Automated EMR Dose History Extraction and Monitoring Aaron Sodickson MD, PhD Section Chief, Emergency Radiology Medical Director of CT, Brigham Radiology Network Brigham and Women s Hospital Harvard Medical School
Disclosures Consultant, Siemens Consultant, Medrad
Objectives Highlight the need for radiation dose history extraction, and desired functionality Demonstrate tools for automated EMR extraction of radiation exposure data Outline quality / patient safety use-case examples Describe use of this data for longitudinal patient-centric dose monitoring
A Drop in the Bucket
Incremental risk argument Exam indications - shades of gray Episodic care decisions cumulative risk vs cumulative benefit
Cumulative Exposure (msv) Patient FP - Cumulative Exposure and LA at 1 X, 1/2 X, 1/4 X Projected CT Rates 4000 3750 3500 3250 3000 2750 2500 2250 2000 1750 1500 1250 1000 750 500 250 0 25 30 35 40 45 50 55 60 65 70 75 80 Age 25 20 15 10 5 0 % Lifetime Attributable Risk (LAR) above baseline
What Can We Do?
Dose Reduction Opportunities 1. Before Scan - Reduce Drip Rate Imaging algorithms, evidence based imaging Decision support: appropriateness, radiation risk Non-ionizing alternatives? Ultrasound, MRI 2. During Scan - Reduce Drop Size Dose-optimized protocols - find the sweet spot Lowest exposure appropriate for the clinical scenario Robust, diagnostic quality exams 3. After Scan Capture patient / exam specific exposure information Convert to patient dose using anatomy, size 4. Continuous Longitudinal dose & risk monitoring in EMR
EMR Dose Extraction: Why Do It? Scientific Test / refine models of biological effects at low dose Regulatory oversight Equipment & practice performance Organization / Institution Benchmarking, quality improvement, patient safety Equipment / Scanner Quality assurance, technique optimization Patient Longitudinal dose monitoring, risk assessment Better informed decision making
EMR Dose Extraction: Desired Features All sites of care All modalities / sources of exposure Modality-specific exposure / technique metrics Accurate patient-centric dosimetry Standardized database format All systems connected!
EMR Dose Extraction: Current Reality Fragmented EMRs, not connected Hospital-centric, not patient-centric Independent modality-specific efforts Different exposure metrics, platforms CT, fluoroscopy Missing important data elements Exposure metrics dose Data access is limited Inaccessible format (screen captures, text reports) Buried in disconnected systems
NEED: Validated Risk Models Reproduced from: Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci USA 2003;100:13761-13766
NEED: Validated Risk Models Need better data in the low dose regime to DIRECTLY test the dose-response curve Need ACCURATE dosimetry in large number of patients to detect increased cancer incidence above 42% baseline Informatics methods for large-scale dose capture testing of underlying risk models
NEED: Better Patient- and Exam- Specific Dosimetry Capture of modality specific exposure metrics CTDI vol, DLP Conversion to patient dose estimates Link to exposed anatomy Correct for patient size 1. McCollough, Leng, Yu, Cody, Boone, McNitt-Gray. CT Dose Index and Patient Dose: They are NOT the Same Thing. Radiology (2011) 259; 311-316 2. Boone, Strauss, Cody, McCollough, McNitt-Gray, Toth. AAPM Task Group 204. Size-Specific Dose Estimates in pediatric & adult body CT exams. 2011 3. Huda, Scalzetti, Roskopf. Effective doses to patients undergoing thoracic computed tomography examinations. Med Phys 2000; 27(5):838-844
GE Dose Screen Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Siemens Dose Screen Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Toshiba Dose Screens Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Philips Dose Screen/Sequence Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
There are many years of exposure data in existing image archives Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Exposing Exposure: Automated Anatomy and Dose Extraction from PACS Cancer Center Community Hospital Main Hospital Outside 400 350 300 250 200 Total Abdomen/Pelvis Head Chest Neck 150 100 50 0 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11
