Integration of digital mammography on PACS


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Integration of digital mammography on PACS

  1. 1. Integration of digital mammography on PACS Summary This paper discusses support for digital mammography on PACS and describes options for connectivity and workflow. It is provided to help in planning the deployment of digital mammo- graphy and connectivity to PACS, and to outline the benefits of Philips iSite PACS. Please consult national or regional regulations for details on requirements for digital mammography.* Introduction With its proven clinical and throughput benefits, digital mammography has become an appealing option for imaging centers and radiology departments. Several studies and publications have shown digital mammography’s advantages in breast cancer detection, including increased sensitivity at a lower dose, improved productivity, and faster patient turnaround as compared to film-screen mammography. Particularly for screening patients under 50 years of age, those with radiographically dense breasts, and premenopausal or perimenopausal women, digital mammography provides greater diagnostic accuracy.1 Transitioning to digital mammography presents challenges that may impact productivity. After an initial decrease in efficiency, radiologists’ reading speed improves over time and is expected to approach those of film, as users become more familiar with the softcopy reading tools. Early PACS workstations were not equipped with reading and workflow tools to support mammography. Early adopters of digital mammography users were compelled to adopt separate IT solutions. The resulting complexity and redundancy led to additional costs and inefficiencies. Philips iSite PACS offers workflow advantages and reading tools to help streamline the transition to digital mammography. iSite PACS can help enhance productivity and reduce costs, with the following benefits: • Enhance workflow by interfacing with ordering systems, reporting systems, and additional workflow tools for a best-of-breed solution. • Improve patient care by providing point-of-care access to physicians throughout the enterprise. • Improve productivity with a single workstation platform and the ability to review multiple modalities simultaneously: digital mammography, MRI, ultrasound, and PET. • Reduce costs by leveraging existing investments in PACS (including archives and workstations). *In the U.S., refer to the Mammography Quality Standards Act of 1992 and subsequent revisions.
  2. 2. Considerations in deploying digital mammography There are a number of technical issues to consider in planning the deployment of digital mammography in your department: Image size: Because of high contrast and spatial resolution (matrix size), digital mammography image file sizes are very large, around 30 MB each (depending on the equipment used). A standard screening exam consisting of four views could be as large as 120 MB, uncompressed. This places significant strains on resources such as network bandwidth, workstation resources, and storage scalability. Workstation and diagnostic monitors: In addition to processor and memory requirements, 5 Megapixel (MP) monitors are required for softcopy reading (monitor requirements may vary between countries). These tend to be significantly more expensive than the standard 2 MP or 3 MP monitors that are commonly used for the interpretation of diagnostic radiology studies. Monitor resolution: The high image resolution of digital mammography (~ 50–100 microns/pixel) makes them less efficient to review by radiologists. For example, the fully displayed digital mammogram expands beyond the boundaries of a 5 MP monitor, requiring the physician to pan and zoom in order to view all pixels. Raw data and image data: Full Field Digital Mammography systems typically produce two sets of data. “For processing” data are the raw data produced by the detector, and typically require extensive proprietary processing to generate “for presentation” data. “For presentation” data are the final images that the radiologist views. Although medical device vendors may provide the option to store both “for processing” and “for presentation” data, this requires twice the storage space while providing limited additional clinical value. Computer Aided Detection (CAD) results: CAD servers can process digital mammography images before the radiologist reviews them. CAD results can be sent to the PACS and displayed on the workstation along with the images to aid interpretation. Prior exams on film: There are two options for managing prior exams on film: • Reading priors on film requires keeping a light box or a Mammolux unit in the reading room near the workstation. Films would have to be requested the previous day for all scheduled patients, taking into account transfer times if films are stored offsite. • You can digitize priors for scheduled patients before exam dates and have the data available on the PACS for the reading radiologist. This option demands an analysis of cost, labor, and space requirements for the digitization equipment and storage space on the PACS. Mammography support on iSite Radiology Philips iSite PACS offers workflow advantages and reading tools to help streamline the transition to digital mammography. iSite can help enhance productivity and reduce costs. Several workflow enhancements and display features have been designed to support mammography softcopy reading workflow: Hanging protocol • Advanced hanging protocols options – users have more options in building hanging protocols (automatic scaling of priors, flip/rotate, multiple links, mirror links, click and drag, series matching rules to designate hanging, zoom factor, image processing). • Sequence of hanging protocols – users can configure multiple protocols to display in a sequence. Display tools • Mammography CAD – interactive display/hide of Mammography CAD Structured Reports results from Hologic (R2) and iCAD. • Step zoom – step sequentially through images at pixel-to-pixel zoom. • True size – automatically scale images so the selected anatomy appears on the monitor scaled to actual size. • Mirrored and non-mirrored panning – users can link any series and pan them simultaneously in a mirrored or non-mirrored orientation. Productivity tools • Roaming magnification glass – quickly zoom in on a small portion of the image with configurable magnification settings in User Preferences. • Keyboard hot keys – Many configurable shortcuts are provided to improve workflow. These are saved as preferences in the user profile and are available on workstations across the system. • Keypad support –all keyboard short cuts can be programmed on commercially available keypads based on user preferences.
