1. How to purchase interoperable Mammo Equipment
Introduction & disclosure of affiliation
Carolyn Reynolds
Connectivity Manager
Hologic, Inc.
IHE Mammography Committee
Stanford Conference on Breast Imaging
April 27, 2006

2. How to purchase interoperable Mammo Equipment vs
How to purchase interoperable Mammo Equipment vs. What to include in the RFP
My original title was “What to include in the RFP”, but for a technical geek like me who’s the one who gets to answer your RFP’s, … slides later, and I’m still not sure that I would have covered the topic to my satisfaction.
So you’re lucky that they only gave me 10 minutes, so I’m just going to hit the high points to give you some food for thought and references that you can turn to, to learn more.

3. Be careful of what you ask for…… …….you just may get it
-Author Unknown
A twist on an ancient proverb..

4. …….because it may not work
Be careful what you
DON’T ask for……
…….because it may not work
And my own twist on the statement

5. A True Story Asked if PACS could store mammography images PACS
modality
Mammo
Workstation

6. A True Story Asked if PACS could store mammography images
Did NOT ask if they could be retrieved
PACS
modality
Mammo
Workstation

7. A True Story Cont’d PACS did not offer
A diagnostic mammo workstation
Ability to print original quality mammo images
Facility ended up investing in a separate storage solution for mammography with more efficient workflow
Workflow inefficiencies were intolerable with existing PACS for accessing prior images, so facility ended up investing in a separate storage solution for mammography with more efficient workflow
PACS
modality
Mammo
Workstation

8. Education – RFPs for Digital Mammography
So, how do you know what to ask for?
For a start, ask for the:
IHE Mammography Image Integration Profile
However……

9. Things to keep in mind Profile was just published this week
1st real world test at Connectathon Jan 2007
Vendor adoption takes time
Product development takes time
Not all equipment is replaced at the same time
But it’s not all doom and gloom……

10. The Good News Many IHE Mammo features are available, today
Other applicable IHE profiles may be of interest
Have been around for a while
Are widely adopted
Increase success in various clinical challenges
e.g. scheduling exams, storing data to CD’s
Education and knowledge are key
Many IHE mammo features are available in products, today
There are other applicable IHE profiles that increase your chance of interoperability which have been around for a while and are widely adopted.
Speaking of education……….

11. IHE Mammography Image Integration Profile
Coming RSNA 2006!
Digital Mammography User Handbook
Goal:
Provide education on deploying IHE to solve mammography interoperability challenges
!! Section on RFP’s !!
Framework
IHE Users
Handbook
Digital
Mammography
My talk is a big infomercial for the Digital Mammography User Handbook. If there’s nothing else that you take away from this talk, I want to know that this reference exists and it will help you reduce surprises and irritations if you consider this info during your purchasing decisions.
Its goal is to provide education on deploying IHE to solve mammography interoperability challenges
And…there’s a section on writing RFP’s. With the goal to put topics that you care about in terms that you understand, while translating your interests into unambiguous product requirements that will lead to interoperability.
What I’m about to go through next is just an example of some of the things you might find in that section. I’ll describe the clinical problem and show you the what some of the language might look like in an RFP, which has been simplified a bit for this presentation. I don’t expect you to absorb any of it now, but it’ here for reference (and the conference organizers will have a copy of my slides) to make available to you.

12. Mammography Deployment Handbook – RFP Section
Example RFP language for
General product information
FFDM Modalities
Diagnostic Workstations
PACS, Archives
Printers
CAD Systems
Film Digitizers
Other IHE Profiles of interest
These are the topics that the handbook will cover, and now I’ll just go through a subset.

13. General RFP Recommendations
Ask vendor(s) for commitment to the IHE Mammography Image Integration Profile (MAMMO).
Ask about:
Upgrade to existing product or new product
Anticipated availability
Budgetary pricing or other possible charges

14. General RFP Recommendations
For each of the components that you will be purchasing….
Request a DICOM Conformance Statement
Request an IHE Integration Statement
A DICOM Conformance Statement is going to provide your technical people the details of what protocols are available for sharing data with other devices, but a
A DICOM conf statement is not enough…to know if you have interoperability.
An IHE Integration Statement is going to explain which IHE clinical problem solutions this product addresses and give you a better chance of interoperability as defined by those solutions.

15. Example IHE Integration Statement IHE Integration Statement
Vendor
Product
Version
Date
Integrated Medical System
Awesome FFDM
1.2.3
1 July 2006
This product implements all transactions required in the IHE Technical Framework to support the IHE Integration Profiles, Actors and Options listed below:
Integration Profiles Implemented
Actors Implemented
Options Implemented
Mammography Image Integration
Acquisition Modality
Partial View
Scheduled Workflow
Assisted Acquisition Protocol Setting
PPS Exception Management Option
Broad Worklist Query
Patient Based Worklist Query
Patient Information Reconciliation
None
Portable Data for Imaging
Media Creator
Links to Standards Conformance Statements for the Implementation
HL7
Not applicable
DICOM
Links for general information on IHE
In North America:
In Europe:
In Japan:
Example
IHE Integration
Statement
Example of what an IHE integration statement looks like. Again, the mammography user handbook will help translate what this all means. Basically, it explains the “package” of defined clinical solutions that can be addressed by a specific product.
The Handbook is what is going to translate what this all means in your language

16. Acquisition Modality- Presentation Requirements
Does your modality:
Differentiate spot and magnified views from regular views (i.e. CC View)?
Yes___
No___
Detect the skin line and differentiate breast tissue from non-breast tissue in the image?
Contain any private or proprietary methods of image display not communicated through the standard DICOM img path?
In General
Does your system encode data in a way that will be compatible with my downstream devices?

