The following post was contributed by Polya Baghelai, MD, medical director of imaging services at Lakeland Health in St. Joseph, Mich.
We’ve all seen the studies correlating a patient’s cumulative ionizing radiation exposure with an increased cancer risk, particularly for younger patients. As radiologists, we’re responsible for educating referring physicians about these risks and ensuring patients receive the most appropriate imaging for their clinical conditions.
Referring physicians can use ACR Select™, the web-based version of the ACR Appropriateness Criteria®, and other clinical decision support tools to select the most appropriate imaging exams at the point of order. To further improve image ordering, radiologists can institute programs to guide referring clinicians toward low-dose exams for at-risk patients.
At Lakeland Health, for instance, we recognized that time-pressed emergency department physicians and other referring clinicians sometimes ordered CT scans even when nonionizing studies could answer their clinical questions. We found a solution to the issue in a Journal of the American College of Radiology (JACR) article from Steven B. Birnbaum, MD, radiation safety officer at Associated Radiologists P.A., about patient-based radiation safety programs.
Using Birnbaum’s article as a guide, we partnered with our EHR team to implement a radiation safety program for patients 40 and younger who have had five or more CTs of the neck, chest, lumbar spine and abdomen, or abdomen and pelvis. Whenever a referring clinician orders an additional CT for a patient enrolled in the program, a Best Practice Advisory (BPA) automatically fires, encouraging the physician to order a nonionizing exam instead. (See the Imaging 3.0(TM) case study.)
We developed the program in coordination with our referring physicians, some of whom were concerned they wouldn’t be able to order a CT, even if they determined one was clinically necessary. In response, we made the BPA a speed bump that suggests ordering a nonionizing exam rather than a hard stop that prevents a referring physician from ordering a CT.
Since the program took effect in 2012, almost 70 CT orders have been canceled or changed to nonionizing exams, reducing the total radiation dose nearly 1,180 mSv — a quantifiable example of the value that our radiologists bring to patient care.