Perfect Pitch: Harmonizing device, manufacturer and technician approaches to ionizing dose

Medical Dealer Magazine | March | Cover Story - Pitch Perfect

In the imaging field, the most meaningful new inroads into patient safety and better health outcomes—two criteria upon which medical reimbursement will now hinge—will be driven by dose reduction strategies.

From professionally led best-practices initiatives like the Image Gently and Choose Wisely campaigns to calls from the FDA to design, market and label low-dose X-ray technologies at the manufacturer level, the imaging industry is being called upon to consider the impact of its products at a macro level.

Whether the market can deliver these improvements effectively and at what speed will depend on how quickly and completely device manufacturers, healthcare professionals and hospital purchasers can adapt to this mandate.


Although they specialize in emergent technologies designed to mitigate the impact of ionizing radiation on patients, Siemens CT product managers Wendy Kreider and Jakub Mochon are hesitant to use the term “low-dose.”

“We think that maybe low-dose is overused a bit and harder to define,” Kreider says. “We’re really trying to find the right dose.”

“The right dose” isn’t necessarily less than 1 milliSievert for every patient and every study, she says, and it isn’t necessarily something that can be achieved purely with technological solutions. But that doesn’t mean that Siemens isn’t trying to get as close as it can.

“I think that one of the most important things we can do for our customers—besides simply education—is to innovate dose-reduction techniques that can be implemented in their workflow,” Kreider says.

The more automation that’s present in the scanning process, Mochon says, the better the patient outcomes across the board. Selecting the right modality and using the lowest possible dose for a pediatric patient is easier to do in a specialty facility that treats children exclusively. But when that same patient presents in the emergency room of a non-pediatricspecific hospital, he says, the scans still need to be done with the least amount of risk to the patient.

“What we’re focusing on is making sure that the use of it is automated, so that it doesn’t depend on the technologist sitting at the console or how tired they are,” Mochon says.


A proven method to lower the amount of radiation absorbed by the body is to lower the amount of energy per thousand electron volts (kV) that passes into it. Stepping down by 20 kV from 120 to 100 or even from 100 to 80 kV lowers the amount of radiation dose in nonlinear function, Kreider points out. “Yet when you look out there at the clinical routine, most people are just scanning at 120 kV.”

“Why is that? When you lower your kV, you need to raise your mA (milliamperage, the measure of tube current) to maintain image quality.” This is not always an easy task and can impact the technologist’s workflow.

In response, Kreider says, Siemens has developed a technology called CARE kV, which automatically selects the optimal kV and in turn adjusts the mA based on the type of exam conducted and the power needed to scan the patient habitus. After setting it up, there’s nothing else the technologist needs to do, she says.

“Your contrast to noise is not changed,” Kreider says. “Just by turning this on in a typical facility, two-thirds of your scans can go from 120 to 100 kV. In addition to CARE kV Siemens offers an advanced iterative reconstruction software called SAFIRE (Sinogram Affirmed Iterative Reconstruction). So we start with a lower kV and then can further lower mA using SAFIRE to reduce the increased noise and you’ve got an image that is just as good, if not tter, than a filtered back projection image with a lower dose.”

Along with Care kV, Siemens has developed a product called CARE Child, which gives the opportunity to scan at 70 kV, “which nobody else is doing right now,” she says.

Another design element that Siemens is working to integrate in its CT units is a piece of technology called the Stellar detector.

Communication among different electronic elements of a CT detector can lead to signal drops, which produces a noisier image. The Siemens Stellar detector eliminates 20 percent of electronic noise, which produces an image of higher diagnostic quality, he says.

In addition to automating the processes that allow for more opportunities to scan at a lower dose, Siemens is working to develop best practices and professional education to help technologists and patients both to spend less time on the scanners themselves.

“We have a variety of FAST applications,” Mochon says. “They’re all related to the automation of things that could be automated. We also work extensively on applications that work in the background without interference with standard.”

“We have an application called Neuro Best Contrast that is built into the imaging reconstruction on our scanners,” he says. “That is the area that we continue to innovate at all times. Another example is Edge technology that works in the background to enable better resolution.

“We’re definitely trying to innovate in a way to automate a lot of the processes,” he says, “but there are some ways in which education is important.”


Small things that technologists do, like patient positioning, can affect the dose, Mochon points out. Yet such things are “too often omitted” from discussions about ways to improve patient outcomes or imaging center throughput.

“The more things that we will do on our side will probably in an automated way ensure perfect positioning of the patient,” he says. “Even today when scanning the head, the scanners with Fast Planning will iso-center the patient for optimized examination’

In the past few years, Kreider says, Siemens has developed and hosted dose-reduction webinars and an “optimized care” consulting process that brings Siemens representatives onsite to visit with customers and develop better workflow procedures.

“We go in and work with them one-on-one for a little while,” Kreider says. “We give them a roadmap for a little while, and at the end of the program, we go back and look at where they are today. Many of our customers we see, they have the same contrast protocols with a Siemens SOMATOM Definition Flash CT system that they did with a 4-slice CT. It really encompasses contrast dose and workflow.”

Speed and automation not only limit the amount of time a patient must spend on the scanning table, but they also factor into how quickly a patient diagnosis can be obtained—say, when trauma center physicians are trying to identify the complexity of a fracture or the severity of a head injury.

