The world of digital mammography offers ample proof that the way things are usually done isn't always the best way to do them.

For example, in the setup most commonly seen at imaging centers and hospitals, radiologists and technologists read digital mammograms on a standalone dedicated workstation (DW). That is, they read the images on a separate piece of equipment than the center's PACS, where all other imaging modalities are read. What's more, the images and results are not available on the Web - or anywhere outside the department - for review by referring doctors.

Doing things this way is much like managing your documents, e-mail, spreadsheets and digital photos on your regular computer - but shuffling over to a separate device across the room to surf the Web. Moreover, it means having to master a new user interface and set of features to use the device.

There is a much better way. At Sansum Clinic, a multispecialty outpatient clinic in Santa Barbara, Calif., now has a fully integrated digital mammography with PACS. Integration that enables them to read mammograms on PACS, and to easily compare current mammograms to both prior mammograms of the same patient and her breast ultrasounds or MRIs. Integration has made the radiologists and technologists far more efficient and productive.

In addition, the economic advantages of integration are substantial. There's no question that their success with mammography/PACS integration has been helped by their PACS vendor's pioneering approach. They have also benefited because the PACS has many advanced features that can be applied to mammography.

But integration is a better idea, no matter how you slice it. Here's the story of Sansum's approach to mammography, and why you should consider doing something similar at your own center.

Early-adopter experience
Sansum was an early adopter of digital mammography, going live with it in July 2003. They took a different view about digital from the start; they wanted to leverage their investment in PACS as much as possible. They wanted to avoid creating a mammography "island" with redundant capabilities, infrastructure, service costs and overhead. So they sought to integrate digital mammography with PACS (to the extent the Food and Drug Administration [FDA] allowed in 2003) at the same time that they implemented digital mammography itself.

FDA requirements in 2003 mandated that digital mammograms be interpreted on the digital workstation of the digital mammography vendor. From the beginning, however, they archived all mammograms on PACS, generated mammography reports on PACS, and distributed images and reports on the Web - all in anticipation of the time when reading on PACS would be possible.

Once the FDA okayed that option, they began exploring its usefulness. Dr. Trambert took the lead with this project, starting in early 2006. He applied existing features and capabilities of Sansum's PACS to mammograms and helped develop new features with the vendor for digital mammography. He evaluated the features' utility with other modalities as well.

Dr. Trambert's experience was positive in virtually every dimension, from convenience to cost savings to workflow efficiency and productivity. Accordingly, he began training other members of his radiology group (the group contracted to read at Sansum) in the approach. This was a relatively simple task because the group, having used the PACS since 1998, had already mastered the user interface; they were experts in reading other modalities and reporting on the system.

With no apparent drawbacks to the integration paradigm and many obvious problems with the DW model, Sansum decided to fully convert to the integrated approach (i.e., reading on PACS included). The clinic "mothballed" its DW and all the redundant hardware, software and processes that went with it.

Sansum completed the switchover in Summer 2008.

Advantages of integration

Digital workstations are manufactured by and purchased from full-field digital mammography (FDDM) vendors, who profit handsomely when the units are sold because they're priced at up to $150,000. DWs are superfluous in the integrated approach, so FFDM vendors lose business when imaging centers integrate mammography into PACS.

The industry's loss is the imaging center's gain, of course. Besides saving the hardware cost of a DW, a center that integrates stands to benefit in other ways:

• In addition to saving the cost of the DW itself, the facility avoids the cost of a separate service contract for the DW and hardware costs associated with the DW, while leveraging similar costs for the PACS.

• The facility also avoids the hardware and labor costs involved with uploading prior mammograms to the DW and separately archiving current studies. Many DWs have limited storage capacity, so priors must be uploaded for each patient, deleted after she leaves, and then uploaded all over again when she comes in for her next appointment. Current studies are sometimes also deleted after the patient leaves, for similar reasons. To overcome the storage problem, some FFDM vendors sell auxiliary devices for permanent archiving of mammograms - but this is a redundant expense and piece of equipment for a facility with a PACS. Generally a PACS doesn't have a storage problem. Once mammograms are archived there, they can usually remain there permanently.

• The facility avoids crowding the radiology department with redundant equipment.

• A DW needs its own database. It's more efficient to leverage the database already being maintained for the PACS.

• When all modalities are on PACS, the radiologist can do all his interpretation work in one place. Using a DW forces the radiologist to physically move to a separate piece of equipment to view mammograms and make comparison of a patient's mammogram to, say, her breast ultrasound or breast MRI needlessly inconvenient.

• Rather than learn a new user interface for the DW, radiologists and technologists use the same interface for mammography that they've already mastered for other modalities on the PACS, making readings easier.

• Radiologists and technologists who review additional views on the DW often have to compete for time on the device with staff using the DW for screening mammograms. This is an inefficient use of time for highly paid clinicians and creates frustrating working conditions, too. When clinicians read mammograms on PACS, there is no competition for equipment because of multiple workstations with five-megapixel monitors around the facility.

• Instead of having one workflow pattern for mammography and a different workflow for modalities on the PACS, technologists have a single, more efficient pattern for all modalities.

• As new software versions for imaging hardware are released, users only need to train on one system (PACS) rather than two (PACS and DW).

• When mammography is integrated with PACS, referring physicians can access the PACS on the Web to view mammograms and read radiologists' reports. Many DWs are not Web-enabled and don't have their own reporting systems. This makes access to images and reports more complicated for referring doctors because they have to access them on different systems, if they can access them at all. On PACS, images and reports can be accessed together with just a few mouse clicks, a process that referring doctors already know and appreciate because of their experience with other modalities on PACS.

• When mammograms are viewed on PACS, the radiologist can use the PACS reporting system to generate a report just as he would for other modalities. Facilities that use DWs often end up using a separate reporting system for mammography alone. This creates another avoidable expense and another system for the radiologist to master.

• Disaster recovery is simpler, cheaper and more efficient to provide when there is a central depository of data, as opposed to having data split between the PACS and a DW.

• Because they can access images for all modalities - not just mammography - from any PACS workstation, radiologists can balance their workloads and take advantage of the PACS' single unified database while doing so. In our experience, workload balancing is far more challenging and costly when mammograms must be read on DWs with a separate database.

Sansum-specific benefits

Many of Sansum's radiologists feel they read mammograms up to twice as fast on PACS as they did previously on the DW. This is because the user interface on our PACS is extremely user-friendly and efficient.

In contrast, many radiologists at Sansum found the user interface on the DW to be just the opposite.

Additionally, our PACS vendor developed new features for mammography, such as new display tools and new means of navigating between images. These new features have turned out to be quite useful for other modalities on the PACS, too.

If you consider all of the benefits, you'll find that the integration model significantly increases a center's capacity to see patients.

Integration makes radiologists and technologists more productive. Indeed the whole center's workflow is smoother and faster. Higher patient volume equals more downstream procedures and, potentially, a mammography operation that can actually pay for itself - a rarity in today's health care economy.

Source: ADVANCE for Health Information Executives

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