THE HEIGHT OF LOW

North Shore-Long Island Jewish Health System is poised to lower radiation dose and improve patient care.

How low can you go?

That’s the question North Shore-Long Island Jewish Health System is asking as it embarks on a project to completely equip its hospital system with low-dose imaging technologies, particularly low dose CT.

In 2009 and 2010, concern about patient radiation dose had reached a fever pitch. Patient CT radiation exposure cases headlined news reports, and studies relating CT scans to higher incidences of cancer gave the issue of radiation exposure during medical imaging a high profile.

The issue didn’t go unnoticed at North Shore-LIJ.

“There has been a lot of attention in the media regarding the potential of radiation exposure,” said John Pellerito, MD, North Shore-LIJ’s chief of CT imaging and associate chairman of radiology. “Not just from CT, but from all radiological studies.” And his patients aren’t shy about sharing their concerns about CT scans, particularly parents with regard to their children.

“We have a lot of wise consumers, and they ask the appropriate questions about when a CT scan is necessary,” he said. “And I’ll reassure them that CT scanning is very safe when used appropriately, and that it’s an effective tool that can save lives. But patients still have concerns.”

According to Michael Dowling, North Shore-LIJ CEO, “The potential of radiation exposure from a lot of CT usage is the essence of a quality issue, and in our system we focus on quality each and every day. It’s part of our DNA.” So with that in mind, North Shore-LIJ started looking at how it could promote this quality agenda by examining issues related to the appropriate utilization of CT and the reduction of radiation dose associated with CT.

North Shore-LIJ initiated a review of its diagnostic imaging equipment used in the system’s 14 hospitals and six outpatient facilities and drew up a $50 million plan to replace and upgrade its radiological inventory with low dose technology.

The program includes upgrades to all modalities, including MRI and ultrasound as well as devices associated with radiation such as x-ray. And part of the plan includes collaboration with GE Healthcare through which North Shore-LIJ is installing GE low dose CT scanners in locations around the New York City area in the next year.

“GE has been one of our vendors for years, and when we went out and did a competitive bid, GE had the best, most robust and innovative technology. And we were impressed by their willingness to work with us as a partner,” Dowling said.

GE Blueprint for Low Dose

At RSNA 2011 last November, GE announced that it was investing another $300 million in low dose technologies and unveiled a variety of dose management product features that now are encompassed within what GE calls its “blueprint for low dose”—another part of GE’s collaboration with North Shore-LIJ.

“For the past several years, we’ve been looking at what it really takes for a health care provider to provide a low dose, high performance CT imaging program,” said Ken Dennison, CT dose leader at GE Healthcare. “And what we are really aiming at is taking the best practices from around the country. That’s really what the blueprint is—it’s the documentation of what the ideal CT imaging program would look like and how to get there.”

A critical part of the blueprint is, of course, the technology. In the case of North Shore-LIJ, the blueprint incorporates 16 advanced CT systems and associated low dose technologies including DoseWatch, a dose management solution that automates the tracking and archiving of dosimetric data; Veo*^, an image reconstruction program that can help physicians produce clear CT scans while exposing patients to under 1 millisievert of radiation; as well as gemstone detectors and dual energy spectral imaging capability.

But, while technology is important, the blueprint involves more than the implementation of the correct hardware and software. It also requires, Dennison says, that health care providers establish the right leadership systems, correct organizational structures, as well as effective competency and training programs.

“They also need to have the right practices in place,” Dennison said. “Including everything from the protocols run on CT scanners to the process through which they develop those protocols, to the way in which they review dose information, track it, measure it, report it, and use it in protocol optimization.”

While North Shore-LIJ is the first to implement the program on a system-wide basis, Dennison says that the plan is for GE to offer this to large health systems around the country.

“The idea is to assess their [health care systems’] current CT practices against the blueprint standards,” said Dennison, with the ultimate goal of helping these health care providers reduce their average patient exposure to radiation by up to 50%, based on longitudinal tracking of average dose.

