Economic turbulence has dashed the hopes of many businesses on
the shoals. Most economists are in agreement that the best way to
navigate the storm is to batten down the hatches by running lean
and by protecting the existing customer base. That means offering
exceptional customer service and more value at each encounter. In
imaging departments, shrinking reimbursement was already forcing
radiology to reevaluate its role as a profit center. Women's health
service line offerings have been recognized as a way to bolster the
return on imaging investments but with a down market, screening
mammography services may not be enough. An emerging differentiator
in women's health programs is the ability to offer same-day breast
screening follow-up. While it is possible to deliver this level of
exceptional customer service, how much does it cost to
The same-day follow-up paradigm hinges on two components: using
digital technology and employing highly trained, efficient
In Boca Raton, FL, one high-volume breast center is using both
components in a symphony of efficient operation played to the tune
of approximately 90,000 billable procedures in 2008 -a record high
for the center. The Center for Breast Care, part of 400-bed Boca
Raton Community Hospital, operates 4 digital mammography units, a
stereotactic biopsy table, an ultrasound biopsy unit, 2 breast
ultrasound systems, an automated breast ultrasound device, a
dedicated breast magnetic resonance imaging (MRI) system, computer
aided diagnosis (CAD) systems, bone density and a positron emission
mammography (PEM) system.
The outlook was not always so positive for the Center for Breast
Care. About 3 years ago, an inefficient workflow and tremendous
delays in report delivery meant that the mammography units were
booked out for 5 months and patients typically had to wait 6 weeks
for screening, according to Kathy Schilling, MD, medical director
of breast imaging and intervention.
The center's workflow was in need of an overhaul and it began by
addressing staffing issues in the mammography rooms. The goal was
to screen a woman every 15 minutes in each of the 4 mammography
rooms. Leveraging digital-radiography (DR) based digital
mammography systems allowed the center to meet this high-volume
target. Compared with cassette-based computed radiography (CR)
mammography systems, the direct digital acquisition on DR units
allowed for tremendously high throughput. However, digital
technology alone was not enough to handle the volume and the center
now staffs 2 radiologic technologists per screening mammography
room to compensate.
The center also employs 8 radiologists exclusively dedicated to
mammography reading. They also scan all prior images to speed up
the workflow. Other workflow enhancing features are having a
universal reading workstation and using CAD software to keep the
radiologists focused. After screening mammograms are completed, the
technologist leads the woman to a waiting room and interacts
directly with the radiologist reading the case. The radiologist
indicates either that the patient can leave or that additional
follow-up is needed. Women can receive additional spot
magnification or ultrasound on the same day and a staff of on-site
nurse practitioners allows for women to schedule follow-up MRI or
nuclear medicine imaging that day.
"These women are the ones who direct their family's healthcare,"
said Dr. Schilling. "When that satisfied patient has a husband who
needs to come in for a colonoscopy, we hope that means that they
will choose Boca Raton Community Hospital."
Expert mammography techs
The Center for Breast Care operates at a high volume and can
justify the overhead required to run an operation of that
magnitude. In Brookhaven, MS, the staff at 110-bed King's Daughter
Medical Center does about 11 screening mammograms on an analog
mammography unit. They are looking at ways to offer high-touch care
at a lower cost. The solution they have devised, but not yet
implemented, calls for an expert mammography technologist to triage
suspicious cases for the radiologists and to provide follow-up
scanning with spot magnification, ultrasound or breast-specific
gamma imaging (BSGI).
"From a customer service perspective, it's a beautiful model,"
said Jim Krichbaum, RT(R), director of radiology at King's Daughter
Medical Center. "However, the idea of relying on an expert
mammography technologist is a subject of discussion within my peer
group of radiology managers. Our senior mammography technologist
has 30 years of experience. She could call out suspicious areas for
the radiologist's attention, and I think many radiologists
recognize the value in that model."
