Overcoming the Challenges of Going Digital Mammography

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Overcoming the Challenges ofGoing Digital
Mammography

• Premier Breakthrough Series
• Orlando, FL
• June 23, 2006

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Overcoming the Challenges ofGoing Digital
Mammography

• Sally Grady, Director of Imaging Services
• Florida Hospital Celebration Health
• Celebration, Florida
• Mark Domalewski, MS, MBA, Corporate Director
  Imaging
• Fairview Health Services
• Edina, MN
• Vicki Petersen, MS, FAHRA, Director PACS
  Services
• Premier Inc. Supply Chain Performance
  Improvement

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Mammography Industry

• Breast cancer facts
• One in seven women who lives to the age of 85
  will develop breast cancer
• Breast cancer is the leading cause of death in
  woman between the ages of 40 and 55
• Every two minutes a woman is diagnosed with
  breast cancer
• 1,600 men are expected to be diagnosed with
  breast cancer this year and 400 are predicted to
  die
• Recommendations
• Early Detection - Regular mammograms
• Breast self exam
• National Breast Cancer Foundation, Inc.

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Digital Mammographic ImagingScreening Trial
(DMIST)

• Funded by National Cancer Institute
• Conducted by the American College of Radiology
  Imaging Network
• Launched Oct 2001 in 35 centers in US and Canada
• Enrollment of 49,500 women completed in late 2003
• Objective Evaluate digital mammography
  technology compared to conventional screen film
  technology
• Key Points
• Digital mammography significantly better than
  film mammography in screening women who were
  under the age of 50, or women of any age who had
  very dense breasts
• Digital mammography allows improvement in image
  storage and transmission because images can be
  stored and sent electronically
• www.dmist.org

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Consumer Awareness

• Press focusing on the stated study benefits of
  digital
• News coverage emphasizing benefits for detecting
  breast cancer
• News coverage of patients with comments such as
  painless, no waiting for 7 days for results,
  etc.
• The market response will be to entice patients to
  digital facilitiesand therefore drive more
  facilities to go digital faster
• Only 11 of 8,850 accredited sites have Full
  Field Digital Mammography (FFDM)

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Market drivers for Mammography

• Optimize patient care
• Improve diagnostic quality
• Reduce time to care continuum
  
• Improve cost position
• Reduce operating costs
• Maximize reimbursements
• Leverage resources
• Improve workflow for techs and radiologists

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Market drivers for Digital Mammography

• DMIST Study
• May provide justification for digital cost
• Patient demand will be influenced by results
• Equipment Life
• Significant analog replacements due in 2006-2009
• The Power of Reimbursements
• National Average for Screening Mammography
• digital vs. film - 132.06 vs. 82.77
• New Technologies

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The Challenges of Digital

• Sally Grady, Director of Imaging Services
• Florida Hospital Celebration Health
• Celebration, Florida

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Florida Hospital Facts

• Our Mission isTo Extend the Healing Ministry of
  Christ
• 7 Campuses in Central FL operating under 1 bed
  license
• 1800 beds currently with an additional 600 beds
  opening in 2008 (Centennial Celebration)
• Flagship of Adventist Health Systems
• Ranked number 1 in the nation for inpatient
  admissions
• (1 million admissions)
• Largest Medicare provider in USA
• 1 Million Imaging exams done on an annual basis

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About Celebration Health

• Opened in the Disney town of Celebration on
• January 5, 1998
• 550,000 sq. ft., 114 beds, 60,000 sq. ft. Fitness
  Center
• Corporate alliances with industry leaders and
  Fortune 500 companies
• Four Purposes
• 1) Excellent Community Hospital
• 2) Living Laboratory
• 3) Destination Healthcare
• 4) 21st Century Expression of Adventist
  Healthcare

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Celebration Health
Seaside Imaging
Changing Cabanas
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CT Scan Castle
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Finding Nemo
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Florida Hospital Mammography Centers

