In my travels when teaching healthcare imaging and IT in
other countries I notice certain areas that
are definitely ahead of other
regions and also some that are lagging behind. The US is finally catching up
with widespread EMR implementations due to the ARRA act incentives requiring
practitioners to meet Meaningful Use requirements unless they want to be penalized
by future reimbursement cuts. We are still lagging behind wide-scale
implementations of Health Information Exchanges, especially as incentives are
running out for creating public ones, but the private ones that are set up by
large provider groups are really taking off.
From a regulatory perspective, the HIPAA regulations were a
game-changer and had a major impact, not only on policies and procedures, but
also on the way that systems implement security and privacy, for example, tracking
activity through audit trails. Here is where a lot of countries follow the US example.
The same is now happening with the requirement to track X-ray Dose, few
countries and/or states are actively enforcing this, unlike the US.
However, as with many regulatory requirements, technology is
running behind and trying to catch up to the requirement to track dose,
especially from CT scans, and also from fluoroscopy, angiographic and
cardiology procedures. Several incidents that happened only a few years ago, whereby
hundreds of patients were severely overdosed at several major medical centers, triggered
stricter dose regulations. Prior to that, it was common to track or at least to
record the dose for radiation therapy and digital mammography.
In radiation therapy, there is a thin line between over
exposing and therefore hurting the patient’s recovery too much and
under-exposing thereby not killing all the cancer cells and risking a
recurrence, and therefore, dose registration has been a practice all along. For
digital mammography, there is a similar concern that too much and frequent
screening could cause, rather than prevent cancer and even though I am not
aware that the dose information has actually been tracked, it has been practice
to at least record it with the images in the DICOM header.
For CT, fluoroscopy, angiography and cardiology procedures,
recording dose has not been common until it became a recent requirement. The
good news is that new modalities now are being shipped with the capability to
export detailed information in the form of DICOM Structured Reports. The bad
news is that this only represents a relatively small portion of the installed
base, and that the infrastructure to archive and register this information is
not there yet. The result is a patchwork of different solutions to capture this
information. The options to capture this information include using the DICOM
header such as used for digital mammography, to capture it as part of the
Modality Performed Procedure Step (MPPS), or as a screen save aka Secondary
Capture.
The MPPS solution is hampered by sparse implementations for
a variety of reasons. Some of the barriers for MPPS implementations are lack of
knowledge and understanding by the user community, a resistance to activate it
by the modality vendors, as it is more work and potentially increases support
issues, and finally poor implementations. An example of the latter is provided
by a major PACS vendor that closes the study upon receiving the MPPS complete,
thereby causing all images sent after that to become “unverified” requiring
intervention. And even if you were able to make MPPS work, the information
about the dose in this transaction does not have a lot of detail and does not
necessarily reflect the complete exposure, especially for fluoroscopy exams
where the part of the exam that does not create images is not part of the dose
recording.
The screen-save solution is somewhat better but also limited
with regard to the information that is recorded, and requires some type of
intelligence in the form of Optical Character Recognition (OCR) or screen
scraping to collect the dose information in a format that can be electronically
stored in a database.
Talking about a database, as of today there are few PACS
vendors that offer a dose management solution as part of their PACS system.
Users might have to rely on third parties to collect that data and, if needed, forward
it to a regional or national registry. There is an open source solution called
RADIANCE (see footnote), but like all open source, there could be a concern
about support and sustainability.
Therefore, despite the requirement for dose registration and
dose management that is only going to be extended to more modalities and
specialties in the future, the technology is trying to catch up and health care
imaging and IT professionals who are tasked with installing and supporting this
are being challenged. Hopefully, when more structured report solutions and dose
management applications become available, this will become easier.
