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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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DIR Corporate-level Aggregate Report Update

The DIR is working to restore Corporate-level reports.


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.


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.