Diagnostic Reading #7: 10 Most Popular Blog Posts from the Second Half of 2014

CARESTREAM Touch Ultrasound System - 1Carestream has worked hard to provide content of value throughout 2014. We have used our blog to deliver information about Carestream technology, address major industry trends, and inform readers about the medical imaging and IT fields. In this edition of Diagnostic Reading, we look at our most read blog posts since July. The topics include, the recent unveiling of our newest technology, industry infographics, image quality, digital 3D mammography, and dose reduction.

1) A LOOK AT THE NEW CARESTREAM TOUCH ULTRASOUND SYSTEM

Carestream unveiled its newest technology in Chicago at RSNA 2014. The CARESTREAM Touch Ultrasound System officially moved the company into the ultrasound market. This post contains information about the new technology, including images that explain its features and capabilities.

2) INFOGRAPHIC: THE EVOLUTION OF RADIOLOGY REPORTING

This infographic follows radiology reporting throughout history. It covers traditional hand written reports, transcribed reports, and voice recognition. Pros and cons of these types of report are listed. Ultimately, the evolution brings us to multimedia reporting and highlights its benefits.

3) UNCOMPROMISED QUALITY: BONE SUPPRESSION AND CHEST X-RAY IMAGES

Since being FDA approved earlier this year, radiologists are 58% more confident in their ability to read chest x-rays with bone suppression software. Since the software produces 2-D images rather than 3-D images, it also reduces the typical dose for patients receiving chest x-rays.

4) DREAM JOB: APPLICATIONS ENGINEER, DIGITAL MEDICAL SOLUTIONS

This Q & A with Marty Pesce asks questions about his experiences as an applications engineer for Carestream. The interview discusses the nature of a job as a radiologic technologist. Pesce also had the opportunity to answer questions about his personal experiences in the radiology field.

5) IMPLEMENTING EFFECTIVE WAYS TO REDUCE AND TRACK RADIATION DOSE FOR X-RAY EXAMS

El Camino Hospital in Mountain View, California, has taken measures to dramatically track and decrease patient dose. The hospital attributes this success to their transition from CR to DR technology. It claims that better imaging software leads to less repeated imaging.

6) DIGITAL BREAST TOMOSYNTHESIS NECESSARY FOR IMAGING DENSE BREAST TISSUE

This post emphasizes the importance of Digital Breast Tomosynthesis (DBT), or 3-D mammography for women with dense breast tissue. Numerous studies are noted by the author, including a JAMA study that found that by using DBT, there was a 41% increase in the detection of possibly lethal cancers.

7) RADIOLOGY’S RESPONSE TO HEALTHCARE CONSOLIDATION – STEP ONE: THE GLOBAL WORKLIST

With hospital mergers becoming prevalent, this post suggests that interoperability will continue to be a challenge. The adoption of software such as CARESTREAM Vue Connect could ease the transition. Combining data allows for both institutions to access their own information, as well as having access to new patient information.

8) THE ROLE OF A FULLY INTEGRATED RIS-PACS: DREAM OR REALITY?

Seventy-eight percent of office based physicians use some sort of electronic health record system (EHR). This post addresses the possibility of  radiologists and physicians working together using RIS and PACS to document patient records. There are inevitable challenges, but ideally this could mean “one patient, one record.”

9) RADIOLOGY AND MACRO HEALTHCARE TRENDS PART II: COST

In a time when Americans find it difficult to afford medical bills, radiologists must be conscientious about cost. Inappropriate imaging exams and lack of quality drive up costs, this post discusses how imaging appropriateness and effective reading of images can reduce costs in the field of radiology. Additionally, the post addresses other ways that health IT can help lower imaging costs.

10) THE THREE-PHASE PROCESS TO IMPLEMENT A PACS-DRIVEN TELERADIOLOGY SERVICE

Innovative Radiology adopted CARESTREAM Vue Motion. Since the implementation, efficiency has been higher. Additionally, Vue Motion connected Innovative Radiology with more than 40 sites in early 2014.

Key Imaging Technology Trends to Watch for at RSNA 2014

RSNA 2014 logoAll major technology advances in the world of radiology and imaging are unveiled or highlighted at the Radiological Society of North America (RSNA) annual meeting in Chicago. This makes it the ideal place to see how the vendors are responding to legislative mandates, economic factors and how new advances in technology that are likely to impact how healthcare is conducted in the coming years.

