Digital Versus AnalogDigital Versus AnalogDigital Versus Analog Digital Versus Analog MammographyMammography

in Healthcare Informaticsin Healthcare Informatics

By By Kim BookoutKim BookoutJulie DreadinJulie DreadinJulie DreadinJulie Dreadin

William LodriguesWilliam Lodrigues

Histo of the Mammog amHisto of the Mammog amHistory of the MammogramHistory of the Mammogram

1895 William Roentgen, a German physicist discovered X-rays.

1913 Albert Solomon, a surgeon in Berlin, uses a conventional X-ray machine to visualize breastconventional X ray machine to visualize breast cancers in 3000 mastectomy specimens.

1956 Robert Egan, a radiologist in Houston, introduced dedicated film for mammography to produce simple and reproducible images with p p p gimproved detail.

Histo of the Mammog amHisto of the Mammog amHistory of the MammogramHistory of the Mammogram

1966 The first dedicated mammography machine was developed.

1980s-1990s Major improvements in mammography equipment including reduced radiation dosage,better film, digital imaging andbetter film, digital imaging and computer-aided detection.

2003 FDA approved 4 digital 2003 FDA approved 4 digitalmammogram units for clinical use

Implementing Digital Implementing Digital p g gp g gMammographyMammography

QualityQuality

SafetySafety

CostCost

Implementation Concerns/ProblemsImplementation Concerns/Problems Implementation Concerns/ProblemsImplementation Concerns/Problems

Analog Mammog aphAnalog Mammog aphAnalog MammographyAnalog Mammography

The actual mammogram method is performed The actual mammogram method is performed the same as digitalthe same as digital

Uses film as both a receptor and a display for Uses film as both a receptor and a display for the image to produce static, fixed images the image to produce static, fixed images

Two minutes for a conventional film Two minutes for a conventional film mammogram to be developed mammogram to be developed

Analog Mammog aphAnalog Mammog aphAnalog MammographyAnalog Mammography

Must be stored in protective Must be stored in protective sleeve/requires large amounts of spacesleeve/requires large amounts of space/ q g p/ q g p

Must be physically transported to otherMust be physically transported to other Must be physically transported to other Must be physically transported to other locations if consultation is necessarylocations if consultation is necessary

Digital Mammog aphDigital Mammog aphDigital MammographyDigital Mammography

The actual mammogram method is The actual mammogram method is performed the same as analogperformed the same as analog

Uses detectors that change xUses detectors that change x--rays intorays into Uses detectors that change xUses detectors that change x rays into rays into electrical signals (pixels) electrical signals (pixels) → transferred → transferred into a digital receptor → converts xinto a digital receptor → converts x--rayrayinto a digital receptor → converts xinto a digital receptor → converts x ray ray energy into numbers → produces an energy into numbers → produces an image displayed on a monitor or printed onimage displayed on a monitor or printed onimage displayed on a monitor or printed on image displayed on a monitor or printed on high resolution printerhigh resolution printer

Digital Mammog aphDigital Mammog aphDigital MammographyDigital MammographyHigher detected quantum efficiency (DQE)Higher detected quantum efficiency (DQE) Higher detected quantum efficiency (DQE) Higher detected quantum efficiency (DQE) ––allows for better detection from dense allows for better detection from dense parenchyma to the skin at a lower radiationparenchyma to the skin at a lower radiationparenchyma to the skin at a lower radiation parenchyma to the skin at a lower radiation levellevel

Distinguishes more shades of gray than film Distinguishes more shades of gray than film mammography mammography –– Images are presented on Images are presented on cathode ray tube monitors cathode ray tube monitors →→ allows for allows for manipulation of images (brightness, image manipulation of images (brightness, image reversal magnification window leveling)reversal magnification window leveling) →→reversal, magnification, window leveling) reversal, magnification, window leveling) →→fewer patient callbacksfewer patient callbacks

Digital Mammog aphDigital Mammog aphDigital MammographyDigital Mammography Electronically archive films Electronically archive films –– storage storage → → decrease decrease yy gg

risk of misplacement, damage; immediate risk of misplacement, damage; immediate electronic transmission; telemedicine and mobile electronic transmission; telemedicine and mobile mammography mammography → image transfer thousands of → image transfer thousands of a og ap ya og ap y ggmilesmiles

Image is displayed within 10 seconds after Image is displayed within 10 seconds after mammogram is performedmammogram is performedmammogram is performedmammogram is performed

Q alit of Digital Mammog aphQ alit of Digital Mammog aphQuality of Digital MammographyQuality of Digital Mammography

DMIST TRIAL DMIST TRIAL (Digital Mammography Imaging Screening)(Digital Mammography Imaging Screening)

Analysis of the mammographic results of 42,760 Analysis of the mammographic results of 42,760 women was performed by the American Collegewomen was performed by the American Collegewomen was performed by the American College women was performed by the American College of Radiology Imaging Networkof Radiology Imaging Network

