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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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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.

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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.

 

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Tailored DIR Analysis; Is your current solution providing less for more?

The Dose Index Registry (DIR) is a powerful, flexible tool from which facilities can learn a great deal.  The most common use is to use the DIR’s dose comparison reports identify dose reduction opportunities:  Never before have facilities been able to identify dose reduction opportunities so easily.

But, there is so much more to glean from the DIR if facilities work with someone who understands how to take advantage of the DIR’s data.  In our opinion, too many facilities spend thousands of dollars each year unnecessarily to purchase expensive third-party solutions when the information is readily available from the DIR for free or at a very low cost.  This article will describe one example of the unique, low-cost analyses Dose Registries Support Services offers its clients as they work to lower doses, increase patient safety, and improve their CT services:  Protocol Use (or in this case) Misuse.

Protocol Misuse:  While reviewing one facility’s DIR data we noted they used two different protocols for RPID22- CT Head wo Contrast; their names were CT Head_wo contrast and CT Head_wo_kyphotic.  The CT Head wo contrast protocol uses the standard field of view while the kyphotic protocol uses a larger field of view (up to 500mm).

In our experience it is common for facilities to use a larger field of view to accommodate kyphotic patients whose kyphosis does not allow them to be positioned at isocenter.  These are typically elderly people whose kyphosis is due to osteoporosis-related compression fractures.  In these cases, technologists often use a larger field of view to image the head which is located some distance above isocenter thereby requiring a larger field of view to image.  Most technologists then reprocess the images to a normal field of view prior to sending the images for interpretation.  While appropriate when warranted, a larger field of view can significantly decrease mage resolution and should be selected only when necessary.  In our experience, the need to use this technique occurs in the low single digit percentage of the time in most community-based facilities.

Protocol Use ExampleWhat concerned us after performing this analysis was that the Kyphotic protocol was used an astounding 49.5% of the time at this single facility!  See Table 1.   We summarized our findings in our report to the department manager.  Upon investigation it was found that one technologist used the kyphotic protocol exclusively whether the patient was kyphotic or not, reprocessing the images to the smaller FOV prior to sending the images for interpretation.  This practice was quickly stopped.

One of my next articles will discuss what Charts 1 & 2 below signify.  Anyone care to guess about what these charts suggest may be happening?   Hint, if you are not doing your quality checks, you should.

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Dose Registry Support Services provides personalized, tailored dose support services to facilities and radiologists.  This story represents but one creative, proprietary analysis Dose Registry Support Services brings to its clients – an approach not generally provided by other solutions.  Is your solution providing these kinds of insights to you?  To learn more about Dose Registry Support Services’ cost effective solutions and how we can help your department improve its CT services contact us or visit www.doseregistry.com.

Gap Analysis

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Providing Low-cost, Tailored & Unique Services to Community Hospitals and Radiology Groups

The Dose Index Registry (DIR) is a powerful, flexible tool from which facilities can learn a great deal.  The most common use is to use the DIR’s dose comparison reports identify dose reduction opportunities:  Never before have facilities been able to identify dose reduction opportunities so easily.

But, there is so much more to glean from the DIR if facilities work with someone who understands how to take advantage of the DIR’s data.  In our opinion, too many facilities spend thousands of dollars each year unnecessarily to purchase expensive third-party solutions when the information is readily available from the DIR for free or at a very low cost.  This article will describe one example of the unique, low-cost analyses Dose Registries Support Services offers its clients as they work to lower doses, increase patient safety, and improve their CT services:  Protocol Use (or in this case) Misuse.

Protocol Misuse:  While reviewing one facility’s DIR data we noted they used two different protocols for RPID22- CT Head wo Contrast; their names were HEAD_WO and Head Kyphotic_ExtendedFOV.  The Head_WO protocol uses the standard field of view while the kyphotic protocol uses a larger field of view (up to 500mm).

In our experience it is common for facilities to use a larger field of view to accommodate kyphotic patients whose kyphosis does not allow them to be positioned at isocenter.  These are typically elderly people whose kyphosis is due to osteoporosis-related compression fractures.  In these cases, technologists often use a larger field of view to image the head which is located some distance above isocenter thereby requiring a larger field of view to image.  Most technologists then reprocess the images to a normal field of view prior to sending the images for interpretation.  While patient friendly and appropriate when warranted, a larger field of view can significantly decrease mage resolution, and should be employed only when necessary.  In our experience, the need to use this technique occurs in the low single digit percentage of the time in most community-based facilities.

Protocol Use ExampleWhat concerned us after performing this analysis was that the Kyphotic protocol was used an astounding 51% of the time at this single facility!  See Table 1.   We summarized our findings in our report to the department manager.  Upon investigation it was found that one technologist used the kyphotic protocol exclusively whether the patient was kyphotic or not, reprocessing the images to the smaller FOV prior to sending the images for interpretation.  This practice was quickly stopped.

