Optimizing CT Imaging with ProAqCt: Enhancing Patient Safety, Image Quality, and CMS Compliance

This is an AHRA Quick Credit article. The corresponding post-test in the AHRA Online Institute is coming soon.

Abstract

This report details the implementation of ProAqCT Radiation Dose and Image Quality Optimization Software at a 14-bed Critical Access Hospital. The project reduced CT radiation exposure, improved image quality, and ensured CMS compliance. Key strategies included system integration, technologist training, and quarterly QA/QC reviews. Early outcomes demonstrate measurable dose reduction, optimized protocol, and actionable insights supporting patient safety and regulatory adherence.

Since becoming an AHRA member in 2022, I have gained access to a wealth of resources that have strengthened my ability to anticipate and prepare for regulatory changes. A pivotal moment came on June 14, 2023, when I attended the AHRA webinar “CMS Plans to Improve Radiation Safety and Image Quality in CT: Are You Prepared?”

That session revealed gaps in our preparedness for the new Centers for Medicare & Medicaid Services (CMS) requirements. Motivated to act, I began reaching out to our current software vendors, only to discover that most were either unaware of the mandates or mistakenly believed their systems were already compliant. Once I shared the official CMS documentation, it became clear that their solutions lacked the necessary capabilities.

It wasn’t until August 2024, at the AHRA Annual Meeting in Florida, that I discovered a viable solution. There, I was introduced to ProAqCT (pronounced pro-act), a vendor offering a platform specifically designed to meet these regulatory expectations. Their solution not only addressed CMS requirements but also supported broader compliance reporting, providing advanced tools and expert guidance.

After being introduced to ProAqCT, I requested a quote and began developing a financial plan for implementation. During that time, AHRA announced grant opportunities through the Putting Patients First Grant Program sponsored by Canon. I applied and was awarded $10,000, which helped offset costs and supported the successful implementation of this critical project.

After my facility, a 14-bed Critical Access Hospital, contracted with ProAqCT, the ALARA platform was released as a free option. While ALARA collected data, it lacked the advanced analytics, corrective guidance, and customer support that ProAqCT delivers. For an organization with limited resources, we needed more than data collection. We required a solution that could translate information into actionable improvements.

This journey underscored a broader reality: while advancements in medical imaging technology, particularly in Computed Tomography (CT), have transformed diagnostic capabilities, they also contribute substantially to cumulative radiation exposure.¹ This raises important concerns about long-term patient safety and regulatory compliance.

This article examines how the ProAqCT Radiation Dose and Image Quality Optimization Software platform effectively addresses these challenges by minimizing radiation exposure, enhancing image quality, and ensuring compliance with evolving regulatory standards.

Regulatory Context

A major regulatory development from the Centers for Medicare & Medicaid Services (CMS) is the introduction of a new electronic Clinical Quality Measure (eCQM) focused on Excessive Radiation Dose or Inadequate Image Quality for CT examinations. Referred to as ExRad, this measure applies to adults under the Hospital Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs. It is designated as:

• CMS1074v2: Inpatient
• CMS1206v3: Outpatient

Voluntary reporting for ExRad began in 2025. CMS originally planned to make reporting mandatory for the OQR Program starting in 2027, but after significant feedback from healthcare providers regarding technical and operational challenges, CMS has proposed keeping the measure voluntary indefinitely.

Even with a voluntary status, reporting offers meaningful benefits. Submitting data for CMS1074v2 and CMS1206v3 can earn hospitals quality program points, including within the Hospital Value-Based Purchasing (VBP) Program. Strong performance — such as achieving scores in the 90th percentile — can improve overall quality scores, which are associated with better value-based reimbursement outcomes. Importantly, hospitals will not be penalized or lose reimbursement for choosing not to submit the measure.

Marketing Brief

Company Overview

Unity Medical Center is committed to improving community well-being by educating and engaging citizens to provide essential services. We uphold this mission through a foundation of core values centered on compassion, integrity, and service.

Purpose of the Project

• Reduce radiation exposure to CT patients.
• Improve diagnostic image quality.
• Ensure compliance with state and federal regulations.

Project Summary

This initiative involves the acquisition and implementation of ProAqCT Dose Optimization Software, which provides:

• Automated patient dose monitoring.
• Image quality scoring.
• Real-time alerting and compliance tracking.

Data will be reviewed quarterly by the Lead CT technologists and a medical physicist to optimize scanning techniques and protocols, maximizing both safety and image quality.

Project Goals

• Reduce radiation dose and image noise in CT imaging.
• Collect quantifiable, reportable data quarterly.
• Ensure full compliance with CMS, state, and federal standards.
• Optimization of ExRad performance for CMS reporting.

