Understanding Mammography Reports And Breast Cancer Screening

Diana is the Director of Health Information Management at XYZ Community Hospital. It is a 250 bed general acute care facility with 15 outpatient clinics. The HIM Transcription Department is responsible for transcribing notes from the hospital, Emergency Department, clinics, and Radiology Department.

The organization is planning for implementation of an enterprise-wide electronic health record system within the next two years. Active discussions are underway about converting the Radiology Department to a new system prior to the rest of the conversion due to their outdated and highly manual processes for processing patients and reports.

The Radiology Department uses a digital dictation system into which radiologists dictate interpretations of films. HIM transcriptionists are assigned to do Radiology transcription on a daily basis. There is a consistent issue of service level agreement that is not presently being met. The departments are separated by two floors in the building. The transcription clerk is responsible for picking up packets (which include the report form) from Radiology frequently throughout the day, leaving them on a shelf in Transcription where the staff pick up the packets and transcribe the report, returning the packet to a done section when the report is completed. The clerk returns reports to the Radiology Department when next they pick up new packets ready for transcription.

Recent complaints from patients and physicians about delays in turning around mammography reports have escalated to the point where Diana and the manager in the Radiology Department (Donna) believe they have to make improvements in the workflow immediately as an interim measure until the EHR can be implemented. Their goal is to achieve the service level agreement for mammograms of 36 hours from the time the patient has the films taken, which has been endorsed by the Medical Staff.

Application Assignment:
Map the current process illustrated in the Case Study using each of the process mapping tools below.
Flowchart
Top Down Process Map
Swimlane Diagram
You will submit three different diagrams illustrating the same process as outlined in the Case Study. You may use Microsoft Word, Power Point, or Visio or another approved tool to map the process. The intent of this assignment is not to know a particular software, rather to know how to map a process using various tools.

What is Mammography?

Mammography reports are instrumental tools in the diagnostic process of breast cancer. The radiologist has the task of analyzing mammographic findings for chances of malignancy and for provision of guidance to clinicians for the necessary course of management. For better comprehension, the reports need to be clear, standard and concise. Screening studies determine whether the examination is normal or where there might be need for further evaluation (Schapira et al, 2018).  

Mammography is basically medical imaging which utilizes the x-ray system to view the inside of breasts. The mammogram enables early detection and the diagnosis of breast conditions in women. The x-ray helps medical personnel diagnose and treat conditions. Small part of the body is exposed to an insignificant dose of ionizing radiation that produces the pictures of body’s inside.

Digital mammography (full field digital mammography) is a system where the x-ray film has been replaced with electronics meant to convert the x-ray into mammographic details of the breast. The breast images are moved to a computer where they are assessed by a radiologist and stored. Computer-aided detection (CAD) systems are built to search mammographic images that are digitized, checking for abnormality in density, mass or calcification which are indications of cancer. This system brings to attention the specific areas observed and the radiologist evaluates the areas (Schapira et al, 2018).

Based on the screening study, the findings can be confirmed and determined whether they are consistent with breast cancer. There are assessment categories that are used to establish the steps forward. The mammographic findings should help put together conclusions and recommendations. The reports are written using guidelines based on Breast Imaging Reporting and Data Systems (BI-RAIDS). This system was developed by American College of Radiology and standardizes the mammography reporting for clarity and decisiveness (Schapira et al, 2018).  

BI-RADS is a system of reporting and assessments which radiologists use to describe the findings in breast imaging reports. The system enables organization of analyses and interprets the findings. The levels range from 0 to 6 and the assessments help in determination of the following steps (Shikhman & Keppke, 2017).

Incomplete Assessment (BI-RADS 0): there is need for additional imaging evaluation and/or comparison to prior mammograms. This indicates that the potential abnormality is not clearly seen or defined ad more tests are required. These tests could involve use of spot compression, magnified views, ultrasound or special mammogram views. There is the point of comparison with older mammograms to observe any changes that may have occurred.

What is Digital Mammography?

Complete Assessment (BI-RADS 1): Negative. This essentially means that there is no substantial abnormality to report. The breasts appear the same with no indication of masses, lumps, structures or calcifications. Negative means there is a positive outcome (Schapira et al, 2018).  

BI-RADS 2: Benign finding. This means the findings are non-cancerous but the descriptions by the radiologist follow the order of benign calcifications, calcified fibroadenomas, lymph nodes in breasts, implants or fat containing lesions. These may be related to previous surgery and the findings are stored for future comparisons.

BI-RADS 3: Probably benign finding. This entails a follow up after short duration. There is a follow up with repeat imaging done after 6 months and more regular follow ups till stability in the findings is achieved. The findings in this level indicate a very high probability of being benign (98%). The findings do not change over the course of time.

BI-RADS 4: Suspicious abnormality. In this case biopsy is considered. The findings are not definitively cancer but they could be it. There is wide range of suspicion in this category. It can be further divided into findings of low suspiciousness to be cancer. Intermediate suspicion of malignancy and moderate suspicion (Shikhman & Keppke, 2017).

