Mammography Acquisition Workflow - Brief Proposal

1. Proposed Profile: Mammography Acquisition Workflow

• Proposal Editor: Carolyn Reynolds
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: Radiology

2. The Problem

There are common practices in mammography which can have a wide variety of workflow results. Even when deploying the Scheduled Workflow and Mammography Image Profiles, variances in the way users and systems behave can lead to department inefficiencies, ambiguous data, special cases for automated billing, and less than optimal acquisition and reading environments.

Taking additional views is just one example of such concerns:

Additional Views

Radiologists often request retakes or additional views after the initial imaging service is completed. Doing so can lead to some of the following issues:

• Additional views may effectively change the type of the exam (i.e. screening to diagnostic, or uni-lateral to bi-lateral). The resulting final exam type is not evident to systems and users.

• Using another study or accession number to add the views leads to archiving, billing, and display presentation problems.

• Some workstation behaviors are incompatible with the needs of mammography, such as not allowing the addition of images to studies that are open or have already been viewed.

• Additional views can be mistaken for complete prior exams.

• Additional views may be data corrections or retakes on previously acquired views. Image Managers and Workstations do not have a mechanism to understand and properly treat images produced as a result of such conditions.

• Additional views may generate additional CAD result reports. This creates confusion as to which objects should be considered for case level processing and which CAD reports should be considered when reading.

• Because additional views are common in mammography, there is no easy, practical mechanism within mammography to declare a scheduled procedure complete. Performed Procedure Steps can continually be added to a study. Misuse of MPPS complete messages and PACS distribution mechanisms can inhibit access to images, CAD result reports, and study annotations. Inferred, incorrect study statuses and improperly organized study objects have also been at issue with many PACS.

3. Key Use Cases

1. A patient comes in for a screening mammogram which is converted to a diagnostic exam upon the technologist discovering a lump. The tech adds an extra view, but no exam type, so the hanging protocol at the workstation is unacceptable.

2. A patient comes in for follow-up in one breast. Since she is close to her yearly exam date, the radiologist calls for imaging the other breast, while the patient is waiting. The original room is unavailable, so another machine is used. The tech generates a new study and accession number. The right and left breasts do not hang together at the diagnostic workstation. The following year, the prior images are hung as two prior studies, not as one complete comparison study.

3. A radiologist views a screening exam and toggles on CAD which shows findings. The radiologist requests additional images to better demonstrate the abnormality. Should the tech add the views to the existing order? Does it depend upon whether or not the patient is still available for imaging that day? How should the exam type (and billing) change from screening to diagnostic if this is necessary?

4. The technologist labels a view incorrectly and doesn’t realize it until after the case is completed and sent to PACS. The view information is corrected at the acquisition modality and the view resent. The images do not hang properly on the workstations and multiple copies of the same image exist, one which is labeled incorrectly.

5. A PACS will not distribute images until a study is complete. A technologist wants the radiologist to view the images before completing the exam. The radiologist can not access the images from the local workstation.

4. Standards & Systems

Existing standards and mechanisms to consider include:

• DICOM

• Existing IHE profiles, actors, and transactions

Existing systems that could be involved in the problem/solution include: FFDM modalities, Mammography CAD servers, Diagnostic and Technologists’ workstations, PACS, and RIS.

5. Discussion

The Topic “Mammography Acquisition” is currently a catch-all topic for issues related to the workflow of ordering, acquisition, processing, archiving, display, and billing for mammography procedures. Upon further investigation, the IHE Mammography committee may further refine the scope of this proposal to keep aligned with the time and resources available to deliver viable solutions to specific use cases.

IHE is a great forum to consider solutions to these clinical challenges. The challenges with additional views might be solved by defining how to apply more generalized scheduled workflow use cases to mammography practices. Where existing profiles may not meet mammography departmental needs, it is believed that the IHE venue may be able to identify other solutions or identify gaps in technology that could be handed off to the appropriate resources (i.e. DICOM committees).

The original profile proposal, “Mammography Acquisition and CAD Workflow” has been separated into two different IHE proposals, although there are several overlapping concerns.