Target Audience

All patients undergoing CT imaging.

Marketing Strategy

We will inform the public about our enhanced safety measures and imaging quality improvements via:

• Unity Medical Center’s website
• Social media platforms
• Press releases to local media outlets
• Updated printed materials, brochures, and handouts

Key Deliverables

Quarterly Consultations with ProAqCT’s Medical Physicist

• Facilitate quarterly virtual or in-person meetings with the assigned medical physicist.
• Prepare site-specific performance data and CT imaging metrics ahead of each meeting.
• Present CT protocols, recent incidents (if any), discussing regarding optimization strategies.
• Document meeting outcomes and recommendations for follow-up.

Quarterly QA/QC Reviews with Unity’s Quality Assessment and Process Improvement Committee

• Align review dates with the committee’s calendar.
• Present findings from internal audits, physicist consultations, and dose tracking systems.
• Collaborate on action plans to address any deficiencies or opportunities for improvement.
• Maintain detailed project records.

Website Updates Promoting CT Safety Improvements

• Work with the communications or IT team to maintain a section of the website dedicated to CT safety.
• Post quarterly updates including policy changes, success stories, dose reduction stats, and patient education materials.
• Ensure all content is reviewed by clinical expert before publishing.

State and Federal Compliance Documentation

• Maintain a compliance calendar to track deadlines for all regulatory filings and audits.
• Collect and organize all necessary documentation (e.g., QC logs, physicist reports, corrective actions).
• Conduct internal pre-audits to ensure readiness.
• Submit documentation to state and federal agencies as required and retain copies for recordkeeping.

Project Time

Figure 1. Gnatt Chart of the expected time frame.

ProAqCT Platform Installation and IT Involvement

One of the key challenges encountered during this phase was the limited availability of the IT team, which contributed to delays in setup. Additionally, hardware shipping delays extended the timeline further. The original time frame for the server build and in-platform installation was one week. However, due to delays, it took approximately eight weeks to fully build and configure the server infrastructure.

The installation of the ProAqCT platform required significant involvement from the IT department. As part of the implementation, the team built an on-site server configured as a VM cluster host running two virtual machines.

The first virtual machine serves as the primary ProAqCT server, responsible for performing data analysis, managing services, and generating reports. The second virtual machine acts as a secure connection point, enabling ProAqCT support to access the on-site server for remote troubleshooting while maintaining strict security controls.

This server is directly connected to the CT machines for real-time data capture and interfaces with the secure jump point used for external access. After installation, another challenge arose with integrating the service with the CT control station. Due to firewall restrictions, communication was only one-way, which ProAqCT resolved by reconfiguring the server.

ProAqCT Platform Technologist Training

Training focused on helping technologists understand how to navigate and interpret the ProAqCT Platform dashboards. While the software interface is relatively straightforward, the challenge lay in ensuring consistent comprehension of the data being displayed.

Tech-savvy technologists adapted quickly, finding the platform intuitive and easy to use. Not so tech-savvy technologists required additional support, particularly in interpreting dose metrics, image quality indicators, and alert thresholds.

The training emphasized the following areas:

• Dashboard Navigation: Locating patient dose data, alerts, and protocol metrics.
• Understanding Metrics: Explaining what the numbers represent (dose indexes, benchmark comparisons, alerts).
• Applying Data to Practice: Showing how to adjust protocols or justify outliers using the information displayed.

To ensure consistency across the department, ongoing support and refresher training were recommended so that all technologists, regardless of technical skill level, could confidently use the platform to support patient safety and quality initiatives.

Additionally, to remain compliant with CMS regulations, we established quarterly review meetings with a physicist and a radiologist. These meetings would focus on reviewing ProAqCT data and making necessary adjustments to protocols and techniques.

Radiation Dose Reduction and Image Quality Enhancement

ProAqCT dose monitoring software supports radiation dose optimization by automatically collecting and analyzing CT dose indices such as CTDIvol, DLP, Effective Dose, and Size-Specific Dose Estimates (SSDE). This data enables imaging departments to maintain doses within Diagnostic Reference Levels (DRLs) and apply the ALARA principle (As Low As Reasonably Achievable).² Using advanced AI algorithms called DeepDose and real-time data analytics, ProAqCT delivers intelligent decision support at the point of care.

ProAqCT dashboards allow our facility to audit scans retrospectively, identify high-dose outliers, and implement corrective actions through staff education and protocol adjustments. To establish a benchmark and identify outliers, we sent the last six months of data to ProAqCT for retroactive analysis. This analysis provided detailed data and helped us optimize our protocols before we officially began using the software, giving us baseline data to demonstrate subsequent improvements. This ensures continuous quality improvement, regulatory compliance, and the avoidance of unnecessary repeat imaging due to suboptimal scan quality.

