What Ethical Responsibilities Do I Have With Regard to Radiographs for My Patients?

Abstract

QI find that more of my new patients are asking about the type and number of radiographs I recommend. What are my ethical obligations in addressing the use of radiographs in my practice?AEthical practitioners strive to provide care to the best of their ability. To accomplish this, we order radiographs based on the patient's condition and risk of disease development or progression. At the same time, we need to consider the patient's wishes as well. The first principle of the ADA Principles of Ethics and Code of Professional Conduct1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2010. American Dental Association, Chicago2010“www.ada.org/sections/about/pdfs/ada_code.pdf”Google Scholar (ADA Code), Patient Autonomy (“self-governance”), expresses in part that “professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment.”Consistent with Section 1.A, Patient Involvement, it is important to share your diagnostic requirements with your patients and discuss their concerns. Depending on the patient's history and risk of oral disease development or progression, you may need to recommend obtaining fewer or more radiographs of specific types. However, the patient may choose a different path from the one you recommend. If you feel that a patient's request to limit the number of radiographs prevents you from providing an acceptable elective treatment, you may consider discussing with the patient options regarding consultation with or treatment by another dentist. This would be in accord with Section 4.A of the ADA Code, Patient Selection, which allows dental professionals “reasonable discretion” in selecting patients.A possible exception may be a patient with a condition requiring emergency care. Section 4.B of the ADA Code, Emergency Service, reads in part, “Dentists shall be obliged when consulted in an emergency … to make reasonable arrangements for emergency care.” When confronted with an urgent care situation in which a patient refuses radiographs even after you have discussed the risks, benefits and alternatives, you may have an ethical obligation to honor the patient's wishes and still provide the best care you can (without obtaining radiographs) to stabilize his or her condition.One way to minimize a patient's exposure to x-rays is to request radiographs from his or her previous dentist, if one exists. You also may contact the patient's insurance company to determine if it has reimbursed another office for the same radiographs that you would like to obtain. If another dental office has a current full series of radiographs, the patient no doubt will appreciate your efforts to obtain them and avoid duplication.If you are receiving a request for radiographs, keep in mind that we have an ethical obligation to make current radiographs available to the patient's new dentist. Advisory Opinion 1.B.1 of the ADA Code, Furnishing Copies of Records, states as follows: A dentist has the ethical obligation on request of either the patient or the patient's new dentist to furnish in accordance with applicable law, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental x-rays or copies of them, as will be beneficial for the future treatment of that patient. This obligation exists whether or not the patient's account is paid in full.1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2010. American Dental Association, Chicago2010“www.ada.org/sections/about/pdfs/ada_code.pdf”Google ScholarIt also is important for you to make certain that the quality of the radiograph is as close as possible to that of the original. If the quality of the duplicated radiographs limits their usefulness for diagnosis, then you will need to obtain new radiographs or have new duplicates made.This is of particular importance with the emergence of digital radiographs. The office of the requesting dentist may not have digital equipment and, even if it does, it may not be in the same format or the software may be incompatible. Therefore, it is important to determine the best way to send or receive the radiographs needed. Just as with duplicated film radiographs, you need to consider the quality of the digital copy. If a printout is required, the patient is best served by sending the dental office a photo-quality image of actual size or larger printed on photographic paper.If the new office has the capacity to store or use the digital images, you need to consider a number of issues. Would the office prefer that the images be e-mailed or sent on a CD? What file format is needed? Are the image files labeled and dated in a manner similar to that used for conventional film radiographs?When furnishing radiographs to another dental practice, make sure you comply with applicable state and federal laws regarding patient privacy and confidentiality. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), make sure you furnish radiographs in compliance with HIPAA Privacy and Security Rules,2U.S. Department of Health and Human Services Health information privacy: understanding health information privacy.“www.hhs.gov/ocr/privacy/hipaa/understanding/index.html”Google Scholar as well as with your practice's HIPAA security policies and procedures. For example, providing radiographs or other protected health information by downloading data onto an unencrypted CD-ROM or other removable device could pose a security risk. Before sending radiographs, consider securing them in accordance with HIPAA guidance3Guidance Specifying the Technologies and Methodologies That Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals. In: Federal Register. Monday, August 24, 2009. Part II: Department of Health and Human Services. 