A Dose of Prevention: The Role of the RIS in Preventing Overexposure
Charles SociaIn many ways, the problem of radiation overexposure still resembles a crime scene. Investigators come in after the fact and attempt to determine what really happened. There is another way, however, according to Charles W. Socia, RT, CIIP, product manager for the information-systems division of FUJIFILM Medical Systems USA—one that focuses on prevention. The 23-year radiology veteran is working to overcome the retroactive-response mentality that still dominates the industry. The idea is to improve care on the spot, while the patient is still on the table. “The majority of the solutions today are focused after the event to analyze overexposures,” Socia explains. “The focus of the Fujifilm solution is to notify users prior to the exposure and provide immediate notification in the event of an overexposure. We provide tools to notify referring physicians, radiologists, and technologists as to patients’ risk levels.” On the heels of several high-profile cases of excessive radiation exposure, the state of California has attempted to improve the situation through a new dose-reporting law, the Medical Radiation Safety Act of 2010 (which went into effect on July 1, 2012). While acknowledging that the state’s efforts probably will not hurt, Socia is not convinced that the law will actually help. “The California law is not going to solve the problem,” Socia says. “It may let more people know what overexposures are happening, but it won’t solve the real problem, which is that patients are being overexposed. Back in the old days, we heard a buzzer go off when we overexposed patients, and the result was a dark film. Those days are gone.” In today’s digital environment, however, dose creep can occur in settings where technologists have no external information to let them know that patients are being overexposed, Socia says. Fujifilm now offers tools to prevent these incidents by providing crucial information that can help determine whether a specific technologist, piece of equipment, or protocol could cause a problem. The Place of the RIS Software engineers at Fujifilm examined ways to adapt the company’s Synapse® RIS and PACS to the task of prevention, and the result is that Synapse systems now are able not only to record modality exposure information, but also to provide real-time decision-support tools that allow for prompt intervention. Limited dose-management tools are also contained in the Communications Module of the Synapse PACS. The key tools are an electronic alert and a cumulative-exposure notification that provides summary totals of individual exposure types (by modality) while technologists are preparing to do exams. Fujifilm’s total solution has the ability to check the protocol, history, and body weight of the patient to provide technologists with information on appropriate exposure levels—integrated within the normal workflow. In the event of an overexposure, critical-alert notifications can be sent directly to referring physicians via fax, email, or text. Socia, who serves on American Board of Imaging Informatics, says, “We have automated the process of sending the information. We are working to provide that information to third-party systems.”
Seeking Standards: The Dose Index Registry One of the ways that FUJIFILM Medical Systems USA is promoting better radiation-dose management is its publicizing of the Dose Index Registry (DIR) launched by the ACR®. Participation in the DIR enables facilities to benchmark their CT dose indices against regional and national standards. The registry is also a first step toward standardizing recommended exposure levels. To participate, facilities enroll in the DIR and receive a unique facility identifier. The ACR software is then installed on a local computer, and CT dose-index information from each of the facility’s scanners is anonymized and sent to the ACR database. Participants receive periodic feedback reports comparing their results, by body part and exam type, with aggregate results. Charles W. Socia, RT, CIIP, product manager for the information-systems division of Fujifilm, says, “The ACR is a leader in the industry in providing solutions, but the reality is that many customers are not aware that the DIR exists. We believe it is our responsibility, as the vendor in primary contact with customers, to provide the information, so that others can improve patient care.” In enabling facilities to compare their dose indices with those of similar-sized hospitals in their regions, the ACR is knocking down walls that have prevented competitors from collaborating on common problems, Socia says. “You have hospitals down the street from each other that do not talk to their competitors,” he explains. “There was no way for these hospitals to know what was normal for their particular areas.” He continues, “In the broad sense, the future, for radiation exposure, is that we will have the ability to know how much exposure the patient has had and to make educated decisions as to how much additional exposure the patient should have, based on real data and real information.”
Currently, the Synapse RIS has an internal referring-physician portal that can be accessed through the electronic medical record (EMR) or hospital information system (HIS) to let the ordering physician know whether the exam being ordered is appropriate for the diagnostic question. The Synapse RIS now has access to appropriateness criteria, with full decision support under development and expected to be available within a year. Referrers also have access to a patient’s cumulative-exposure record, so they can choose different exams for patients at risk for high levels of exposure. “Access to communication with an expert and/or radiologist is also provided within the working environment, provided there is standardization of communication between systems,” Socia says. “The RIS currently supports instant messaging, text messaging, and email to interact with the radiologist through the referring-physician portal. The goal, for the future, would be to integrate these tools directly with the EMR, HIS, or computerized provider order entry (CPOE) system.” With dose management built into the Synapse RIS, radiologists, referring physicians, technologists, and nurses are able to work with relevant information in a central place. Referring physicians know whether patients are well above an acceptable level of cumulative exposure, and they can assess whether exposing the patient is worth the risk. It’s still a human decision, but it’s a better-informed decision. Fujifilm achieved this functionality by storing multiple levels of data, essentially creating a variety of buckets and differentiating dose type based on the machine used. “Depending on which piece of equipment a procedure is done on, the RIS will identify that piece of equipment automatically,” Socia explains. “From there, it will assign a value based on DICOM header elements or the elements the institution wants to track for that particular machine. It gives you the ability to isolate particular dose types that are not necessarily equal.” Socia acknowledges that despite access to all of these dose measurements, there is ultimately no reliable way to determine the patient’s risk (if any) of developing cancer. “Fujifilm is providing the tools to reduce the dose, allowing physicists to do their analyses of what the dose exposure is and come to a standard,” he says. “Once that’s adopted, we’ll have the ability to tie that directly into the RIS to provide better reporting of actual patient risk.” Not So Standardized Before the scenario described becomes the standard of care, considerable work needs to be done and system interoperability needs to improve. CPOE, spurred by EMR adoption and the meaningful-use program, is just now being implemented at the referring-physician level. Too often, “The physician orders the exam by writing a note on a piece of paper and handing it to somebody to go find a computer, telephone, or fax to send that information to a third-party system,” Socia says. It might sound quaint, but it amounts to a health-care problem not easily solved by any one vendor. The problem extends to the ways that physicians get their information. “The number-one medical reference used by referring physicians to diagnose and treat their patients is Google,” Socia says. “We’re using Google because we don’t have the appropriate tools and the appropriate functionality to access data housed in the silos of the radiology system or the pharmacy.” Lack of standardization also affects radiation-exposure metrics for older legacy equipment in use today, Socia reports. One example is the indicator used on CR images to gauge the exposure factor. Of the six major manufacturers of CR equipment, only two use the same value prior to changes in recent years. The problem is that users can get exactly the same number from two different machines, but each number often means something different. “For one machine, if the value goes up, it means that the exposure is lower, and for another machine, if the value goes down, it means that the exposure is lower,” Socia explains. “The Image Gently campaign has publically asked that all vendors adhere to a standard Exposure Index as defined by IEC 62494-1.  In the meantime legacy equipment in many facilities does not yet provide the same scale for the Exposure Index.” Until recently, there simply was no focus on dose; this is one reason for the lack of standardization. “Radiation exposure was something that everyone knew about, but finding solutions was not a primary focus of either customers or vendors,” Socia says. “Frankly, the focus was on getting more patients’ exams done faster. We believe efficiency and top-notch patient care can go hand in hand.” Greg Thompson is a contributing writer for Radinformatics.com.