Based on trends and new product releases Imaging Technology News (ITN) magazine monitors throughout the year, here is a list of some of the items I expect to be the hot topics at RSNA 2014.

1) Women’s Health

Breast imaging has seen a lot of increased interest in the past year. A lot of this has to do with the rapid expansion of 3-D mammography, also known as digital breast tomosynthesis (DBT). The second part of this is due to new legislation in several states and pending in Congress to require clinicians to inform women if they have dense breasts, which can greatly limit diagnostic accuracy in traditional mammography. Until recently, there was not much that could be done for women with dense breasts, but advances in breast MRI, automated breast ultrasound (ABUS) and tomosynthesis now offer options to better screen these patients. Of these, tomosynthesis will likely become the primary modality, since it is substantially similar to current mammography workflows. It also offers the ability to view slices of the breast to better differentiate real lesions from areas of overlapping dense tissue. Imaging centers across the country are leveraging their new tomosynthesis machines in public ad campaigns to attract new patients.

2) Radiation Dose Reduction

Well publicized overdoses of ionizing radiation from CT scans have inspired legislation in Texas and California to force hospitals and imaging centers to now record and monitor patient dose exposures. Other states are expected to follow suit with their own legislation. Additionally, earlier this year the Joint Commission changed its rules for credentialing facilities by now requiring dose-recording software so facilities can get a handle on doses used and how to reign in high-dose outliers. Congress also passed H.R. 4302 earlier this year, which delays the large cuts in Medicaid called for by the Sustainable Growth Rate (SGR) if imaging facilities meet new requirements for stricter patient radiation dose safety controls in efforts to lower dose.  Expect to see many new software options on the show floor that record the dose from each exam from multiple X-ray and nuclear imaging modalities. These systems often package that data into dashboard management apps to monitor doses based on specific machines, protocols, departments and technologists. Some software will also help interface data for easier upload to the American College of Radiology (ACR) Dose Index Registry.

3) Enterprise Imaging

“Enterprise” recently has become a major buzz work in imaging and this year many vendors will feature solutions that enable image and report access anywhere in a hospital or healthcare system without the need for dedicated workstations. Enterprise imaging also is likely the next evolutionary step in image storage and management, which will take the responsibility for imaging management away from radiology and place it into the hands of IT. This makes sense from the standpoint that today, reports and images collected from all departments in actually just computer data. Also, as imaging expands to include digital files from all hospital departments (pathology, orthopedics, cardiology, radiology, OB/GYN, internal medicine, etc.) access to images will no longer need to be routed through the radiology PACS or dozens of potentially incompatible image storage systems.  Enterprise imaging is often tied to Web-based software systems and a vendor neutral archive (VNA). These usually use Web-based cloud computing vendors that offer virtually unlimited storage capacity, while at the same time often offering a disaster recovery solution. Use of vendor neutral platforms is supposed to enable easier integration of data from disparate systems throughout the hospital so it can be made available in one place via the electronic medical record (EMR). Interoperability has greatly improved in recent years, but buyers should be watchful, as some systems interface better than others, and all will have some technical hiccups.

4) Less Expensive and More Efficient Imaging Systems

Due to the economic downturn, stagnation in healthcare capital spending due the uncertainties involved with the Affordable Care Act (ACA) and declining reimbursements, vendors now offer a variety of more affordable imaging systems than in the past. Additionally, all imaging systems and software are now graded of workflow efficiency and patient throughput, where speed and automation to save staff time are key.

5) Concentration of IT, Not Imaging Hardware

While PET/MR and state-of-the-art high-slice CT scanners are innovative and have a certain wow factor, the RSNA show floor and has largely transitioned to being an imaging software market place. Note above I only briefly mentioned actual imaging systems under the first subhead, the rest is IT related. You are hard-pressed to find anything regarding the gasping corpse of analog imaging on the show floor, since everything imaging today is digital. This includes the image files, the reports, how that data is stored, attached to EMRs and transferred to referring physicians.