  3. 3. Sample workflow 1. Exam is scheduled on RIS/HIS and HL7 order message is sent to iSite. 2. Acquisition Modality queries Philips iSite PACS DICOM Modality Worklist (DMWL). 3. Prior imaging studies and physicians’ annotations for recalls can be viewed on iSite Enterprise inside mammography procedure room. 4. Acquisition modality acquires images and sends “for processing” raw data to CAD server. 5. Acquisition modality sends “for presentation” images to iSite. Integration of mammography workflow There are several options to integrate digital mammography workflow with iSite PACS: HIS/RIS Dictation/ Reporting CAD 4 “For Processing” images 6 CAD SR 3 Priors OR Recalls 2 DMWL 5 “For Presentation” images 9 Distribution iSite 1 HL7 order 7 Images + Priors + CAD 8 Annotations iSite Enterprise Mammography Room iSite Enterprise workstations iSite Radiology Figure 1. Workflow using iSite Radiology for mammography SCR 6. CAD server sends CAD results to iSite in the form of DICOM Mammography CAD Structured Reports or as DICOM Secondary Capture images. 7. Radiologist reviews images, priors and CAD results on iSite Radiology. 8. Radiologists can mark key images and annotate images for mammographers in the case of recall or to emphasize findings for referring physicians. 9. Images and associated information are available to referring physicians on any computer through iSite Enterprise. Using iSite Radiology for softcopy reading (SCR)
  4. 4. Sample workflow 1. Exam is scheduled on RIS/HIS and HL7 order message is sent to iSite (third-party specialty workstation may provide, if available). 2. Acquisition Modality queries Philips iSite PACS DICOM Modality Worklist (DMWL) (third-party specialty workstation may provide, if available). 3. Prior imaging studies may be queried and retrieved from the specialty workstation (if available) or may be sent manually from iSite to third-party specialty workstation. 4. Priors and physicians’ annotations for recalls are sent from third-party specialty workstation to third-party QA workstation (priors can be sent manually from iSite to third-party QA workstation–not shown in figure above). 5. Acquisition modality acquires images and sends “for processing” raw data to CAD server. 6. Acquisition modality sends “for presentation” images to third-party specialty workstation and a copy to iSite for long term archive. 7. CAD server sends CAD results to third-party workstation (CAD results can be sent to iSite for long- term archive). 8. Radiologists review images, priors, and CAD results on third-party workstation. 9. Images and reports are available on iSite for enterprise- wide distribution to referring physicians. Potential workflow limitations: 1. Third-party specialty workstations may not provide HL7 integration, thus requiring additional tools to view prior diagnostic reports. 2. Third-party specialty workstations may not provide Patient Information Reconciliation capability associated with HL7 integration, requiring additional work to resolve exceptions. 3. Third-party specialty workstations may not be able to write imaging studies to portable media such as CD or DVD. 4. Third-party specialty workstations may require additional workflow steps to retrieve prior imaging studies, especially non-digital studies. 5. Third-party SCR workstation may not be capable of displaying multimodality or prior imaging studies such as ultrasound, MRI, or PET. 6. Annotations, key images and measurements created on third-party SCR by physicians are typically stored in proprietary format and may not be viewable on iSite Enterprise or iSite Radiology for referring physicians. 7. The iSite Radiology Exam Status would need to be changed to “Mark Read” manually, requiring additional workflow steps. 8. Third-party specialty workstations may not be able to print hard copy film. Using a third-party workstation for SCR The following diagram shows an example configuration with a third-party workstation and does not cover all possible configuration options. 3rd party QA HIS/RIS Dictation/ Reporting Third Party workstation CAD 7 CAD SR 4 Recall Images 2 DMWL 6 “For Presentation” images 2 DMWL 8 Distribution iSite 1 HL7 order 3 Manually Retrieve Priors Mammography Room 5 “For Processing” images iSite Enterprise workstations Figure 2. Workflow using third party workstation for mammography SCR
  5. 5. Conclusion Digital mammography offers opportunities to improve patient care, but also presents costs, demands on infrastructure, and potential delays that a department must weigh against the benefits. Philips iSite PACS offers one solution for digital mammography workflow to help overcome these challenges. Together with the diagnostic and cost-saving benefits of digital mammography, iSite PACS can help you deliver better, more efficient patient care. References 1. Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005 Oct 27;353(17):1773-83.
  6. 6. © 2007 Koninklijke Philips Electronics N.V. All rights are reserved. Philips Medical Systems Nederland B.V. reserves the right to make changes in specifications and/or to discontinue any product at any time without notice or obligation and will not be liable for any consequences resulting from the use of this publication. Printed in USA BOT-07-03425/000 * NOV 2007 Philips Medical Systems is part of Royal Philips Electronics Interested? Would you like to know more about our imaginative products? Please do not hesitate to contact us. We would be glad to hear from you. On the web Via email By mail Philips Radiology Informatics 4100 E. Third Ave., Suite 101 Foster City, CA 94404 USA By phone Asia Tel: +852 2821 5888 Europe, Middle East, Africa Tel: +49 7031 463 2254 Latin America Tel: +55 11 2125 0764 North America Tel: +1 877 318 1808 (US, Canada) +1 650 228 5555