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Dose Registry Support Services – Our Story

At my direction, our facility began submitting CT dose data to the ACR’s Dose Index Registry® (DIR) in early 2013.  During the following months I learned to use the DIR to identify dose reduction opportunities, and lower our CT doses.

In August 2105 The Joint Commission (TJC) updated its diagnostic imaging Elements of Performance requiring all TJC-accredited facilities to:

  • Establish upper and lower dose thresholds for every diagnostic CT study;
  • Identify the studies whose total dose exceeded their expected upper range (“dose incident”);
  • Compare each dose incident to an external benchmark; and,
  • Review and analyze the dose incidents to see why they exceeded their expected total dose.

The challenge:  How were we going to meet these new requirements?

I considered using our scanners’ XR-29 capabilities to meet these TJC’s new requirements, but quickly concluded that they do not meet the new TJC requirements for several reasons, the two most important being:

  1. XR-29 is generally set to test only a subset of studies performed on a scanner, and
  2. XR-29 produces pre-scan, series-level notifications, whereas TJC requires facilities compare each study’s total final dose to its expected dose threshold.

This was confirmed by TJC.

I considered trying to identify dose incidents manually, but it became quickly apparent that was impractical – staff were simply too busy to be tasked with manually recording and comparing actual total doses against a table of expected doses at the end of each exam.

By that time, we had been participating in the DIR for about 3 years.  I wondered if we could use our DIR data to meet TJC’s requirements.  I downloaded our DIR total study dose data and found I could use it to establish statistically valid upper and lower expected thresholds for every study we were doing.  What I liked about this was that these would be our expected dose ranges, not someone else’s expected ranges.  The goal, after all, was to identify studies show doses were aberrant for our facility and our protocols, not someone else’s facility or protocols.

I also determined it was possible to test all studies going forward against our newly created dose thresholds, and identify only those studies that exceeded their expected range.  I honed and implemented this approach and later expanded it for use across our multi-facility health system.  I published an article in the JACR (August 2016) describing this method.

During this development period, our health system was exploring the purchase of a third-party platform to meet TJC’s new requirements.  However, they grew increasingly concerned about the platforms’ costs (initial and ongoing) and complexity.  We had heard stories at that time (and still do today) that many facilities struggle to use these platforms, with some resorting to hire dedicated staff to operate them, increasing their costs even more.  Some installed them, yet were never were able to fully realize their capabilities.

Expensive, complex dose monitoring systems are manageable for large facilities with significant resources.  However, that is not the world within which most of us find ourselves, and certainly does not describe the world within which I worked.  Small to mid-sized community-based facilities need and want effective solutions at a reasonable cost.

After proving the concept and honing the service, I formed Dose Registry Support Services to offer this as a service to other facilities in need of a cost-effective dose monitoring and general DIR support.  The health system I began with estimates using our DoseID service saves them $100,000 per year or more, compared to some other solutions, and requires no additional staffing.

Dose Registry Support Services Approach  Our approach is different than other dose monitoring solutions.  Instead of offering a platform or product, we offer, for all practical purposes, a service which leverages the facility’s participation with the ACR’s Dose Index Registry.  We work with staff directly and collaboratively to enhance the facility’s use of the DIR to identify dose incidents and dose reduction opportunities.  In essence, we are a low-cost extension of existing staff, using the facility’s own DIR data which results in a comprehensive, effective program, at a very low cost.

Dose Registry Support Services is very staff friendly   Staff does nothing different outside their normal daily routine.  Dose Registry Support Services calculate the system’s expected dose ranges based on that facility’s historical dose data, identifies only those studies whose total dose exceeded its upper threshold, then provides a list of “dose Incidents” to each site once a quarter for them to review.  We also automatically compare the study’s dose to the external benchmark.  Staff needed only to look up each “incident” to see why it was higher than expected.  (We can’t do that part for them.)  We are currently providing DoseID services to eight TJC-accredited hospitals and two TJC-accredited imaging centers in Iowa and Illinois.

We also provide general Dose Index Registry support (Exam Name Mapping and review support) and, if they wish, help facilities review their standard DIR report reviews to identify overall dose reduction opportunities based on how their doses compare to other DIR participants.  Our goal is to help Radiology Departments and staff been recognized as a leader in dose reduction within their facility.