The ACA pushes healthcare reform almost entirely through IT innovations and the digitalization of healthcare in an effort to make data more accessible and efficient. As Stage 2 meaningful use criteria begins to creep into specialties such as radiology and all others that rely on imaging, greater emphasis will be placed on some key new technologies on the show floor. This includes computerized physician order entry (CPOE) for imaging orders. Patient engagement is a key element, which I suspect will center on easy to use patient portals that are smart phone friendly to access their medical images, test results, etc. Another biggie for Stage 2 is remote viewing systems that allow easy image access to anyone who needs to see them who are not connected to the PACS. There has been an explosion of these remote image viewing systems over the past couple years. The new normal for most of these apps is to be tablet and smart-phone friendly to allow image and report access anywhere a physician happens to be.

DDavid_Fornell_ITNave Fornell is the editor of Imaging Technology News (ITN) and Diagnostic and Interventional Cardiology (DAIC) magazines, which both cover the latest technology trends. He reports on technology advances at several key imaging, healthcare IT and cardiology meetings each year.

Digital Breast Tomosynthesis Necessary for Imaging Dense Breast Tissue

Digital Breast Tomosynthesis

The image on the left is a DBT image, and the image on the right is traditional 2D mammography.

Digital breast tomoysnthesis (DBT), or 3-D mammography, has often been referred to as being the key to advancement in breast imaging. With more and more states passing laws requiring that women be notified if they are classified as having dense breast tissue, DBT is proving to be beneficial in accurate detection—a JAMA study showed that using 3-D mammography resulted in a 15% reduction in recall rates and a 41% increase in the detection of potentially lethal cancers.

Dense breast tissue and the accompanying notifications to women who possess it has become a frequent conversation topic over the past couple years. As of now, 20 states have enacted laws that require medical professionals to notify women if their mammograms reveal them to have dense tissue. Organizations such as Are You Dense Advocacy are fighting the good fight trying to get more states on board with these notifications because of the major risk dense breast tissue presents— making it more difficult to detect cancer in a mammogram than normal tissue.

At the International Congress of Radiology (ICR) in September 2014, Dr. Marwa Adel from Misr University for Science and Technology and Cairo Scan in Egypt presented two cases:

  1. The first case, Dr. Adel and company compared breast cancer visibility in digital mammography with that of DBT. Cancer visibility was ranked higher for DBT than for digital mammography in 52% of cases and was equivalent in 49 cases (33.6%). When observing the group with higher breast tissue density, the cancers were rated more visible in 64.6% of the cases.
  2. In the second study, DBT also proved better than digital mammography in image quality of masses. DBT was rated as equivalent or superior to digital mammography in 96% of the total findings.

Dr. Adel and the other authors of the studies concluded that DBT is superior to digital mammography in diagnostic performance. Particularly when it comes to dense breast tissue, it is clear that the use of DBT is vital to providing improved diagnosis to patients.

There are important questions regarding financial, technical, product, and workflow issues related to DBT that should be answered before a facility installs a system. As women’s healthcare continues to evolve, more and more facilities are able to implement DBT machines and be in a position to provide the highest quality of care to their patients.

At RSNA 2014, Carestream will showcase enhancements to its DBT module including a DBT image map that indicates the location and orientation of the currently displayed slice in the breast, a slabbing tool that allows  adjust of the slab thickness , improved workflow settings and the display of DICOM-compliant 2D synthetic views, which are calculated from the 3D dataset.  For more information, you can visit us in South Hall at booth #4735.

UPDATE, NOVEMBER 10, 2014: According to an article published last week by Health Imaging, “the Centers for Medicare & Medicaid Services (CMS) established two new add-on codes that will go into effect Jan. 1, 2015, and extend additional payment when DBT is performed along with 2D digital mammography.”  You can click the link to get more details about the designated codes and payment amounts for DBT. CMS said it will also “revisit payment for DBT and 2D mammography for 2016 as part of a review under its misvalued codes initiative.”

Ron Muscosky, Worldwide Product Line Manager, HCIS, Carestream Ron Muscosky, Worldwide Product Line Manager, Healthcare Information Solutions, Carestream 

 

 

JAMA Study Showcases the Benefits of 3-D Mammography

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

The case for the importance and relevance of mammograms has had its battles in 2014. The CNBSS announcement sought to prove that mammograms do not result in better detection and essentially, do not save lives. Those working in women’s health were up in arms about this study, claiming it as being dangerous and working to discredit it. With an announcement made yesterday by the Journal of the American Medical Association, the pro-mammogram field has secured a victory.

