver care, is a growing trend and the more forward-thinking radiologists are catching on.

When Siddharth Prakash, MD, DABR, Vanguard Medical Imaging P.C. (Melville, NY), was deciding on which PACS to purchase for his imaging center, he needed to make sure he could send radiological reports to the physicians at a relatively inexpensive cost. “I was looking for a PACS provider that was looking into the future and trying to incorporate other devices, such as iPads and smart phones, and a simple system for contacting referring doctors,” said Dr. Prakash. “I wanted to find a solution that was taking the next step—communication.”

For Dr. Prakash, delivering a report to a mobile device gives his imaging center a competitive edge.  “More doctors want to see reports on their mobile devices, and when we provide this, they remember that my practice was able to do that, while others were not,” said Dr. Prakash.

How quickly could mobile-device medicine become a reality?

Well, it already is among hüber techy radiologists. But even the Board of Directors of RSNA is pondering the practical application of using mobile devices in the clinical setting. This year, RSNA launched a new learning management system to make RSNA education content available on mobile devices, in response to member demand.2 And along Dr. Prakash’s line of thinking, the theme of the RSNA 2013 annual conference is Power of Partnership: Partnering with the referring physician. The theme underscores the importance of radiologists providing a service that meets the needs of their physician partners.

No doubt smartphones on some level are a distraction—and dangerous when talking, texting and driving at the same time. But they also are very useful and there is no sign of turning back. As radiologists embrace the EHR, just like moving from analog to digital, they are now moving from desktop to mobile because these systems become so much more valuable when they “talk” to one another.3

The Top EHR Mobile Applications1

  1. remotely review charts
  2. update charts
  3. assign tasks
  4. view schedules and appointments
  5. send messages to practice staff
  6. lab orders and result review
  7. permit electronic prescribing
  8. patient encounter documentation
  9. input vital signs
  10. access EHR data after office hours


1. Slabodkin G. Survey: Doctors overwhelmingly favor mobile devices and apps for EHRs – FierceMobileHealthcare Updated June 3, 2013. Accessed July 31, 2013.
2. RSNA Board of Directors Report. RSNA. Posted March 1, 2013. Accessed July 31, 2013.
3. Shrestha R. Enterprise Imaging: Enabling true image exchange. Applied Radiology. 2013;5:20-21.

Guess the X-Ray– August’s Image Challenge

It’s time for yet another image challenge! Last month was too easy and we think this one will stump you! Give it your best guess. Please leave your answer in either the comment section below or on  our Facebook page. The challenge will run until August 31 or until the first person correctly names the item in the image. Good luck and happy guessing!

Sorry…Carestream employees and their agencies are prohibited from entering.

August Image