managing radiation dose: ihe rem profile kevin o’donnell toshiba medical systems co-chair, ihe...

Managing Radiation Dose:Managing Radiation Dose:IHE REM ProfileIHE REM Profile

Kevin O’DonnellKevin O’DonnellToshiba Medical SystemsToshiba Medical Systems

Co-chair, IHE Radiology Planning CmteCo-chair, IHE Radiology Planning CmteMember, DICOM Standards Cmte & WG-6Member, DICOM Standards Cmte & WG-6Member, MITA X-Ray SectionMember, MITA X-Ray Section

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MotivationMotivation

X-Ray based imaging can provide tremendously useful information

Patient Dose is an important consideration

Potential benefit > potential risk

… but the risk should still be managed

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Why Measure / MonitorWhy Measure / Monitor

“I think patientdose is improving.”

“I think it’sgetting worse.”

Managing in the presence of data is far better and easier than managing in its absence. – Robert Glass

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Why Measure / MonitorWhy Measure / Monitor

Technology is constantly changing

Technique is constantly evolving

Understanding continues to improve

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Why Measure / MonitorWhy Measure / Monitor

ALARA Guidelines for Physicians (Patient Dose) As Low As Reasonably Achievable

Patient Dose < = Reasonably Achievable Dose

A < = B

Should be easy / automatic / routine

Can we make the data readily available…

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… … A New IHE ProfileA New IHE Profile

What’s an IHE Profile?

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IHE in One SlideIHE in One Slide

IHE helps vendors implement & test functions that span multiple systems

Profiles are implementation guides how to use existing standards to address a specific problem scenario

Connectathons are test events managed testing of Profile implementations

IHE helps users purchase & integrate multi-system solutions list required IHE Profile support in RFPs

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IHE ConnectathonIHE Connectathon

One Week;

70+ vendors;

350+ engineers;

Thousandsof tests;

Managed process;

Find & resolve issues.

Results @www.ihe.net

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IHE Radiation Exposure Monitoring Profile

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National Registry

Archive

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Dose Analysis& Reporting

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Outlier: #Performing Phys.Over Target: 12.2%

Outlier: #Performing Phys.Over Target: 12.2%

Outlier: #Performing Phys.Over Target: 12.2%

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A New IHE ProfileA New IHE Profile

IHE Radiation Exposure Monitoring Profile Integration of systems reporting dose and systems

which receive, store, or process those reports Modalities, PACS, RIS, Workstations, Registries

Facilitate compliance with Euratom 97/43,ACR Guidelines, etc.

Directly based on DICOM Dose Reports Creation, Collection, Distribution, Processing

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DICOM Dose ReportsDICOM Dose Reports

“SR Objects” – DICOM Structured Reports Easily ingested (and regurgitated) by PACS

Granularity : “Irradiation Event” + Accumulated Dose over Study, Series

Templates: CT, Projection X-Ray (Mammo, Fluoro)

Not addressed: NM, RT

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What about using MPPS?What about using MPPS?

Modality Performed Procedure Steps Status messages back to RIS / PACS

Transient Information designed for workflow; not persistent archiving

Lacks complete dose details

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What about Image Headers?What about Image Headers?

Mostly Exposure details (for interpretation)

No image; no dose deleted due to quality / patient motion

More images; more dose extra reconstructions; post-processing

Lacks complete dose details

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What To MeasureWhat To Measure

So many choices… Exposure, Dose, Dose Index, Estimated Dose,

Effective Dose, Estimated Effective Dose, … CTDIw, CTDIvol, CTDI100, CTDIfreeair, …

Solution: Collaborated with IEC Subcommittee 62B Established a baseline & a pipeline Upgrade when necessary

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Key MeasurementsKey Measurements

CT Dose DLP, CTDIvol, kVP, mA, sec Effective Dose [ Optional ]

(Reference estimation method)