3-D mammography, known in the medical field as breast tomosynthesis, was the focus of a study released on June 24, 2014 in JAMA. The results of the study showed that using 3-D mammography resulted in a 15% reduction in recall rates and a 41% increase in the detection of potentially lethal cancers. These results are certainly positive, especially as millions of women will be having the mammograms and/or digital breast tomosynthesis this year.

This image shows the difference between digital breast tomosynthesis (DBT) and traditional 2D mammogram technology.

This image shows the difference between digital breast tomosynthesis (DBT) and traditional 2D mammogram technology.

The benefits of tomosynthesis do not come without issues. First off, the machines are expensive upfront costs for facilities. The New York Times article about the study estimated the tomosynthesis machines to cost about $500,000—almost double the cost of digital mammography machines. Reimbursement is an issue in some facilities—both in terms of the technology and from insurance companies since tomosynthesis exams are new to women’s health initiatives.

Second, the images captured by 3-D mammography machines create bigger volumes of data since the file size of a 3-D image is exponentially larger than a 2-D one. This creates the need for more storage space, resulting in higher IT costs for the facility.

Third, 3-D mammography images are creating a bottle-neck in terms of efficiency in reading and analyzing the exams. There is more substance to study and analyze in a tomosynthesis exam, so initially it takes longer for the radiologist to read and report the exam. Workstations with dedicated tools for tomosynthesis are helping to reduce this reading time.

Even with these three issues, the benefits that 3-D mammography provides to the patients outweighs each one. Providing quality care to the patient should always be the number-one priority for medical professionals. If it takes more expensive equipment, then the facility should make the investment because the benefits has the potential to save lives. Giving that up to save money and time is not worth the risk.

Q&A: Digital Breast Tomosynthesis

Ron Muscosky, Worldwide Product Line Manager, HCIS, Carestream

Ron Muscosky, Worldwide Product Line Manager, HCIS, Carestream

Digital breast tomosynthesis (DBT) is becoming increasingly popular in healthcare, but there are still many uncertainties surrounding it. Below are common questions healthcare organizations are asking about DBT and it is my goal to provide as thorough and accurate of answers as possible to demonstrate this technology’s value.

1.   What is DBT and how does it differ from/compare to traditional mammograms?      

DBT is a mammography procedure that uses low dose X-rays to create a three-dimensional image of the breast. Also referred to as ‘3D mammography’, the tomosynthesis scanner partially rotates around the breast and takes about 10 to 15 images from many different angles. As with traditional mammograms, the breast is compressed during the exam. The radiologist can then view the breast tissue in narrow slices, similarly to CT scan images.

 2. What benefits does DBT provide to physicians and patients?

With two-dimensional mammography, overlapping tissue can mask suspicious areas. Since thin layers of breast tissue are viewed with DBT, the overlap is removed and abnormalities are much easier to recognize. Studies have shown improved tissue identification, improved tumor visualization, and a lower recall rate for additional testing. Because of this, digital breast tomosynthesis has the potential to improve on the accuracy of mammography.

DBT

3. What are the challenges health facilities face when implementing DBT?

Financial:  Cost is a challenge due to the lack of reimbursement.  As patients become more aware of the benefits that DBT can bring, they’re asking for it.  Even with the lack of reimbursement, many facilities are adding DBT to prevent a loss of patients to other facilities offering this technology, and/or to provide better patient care.

Technical: Technical challenges include the size and format of DBT data.  DBT images can be very large, several times the size of conventional mammograms, so the transfer and storage of this data can be challenging.  Additionally, some acquisition device vendors have been generating data in a proprietary format (due to the lack of a DICOM standard format in the past), and in some cases still storing data in a proprietary format.  This presents challenges for healthcare facilities looking to standardize their data or use a mixture of vendor products.

Product:  As healthcare facilities add DBT to their breast imaging procedures, many are finding that their existing storage and viewing solutions do not yet support this technology.  This presents the facilities with the challenge of how they are going to store and view this data.

