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DIR Transitioning to a New Data Transmission System – Facilities MUST upgrade

Earlier this week facilities participating in the Dose Index Registry received the email copied below announcing the DIR’s transition away from the TRIAD Server to DIR Link. Please note, this change requires facilities to contact the DIR and arrange to schedule the upgrade – it is a reasonably simple upgrade, but it is not something the facility can do on its own – it requires working with the DIR.

THE DIR requests participating facilities complete the Installation Questionnaire (see link below) and submit it to them by May 20th.

The article below contains more information.

The ACR is pleased to announce beginning in June 2022, Dose Index Registry facilities will receive support to transition to DIR Link, an enhanced data transmission interface, and retire use of the TRIAD Site Server. This is part of a larger ACR initiative to introduce the next generation of TRIAD called ACR Connect – a server-based platform that will support interfaces to the National Radiology Data Registry (NRDR), ACR Accreditation, and other ACR clinical research initiatives.

All DIR-participating facilities will need to transition to DIR Link by the end of 2022 for continued data submission to the DIR.

What do you need to do?

Get started by designating someone at your facility who is familiar with DIR data transmission to complete the DIR Link Installation Questionnaire about your facility’s technical environment and preference for a DIR Link installation month. 

Please submit the questionnaire for your facility by May 20.  Note: A limited number of time slots are available each month.  Respond early to reserve time in the month that best fits your schedule. 

ACR will contact you two weeks in advance to schedule an installation meeting.  During this meeting the ACR team will work with your IT support and/or a facility or registry administrator to transition to DIR Link for CT scanner and fluoroscopy system data submissions.  The transition process should take approximately one to three hours depending upon a facility’s set up. 

What are the benefits?

Example enhancements offered by DIR Link include automation whereby facilities no longer need to un-install the current software version and re-install updated software versions. Plus, DIR Link enables traceability between NRDR and local site data for easier investigation of data submission issues and reported dose outliers.

What are the technical requirements?

  • DIR Link and ACR Connect run on Linux and Windows operating systems. Windows 2016 and Windows 2019 are supported Windows OS platforms. Click here for system specifications and requirements.
  • CT scanner and fluoroscopy systems must be configured to send Radiation Dose Structured Reports (RDSR). DIR Link does not support secondary capture image data submission.  Click here for details.

See the DIR Link Knowledge Base article for more details. For any questions, or concerns regarding the DIR Link rollout, please reply to this message or email us at

Thank you,

NRDR Support

800-227-5463 ext. 3535

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Using Pivot Tables to Review Exam Name Mappings

I was a participating speaker in the April 21, 2022’s ACR DIR Training Webinar Series titled Dose Index Registry: All About Mapping. As I was preparing for the webinar I created the following instructional video on behalf of the DIR on how to use Pivot Tables to identify potentially mis-mapped or inconsistently mapping studies. Here is a link to that video.

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Plan your Dive; Dive Your Plan

A few years ago, I had the pleasure of hearing Andrea Browne, Ph.D speak about the then newly released Joint Commission Dose Incident Identification requirements (PI-02.01.01.A6 standards). Dr. Browne is a Diagnostic Medical Physicist with The Joint Commission and served as one of the primary liaisons between TJC and TJC-accredited organizations as these standards came into effect.

These new standards required facilities to

  1. develop expected dose ranges for every CT study they performed;
  2. compare each study’s final total dose to its expected range;
  3. identify all studies whose total final dose expcced its expected range (referred to as a “dose incident”);
  4. compare all dose incidents to an external benchmark; and,
  5. review all dose incidents to see why it exceeded their expected range.

One of Dr. Browne’s favorite sayings was Plan Your Dive and Dive Your Plan. Translated, she meant that facilities should have policies in place governing these and other TJC-related requirements (i.e., Plan your Dive), then they must follow the policies (Dive Your Plan).

