SSPs take on larger role in digital mammography


Digital mammography represents the last frontier for diagnostic imaging departments and imaging centers that have implemented PACS. For some imaging centers, particularly those specializing in breast imaging, digital mammography provides the catalyst for converting to digital image management. Many facilities that do not have the preparation or the staff to accomplish this transition seek a ready-made solution.

Digital mammography represents the last frontier for diagnostic imaging departments and imaging centers that have implemented PACS. For some imaging centers, particularly those specializing in breast imaging, digital mammography provides the catalyst for converting to digital image management. Many facilities that do not have the preparation or the staff to accomplish this transition seek a ready-made solution.

Medical facilities with established PACS do not necessarily have the network infrastructure or storage capacity to support the influx of large data sets, whether generated by multislice CT or digital mammography systems. A typical digital mammography image is 30 MB, and a four-image screening study is 120 MB. A diagnostic exam may have as many as eight images, or 240 MB. The amount of storage doubles if unprocessed data are also retained. Even using 2:1 or 3:1 lossless compression, an exam can range from 10 to 160 MB in size.

A center's capital equipment budget for replacing or upgrading PACS storage may not be available at the time digital mammography equipment is purchased. It may not be possible for a period of time to incorporate digital mammograms within a facility's existing PACS. A temporary archive provides an interim solution by capturing the images in their original DICOM format and retaining them until they are ready to be migrated into an upgraded or replacement system.

Digital mammography has provided a new opportunity for storage service providers (SSPs). Two companies have created product offerings specifically targeted for this emergent market. Philadelphia-based i3Archive made its National Digital Medical Archive (NDMA) commercially available to healthcare facilities in January 2004. InSiteOne in Wallingford, CT, introduced its InDex Breast Imaging Archive in February 2005 as an extension of its general radiology service.


An SSP provides storage and retrieval of digital images on a fee-per-study basis. Services are available for onsite and offsite storage management and archiving, long-term offsite storage only, and disaster recovery. Offsite images are accessed rapidly using the Internet over a secure virtual private network (VPN). The primary advantages of using an SSP are elimination of capital equipment purchases and associated maintenance contracts, obsolescence protection, and outsourced management by IT staff. Depending on a healthcare facility's circumstances, the business case for using an SSP may match or be more cost-effective than internal storage management.

Imaging centers that have invested $400,000 to $500,000 in a digital mammography acquisition device and diagnostic workstation may not have the mindset or the funds to purchase a storage system. An ideal storage system must be scalable and able to accept images from multiple modalities, such as breast MRI, breast CT, and ultrasound, in addition to mammography.

Although scalable systems may be configured with a minimum module of storage capacity, this may still represent one to two years of an underutilized investment. According to Don Alvarez, director of Siemens Women's Health, an SSP contract is a more intelligent choice for a customer who can invest only in a scalable system that meets immediate needs but cannot be expanded.

"Imaging centers performing fewer than 7500 mammography procedures should be looking at an SSP solution, not making a huge capital investment in IT technology," said Mitchell Goldburgh, InSiteOne's senior vice president of marketing and sales.

SSPs charge a one-time storage fee for the life of an exam with a one-time site setup fee. The SSP supplies and maintains all software and hardware. The fee per exam is based on annual volume, services provided, and length of the contract commitment. The average cost per exam typically ranges from $2.50 to $7. Even assuming the highest fee for a very low volume imaging center, this represents only 70¢ per year over the minimum 10-year retention requirement of the Mammography Quality Standards Act. That 70¢ investment not only provides secure, redundant storage (as mandated by the Health Insurance Portability and Accountability Act), but probably will also include several technology obsolescence upgrades to keep pace with data storage innovations.

SSPs also function as a surrogate application service/PACS provider, said John Neugebauer, director of breast imaging at Vasant in Hamden, CT, a distributor for InSiteOne.