Workflow: DBT creates more data than a a conventional mammogram, increasing the time to read a case.  Just like when digital mammography was first introduced, users are experiencing a learning curve with reading the images with the use of workstations and the tools they provide.   In addition, some workstation vendors have very limited, if any, tools to optimize the reading of DBT exams, which magnifies the challenge.

4. How do providers overcome these challenges?

Financial:  Some facilities are absorbing the costs by marketing the value of  DBT and bringing in more patients.  Others are charging the customer an extra fee to help offset the costs.

Technical:  The data size challenge is overcome by careful planning of the network infrastructure and storage requirements.  Acquisition device manufacturers are recommending a 1Gbps network to accommodate the image transfers, so facilities are either planning for this when building new or upgrading their existing infrastructure.  We have found that in addition to adequate network bandwidth, the use of lossless compression and intelligent routing/pre-fetching of data are extremely important to efficiently move such large amounts of data around transparently to the user.  This is especially true when reading is performed across multiple facilities and/or remotely.

Regarding the data format, DICOM now supports a new SOP Class that specifies how such data can be transmitted in a standardized format for interoperability between various vendors’ equipment.  Most acquisition device vendors have adopted this standard, but existing proprietary data, and in some cases newly acquired data, still remain in proprietary formats.  To address this issue, some acquisition device vendors are offering a service where the proprietary data can be converted to DICOM standardized data.  This needs to be planned for ahead of any implementation of DICOM compliant equipment, since the conversion process can take some time to complete.

Product:  Facilities that add DBT and find their existing solutions don’t support this technology are faced with either waiting for their existing solution to support this technology or purchasing another product that will provide such capabilities.  Due to the importance of DBT, many facilities are choosing to replace or adjunct their existing solution with a product that supports this technology.

Workflow: We believe the learning curve radiologists are experiencing with the DBT technology will decrease over time, just as it did with digital mammography when it was first available.

The tools provided by an equipment vendor can also significantly decrease the time to read a DBT exam.  It is important that a facility chooses a product with the appropriate tools to optimize their workflow.  This includes not only the basic tools that automatically scale and position both 2D and 3D images, but also advanced tools that can help localize pathology and allow one to quickly navigate both current and prior studies.  With conventional mammography, digital breast tomosynthesis, synthetic 2D mammography, and other mammography procedures being generated (e.g. breast US, breast MRI, etc.), workstations with hanging protocols that can support and display all of these in an efficient manner become extremely important as well.

5. What are the key points you hope attendees will take away from your panel discussion at SIIM? 

Although there are a number of challenges with implementing DBT, solutions exist for each challenge and that will only improve in time as the technology matures.  It is also important for attendees to plan their environment and product selections, knowing what challenges have been faced by others and how they have been resolved.

 Editor’s Note: Ron will be participating in a panel session on “Problems and Solutions in Breast Tomosynthesis” during SIIM 2014. The session will be held on Thursday, May 15 from 12-1 pm in Exhibit Hall B – Innovation Theater.

Sizing Things Up

Marianne Matthews, Editor, Imaging Economics

Marianne Matthews, Editor, Imaging Economics

Guest post by Marianne Matthews, editor of Imaging Economics.

I had to chuckle recently when Jockey rolled out its new bra sizing system. Everyone from fashionistas to morning talk show hosts seemed obsessed with the news. It even garnered coverage (pardon the pun) on the front page of The New York Times. While some called the new bra sizing system important, others deemed it unnecessary and even downright confusing.

When it comes to their breasts, American women have a lot more important things to think about. And some of it—like understanding the real implications of breast density—can be as confusing as going from a 34B to a 7-36.

Although 10 states have now enacted breast density notification laws, the issue remains controversial. Proponents say it’s a no-brainer. They point to studies that show that increased breast density correlates with increased breast cancer risk. Experts say those with extremely dense breast tissue have twice the risk of breast cancer compared to those with average breast density. Moreover, dense breast tissue makes it hard to spot cancer on a mammogram.

So why not just enact legislation that mandates informing women of their density?

Well, there are a lot of reasons not to. Some of those opposed say the science is not perfect, density studies are misleading, and density alone is not necessarily a major cancer risk. Others fear the notification legislation will lead to too many tests and unnecessary biopsies. Still others object on principle to the government legislating medical care.

