Challenges of Standardizing Imaging Protocols and How Software Can Help

Most referring physicians have a working knowledge of examination types sufficient to order appropriate imaging. A doctor cannot, however, be expected to have familiarity with the complex array of protocols available. It is radiologists who determine the correct protocol when it comes to diagnostic imaging. With each selection, they consider the physician's diagnostic needs and the patient's safety. Standardizing protocols promote process efficiency and reliable results. However, there are challenges in implementation and usage. User-friendly software helps organizations overcome those obstacles.

Reducing bias and inconsistency

One of the advantages of contemporary imaging equipment is the variety of parameters, allowing diverse protocols. However, attempting to tailor each exam with this vast range of possibilities can overwhelm even an experienced radiologist. A complicated, one-off approach might be suitable for a particularly unique patient/rare disease/unusual circumstance. However, most exams fall into a more routine category. Standardized protocols mitigate burnout and help the department deliver uniformly optimal care to all patients.1

Radiologists are sometimes the source of variations in the protocol, circumventing set departmental policies for a personal approach genuinely believed to be superior or more appropriate for a subspecialty. "Protocol creep" may also seep in as unapproved shorter or simpler protocols. These variations deteriorate the value chain and impact the patient experience.

Standardized protocols squelch protocol creep by making selection virtually non-negotiable. Software-driven systems make standardization a viable solution, even for large organizations with multiple locations across diverse demographics and specializations.1

Collecting standard protocols

The first step in standardization is gathering a set of accepted protocols that meet the needs of your organization, as determined by a focus group of radiologists, radiologic technologists, and medical physicists. You might think of this process as (depending on when you were born) making a mixtape or an iTunes playlist with your favorite songs so you have the same songs everywhere, all the time.

Protocol management software allows you to import custom protocols or select from a multitude of approved protocols, building a cloud-based library personalized to your organization's needs. The protocols (including guidelines for contrast delivery and positioning) are then published as "standard" for the appropriate fleet of devices and pushed to scanners across the organization.1

Clearing the geographical hurdle

In the 80s or 90s, if you wanted to share your music compilation with friends, you had to make copies of the cassette tape or burn duplicate CDs, then hand them out one by one. The equivalent exists in imaging. Protocol changes are downloaded to a USB flash drive ("thumb drive" or "memory stick"). Then the lead technologists (CT, MRI, or X-ray) gets in the car and navigates to each department to physically install the update on every applicable scanner.

It is an inefficient use of time for a highly qualified technologist, accompanied by a multitude of headaches. Most busy imaging departments cannot justify giving protocol update priority over scanning patients. Since a manual update requires access to the scanner, that usually means completing the install after hours or on weekends.1

Protocol management software can allow editing protocols offline, without interrupting clinical practice. It can be handled during regular business hours, without having a scanner idle, disrupting the department's schedule, or inconveniencing patients. It allows the lead technologist to complete the task efficiently, from his or her workstation, with the confidence that the edit has instantaneously reached all scanners in the enterprise. It is comparable to sharing a revised playlist with a group of friends, via few mouse clicks.1

Maintaining adherence to protocols

Protocol management software is a role-driven system. Recognizing the rare need for variation, standard protocols can be overridden with proper log-in authorization. This does not, however, result in a modification to the standard protocol, so future scans are not affected.1

Software standardization of protocols minimizes the risk of deviations through transparency. Every variation from a standard protocol is tracked and evaluated by a protocol development team. A "no exceptions to the rule" philosophy backed by deviation tracking is a cultural shift which can feel uncomfortable initially. Buy-in hinges on proper presentation to the staff with valid justification.1

Shands teaching hospital at the University of Florida College of Medicine in Gainesville was a front-runner in the concept, initiating standardized nomenclatures for imaging. In a 2014 report in Radiology Business2, Anthony A. Mancuso, MD, professor and radiology department chair said, "Without this type of structured information, it is difficult for the clinician to determine if the radiologist who completed the report possesses knowledge in that domain and whether the data are of real value. That all ties into patient care." Mancuso also noted, "Quite simply we tell them this is non-negotiable because we owe it to our patients. They understand the logic in that argument."2

Satisfying regulatory concerns

To hospital administrators, The Joint Commission3 is a familiar name. Accreditation and certification by The Joint Commission is a nationally recognized indication of a healthcare administration's commitment to the Commission's vision that, "all people always experience the safest, highest quality, best-value health care across all settings."2

Among the Commission's standards for continued accreditation is the review of imaging protocols on a "regular" (not defined but generally deemed to be annual) basis. A team consisting of at least one radiologist, technologist, and medical physicist reviews all imaging protocols to ensure they track with the latest medical practices.

Traditionally, that means maintaining a detailed log of the review process, its participants, every protocol reviewed, and procedures for protocol edits/implementation.

Protocol management software tracks updates in real-time, providing an on-demand log. It can be used to route proposed protocol edits to the appropriate approval team without the need for calling a meeting or compiling detailed minutes suitable for presentation to the Commission's auditors.

The system documents every step of the annual review process, showing:

  • What was reviewed
  • Who reviewed it
  • When it was approved

The software tracking system eliminates the need to frantically locate old email threads during the Commission's survey. It also minimizes the risk of the audit resulting in an RFI (request for information) or process improvement recommendations.

Outsourced protocols selected from the cloud library (as opposed to creating your own protocols and saving them to the library), presents an additional advantage in maintaining regulatory compliance. Verification of the approval process reverts to the originator of the protocol, rather than the organization being audited.

Image gently and image well

That was the objective of the Departments of Radiology and Medical Physics at the University of Wisconsin–Madison4 when they began their journey to standardized CT protocols. UW partnered with GE Healthcare in implementation of a cloud-based protocol manager tool citing in part "the potential to save time and resources for imaging services, relying on GE scanners."4 They indicate the high annual cost of reviewing and optimizing protocols as a primary factor in the decision to choose a software standardization solution. It also aligns with the institution's efforts to "reduce dose, enable the acquisition of more clinically useful images, and reduce the frequency of repeat scans."4

A software system that helps to overcome challenges of standardized protocol management can be beautiful music to a team tuned-in to peak patient experience.


  1. Interview with Ken Denison, Global Director of Marketing for Digital, MICT, GE Healthcare. July 30, 2019.
  2. Standardization: An Answer to Three of Radiology's Vexing Problems. Radiology Business. August 3, 2019.
  3. About The Joint Commission. The Joint Commission. August 3, 2019.
  4. UW GE CT Protocol Partnership. University of Wisconsin School of Medicine and Public Health Department of Radiology. August 3, 2019.