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

2. Motivation • 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. 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

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5. REM Profile: Actors & Transactions

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. 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. 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

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… • 3rd Party Workstations • RIS, PACS

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

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. 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/ )

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 )

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

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. 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