Monday, August 31, 2015

Challenges to rolling out 3D breast tomosynthesis

3D breast tomosynthesis presents significant challenges
for the IT department charged with implementation
Jude Mosley, Sentara manager of IT, manages the PACS system in Hampton Roads and Northern Virginia regions for Sentara Healthcare headquartered in Norfolk, Virginia. The 127-year non-profit integrated healthcare system with a mission to improve health every day operates 12 hospitals, urgent care centers, advanced and specialty imaging centers, home health, hospice, rehab centers and medical transport services. Sentara is supported by multiple medical groups including 3,800 providers and 30,000 employees. Sentara also offers health plans through its Optima Health insurance covering 455,000 people. Mosley started as a radiology technologist and has practiced as a Rad Tech with every modality including, MRI, CT, mammography, diagnostics, and angiography. She was radiology director for Sentara from 1993 to 2002 when she moved over to IT where she has been managing PACS since 2002. 

Q. Can you give us an idea of the size of imaging services at Sentara?
Sentara Hampton Roads does close to 1.2 million total imaging studies per year and has close to 13.5 million stored images archived from 2002 to present. We do another 100,000 annual studies on the PACS system in our northern Virginia region on their PACS system. 

I lead a team of 13 providing PACS applications support. Of those, 10 are based at operation sites, working with radiologists and providing hands-on help for end-users. Three from my team are based at our central IT office, managing moves and changes for upgrades testing and modality changes, worklist and configuration changes, RIS and voice recognition interfaces, among other items. My team also collaborates with the four member PACS technical team, which handles all hardware changes and core infrastructure.

Q. What systems are you using?
We have Agfa Impax PACS in the Sentara Hampton Road region and Fuji Synapse in the Northern Virginia region.

Q. When was the decision made to implement 3D breast mammography?
Sentara and its physician partners had been tracking with the technology and industry developments related to 3D for years. Sentara leadership at the highest level agreed the technology and findings related to outcomes merited a closer look.

In 2013, we implemented 3D mammography at two pilot sites and shortly thereafter we deployed the technology throughout the rest of the system in a phased implementation effort. The challenges of going from 2D to 3D were significant. To give you a little perspective, when Sentara initially piloted 2D, we quickly decided all Sentara breast centers would offer digital mammograms.  At that time, we went from storing no digital mammograms to storing all digital mammos. Even that was a big change. Storage requirements went from two terabytes a year to almost double that within 12 months, because digital mammos are so large. And that was just for 2D imaging. The transition from 2D to mostly 3D has been an even greater challenge technically. 

I work closely with the imaging directors who included IT when budgeting for 3D mammography.  The budget included the cost of the additional storage and increased bandwidth needed for 3D. We estimated about 30 to 50 percent of patients seeking mammograms would transition to 3D.

Q. Was your department involved in the decision from the start?
Oh yes. We are organized with different branches of IT, and I work in the medical systems department. At Sentara instead of having a PACS administrator, our PACS site coordinators are at the hospital or site, and the medical systems department really acts as a liaison between medical IT and operations. That's how I look at my job. I work closely with all of the imaging directors, and we meet monthly to stay connected. I was radiology director for 10 years in the system before I transferred to IT so they all know me really well. During our discussions about transitioning from 2D to 3D, the imaging directors were looking at me to see what my reaction would be when they first told me that 3D would require 4 times the storage needed for 2D mammograms. They laughed when I had this kind of convulsive shake. 

Q. Can you talk a little about the changes and upgrades needed?
The biggest change was the bandwidth required. One of the things I've learned over the years is you really can't go by the minimum requirements of systems. Its best to consider the recommended requirements. Hologic does recommend a gig (1GB) connection to the modality and to the workstations. The biggest cost and one of the longest lead times in the site upgrades was upgrading to a gig. Because not all of the 3D mammography units are on the hospital campus, this required getting the connection upgraded to a gig for outpatient campuses. Coordinating with the WAN team, and our ISP vendors increased the time needed to bring up 3D Hologics systems to the network. 

The recommended requirement was to have the modality and reading stations at a gig connection. We had always been at 100 (MPS), so we had to upgrade to 10 times the speed because we would be sending such large datasets across the networks. We worked with the Wide Area Network team on the cost to configure each site and the cost to connect a gig (speed) at the backbone for the hospital. That was the longest lead-time and longest implementation. That was a big deal and a big cost. Even though the machines are expensive, the other things that need to happen for implementing at multiple sites were also expensive.

Q. Were there storage issues?
Yes there will be storage issues and ongoing needs. Fortunately we were able to plan and budget for the additional storage needs. 

Q. What were the biggest challenges you faced with these upgrades?
After the Wide Area Network bandwidth and storage challenges, the next thing was that the PACS systems weren't ready for 3D reading or viewing yet. Initially there was no other option than to read from Hologic workstations. The challenge was that all prior images were on the PACS systems. The 3D images are great for mammography. Ultimately, those two services worked to create a standard (compatible) image. To read those standard images then required an upgrade so there were some challenges. Currently, we're in the process of upgrading our two (PACS) systems to be able to read 3D. 

We also support the storing of 3D. That in itself was another challenge. There is a thing called screen capture objects and then BTO or Breast Tomo Objects, which are true DICOM. That made a difference in how those images are stored, where they can be viewed and what would happen in the future. There is a lot of learning that goes on. We really asked a lot of questions so we understood what it really meant for our processes and systems. 

Q. Did you need to do additional training?
We do not need additional training. We don't support the Hologic modality, or anything like that, those are all vendor supported. There was really no more training needed from the PACS perspective. We did train operations to be aware of and understand all of the caveats and how they could or could not use the two systems together. For example, the 3D mammo machines don't burn to a CD because no vendor had a  viewer built for displaying the images from the CD. We were faced with the question of how we would distribute the images now. Film isn't an option; it would take an entire box of film. Fortunately this has been resolved. Last fall PACS Gear (now Lexmark) media writer included the viewer for 3D mammograms. We really trained the users to watch for these types of things. 

Q. Did you upgrade workstations?
We had to upgrade Agfa PACS last year that would allow for post processing, post review of the 3D tomos. Hologic did work with Barco monitor vendors, and we are using a newer model than what we had. We did replace some of earlier 5MP monitors.

Q. Were there workflow issues?
Yes, since all new studies were being read from a Hologic machine, the radiologists also wanted all prior studies to be read from the Hologic workstation versus Agfa or Fuji. Consequently we had to work on prefetch rules with Hologic, Agfa, and Fuji so the images would prefetch in a timely manner for the clinicians and radiologists. 

That was a bit of a learning curve for our existing staff, but it will be a bigger learning curve for new users. Unlike the prefetch we have on PACS, the  process with Hologic only performs a  prefetch one study at a time, once the first image comes over. There were some challenges at first. Now everyone is prefetching the studies back to the Hologic station.

Q. How important was a collaborative culture at Sentara between IT and the radiologists?

Our imaging team is very good about making us aware of new technology. Any new technology has to go through a technical review committee, which includes security, my team, and all the rest of the IT teams including WAN, LAN, and desktop. We also include the vendor to make sure we know what is going on. We also bring in an applications/operational point of contact, so we all understand the plan, next steps, cost expectations, and the timeline. Coordinating in advance is essential. Weve had great success breaking projects into phases so lessons learned (at each phase) can be used to help the next phases. Each phase of implementation goes smoother. Of course, including the vendor is crucial to making some of the changes. What I tell our PACS team is that the operation team owns the modality, and we own from the jack back to PACS. This helps us remember we have to collaborate with operations to make day-to-day operations work well too.

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