With the BSGI camera, King's Daughter has a potential third
level of same-day follow-up services that can provide a 98% rate of
confirming the presence of malignant breast cancer, according to
After the initial mammogram, an ultrasound could determine
whether the lesion is solid or cystic and, in most cases, a
subsequent BSGI scan could be ordered and performed on the same
day. The camera uses a technetium-99 radiotracer, which Krichbaum
says is always in abundant supply at King's Daughter. Taking into
account that the BSGI camera confers a significant amount of
diagnostic confidence at a lower price tag than MRI, smaller
facilities like King's Daughter can potentially use these devices
in conjunction with expert mammography technologists to provide
faster and more definitive diagnoses for their patients.
In this highly competitive climate, delivering same-day
follow-up could help healthcare providers increase referrals while
improving the care of women in their communities.
LCD Monitor Trends
Digital acquisition is the key to optimizing a breast imaging
workflow. As the move to digital continues, image review is now
being done primarily on 5 megapixel (MP) monitors. In the past,
cathode ray tube (CRT) displays were the only U.S. Food and Drug
Administration approved way to read digital mammography. Recently 5
MP grayscale liquid crystal display (LCD) monitors have been
supplanting their larger CRT brethren as the platform of choice for
digital reading. But as the market evolves it is becoming
increasingly more difficult to choose which display has the best
Vendors compete on factors like display brightness, viewing
angle, shades of gray, calibration software and many other areas.
One often-overlooked area is the graphics card that drives the LCD
"To improve the productivity, radiologists need to have the
images on screen as fast as possible and they need to read as many
as possible every day," said Hideyuki Honda, marketing manager for
North America at Eizo Nanao Technologies Inc., Cypress, CA. "They
need a powerful graphics card to do that because the mammography
image is very large. Having more memory on the graphics card
enables images to appear faster."
When purchasing a 5 MP display, manufacturers offer either
proprietary graphics cards or the ability to work with third-party
graphics card manufacturers. Third-party integration allows users
to realize a lower price point. Proprietary graphics cards offer
the benefit of being completely optimized for medical-grade display
and review. As technology continues to advance however, third-party
cards are becoming more competitive with the technical features of
The evolution of digital mammography displays
The next step in digital mammography viewing could be trading in
a dual-head 5 megapixel (MP) setup for a single 10 MP widescreen
monitor. This configuration has obvious advantages, since there
would be only 1 calibrated brightness across the entire monitor.
Further, with 1 large-format monitor, there is more on-screen "real
estate" compared with 2 LCDs. However, reading on a widescreen
monitor could pose significant challenges for radiologists.
With the wider format, it is unclear how much diagnostic
information will be viewable in the far corners of such a screen.
In this case, factors like off-angle viewing would play a
significant role in clinical acceptance of the device. Currently,
there is not a significant difference in viewing angle among most
of today's 5 MP LCD offerings (Table 1).
Discernable differences exist in factors like peak luminance and
backlight life. For instance, peak luminance, which is measured in
, must be ≥400 cd/m
for diagnostic mammography. While many monitors can be calibrated
higher than 400 cd/m
, the tradeoff is usually decreased backlight life. Backlight life
reported in Table 1 is typically the number of hours to 50%
Even though 10 MP offerings may be technically superior to 5 MP
displays, there is still a possibility that the technology never
sees the light of day.
"The 16 MP monitor that was introduced to the market years ago
ultimately failed because it was not possible to produce," said
industry veteran Albert Xthona, product manager, digital
mammography, BARCO, Kortrijk, Belgium. "Similarly, the 10 MP
configuration may reach clinical adoption but it is a little early
to say if it will become the clinical standard."
"[The major drawback to having one 10 MP monitor is that] the
entire workstation will be down in the event of a hardware
failure." said Hideyuki Honda, marketing manager for North America
at Eizo Nanao Technologies Inc., Cypress, CA. "With a dual-head
setup, you can continue your work on one monitor if it is an urgent
Ultimately, the decision to purchase a 5 MP display will be
driven by many factors, and sometimes the decision is made as part
of an overall mammography workstation package. In today's economy,
it would be prudent to spend extra time scrutinizing the features
of LCD displays to ensure that radiologists are reading on a
monitor that satisfies their needs.
1. Hoffman J. Chart Smart: LCDs.
Enterprise Imaging and Therapeutic Radiology Management.
Accessed April 20, 2009.