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Cross-Enterprise Screening Mammography Workflow in the OBSP. Elizabeth Stark, Leafsprout Technologies Inc. April 22, 2012. Ontario Breast Screening Program (OBSP). Province of Ontario, Canada 155 screening facilities within program, overseen by 8 regional centres

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Cross enterprise screening mammography workflow in the obsp

Cross-Enterprise Screening Mammography Workflowin the OBSP

Elizabeth Stark, Leafsprout Technologies Inc.

April 22, 2012

Ontario breast screening program obsp
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



Physical breast examination and mammography

No longer eligible for OBSP

After 1 or 2 years


Single read


Woman phones screening centre and books appointment


Increased awareness of OBSP and of screening benefits

Results sent to GP



After 1 or 2 years


Reminder letter




Obsp general features
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


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.)


  • 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

Recruitment gps
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


  • Woman phones OBSP screening facility and arranges an appointment – or – woman’s GP arranges on her behalf


  • 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

  • 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


  • 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)

  • 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


    • 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


    • 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


  • Report -> paper (or electronic) -> transcribed to proprietary format for OBSP db

  • Action on recommendations
    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