Now that we are finally discussing electronic health records (EHR) and personal health records (PHR) and patient safety, we shouldn’t ignore the cumulative exposure to ionizing radiation from diagnostic and treatment modalities such as X-ray, CT, Gammaknife, etc.
It has been known for a long time that tissue damage from X-rays is cumulative and will increase cancer risk, though hard and fast numbers are difficult to determine for each individual. Instead guidelines have been established to safeguard both health workers, patients and the unborn. Workers are in a better position because they carry radiation badges which must checked und occupational health requirements. Most patients rely on the primary health provider but this is at best hit and miss. In the preponderance of cases no tracking done because there is no quantitative data generated or stored other than general information indicating an order for X-rays or a report.
We are know at a place where not only can the new systems deliver good estimates of radiation delivered to the tissue, we soon can share the data with other environment based on the upcoming health information exchange (HIE) protocols.
The only issue remains is how this data can be accrued and collated for a given person. Although the data need not physically reside in a single system, administratively it is easier.
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Hi GreenLeaves – you raise an important point.
ReplyDeleteAt lifeIMAGE we are building a service that will make it easier for patients to store, manage and share the exams in their medical imaging history, no matter where their exams are originally performed. In addition to storing the relevant image and report information the Inbox will estimate the radiation exposure level for each exam a patient undergoes, making that data much more accessible moving forward. I look forward to sharing more information in the coming months.
Jackie Walsh
www.twitter.com/lifeimageinc
www.lifeimage.com
This is a much more complex issue than you're probably considering. I am not the radiation expert here but do know that there are different types of dose and that they all have accumulating effects. In the area of penetrating dose, a CT scan of the abdomen and a CT scan of the brain are radiating two different parts of the anatomy, the two values do not add. There is also the question of how much of the dose is absorbed by tissue and how much passes through?
ReplyDeleteTo simply collect information regarding dose and adding those numbers to a table has little or no value in managing harmful levels of exposure to the patient. Also, to collect data sometimes and not always has limited value especially if that information were to be used in patient care. An office that does not participate in sharing exposure data could be performing X-Rays and years later another physician could be reviewing exposure data to weigh the risk/benefits of another procedure.
Then there’s the matter of where the data is going to reside. Will each country have its own national repository of radiation exposure? Will each state manage the data instead? When budgets get cut, will the program get cut? There are no planet wide repositories for this data and it’s not likely that all nations will ever cooperate at that level. That brings as to a point where we have to decide on the scale of the repositories. We can no longer assume that Healthcare is bound by nations, so there also has to be a means of sharing or exchanging data globally.
This is an important topic and an issue that really does need to be addressed but do not underestimate the scope of this endeavor. It is also important to recognize the limitations of the acquired data and not to place too much value on the numbers. IHE has done some good work on this topic and has also identified the technical and practical limitations of monitoring radiation dose.
Over time, the data management will improve as will the techniques for acquiring the data. If in the end we have rough approximations of radiation dose, we will be much better off.
Posted on behalf of Tibor Duliskovich who had difficulty posting
ReplyDeleteAllow me a comment here Mike, I did try to post on your blog page, but the comment field would not let me type, copy or paste anything in, you need to fix it.
US is well behind Europe in this respect. 15 years ago, working for an FDA-like government institution in Hungary, we were required to track population exposure to ionizing radiation, both man-made (medical exams, nuclear power plants, etc.) and natural (miners. pilots, radon) on individual and national level.
DICOM has several ways to address this issue. Modality Performed Procedure Step MPPS includes a mechanism to communicate data about radiation dose values to which the patient has been exposed if imaging involved ionizing radiation.
The X-Ray Radiation Dose SR IOD is used to convey the exposure characteristics and patient dose from X-Rays generated by modalities. The different DICOM tags can be find in PS3.2 - 2008 (08_02pu.doc here ftp://medical.nema.org/medical/dicom/2008/ ) and they cover everything from exposure parameters, to total time of fluoroscopy, to entrance dose, etc.
Radiation therapy doses are reported in the RT Dose DICOM IOD.
IHE has a proposal for Radiation Dose Profile here: http://wiki.ihe.net/index.php?title=Radiation_Dose_Profile_-_Detailed_Proposal .
If modality does not report the dose, which is frequently the case, the dose can be calculated assuming standard exposure geometry and generator settings. This data is readily available in public domain for decades.
All the technology to calculate or estimate the patient dose exists, it is simply not a priority for modality and PACS/EHR vendors. There is no enforcement as far as I know.
Hope this helps a bit,
Tibor
NEJM: Do benefits outweigh radiation risk in medical imaging?
ReplyDeleteIn a retrospective analysis of nearly 700,000 non-elderly Americans who underwent at least one medical imaging procedure over a three-year period, approximately 20 percent received a moderate to very high dose of radiation, according to data in the Aug. 27 New England Journal of Medicine. Michael S. Lauer, MD, who wrote the accompanying perspective, stated that most imaging tests haven’t yet proven their benefit compared with the potential risks and costs
Read more at: http://is.gd/2At61