Distance is not an issue   Because of the nature of our work, all of our work can be done remotely. Having said that, if a facility would like us to come on site, we are able to accommodate the request.

No up-front costs; not contracts; no long-term commitments   The DIR is a powerful tool:  Dose Registry Support Services helps facilities leverage its power.  Best of all:  There is nothing to buy, no up-front costs, and no long-term commitments or contracts.  Facilities have nothing to lose by giving our services a try.

Michael Bohl, Owner

Customer comments:

“I don’t often recommend products or services, but I highly recommend Dose Index Registry Support Services.  Their DoseID program is the most cost-effective way we found to meet The Joint Commission’s requirement to 1) establish expected dose ranges for every protocol; and 2) identify exams that exceed their expected range; and, their assistance with our Dose Index Registry review and maintenance has been extra-ordinarily helpful to our staff.   By far, the best value I found for meeting The Joint Commission’s dose monitoring requirements.   Steve J., Chicago

 “Looks like we are continuing to make progress on lowering doses to our patients. That is very exciting news.”

 “Thank you so much for staying on top of these . . . I really appreciate all of your help.”

 “I really found your information helpful and will use it to improve our current system.”

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Over 800 People Have Taken Our Free Fluoroscopy Training Course; Now Try Our DoseID Program

As of this week, since its publication in December, 2018 over 800 people have taken our free Fluoroscopic Dose Optimization: Tools and Techniques for Pediatric and Adult Patients course and received their certificate of completion.  This course is designed to meet The Joint Commission’s annual education training requirements for fluoroscopy users. If you or your staff took advantage of this, thanks, and I hope you found it useful. 

If you found our Fluoroscopy training course useful, you may want to take a look at our Joint Commission-compliant CT Dose Incident identification program – DoseID – a program designed to meet The Joint Commission’s requirement to identify dose incidents.

  • Is your department struggling to understand or meet the Joint Commission’s requirement PI.02.01.01 which requires facilities to
    • Establish expected dose ranges for every CT exam;
    • Identify studies that exceeded the upper threshold;
    • Review and analyze CT dose incidents – incidents when the actual total dose exceeded your facility’s dose threshold for that exam; and then,
    • Compare your dose incidents to an external benchmark? 
  • Did your facility purchase an expensive third-party platform only to discover it is too complex and difficult to use, often to the point it goes unused? 
  • If your facility purchased a third-party platform, did it have to hire dedicated staff just to use it, or are you struggling to keep staff trained on how to use it?
  • Is your department still trying to meet this requirement on your own, but finding it difficult and time consuming? 
  • Are your department managers and/or staff frustrated? 
  • Is your facility spending more than $4,000 per year?
  • Would you like a less expensive solution that actually provides you with actionable information your staff can use?

If you answered “yes” to any of the above questions take a look at Dose Registry Support Service’s DoseID program.  We provide a yearly service at a cost less than many facilities spend in 1 to 3 months on other solutions, and we do most of the work for you.  No hardware or software to purchase; no up front costs; and, no  long-term commitments. 

Our DoseID program is one of the most cost-effective and user-friendly CT dose optimization programs available designed to meet the Joint Commission’s dose incident identification requirements. 

We are able to do this because we leverage your participation in the ACR’s Dose Index Registry.   The DIR is a powerful tool, yet many facilities fail to grasp its utility or take advantage of it.  We help you leverage your participation in it to optimize your doses and meet TJC’s requirements, and do so at a fraction of the cost of other programs.   

Don’t misunderstand – the other third-party platforms are wonderful products, particularly for health systems with large budgets and the staff to use them.  We would never discourage any facility from purchasing one if they have the resources to do so.  However, that is not the world many small to mid-sized community hospitals find themselves in today.  We designed our product to meet the needs of facilities that want an effective program, but one which is also affordable and easy to implement and understand.   If this describes your facility, we may just be the solution you need.

Our service requires no up-front costs, no hardware or software to buy, and there are no annual maintenance or support fees to pay. Because this is a service, we do the work for you and work directly with staff to identify dose reduction opportunities. Simple, but very effective. Our customers will tell you exactly how well this is working for them.