One of my next articles will discuss what Charts 1 & 2 below signify.  Anyone care to guess about what they represent and what their trend lines suggest?   Hint, if you are not doing your quality checks, you should.

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Dose Registry Support Services provides personalized, tailored dose support services to facilities and radiologists.  This story represents but one creative, propriety analysis Dose Registry Support Services brings to its clients – an approach not generally provided by other solutions.  To learn more about Dose Registry Support Services’ cost effective solutions and how we can help your department improve its CT services contact us or visit www.doseregistry.com.

Gap Analysis

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Using the DIR to Meet CMS’s Quality Reporting Requirements in Radiology: Important Information You Need To Know

In 2018 radiologists may report three Dose Index Registry (DIR) Measures to meet a portion of their MACRA/MIPS Quality Payment Program (QPP) requirements.  These submissions will contribute to an overall Quality Score.  In years past merely participating in the DIR qualified as meeting the DIR-eligible QPP Measures.  However, in 2018 merely participating in the DIR is not enough; instead, radiologists will be evaluated based on how their submitted doses compare to others in the DIR.  The aim of this article is to discuss the three DIR Measures which radiologists may report, the implications of the doses they submit to the DIR, and what steps radiology groups need to take now to ensure success.

Discussion

In 2018 CMS is accepting DIR data to qualify for 3 High Priority non-MIPS Measures:

  1. ACRad 31: Percent of CT Abdomen w/ contrast exams whose Total DLP per Exam is at or below the Diagnostic Reference Level as reported by the DIR for all facilities;
  2. ACRad 32: Percent of Chest wo/ contrast exam whose Total DLP per Exam is at or below Diagnostic Reference Level as reported by the DIR for all facilities; and,
  3. ACRad 33: Percent of CT Head/Brain wo/ contrast exams whose Total DLP per Exam is at or below Diagnostic Reference Level as reported by the DIR for all facilities.

ACRad 2018 Measures

Note:  The Diagnostic Reference Levels (DRLs) are defined as the 75th Percentile; Achievable Doses (ADs) are defined as the Median reported dose for All DIR Sites.

Measure Credit & Score Discussion

To qualify for the Measure the reported Total DLP per Exam must be at or below the DRLs as reported by all DIR Sites.  If the Total DLP per Exam submitted is above the DRLs the radiologist will not meet Measure.  It is important to understand that all QPP calculations for DIR-related Measures are performed at the TIN level, and not by individual radiologist.

If the Total DLP per Exam submitted by the radiology group is below the DRLs the group radiologists will receive credit for the Measure.  The quality score awarded will be determined by comparing the group’s submitted doses to the doses submitted by other qualifying submitters.  In short, the lower the submitted doses on a comparative basis the higher the quality score awarded.

Here is an example.  As seen in Table 2 below, this fictitious group’s Median Total DLP per Exam for CT Abdomen w/ contrast was 1,093, which is above the 75th Percentile DRLs Dose for All DIR Sites (1061).  Therefore, none of the group’s radiologists would qualify for ACRad31 because the group’s Median doses were above the DRLs.

The fictitious group’s Median Total DLP per Exam for CT Chest wo Contrast (509) is below the 75th Percentile DRLs Dose for All DIR Sites (521).  This means the group’s radiologists would qualify for ACRad 32 Measure.  However, it is important to note that in this case, the Median reported dose is only marginally lower than the DRLs.  This means that, while qualifying for the Measure, the group is likely to be awarded minimal quality points.

Lastly, the fictitious group’s Median Total DLP per Exam for CT Head/Brain wo contrast (694) is below the 75th Percentile DRLs Dose for All DIR Sites (1066), which qualifies them ACRad33 Measure.  Additionally, their 694 Median dose is also well below the ADs reported by All DIR sites (872).  This means the group would likely receive a higher quality score since their doses are lower than most others submitting data.

Table 2 2018 QPP Measure Article

Challenge:  Who is monitoring the DIR on radiologists’ behalf? 

For many hospital-based practices, a facility technologist usually has the responsibility to map the studies to the DIR.  This has interesting implications for the radiologist.

While not complicated, exam mapping is nuanced, and therefore, the person performing it should have a working understanding RadLex Playbook Identifiers (RPID), the exam name mapping nomenclature, and how to perform the exam name mapping crosswalk to the Dose Index Registry.  Without adequate understanding of how RPIDS fit into the DIR it is easy for the person mapping studies to innocently mis-map studies, which can and will lead to undesirable outcomes for radiologists’ QPP reporting, while having no noticeable impact or consequences at the facility level.