• 5 Womens Centers
• 2 Provide Screening and Diagnostic, all others
  are only screening centers (all have US, Dexa)
• Celebration Health only site to offer FFDM
• Overall Mammo Volumes for all 5 Centers
• -- 2004 45,810 (27 Diagnostic, 73
  Screening)
• -- 2005 48,964 (26 Diagnostic, 74
  Screening)
• 11,000 Dexa Scans Annually
• 2,170 Localizations in 2005
• 2,192 Biopsies in 2005

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Mammography Tea Garden
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Celebration Health
Digital Mammo unit
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Todays Challenges - Equipment

• Cost / Reimbursement Analog vs. Digital
• Mixed Environments Analog and Digital
• Mixed Vendors Capabilities (plate size,
  proprietary image formats, etc.)
• Workstations (mixed vendors)
• -- Mixed Vendors vs. Vendor-Neutral
• -- Multimodality vs. Mammo Specific
• -- Features and Functionality
• -- Hanging Protocols (screening and
  diagnostic)
• To CAD or not to CAD
• Storage Capacity

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Todays Challenges - Resources

• Backlog
• -- Screening vs. Diagnostic exams (days out)
• -- Capacity
• Policies (must enter the system with a screening
  exam)
• Radiologists
• -- Mammographers ( within group)
• -- Reimbursement
• -- Productivity (compare to CT/MR
  expectations)
• Technical Staffing/Staffing Model
• -- Availability of Technologists
• -- Analog vs. Digital
• -- Technologists vs. Tech Assistants

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Todays Challenges - Workflow

• Transition from Analog to Digital
• -- Patience is a Virtue!
• -- Previous Images (what to do with all that
  film ordo I still
• have to make a jacket?)
• -- Comparisons Film vs. Soft Copy
• Reading Room Set-Up
• -- Number of workstations
• -- Viewboxes
• -- Space
• Change in Technologist Workflow
• When to Print

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Todays Challenges - Marketing

• Competitive Environment
• To Market or Not to Market
• -- Do women really make the healthcare
  choices for the
• the family?
• -- Do you have capacity?
• -- Do you have a backlog?
• -- Do you have enough radiologists and
  technologists?
• -- Do you market FFDM if not all your sites
  have it?

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Todays Challenges - Futures

• End to End Breast Care Program
• -- How do we take care of a woman from birth
  onward?
• Current management is symptom driven with
  inadequate
• attention to risk assessment and early
  intervention
• Future management personalizes screening,
  diagnostic
• protocols, and treatment according to the
  womans
• individual risk factors and pathology
• Result Timely, integrated, multi-specialty care
  with improved outcomes

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Mark Domalewski, MS, MBA, Corporate Director
Imaging Fairview Health Services Edina, MN
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Fairview Health Services

• Facilities
• 7 hospitals
• 31 primary care clinics
• 50 specialty clinics
• 4 urgent care centers
• 25 Institute for Athletic Medicine locations
• 19 senior housing facilities
• 6 long-term care facilities
• 25 retail pharmacies
• 6 home medical equipment locations
• 4 home care and hospice agencies

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Fairview Health Services

• Employees
• 19,052
• Outpatient Visits
• 2,613,000
• Inpatient Admissions
• 80,523
• Employed Physicians
• 256
• Affiliated Physicians
• 4000

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Imaging Installed Base ( of Units)

• General X-ray 43 (75K)
• Ultrasound 37 (150K)
• Computed Radiography 27 (75K)
• Portable X-ray 25 (30K)
• Mobile C-arm 25 (125K)
• Mammography 20 (85K)
• Fluoroscopy 14 (350K)
• Computed Tomography (CT) 14 (1M)
• Nuclear Medicine 13 (400K)
• Magnetic Resonance Imaging (MRI) 9 (1.5M)
• Bone Density 9 (30K)
• Interventional Radiology 8 (1.5M)

