Measuring radiation

Intermountain Healthcare recently launched the nation's first enterprise system to measure and report cumulative medical radiation exposure of patients. Across our 22 hospitals and 185 clinics, our systems and personnel are now compiling data on the cumulative radiation that patients receive from about 220,000 higher-dose procedures and imaging exams each year. In developing the system, whose data is available to clinicians and patients through Intermountain's electronic health records, my colleagues and I have learned valuable lessons that we hope will help other healthcare providers with similar ambitions.

While a patient's individual situation typically dictates the imaging procedure needed, knowing a patient's radiation exposure history can help physicians and medical caregivers determine which type of imaging test is best. The benefits from a procedure usually outweigh the slightly increased cancer risk from exposure to radiation, but the potential risk of radiation should be considered before these imaging tests are performed. In some cases, equivalent information can be obtained with a medical test that does not use radiation, such as ultrasound or MRI scans.

Having such information available is especially helpful for children with certain chronic health problems, as they may need to have many tests involving radiation during their lifetime.

In developing the system, we created a database into which we could record the examinations provided in four key areas: CT scans, cardiac nuclear medicine, the cardiac catheterization laboratory and the radiology special procedures lab. This would cover the majority of higher-dose exposures.

We initiated a two-year development project with three teams of researchers. The first team would write the software to record the exams into the database and connect that database to IT reports available through our electronic health records. The second team would develop educational materials for the reader: radiation professionals, referring physicians and patients. The third team would develop and pilot-care process models for two specific focus areas where we believed there was opportunity to reduce exams being performed.

These two focus areas are the use of CT for evaluation of pulmonary embolism and the use of cardiac nuclear medicine procedures. The care process models drew upon a thorough literature review and involved a multidisciplinary team to determine how these tests should most appropriately be used in caring for patients.

The three teams went about their work, completing the project last August. The new system became operational in December, with all educational materials available, and is being rolled out across all Intermountain hospitals and clinics in 2013. The lessons learned include the following:

First, the complexity of measuring doses is profound. For every modality, there is a different way of measuring and recording the dose. Not only do the different imaging modalities record dose differently, standard dose reporting procedures have only recently begun to emerge, and within a modality there is variability in how dose is reported. We developed standard procedures to handle these variables and convert all doses to a standard metric. The metric we chose is effective dose as measured in millisieverts.

All of these “measurements” are really estimates. My hope is that, over time, the technology and science will advance and that it will become a national priority to improve the accuracy of these estimates.

Second, getting consensus on the educational materials is complicated, as there is room for debate on the science, especially as it relates to the seriousness of dosage risks. Creating ultimate buy-in is a function of representation of key departments, thorough airing of concerns, personal rapport among representatives and keeping the focus on the shared goal of ensuring that patients are exposed to no more radiation than necessary.

Third, even within a single hospital system, standardization is complex, as individual hospitals have different machines and protocols. Here, the hospital system's senior leadership is key. Intermountain pursued this entire initiative with support from senior management at its highest levels and the board of directors. It was clear that this was a priority all the way to the top, and that certainty was essential to success.

Fourth, collecting and measuring the data makes improvement possible. We now have six months' worth of data, and with it we are already generating improvement. This data has shown us internal variation and identified the biggest opportunities for improvement in radiation reduction. Access to this data is potentially the most powerful feature of this project, as it gives us an objective means of identifying problems, instituting change and documenting impacts.

In the short time in which we have had access to this data, we have already reduced radiation, avoided unnecessary treatments and found alternatives that do not involve radiation.

Intermountain's new system has broad implications. It enables our clinicians to make recommendations to patients with their record of radiation exposures in mind, while also enabling our patients to understand their history of exposure. It allows us to measure and reduce radiation exposures across our hospitals and clinics. It encourages standardization of best practices.

Transparency and discipline in the use of radiation exposures are the key, and systems such as Intermountain's are essential to ensuring both.

Dr. Keith White is medical director of imaging services at Intermountain Healthcare, a not-for-profit healthcare system based in Salt Lake City.