This post will be of particular interest if you are an imaging professional at a US hospital or imaging center that performs CT scans on Medicare or Medicaid patients – even more so if you manage the equipment budget.
Having addressed all the new state regulations and Joint Commission recommendations on CT radiation exposure tracking and minimization, you may think that you are on top of things. But there is another impending item by the name of NEMA-XR-29-2013 that you may need to factor into your plans.
Depending on an institution’s exact situation, NEMA-XR-29-2013 could either be a pebble or a boulder, financially speaking.
What is NEMA-XR-29-2013?
While it sounds like the name of a robot from a science fiction movie, NEMA-XR-29-2013 is actually a standard assembled and published by the National Electronic Manufacturer’s Association with the title: Standard Attributes on CT Equipment Related to Dose Optimization and Management.
The standard basically describes a number of capabilities that a CT scanner should have in order to be considered up to date with respect to minimizing a patient’s radiation exposure due to scans.
Why should I care?
This somewhat obscure standard would be mainly the concern of device manufacturers and RFP writers except for on additional thing: the Protecting Access to Medicare Act of 2014. Starting in January 2016 if you perform a scan on a CMS patient on a scanner that fails to meet the NEMA standard above, you will get paid 5 percent less than normal. Furthermore, in 2017 that penalty will increase to 15 percent. Therefore, it is worth a check to see where your CT equipment stacks up against the standard and use this penalty to figure out what it might cost to fix deficiencies.
How bad is it likely to be?
As the “2013” in NEMA-XR-29-2013 suggests, the standard dates from the year 2013. So if you’ve got a scanner older than last year, there is a good chance that it does not have every attribute required. But even scanners after that date may not be in complete compliance, given the fact that medical devices have long development cycles and adherence to the standard was, until Congress acted, just a recommended best practice.
By some estimates up to 30 percent of customer CT equipment still currently in the field may be affected (at least those are the rates expected for outpatient centers).
If your CT scanners are all compliant, then you are golden and really don’t need to read the rest of this article except for its entertainment value. On the other hand, you may discover that you need to pay a substantial fee per scanner for an upgrade that gets your gear into compliance with the standard. Or worse, you might find that your particular scanner has no upgrade path to compliance at all.
2016? That is years away, right?
Yes, except the planning that goes into developing your equipment budget cycle probably starts later this year. You will want to start calling each of your CT vendors and getting some budgetary quotes well before you are in budget planning crunch mode.
It is possible that you find yourself the owner of some older CT scanners for which the aggregate upgrade price tag is huge. Or worse, you may find yourself with a scanner so old that it cannot actually be upgraded at all – and thus you are looking at a huge and unexpected capital purchase to replace it. If so, before you commit a large portion of your 2016 imaging equipment budget to this, you might want to consider alternatives. In particular, now might be a good time to take a hard look at the utilization of the older scanner versus other compliant scanners close by. Because utilization targets are going up across the board, you may find that the best plan is to simply to figure out how to route more patients to fewer modern scanners and stop using the older one.
Here are the specific attributes required by NEMA XR 29-2013:
- Check expected dose prior to performing a single exam versus threshold values and alert operators when exceeded
- Generate DICOM radiation dose structured report objects (RDSR)
- Provide Automatic Exposure Control (AEC) to intelligently vary the exposure based on regions the body (e.g. lower dose when traversing less dense organs like lungs)
- Utilize distinct adult and pediatric acquisition protocols
As you can see, these are all very reasonable things that patients should expect from equipment being used for scans. In particular, the first item (expected dose warning to operators immediately prior to the exam) can help prevent serious errors that have been known to happen, such as radiation overexposure at Cedars-Sinai and a radiation overdose at a California hospital. Previous measures were based on retrospective reporting and therefore would only have helped after the first patient was over-exposed (still beneficial for subsequent patients, but we can do better).
Even if you believe that your scanner meets all of the above attributes, it is worth confirming this with the manufacturer. There may be specifics within the standard that are not fully met by the actual implementation, particularly if the manufacturer was developing the capabilities in advance of the final standard being published.
What do you think about the CT radiation minimization rules? Please feel free to leave me a comment.
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