45 CFR Parts 160 and 164: Breach Notification for Unsecured Protected Health Information—Interim Final Rule. Vol. 74; No. 162:42742.“http://edocket.access.gpo.gov/2009/pdf/E9-20169.pdf”Google Scholar to decrease the likelihood that you will be required to provide notification to patients, the U.S. Department of Health and Human Services and, in some cases, the media in the event of a breach. Certain state laws also apply to breaches of patient information.Another issue that may arise with regard to the ethical use of radiographs involves advertising. When announcing to the public our use of digital radiography, we must consider the truthfulness of our statements. Section 5.A, Representation of Care, states that “Dentists shall not represent the care being rendered to their patients in a false or misleading manner.”It has become increasingly common to come across dentists' advertisements that quote figures on how much less exposure to radiation the patient can expect with digital radiography. Some manufacturers of digital systems claim an exposure reduction of up to 90 percent. This can sound appealing to a prospective patient, especially one who is concerned about exposure to radiation. Therefore, it is important for the dentist to examine the science involved, instead of relying on a manufacturer's claims, when providing information to the public.A search of the current literature4van der Stelt PF Better imaging: the advantages of digital radiography.JADA. 2008; 139: 7S-13SPubMed Google Scholar, 5van der Stelt PF Filmless imaging: the uses of digital radiography in dental practice.JADA. 2005; 136: 1379-1387PubMed Google Scholar on digital radiography revealed more realistic reductions of 0 to 50 percent per digital radiograph compared with the radiation dose for F-speed film. Even that range of reduction may be offset by the fact that images are retaken more frequently with digital systems than with film.4van der Stelt PF Better imaging: the advantages of digital radiography.JADA. 2008; 139: 7S-13SPubMed Google Scholar In addition, with some digital systems, the reduction in exposure actually may be quite limited and possible only when the appropriate exposure setting is used.5van der Stelt PF Filmless imaging: the uses of digital radiography in dental practice.JADA. 2005; 136: 1379-1387PubMed Google ScholarRadiography is one of our most important diagnostic tools. Exposure to a small amount of radiation is required to accomplish this. The American Dental Association Council on Scientific Affairs6American Dental Association Council on Scientific Affairs The use of dental radiographs: update and recommendations.JADA. 2006; 137: 1304-1312PubMed Google Scholar recommends using the ALARA principle (that is, “as low as reasonably achievable”) when weighing the risks and benefits of obtaining radiographs. We have many means of limiting exposure—from techniques to film speed to use of digital radiography. Simply making sure your equipment is optimal, such as using rectangular collimation rather than circular collimation, will help significantly.6American Dental Association Council on Scientific Affairs The use of dental radiographs: update and recommendations.JADA. 2006; 137: 1304-1312PubMed Google ScholarOur training teaches us when radiographs are indicated for optimal diagnosis and provision of timely treatment. Almost every procedure we perform involves risks and benefits. To provide the best care, ethical practitioners must balance diagnostic needs and evidence-based science with their patients' desires. Maximizing the efficiency of radiography is one of the ways we accomplish this. QI find that more of my new patients are asking about the type and number of radiographs I recommend. What are my ethical obligations in addressing the use of radiographs in my practice? I find that more of my new patients are asking about the type and number of radiographs I recommend. What are my ethical obligations in addressing the use of radiographs in my practice? AEthical practitioners strive to provide care to the best of their ability. To accomplish this, we order radiographs based on the patient's condition and risk of disease development or progression. At the same time, we need to consider the patient's wishes as well. The first principle of the ADA Principles of Ethics and Code of Professional Conduct1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2010. American Dental Association, Chicago2010“www.ada.org/sections/about/pdfs/ada_code.pdf”Google Scholar (ADA Code), Patient Autonomy (“self-governance”), expresses in part that “professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment.”Consistent with Section 1.A, Patient Involvement, it is important to share your diagnostic requirements with your patients and discuss their concerns. Depending on the patient's history and risk of oral disease development or progression, you may need to recommend obtaining fewer or more radiographs of specific types. However, the patient may choose a different path from the one you recommend. If you feel that a patient's request to limit the number of radiographs prevents you from providing an acceptable elective treatment, you may consider discussing with the patient options regarding consultation with or treatment by another dentist. This would be in accord with Section 4.A of the ADA Code, Patient Selection, which allows dental professionals “reasonable discretion” in selecting patients.A