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DoseID: An affordable, effective, and staff friendly Dose Monitoring Solution

DoseID is an affordable, turn-key CT Dose Monitoring service for hospitals, health systems, imaging centers, and physician practices. Our DoseID service leverages your participation in the ACR’s Dose Index Registry to comply with The Joint Commission’s requirements to create Expected Dose Ranges for every study and then identify individual exams that exceed their expected range; and, it does so with little daily impact on staff and without having to purchase an expensive third-party solution.

  • Does your current solution require you to pay large annual maintenance fees or have dedicated staff to operate it?
  • Is your current solution complex and difficult to use, often to the point it goes unused? 
  • Is department management and/or staff frustrated with your current solution? 
  • Is your department struggling to understand or meet the Joint Commission’s requirement to establish expected dose ranges for every CT exam, identify studies that exceeded the upper threshold, and then review and analyze CT dose incidents – incidents? 
  • 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 our 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 upfront 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 expensive third-party platforms are wonderful products, particularly for health systems with large budgets and the staff to use them. I would never discourage anyone from purchasing one if they have the resources to purchase and use them. However, that is not the world many small to mid-sized community hospitals find themselves in today. DoseID is designed to meet the needs of facilities that want an effective program, but one which is also affordable and easy to implement and understand.   

Our DoseID 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. Click here to see what our customers are saying.

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

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Free 2 CE course: “Using the DIR to Implement an Effective CT Dose Monitoring Program and Meet The Joint Commission’s Dose Incident Identification Requirements.”

I just published the FREE independent study course I wrote of earlier titled “Using the DIR to Implement an Effective CT Dose Monitoring Program and Meet The Joint Commission’s Dose Incident Identification Requirements. The course consists of a 100 minute video presentation followed by a 16 question exam.  Registered Radiologic Technologists successfully completing the course will earn 2 CE credits.  However, anyone interested may take the course without taking the exam.  The course is available at www.doseregistry.com

Click on the Course title in the Featured Course menu along the right border.

Note: Users wishing to enroll in the course should first create an account on the website, then login and enroll in the course.    

In this course, I share with you

  • Why dose monitoring is important;
  • 4 of the most useful DIR Reports and how to generate them, including the new Interactive reports;
  • Tips to make Exam Name mapping easier, including how to use the Bulk Mapping option;
  • Success stories others have had using this approach, which provides additional insight for using the DIR;
  • Advice on assigning User Roles; and,
  • How to use the DIR to meet TJC’s Dose Incident Requirement without the need for expensive third-party dose monitoring systems.

As you will hear, the Dose Index Registry is a powerful tool. We only need to understand how to use it and what it is telling us.  At the end of this course you will have enough information to implement an effective, low cost dose monitoring and optimization program at your facility.  My real objective is to have Radiologic Technologists BECOME LEADERS in dose reduction within their institution.  The success stories you will hear are technologist-generated success stories which, in many cases, were then broadly shared within their organizations. 

Please share this with your management and technical staff if they would like to learn more about how to use the Dose Index Registry to reduce CT doses and implement a low-cost, yet effective CT dose optimization program and/or meet TJC’s Dose Incident Identification requirements, or simply want free CE.  If  you are a member of a state chapter or national association feel free to share it with them as well.  The course if free for all. 

Sincerely,
Mike Bohl
Dose Registry Support Servicers
mbohl@doseregistry.com

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About the speaker:  Michael Bohl founded Dose Registry Support Services in 2015 to support Radiology Departments’ use of the Dose Index Registry to optimize doses and meet The Joint Commission’s mandate to identify and review Dose Incidents.  Mr. Bohl is a nationally recognized speaker and has extensive experience in radiology group, imaging center, and hospital management.  He has authored several articles, including an article titled Meeting The Joint Commission’s Dose Incident Identification and External Benchmarking Requirements Using the ACR’s Dose Index Registry published in the August 2016 edition of the Journal of the American College of Radiology.  For more information see Mr. Bohl’s LinkedIn profile, visit www.doseregistry.com, or email us by clicking here.