In regard to identifying Dose Incidents, TJC didn’t set out exactly how this was to be done. Instead, it left it up to each facility to determine for itself how they would do it. I encourage my clients to have a set of policies specifically related to how they plan to identify dose incidents, and then follow them. These policies should also include timeframes for review and updating certain aspects used in the process, e.g., the expected ranges.

My questions to you are simply:

  1. Do you have a set of policies in place governing how you identify dose incidents? and,
  2. Are you following them?

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Fluoroscopic Safety Course and Self-test w/ Certificate

I am making my Fluoroscopy Safety Course designed to meet The Joint Commission’s annual training requirement for technologists/staff that use fluoroscopy free for anyone wishing to use it. This document contains the course, a self-test, and a certificate. I suggest staff take the course/exam, complete the certificate, and then have their facility supervisor sign it and keep it for documentation purposes. The course may be reused each year.  J Everything you need is in the pdf. Click on the link below to download the course, self-test, and certificate.

If you or your facility is struggling to meet The Joint Commission’s requirement to monitor CT doses, create expected dose ranges for each study, and identify studies that exceed their expected doses, let Dose Registry Support Services do it for you. 

Our DoseID service leverages your participation in the ACR’s Dose Index Registry to provide a very low-cost service, typically costing about $3,500 for a single hospital. Multi-system hospitals get substantial reductions for each additional facility covered (e.g., $650 for each additional hospital*. 

No hardware or software to purchase, no on-going maintenance contracts, no surprise billing or long-term contract needed.

For more information visit or contact me on LinkedIn.

* up to five facilities total

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DIR to stop accepting Secondary Captures; Are you ready?

In December 2020 the NRDR sent the following message to their users outlining their intention to stop accepting Secondary Capture Dose data, moving to accept only RDSRs: NEW participants registering for the DIR registry in 2021 will only be permitted to send records using the Radiation Dose Structured Report (RDSR).  Secondary capture (OCR) image data can be sent in addition to the RDSR but will not be accepted as the sole means of transmission.  For now, existing sites will still be able to send secondary capture as their sole transmission method – however the registry does intend to disable this support later in 2021.

It is important you check to see if you are sending RDSRs or Secondary Captures. I’ve found several scanners that were capable of sending RDSRs but instead were sending Secondary Captures. If the NRDR stops accepting Secondary Captures it means those scanners doses will no longer be in the DIR, potentially affecting your sites ability to comply with several Joint Commission dose monitoring rules.

It’s relatively easy to check.

  • Log into the DIR
  • Go to Interactive Reports/Dose Information by Exam; then
  • Complete the Corporate Account/Facility and Date drop down menus

In addition to the table displayed, you will also see a File Type Pie Chart in the upper right. This pie chart shows the percentage of RDSRs (blue) and Secondary Capture (red) your facility submitted over the selected date range.

As you can see, this facility is sending 9.7% of their studies as Secondary Captures. This will be a problem unless corrected. This facility happens to have two scanners, so it was helpful to see if the issue was present on one or both scanners.

To assess the scanner status go to Interactive Reports/CT Standardized Dose Index Reports. As before, complete Corporate Account/Facility and Date drop down menus. Then click on Boxplot by Scanner tab along the top menu.

The report will look something like the image to the right. In this case, note that Scanner 1’s dots, which represent individual exams, are all colored red. This indicates they are secondary captures, which Scanner 2’s dots are blue signifying RDSRs. In this case, Scanner 1 is sending 100% of their studies as Secondary Captures. When the DIR stops accepting them, if nothing is done between now and then, no dose information from this scanner will be in the DIR.

In this case, it was a (relatively) simple matter of working with the service engineers to set the scanner to send RDSRs.

Dose Registry Support Services: As always, if you are not satisfied with the dose monitoring platform you are using, or perhaps own but aren’t using, consider Dose Registry Support Services. We leverage your participation in the DIR to provide one of the most cost-effective and staff friendly solutions available. No hardware to buy or maintain, and no long term contracts.

For more information contact us.

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Expanding Your Use of the DIR to Include Fluoroscopy, Nuclear Medicine, and Digital Radiography Doses

Here is an interesting article on the ACR’s Dose Index Registry (DIR). It is titled “Physicist Spotlight: Meet the Chair of the ACR Dose Index Registry Committee.”

