Training needs for professionals in conventional radiology (radiology technicians, physicists, radiologists) joining digital radiology

Training needs for professionals in conventional radiology (radiology technicians, physicists, radiologists) joining digital radiology Guidelines on education and training for digital radiology Author: S. Vetter Lead Partner: Diakonissenkrankenhaus Karlsruhe, Germany Contents: 1. Introduction 2. Rationale and results of a survey 3. General considerations on the education and training of radiographers 4. General considerations on the education and training of medical physicists 5. General considerations on the education and training of radiologists and other medical doctors involved in X-ray diagnostics Annexes 1. Outline for general education and training aspects in digital radiology 2. Outline for specific education and training aspects in computed and digital radiography 3. Outline for specific education and training aspects in digital fluoroscopy 4. Outline for specific education and training aspects in digital mammography 5. Outline for specific education and training aspects in digital visualisation and reporting 6. Structure and content of specific training sessions for education in Interventional and Digital Radiology 7. Sample of questionnaire Bibliography 1

1. Introduction: Recently there has been a series of rapid technical developments in diagnostic imaging, with the introduction of various new imaging modalities for projection imaging as well as fluoroscopy. Besides the basic physical properties of every imaging system based on the use of diagnostic radiation, these new modalities introduce various new physical and technical aspects to the acquisition, postprocessing, analysis and quality control of X-ray images. Given the rapid evolution of technology, these technical aspects, specific to digital imaging, have not been widely introduced into institutionalised education and training of radiology professionals. Nevertheless, a basic knowledge of the physical properties of these new technologies and especially how these may be used for improvement of medical diagnosis and/or reduction of the radiation dose delivered to the patient is mandatory according to the patient protection directive. In this regard an understanding of measures for quality control is essential to guarantee for examinations which fulfil the diagnostic standards. 2. Rationale and results of a survey: This recommendation is based on a workpackage included in the DIMOND III work programme. It was proposed to give an advice on the construction of curricula for the education and training of all professionals involved in digital radiology, based on the rationale given in the introduction. Before such a proposal is to be given a basic survey on the existence and specification of educational and training needs, the availability of institutionalised training programs and the personal experience of centres of excellence, which already performed the transition from conventional to digital radiology has to be attempted. The survey was performed among the partner hospitals of the DIMOND III project. In a first introductory phase a literature survey was performed by the project partner Innsbruck University Hospital, to search for written resources concerning training aspects in conventional/digital transition. However we realised that there is no evidence of articles directly addressing this topic in the medical literature. Nevertheless there are some authors who touch on it in the discussion of papers concerned with the introduction or application of digital technique to modern radiology and some of them are listed in the references. Based on this literature survey and the experience gained at the Innsbruck University Hospital with digital radiology and introduction of one of the largest PACS systems in Europe a questionnaire was designed (a sample of the questionnaire is presented in the annex), to evaluate the experience of other DIMOND partners with the introduction of digital radiology at their sites. The questionnaire was divided in two parts, one part analysing the size of the partner hospital, its radiographic equipment and staff sources. This part was answered by our contact person at the partner site. The second part directly addressed relevant aspects of digital radiology such as the utilisation of training resources, experience with digital radiography, etc. A total of 63 questionnaires were received from the partner institutions. Some results of the survey will be given in this paragraph. 2

2.1. Availability and utilisation of educational resources: Between 30% and 35% of the professionals who answered the survey stated that on introduction of digital modalities they acquired their knowledge on the job ( learning by doing ), another 23% to 28% on the job assisted by the vendor (see graph 1 for radiologist). Literature is the main additional resource used in all groups (45% to 67%), whereas modern knowledge sources such as the internet are only sparsely used and mainly by physicists (33%) (see graph 2 for radiologist). When new digital modalities were introduced, which educational resources were used? Workshop with vendor 12% 9% 8% 0% 8% 28% Training on the job (assisted by vendor) Training on the job (learning by doing) Visit to other hospital Workshop at scientific meeting 35% Dedicated educational program Others W hich additional resources did you use? 23% 2% Literature Video/CD-Rom Inte rne t Others 15% 60% 2.2 Ongoing training measures: In this paragraph the users were asked on the availability and use of educational as well as training resources and on their impression which amount of initial and ongoing education is appropriate. 3