To be honest, I’ve had trouble sizing up the issue myself. Originally, I was all for notification legislation. Then, when I had a mammogram a few months ago, I talked to my radiologist. Turns out, she’s adamantly opposed to the density notification because she believes it will lead to “panic” among women. She’s not the only expert who feels density notification will only confuse women further, perhaps make them think they have cancer, or mistrust mammography altogether. She’s got a point. (There is a great deal of confusion among the highly educated women I know about breast density.)

So, I’ve gone round and round on the issue and come full circle. On balance, I think it’s a good thing. At this point, I see at least three simple reasons to support density notification laws.

First, in today’s society, patients are expected to be their own advocates—and doctors have pretty much made that the case. Doctors spend very little time in office visits actually communicating with patients. We’re expected to arrive prepared with our list of complaints and questions—and cover them all in less than 10 minutes. We’re expected to know our numbers. In some cases, we’re even forced to follow up on test results because all too often the physician’s office doesn’t bother to call with results. So, since we’re expected to be sophisticated patients—which takes some of the burden off of doctors—we need to be informed about our own bodies. That’s as good a reason as any to let women know if they have dense breasts.

Second, there is no turning back. Advocacy organizations are succeeding on Capitol Hill. In addition to the 10 states that already have density notification laws on the books, several more state legislatures have introduced legislation in 2013. What’s more, Federal legislation is under way. My point: You can’t put the genie back in the bottle.

Finally, as a radiologist, if you come out against density notification, you’re probably shooting yourself in the foot. Though I remain loyal to my breast imager, my guess is most women would not find her views all that favorable. In short, it’s politically incorrect for a women’s imaging provider to oppose the density movement.

So, you might as well use the density issue as an opportunity to educate your patients. Talk to her; get closer to her; show her radiology’s value. You can either be viewed as a foe or join the fight. That’s about the size of it.

RSNA ’12 Preview: Digital Breast Tomosynthesis and PACS Integration

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

When RSNA opens on Sunday, we can expect digital breast tomosynthesis (DBT) to dominate the attention of providers and radiologists interested in women’s imaging. A scan of the scientific and educational sessions featured in AuntMinnie’s “Road to RSNA 2012: Women’s Imaging Preview” highlights the early evidence of increased cancer detection and lower recall rates, which is driving interest in DBT in spite of lingering questions about reimbursement.

For providers who have adopted or on the cusp of offering DBT, however, we expect the discussions in the exhibit halls to extend beyond potential clinical benefits to the IT considerations raised by DBT early adopters. For example, DiagnosticImaging.com reported earlier this Spring on a KLAS report that highlighted the PACS integration challenges of DBT:
“Doctors are reporting interruptions in their day because not all PACS accept tomosynthesis studies. “It has created a workflow concern for radiologists who have to leave their office or reading room and come out to the tomosynthesis workstation to read the study,” said Monique Rasband, author of the report, Women’s Imaging 2012: Tomosynthesis Makes a Splash.” The doctors do say, however, that this extra time seems worth the effort because of the procedure’s effectiveness, she said.
While capturing the best breast images possible is important, it is just one piece of the care continuum. For DBT to succeed the reading environment must help radiologists make a fast, accurate diagnosis with minimal disruption to the diagnostic workflow.

 

At RSNA, we’ll be demonstrating our Digital Breast Tomosynthesis (DBT) Module for our CARESTREAM Vue Mammo Workstation that lets radiologists read all procedures from a single desktop. The workstation displays digital breast tomosynthesis studies, traditional mammograms, breast ultrasound, breast MRI and general radiology exams to help equip radiologists to work efficiently from a single desktop.

 

Here a quick video overview of how it works:

Comparison tools enable radiologists to use personalized hanging protocols for DBT exams along with other procedures. Specialized tools can further enhance productive reading: automatic positioning of DBT and mammograms eliminates manual manipulations; automatic “same sizing” of DBT and mammograms aid in comparing changes in anatomy; and concurrent magnifying glasses provided close-up comparison of pathology across multiple views and procedures. DBT exams can be viewed in cine mode or by scrolling.

If digital breast tomosynthesis is on your agenda at RSNA, swing by the Carestream booth (#2636) to get hands on with our DBT module or schedule your appointment now. 