Additionally, even if the exam name mapping is correct, it is possible for the dose reported to the DIR to be inappropriately inflated.  This can occur at the time of the exam if the technologist selects an incorrect protocol or misapplies the selection.  Here are two real-world examples:

Example 1 – Incorrect Mapping of Exams:  It is not uncommon for the person mapping exam names to map both single and multi-phase Abdomen/Pelvis studies w/ contrast RPID145 – CT Abdomen/Pelvis w/ contrast.  Doses for multi-phase studies are often double or more that of single-phase studies.  If that is occurring at the reporting group’s facility the doses reported QPP purposes will be inflated leading to lower quality scores and, if taken to an extreme, could lead to failure to qualify for the Measure.

Example 2 – Misapplication of a scanner protocol that results in additional series being performed under the protocol:  Don’t be misled by use of the word “protocol.”  For example, if a referring physician orders a CT Brain without and with contrast, it is possible for the technologist to select the CT Brain without contrast scanner protocol, then just perform both the without and then the with series with that protocol.  This would cause the DIR to map the study to RPID22, CT Brain wo contrast, but with double the dose.  Please note that in this example the RIS/PACS , reporting, and billing processes would correctly reflect the without and with study performed; only the DIR would be mis-mapped.

Strategy for radiology groups to maximize the DIR for QPP purposes

First and foremost, radiology groups need to take proactive steps by reviewing their facility’s most recent DIR report with special attention paid to exams related to QPP Measures ACRad 31, 32, or 33:  CT Abd/Pelvis w/ contrast, CT Chest wo contrast, and CT Brain wo contrast studies.  This includes reviewing the most recent set of Aggregate Reports to see if they are above or close to the DRLs and a detailed review of the Exam Name Mappings to identify any obviously mis-mapped studies.

If the Aggregate Results show the group’s Total DLP per Exam is at or near the Median (the ADL) for All DIR Sites, then they are likely well-positioned for submitting data to CMS.  In this case, the group, in my opinion, should perform an Exam Name Mapping Review just to eliminate the possibility of having obviously high dose studies mis-mapped to these studies.

However, if the Aggregate Results show the Total DLP per Exam submitted by the facility is near or above the 75th Percentile for All DIR Sites (DRLs) the group needs to take immediate action to determine why their doses are higher than many others reporting and explore opportunities to correct them.  In many cases, correcting them can be as simple as remapping incorrectly mapped studies e.g., remapping multi-phase from the single-phase RPID to the more appropriate multi-phase RPID.  In this case I also suggest the group undertake a more detailed, exam by exam review of the dose distribution during the review period.

Of course, high doses could also be caused by the scanner protocol scan parameters settings for the study.  Groups may also want to perform an in-depth review of the scan parameters for the QPP-related studies.  This would be worthwhile regardless of the current Aggregate Report levels to ensure doses are as low as possible.  The confounding factor here is that most facilities have multiple scanner protocols that need to be reviewed.  Multiple scanner protocols are relatively easy to identify by combining two DIR exports then using Excel VLOOKUP and Pivot Tables functions to combine and display the results.  Unfortunately for radiologists, staff typically involved with the DIR lack the Excel skills to perform this analysis.

Summary

In 2018 CMS is determining QPP success and awarding Quality points for DIR Measures ACRad31, 32, and/or 33 based on how the group’s reported DLP levels compare to others in the DIR. It is important for radiologists to review their DIR reports and take proactive steps to position themselves to maximize their opportunity in the QPP quality program.  Radiologists planning to use the QPP DIR Measures should review the most recent Aggregate Reports and the facility’s Exam Name Mappings for their QPP-related exams.

If the review identifies high DLP levels due to exam name mapping errors changes made today will correct previously submitted scan data for QPP purposes for the entire reporting year.  If high DLP levels are due to scanning parameters, changing parameters will lower doses from that point in time forward.  In both cases, it is important to take steps to review the current state soon for the 2018 reporting cycle.

—Dose Registry Support Services—

Dose Registry Support Services is able to provide the reviews described above, including the recommended initial Aggregate Report and Exam Name Mapping Review.  We can also provide more in-depth review and analysis specifically tailored to your needs, as well as a provide a framework and support for scan parameter review.

Our Basic Review service consists of a review of a single Master Account level Aggregate Report – Master Facility Excel Report (Adult) and Exam Name Mapping Export, and includes a review of:

  • the Total DLP per Exam doses Master level (overall) and for each site contained in the Master account for the QPP Measured studies; and,
  • the Exam Name Mapping review attempts to identify clearly mis mapped studies based on the protocol name submitted to the DIR.

Upon completion we will provide you with a written report of our findings and recommendations.  The total cost for a Basic Review is $175.000 per Master Account.

Click here to contact Dose Registry Support Services.

Sincerely,

Michael Bohl