Joint Commission Alert on Radiation Risk

In June 2009 I blogged about measuring cumulative radiation exposure and yesterday the Joint Commission issued Sentinel Event Alert No. 47 addressing radiation risks of diagnostic imaging.

This Alert focuses on diagnostic radiation and does not cover therapeutic radiation or fluoroscopy. The Centers for Medicare & Medicaid Services (CMS) will require the accreditation of facilities providing advanced imaging services (CT, magnetic resonance imaging (MRI), positron emission tomography (PET), nuclear medicine) in non-hospital, freestanding settings beginning January 1, 2012.

The recommended approach to eliminate avoidable radiation dosing is:

• Right Test
• Right Dose
• Effective Processes
• Safe Technology
• Safety Culture

Thoughts on EHR Difficulties and Failures – #2

The transformational character of introducing an electronic health record (EHR) into an enterprise must be well planned and based on foundational work. Because an integrated environment is so interdependent, the absence of policies coordinating the building of interrelated modules and applications can lead to wasted effort and create rework once the unworkability or excessive cost of supporting the configuration is recognized.


Another aspect of dissipating effort and resources are the adoption of deadlines without having contingency plans that allow for the flexible deployment of the EHR to occur after it has successfully passed testing and user acceptance. Often the deadlines are linked to some other events whose prime focus in not the EHR. Similarly, an organization’s executive management must ensure that the project scope is maintained and vigilantly stop or downgrade unassociated projects or unnecessary scope creep.


Establishing the methods for change management (in the integrated environment), coordination and scheduling of build and testing environments, and establishing a sercurity model for user and application access can lead to signigicant simplification of security maintenance while safeguarding protected health information (PHI). Planning for the vetted release of information to indivuals and other healthcare providers should be addressed as part of the architectural design of the EHR. The trend line is that health information exchange (HIE) is becoming one of the main tentants of ARRA HITECH Meaningful Use requirements.

Thoughts on EHR Difficulties and Failures – #1

Having engaged in a number of EHR implementations, I am continually struck by the lack of forethought exhibited by many layers of healthcare management. This is all the more disconcerting considering the initial and long-term cost of an integrated electronic medical/health record (EHR) which usually runs into the millions of dollars.

The lack of planning starts with or even before the inception of an EHR project and lays the seeds for increasing the overall cost over the lifetime of the product by limiting its abilities in handling new practice areas, making it difficult to scale up (or down) in size, and ensure that the application is supportable with a reasonable number of IT and clinical staff.

Most facilities embarking on their first integrated EHR do not comprehend how transformational and even disruptive the implementation will be. The EHR is not primarily an IT project but social and business transformation of the organization. Just like communications and technology have flattened the earth, the EHR flattens the organization. Suddenly, a huge amount of sensitive information is just a click away and a sensible and comprehensive policy needs to be in place to ensure data safety while ensuring authenticated accessibility. Such a security policy needs to be mapped out and model adpoopted that ensures clinical usability while complying with the Sarbanes-Oxley Act, HIPPA and HITECH ARRA and a slew of specialty, regional and state requirements.

Getting the EHR to go-live is just the start of the journey. Operational funding for increasing data storage, increased auditing requirements, continuing process and application improvement, enhance change control for updating the core application and all the attached ancillary systems, increased training requirements for new and temporary employees, downtime and recovery policies, procedures and testing need to have long-term funding guaranteed.

Radiation Exposure

Although there are efforts to create a technological and procedural solutions (see California Bill 1237 and FDA efforts) for determining exposure to ionizing radiation exposure during diagnostic imaging procedures, these will fall short for many different reasons. Some can be traced to calculating the effective absorbed dose which is a function of multiple parameters ranging from the imaging system (amperage, voltage and efficiency of the system generating the radiation), the patient (size, obesity and exposed tissues/organs), and the expertise of the technologist setting up the patient.

The shortcommings should not stop the process of getting imaging vendors to include data from the machine in the Dicom header but they also need to focus more on the whole process of taking images. Radiologist can have a lot of input into the selecting the most appropriate modality, protocol, and use of contrast media. The technologists can ensure that the region of interest is not exceeded and the amperage and voltage are tweaked to deliver a good image with low radiation exposure. The vendors can provide training and built in protocols to optimize the image and area of interest.

The overarching philosophy governing the imaging group can ensure that radiologist and technologist agree on making the patient’s welfare central to their imaging service. Sharing the images with other facilities (Health Information Exchanges (HIE) and RHIOs) can reduce unnecessary re-imaging. Only participation with groups such as LeapFrog and regional HIEs will help move groups and organizations to to better and truly patient-centered care.