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NRDR DIR Report Format Change Webinar

Effective this reporting cycle (Q3 2019), the DIR changed its report formats. As of October, 2019 the quarterly DIR Aggregate Excel reports we have become accustomed to will no longer be produced. These reports will be replaced by data that is currently available in the corresponding Interactive Aggregate Reports. The DIR held a webinar October 29th describing the changes and giving an introduction on how to use the new reports. Here is a link to a recording of that webinar: Oct 29, 2019 ACR Dose Index Registry Webinar.

As we’ve written in other posts, we believe these are positive changes: The new Tableau-based reports have advantages that the fixed, hard-copy Excel worksheets did not have. Having used the Interactive Reports for some time now, we find them incredibly useful, but they are not without a learning curve.

The challenge: The new report format requires facilities to self-generate much of the information that was previously provided in the fixed report. Based on my experience, some facilities may find having to self-generate some of the reports inconvenient and somewhat confusing, at least without some guidance.

The first step for facilities to make this as easy as possible is to view the webinar at the link above. After that, if you are still finding it challenging, feel free to contact us. Dose Registry Support Services are here to help make the DIR simple to use and understand; and, we can do so at a fraction of the cost of the more expensive third-party applications (which themselves are complex and difficult to use and understand).

In our opinion, the DIR is one of the last, best bargains in healthcare. We’re here to help you make the most of it. If you are attending RSNA and would like to schedule a meeting, or if you would like to speak with us, send an email by clicking here: Dose Registry Support Services.

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Dose Reduction Success Stories

I want to share some exciting information concerning one of our client’s dose reduction successes. I recently completed an analysis of this site’s doses (Total CTDIvol) from 2013 through YTD 2019. This is interesting because during this time period the equipment did not change.

The chart below illustrates what can be accomplished using the ACR’s Dose Index Registry to lower doses over time. The blue column represents the baseline – the average Total CTDIvol for that RPID in 2013, the site’s first year it participated in the DIR. Each column to the right represents the average Total CTDIvol for each subsequent year for that RPID through Q3 2019.

Dose Reduction Successes: The first two sets of columns above show that this client, with our help, has reduced their average Total CTDIvol for their CT Chest studies in 2019 to less than 80% of what it was in 2013, and its average Total CTDIvol for their CT Brain w/o contrast studies in 2019 to about 60% of what they it was in 2013. The chart also shows that their average Total CTDIvol for their CT Neck, Aorta w/ Lower Extremity Angio, Lower Extremity w/o contrast, and IAC studies in 2019 are about 45%, 55%, 40%, and 50% lower, respectively, than they were in 2013. Overall, when reviewing the entirety of the work done at this site each year, the average Total CTDIvol per study in 2019 is about 75% of what it was in 2013.

This chart also illustrates the continuing focus this site placed on this project. Note that, with the exception of the CT Neck, most studies’ Total CTDIvol were reduced gradually. This is illustrative of the site’s continued and long term focus on dose reduction: The management and staff didn’t just look at the process as “one and done;” they looked at this as a long-term process, and continued to look for ways to optimize their doses.

In the end, this is their department’s success story. Using this information, the site is able to show that the radiology department is taking the lead on an important patient safety initiative, and get the recognition they deserve within their institution. Dose Registry Support’s role in this was not to do this work for them: Our role was to help staff understand the DIR, identify where the dose reduction opportunities were, and to point them in the right direction. At the end of the day, this process must be lead by the staff and management on site, working with their radiologists and medical physicists, in order to be successful. Without department/staff leadership, it can’t succeed.

If your site is struggling to use the DIR, Dose Registry Support Services can help. We can make the DIR easy and understandable, and do so at a very low cost. While nothing guarantees success – we are confident we can help those who are motivated and want to succeed.

Contact us for more information. If you are attending RSNA 2019 and would like to meet and discuss our services, we can do so.

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DIR Webinar Describing Dose Reporting Format Changes

Webinar: The DIR is hosting a webinar at 1:00 p.m. CDT on the 29th to review their new reporting formats. Dose Registry Support Services encourages DIR facilities to register for this webinar by clicking on the following link: https://attendee.gotowebinar.com/register/2608624724178001666

Details: Effective this reporting period, the NRDR has significantly changed the dose monitoring reports it provides to their enrolled facilities: The NRDR has replaced the hard-copy, color-coded Excel Aggregate Reports with a corresponding set of Interactive Aggregate Reports. The new, Tableau-based, Interactive Aggregate reports offers facilities unprecedented near real time and flexible access to their data in ways the fixed, hard-copy Excel worksheets simply could not.  These changes will alter the general nature of what facilities receive directly from the DIR and what facilities will be responsible for generating themselves.

