1. Managing Radiation Dose: IHE REM Profile
Kevin O’Donnell Toshiba Medical Systems
Co-chair, IHE Radiology Planning Cmte Member, DICOM Standards Cmte & WG-6 Member, MITA X-Ray Section

2. Motivation
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

3. Why Measure / Monitor
“I think patient dose is improving.”
“I think it’s getting worse.”
Managing in the presence of data is far better and easier than managing in its absence. – Robert Glass

4. Why Measure / Monitor Technology is constantly changing
Technique is constantly evolving
Understanding continues to improve
Rules of thumb and gut understanding are unstable in the face of current rapid changes that affect dose, sometimes counter-intuitively.
Our understanding of the health effects of radiation is still incomplete and continues to improve.

5. Why 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…
Physicians are asked to follow guidelines, like constraining their patients dose to As Low As Reasonably Achievable (ALARA), but they can be frustrated by the fact that it's difficult to see what a given patient's dose actually was, and almost impossible to assemble comparison values as to what is reasonably achievable.
How do you see A at your site. Where you get B (keeping in mind the moving targets) Do you collect numbers? Is it easy?

6. … A New IHE Profile
What’s an IHE Profile?

7. IHE 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

8. IHE Connectathon One Week; 70+ vendors; 350+ engineers;
Thousands of tests;
Managed process;
Find & resolve issues.
The outcome is vendor products with working implementations of IHE Profiles like REM

9. IHE Radiation Exposure Monitoring Profile
National Registry
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Over Target: 12.2%
Performing Phys.
Outlier: #
Over Target: 12.2%
Performing Phys.
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Over Target: 12.2%
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Dose Analysis
& Reporting
Archive
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10. 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
Creation, Collection, Distribution, Processing
Facilitate vendor implementation and hospital deployment of this useful new mechanism for tracking radiology dose in your institution.

11. 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)
Not addressed: NM, RT

12. 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

13. 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

14. What To Measure So many choices… Solution:
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

15. Key Measurements CT Dose Projection X-Ray Dose Mammography Dose
DLP, CTDIvol, kVP, mA, sec
Effective Dose [ Optional ] (Reference estimation method)
Projection X-Ray Dose
DAP, kVP, mA, sec
Fluoro Dose, Fluoro Time
Mammography Dose
AGD, Entrance 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

16. Other 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

17. DICOM 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.

18. Creating SR Dose Reports
Modalities
CT, XR, XA, MX
“Readers”
CR, DX, Film Digitizers
3rd Party Workstations
RIS, PACS

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

20. 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

21. Using SR Dose Reports National Registries Individual Dose Record
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

22. REM Profile: Actors & Transactions
Actor/Flow of IHE REM Profile

23. 2009 Connectathon Participation
Vendors Planning to Test IHE REM Profile GE
Siemens
Toshiba
Results will be posted:
CMI
Infimed
Krucom

24. What to Ask For IHE DICOM 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

25. Takeaway Start planning: IHE REM Profile
How will this support your Radiation Safety Plan
IHE REM Profile

26. Questions ?

27. Timeline Nov. 2007 June 2008 Aug. 2008 Feb. 2009
DICOM CT Dose Reports published
(DICOM Proj. X-Ray Dose Reports already published)
June 2008
IHE REM Profile published
Aug. 2008
Vendors sign up to test REM Implementations
Feb. 2009
Connectathon Testing of REM Profile (Chicago)
Results posted:

28. The IHE Process Users IHE Vendors Standards RFP IHE Integration
Real-World
Integration
Problems
RFP
(Profiles &
Actors)
Users
Select
IHE
Profiles
IHE
Standards
(DICOM, HL7, etc)
IHE
Integration
Profiles
IHE Technical
Framework
Results
IHE
Connectathons
IHE
Demonstrations
Users and Vendors can be sure they are talking about the same thing because their RFPs and Integration Statements reference the detailed Technical Framework.
IHE
Integration
Statement
(Profiles &
Actors)
Vendors
Product
with IHE