244 Units, 66.25M
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Current Scope of Services
45,421
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Current Scope of Services
9140
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Current Equipment Status
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Premier Recommendations 06-07
Over 3M!
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Breast Imaging Strategy
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Guiding Principles

• Decisions will be based on what is best
  for patients
• Interpretations are provided by dedicated,
  sub-specialist radiologists
• Exams are performed by dedicated mammography
  technologists
• Screening exams are performed at times and
  locations that provide maximum patient
  convenience
• Diagnostic (i.e. call back) exams are offered
  within 24 hours
• 95 of pathology reports are available within 24
  hours, with a communication plan with the patient
  if results are delayed
• Preliminary diagnostic reports are available
  before the patient leaves the facility
• We will implement an organizational/business
  model in which there will be no competition
  between FV sites or between FV and the physician
  groups. This will result in coordinated
  technology acquisition and service expansion
  decisions and joint radiologist/administrative
  decision making

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Thresholds of Quality - Technical

• Technologists must have passed mammography
  registry- RT(M)
• Technologists must perform at least 1000
  mammograms/year
• Full Field Digital with Computer Aided Detection
  at every screening facility (or Computed
  Radiography if FDA approved)

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Thresholds of Quality - Professional

• ACR and MQSA lead radiologist/site director will
  spend clinical time exclusively in breast
  imaging, which will be greater than half time
• Must meet ACR credentialing criteria
• Screening readers will interpret at least 5000
  mammograms per year

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Going Digital

• Most of our clinics perform general X-ray and
  mammography in low volumes
• How to justify the significant investment in
  digital technology when there is clearly no
  financial return
• Please email answers to..

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Thresholds of Quality - Professional

• Lead radiologist will monitor performance audit
  on all interpreting radiologists as reported in
  current edition of BI-RADS and make
  recommendations for CME or even termination of
  interpreting privileges based on
• Recall rate lt10
• Cancer detection rate between 2 -10/1000
• Specificity gt90
• Sensitivity gt85
• Positive biopsy rate (PPV2) 25-40
• PPV1 5-10
• Tumors found stage 0 or 1 gt50
• Tumors found minimal cancer gt30
• Node positivity , 25
• Prevalent cancers found per 1000 6-10
• Incident cancers found per 1000 2-4

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Metro Clinic A

• Performs 1400 screening mammograms per year
• Net revenue 82.77 X 1400 115,878
• Performs 3800 X-rays per year
• Net Revenue 37 X 3800 140,600
• Full field digital mammography unit 450,000
• Direct digital x-ray unit 400,000

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Tomorrows Opportunities

• New Technologies
• CRM
• Environment configurations
• FFDM vs. CRM
• Reductions in equipment costs
• Financial Analysis
• Operationalizing costs
• No capital dollars

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Other Considerations

• Computer Aided Diagnosis (CAD)
• Workflow with PACS and previous analog studies
• Mini-PACS
• Separate Workstations?
• What is the future of breast imaging technology
• Tomosynthesis
• CT
• MRI
• CRM

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Our Conclusions

• Digital Technology supports overall strategy to
  improve quality and increase market share
• Finances only work in higher volume settings
• May become a cost of doing business, like PACS
• Technology is ever changing and any purchase may
  need to be considered over a shorter timeframe
  than typical for mammography
• A little scary.

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• Sally Grady, Director of Imaging Services
• Florida Hospital Celebration Health
• Celebration, Florida
• sally.grady_at_flhosp.org 407.303.4289
• Mark Domalewski, MS, MBA, Corporate Director
  Imaging
• Fairview Health Services
• Edina, MN
• mdomale_at_fairview.org 952.836.3536
• Vicki Petersen, , MS, FAHRA, Director PACS
  Services
• Premier Inc. Supply Chain Performance
  Improvement
• vicki_petersen_at_premierinc.com 407.256.1440