Reading Digital Breast Tomosynthesis Exams From a Single Desktop

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

A recent article in the Wall Street Journal on 3-D mammography discussed the potential for digital breast tomosynthesis (DBT) to enhance the detection of cancers. I was reminded of how important it is to not only capture the best breast images possible, but also to have an efficient and effective system that helps radiologists make an accurate diagnosis.

As I revisited the accomplishments our team has achieved in designing a new module that displays DBT exams on our mammography workstation—while also displaying digital mammograms, breast ultrasound, breast MRI and general radiology exams from a single desktop—I was struck by how easy it is (or could have been) to add yet another dedicated workstation to the radiology reading environment and then falsely believe we have actually improved the diagnostic workflow.

We resisted that path. Our team has long demonstrated our commitment to supporting multiple digital breast imaging modalities on our mammography workstations, and we have fiercely resisted the temptation add new, single-use workstations that might seem alluring because of their “dedicated” nature—when in fact they add costs and create inefficiency. Supporting multiple breast imaging modalities—as well as general radiology exams—enables radiologists to deliver a faster diagnosis to referring physicians and can ultimately enhance patient care.

Our smartly designed tomosynthesis module streamlines workflow by allowing healthcare providers to store, route, display and query/retrieve DBT exams from DICOM-compliant acquisition devices, so radiologists have all the tools they need on one workstation. Comparison tools enable radiologists to use personalized hanging protocols for DBT exams along with other procedures, especially the 2D mammograms. In addition, specialized tools that further enhance productivity include: automatic positioning of DBT and mammograms that eliminates manual manipulations; automatic “same sizing” of DBT and mammograms that aid in comparing changes in anatomy; and concurrent magnifying glasses that provide close-up comparison of pathology across multiple views and procedures.

With our advanced sys­tem, radiologists can quickly and easily read exams from all modalities and vendors at a single workstation. And working smart is an important element in improving patient care.

How do you view or plan to view digital breast tomosynthesis? What do you think about 3D breast imaging?

For Mammography Tech Technology Has Changed Everything

Sherri Ford, RT(R)(M)(BD)

Editor’s Note: Sherri Ford is a Mammography Technologist at Premier Imaging in High Point, NC.  She has her A.A.S. degree in Radiological Technology and a B.S. in Health Administration.  She has over 19 years experience in the mammography field ranging from mammo-screenings, diagnostics, stereo biopsies and needle localizations.  She has worked as a PACS systems supervisor and has designed training programs for occupational nurses regarding osteoporosis and bone density testing.  Sherri is also a member of ACR, ASRT and HIMSS.

Q: You have a varied experience as a technologist from a PACs supervisor to mammography.  What are the major changes you have seen in the mammography workflow?

A: Technology changes everything. While technology is almost always eagerly awaited in mammography facilities, implementing new machinery often results in workflow growing pains. When digital mammography was introduced several years ago, facilities frequently floundered, causing workflow to slow down. The past five years has seen department workflow changes as processes were perfected, allowing more patients per hour. Many facilities have moved to a paperless system further speeding up workflow. As technologists, we have had to learn how to manage exam times, review images for technical quality in a new medium and not lose sight of the fact that our patients are individuals with feelings. Technology creates efficiency, confidence in the screening process and improved image quality but the equipment is costly. To offset the increased costs, schedules are packed tight and patients are streamlined from registration to exam result. Over the past several years, the most noticeable change in mammography workflow is undoubtedly the rapid pace. While increased volumes are a positive trend, indicating women are committed to the fight against breast cancer and health administrators are committed to providing the services, technologists must balance efficiency and compassion.

Q: Has the economic situation over the last few years impacted how you do mammography?

A:  Healthcare was one of the last industries to respond to the economic crisis and is one of the last industries to recover as economic conditions slowly improve. When unemployment peaked many lost their health insurance but not their need for healthcare. Health organizations were faced with the problem of meeting level or increased demand for services with severely diminished revenue streams. Mammography tends to be a loss leader for many health organizations to begin with and the downturn in the economy hit just on the heels of acquiring new digital equipment, further compounding financial challenges. Most mammography centers responded to the conditions by increasing volumes and reducing payroll hours to address cost control but savvy administrators marketed the services to attract new mammography patients and retain the existing ones. Programs became available to provide low or no cost mammograms with the expectation these patients would be a source of referrals, sending new patients to the organization for other health needs.

