California’s Dose Puzzle Is Radiology’s Challenge

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 - California's Dose Puzzle Is Radiology's Challenge

The imaging informaticists, physicists, physicians, and vendors’ representatives who gathered at the Society for Imaging Informatics in Medicine regional meeting, Practical Imaging Informatics, in Long Beach, California, on March 22, 2012, didn’t arrive in covered wagons, but they did have much in common with the state’s pioneer settlers. On September 29, 2010, California’s SB 1237 was signed into law as the Medical Radiation Safety Act,¹ effectively putting all providers of CT exams on notice that beginning July 1, 2012, they would be required to begin reporting technical parameters and radiation dose for each study.

Prompted by an outpouring of popular dismay over reported episodes of overradiation in California and elsewhere, the legislation does not mandate how much radiation is permissible—just that the dose be recorded in the PACS and the radiology report, and that incidents of overradiation be reported. The public, however, is unlikely to be much interested in the nuances of the law, according to J. Anthony Siebert, PhD, professor of radiology at the University of California–Davis, who moderated the “Radiation Dose Monitoring in California” sessions. “Individual patients see this, and now, they are wondering what their dose is,” he says.

Therein lies the rub. While there are measurements of volumetric CT dose index, dose–length product, effective dose, and absorbed dose (among others), there currently is no way to calculate and send the patient’s dose to PACS automatically, robustly, and accurately. California providers of CT exams and radiation therapy are bound to comply with the new act; the challenge is how to do so. Even the most advanced and conscientious providers are struggling to overcome the limitations of technology, informatics, personnel, and the science of dosimetry.

With radiation dose increasingly on the radar of regulators and payors nationwide, imaging stakeholders are well advised to join the pioneers in California who are seeking answers to a very complex problem: What is the best way to calculate patient dose?

Along with Siebert, four other presenters addressed this question. Bette Blankenship, MS, DABR, is a medical physicist at Sharp Memorial Hospital (San Diego, California). Christopher Cagnon, PhD, DABR, is chief of radiology physics at the University of California–Los Angeles (UCLA) Medical Center. Michael McNitt-Gray, PhD, DABR, FAAPM, is a professor in the department of radiological sciences of the David Geffen School of Medicine at UCLA.

Together, these three presented “Radiation Dose in a Clinical Environment: Benefit and Risk—The User’s Perspective.” Lisa Russell, inspector, compliance and enforcement, for the California Department of Public Health (CDPH), then presented “The California Dose Reporting Law: Implications and FAQs—The Government’s Perspective.”

With enactment of the Medical Radiation Safety Act, California providers have been pushed beyond the debate over the relative risks of medical radiation. In referring to the issue of radiation exposure, Seibert notes that many of the reported incidents have been due to human (rather than technological) problems, in terms of using the equipment properly and safely. He does, however, acknowledge the stochastic risks of ionizing radiation seen with extremely high doses, as at Hiroshima and Nagasaki, Japan.

Reporting Dose the Right Way
While California CT providers scramble to patch together solutions to meet the demands of the Medical Radiation Safety Act, the physics community does have a vision of a more elegant solution to dose reporting, as articulated by Michael McNitt-Gray, PhD, DABR, FAAPM, a professor in the department of radiological sciences at the David Geffen School of Medicine at the University of California–Los Angeles (UCLA).

Phase 0: McNitt-Gray calls where we are now phase 0. Resources include the patient protocol page and a DICOM Radiation Dose Structured Report (RDSR), which is information that could be dictated into the radiology report.

Phase 1: By July 1, 2012, McNitt-Gray hopes that all UCLA CT systems will be able to produce a DICOM RDSR or a patient protocol page, with some informatics assistance, to generate an HL7 message that would automatically insert the information into the radiology report.

Phase 2: The next step would be to adjust the DICOM RDSR by body region and size, and automatically insert that into radiology report. “We are not going to get there by July 1, but we are going