possible exception may be a patient with a condition requiring emergency care. Section 4.B of the ADA Code, Emergency Service, reads in part, “Dentists shall be obliged when consulted in an emergency … to make reasonable arrangements for emergency care.” When confronted with an urgent care situation in which a patient refuses radiographs even after you have discussed the risks, benefits and alternatives, you may have an ethical obligation to honor the patient's wishes and still provide the best care you can (without obtaining radiographs) to stabilize his or her condition.One way to minimize a patient's exposure to x-rays is to request radiographs from his or her previous dentist, if one exists. You also may contact the patient's insurance company to determine if it has reimbursed another office for the same radiographs that you would like to obtain. If another dental office has a current full series of radiographs, the patient no doubt will appreciate your efforts to obtain them and avoid duplication.If you are receiving a request for radiographs, keep in mind that we have an ethical obligation to make current radiographs available to the patient's new dentist. Advisory Opinion 1.B.1 of the ADA Code, Furnishing Copies of Records, states as follows: A dentist has the ethical obligation on request of either the patient or the patient's new dentist to furnish in accordance with applicable law, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental x-rays or copies of them, as will be beneficial for the future treatment of that patient. This obligation exists whether or not the patient's account is paid in full.1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2010. American Dental Association, Chicago2010“www.ada.org/sections/about/pdfs/ada_code.pdf”Google ScholarIt also is important for you to make certain that the quality of the radiograph is as close as possible to that of the original. If the quality of the duplicated radiographs limits their usefulness for diagnosis, then you will need to obtain new radiographs or have new duplicates made.This is of particular importance with the emergence of digital radiographs. The office of the requesting dentist may not have digital equipment and, even if it does, it may not be in the same format or the software may be incompatible. Therefore, it is important to determine the best way to send or receive the radiographs needed. Just as with duplicated film radiographs, you need to consider the quality of the digital copy. If a printout is required, the patient is best served by sending the dental office a photo-quality image of actual size or larger printed on photographic paper.If the new office has the capacity to store or use the digital images, you need to consider a number of issues. Would the office prefer that the images be e-mailed or sent on a CD? What file format is needed? Are the image files labeled and dated in a manner similar to that used for conventional film radiographs?When furnishing radiographs to another dental practice, make sure you comply with applicable state and federal laws regarding patient privacy and confidentiality. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), make sure you furnish radiographs in compliance with HIPAA Privacy and Security Rules,2U.S. Department of Health and Human Services Health information privacy: understanding health information privacy.“www.hhs.gov/ocr/privacy/hipaa/understanding/index.html”Google Scholar as well as with your practice's HIPAA security policies and procedures. For example, providing radiographs or other protected health information by downloading data onto an unencrypted CD-ROM or other removable device could pose a security risk. Before sending radiographs, consider securing them in accordance with HIPAA guidance3Guidance Specifying the Technologies and Methodologies That Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals. In: Federal Register. Monday, August 24, 2009. Part II: Department of Health and Human Services. 45 CFR Parts 160 and 164: Breach Notification for Unsecured Protected Health Information—Interim Final Rule. Vol. 74; No. 162:42742.“http://edocket.access.gpo.gov/2009/pdf/E9-20169.pdf”Google Scholar to decrease the likelihood that you will be required to provide notification to patients, the U.S. Department of Health and Human Services and, in some cases, the media in the event of a breach. Certain state laws also apply to breaches of patient information.Another issue that may arise with regard to the ethical use of radiographs involves advertising. When announcing to the public our use of digital radiography, we must consider the truthfulness of our statements. Section 5.A, Representation of Care, states that “Dentists shall not represent the care being rendered to their patients in a false or misleading manner.”It has become increasingly common to come across dentists' advertisements that quote figures on how much less exposure to radiation the patient can expect with digital radiography. Some manufacturers of digital systems claim an exposure reduction of up to 90 percent. This can sound appealing to a prospective patient, especially one who is concerned about exposure to radiation. Therefore, it is important for the dentist to examine the science involved, instead of relying on a manufacturer's claims, when providing information to the public.A search of the current literature4van der Stelt PF Better imaging: the advantages of digital radiography.JADA. 2008; 139: 7S-13SPubMed Google Scholar, 5van der Stelt PF Filmless imaging: the uses of digital radiography in dental