Projection X-Ray Dose DAP, Dose@RP, kVP, mA, sec Fluoro Dose, Fluoro Time

Mammography Dose AGD, Entrance Exposure @ RP, kVP, mA, sec Compression, Half Value Layer

ftp://medical.nema.org/medical/dicom/2008/08_16pu.pdf

ftp://medical.nema.org/medical/dicom/final/cp874_ft.pdf

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Other Details in Dose SROther Details in Dose SR

Full Patient / Order / Study Details

Unique ID for each Irradiation Event

Equipment ID

Patient Position, Anatomy imaged

Imaging Geometry (projection)

Collimation

X-Ray Filters, Anode Target Material

Calibration, Phantom, Dosimeter

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DICOM CP 874DICOM CP 874

Updated details for REM Implementers Will apply to 2009 Connectathon

Minor adjustments to DICOM templates Require identification of irradiating system Require Target Region Optional references to persons who ordered / performed Code to differentiate interventional procedures from diagnostic etc.

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Creating SR Dose ReportsCreating SR Dose Reports

Modalities CT, XR, XA, MX

“Readers” CR, DX, Film Digitizers

3rd Party Workstations

RIS, PACS

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Storing SR Dose ReportsStoring SR Dose Reports

Usually stored in the Study folder Archive, Backup, Reconciliation Query / Retrieve

Can be sent to other destinations

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Using SR Dose ReportsUsing SR Dose Reports

Possible applications:

Radiation QA Periodically Query / Retrieve Reports from Archive Set policies/standards and flag deviations Set goals for improvement and track; Implement protocol changes and compare difference in dose

Patient Impact Evaluation e.g. if Patient identified as pregnant post-facto

Dose Mapping Store data in realtime from Modality to Mapping Workstation

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Using SR Dose ReportsUsing SR Dose Reports

National Registries Anonymize and submit Dose Reports to Register Compile Population Risk Estimations Derive Dose Reference Levels Provide Site-Site Comparisons

Individual Dose Record Collect Dose Reports over time

Clinical Trials Collect Dose together with Images Demonstrate both improved detection &

reduced dose

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REM Profile: Actors & TransactionsREM Profile: Actors & Transactions

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2009 Connectathon Participation2009 Connectathon Participation

Vendors Planning to Test IHE REM Profile

GE

Siemens

Toshiba

Results will be posted: http://ihe.univ-rennes1.fr/con_result/

CMI

Infimed

Krucom

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What to Ask ForWhat to Ask For

IHE Radiation Exposure Monitoring Profile (REM) Check Product: IHE Integration Statement

DICOM X-ray Radiation Dose SR Storage

• CT Radiation Dose Template, or• Projection X-Ray Radiation Dose Template

Check Product: DICOM Conformance Statement

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TakeawayTakeaway

Start planning: How will this support your Radiation Safety Plan

IHE REM Profile www.ihe.net www.ihe.net/Technical_Framework/index.cfm#radiology

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Questions ?Questions ?

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TimelineTimeline

Nov. 2007 DICOM CT Dose Reports published (DICOM Proj. X-Ray Dose Reports already published)

June 2008 IHE REM Profile published http://www.ihe.net/Technical_Framework

Aug. 2008 Vendors sign up to test REM Implementations

Feb. 2009 Connectathon Testing of REM Profile (Chicago) Results posted: http://ihe.univ-rennes1.fr/con_result/

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Users

IHE

Vendors

RFP

(Profiles &Actors)

Standards

(DICOM,HL7, etc)

Standards

(DICOM,HL7, etc)

Standards

(DICOM,HL7, etc)

IHEIntegrationStatement

(Profiles &Actors)

Results

SelectIHE

Profiles

IHEIntegration

Profiles

IHEIntegration

Profiles

IHEIntegration

Profiles

IHE TechnicalFramework

Productwith IHE

IHEConnectathons

IHEDemonstrations

Real-World

Integration

Problems

The IHE ProcessThe IHE Process