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Diagnostic Imaging Radiation CDS

Joseph Adams

Background
In 1980, the average American had a medical radiation dose of 0.54 mSv. By 2006, that amount increased 600 percent, to 3.2 mSv per capita. The worldwide average background radiation dose is estimated at 2.4 mSv per year (RSNA, 2008).

Background cont.
The amount of imaging orders, in particular CT, has grown exponentially
Easily performed Provide quick diagnostic interpretation Provide reassurance of nothing overlooked

Too often, advanced imaging exams are ordered even when they are not appropriate for patient symptoms

Background cont.
In addition to incurring unnecessary exams, increased healthcare costs, and resource burdening, patients are exposed to increasing amounts of radiation. While advanced imaging provides tremendous benefits as diagnostic tools, careful consideration of exam appropriateness is important. The benefits usually outweigh the risks. However, as patients undergo numerous exams, the balance shifts and cumulative risks manifest.

Objective
Maintain patient doses As Low As Reasonably Achievable (ALARA) through the use of Computerized Decision Support.
Avoid unnecessary or repetitive studies Compare benefits vs risk of exams that utilize ionizing radiation (CT) and alternatives (MRI, Ultrasound, etc.) Tailor exam based upon individual patient

Current State
As of 2007, no standard exists for acquiring, evaluating, and archiving radiation dose information. No federal requirements exist in the US for monitoring or reporting lifetime cumulative radiation dose for patients.
(Colang, Killion, & Vano, 2007) (Colang, Killion, & Vano, 2007)

Installed base of CT equipment has limited capabilities with respect to capturing dose information, but newer releases are starting to supply the proper SR dose report. There are a few radiology-specific CDS which address exam appropriateness criteria such as Nuances RadPort
(Clunie, 2009)

DICOM SR Dose Objects


Integral to maintaining ALARA, DICOM SR Dose Objects:
view the dose a patient (or particular organs) received for a certain exam, hospital stay or course of treatment view a patients cumulative dose history determine if a given patient dose exceeds maximum guidelines or is otherwise an "outlier" requiring investigation compute the population "dose profile" for a certain hospital or region compute the population "dose profile" for a certain pathology compare "dose profiles" against other sites/regions, against local policy targets or against standards of practice
http://wiki.ihe.net/index.php?title=Radiation_Dose_Profile_-_Detailed_Proposal

IHE REM Profile

Source: http://wiki.ihe.net/index.php?title=Radiation_Exposure_Monitoring

ACR DIR
American College of Radiology Dose Index Registry (DIR)
Collect and provide feedback on dose estimate information from various modalities. A pilot program focusing on CT that allows participants to compare average CTDIvol and DLP values across facilities is currently in progress.
CTDIvol represents the radiation dose of a single CT slice DLP is measure of total radiation exposure for the whole series of images DLP = CTDIvol x irradiated length

ACR Appropriateness Criteria

Source: http://www.nuance.com/healthcare/pdf/ds_healthcare_radport.pdf

Key Systems
Ordering
EHR CPOE Central Scheduling

Clinical Records and Patient Management


EHR Radiation Dose Repository Regional HER PHR RIS PACS Dictation Oncology Management System

Departmental Data Management

Clinical Content
Imaging modalities Therapeutic Devices

System Integration

Ordering

Ordering

Tailor by individual patient

Source: http://www.aapm.org/meetings/2010CTS/documents/0830_Brink_AAPM_CT_Dose_Summit_4_29-2010.pdf

Tailor by individual patient


RLQ Pain in Pregnancy (w/ Fever, WBCs)

US and MR are more appropriate than CT for RLQ pain in pregnant woman
Source: http://www.aapm.org/meetings/2010CTS/documents/0830_Brink_AAPM_CT_Dose_Summit_4_29-2010.pdf

Protocol

Modality Worklist

Image Acquisition

Interpretation

Documentation

Conclusion
Limitations Further Considerations