“And we know that’s achievable,” Dennison said, adding that as a leader in the industry, GE “felt it was time to step up and work hand in hand with health care providers to realize the value of the technologies they are buying and installing and to get the most out of them.”

According to Dennison, GE is getting ready to announce a partnership with several other health care systems, in addition to North Shore-LIJ. “But it’s not going to be a one-size-fits-all model,” he explained. “We do think there are components of the model that fit everywhere, and adapting them to other systems—based on their current situation, capabilities, and clinical needs—is what the blueprint is all about.”

The initial step in the process of incorporating the blueprint in a health care system is to go through an assessment process, which, says Dennison, usually involves a series of interviews with key stakeholders involved in running CT programs—such as radiology directors and administrators, radiologists, technologists, or radiation officers.

“Beyond that, it becomes a series of conversations about how we can work together to implement a solution,” Dennison said. “And those become very customized around the strengths and opportunities in each individual system.” That solution could involve a number of steps, including staff dose management education, process improvements, and equipment assessments.

Since North Shore-LIJ is the first large system that has implemented the blueprint, Dennison says that GE wants North Shore’s experience to demonstrate that this programmatic low dose strategy works.

“We have seen the programmatic approach work in some health care centers,” Dennison said. “For example, we’re going to be publishing a guidebook associated with a GE blueprint program that we developed in conjunction with New York-Presbyterian/Weill Cornell. They’ve seen a 34% to 44% reduction in dose without adopting new technology, without doing anything other than focusing on how to take a scientific approach to getting to the right quality diagnostic imaging at the lowest possible dose.”

In North Shore’s case, GE plans on gathering pre- and post-implementation data of some of the blueprint program practices, such as the DoseWatch tracking system and the Veo*^ technology, submit it to a third party (Oxford Analytica) for analysis, and have those practices validated. According to Dennison, GE recently went through a similar kind of analytical process to validate a stroke care solution at Saint Luke’s Neuroscience Institute in Kansas City, Mo.

A Win-Win for the Hospital and the Patient

While Dowling acknowledges there is a serious expense involved in this project—the 16 GE low dose scanners will cost $12 million—”if there is a technology out there that protects patients from radiation, then this is what we should be doing.

“We like to think we are innovative and the first to the market to do a lot of these things,” Dowling said. “So hopefully we’ll have an advantage in that we’re doing everything we can to minimize harm to the patient from any technology we use. It’s a win-win—but the real winners will be the patients who can be confident that if they come to us for a CT, they are going to get the low dose.”

Pellerito is looking forward to taking advantage of what the GE low dose technology, such as dual energy spectral imaging, has to offer. “For example, we’ll be able to do a single CT angiogram and be able to produce an image where you can just see the angiogram with the bone subtracted, without having to do a pre- and post-contrast scan,” Pellerito said, adding that a common application of that dual energy technology will be in distinguishing between calcium kidney stones and noncalcium stones, by doing just a single scan.

He expects the new scanners to be installed in 10 North Shore-LIJ facilities over a 6-month period and, like Dowling, believes that the North Shore-LIJ low dose partnership with GE says something about his health care system’s commitment to quality and patient safety.

“We’re excited that our system is one of the first in the country—certainly the first in our area—to offer this [low dose blueprint] to our patients,” said Pellerito. “We’re able to offer patients a safer alternative and I’m excited that our patients are going to benefit from this.”

Dennison believes that beyond the desire to lower dose, the importance of North Shore-LIJ’s involvement—as well as the involvement of other health care systems—in the GE Blueprint program is the sharing of information and best practices.

“Usually, community health care systems don’t have access to the caliber of physicists and radiologists who are at the bigger academic programs,” he said. “But through the blueprint, we think we can spread a lot of that expertise and knowledge and continue to drive dose lower. There’s a huge opportunity here for CT imaging to be seen as a quality leader, and when you look at how health care is changing in this country, that’s really where we need to go—to demonstrate high-quality outcomes and the best results for our patients.”

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Michael Bassett is a contributing writer for Axis Imaging News.