Dose Registry Support Services believes these are positive changes: The new Tableau-based reports have advantages that the fixed, hard-copy Excel worksheets did not have (albeit the hard-copy reports were easy to understand and use).  Having used the Interactive Reports for some time now, we find them incredibly useful, but they are not without a learning curve.

The challenge: The new report format requires facilities to self-generate some of the reports the most useful reports that were previously compiled and sent directly to them. Some facilities may find having to self-generate some of the reports inconvenient and somewhat confusing, at least without some guidance.

Webinar: To that end, the DIR is hosting a webinar at 1:00 p.m. CDT on the 29th to review the new reports.  Dose Registry Support Services encourages its clients, customers, and friends to register and attend the webinar, by clicking on the link in the first paragraph above.

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Dose Registry Support Services: Are you looking for a CT Dose Monitoring solution or frustrated by the complexity of your current solution? Is your current solution confusing to the point of non-use? If so, please consider DoseID.

DoseID is an affordable, turn-key CT Dose Monitoring service for hospitals, health systems, imaging centers, and physician practices. Our DoseID service leverages your participation in the ACR’s Dose Index Registry to comply with TJC’s mandate to create Expected Dose Ranges for every study the identifies individual exams that exceed their expected range, and it does so with little daily impact on staff and without having to purchase more expensive third-party solutions.

  • Is your department struggling to understand or meet the Joint Commission’s requirement PI.02.01.01 requiring facilities to establish expected dose ranges for every CT exam, identify studies that exceeded the upper threshold, and then review and analyze CT dose incidents – incidents when the actual total dose exceeded your facility’s dose threshold for that exam? 
  • 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 to use it?
  • Is your department still trying to meet this requirement on your own, but finding it difficult and time consuming? 
  • Is department management and/or staff frustrated with your current solution? 
  • 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 our 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 upfront 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 expensive third-party platforms are wonderful products, particularly for health systems with large budgets and the staff to use them.  I would never discourage anyone from purchasing them if they have the resources to purchase and use them. However, that is not the world many small to mid-sized community hospitals find themselves in today.  DoseID is designed to meet the needs of facilities that want an effective program, but one which is also affordable and easy to implement and understand.   

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. Click here to see what our customers are saying.

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

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DoseID – Affordable Joint Commission Compliant CT Dose Monitoring Solution

Are you looking for a CT Dose Monitoring solution or frustrated by the complexity of your current solution? Is your current solution confusing to the point of non-use? If so, please consider DoseID.

DoseID is an affordable, turn-key CT Dose Monitoring service for hospitals, health systems, imaging centers, and physician practices. Our DoseID service leverages your participation in the ACR’s Dose Index Registry to comply with TJC’s mandate to create Expected Dose Ranges for every study the identifies individual exams that exceed their expected range, and it does so with little daily impact on staff and without having to purchase more expensive third-party solutions.

  • Is your department struggling to understand or meet the Joint Commission’s requirement PI.02.01.01 requiring facilities to establish expected dose ranges for every CT exam, identify studies that exceeded the upper threshold, and then review and analyze CT dose incidents – incidents when the actual total dose exceeded your facility’s dose threshold for that exam? 
  • 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 to use it?
  • Is your department still trying to meet this requirement on your own, but finding it difficult and time consuming? 
  • Is department management and/or staff frustrated with your current solution? 
  • 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 our 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 upfront 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 expensive third-party platforms are wonderful products, particularly for health systems with large budgets and the staff to use them.  I would never discourage anyone from purchasing them if they have the resources to purchase and use them. However, that is not the world many small to mid-sized community hospitals find themselves in today.  DoseID is designed to meet the needs of facilities that want an effective program, but one which is also affordable and easy to implement and understand.   

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. Click here to see what our customers are saying.

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

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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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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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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