1. Radiation Exposure Monitoring (REM) Profile Kevin O’Donnell Toshiba Medical Research Inst. - USA Co-chair, IHE Radiology Planning Cmte IHE Radiology

2. 2Motivation X-Ray based imaging can provide tremendously useful information Patient Dose is an important consideration Potential benefit > potential risk … but risk should be managed responsibly

3. 3 A 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

4. 4 IHE Radiation Exposure Monitoring Profile some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 National Registry Archive Dose Information Reporter some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 Outlier: # Performing Phys. Over Target: 12.2% Outlier: # Performing Phys. Over Target: 12.2% Outlier: # Performing Phys. Over Target: 12.2% some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 some text: # Numerical Details 12.2 14.5 11.8 7.6 9.5 10.9 Numer 12.2 14.5 9.5 10.9

5. 5 REM Profile: Actors & Transactions

6. 6 DICOM 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) – DR/CR Not yet addressed: NM, RT

7. 7 Key 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/2009/09_16pu.pdf

8. 8 Other Details in Dose SR Full Patient / Order / Study Details Unique ID for each Irradiation Event Equipment ID, Ordering Doc, Performing Tech Patient Position, Anatomy imaged Imaging Geometry (projection) Collimation X-Ray Filters, Anode Target Material Calibration, Phantom, Dosimeter

9. DICOM SR Template 9

10. 10 Creating SR Dose Reports Modalities – CT, XA/XRF, X-Ray, Mammography “Readers” – CR, DX, Film Digitizers – Note challenge if tube and detector don’t talk… 3 rd Party Workstations RIS, PACS

11. 11 Storing SR Dose Reports Usually stored in the Study folder – Archive, Backup, Reconciliation – Query / Retrieve Can be sent to other destinations

12. 12 Using 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

13. 13 Using 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

14. IHE REM Changes Final Text CPs – CP195 - Internationalize Series Description (RAD-62) – CP197 - Replace Register with Registry – CP198 - Remove weakening of DICOMDIR (RAD-63) Almost Final Text CPs – CP196 - REM De-identification (RAD-63) – CP199 - Patient Longitudinal Record Use Case – CP200 - Alternative Submission Transport Mechanisms (RAD-63) – CP203 - Require Irradiation Event UID in Images – CP204 - Record Patient Characteristics in Dose Reports ( See www.ihe.net/Technical_Framework/ ) 14

15. DICOM SR Changes Incorporated CPs – Use DICOM 2009 PS3.16 – incorporates CP-874 and more Final Text CPs – CP-957 – Add CT Exposure Modulation Type – CP-963 – Add DateTime Started to Irradiation Event WIP CPs – CP-1063 – Clean-up Dose Reports – CP-1065 – Improve Device Identification – CP-1068 – CT Scan Location – CP-1070 – Additional Codes for Dose Information Source – CP-1075 – CT Dose for Constant Angle Acquisitions – CP-1076 – Fix participant relationship in TID1020 – CP-1077 – CR Dose Report ( See dclunie.com/dicom-status/status.html ) 15

16. Profile Overviews: Profile Specs.: Profile Overviews: wiki.ihe.net/index.php?title=Profiles Profile Specs.: www.ihe.net/Technical_Framework

17. 17 Why not use 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

18. 18 Why not use MPPS? Modality Performed Procedure Steps – Status messages back to RIS / PACS Transient Information – designed for workflow; not persistent archiving Lacks complete dose details