I encourage you to pay specific attention to the article’s discussion of the DIR’s ability to accept and compare doses, not only from CT scanners, but now also from Fluoroscopy, Nuclear Medicine/PET, and Digital Radiology units.

As many of you know, I’ve spent the past few years assisting hospitals and imaging centers enroll in and use the DIR to lower CT doses and meet the Joint Commission’s requirement to establish dose thresholds for each exam and then identify individual studies which exceed their threshold, all with the need for an expensive third party dose management software. I am now encouraging you to consider adding data from these other modalities as well. If you are currently enrolled in the DIR, it’s as easy as directing asking your service engineer to set up each units DICOM output to send its output to your TRIAD server.

The best news is there is no cost to add these other modalities to your DIR account.

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Exam Name Mapping Guide – A Useful Tool

Exam Name Mapping in the DIR is one of the most important, yet under-appreciated, duties for those managing their facility’s DIR program. It is important inter-exam mapping is maintained. By that I mean similar studies should be assigned to the same RPID. Sounds easy, but it isn’t for a variety of reasons. First and foremost, the DIR’s RPIDs are based on RadLex Playbook developed by RSNA to provide a standard system for naming radiology procedures. The RadLex Playbook is highly granular, which is necessary when naming exams. However, that level of granularity makes maintaining DIr exam name mapping consistency a challenge as nearly all RPIDs are presented as a mapping option to DIR users.

For example, below is a table of all Lower Extremity RPIDs available in RadLex, many including details such as Right or Left. This is necessary in a name, but not so much when assigning an exam to the DIR. Also, note that there are several possible RPIDs that could be assigned for a Tibia Fibula exam.

  • RPIDs 25-30: CT LE with laterality and contrast choices (6);
  • RPIDs 2042 – 2050; CT Tibia Fibula with laterality and contrast choices (9); and,
  • RPIDs 3468-3470; CT Tibia Fibula with contrast choices (3);
    • and that does no include the more generic RPIDS also included in the table.

Staff assigned mapping duties often find it difficult to determine to which RPIDs similar exams have been assigned, which can lead to inconsistent mappings. This means one person could assign TibFib exams to the RPIDs 25-30, another could choose the 2,xxx series RPIDS, yet someone else could select the 3,xxx series RPIDs or even some of the generic ones. In my experience, not only is this possible, it is fairly common.

I encourage all facilities using the DIR to pay particular attention to their Exam Name Mappings by

  1. Reviewing them for consistency; and,
  2. Developing a Mapping Table of codes in use at your facility for reference purposes when mapping any unmapped studies as they arise.

These two steps will go a long way towards ensuring higher levels of inter-exam naming consistency.

Here is an example of one of my Mapping Tables. The box on the left indicates which categories of RPIDs for which I developed specific Mapping Tables. The box on the right represents my Mapping Table for Multiphase body exams which I want people using when mapping any new unmapped exams in this category. Obviously, if a completely new and different exam arises, we’d look for a more appropriate RPID, but the reality is that most newly unmapped studies end up being a new version of a previously mapped exam. This helps ensure the new version is assigned to the RPID we want used.

I have made my basic set of tables available for purchase on my website for $24.99. This includes my recommended RPIDs for all Types shown above. It also allows you to modify them for your own purposes. Compared to the amount of time you’d spend developing your own, $25 is a bargain. However, there is no reason you can’t build it yourself, and I encourage you to do so. You’ll make the lives of those who perform your Exam Name Mapping so much easier, and have a much more consistent set of assigned RPIDs.

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Change Coming To Your NRDR Login

All ACR National Radiology Data Registry (NRDR) users, including those that use the ACR’s Dose Index Registry, should receive the email copied below alerting users to a Dec 1st email which will prompt them to change their NRDR login. Please read the email below for more details.