For more information visit www.doseregistry.com or email us by clicking here

Michael Bohl, Founder & CEO
Dose Registry Support Services

 Bohl Radiologic Technologist Scholarship Fund
Mercy College of Health Sciences, Des Moines, IA
Please consider a donation – all donations matched 100%, doubling the impact

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Free Course: Fluoroscopic Dose Optimization: Tools and Techniques for Pediatric and Adult Patients

I created a course titled “Fluoroscopic Dose Optimization: Tools and Techniques for Pediatric and Adult Patient” and am making it available to anyone wishing to use it for free. The course is designed to meet The Joint Commission’s annual training requirement for physicians and technologists.

It covers and/or provides links to the following information:

• Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® campaign; and,

• Safe procedures for operation of the types of fluoroscopy equipment they use.

Upon completion of this course the participant will receive a certificate of annual training for Joint Commission verification purposes.

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CT Dose Monitoring:  Are you frustrated by your current CT Dose Monitoring system? Is it difficult or hard to use? Dose Registry Support Services makes dose monitoring understandable and easy. We leverage your participation in the Dose Index Registry (DIR) to provide a cost effective, comprehensive and Joint Commission compliant dose program. No hardware or software to buy, no long-term commitments, and for the most part, we do the work for you and provide you with the information you need. Most facilities pay less than $5,000 per year, but derive benefits far in excess to what they are currently receiving from much more expensive systems. We make dose monitoring understandable and easy.

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DIR Corporate-level Aggregate Reports Are Back- Update

As I wrote previously, access to Corporate level Aggregate DIR reports were several restricted after the NRDR changed the organizational structure for facilities submitting data.  One of the biggest changes was the establishment of the “Corporate” account under, and to, which all child sites would be assigned.  Initially, the Corporate level Aggregate reports were not available to anyone.  A few weeks later they become available, but only to those with Corporate level access. 

Post transition, each site still had access to its set of Aggregate reports.  Site level Aggregate reports show how that site compares to other similar facilities, regionally and by type of facility. However, immediately post transition, the Corporate (formerly Master) level Aggregate reports at  were no longer available.  Corporate level reports are particularly useful for multi-site facilities because they providea glimpse of how doses for any given RPID compare between child sitefacilities.

I am pleased to inform my clients/readers/followers that that DIR Corporate level Aggregate reports are back and available to Registry and Facility Administrators!  Simply choose the Corporate level account in the site selection menu, then select Corporate Account Aggregate Reports from the left menu.

As always, Dose Registry Support Services offers cost-effective DIR support. 

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Joint Commission Compliant Fluoroscopic Dose Optimization Course

This course is designed to meet The Joint Commission’s annual training requirement for physicians, non-physicians, and ancillary personnel who use fluoroscopic equipment.  It covers and/or provides links to the following information:

  • Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® campaign; and,
  • Safe procedures for operation of the types of fluoroscopy equipment they use.

Upon completion of this course the participant will receive a certificate of annual training for Joint Commission verification purposes.  Click the link below for more information.

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DIR Corporate-level Aggregate Reports Are Back

Several months ago the NRDR changed the organizational structure for facilities submitting data.  One of the biggest changes was the establishment of the “Corporate” account under, and to, which all child sites would be assigned.  Post transition, each site still had access to its set of Aggregate reports.  Site level Aggregate reports show how that site compares to other similar facilities, regionally and by type of facility.  However, immediately post transition, the Corporate (formerly Master) level Aggregate reports at  were no longer available.  Corporate level reports are particularly useful for multi-site facilities because they provide a glimpse of how doses for any given RPID compare between child site facilities.

The good news is that Corporate level Aggregate reports are back!

The challenge may be in getting set up with the authority to view them.  From what it appears, being a Registry Administrator at the Child Sites does not provide access to them.  it appears users will need access to the Corporate level account.  Even Child Site DIR Registry Administrators don’t seem to have access to the Aggregate reports.  I will follow up with the NRDR and see what access options are available.

In the meantime, if your facility is struggling to use the DIR effectively to meet the Joint Commission dose incident identification requirements, or in efforts to establish a general dose reduction program, Dose Registry Support Services can help.

