Experts agree: Physicians have become too reliant on High Technology Diagnostic Imaging (HTDI).

"I always say the CT scan is the new physical exam," said Dr. Joseph Barkmeier, Medical Director of Diagnostic Services at Carle Foundation Hospital, as he introduced How Much is Too Much? High Tech Imaging Use and Radiation Safety, a Quest-sponsored continuing medical education (CME) conference in Urbana on May 24. A similar conference was held in Chicago on May 23.

"Unnecessary radiation exposure from HTDI is predicted to be the next asbestos," said Quest President and CEO Dr. Gail Amundson. "HTDI is the fastest growing physician-directed expenditure in healthcare, far outstripping general medical inflation."

Nationally, it is estimated that 20 to 30 percent of currently performed HTDI exams are medically unnecessary or inappropriate, accounting for about $30 billion in waste annually and exposing patients to cancer causing radiation.

Said waste includes inappropriate and duplicate testing, and also costs associated with incidentalomas. Incidentalomas are things identified that did not need to be, including shadows that are "just doing dandy inside us" that are discovered and treated needlessly, according to Amundson.

The increase in HTDI is due to many factors including technical advances, fragmented care, proliferation of equipment, defensive medicine, aging patients, patient demand, and fee-for-service payment.

"We got all kinds of things bumping around in this equation," said Dr. Robert Parker, Chief Medical Officer of Health Alliance Medical Plans. Parker added that reform will mean cultural change with many barriers, including doctors resistant to control or simply determined to maximize care.

"We are always afraid of missing something. We miss something, we lose," said Parker. The reasons might be benevolent, but the overuse of HTDI is unsustainable.

Decision Supports

Decision-supports tools offer a potential solution to unnecessary imaging. Embedded in the electronic order process, decision-supports guide the provider through a series of criteria to help determine and/or reinforce judgment for appropriate imaging.

Decision support systems do not deny a scan. They simply help ensure the doctor has considered everything and may also provide evidence-based support for a patient questioning the physician's decision.

"It is called decision supports. It supports the decision. It doesn't make the decision for you," said Dr. Philbert Chen, physician at Carle Foundation Hospital and Medical Director at Community Partners Health Plan.

"This makes me a better physician," said Amundson.

Decision-support solutions are proposed to replace Radiology Benefit Management (RBM) processes, which require the provider to submit a request to the insurance company before the test can be performed.

"RBMs are a Rube Goldberg add-on that made a complex system more complex," said Dr. Barry Bershow, former Vice President for Quality for Fairview Health Services. RBM processes are described as an expensive, temporary solution that does not change physician thinking.

"Does anyone know how to teach a dolphin how to jump through a flaming hoop?" Bershow asked.

As the dolphin accomplishes milestones, Bershow explains, it is rewarded with a herring. Eventually, the dolphin associates leaping through the hoop as a rewarded activity. The conditioning does not work unless the dolphin is immediately rewarded. Decision supports offer that immediate feedback to influence the doctor's imaging philosophy.

"Doctors are really like dolphins," Bershow said.

Radiation Dosage

According to data gathered from events at Hiroshima and Nagasaki, it is estimated that approximately 29,000 future cancers could be related to CT scans performed in 2007. And Americans are taking in more radiation than ever before.

The United States population's total radiation exposure nearly doubled over two decades due to an increase in CT, nuclear medicine, and interventional fluoroscopy. In the early 1980s, medical procedures accounted for 15 percent of the US population's radiation exposure. In 2006, that number more than triples to 48 percent, while at the same time, the total radiation exposure per individual nearly doubled from 3.6 to 6.2 mSv (millisiever).

Conference participants were provided with reference cards to easily equate the radiation dosage of each test by its equivalence in number of chest X-rays. This is information that has not always been readily available to providers. Contact us for your card (309-282-8820).

"I do not fault clinicians for not knowing this," Amundson said. The chest X-ray packs an estimated radiation dosage of .02 mSv, the equivalent of radiation gathered on a round trip flight between New York and Los Angeles. Coronary Angiography, for example, carries an estimated effective dose of 20 mSv, the equivalent of 1000 chest X-rays. This shocked the audience.

Interested in your annual radiation dosage? The American Nuclear Society provides this calculator. To get a better idea of radiation dosages, including comparisons to nuclear accidents and fatal dosages, check out this chart. (Note the disclaimer at the bottom.)

Health Information Exchange

Denise Graves, owner of Health and Services of Peoria or HSPeoria.com, served on Quest's High Tech Imaging Team. Representing the consumer perspective on the panel, Graves spoke on recent events where she used her knowledge gained from the team to advocate for herself and her family.

"Before, we just plain trusted our doctor, even if we didn't know what was going on," said Graves. She encouraged other consumers to take control of their own care.

"There is currently no hub the doctor can plug into and see the history for a patient," said Graves. "You need to be that hub for the doctor."

That hub is under construction in the form of the Health Information Exchange (HIE). HIE is a dedicated network to share patient information from electronic medical records, insurance claims, and other sources, such as prescribing information, in an electronic format between healthcare providers.

For example, an HIE makes it possible for a physician, with patient permission, to have access to a patient's complete health history during an office visit.

If tests are conducted at three different hospitals and a physician office, the physician will be able to see all the results from participating organizations. HIE will help prevent duplicate testing and help providers flag patients who may be risking radiation overexposure.

How much is too much?

One question stumped the panel. The question came from a retired doctor, who drove all the way from Peoria to get the answer to the conference's title question.

"How much is too much?" the doctor asked, his wife receiving radiation treatment for multiple cancers.

"More is worse," Chen said, adding that there is a risk / benefit trade-off in effect. "It depends on what level of worse you are willing to tolerate. Every single dose causes damage. The body can repair itself to an extent."

The question is certainly relevant concerning ongoing issues with nuclear reactors following the recent earthquake in Japan. However, science is unable to provide rigid gauges. The result is radical variation across hospitals, labs, and even individual providers.

However, the movement to curb such overuse is gaining momentum and media coverage. Decision supports are being used successfully and improving care in other states. Quest has been instrumental in starting the discussion about the use of decision supports for high tech imaging orders in Illinois.

"Quest is really your vehicle to do this in Illinois," said Amundson.