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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.


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

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.


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.


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.


Michael Bohl

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Watch Now: Using the DIR to Implement an Effective and TJC Compliant Dose Monitoring Program Webinar

Using the DIR to Implement an Effective and TJC Compliant Dose Monitoring Program” is now available for viewing.  Recorded by Michael Bohl, MHA, BSRS, CEO of Dose Registry Support Services, this webinar reviews how several radiology departments are using the ACR’s Dose Index Registry to implement effective, comprehensive and cost-efficient dose monitoring programs, and meet The Joint Commission’s requirement to establish dose ranges for every study and then identify studies that exceed their expected range. 

 Upon completion, viewers are eligible to receive 1.0 CE credit from the ASRT.

 Dose Registry Support Services provides cost-effective support to facilities using the Dose Index Registry.  In many cases, facilities find they are saving $50,000 to $100,000 annually, or more, using this approach. 

 If your facility is looking for ways to reduce costs, take a look at what Dose Registry Support Services can do for you.    

Click here to view the webinar.

Click here to request a copy of the slides.

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Dose Registry Support Services: What we do and why you should consider using our services

Dose Registry Support Services is founded on two premises:

  1. Radiology departments should lead their facility’s dose reduction efforts;
  2. Facilities need and want effective solutions at a reasonable cost.

Our service is designed to achieve both.  I developed this service for a health system in the mid-west.  We enrolled some of their facilities in the DIR in 2013 and had excellent success reducing doses.

As the health system searched for solutions to TJC’s dose monitoring and incident identification requirements, it found plenty of companies willing to sell them very expensive solutions.  We heard stories then, and still do today, about how many of those same facilities struggled to use them.  Some have hired dedicated staff, increasing their costs even more.  That is all well and good, particularly if the facility is a large health system with significant resources.  However, that is not the world within which many of community-based facilities find themselves.  Most community-based facilities need and want effective solutions at a reasonable cost.  That is why I developed my program of using the facility’s DIR to do essentially the same thing.  This mid-west health system estimated that our DoseID program is saving them $80,000 to $100,000 per year.  And, best of all, it works well.

If you are unsatisfied with your current dose reduction efforts and/or dose monitoring platform, or your staff is challenged to understand and/or use the DIR, continue reading.  Dose Registry Support Services can provide you with a program that works and is tailored to your specific needs – a program that supports you and your staff, keeps radiology at the center of the dose reduction efforts within your organization, and is extremely cost-effective with no long-term commitments.

Best of all, there is nothing to purchase up front and no long-term commitments.  If you were to decide you no longer need our services, we simply stop.


Dose Registry Support Services offers two distinct services:

  1. DIR support
    1. DIR set-up advice;
    2. Exam name mapping and maintenance; and/or
    3. Result review and recommendations.
  2. TJC compliance (Dose ID)
    1. Establishment of Expected Dose Ranges for every scanner protocol; and,
    2. Identification of Dose Incidents (e.g., identify studies that exceeded their expected range).

DIR support:  Our DIR support service (#1 above) is essentially an ala carte service – the client chooses what they would like Dose Registry Support Services to do for them and what it will do themselves.  Some facilities want Dose Registry Support Services to perform all DIR-related work, including mapping, remapping, and report review, while others may want to perform these tasks themselves, with us acting as advisors.

One of our goals is to teach local staff how to use the DIR so they can eventually perform the mappings and reviews after becoming comfortable with the process.  Some facilities find their staff needs some guidance initially, but as they become more comfortable they are able to perform some or all of the tasks themselves.  Others find it cost-effective to have us do most of the maintenance and initial review work.

Dose ID:  Our Dose ID service (#2 above) provides a turn-key solution for meeting TJC’s requirement to establish dose ranges for every protocol and then identify any study whose total dose exceeded its expected range.  We calculate expected ranges tailored to your facility by using your DIR data; expected ranges for TJC purposes are not based other facilities whose doses may have a completely different profile.  This means we calculate dose incidents that truly represent studies that are abnormally high for your facility.  The best part is that staff’s daily workflow remains unaltered.

Distance:  Distance is not an issue:  Our services can easily be provided remotely through email and video teleconferencing.  Having said that, if a facility would like to set up an on-site meeting initially, or meet semi-annually or annually, we are able to arrange it.

Contracts:  The best news is that there is nothing to purchase up front and no long-term commitments.  If you were to decide you no longer need our services, we simply stop.

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Using the DIR Webinar Follow-up

Yesterday’s webinar titled Using the Dose Index Registry® to Implement an Effective Dose Monitoring Program was a resounding success with over 400 registrants attending, with an abundance of follow-up questions during the last 10 minutes.

During the webinar I shared several tips and hints for getting started using the DIR, as well as how Dose Registry Support Services has helped its client facilities to implement an effective, low-cost dose monitoring program and meet The Joint Commission’s requirement to establish Expected Dose Ranges and then identify the exams that exceed their expected range, avoiding the need to purchase expensive third-party solutions.  One hospital system estimated our approach saves them $80,000 to $100,000 per year.

For more information on what Dose Registry Support Services can do for you please visit or send us an email.

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Dose Registry Support Services Success Stories

Here are recent examples of the successes two of our sites reported to their radiation safety committees.

This first example is a chart showing one facility’s average monthly Total DLP for its Chest Angio studies from early 2016 through Q1 2018.  Overall, this site reduced its average Total DLP for its Chest Angio studies by 38%.  Note the stepwise dose reduction.


The second example shows how another site reduced its Total CTDIvol for Routine Neck studies by 67%.  Each point in the chart below represents an actual study.  Perhaps even more striking is the remarkable reduction in inter-study variability in recorded Total CTDIvol.