 

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Meeting TJC’s 2019 Fluoro Dose Monitoring & Review Requirements – We Can Help

Effective January 1, 2019 The Joint Commission (TJC) is requiring TJC accredited facilities to establish expected fluoroscopy dose or fluoro time levels, record each study’s reference air-kerma dose (or fluoro times and number of films if the unit is not air-kerma enabled), and review any study that exceeds it expected limit.  TJC also sets out minimum medical physicist testing of fluoro equipment, ongoing education requirements for all fluoroscopy operators (including radiologists).

Dose Registry Support Services is able to assist facilities comply with these requirements by provide a set of draft policies addressing TJC’s new requirements and help managers with the details.   For more information on how we can help your facility meet TJC’s Fluoroscopy an/or CT Dose Incident Identification requirements contact us by clicking here.

If your facility is struggling to understand or use the ACR’s Dose Index Registry to monitor CT doses, we can help

 

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A Challenge to Radiology and its Professional Associations: Advocate for the Implementation of IHE’s Management of Acquisition Protocols (MAP) Profile

By Michael Bohl, MHA, BSRS and Timothy P. Szczykutowicz, PhD, DABR 

It is widely recognized that CT scanner protocols are inconsistently named and often needlessly duplicated within hospitals and imaging centers, and even individual scanners.[1] One mid-sized health system reported, after a manual protocol review, that it had as many as twenty-three differently named protocols on its nine scanners for two of its most commonly performed procedures, with one scanner having seven different names for the same study. Inconsistently named and duplicated scanner protocols represent a serious patient safety issue: Inconsistently named protocols cause confusion among the staff when moving from scanner to scanner, and duplicated protocols increase the risk that protocols with incorrect scan parameters will be selected. Inconsistently named and duplicated protocols also make it significantly more difficult to standardize and update protocols which increases the risk that some protocols won’t be updated when changes are made (i.e., is the health system mentioned above really going to find and change twenty-three protocols?). This issue is exacerbated by the absence of an efficient and centralized process for comparing protocols in use across a pool of scanners: Today, one must manually move from scanner to scanner to review and update protocols. [5]

The effort required to curate one’s CT protocol set and ensure compliance with organizations like the Joint Commission and the American College of Radiology is a costly one. Several studies have documented costs over 150k per year. [2][3] The vast majority of sites around the country fulfill the same basic set of orders, exams like routine heads, abdomens, chest, etc. This is why national dose registries work; sites are all performing similar exams so mapping doses to a common code is possible. Each site, however, is left to manage this protocol creation, review and updating internally.[4] This represents a huge waste of duplicated effort within healthcare.

In 2016 IHE Radiology developed a framework for the centralized management of scanner protocols – Management of Acquisition Protocols (MAP). MAP is based on the new DICOM CT Defined Procedure Protocol object. In August 2017, IHE Radiology released its Technical Framework Supplement for Management of Acquisition Protocols (MAP).  When implemented, MAP will allow facilities to monitor and review scanner protocols in use on various makes and models of scanners throughout a health system or hospital from a centralized computer. This has important patient safety implications, particularly as they relate to radiation dose management, protocol consistency, image quality, and staff performance.

The challenge today is implementation and deployment: How do we inform and educate our clinical, technical, physicist, and vendor communities about this capability, and how to we convince our medical imaging systems to incorporate MAP functionalities in their imaging systems.

At the time of this writing, all of the major CT vendors are creating tools to facilitate protocol management. The issue with these efforts is that none of them are implementing MAP, so each vendor’s solution will be a single vendor solution which will not work in the multi-vendor environment that is reality for facilities. This is analogous to a vendor forcing you to use their own PACS in order to view images from their devices.  IHE Profiles are free for system vendors to incorporate into their products. However, this requires system vendors to allocate scarce development resources which most are reluctant to do unless they believe there is both a need and, more importantly, customer demand for the profile. The challenge, and where the adoption process too often breaks down, lies in this last step – creating enough demand so system vendors will implement it.

