Digital mammography transition: The agony and the ecstasy

The clinical benefits of digital mammography have been well established, but the particulars of how to transition from film-screen to the new technology can be elusive. What exactly does it take to go digital?

Transition issues are legion and will require patience and foresight to address, according to Dr. Michael Linver, vice president of the National Consortium of Breast Centers (NCBC) in Warsaw, IN, and a practicing radiologist at X-Ray Associates of New Mexico in Albuquerque. His center is nine months into its digital mammography changeover.

"The most exciting part about digital is the ability to send images wherever they're needed," Linver said. "But to get there, you have to set up a whole new flowchart for efficiency, because the patient flow and the employee flow are going to be entirely different than what they were with analog."

And there's no denying it -- there will be pain, according to Linver.

"The problems you'll face when you transition are unavoidable," Linver said. "There are too many major changes to the way things are done and how long tasks take when switching to digital mammography. But it's better to know what they are from the beginning, rather than run into them midstream."

Self-evaluation: Does digital make sense?

Begin by assessing whether digital is the right technology for your particular facility, advised Dr. Jay Parikh, medical director of the women's diagnostic imaging center at the Swedish Cancer Institute in Seattle. Parikh spoke at the recent NCBC annual conference in Las Vegas.

"Evaluate your current situation from a variety of angles," he said. "Equipment, structure, analog workflow, capacity, informatics, and the outcome you're aiming for."

A facility should consider the following items, among other factors, when deciding whether to transition to digital mammography:

  • Number of film-screen mammography units in service, their age, and downtime for each
  • Number of upgradeable units
  • Size of the facility
  • Number of mammography suites and ancillary rooms
  • Number of file rooms
  • Analog workflow: scheduling, changing areas, wait time
  • Cases per unit, per tech, and per radiologist each day
  • PACS and/or RIS capacity
  • An appropriate pace for the conversion from analog to digital
  • Is everyone -- including radiologists, administrators, technologists, IT staff, and physicists -- on board?
  • What are the primary goals?

Linver's center was one of the last major groups in its area to get the technology, and it bought eight digital units at once.

"Competition was about 95% of what motivated us," Linver said. "I don't regret the decision. We had to do it in order to be perceived by our market as state-of-the-art. Women were calling and asking if we had digital mammography, and when we'd say, 'Well, no, but -- ' they'd slam the phone down."

Technology comparison

Once a facility has a strong sense of its existing resources and its goals in switching over to digital mammography, it can begin to weigh the pros and cons of available technologies.

The facility's representatives, whether they are radiologists, technologists, or administrators, can begin to gather information about digital mammography technology by attending conferences and meeting with vendors there, making site visits, and networking with other facilities that are already using digital, Parikh said.

"The four key areas to consider when evaluating technology are acquisition, processing, display, and storage," he said.

Image acquisition

A radiologist should assess the quality of the image produced by a particular digital mammography system; this is where site visits are crucial.

Image processing

Can the unit alter contrast and brightness and enlarge areas?

"You have to play with the toys," Parikh said. "Ask around until you've had a good amount of time to actually use a range of devices."

Image display

For soft-copy display, consider the expense of the monitors and any professional training or technology support that will be needed. Compare LCD features versus CRT, including expense, clarity of the images, luminescence, life expectancy, lesion conspicuity, volume, and heat load. For hard-copy display, consider image quality, how the printer will interface with the digital system, and material expenses.

Image storage

Digital mammography reduces or eliminates the need to store film and, therefore, the costs of that storage. It can also reduce the number of staff involved with managing film.

Also crucial in the image storage arena is PACS workflow. What kind of network bandwidth will be necessary? Is the PACS system compatible with Integrating the Healthcare Enterprise (IHE) profiles? Will the PACS that is managing the digital systems be integrated with the hospital's PACS, with speech recognition technology? Computer-aided detection software?

"Incorporating the digital system into a PACS or RIS is a huge issue," Linver said. "You better be sure you have a good IT team before you even venture into digital. Having a PACS system that will work efficiently for you is crucial."

Finally, evaluate each vendor's service program, Parikh suggested. "Meet with the company's local service team, and check out its track record," he said. "Not all service contracts are created equal."

The wonders of workflow

Key considerations for a facility regarding workflow issues include computed radiography (CR) versus digital radiography (DR), technologist workflow, and radiologist workflow.

CR versus DR

Computed radiography can be a good option if the center is low volume, has new analog equipment, and has a limited budget, and if service maintenance costs are low. Digital radiography can be a good option for a center that has old analog equipment, high service maintenance costs, a higher budget, and higher volume, and one that can perform advanced applications such as digital tomosynthesis.

Technologist workflow

With CR technology, the workflow is analog type; with DR, there's no cassette handling or film processing, so the technologist can take more exams per hour.

Radiologist workflow

Things to consider when evaluating radiologist workflow include how many reading rooms a facility has and how ergonomic they are, whether old films need to be scanned, radiologist interpretation times, hanging protocols, and annotation transmission.

"With digital radiologists having twice as much data to look at, it could take them twice as long, at least in the initial transition stages," Linver said.

Also consider the screening versus diagnostic factors. Screening is an analog-type environment that is quiet and undisturbed, whereas diagnostic has interruptions that can make the radiologist lose his or her position in hanging protocols.

"The reading area will need to have room for several banks of monitors and lighting, and the ability to adjust the ambient light," Linver said. "Digital monitors are much less bright than viewboxes, so the surrounding light needs to be at an absolute minimum."

Cost, negotiation, and installation

Evaluate the cost of full-field digital mammography (FFDM) per unit, per plate. In addition, determine what ancillary equipment (i.e., monitors, printers), space, electrical outlets, service support, and professional education will be needed.

  • Space: Comfortable rooms contribute to patient comfort. You'll still need film-screen mammography viewboxes. If a new center is being built from scratch, use an architect with experience.
  • Electrical: Install IT lines in advance, calculate added power load and lines, and establish backup circuits.
  • Ventilation: Reading rooms generate a large amount of heat, with alternators, bright lights, and viewboxes. Make sure you have a contractor who can help you ventilate the area properly.

Don't just go for the cheapest unit, Parikh said. "Look for value-added expense, and negotiate service contracts up front," he said.

Finally, consider operational issues when installing, according to Parikh. "You will most likely have reduced capacity during installation and slow ramp-up during implementation," he said.

Agony to ecstasy

Work through the transition, though, and you'll most likely come out the other end with a more streamlined workflow and the benefits of digital at your fingertips, Linver said. Most centers find that after a period of time that varies with each practice, everyone -- from administrative staff to technologists to radiologists -- can work with digital technology at a similar or faster pace than analog.

"Digital has changed and will continue to change the mammography landscape," he said. "As more and more centers go digital, we'll begin to see screening centers of excellence and the ability to offer high-quality imaging to rural areas. So even with the pain of transition, there are good things that come out of digital mammography."

By Kate Madden Yee
AuntMinnie.com staff writer
May 5, 2009

Related Reading

Research assesses mammography's value, April 2, 2009

Mammography procedure volume drops 16% since 2000, March 17, 2009

Radiologists overestimate breast imaging malpractice risk, February 9, 2009

Breast centers can manage malpractice risk, January 13, 2009

Walking the tightrope: The legal and regulatory impact of digital mammography, October 11, 2007

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