practice.JADA. 2005; 136: 1379-1387PubMed Google Scholar on digital radiography revealed more realistic reductions of 0 to 50 percent per digital radiograph compared with the radiation dose for F-speed film. Even that range of reduction may be offset by the fact that images are retaken more frequently with digital systems than with film.4van der Stelt PF Better imaging: the advantages of digital radiography.JADA. 2008; 139: 7S-13SPubMed Google Scholar In addition, with some digital systems, the reduction in exposure actually may be quite limited and possible only when the appropriate exposure setting is used.5van der Stelt PF Filmless imaging: the uses of digital radiography in dental practice.JADA. 2005; 136: 1379-1387PubMed Google ScholarRadiography is one of our most important diagnostic tools. Exposure to a small amount of radiation is required to accomplish this. The American Dental Association Council on Scientific Affairs6American Dental Association Council on Scientific Affairs The use of dental radiographs: update and recommendations.JADA. 2006; 137: 1304-1312PubMed Google Scholar recommends using the ALARA principle (that is, “as low as reasonably achievable”) when weighing the risks and benefits of obtaining radiographs. We have many means of limiting exposure—from techniques to film speed to use of digital radiography. Simply making sure your equipment is optimal, such as using rectangular collimation rather than circular collimation, will help significantly.6American Dental Association Council on Scientific Affairs The use of dental radiographs: update and recommendations.JADA. 2006; 137: 1304-1312PubMed Google ScholarOur training teaches us when radiographs are indicated for optimal diagnosis and provision of timely treatment. Almost every procedure we perform involves risks and benefits. To provide the best care, ethical practitioners must balance diagnostic needs and evidence-based science with their patients' desires. Maximizing the efficiency of radiography is one of the ways we accomplish this. Ethical practitioners strive to provide care to the best of their ability. To accomplish this, we order radiographs based on the patient's condition and risk of disease development or progression. At the same time, we need to consider the patient's wishes as well. The first principle of the ADA Principles of Ethics and Code of Professional Conduct1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2010. American Dental Association, Chicago2010“www.ada.org/sections/about/pdfs/ada_code.pdf”Google Scholar (ADA Code), Patient Autonomy (“self-governance”), expresses in part that “professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment.” Consistent with Section 1.A, Patient Involvement, it is important to share your diagnostic requirements with your patients and discuss their concerns. Depending on the patient's history and risk of oral disease development or progression, you may need to recommend obtaining fewer or more radiographs of specific types. However, the patient may choose a different path from the one you recommend. If you feel that a patient's request to limit the number of radiographs prevents you from providing an acceptable elective treatment, you may consider discussing with the patient options regarding consultation with or treatment by another dentist. This would be in accord with Section 4.A of the ADA Code, Patient Selection, which allows dental professionals “reasonable discretion” in selecting patients. A possible exception may be a patient with a condition requiring emergency care. Section 4.B of the ADA Code, Emergency Service, reads in part, “Dentists shall be obliged when consulted in an emergency … to make reasonable arrangements for emergency care.” When confronted with an urgent care situation in which a patient refuses radiographs even after you have discussed the risks, benefits and alternatives, you may have an ethical obligation to honor the patient's wishes and still provide the best care you can (without obtaining radiographs) to stabilize his or her condition. One way to minimize a patient's exposure to x-rays is to request radiographs from his or her previous dentist, if one exists. You also may contact the patient's insurance company to determine if it has reimbursed another office for the same radiographs that you would like to obtain. If another dental office has a current full series of radiographs, the patient no doubt will appreciate your efforts to obtain them and avoid duplication. If you are receiving a request for radiographs, keep in mind that we have an ethical obligation to make current radiographs available to the patient's new dentist. Advisory Opinion 1.B.1 of the ADA Code, Furnishing Copies of Records, states as follows: A dentist has the ethical obligation on request of either the patient or the patient's new dentist to furnish in accordance with applicable law, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental x-rays or copies of them, as will be beneficial for the future treatment of that patient. This obligation exists whether or not the patient's account is paid in full.1American Dental Association American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to January 2010. American Dental Association, Chicago2010“www.ada.org/sections/about/pdfs/ada_code.pdf”Google Scholar It also is important for you to make certain that the quality of the radiograph is as close as possible to that of the original. If the quality of the duplicated radiographs limits their usefulness for diagnosis, then you will need to obtain new radiographs or