Demand is often generated by what we call “influential champions:” People who not only believe in the newly developed profile’s purpose but are also able to convince others of its significance. In some cases, the champion is the same entity or group that initiated the profile. This is particularly true when the profile proposal originated from one of the involved vendors who identified the need for a cross-vendor solution and then championed its adoption. However, profile proposals submitted by individuals, consultants, and/or healthcare institutions sometimes lack the influential champion required to convince the system vendors to devote the resources necessary to implement the profile. When this happens, implementation is often delayed until the user base begins asking for it.

The challenge then becomes: How to generate the demand necessary to convince the system vendors to implement the profile? For purposes of this discussion, I will categorize champions into two categories: End-user champions and Professional Association champions, each of which present their own challenges.

End-user Champions: These are individuals at the operational level, primarily within facilities that would use the profile. They include, but are not limited to, clinical users, administrators, technologists, physicists, bio-medical engineers, IT staff, and purchasing agents.

The challenge for creating demand from this group is that it is extremely difficult to educate and organize enough end users to achieve and sustain the critical mass of demand necessary to drive adoption by their system vendors. In short, the fragmentation among this cohort makes it difficult to achieve a sustained level of demand.

Professional Association Champions: This refers to the professional associations to which the end-user communities belong. They may be clinically, administratively, technically, or scientifically-oriented organizations; but, the one thing they have in common is that they represent the collective interests of their members. In the case of MAP, the professional associations of interest are those representing radiology’s clinical, technical, administrative, and medical physicists’ interests, among others.

Professional Associations have three characteristics individual end-users don’t – the ability to leverage their resources to:

1.      Identify subject matter experts within their membership; i.e., members who understand the technical issues well enough to discuss, and educate other members about, the profile;

2.      Educate and influence hundreds, perhaps thousands, of end-users with relative ease; and,

3.      Exert a greater collective influence with system vendors than their individual members.

These 3 characteristics, if properly harnessed, have the potential to drive the demand necessary to convince system vendors to implement MAP as quickly as possible. This can be accomplished by writing or commissioning articles for their publications, hosting IHE-related sessions at their their conferences, and engaging their membership through their listservs or other social media posts. Collectively, these activities will raise awareness, educate end-users to this and other important IHE profiles, and ultimately lead to better solutions and increased patient safety.

Summary: IHE Radiology’s Management of Acquisition Protocol Profile (MAP) represents a crucial step forward for the responsible management of CT protocols and radiation dose monitoring, and many believe it needs to be developed and released for use quickly. Given the difficulty in generating organic demand from the end-user community, radiology’s professional associations need to take the lead on this issue to:

1.      Educate their membership about the benefits of IHE’s MAP profile;

2.      Encourage members to individually ask their scanner vendors to implement it; and,

3.      Collectively work to influence system vendors to implement it.

The American Association of Physicists in Medicine is an example of a professional organization with a task group set-up with liaisons from equipment vendors,[6] but more societal efforts are needed, especially from the radiology management and administration facets of our field.

For more information about MAP or other IHE-related topics contact secretary@ihe.net.

References

[1] Zhang, D., Savage, C. A., Li, X., & Liu, B. (2015). Data-driven CT protocol review and management—experience from a large academic hospital. Journal of the American College of Radiology, 12(3), 267-272.

[2] TP Szczykutowicz and Myron Pozniak. A team approach for CT protocol optimization.

Radiology Management Nov/Dec Issue 2016

[3] Siegelman, J. R., & Gress, D. A. (2013). Radiology stewardship and quality improvement: the process and costs of implementing a CT radiation dose optimization committee in a medium-sized community hospital system. Journal of the American College of Radiology, 10(6), 416-422.

[4] TP Szczykutowicz, R Bour, M Pozniak, and F Ranallo. Compliance with AAPM Practice

guideline 1.a: \CT Protocol Management and Review” from the perspective of a University

Hospital. Journal of Applied Clinical Medical Physics 16:2 2015

[5] Grimes, J., Leng, S., Zhang, Y., Vrieze, T., & McCollough, C. (2016). Implementation and evaluation of a protocol management system for automated review of CT protocols. Journal of applied clinical medical physics, 17(5), 523-533.

[6] AAPM Task Group 309, Protocol Management System Design.. Website URL https://www.aapm.org/org/structure/default.asp?committee_code=TG309

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This article was jointly published by the RBMA and AHRA as a service to its members, and is reprinted here on LinkedIn with permission.  Click here for more information on RBMA and AHRA

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DIR Corporate-level Aggregate Report Update

The DIR is working to restore Corporate-level reports.

