Digital mammograms are now being delivered at more than 50% of the mammography sites in the nation. While the technology was validated in the US National Cancer Institute’s Digital Mammographic Imaging Screening Trial,1 the small statistical advantage of digital over analog mammography was found primarily in younger, premenopausal patients with radiographically dense breast tissue.
Continuing research has extolled the virtues of digital mammography, but the truth is that analog mammography is still very good. The digital image has presented breast imagers with an incremental improvement in the quality of the image that they interpret. From an image perspective, digital mammmography has been an evolutionary (rather than a revolutionary) change. It is fair to comment, however, that the major impetus for acquiring digital mammography came from marketing pressure.
From the perspective of process and workflow, however, digital mammography is nothing short of revolutionary, but only if you are open to, budget for, and integrate digital mammography for its abilities to enhance the delivery system, as well as for its direct image value. Digital mammography can be a game changer, and it can add value to your organization that goes far beyond the incremental increase in reimbursement. Digital mammography, however, can accomplish this result only if you reengineer your entire delivery system to become a digital system and become a truly digital breast center.
The Digital Image
There is value in the digital image. We all know about the interpretive enhancement provided through window and leveling functions, electronic magnification, and other interpretation tools. While these are helpful adjuncts in the interpretive process, step back for a moment and view that image with new eyes. It is digital, and it can be annotated with arrows or ovals to identify areas of interest. Little electronic notes can further describe these, and some systems can be configured to allow the addition of voice clips to patient files.
With this level of information available on a recalled patient, for example, the technologist can move directly to the additional imaging required, without needing to go over the file first with the physician. It should even be possible to indicate relative level of complexity for recalled patients (for use by schedulers in allocating time for the diagnostic visit).
Annotation can work both ways, and it can work in real time. The traditional work pattern in a diagnostic mammogram is for the technologist to acquire the images, then leave the patient in the mammography room and go to the reading area to discuss with the physician what should be done next. At that time, the technologist can also communicate any ancillary issues to the physician (for example, the patient is complaining of a new pain in her left breast). Beyond the obvious fact that, in a busy breast center, the technologist might have to wait in line to talk with the physician, the patient has been left (half naked) to fend for herself until the technologist returns.
With a proper digital system, the patient’s images can appear at the top of the physician’s worklist as soon as they have been acquired. The technologist can also add annotations (for example, the patient is quite frail and very sensitive to compression) that might assist the physician in ordering additional studies. Both patient care and throughput are improved by keeping as much of the professional interaction between the physicians and technologists in an electronic format as possible.
Patient-care improvement is an important point that cannot be overemphasized. The previous example illustrates the ability to keep the technologist with the patient during a diagnostic mammogram; in screening, digital imaging also allows significant reductions in the time required to acquire the images. In fact, depending on the equipment being used, the actual time from initial positioning through acquiring the last image ranges from 5 to 8 minutes.
A very short visit might make the patient (and the technologist) feel rushed, so many successful centers assign two technologists to each screening room. In this scenario, the technologist is with a single patient for closer to 20 minutes, but only has 10 minutes of room time. The additional time is spent discussing the patient’s history and any new problems. Note that additional workstations and space should be provided for obtaining