have new duplicates made. This is of particular importance with the emergence of digital radiographs. The office of the requesting dentist may not have digital equipment and, even if it does, it may not be in the same format or the software may be incompatible. Therefore, it is important to determine the best way to send or receive the radiographs needed. Just as with duplicated film radiographs, you need to consider the quality of the digital copy. If a printout is required, the patient is best served by sending the dental office a photo-quality image of actual size or larger printed on photographic paper. If the new office has the capacity to store or use the digital images, you need to consider a number of issues. Would the office prefer that the images be e-mailed or sent on a CD? What file format is needed? Are the image files labeled and dated in a manner similar to that used for conventional film radiographs? When furnishing radiographs to another dental practice, make sure you comply with applicable state and federal laws regarding patient privacy and confidentiality. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), make sure you furnish radiographs in compliance with HIPAA Privacy and Security Rules,2U.S. Department of Health and Human Services Health information privacy: understanding health information privacy.“www.hhs.gov/ocr/privacy/hipaa/understanding/index.html”Google Scholar as well as with your practice's HIPAA security policies and procedures. For example, providing radiographs or other protected health information by downloading data onto an unencrypted CD-ROM or other removable device could pose a security risk. Before sending radiographs, consider securing them in accordance with HIPAA guidance3Guidance Specifying the Technologies and Methodologies That Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals. In: Federal Register. Monday, August 24, 2009. Part II: Department of Health and Human Services. 45 CFR Parts 160 and 164: Breach Notification for Unsecured Protected Health Information—Interim Final Rule. Vol. 74; No. 162:42742.“http://edocket.access.gpo.gov/2009/pdf/E9-20169.pdf”Google Scholar to decrease the likelihood that you will be required to provide notification to patients, the U.S. Department of Health and Human Services and, in some cases, the media in the event of a breach. Certain state laws also apply to breaches of patient information. Another issue that may arise with regard to the ethical use of radiographs involves advertising. When announcing to the public our use of digital radiography, we must consider the truthfulness of our statements. Section 5.A, Representation of Care, states that “Dentists shall not represent the care being rendered to their patients in a false or misleading manner.” It has become increasingly common to come across dentists' advertisements that quote figures on how much less exposure to radiation the patient can expect with digital radiography. Some manufacturers of digital systems claim an exposure reduction of up to 90 percent. This can sound appealing to a prospective patient, especially one who is concerned about exposure to radiation. Therefore, it is important for the dentist to examine the science involved, instead of relying on a manufacturer's claims, when providing information to the public. A search of the current literature4van der Stelt PF Better imaging: the advantages of digital radiography.JADA. 2008; 139: 7S-13SPubMed Google Scholar, 5van der Stelt PF Filmless imaging: the uses of digital radiography in dental practice.JADA. 2005; 136: 1379-1387PubMed Google Scholar on digital radiography revealed more realistic reductions of 0 to 50 percent per digital radiograph compared with the radiation dose for F-speed film. Even that range of reduction may be offset by the fact that images are retaken more frequently with digital systems than with film.4van der Stelt PF Better imaging: the advantages of digital radiography.JADA. 2008; 139: 7S-13SPubMed Google Scholar In addition, with some digital systems, the reduction in exposure actually may be quite limited and possible only when the appropriate exposure setting is used.5van der Stelt PF Filmless imaging: the uses of digital radiography in dental practice.JADA. 2005; 136: 1379-1387PubMed Google Scholar Radiography is one of our most important diagnostic tools. Exposure to a small amount of radiation is required to accomplish this. The American Dental Association Council on Scientific Affairs6American Dental Association Council on Scientific Affairs The use of dental radiographs: update and recommendations.JADA. 2006; 137: 1304-1312PubMed Google Scholar recommends using the ALARA principle (that is, “as low as reasonably achievable”) when weighing the risks and benefits of obtaining radiographs. We have many means of limiting exposure—from techniques to film speed to use of digital radiography. Simply making sure your equipment is optimal, such as using rectangular collimation rather than circular collimation, will help significantly.6American Dental Association Council on Scientific Affairs The use of dental radiographs: update and recommendations.JADA. 2006; 137: 1304-1312PubMed Google Scholar Our training teaches us when radiographs are indicated for optimal diagnosis and provision of timely treatment. Almost every procedure we perform involves risks and benefits. To provide the best care, ethical practitioners must balance diagnostic needs and evidence-based science with their patients' desires. Maximizing the efficiency of radiography is one of the ways we accomplish this.