Efficiency in Breast Imaging

Educating Patients and Referring Physicians 

Time, energy, and personnel resources are conserved when referring physicians and their patients understand the needs and policies of the breast imaging facility. Information pamphlets, made available in referring physician offices, may provide all the important information a patient and the referring office need to ensure that the imaging facility can efficiently schedule, perform, and interpret procedures and communicate results. Such patient resources may also serve as an excellent marketing tool. Information that referring physicians, their staff, and patients should know when scheduling breast imaging procedures include:

Referring physicians and their patients need to understand that it is the responsibility of the breast center to schedule additional imaging that may be required to complete the assessment of suspected abnormalities. It is highly inefficient and inappropriate to defer to the referring physician to make such arrangements.

Screening versus Diagnostic 

The time required for completing a standard two-view screening mammogram is minimal and much more predictable compared with the time required for many diagnostic mammograms. The efficiency with which screening can be accomplished depends on the skill of the technologist and the need for her to perform various other tasks related to the procedure, eg, bringing the patient from the waiting area to a dressing room, instructing the patient about undressing and preparing for the examination, bringing the patient to the mammographic room, obtaining or reviewing the patient’s history, retrieving, hanging, and reviewing the previous films, developing films, loading cassettes, reviewing the new images, instructing the patient about dressing, collating paperwork and films, and perhaps hanging the films for interpretation. These are examples of at least 75% of the tasks performed by most breast imaging technologists that are unrelated to their specific training and skills.

Diagnostic mammography is less predictable as to the time that will be required to complete the study. Because some diagnostic studies may require as much as an hour to complete, a common practice is to allow 30 minutes or more for each diagnostic study. The “hope” is that for those who require more time there will be additional time made available from those who require less time. However, it is possible to predict the amount of time with fair accuracy by knowing what specific views or studies will be required. For example, if an exaggerated CC view is needed to visualize a prominent tail of Spence, no more than 5 minutes will be required to obtain this single image. On the other hand, if CC and MLO spot magnification images of right breast calcifications and sonography of a left breast nodule are required, 30 minutes would be a reasonable estimate for the time required. Therefore, the time for diagnostic imaging can be predicted with considerable reliability by the radiologist interpreting the screening study, or by the scheduling personnel following specific criteria based on the clinical information. Time can thus be allocated in 15-minute increments: Level 1 = 15 minutes, Level 2 = 30 minutes, Level 3 = 45 minutes, and Level 4 = 60 minutes. Schedulers must have a basic familiarity of the various breast imaging procedures and be provided specific guidelines for assigning time slots.

The efficiency with which screening mammography examinations can be performed and interpreted is dependent on the commitment to dedicated screening and to streamlined batch film interpretation. Dedicated screening implies that only screening mammograms are performed, without direct involvement of the radiologist and with all screening exams interpreted as a batch in a quiet, distraction-free environment where all studies are preloaded on automated viewers with appropriate comparison films. In this setting, CC and MLO views of each breast are taken and checked for adequacy. The only additional views are those to correct for technical or positioning deficiencies. Patients understand that they will have their mammograms interpreted after they have left the breast center and will be notified of the results in writing. All the mammograms for the day are preloaded onto automated viewers with their appropriate comparison films. The task of the radiologist is to decide whether the study is negative and the patient may return to annual screening or further workup is required and the patients will be called back by the breast center. The time taken to describe various details noted on the screening study restricts the number of studies that can be interpreted per hour. Efficient and accurate interpretation of screening mammograms requires an experienced breast imaging radiologist, confident in his/her competence in recognizing the wide spectrum of “normal findings” and able to quickly triage images to identify aberrations from normal.

In some breast centers, it is difficult to have dedicated space for screening and diagnostic mammography. Some with relatively low volume may argue that they have no real need to separate screening from diagnostic mammography and have time to convert screening to diagnostic on the spot and to have the radiologists available for “on-line” interpretation of screening studies. Even such small volume practices can improve efficiency by blocking time for screening, for diagnostic examinations, and for batch reading screening studies. The author can attest to a higher level of sensitivity and specificity when batch reading screening mammograms at a rate of 50+ per hour (in a dark, quiet, distraction-free room with virtually no film handling and minimal paper work) than when reading 6 screening mammograms in the milieu of working up diagnostic patients and performing interventional procedures. In addition, studies have shown that batch reading reduced callback rates.2, 3

Acquiring Information 

Complete and accurate information is essential for the proper performance and interpretation of breast imaging studies. Mechanisms that streamline the acquisition of information and minimize the risk of having insufficient information at the time of interpretation should be made a high priority when defining operational policies and procedures. This requires that the breast center has control over its own scheduling, not the hospital and not main radiology. Much of the necessary information can be collected at the time of scheduling, when scheduling is done by trained and informed scheduling personnel. A clear understanding of the imaging needs, based on the presence or absence of signs or symptoms, demographic information, and instructions regarding the obtaining of previous films can all be part of the scheduling process that will reduce the time patients spend in the facility before their studies are completed. In addition to information about the clinical concerns, specifics about the patient’s understanding of the “problem” and relevant historical information is part of every breast imaging study.