Q: Do women have specific requests for technology they have heard about and if so what are they asking for?

A:  Breast cancer screening relies most heavily on mammography primarily because the system has proven to be successful, accessible and cost efficient. However, mammography does not find all cancers and research continues to find new methods for screening and diagnosis. Periodically, patients will hear or read about new technologies and ask if they are available. Most of the time, patients will ask me about screening methods that do not require compression but rarely mention specific technologies. As healthcare becomes more transparent, however, this may change because the public will have greater access to information about diagnostic testing. Also, patient requests for new technology increase when it is introduced into the community.

Q:   Is your facility doing digital breast tomosynthesis?

A: With the recent FDA approval of Breast tomosynthesis, breast cancer screening has a remarkable new tool to aid in earlier detection, especially in women with dense tissue. Despite the success stories tomo has produced, it is not widely utilized in the US yet. Health insurance does not reimburse for tomo exams at this time, considering the technology investigational and many facilities cannot absorb the cost. Some facilities pass the cost on to the patient as an up charge to a mammogram, usually offering the patient the option of having the tomo and paying or declining the exam. I recently had the opportunity to observe several tomo exams and believe this technology will become the industry standard for screening. My facility is not currently offering tomo but is evaluating the technology. Breast tomo offers new possibilities in breast cancer screenings and should be embraced with excitement and anticipation.

Ask Anne: Changing Mammography Techniques for Digital Technology

Anne Richards, Carestream

Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream

One of the most common questions I receive for my “Ask Anne” feature here on Everything Rad is, “How will I need to adapt my positioning techniques when I move from analog imaging to digital?”

This month, Brigitte Hurtienne, chief radiographer at the Mammography Reference Center at the University Clinic in Munster, Germany, offered to share her experience:

Art of positioning

Whether using an analog or digital mammography system, the art of positioning is very similar. But digital imaging has advantages: the dynamic range afforded by digital mammography (16,000:1) is far superior to analog imaging (100:1).

The optical densities (OD) displayed on film are limited to 100 shades of gray, not all of which can be displayed at any time because the OD of the film is limited and fixed, and is determined by the x-ray exposure technique.

In a digital image the dynamic range depends on the computer’s window/level attribute and the radiologist can

Brigitte Hurtienne

Brigitte Hurtienne, Chief Radiographer, Mammography Reference Center, University Clinic in Munster, Germany

manipulate a digital image through 16,000 shades of white-gray–black.

So, in the digital technique, we often can make more skin wrinkles visible. Skin wrinkles may produce pseudoarchitectural distortions or may obscure surrounding structures.

Good positioning, at least for the mediolateral oblique view without skin wrinkles, is, therefore, very important. If hand pressure is discontinued before sufficient compression is applied, it will result in a poor separation of tissue and a downward-sloping of the breast contour, sometimes creating a skinfold in the inframammary ridge. An inadequate positioning technique in this region using suitable picture processing algorithms can lead to a loss of information.

Careful hand work – smoothing out the breast with the entire palm of the hand forwards and upwards, support with the ball of the thumb during compression, and smoothing out the inframammary ridge – prevent a sagging of the breast to the caudal and a wrinkle-free presentation of this region. Insufficient picture processing can be avoided in most cases.

Artifacts

There are also some differences in the types of artifacts that are seen in analog vs. digital imaging. In the analog world, we differ between film and screen handling artifacts and positioning artifacts. These artifacts are more common and can occur by improper handling of films and screens. Improper handling of films and screens could be exposures from creases, dirty screens, dust, scratches or from the object table, grid and static artifacts.

Some artifacts may be seen on both analog and digital systems, such as patient related artifacts (e.g. motion artifacts) and hardware related artifacts (e.g. x-ray tube filter defects and antiscatter grid defects).

Especially in the digital world, there are artifacts due to software processing errors or digital detector deficiencies. Pixel artifacts such as dead pixels or groups of dead pixels and dead lines can be caused by an imperfect detector.

Dust in the compression paddle, a not properly adjusted exposure, and problems with the image processing to a high noise level are further sources of an improper result. Problems with the reconstruction at the workstation can be the result of an improper display or problem with the sending of the images to the workstation.

Have you adjusted your technique for digital? What advice do you have for other radiographers or mammographers?