Unlike some other dose monitoring and reduction solutions that are confusing and complicated to use, and leave you largely on your own after installation, Dose Registry Support Services works directly and personally with staff to identify and investigate dose reduction opportunities on an ongoing basis; and we do so at only 10% to 15% of the cost of many third-party solutions.  Also our service does not require the facility to add staff or devote a partial (or full) FTE.

Additionally, because we work in a collaborative fashion with the facility’s staff, radiology department staff remain involved in the process, learn from their involvement, and are able to take (and own) these successes to the safety committee.  In short, ours is more of a service that works with you and your staff than a product – a service that works with you and your staff to reduce CT doses.

If you are considering purchasing a third-party solution, or if the solution you purchased is sitting unused in the corner because it is overly complex, you may want to consider having us help you.  We make you better.

Michael Bohl, Owner and CEO




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TJC Dose Monitoring Requirements: XR-29 Dose Notifications Don’t Meet Them

When the facility I was working with was exploring using their scanners’ XR-29 Notifications to meet PI 02.01.01.A6 Dose Incident Identification requirements we reviewed the technical elements underpinning XR-29’s Dose Check feature.  After reading them we grew very concerned that XR-29’s dose notifications would not meet TJC’s requirement.  The facility submitted a question to TJC asking about this specific issue.  We were correct to be concerned; TJC’s response indicated XR-29 Dose Notifications don’t meet the requirements.  Here is a copy of their response:


TJC requires facilities establish the expected total dose ranges (CTDIvol, DLP, or SSDE) for each protocol and then test the actual total dose imparted after the exam has been completed to the protocol’s expected total.  The total is across all irradiation events;  this includes the sum of the pre-monitoring, bolus tracking, and then actual scan series dose values.  In the image below that equates to the Total DLP at the top of the image or the sum of the doses listed in the CTDIvol values column. 

Dose Page

There are several ways of complying with TJC’s dose incident identification requirements, some expensive, some free or nearly so. 

You may get lucky and have TJC auditors that don’t yet understand the technical aspects of dose monitoring.  However, this facility did not want to take that chance.  Dose Registry Support Services can provide facilities with a very low-cost, fully TJC compliant program using your DIR data and avoid the expense of purchasing and then operating a third-party software solution. 


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Dose Index Registry Exam Name Mapping Made Easy – On Sale

Reviewing existing exam name RPID mapping assignments is one of the most important Dose Index Registry® (DIR) maintenance tasks facilities should routinely perform. IncorrecBookcovertly mapped studies can result in misleading and/or incorrect Aggregate and Standardized Dose Reports. This guide is written to provide the reader with an easy method of validating your RPID mappings and identifying potentially incorrectly mapped studies for correction using the DIR’s bulk editing feature.  Includes step by step instructions.

The paperback is on sale at for $7.27.

Click here for more information.

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Announcing the Dose Index Registry® Support Services LinkedIn Group

I am renaming and repurposing my LinkedIn radiology management group to concentrate on supporting use of the ACR’s Dose Index Registry ® rather than a general radiology business forum. The new group is named “Dose Index Registry Support Services.” 

If you are a LinkedIn member and would like to join the new group enter Dose Registry Support Services in the search box.  You should see the group listed in the search query. 

Dose Registry Support Services is committed to providing the most cost efficient support available supporting facilities monitor and reduce their CT doses.  In many cases we can save facilities $60,000 to $100,000 or more each year, compared to some other third party-solutions.  

If you are struggling to implement an effective dose monitoring and dose reduction solution, please contact Dose Registry Support Services.   

Michael Bohl

Dose Registry Support Services

* Please note that the Dose Index Registry® Support Services LinkedIn group is not affiliated with or moderated by the American College of Radiology. Dose Index Registry® is a registered trademark of the American College of Radiology.

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Conference Speaking Engagement: Dose Index Registry – Tips, Tricks, and Lessons Learned

I just returned from having presented at the Health Connect Partners 2017 Radiology & Imaging Conference.  My topic:  Using the DIR to Meet TJC’s Dose Incident Identification & Review Requirements.

During the presentation  I gave an overview of the DIR and shared what we’ve learned from having participated in it for four years, including specific areas we discovered for improvement.  Along the way I shared stories and anecdotes, and charts and graphs.    I also gave tips, tricks, and lessons learned attendees could take home and use themselves, including how to perform important quality checks on their DIR data – a critical step many overlook.

I also reviewed how and why we chose to use the process referred to as DoseID on this website to meet the Joint Commission’s requirements to establish expected dose ranges, test each exam against its expected range, and, identify any test that exceed its expected range (a dose incident), rather than buy an expensive third-party dose monitoring system.

(Hint, the words/phrases “very effective, low cost, and facility-specific” come to mind.)

I also went into some detail why XR-29 dose alerts/notification do not meet TJC’s dose monitoring requirements, including a review of the XR-25 Dose Check standard which forms the foundation of XR-29’s dose alerts and notifications.

(Hint:  While XR-29 alerts are pre-scan alerts, TJC requires facilities to check the total final dose as reported by the scanner at the conclusion of the exam against its expected range.  By definition, a pre-scan alert is not, does not, and cannot, represent the final actual dose,  which is one of the reasons why XR-29 dose alerts don’t meet TJC requirements.)

If your organization has an upcoming conference and you think its members would benefit from learning more about the Dose Index Registry, including tips, tricks, and lessons learned, please contact me by clicking here .

Need help getting more from your participation in the ACR’s Dose Index Registry® ?  Let Dose Registry Support Services tailor a program designed specifically to help your department succeed.  Contact Dose Registry Support Services to see how we can help.

Michael Bohl
Twitter:  @BohlM