Referral or Request Forms 

The referral or request form is a common vehicle for clinicians to provide the imaging facility a clear understanding of the clinical concerns. Requests for imaging studies that come with incomplete or ambiguous information often result in procedure delays or in unnecessary or inappropriate studies. Properly designed, a referral form provides documentation that a screening patient has no signs or symptoms and, when needed, provides authorization for the imaging facility to complete additional imaging (Fig. 1).

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Figure 1. Breast imaging referral form.

History Forms 

History forms have been the traditional tool for acquiring and recording relevant information. Usually the patient is given a history form to complete at the time she arrives for her appointment, but this is also a form that could be downloaded from a facility’s Web site, with instructions for the patient to complete the form and bring it to her appointment. Then, the time to complete the form before the patient can be brought in for her study is eliminated. The technologist assistant or a clerk can check for completeness, leaving the technologist to review the clinical content of the history and expand on items that might need explanation. The design of a history form requires careful attention to ensure that it is brief, easily understood, requires little explanation, and can be easily reviewed by the imaging facility’s staff (Fig. 2).

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Figure 2. History form.

Comparison Films 

The benefit of having previous films to compare has been firmly established. The need for additional workup of ambiguous mammographic findings is reduced by having previous images that either confirm stability or lead to a higher level of concern. Having the previous films available at the time of interpretation of the current study is the most efficient way to ensure that comparison with previous films is accomplished. Several considerations arise when determining the best protocol pertaining to previous films.

It has been our practice to ask each new patient to bring any previous outside films with her. Although compliance with this request has been low (30% to 50%), the patients’ help significantly reduces the number of outside studies that we must obtain. All patients who have had previous films at another facility are asked to sign a release to obtain the previous films, ensuring that we can proceed with requests for the films when necessary. If release forms can be downloaded from a facility’s Web site, signed and faxed back to the facility, it may be possible to have previous films available at the time of the patient’s scheduled appointment. It is expensive and labor-intensive to call for previous films, handle the films, hang them for display with the current study that has already been interpreted once, and then have a comparison interpretation with an addendum generated and sent to the referring physician. There are no data that show a significant benefit in comparing previous films when the current study is deemed entirely normal. Wilson and coworkers, at the University of Michigan, found no significant benefit in comparing previous films with a completely normal study, noting average labor and postage cost was $21.49.4 This should bring into question the pervasive practice of always making a concerted effort to ensure that previous studies are obtained and compared.

If comparison films are unavailable at the time, but considered important, a preliminary report is generated, stating that an addendum will be provided when the previous films have been obtained and compared. Although this practice requires a second reading and interpretation, it ensures timely reporting and alerts the clinician to the need for the comparison study.

The accepted practice in most facilities is to compare the second most recent study. Other studies are compared only if the need for earlier comparisons is deemed necessary.

Image Display for Interpretation 

The conventional viewbox for display of x-ray images may be fine for an occasional review of films, but should be relegated to the “unacceptably inefficient” category. The time required to sort through film jackets to select and hang the appropriate comparison films with the current films, bring out previous reports, then refile the reports and films in their jacket is a waste of the radiologist’s time and is a distraction. Automated film viewers, equipped with variable light intensity and the option to mask extraneous light have become the standard for display and interpretation of breast images. Preloading imaging studies, with appropriate comparison images, greatly increases the number of studies that can be interpreted per hour and enhances the reader’s ability to maintain focus with minimal distraction.

Ultrasound images recorded on 14 × 17-inch film cannot be hung with mammographic films on most mammography film viewers. Leaving them in the jackets to be pulled and displayed separately on a large format viewbox is inefficient. Ultrasound images recorded on 8 × 10-inch or 10 × 12-inch films are easily loaded on automated viewers for review alongside mammographic images.

Generating Reports 

Methods used to generate breast imaging reports vary widely. Each has its advantages and disadvantages. As in most cases, achieving efficiency comes at a cost that may or may not be acceptable. So called “canned” reports are efficient in minimizing the need for dictation. “Macros” are predefined phrases or paragraphs that can be inserted into canned reports with two or three key strokes, allowing for an efficient way to customize or modify reports. By selecting from a list of macros, detailed unique reports can be generated. Mammographic report software programs, built around the concept of macros, enable the radiologist to select from a menu of items to document the procedure, the clinical concerns, imaging findings, final assessments, BI-RADS™ classifications, and final recommendations. These programs have the advantage of providing a mechanism for patient tracking and for auditing procedures and findings. The weakness of most commercial systems, in the judgment of the author, is their limited flexibility for modification of wording and formatting to reflect the needs or preferences of the user. If the radiologist is forced to edit the report to modify wording or formatting, efficiency and the advantage of not having a transcriptionist is lost. Many radiologists argue that these programs are less efficient for the radiologist than conventional dictation/transcription. Voice recognition technology is coming into its own. The radiologist, with voice recognition equipment, has freedom to use his or her specific wording, formatting as preferred, integrate macros, or generate canned reports. Voice recognition systems also allow immediate display of the written report, ready for proofing, editing, and signing.