Best-practices dose management techniques and improved workflow strategies not only improve the overall throughput of a hospital or imaging center, but they also will play a greater part in delivering the personalized care toward which the medical field is headed. Things like patient data accumulation software can help identify the “frequent flyers” in the E.R., Mochon says, which can help providers make sure “that you don’t use imaging too often on the same patient.”

“I think something that you are going to hear about is actually measuring dose [more accurately],” Kreider says. “We look at K factors to take a DLP (dose-length product) dose value to a mSv; is that really accurate? It’s made for an average, and doesn’t really take into consideration the patient size,” she says.

Information on size-specific dose measurements “will help all the vendors and healthcare facilities” with some of the pending regulations, Kreider says. Even a decent dose of ionizing radiation in most cases is preferable to the iatrogenic risks of exploratory surgery.

“I think getting to that right dose in an automated way is probably where the future is going to be,” Mochon says. “I don’t think we’ll be able to totally run away from ionizing radiation. We could probably do a lot of these on an MRI. But when you need a quick diagnosis, there’s no better tool than CT.”


Although the latest and greatest technology is certainly the optimal way to attack the problem of dose reduction/optimization, not every hospital is able to afford the bestavailable technology, says Robert Costa, Director of Global Sales for the United Kingdom-based Oxford Instruments.

That’s why there’s a premium on what he calls “value-added” refurbished devices—i.e., those that come preloaded with dose-reduction and image intensification/ magnification software.

“Refurbished gear has a huge value,” Costa says, “but if we were able to get it with that software on there,” it can add to the dollar figure. By way of example, he says that the ASIR software developed by GE can add a few extra zeroes to the value of a refurbished piece of equipment. (The software alone retails for $180,000 to $200,000 from the manufacturer, he says).

But even aftermarket or thirdparty post-processing software along the lines of SAFIRE is hardpressed to deliver “that 50 percent [dose reduction] that everybody’s touting,” Costa says.

“It would almost force you into getting that level of software [from the OEM,” he says. “Before you can even get a decent image out of [most third-party solutions, the image] has to go out of their software to a server and then to a PACS system. You’ll ever see it back on the console.

“But if you have no choice to afford $200,000...that’s your only option,” Costa says.

Costa forecasts that without federal legislation mandating greater dosereduction technologies as standard issue on scanning platforms, equipment upgrades are going to be the only way to achieve those ends.

“They’re targeting more of the older equipment,” he says; “there’s actually been some mandates out where you’ve got to have some four-slice [scanners] before Medicare will reimburse. There’s really nothing that’s mandated; it’s more of, ‘hey, we get it.’

“It’s also how it’s being tracked for the life of the patient,” Costa said. “Until you have some common system that tracks the cumulative dose... until they figure out a way that I don’t have to take my child to five different radiology centers to keep them from getting blasted with the scan— what stops that?”
In the meanwhile, Costa says, the expansion of refurbished MRI devices is accounting for a greater and greater portion of the business he does—as much as “50 percent of our core business,” he says. Even with that being the case, Costa said there will still be a greater need for low-dose CT simply given the applications of the technology and the breadth of its installation base.

“Let’s say Obamacare kicks in and everybody has access to this equipment,” he says. “The system’s going to be buried. ‘My knee’s been bothering me, what do you mean I have to wait six months?’ An MRI takes a lot longer to get that image. CT provides not just an image to go get in the guy’s head. It’s right next to the emergency rooms, trauma centers, because it’s fast. You can get the image up in a couple minutes as opposed to a couple hours.

“A guy who’s traumatized [may not have that time to wait],” he says.


ECRI Senior Associate Rohit Inamdar, who provides device consulting to hospitals, says thorough training can prevent many dosing errors. Inamdar visited several California medical centers where technicians had imaged single slices of stroke patients’ brains as many as 40 times using CT perfusion, using up to eight times the normal radiation dose. The technicians had not received proper training for the new procedure.

“When you’ve got pretty high dose technologies in use, if you introduce a new procedure and you failed to train your staff on that new procedure, there’s a second risk in high-dose technology,” Inamdar says.

“If you are a patient you should expect good care. What do we all do to make sure these quality standards are met?” Inamdar says that because most dose events are a result of human error, anyone who touches radiation-emitting equipment should take ownership in dose optimization. To avoid errors from the outset, training should be considered as part of the cost of new equipment. “When you buy a $1 million or $2 million CT scanner, put refresher training into your cost and then compare one vendor’s offer against another,” he suggests. “This is where you can negotiate ongoing training and put it into the cost of your product.”

Two groups need training: those operating the equipment and those maintaining it. “You make sure you have people who are trained on how to maintain that product, because this is how you keep your product running safely,” Inamdar says.

In a facility that is operating older equipment, biomeds’ ability to keep all components in good shape can go a long way. “Image intensifiers in old fluoroscopy systems lose their ability to intensify, and over the years you’re using slightly higher and higher dose,” Inamdar explains.

Purchasers should also consider cost-effective add-ons. “There are third-party products that do dose optimization at a quarter of the cost... that will reduce dose 40 to 80 percent by optimizing the image,” Inamdar says, though expectations should be realistic. For example, “It might take a few seconds extra in this [third-party] workstation. An extra few seconds – does that really impact what you’re doing; your operation? It doesn’t.”