Mammograms interpreted by 2 radiologists at Mammograms interpreted by 2 radiologists at each of 33 facilitieseach of 33 facilities

Q alit of Digital Mammog aphQ alit of Digital Mammog aphQuality of Digital MammographyQuality of Digital Mammography

Sensitivity and specificity of digital Sensitivity and specificity of digital mammography was higher for women:mammography was higher for women:g p y gg p y g

Under the age of 50Under the age of 50 Under the age of 50Under the age of 50 With dense or heterogeneously dense breastsWith dense or heterogeneously dense breasts

Pre or perimenopausalPre or perimenopausal Pre or perimenopausalPre or perimenopausal

Digital s AnalogDigital s AnalogDigital vs. Analog Digital vs. Analog CC Images of Fatty breastCC Images of Fatty breastCC Images of Fatty breastCC Images of Fatty breast

Digital s AnalogDigital s AnalogDigital vs. AnalogDigital vs. AnalogMLO images of fatty breastsMLO images of fatty breastsMLO images of fatty breastsMLO images of fatty breasts

Digital s AnalogDigital s AnalogDigital vs. AnalogDigital vs. AnalogCC images of dense breastsCC images of dense breastsCC images of dense breastsCC images of dense breasts

Digital s AnalogDigital s AnalogDigital vs. AnalogDigital vs. AnalogMLO images of dense breastsMLO images of dense breastsMLO images of dense breastsMLO images of dense breasts

Digital CC and MLO Images Digital CC and MLO Images g gg gDemonstrating Skin LineDemonstrating Skin Line

Digital CC and MLO Images Digital CC and MLO Images g gg gDemonstrating Skin ThickeningDemonstrating Skin Thickening

Safet of Mammog aphSafet of Mammog aphSafety of MammographySafety of MammographyAnalogAnalog DigitalDigitalgg

Radiation doseRadiation dose Physical films must bePhysical films must be

gg Radiation dose Radiation dose –– (must (must

consider diagnostic accuracy of consider diagnostic accuracy of benign masses & calcifications)benign masses & calcifications)Physical films must be Physical films must be

stored stored → loss leads → loss leads to repeat exams, to repeat exams,

g )g )

Films are Films are electronically stored electronically stored

i fili /l ↓i fili /l ↓increasing costs and increasing costs and XRT exposureXRT exposuref l d df l d d

→ misfiling/loss ↓→ misfiling/loss ↓ Films can be sent Films can be sent

over internet etc forover internet etc for If consult needed If consult needed → →

films must be films must be physically transportedphysically transported

over internet, etc. for over internet, etc. for evaluation (analog evaluation (analog films can be digitized)films can be digitized)

physically transportedphysically transported

Cost Compa isonCost Compa isonCost ComparisonCost Comparison

DMIST Trial revealed that:DMIST Trial revealed that: Relative to analog Relative to analog

mammography, screening mammography, screening for breast cancer using for breast cancer using digital mammography is notdigital mammography is notdigital mammography is not digital mammography is not costcost--effective.effective.

Analog and digital Analog and digital h h d i ilh h d i ilmammography had similar mammography had similar

results in breast cancer results in breast cancer detectiondetection

Cost Compa isonCost Compa isonCost ComparisonCost Comparison

Digital equipment is expensive upDigital equipment is expensive up--front front but consideration of other aspects is but consideration of other aspects is ppnecessary (factor of 4)necessary (factor of 4) Film costs (processing, staff, & storage)Film costs (processing, staff, & storage)Film costs (processing, staff, & storage)Film costs (processing, staff, & storage) DowntimeDowntime Technologists (QC efficiency)Technologists (QC efficiency) Technologists (QC, efficiency)Technologists (QC, efficiency) ReimbursementReimbursement

P oject ImplementationP oject ImplementationProject ImplementationProject Implementation

Feasibility studyFeasibility study Project managementProject managementj gj g

InitiationInitiation PlanningPlanning ExecutionExecution Control and monitoringControl and monitoring

Cl i th j tCl i th j t Closing the projectClosing the project

ImplementationImplementationf H l i Di it l M hf H l i Di it l M hof Hologic Digital Mammography of Hologic Digital Mammography

SystemSystemyy Staff Training Staff Training –– Provided by vendorProvided by vendor

l l fl l f Equipment Equipment –– Poor initial evaluation of Poor initial evaluation of hospital needshospital needs

Dictation interfacing with established Dictation interfacing with established EMR/Epic systemEMR/Epic system

Technology problems are ongoing and Technology problems are ongoing and being dealt withbeing dealt withbeing dealt withbeing dealt with

Digital Imaging Within Healthcare Digital Imaging Within Healthcare g g gg g gInformatics Informatics