Dashboards

Figure 2. The CT exam view in ProAqCT provides comprehensive tools for analyzing dose and image quality metrics at the study level. Users have access to a full DICOM viewer, allowing for subjective evaluation of image quality, as well as assessment of patient positioning and isocenter alignment. At the exam level, users can configure custom alerts for: image noise (Global Noise Index – GNI), CMS ExRad metrics, dose metrics (e.g., CTDIvol, DLP), repeat series detection, isocenter deviation, acquisition parameters such as kVp, collimation, and pitch.

Real-Time Alerts and Threshold Management

A core functionality of dose management software is the generation of real-time alerts when dose thresholds are in danger of being exceeded. These thresholds are established based on institutional policies, historical data, or national benchmarks. When triggered, alerts prompt technologists to confirm or adjust scanning parameters before proceeding, ensuring that any exposure above recommended levels is clinically justified and properly documented.³

Figure 3. ProAqCT provides robust analytics for patient dose monitoring, enabling users to benchmark protocol performance against external standards.

Left: The dashboard displays exam total DLP for the top 10 protocols by volume. The red dot represents the protocol’s median dose, while the blue box shows the external benchmark range (25th to 75th percentile).

Right: The Global Noise Index distribution reflects image noise across exams, offering a quantitative assessment of image quality, continuous optimization, and compliance with ALARA principles.

The real-time alert is initiated at the CT workstation following the acquisition of the scout image. Before proceeding with the scan, the technologist is required to acknowledge the alert and modify the technique as needed. Additionally, an automated email notification is sent to both the lead CT technologist and the technologist who performed the exam, providing visibility into the dose exceedance and prompting timely review and follow-up. An example of an email notification is shown below.

Dear Sara,

Please perform a quality review on accession#: 0000000 performed on 2025-05-15 09:07:29.

Additional notes: Please take a look at this patient’s dose and add comments

Please login to ProAqCT and add your reviewer notes within 48 hours. Please contact admin (jpachon@proaqct.com) for more information.

Figure 4. Email from ProAqCT to lead providing real-time patient dose monitoring. The email displays exam description, DLP, avg. CTDLvol, SSDE, eff Dose, and scan length. Requesting your review for continuous optimization and compliance with ALARA principles.

ProAqCT prevents inadvertent overexposure by closely monitoring patient-specific dose and promotes standardization in image quality across technologists, scanners, and patient demographics. It is especially valuable for monitoring vulnerable populations, such as pediatric or oncology patients, and those requiring routine follow-up imaging. Additionally, all alerts are automatically logged and included in reports for CMS, accreditation agencies, state regulators, and internal audits, providing traceable evidence of regulatory compliance.

Figure 5. Real-time alert notifications: ProAqCT enables users to configure protocol-specific alerts tailored to patient size or population including alerts for pediatric and adult patients.

Figure 6. Dashboards display common alert categories along with a breakdown of actionable versus justified alerts. All dashboards are interactive to easily drill down on the data.

Figure 7. Easily monitor technologist performance to identify differences in practice or standard operating procedures.

Figure 8. Left: Patient-specific organ dosimetry pictured. Patient-specific computational phantoms are selected according to the patient’s body habitus, age, and gender. ProAqCT calculates organ doses for the region scanned (indicated by blue box) and scan parameters used.

Right: Thirty-three organ doses (in milli-gray (mGy)) are calculated in addition to whole body effective dose (in millisievert (mSv). ICRP 60 and ICRP 80 effective dose is also reported.

Figure 9. ProAqCT’s fetal dose calculator determines organ doses based on gestational age and CT exam scan range. Cumulative organ and effective dose for the fetus can be determined for any number of CT exams within the gestational age. ProAqCT also allows users to track and set alerts for fetal organ dose and whole-body effective dose thresholds.

Figure 10: Longitudinal Dose monitoring. Patient cumulative effective dose can be tracked and trended over time for all exam types in the patient’s history. As shown here, the patient cumulative dose is reported for five exams of the patient’s history. Alert thresholds can be set on cumulative effective dose in user defined time periods. ProAqCT consolidates patient dose data using multiple unique identifiers including MRN, DOB, and patient name.

Quarterly Review Process QA/QC

Quarterly review with ProAqCT enables systematic benchmarking, outlier detection, and protocol optimization. Data demonstrates that targeted adjustments, such as reducing the automatic mA in the Routine Helical Head protocol, can meaningfully reduce radiation dose without compromising diagnostic image quality. Continuous monitoring supports compliance with national standards and promotes patient safety through dose optimization.