If you have any issues I’ve found the NRDR Help Desk very responsive. You can contact them at Of course, you can also contact Dose Registry Support Services if you need help on this or any other Dose Index Registry issue.


Dear NRDR User:

As part of the ongoing commitment by the ACR® to enhance our systems and protect NRDR participant data, the National Radiology Data Registry (NRDR) will institute single sign-on (SSO) technology on Dec. 1, 2020. The login enhancement, called ACR Login, employs technology from SSO market leader Okta that allows you to easily access your NRDR account, while keeping your information safe. This change will impact your NRDR login.

When Will This Happen?

On Tuesday, Dec. 1, you will receive an email prompting you to “Activate Your ACR Login.”  Once you click on the link, you will need to create a new password and a select a form of multifactor authentication to add an additional layer of security to your account. You will use this new information to access NRDR going forward. 

Action Required

Look for an email from “ACR” on Dec. 1, then create your new password and select your multifactor authentication to access your NRDR account.


Learn more about the new ACR Login. If you have any questions, please contact



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New Scanner Dose Review – A Unique DoseID Service

Generally speaking, today’s scanners are much more dose efficient than the ones they are replacing. When a site installs a new scanner I like to provide them with an overview of just how their doses changed so they can share their success within the institution.

One of my clients installed a new scanner a few months ago so I prepared my report for them. Their new scanner was imparting doses that were 30% to 80% lower than their previous scanner, depending upon the study group (RPID). That is, with the exception of one study – CT Brain. The doses for CT Brains were about 30% higher on the new scanner than they had been on the scanner they replaced. This seemed counter-intuitive to me so I decided to look into it a little further

My initial review found that CTDIvol was essentially identical between the two scanners. However, Total DLP was approximately 30% higher. The chart below plots both CTDIvol and Total DLP for CT Brain w/o Contrast studies for both the old scanner and the new scanner. Each dot represents a single study, and plots both the study’s CTDIvol and Total DLP. As you can see, the CTDIvol was consistent between scanners.  However, Total DLP was markedly higher on the new scanner.

CTDIvol essentially represents base scanner settings while DLP is based on CTDIvol, but then adds a scan length component (hence the name Dose Length Product).  Was it possible the protocol or some staff could be setting up the scans so they are scanning further (above and/or below) the desired area on the new scanner than they used to scan on the old one?  Were there other factors causing the increase?

To answer these question I ran the DIR’s Exam Detail Report which details the scan parameters of each irradiation event within a study, and includes data such as actual scan length, pitch factors used, kVp and scan rotation time.

The table below represents 3 studies from the old scanner in the top heavy-bordered section, and 3 studies from the new scanner in the lower heavy-bordered section. Each study is grouped using the same color-coding within each section.

The Exam Detail Report confirmed that the old and new scanner used approximately the same CTDIvol per study, but the new scanner’s Total DLP is approximately 30% higher than the scanner it replaced. It also showed that

  • The new scanner uses 3 irradiation events where the old scanner used 2 events
    • probably two scouts and one study acquisition event;
  • Scan length of the acquisition stage is longer on the new scanner;
  • Pitch is set to .625 on the new scanner (Spiral) and 1.0 on the old scanner (constant angle);
  • kVp is the same on both scanners; and,
  • Scan rotation is .75 seconds on the new scanner and 1 sec on the old scanner.

My role is not to recommend specific protocol changes. My role is to help facilities identify potential opportunities for dose reductions and point them in the right direction. To that end, I shared this information with the site so they could work with their radiologists, physicists, and application specialists to determine if there is an opportunity to reduce image dose while maintaining image quality. Perhaps the CT Brain protocol in use is the protocol this site wants and needs. But again, what struck me was that virtually ever other study group had significantly lower doses on the new scanner, except CT Brain. On that fact alone, I felt it was worth reviewing the exam details.

Given the information above, do you see a potential to reduce these doses? If so, where?


Please keep Dose Registry Support Services in mind if you or your facility are looking for a low-cost, staff-friendly, and Joint Commission compliant dose monitoring solution. or more information visit or email me by clicking here.