Internet/electronic export and retrievalInternet/electronic export and retrieval Images can be retrieved from remote sites for Images can be retrieved from remote sites for

evaluation/consultationevaluation/consultationevaluation/consultationevaluation/consultation Used in telemedicineUsed in telemedicine Helpful to providers when performing procedures in Helpful to providers when performing procedures in

the OR or other facilities where reference to thethe OR or other facilities where reference to thethe OR or other facilities where reference to the the OR or other facilities where reference to the mammographic study is necessarymammographic study is necessary

Personal Health RecordPersonal Health Record digitized images can bedigitized images can be Personal Health Record Personal Health Record -- digitized images can be digitized images can be integrated in the PHR allowing for integrated in the PHR allowing for comprehensive healthcare and empowering the comprehensive healthcare and empowering the

ti tti tpatientpatient

Digital Imaging Within Healthcare Digital Imaging Within Healthcare g g gg g gInformaticsInformatics

l l h dl l h d Electronic Health RecordElectronic Health Record Allows for integration of images within the recordAllows for integration of images within the record

P id f i t ti ith d t b th t dP id f i t ti ith d t b th t d Provides for integration with databases that record Provides for integration with databases that record BIRADS and subsequent follow up action BIRADS and subsequent follow up action

Statistical analyses and evaluation of this data isStatistical analyses and evaluation of this data isStatistical analyses and evaluation of this data is Statistical analyses and evaluation of this data is presented for MQSA evaluation as well as individual presented for MQSA evaluation as well as individual radiologist and overall clinical evaluationradiologist and overall clinical evaluation

Digital Imaging Within Healthcare Digital Imaging Within Healthcare g g gg g gInformaticsInformatics

MQSA MQSA (Mammography Quality Standards Act)(Mammography Quality Standards Act)

Established 1994Established 1994 Created by US Food and Drug AdministrationCreated by US Food and Drug Administration Evaluates physicians, technologists, physicistsEvaluates physicians, technologists, physicists

l l d dhl l d dh Quality control program and adherenceQuality control program and adherence Quality and amount of radiation used to obtain Quality and amount of radiation used to obtain

imagesimagesimagesimages Mammography follow up programMammography follow up program Yearly accreditation inspectionYearly accreditation inspectiony py p

Digital Imaging Within Healthcare Digital Imaging Within Healthcare g g gg g gInformaticsInformatics

Combination of the EHR and the digital Combination of the EHR and the digital mammography systemmammography systemg p y yg p y y Creates a record to be evaluated by MQSACreates a record to be evaluated by MQSA Statistical records (BIRADS categories,Statistical records (BIRADS categories, Statistical records (BIRADS categories, Statistical records (BIRADS categories,

provider specific PPV)provider specific PPV) Ensures appropriate patient follow upEnsures appropriate patient follow upsu es app op ate pat e t o o upsu es app op ate pat e t o o up

Digital Versus AnalogDigital Versus Analogg gg gSummarySummary

Digital Digital Still in its infancyStill in its infancy

Analog Analog Has reached its peakHas reached its peakyy

Ability to add Ability to add applicationsapplications

pp Set applicationsSet applications Cost savings up frontCost savings up front

Cost savings over timeCost savings over time Greater efficiencyGreater efficiency

Cost sa gs up o tCost sa gs up o t Less efficientLess efficient Unable to integrateUnable to integrateyy

Able to integrate into Able to integrate into EHR/PHREHR/PHR

Unable to integrate Unable to integrate into EHR/PHRinto EHR/PHR

(M. Ulissey, personal communication, April 7, 2009)

QUESTIONSQUESTIONSQQ

Refe encesRefe encesReferencesReferences

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Pisano, E. D., et al. (2005). Diagnostic performance of digital versus film Pisano, E. D., et al. (2005). Diagnostic performance of digital versus film mammography for breastmammography for breast--cancer screening. cancer screening. The New England Journal of Medicine, The New England Journal of Medicine, 353, 1773353, 1773--1783.1783.

SameiSamei E Saunders R S Baker J A & Delong D M (2007) DigitalE Saunders R S Baker J A & Delong D M (2007) Digital SameiSamei, E., Saunders, R. S., Baker, J. A., & Delong, D. M. (2007). Digital , E., Saunders, R. S., Baker, J. A., & Delong, D. M. (2007). Digital mammography: Effects of reduced radiation dose on diagnostic performance. mammography: Effects of reduced radiation dose on diagnostic performance. Radiology, 243, Radiology, 243, 396396--404404

TostesonTosteson, A. (2008). Cost, A. (2008). Cost--effectiveness of digital mammography breast cancer effectiveness of digital mammography breast cancer screening. screening. Annals of Internal Medicine, 148Annals of Internal Medicine, 148(1), 1(1), 1--10.10.

United States Food and Drug Administration. (2002). United States Food and Drug Administration. (2002). Mammography quality Mammography quality standards act regulations. standards act regulations. Retrieved April 5, 2009, from Retrieved April 5, 2009, from http://www.fda.gov/CDRH/mammography/frmamcom2.html#s9001http://www.fda.gov/CDRH/mammography/frmamcom2.html#s9001