Quarterly meetings are conducted with ProAqCT to systematically review CT dose data. As part of this process, the 10 protocols with the highest exam volumes are identified. For each protocol, the mean patient dose is compared with current national benchmarks, such as those provided by the American College of Radiology (ACR) and the Dose Index Registry (DIR). Protocols that exceed the 75th percentile or fall below the 25th percentile are flagged for review.

The ProAqCT physicist issues recommendations for adjustments when protocols deviate significantly from benchmarks. Outlier analysis is also performed each quarter, identifying the 10 highest patient doses.

These outliers are compared against national benchmarks and formally reviewed by the committee. Following any protocol changes, data is re-analyzed in the subsequent quarter to determine whether improvements have occurred or if further modifications are warranted.

Example: Routine Helical Head Protocol

During review, the Routine Helical Head protocol was identified as exceeding the 75th percentile. The automatic mA was reduced from 273 to 245, resulting in a measurable reduction in patient dose while maintaining diagnostic image quality.

Table 1. Impact of Protocol Adjustment (Routine Helical Head)

Benchmarking of High-Volume Protocols

Table 2. Benchmarking of Top 10 CT Protocols (Q2 2025)

*Post-adjustment values.

Outlier Analysis

Outlier review identified 10 cases in Q2 2025 where radiation dose exceeded the national 75th percentile. Each was reviewed by the CT Dose Committee to determine if protocol deviation, patient size, or other clinical factors explained the variance.

Table 3. Outlier Cases Identified (Q2 2025)

Compliance With CT Dose Monitoring Standards

Establishing CT Imaging Protocols

CT protocols are established in accordance with national standards of practice. Protocols account for clinical indication, contrast administration, patient age, body habitus, and expected radiation dose ranges. ProAqCT supports this by allowing facilities to define dose ranges based on demographic factors and by tracking protocol changes.

Maintaining CT Imaging Protocols

Protocols are reviewed regularly with input from radiologists, medical physicists, and lead technologists to ensure alignment with evolving standards and equipment updates. ProAqCT facilitates review by providing automated reports, including temporal dose trends, benchmark comparisons, protocol distributions, and outlier analysis.

CT Dose Benchmarking

All cases where dose indices (CTDIvol, DLP, SSDE) exceed protocol ranges are reviewed and compared with external benchmarks. ProAqCT supports this process by generating alerts at the patient, exam, or series level and by providing local and national reference thresholds. The system calculates percentile distributions (25th, 50th, 75th, and 95th) across age and size categories, enabling facilities to monitor performance relative to national standards and to compare results across sites and scanners.

ALARA and ProAqCT in the Context of CMS Compliance, Leapfrog, and MIPS

ALARA Gateway offers a free, vendor-neutral software platform designed to support healthcare organizations in meeting CMS CT Dose Index Reporting requirements under the HOQR program. The free version includes:

• Automated CMS measure calculations (Size Adjusted DLP, and Image Quality).
• Continuous security monitoring and automatic updates.
• Multi-modality DICOM ingestion and EHR data mapping.

ALARA's free services are limited to measure calculations and security functions. Additional capabilities are available at a cost, such as:

• Cloud enablement
• Advanced medical imaging integration
• Health system partner integrations
• Data-sharing with health tech partners
• Integration assistance
• Premium customer support

While ALARA provides foundational compliance support, it does not offer decision support tools, image quality feedback, or real-time alerts features essential for full quality improvement under CMS and Leapfrog Group's Radiation Dose Safety Measures.

In contrast, ProAqCT is a dose and image quality optimization platform that meets the CMS requirements to report the ExRad eCQM. This is particularly valuable for facilities with limited resources. At our facility, we lack in-house physicists and radiologists. ProAqCT provides the necessary expertise and guidance to analyze outlier scans, improve protocol performance, and bring our processes into compliance.

ProAqCT also supports Leapfrog reporting by collecting and formatting the specific dose and image quality metrics required for submission. It provides automated, real-time feedback on performance, helping ensure compliance and boosting performance scores.

Leapfrog’s Pediatric CT Radiation Dose measure requires hospitals to report, for routine head and routine abdomen/pelvis CT scans in pediatric patients, the 25th, 50th, and 75th percentiles of the Dose Length Product (DLP), stratified by five pediatric age groups. If a hospital has fewer than 10 exams in a given age group and anatomic area during the reporting period, it is not required to report that stratum.^4 5

Our current patient demographics cover all ages, but the geriatric population represents the majority of those we serve. Because of this, we perform very few pediatric exams and do not meet the minimum number of pediatric exams needed for certain age/anatomy strata. Therefore, we are currently unable to report in the pediatric category under Leapfrog’s criteria. That being said, if our demographics shift in the future to include more pediatric patients, we will be able to report to Leapfrog through the ProAqCT platform and fully meet the requirements.

Summary