17. Workstations Data Requirements
Does your workstation:
In General:
Can the workstation handle the necessary data for mammography images and CAD results?
Does it know how to tie the two together?
Support and display DICOM Digital Mammography X-Ray objects with an intent type of FOR PRESENTATION?
Yes___
No___
Support and display Mammography CAD Structured Reports?
Use the Referenced Source Image Sequence attributed to tie “for presentation” images to CAD results performed on “for processing” images?

18. Workstations Hanging Protocols
Can your product handle mammography hanging protocols correctly?
VS.

19. Workstations Hanging Protocols
There is not “one size fits all” protocol for mammography
As part of your RFP, clarify your own preferred layouts and desired sequence of layouts
Make sure HP’s are determined by factors on next slide, not the traditional study and series description attributes.
Hanging protocol functionality that has been designed for other modalities in mind may be inappropriate for mammography reading – examples: site example here such as ordering of images, orientation, etc.

20. Workstations Hanging Protocols
Can your hanging protocols simultaneously display current & prior 4 view screening mammographic images?
Yes___
No___
Do your hanging protocols use the following attributes to determine placement and orientation of mammography images?
View Code Sequence
Laterality
Patient Orientation
View Code Sequence Modifier
Do your hanging protocols require specific values in study description or series description attributes?
Sample language for RFP
All these factors are enough to get orientation and placement correct.

21. Workstations Size Presentation
Can your workstation:
Does your product handle sizing correctly?
VS.
Display a patient’s images the same relative size, based upon the imager pixel spacing attribute, even if images were captured on detectors of different size and resolution?
Yes___
No___
Display images in the actual physical size as on the detector by using the imager pixel spacing attribute and the physical size of the monitor in calculations? (“true size” mode)
Display image pixels such that one pixel on the monitor’s resolution equates to one pixel of the detector resolution? (1:1 pixel mode)

22. Workstations Display & Contrast Adjustment
Can the workstation be calibrated according to the DICOM Grayscale Display Function which site control over maximum and minimum luminance?
Yes___
No___
When adjusting contrast and inverting image pixels, can the workstation keep the air gap black.
Use imager pixel padding value multiplied by radiographic magnification for the basis of measurement tools?
Does the workstation provide a method to render and apply all available window/center, VOI LUTs, or VOI LUT Function attributes?
Will you get the grayscale right?
Can you keep the air gap (non breast tissue) area black during contrast adjustments and inversions?
Will my measurements be correct?

23. PACS / Archive Data Requirements
Does your archive:
Support storing and returning in tact all attributes for DICOM Digital Mammography-for presentation image objects?
Yes___
No___
Support storing and returning in tact all attributes DICOM Digital Mammography for processing image objects?
Support storing and returning in tact all DICOM Mammography CAD Structured Reports?
Knowingly add, change, or delete any DICOM attributes related to the above objects? If so, explain______________________________
Can I store all the data necessary to support digital mammography on my PACS?
Can I get back out all the data that I stored, or has it been modified in some way?
Is it possible that a PACS data modification could break the functionality of other components?

24. Print Application Modality, Workstation, or PACS
Can your product print film with:
The proper maximum density?
The proper physical size?
Annotations per MQSA requirements?
Minimum to no border at chestwall?
When printing:
Does your product use the Imager Pixel Spacing attribute to send the Requested Image Size attribute to the printer (a.k.a. true size printing)?
Yes___
No___
Does your product justify the chestwall to the edge of the image before printing?
Can your product send the maximum density attribute to the printer for mammography images, recognizing that it is likely different than that used for other modalities?

25. Printers Can your printer: Print images “true size”?
Print at a maximum density appropriate for mammography?
Print with minimal borders at the chestwall?
Can your printer:
Print true size based on the Requested Image Size (2020,0030) within a precision of a maximum 2% error in linear distance?
Yes___
No___
Justify and print mammography images such that film borders are less than 5mm at the chestwall (edge of the image)?
Apply the requested Maximum Density attribute, printing with a maximum optical density no less than 3.5?

26. CAD System
Can your CAD system:
Provide results using the Mammography CAD Structured Report DICOM object?
Yes___
No___
Send results to both PACS and workstations automatically?
Use DICOM Storage Commitment transaction for reports sent to any destination?
How can I have confidence in the sending and receipt of CAD results?

27. Summary Educate yourself on what to ask for
Ask vendors about their commitment to IHE Mammo
Get a copy of the existing IHE Users Handbook
Get a copy of the IHE Mammography User handbook – RSNA 2006
Have technical resources read the IHE Mammo Technical Framework
Educate yourself on what to ask for – better yet, make sure that you tell your PACS techie your requirements & get him or her to educate themselves on IHE specifics
Ask vendors about their commitment to IHE Mammo – be specific about IHE MAMMO – there are many flavors of IHE and you want to make sure you’re talking about the same details

28. More information…. IHE Web site: http://www.ihe.net
Technical Frameworks
Users Handbooks
IHE Fact Sheet and FAQ
IHE Integration Profiles: Guidelines for Buyers
IHE Connect-a-thon Results
Presentations
Vendor Products Integration Statements