Cross-Enterprise Screening Mammography Workflow in the OBSP

1. Cross-Enterprise Screening Mammography Workflowin the OBSP Elizabeth Stark, Leafsprout Technologies Inc. April 22, 2012

2. Ontario Breast Screening Program (OBSP) • Province of Ontario, Canada • 155 screening facilities within program, overseen by 8 regional centres • 475,506 women screened in 2010 → 3068 women per unit • Hospitals, clinics, mobile vans • Applicable guidelines: • National guidelines: Quality Determinants of Organized Breast Cancer Screening Programs, Health Canada (2003). • Provincial guidelines: Ontario Health Technology Advisory Committee guidelines on screening mammography • CAR (Canadian Association of Radiologists) guidelines Early notions regarding screening: “There is a passion for hunting something deeply implanted in the human breast” – Charles Dickens

3. Workflow EXAM Physical breast examination and mammography No longer eligible for OBSP After 1 or 2 years REPORTING & EVALUATION Single read APPOINTMENT Woman phones screening centre and books appointment INITIAL RECRUITMENT Increased awareness of OBSP and of screening benefits Results sent to GP [+] [-] After 1 or 2 years RECRUITMENT Reminder letter ASSESSMENT [-] [+]

4. OBSP: General features • Growth model: most are pre-existing sites who apply to join program • Within OBSP, each site has control over the mechanisms in use within facility (workflow, worklist management, data storage mechanisms) – subject to some general requirements • Terminal to central OBSP database – data entered in proprietary format • Tight Quality Control • Extensive record keeping, analysis of results and performance

5. Recruitment Eligible women: • 50 – 74(+) • Mammography and physical breast exam • Every 2 yrs. • If ≥ 75% mammographic density, annually • 30 – 69, high-risk women (hereditary risk) • MRI, mammography and physical breast exam • Screened annually “Formidable is the enemy that lies hid in a [wo]man’s own breast” – PubliliusSyrus (Roman author 1st century B.C.)

6. Recruitment • Recruitment and scheduling are two separate processes in Ontario • Privacy issues • Scheduling initiated by woman, not by OBSP • Recruitment focuses on increasing awareness • GPs play a large role in raising awareness -> OBSP devotes significant effort to recruiting GPs • Also: brochures, posters, PSAs, efforts to reach target audiences (neighbourhoods, ethnic groups, etc.) by various means (e.g., hairdressers!) • Reminder letter – one month before next appointment

7. Recruitment – GPs • Relationship with GPs managed by Regional Centre • GP refers women in his/her practice to OBSP for breast screening • Targeted mailout – GPs can send letters to women 50+ within their practices, inviting them to participate in OBSP (OBSP can assume costs and even workload associated with this) • GP can specify preferences: • referrals for assessments to go to specific facilities; • GP to handle referrals for assessments if desired. Trusted GPs can provide reassurance to women anxious about the screening process: “Your legs and breast bristle with shaggy hair but your mind, Pannicus, shows no signs of manliness” – Marcus Aurelius

8. Scheduling • Woman phones OBSP screening facility and arranges an appointment – or – woman’s GP arranges on her behalf Dataflow: • OBSP Site controls its own scheduling • Site has its own RIS or RIS/PACS, manages scheduling according to its own practices • Priors located and requested, if necessary • After appointment scheduled, pertinent info passed to OBSP central database (via terminal) in proprietary format • Date, time, place for appointment • Basic demographic info (name, address, phone number, etc.) • Any requests for priors from other sites • OBSP central database finds existing OBSP Client #, or creates new one

9. Admission • Client presents herself at OBSP Site • Demographics collected / verified • Consents signed: • screening results to be propagated to GP; • OBSP to book any further assessments required; • info for any further assessments to be propagated back to OBSP; • consent to be contacted regarding participation in studies as applicable. • Clinical history (during Admission or Exam) – for clinical interpretation, future studies Dataflow: • Accession # assigned in RIS • Pertinent info transcribed and transmitted to OBSP central db: • Demographics • Consents (yes/no) • Clinical history • Worklist and original paperwork / electronic storage managed by Site according to its processes (subject to some basic requirements)

10. Exam • Physical breast examination – Nurse Examiner • Mammographic exam – 2-view exam for each breast (4 views total) – ideally, priors are available for reference during this step (but not required till Reporting) • High-risk: MR exam – separate visit • Recalls / retakes: tightly controlled, reasons documented and statistics kept; images kept and read if any diagnostic value Dataflow: • Nurse Examiner’s findings -> paper -> transcribed for OBSP db • Mammographic Tech’s notes (including technical parameters of image acquisition: mAs, kVp, thickness, anode, filtration, etc.) -> paper -> OBSP db • All images stored in local PACS – according to local processes • Exam added to reading worklist (managed by Site according to their own processes) • Recall / retake statistics -> Regional Office each month for analysis The ancients were right about compression: “But curb thou the high spirit in thy breast, for gentle ways are best” – Homer

11. Reporting • Single reading, CAD optional, priors required (if they exist) • Radiologist usually onsite, but not always: mobile van, teleradiology • Radiologist takes into account • Nurse examiner’s findings • Mammo tech’s notes • Images • Clinical history … and makes a recommendation (further assessment / return in 2 yrs / return annually / etc.) • Radiologist requirements (CAR-MAP, Health Canada guidelines for breast screening programs) • ≥ 3000 mammograms / yr • Continuing medical education • Quarterly participation in rounds • Responsible for maintaining outcome data (positive predictive value) – OBSP does much of this Dataflow: • Report -> paper (or electronic) -> transcribed to proprietary format for OBSP db

12. Action on Recommendations • Client’s GP notified of screening result immediately (max. 2 wks) – by letter • Client notified by letter 2 wks later • Or – if no GP specified – Client notified directly, immediately • Referral for assessment: • Can be handled by OBSP (OBSP-affiliated Assessment Centres) • Can be handled by GP (external assessment centres) • Results of assessment -> OBSP Central Office -> OBSP db (consent rate > 98%) • Outcome statistics provide feedback on performance of OBSP

13. Thank you!