Two expert presenters – one from the U.S and one from Europe - offered review and advice to a remote audience last week about increasing regulations to document and optimize patient radiation exposure.

The webinar, entitled “Informatics Resources for Radiation Exposure Monitoring (REM)" was hosted by the Society for Imaging Informatics in Medicine (SIIM), and roughly 100 imaging experts tuned in.

“I think folks have been taken by surprise by XR-29 and the PAMA requirement, even though the discussion has been going on for some time,” Dr. Tessa Cook, Ph.D., assistant professor of radiology at the University of Pennsylvania told HCB News. She was one of the two webinar presenters. “The Joint Commission requirement for July 1, 2015 (documenting parameters in the EMR) was much easier to meet, as most sites at least already had scanners that generated legacy dose sheets…”
Cook noted that there has been confusion about the requirements to make imaging equipment compliant with XR-29. XR-29 was included in the Protecting Access to Medicare Act (PAMA) under an aggressive timeline to improve patient radiation exposure safety. The XR-29 provisions of PAMA went into effect at the beginning of this year.

In the presentation, Dr. Cook made three main points to the audience:

• Radiation exposure monitoring is more than just installing software


• Periodically reviewing and acting on dose indices is the most effective way to decrease radiation exposure for patients without sacrificing diagnostic image quality


• The radiation exposure monitoring initiative must be a collaborative effort between radiologists, medical physicists, and IT/CIIP experts in order to be successful

She also stressed another often misunderstood aspect of meeting the new standards.

“It’s always important to remember that we are monitoring dose indices, not actual patient doses,” said Cook. “If these are included in a radiologist’s report, it is wrong to say “your radiation dose for today’s examination was X mGy or Y mGy-cm. This propagates misinformation and causes patients to worry about whether they are getting too much radiation.”

Starting the beginning of this year and going forward, XR-29 reduces imaging payments up to 15 percent if CT scanners do not meet new operating requirements. These include: DIACOM XR-29-2013 compliance; CT dose check features; automatic exposure control; and adult and pediatric reference protocols.

Depending on the requirement, there are also other challenges, according to Dr. Cook. In California in 2012, for example, she said that radiologists did not want to risk making mistakes by typing the dose indices into every CT report. A solution centered around finding radiation monitoring vendors with products that would automatically extract that data to integrate it into the report.

However, with XR-29, she said, compliance may require a firmware upgrade. This becomes a cost-benefit budget decision weighing the lower payments to upgrade cost, as well as patient safety considerations.

“There has also been confusion about what’s required to make equipment compliant with XR-29 - software add-ons, firmware upgrades, replacement - and how to document compliance, when audits may occur, and what form they would take,” Cook noted. “There is now very helpful information on the Medical Imaging and Technology Alliance’s website regarding all this, including a letter from MITA to CMS and the response from CMS.”

The second presenter, Annalisa Trianni, DMP, a medical physicist at Udine University Hospital in Italy, reiterated many of Cook’s talking points. She said that European legislation has also been enacted and is pending related to patient radiation safety. Trianni added that in some cases reproductive exams are required to be offered for patients depending upon their exposure levels. And she noted that there is a need for common dose language in Europe.

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