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Previously, the NRDR announced several changes to its portal effective August 18, 2018.  The changes included:

  • Changes to the organizational structure;
    • e.g., Master/Child accounts;
  • Adding a new user type – Service User;
  • Introduced a new pricing option for limited;
    • i.e., single registry enrollment vs. multiple registry enrollment;
  • Simplified the new facility application workflow; and,
  • Several other important changes.

Click on the link above to read the announcement and details.

I want to draw your attention to a couple of specific changes the NRDR made to the Dose Index Registry specifically.

  • The DIR report menu has new submenus for Interactive Reports which provide some new and interesting functionalities, including Tableau reports; and,
  • With the exception of CTDIvol Boxplot reports, all Operational Reports remain.

There is one set of reports that was inadvertently removed from the portal – the Corporate Level Aggregate Reports.  While each child site’s report contains the DIR results for that child site, the Corporate level report contained the results from all child sites for easy side by side comparison.

However, I have been informed by the DIR that it is working to restore Corporate level reports.  I will provide an update when this comes available.

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As always, if you are challenged to use or understand the DIR we are here to help.   The DIR is a powerful (and nearly free) tool for identifying dose reduction opportunities and meeting The Joint Commission’s Dose Incident Identification requirements.  If you are looking to implement a low-cost, highly effective program, that is staff-friendly, take a look at how Dose Registry Support Services can help you achieve your goal.  We offer a service, not a product.  This means that we work with you and your physicists directly – we don’t sell you a platform then walk away.  No contracts.  No upfront costs. No long-term commitments. Tailored to meet your needs.  

 

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Important Announcement: The DIR Restructured – Existing Users Should Confirm DIR Account Status and Data Access

The NRDR restructured all existing DIR accounts effective August 18, 2018.  This changed the way sites are structured, reassigned some users, added a new user type, and limited the data to which some of the users have access.  It also eliminated a few reports.

If you are a DIR user at any level it is important you log in and check your account status to make sure it works for you and that you can access the reports and perform the tasks you were able to do prior to the change. 

Here is a summary of the changes taken in large part, and sometimes copied directly, from the NRDR Announcement.   As always, Dose Registry Support Services is ready to help facilities navigate the DIR/NRDR.   Michael Bohl

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Master Accounts have been replaced by Corporate Accounts.  Corporate accounts will not accept data whereas previously they would.  Corporate Accounts are managed by a single Corporate Account Administrator who is responsible for all communications with the NRDR team.

Critical to Understand:  Corporate Account Administrators have no default access to data management for their facilities, e.g. submitting data via web forms, data upload files or web services, viewing data through the portal, searching cases/exams for all subordinated facilities, accessing patient data, etc.

In order to have access to facility data, Corporate Account Administrators must also have a specific user profile associated with the facility ID such as Facility Administrator, Registry Administrator or Facility User.  If you used your Master Account administrator log in credentials to submit data or review reports you may not be able to do so under those credentials today – you would have to create a second account type to do so.  You won’t know until you log in and test the system.

For existing “Master” facilities, the master facility ID will become the corporate account ID, and the master Facility Administrator will become the Corporate Account administrator.

For standalone facilities, the existing Facility Administrator will become the Corporate Account Administrator, and a new Corporate Account ID will be created and sent to them.

The Facility Administrator, Registry Administrator, and Facility User roles remain unchanged. You can find more information in link to NRDR Accounts and Profiles link accessible through the Announcement document link above.

There is a new user type named Service User.  The new Service User profile allows support staff, such as IT personnel, to have NRDR credentials without access to data or reports. Service User profiles are corporate-level roles and are associated with all facilities within a corporate account, so there is no need to update a Service User’s profile when facilities are added to a corporate account.

The NRDR announcement also discusses the new TRIAD Site Server v.4.5.  You may want to plan to upgrade as it contains several convenient features like mapping a new scanner directly from the unmapped Data tab and the ability to view the number of scans submitted by scanner.

There are other changes as well.  Please click on the Announcement link at the beginning of this post to read more.