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. 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. 
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.  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. 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, 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 firstname.lastname@example.org.
 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.
 TP Szczykutowicz and Myron Pozniak. A team approach for CT protocol optimization.
Radiology Management Nov/Dec Issue 2016
 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.
 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
 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.
 AAPM Task Group 309, Protocol Management System Design.. Website URL https://www.aapm.org/org/structure/default.asp?committee_code=TG309