Film Filing, Storage, Sending, and Retrieval 

There is no place in diagnostic imaging where access to comparison films and reports is more important than in mammography. Immediate access to previous studies requires close proximity to the file room where film jackets are stored with a filing system that minimizes the risk for misfiling. Separate filing and a smaller jacket improves access to breast imaging studies and reduces the need to deal with films from multiple other examinations and the risk of having the patient’s film jacket checked out to another department.

When outside facilities request patients’ films, many facilities make and send copies. The patient is entitled, by law and on her request, to have her original films sent anywhere she chooses. The cost and inefficiency of making copies and sending them should make the choice between sending copies or sending originals easy.

Appropriate Use of Personnel: Professional, Technical, Clerical 

As indicated above, 75% of the tasks usually performed by a mammography technologist are unrelated to her training and skill as a mammographer and could be performed by an assistant at half the salary required by mammographers. By keeping the technologist free to perform mammographic procedures and delegating the nontechnical tasks to a technology assistant, one technologist and an assistant can perform as many mammograms per hour as two technologists. The technology assistant can also serve as the female attendant and assistant for sonograms and procedures performed by the radiologist, thus eliminating the need to take the technologist away from the mammographic unit. When only a female attendant is needed, the use of clerical staff may be more efficient than using a technologist.

Who physically performs breast ultrasound studies varies, depending on the preference of the radiologist and availability of ultrasound technologists. In many practices where the radiologist is comfortable in performing ultrasound studies and dedicated breast ultrasound equipment is easily accessible, radiologists will argue that, not only is an ultrasound technologist’s time not required, but that their own time is saved when they perform the procedure. Breast ultrasound interpretation is significantly improved with the real-time information that comes from performing the procedure. Performing breast ultrasound procedures is significantly facilitated by understanding the imaging and clinical concerns, especially with the added benefit of palpation. The benefit of sonographic-guided palpation and palpation-guided sonography cannot be overstated. By performing the ultrasound procedure, the radiologist has the advantage of completing the imaging/clinical correlation, interpreting the findings in real-time, communicating findings, and establishing rapport with the patient as the study is being performed. In our own practice and those of other radiologists who do their own ultrasound studies, fewer images are recorded and less time is required to complete and interpret the study than is required when the study is performed by an ultrasound technologist.

Having immediate access to a high-quality ultrasound unit, preferably with spatial compounding, is essential for maintaining an efficient patient flow. Requiring patients to wait for an ultrasound unit to become available or be transported to another area for an ultrasound examination is an expensive inefficient use of time and is one of the major reasons for patient back-up in the breast center. Breast centers with a high volume of diagnostic imaging studies will need to have more than one dedicated breast ultrasound unit.

Scheduling breast imaging studies requires knowledge of the various imaging studies and procedures and which of those will most likely be required to properly workup screening or clinically detected concerns. Considerable training and experience is required to have highly efficient breast imaging scheduling. Many radiology practices use a centralized scheduling service for all imaging studies – whether by the hospital or by main radiology. This is one of the most significant operational mistakes breast centers make. Even in outpatient centers that are imaging only, if the volume of breast imaging can justify dedicated breast imaging schedulers, errors are reduced and efficiencies will be gained.

Workflow 

There are two particularly important design rules that facilitate the efficient flow of patients in a breast imaging facility: first, separate patient traffic from staff work areas, and second, provide sufficient dressing rooms so that an examining room is never used for dressing (Figure 3, Figure 4). The degree to which these rules can be incorporated into the design of a breast imaging facility depends on the availability of space and the appreciation of their importance by those with decision-making authority.

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Figure 3. Patient and staff traffic patterns. This graphic illustrates the concept of separating patient and staff traffic patterns. The light gray areas define the patient waiting and hallways. The darker stippled area defines the staff work area. The white areas represent various rooms for either the staff or for patient examinations.

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Figure 4. Dressing room configuration. By providing two dressing rooms that open directly into each examination room, one patient can be dressing while the other is having her examination. When the examination is completed, the patient is returned to her dressing room and the next patient is brought in for her study.

Policies and Procedures Manual 

A facility should maintain up-to-date policies and procedures that include protocols for day-to-day operations and definition of responsibilities for each professional, technical, and clerical employee. Each employee should be required to be familiar with the latest version of the policies and procedures. A policies and procedures manual should include a specific description as to when and how the policies and procedures are to be revised or updated. Policies and protocols should be carefully stated, periodically reviewed, and modified as needed to improve the quality of patient care and improve operational efficiency and cost-effectiveness.

According to the American College of Radiology, there was a net loss of 699 breast imaging facilities from April 2001 to March 2004; 1378 services closed and 679 opened. Financial problems were given as a reason for closing in 35% of the facilities. The most effective way to successfully provide breast imaging services that are so poorly reimbursed is to improve the operational efficiencies and reduce the cost of providing the service. Improving efficiency is part of improving quality and should be an ongoing priority for all breast imaging practices.