B-RADS 5: Highly suggestive of malignancy. This requires that necessary action take place. Findings are cancer-like with 95% chance of being cancer. Biopsy is highly recommended. High density masses and calcification may be observed.

BI-RADS 6: Known biopsy-proven malignancy. The findings are applicable on a mammogram with previous determination of cancer by prior biopsy. This I used to assess the response of cancer to treatment (Shikhman & Keppke, 2017).

Mammography consists of pertinent information which appears at the top. This displays the details of the patient and reason for the mammogram. The clinical history of the patient follows. This includes history of breast conditions and any medication the patient is using. The procedure entails explanation of types of mammograms taken and the various views for screening. Other sections are notations done on the previous studies, description of breast composition and the descriptions of findings and modifiers (Schapira et al, 2018).

Process in general are tools that give the workflow processes visual perspective. This shows all the steps in the process and the existing relationships between them. The tools help in gauging the relationship between inputs and outputs in a system. Process maps are used in starting initiatives as a way of understanding the process (Fossland & Krogstie, 2016).

Assessment Categories in Mammography Reports

Flowcharts are visual representation of the various steps or sequences and the decisions involved in a particular process. This is a very vital tool in business and institutions. The steps in the process are indicated by use of diagram shapes. The steps are usually linked with interconnecting lines and arrows that display the direction of flow. This presentation enables the logical viewing and following of the process from its point of initiation to the very end. Much efficiency is attained with proper design and construction of the flowchart (Fossland & Krogstie, 2016).

There are different symbols or shapes used in flowcharts. The varying shapes present different meanings in their application. There are symbols for start and end points, indications of process or decisions that are made, input or output connector, preparation, storage or documentation. It is imperative that the meanings of the symbols be well understood in order to appropriately perceive the process.

Flowcharts can be used in a range of disciplines. They are used in technology, business, engineering, science, government, medicine, education and manufacturing. Flowcharts are utilized in designing programs or systems, documentation of processes, workflow documentation, project planning and auditing of processes. They are also used in mapping algorithms, management of data and in various engineering processes (Fossland & Krogstie, 2016).

This is a tool that is used in mapping the high levels and then progressing to the deeper levels in the process. The initial step is listing the first process at the highest level. The high level step is input at the top of the process map. The processes that fall under the high level step are listed below so as to gain insight in the details involved in each high level step. The processes for all the high-level steps are subsequently listed in the top down approach (Boutros & Cardella, 2016).

Top down process maps are constructed suing squares in place of the modules or activities in an organization. Lines connect the activities representing ownership between activities and successive sub activities as is the case in the process flow of an organization.

This top down process map is important when starting projects. Ii is used many situations when investigating process triggers. It also shows what the establishment provides to customers, both internally and externally while fully comprehending the context (Boutros & Cardella, 2016).  

Important factors to observe possible confusion between inputs and outputs or customers and suppliers when these aspects are available in the process flow. There are critical connections that can be made with the rest of the organization. An important aspect is how well the requirements for each category, in put or output is understood. Disagreement may arise in some cases about how the area fits in the entity.

Swimlane diagrams can also be referred to as cross-functional diagrams. This diagram shows the steps in a workflow or process flow. The activities involved in the process flow are grouped into ‘swimlanes.’ The swimlanes are vertical or horizontal representation of activities that fit within the category that they are illustrated under. The lanes may be based on actors in charge of performing certain roles, the stage of the process where the activity occurs or the areas that require emphasis in communication through the diagram. Swimlane diagrams communicate more information on who performs certain actions or when they take place (Boutros & Cardella, 2016).

Institutions or entities have internal and external requirements in the documentation process. The diagrams are important in precisely enabling this. They are crucial for reporting of standards or compliance among other functions. Some reasons for using swimlane diagrams can be the documentation of enterprise resource planning implementation. The documenting process is part of the implementation planning. This is a way of maintaining standards and certification which are important factors that customers, especially patients consider. This tool is utilized in ensuring compliance with the regulation that have been established. It is also a means of a means of preparing for eventual transfer of leadership or ownership.

Some internal reasons for using process flow documentation is to ensure quality work majorly due to consistency and provision of visibility. This helps in observation of the process of job performance by the management. The workflow diagrams help in initiating process improvement in organizations. Additionally, the tool provides flexibility to all employees who are able to learn how to perform different jobs (Boutros & Cardella, 2016).

References

Schapira, M. M., Barlow, W. E., Conant, E. F., Sprague, B. L., Tosteson, A. N., Haas, J. S., ... &

Herschorn, S. D. (2018). Communication Practices of Mammography Facilities and Timely Follow-up of a Screening Mammogram with a BI-RADS 0 Assessment. Academic radiology.

Fossland, S., & Krogstie, J. (2016). Enterprise Process Modeling in Practice–Experiences from a

Case Study in the Healthcare Sector. In Enterprise, Business-Process and Information Systems Modeling (pp. 365-380). Springer, Cham.

Boutros, T., & Cardella, J. (2016). The basics of process improvement. CRC Press.

Shikhman, R., & Keppke, A. L. (2017). Breast, Imaging, Reporting and Data System (BI RADS).