GROK Generalized Radiation Observation Kit Name from RA Heinlein, Stranger in a Strange Land Code extended from David Clunie s open source PixelMed DICOM Toolkit Optical Character Recognition (OCR) of dose report screens, combined with image DICOM attributes Extracts CT exposure metrics CTDI vol and DLP Automatically assigns the exposed anatomy http://www.brighamandwomens.org/research/labs/cebi/grok/
GROK Validation Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
GROK Validation Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Institutional Benchmarking Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
CT Protocol Quality Control Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
CT Protocol Quality Control
CT Protocol Quality Control
Patient-Centric Longitudinal Dose Monitoring Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Patient-Centric Longitudinal Dose Monitoring Sodickson, Warden, Farkas et al. Exposing Exposure: Enhancing Patient Safety Initiatives through Automated Anatomy-Specific CT Radiation Exposure Extraction. Radiology 2012 (in press)
Mettler, Bhargavan, et al. Radiologic & Nuclear Medicine Studies in the US & Worldwide. Radiology 2009; 253;520 PARSE GROK GROK PARSE GROK = General Radiation Observation Kit PARSE = Perl Automation for Radiopharmaceutical Selection & Extraction http://www.brighamandwomens.org/research/labs/cebi/grok/ http://www.brighamandwomens.org/research/labs/cebi/parse/
PARSE Perl Automation for Radiopharmaceutical Selection & Extraction Ikuta, Sodickson, Wasser et al. Exposing Exposure: Enhancing Patient Safety through Automated Data Mining of Nuclear Medicine Reports for Quality Assurance and Organ Dose Monitoring. Radiology 2012 (in press)
PARSE Validation # tracers: 1 1 >1 Combined # injections: 1 >1 >1 Bone Scan Tc-99m MDP Rest / Stress cardiac Tc-99m sestamibi V/Q scan Xe-133 / Tc-99m MAA Ikuta, Sodickson, Wasser et al. Exposing Exposure: Enhancing Patient Safety through Automated Data Mining of Nuclear Medicine Reports for Quality Assurance and Organ Dose Monitoring. Radiology 2012 (in press)
Distribution of Administered Activity for I-131 Sodium Iodide Frequency Administered Activity (mci) Ikuta, Sodickson, Wasser et al. Exposing Exposure: Enhancing Patient Safety through Automated Data Mining of Nuclear Medicine Reports for Quality Assurance and Organ Dose Monitoring. Radiology 2012 (in press)
Quality Assurance Ikuta, Sodickson, Wasser et al. Exposing Exposure: Enhancing Patient Safety through Automated Data Mining of Nuclear Medicine Reports for Quality Assurance and Organ Dose Monitoring. Radiology 2012 (in press)
Dose Calculations PARSE Organ Dose = (mci) * (37) * (conversion factor) Effective Dose = Σ T [ (Organ Dose) * (W T ) ] 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann ICRP. 2007;37:1 332. Stabin, Stubbs, Toohey. Radiation Dose Estimates for Radiopharmaceuticals. Washington, DC: U.S. Nuclear Regulatory Commission, U.S. Department of Energy, U.S. Department of Health and Human Services; 1996.
Cumulative Doses, Breast Cancer Patient Ikuta, Sodickson, Wasser et al. Exposing Exposure: Enhancing Patient Safety through Automated Data Mining of Nuclear Medicine Reports for Quality Assurance and Organ Dose Monitoring. Radiology 2012 (in press)
Acknowledgements NIH - National Library of Medicine: R01LM010679-01: Automated Radiation Monitoring and Decision Support to Reduce Cumulative Exposure BWH - Center for Evidence Based Imaging Ramin Khorasani Graham Warden Ichiro Ikuta Luciano Prevedello Eliott Wasser Kathy Andriole Ali Raja Cami Farkas Bobby Bransfield Dick Hanson http://www.brighamandwomens.org/research/labs/cebi/grok/ NAS/IOM http://www.brighamandwomens.org/research/labs/cebi/parse/ 12/08/2011
Automated EMR Dose History Extraction and Monitoring Aaron Sodickson MD, PhD Section Chief, Emergency Radiology Medical Director of CT, Brigham Radiology Network Brigham and Women s Hospital Harvard Medical School