Martin H. Reed, M.D., of the Canadian Association of Radiologists, addressed computerized provider order entry systems.

At a first of its kind meeting at RSNA 2007, radiologists fromacross the globe gathered to discuss concerns about patient radiation dose, the impact of computerized provider order entry (CPOE) systems and other issues facing the specialty.

The meeting included representatives of RSNA and the RSNA International Advisory Committee, the International Society of Radiology and European Society of Radiology, as well as radiologists from Canada, Brazil, China, France, Sweden, Japan, Austria, Germany, Australia, South Korea, Mexico, Hong Kong and Argentina.

Radiation Dose, Reduction Methods Vary Globally

Addressing the issue of reducing radiation dose to patients, leaders agreed it will require the effort of radiologists and nonradiologists as well as imaging equipment vendors.

James A. Brink, M.D., presented "Use and Misuse of Radiation in Medicine" and focused on the magnitude of radiation dosage in the U.S. In 1980, the average American had a medical radiation dose of 0.54 mSv. By 2006, that amount increased 600 percent, to 3.2 mSv per capita. The worldwide average background radiation dose is estimated at 2.4 mSv per year.

"There has been an exponential increase in CT use in the last 25 years," said Dr. Brink, a professor and chair of the Department of Diagnostic Radiology at Yale University School of Medicine and chief of diagnostic radiology at Yale-New Haven Hospital. Dr. Brink is helping evaluate new technologies to simultaneously improve resolution on helical CT scanning and reduce radiation dosage.

"CT is a relatively high dose procedure, with a typical dose of 10 mSv," Dr. Brink continued. "Doctors in the U.S. order a lot of CTs because they are easy to perform and give quick results.”

In comparison, Dr. Brink cited work by Fred Mettler, M.D., of the National Council on Radiation Protection & Measurements (NCRP), which indicated that in Europe, the average medical radiation dose ranges from 0.7 to 2.0 mSv per capita. European doctors have done a much better job of limiting radiation exposure with strict referral criteria and justification criteria, said Dr. Brink. "Radiologists in the United Kingdom are the legal gatekeepers of radiation exposure," he said.

In the U.S., "There is resistance to allowing radiologists to be the gatekeepers, so we need to teach all other physicians about radiation protection," said Dr. McLoud, associate radiologist-in-chief and director of education for the Department of Radiology at Massachusetts General Hospital in Boston and a professor of radiology at Harvard Medical School.

2008 RSNA president Theresa C. McLoud, M.D. (a), and Lizbeth Kenny, M.B.B.S. (b), of the Royal Australian and New Zealand College of Radiologists, participated in the international radiology special session at RSNA 2007.

Participants agreed doctors in other specialties need more education about radiation exposure risk. Swedish radiologist Hans Ringertz, M.D., Ph.D., said he saw improvements in his country when cardiologists themselves started getting too much radiation exposure.

2007 RSNA President R. Gilbert Jost, M.D., said it would be helpful for vendors to agree on a standard methodology for electronically reporting the radiation dose from each examination. Making the data available in a standard format that is easy to review would motivate both radiologists and manufacturers to do a better job, said Dr. Jost, the Elizabeth Mallinckrodt Professor of Radiology, chair of the Department of Radiology at Washington University School of Medicine, director of the Mallinckrodt Institute of Radiology and radiologist-in-chief at Barnes-Jewish Hospital in St. Louis.

Dr. Jost added that such a project might be appropriate for the Integrating the Healthcare Enterprise (IHE®) initiative, with a public demonstration staged at an upcoming annual meeting.

Noted Dr. McLoud: "We need to maintain a balance. CT provides tremendous benefits, so we should resist being too negative about it."

CPOE Systems Can Drive Appropriate Imaging Worldwide

Participants in the special RSNA 2007 meeting also considered radiology’s role in CPOE systems. By enabling physicians to enter orders into a computer system and communicate the orders electronically to other departments, CPOE systems are designed to eliminate paperwork and unnecessary steps, improve communication and minimize errors.

Presenter Martin H. Reed, M.D., F.R.C.P. (C), presented a CPOE system in use in Canada. Dr. Reed is chair of the Canadian Association of Radiologists (CAR) Guidelines Working Group and was lead investigator for Clinical Decision Support in the Diagnostic Radiology Project at the Children’s Hospital (see RSNA News, December 2007). He launched the project after noting an increase in diagnostic imaging volumes.

"Ten to 20 percent of diagnostic imaging exams did not contribute to patient management," said Dr. Reed, a professor of radiology and pediatrics at the University of Manitoba and chair of the Department of Radiology at Children’s Hospital in Winnipeg. "There was an increase in radiation dose, cost, waiting time and anxiety."

CAR issued its guidelines on the Internet and on CD, said Dr. Reed, adding, "But we all know that guidelines are not always followed." CAR then persuaded the Canadian government to pay for a study of computerized radiology orders that included the guidelines. In the Manitoba project, a referring physician ordering a radiologic procedure was required to provide information on a patient's condition.

If the imaging study was appropriate, the order was sent through to radiology. If not, the physician would get an electronic message—for example, a physician might be told that a child with asthma did not need radiography. The physician could seek another test as recommended by the guidelines or override the message.

During the study from July 2006 to August 2007, more than 8,000 radiology examinations were ordered. About 20 percent were covered by CAR guidelines, with no guidelines in place for the remaining orders. Approximately 10 percent of the orders overall were considered inappropriate based on the guidelines, said Dr. Reed.

"We have a lot of work to do in improving educational intervention for diagnostic imaging," he said. "We need to look at areas without guidelines and create them."

Lizbeth Kenny, M.B.B.S., of the Royal Australian and New Zealand College of Radiologists, noted: "We need clinician buy-in. Otherwise, the guidelines will be ignored."

The meeting concluded with the group considering development of an international white paper on radiation dosage.