"There's been lots of struggling to respond to the requirements of this law, but I think it's an extraordinary thing," says Smith-Bindman, director of the Radiology Outcomes Research Laboratory at the UCSF Medical Center, San Francisco, who contributed to a December 2011 Institute of Medicine report on decreasing potential environmental risks associated with breast cancer. She's also principal investigator on a project at the five University of California medical centers to standardize and optimize CT doses system-wide and report those doses as part of patients' electronic health records (more information on the project is on page 24).
Her research shows that CT radiation doses are often 30 to 50 percent higher than they need to be for adequate imaging. The increased exposure is of acute concern because her research also notes a five-fold increase in the number of CT scans in the past 20 years, to about 75 million in 2010. In addition, a study published in The New England Journal of Medicine estimates that 30 percent or more of advanced imaging studies may be unnecessary.
But Smith-Bindman also identified an enormous opportunity for information technology to play a central role in tracking and reducing long-term radiation exposure. Her studies found that the mere act of tracking doses can encourage a facility to reduce them, without hurting overall image quality. "Radiology has this incredible electronic data and we have not done a good job of using it for quality improvement and patient-centered care," Smith-Bindman says. "We need to put this information in a special place in the electronic record where it can be accessed." She says that too often, the dose information is locked in an image and never makes it to electronic health record systems, where physicians besides the radiologist can use it to evaluate whether the value of a CT scan is worth the additional radiation exposure.
The new California law, which went into effect July 1, requires each CT report to include information about the radiation dose emitted by the machine during the exam. It was passed in 2010 in response to a 2009 incident at Cedars-Sinai Medical Center in Los Angeles where more than 200 patients accidentally received several times more radiation than they should have during CT perfusion studies for stroke. Many suffered hair loss and skin burns, and they may be at higher long-term risk for cataracts and cancer. If dose information had been included with each report, the error would likely have been caught much sooner.
Tracking, and in the process reducing, medical radiation exposure is a top priority nationwide, in the wake of the rise in CT scanning and increasing use of interventional radiology and nuclear medicine. A 2009 report by the National Council on Radiation Protection and Measurement found that while CT, interventional fluoroscopy and nuclear medicine studies make up only 26 percent of imaging procedures using radiation, they contribute 89 percent of the total yearly exposure to radiation.
CT scans in particular have attracted attention because they've become the tool of first choice in diagnosing many conditions, even though they use large amounts of ionizing radiation, which can cause genetic damage to cells and increase the risk of cancer. As an example of the increased reliance on CT scans, a study from the University of Michigan, released last year, found that nationally the rate of CT use in emergency departments grew 11 times faster than the rate of ED visits between 1996 and 2007.
Many observers believe other states will follow California's example, and multiple national campaigns are aimed at reducing medical radiation exposure. Last year the American Medical Association adopted a resolution that supports tracking imaging procedures in EHRs to help physicians discuss radiation exposure issues with their patients. Also last year, the Joint Commission issued an alert urging providers to use diagnostic radiation carefully and issued a series of recommendations, including :
* Using imaging techniques other than CT, such as ultrasound or magnetic resonance imaging (MRI), and fostering collaboration between radiologists and referring physicians about the appropriate use of diagnostic imaging.
* Expanding the radiation safety officer's role to explicitly include patient safety as it relates to radiation and dosing, as well as education on proper dosing and equipment usage for all physicians and technologists who prescribe diagnostic radiation or use diagnostic radiation equipment.
Increasingly, I.T. staff in facilities that perform CT scans may be asked to participate in initiatives to capture and record radiation doses, provide radiation exposure history as a routine part of the electronic health record, and participate in national dose registries designed to help determine how well the facility is optimizing its use of radiation. At the same time, the CT scanners will benefit from new advances in software that allow more sophisticated image analysis and can further cut the dose of radiation needed to produce a diagnostic-quality image.
Elizabeth Gardner’s cover story in the November issue of Health Data Management examines how regulators, providers and vendors are tracking and reducing radiation exposure.