"Many breast imaging centers have been effectively isolated from PACS implementation because their primary modality has been outside the center of this digital imaging evolution," Neugebauer said. "The centers lack the IT staff to plan and manage PACS. They welcome the proven, sophisticated solutions offered by an SSP."

HerSpace: Breast Imaging Associates is a small, independent breast imaging and diagnostic services center with large-scale ambitions. Dr. Beth Deutch, the center's founder and sole radiologist, was among the first dozen radiologists in the U.S. to become credentialed in digital mammography, and she remains an enthusiastic proponent of the technology.

The center was launched in August 2002 to provide patient-oriented breast care in a facility equipped with state-of-technology modalities: digital mammography, high-resolution ultrasound, and information systems. It began offering breast MRI this year.

"When we did our equipment planning in 2001, disc storage was expensive. We decided to take a look at ASP offerings," said Larry Rubin, business manager of HerSpace. "To our surprise, InSiteOne, an established SSP vendor for PACS, offered a package for offsite storage that was cheaper than any purchase option available."

Added value included 100% hands-free HIPAA compliance, 24/7 technical support, and security and virus protection that his small center could not replicate, he said.

HerSpace generates its patient work list a day in advance, and, as a matter of protocol, transfers the entire patient file (which may contain multimodality images) over a T1 Internet VPN for review the next day.


Radiology Ltd. in Tucson recently replaced the PACS serving its nine locations. It maintains a separate archive for digital mammography. Five units are installed in two imaging centers at the opposite ends of the city, where a combined total of 125 to 160 mammograms are performed daily. Radiology Ltd. became i3Archive's first commercial customer in May 2004.

"It is far more efficient to outsource management of a dedicated archive for digital mammograms than to deal with the storage growth and network requirements of the data generated," said PACS administrator Ron Cornett. "We can add digital mammography units wherever we need them without needing to evaluate the impact on our PACS and its network."

Murray Hill Radiology & Mammography in New York City recently initiated an SSP contract with i3Archive's NDMA. Dr. Julie Mitnick, the center's founder, was among the first to offer digital mammography in Manhattan, having installed a system in 2000. The state-of-the-art facility relies primarily on digital imaging that includes digital mammography, stereotactic biopsy, breast ultrasound, and dedicated MR imaging of the breast.

The recent addition of the breast MRI system and the exhaustion of memory on an existing onsite storage system required the practice to reevaluate its digital imaging storage requirements, said Jill Vincente, imaging center consultant. With Manhattan real estate at a premium, the onerous space and cooling requirements for onsite data storage and the necessity for dedicated IT personnel made an SSP service an easy choice.

Both i3Archive and InSiteOne have implemented strong security measures for their clients.

"Security is one of the most important components of our solution," Goldburgh said.

NDMA security incorporates strong certificate-based authentication, and, like InSiteOne, includes data security measures between its archive and customer point of presence.

"Any customer concerns regarding images being stored in a central image repository are fully alleviated by educating them on the deliberate measures taken to ensure data integrity and image level security," said Derek Danois, president of i3Archive. "All images are 'tagged' with strong authentication certificates at their point of origin. Image management and transfer at all levels are highly regulated and monitored."

SSPs are very willing to provide prospective customers with detailed explanations of the security measures and redundancy of their products, as well as their compliance with HIPAA and MQSA regulations. Involvement of healthcare security managers is recommended so that all issues can be identified and resolved prior to implementation. This is also an appropriate time to discuss data migration options. Both i3Archive and InSiteOne retain information in the DICOM format received.

Ms. Keen is a PACS consultant and imaging technology analyst with i.t. Communications, headquartered in Palm Beach, FL. Her industry consulting includes engagements with Agfa Healthcare, Eastman Kodak Company, GE Healthcare, Imaging Dynamics Company, IDX, Merge-eFilm, Philips Medical Systems, Siemens Medical Systems, SmartPACS, Sorna Corporation, and Talk Technology.

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