Dose Monitoring Poses Challenges and Raises Questions for Radiologists

LONG BEACH, Calif. - Dose reporting, practiced and mandated by only a couple of states today, is gaining traction as a growing concern as patients and legislators take notice, according to professionals at SIIM 2014.

Originally, monitoring dose was primarily in the best interest of the patient, but as we near Jan. 1, 2016, radiologists will be seeing reimbursement cuts related to dose management. The legislation, included in H.R. 4302, the Protecting Access to Medicare Act of 2014, includes a component that allows for reimbursement reductions for CT equipment that does not meet the NEMA Standard XR-29-2013. The payment reduction starts at 5 percent for 2014, and grows to 15 percent for 2017 and later.

The underlying issue with dose is how to ensure patient safety and still get a diagnosis.

One of the first steps to monitoring dose is protocol review and determining the value for the patient. Radiologists should be looking at images and determining if that study could have been done with a lower dose and a little more noise, Kevin O’Donnell, co-chair of the IHE Radiology Planning Committee, said at SIIM. Radiologists should be reviewing protocols to get them down to “good enough to get the diagnosis.”

In California, one of the few states that has passed legislation regarding dose monitoring, the effort is to put the quantity of studies history in front of the ordering physicians in an effort to incorporate dose with clinical decision support and electronic health records, so the ordering physician gets a best practice alert when a patient has undergone a large amount of studies, Scott Foster, radiology informatics manager at the University of California Davis Medical Center said. While that’s the hope, “our implementation at this point is a place to store the data in an appropriate fashion,” Foster said.

The American College of Radiology (ACR) recognized there was a lack of data regarding dose and created a data registry that allows facilities to compare their CT dose indices to regional and national values.

Institutions that don’t have an existing dose hub can sign up for the ACR’s dose index registry (DIR), the system allows all of your dose information to be routed to their registry, either through PACS or modalities, O’Donnell said. In return, twice a year, your institution will get a report back from the registry that indicates your dose profile and compares it to other profiles in your geographic region, similar hospital type, etc.

The DIR has been qualified by the American Board of Radiology (ABR) for meeting the criteria for practice quality improvement, toward the purpose of fulfilling requirements in the ABR Maintenance of Certification Program, according to the ACR.

CT scanner manufacturers have also recognized the need for monitoring dose and have implemented features accordingly. In addition to the dose related tracking and reports, features shipping in all new CTs since 2012 and even back implemented in older systems by some vendors, include Dose-Check which allows institutions to set unique dose thresholds and trigger alerts for high dose in reports, O’Donnell said.

The existence, or lack thereof, of standards or thresholds for proper dose monitoring was a common concern among radiology professionals at SIIM. The American Association of Physicists in Medicine (AAPM) is your friend in this regard, O’Donnell said. AAPM has gone through these and determined a reasonable target for some of these studies. The main intention of the standards, O’Donnell said, is to catch outliers.

“A lot of the state law is about transparency, it’s about making sure the dose is out there and visible,” O’Donnell said. “The California law is becoming a template for a lot of other groups.”

As dose monitoring continues to grow and practices are forced to comply with federal standards, the biggest challenge facing dose monitoring, Foster said, is a lack of a clinical decision support for dose.

There is nowhere really to store and aggregate date in our systems for dose, whether it’s in PACS or electronic health records, Foster said. Because of that, we don’t have a great way to know a true clinical decision support model so that a physician ordering a test can see whether the patient has had a lot of dose.

A recent Diagnostic Imagingpoll found that the majority of organizations monitor dose and embed the information in the report, or are in the process of implementing a system.