While again a large group (25% to 36%) trains on the job without professional support, the next important resource differs among radiologists/physicists and radiographers. While the first two rely mainly on experience gained on scientific meetings, the latter rely mainly on the exchange of knowledge with visiting specialists (which is considered the third important task in the first group of professionals). In all three groups there is a surprisingly low availability of dedicated in house educational programs (less than 5%) (See graph 3 for radiographers). Which ongoing training measures do you use? In house Presentations,... 18% 14% 5% In house Educational program On the job 27% 9% 27% Workshops, scientific meetings... Visits by specialists Others The time required for initial training is considered somewhat different in all groups, but a time of 5 15 training hours is considered effective by the majority of radiologists and radiographers, whereas physicists consider a minimum of 10 15 hours. About one third of all staff members however consider more than 25 hours necessary. For continuous education again a majority of the surveyed professionals in any group consider 5 10 training hours on a three year term appropriate. About 80% of the surveyed people believe that there is no training resource offered by a national society in their country (which may either be definitely unavailable or unknown by the staff members). The positive answers to this question mainly derive from our partners in Germany and Austria. 2.3 Changes experienced during the transition from conventional to digital radiology: In this section of the survey the question on changes in the daily routine caused by the new technology was addressed according to the experience of the professionals. 2.3.1 Introduction of computed radiography: For the introduction of CR there is a high level of agreement among the three groups: 40% of them believe to experience changes in the image appearance, mainly the radiographers but to a lesser degree also physicists and radiologists believe that a different image/dose relationship exists, and all three agree on a need for new quality criteria (see graph 4 for radiology technicians). 4

When computed radiography was introduced, which of the following did you encounter? 24% 40% Different image appearance Different image/dose relationship Need for new quality criteria 36% 2.3.2 Introduction of digital radiography: Almost the same data, which were gained for CR, were revealed for the introduction of digital radiography. 2.3.3 Introduction of digital fluoroscopy: Almost the same data, which were gained for CR, were revealed for the introduction of digital fluoroscopy. 2.3.4 Introduction of digital mammography: Again the same impression was revealed in the survey (different image appearance, etc.) however the experience in this regard is limited as only two of the partner hospitals have a digital mammography installation. 2.4 Continuous program of evaluation/quality control: The professionals in the partner institutions were asked on the existence of a program for continuous evaluation/quality control for digital radiology concerning technical resources and staff. While the availability of institutionalised technical quality control is considered high (>70%), organised measures of quality control for staff are scarce (14% - 30%), with the lowest numbers given for radiology technicians. 2.5 Relevant educational and training issues: All groups were asked to state their personal impression on their knowledge/need for additional education concerning aspects relevant for education and training in digital radiology. The possible aspects included the following: Dose level compared to conventional radiography Image/dose relationship Potential for dose reduction Postprocessing capabilities 5

Measures for quality control Physical properties of imaging system Basics of digital image acquisition Differences in image characteristics 2.5.1 Digital radiography: There were no major differences in the answers given by radiologists and radiographers, which is why these two groups are discussed together. Asked for sufficient knowledge the fewest positive answers in both groups were for Measures for quality control which is reflected by the impression of a need for additional education in these aspects (most frequent answer). For the physicists the most important aspect, for which additional education is thought necessary, is Postprocessing capabilities and Differences in image/dose relationship. All other aspects are found almost equally necessary in all three groups, there is no aspect where additional education is found inappropriate (see graph 5). Educational and training issues relevant for digital radiography (sufficient (need additional knowledge) education) Dose Dose level level compared compared to to conventional conventional radiography radiography Image/dose relationship Image/dose relationship Potential for dose reduction Potential for dose reduction 10% 12% 13% 10% 10% 12% 11% 11% Postprocessing capabilities Postprocessing capabilities Measures for quality control Measures for quality control 10% 13% 10% 13% 5% 14% 11% 11% 14% 10% Physical properties of imaging system Physical properties of imaging system Basics of digital image acquisition Basics of - digital Storage image phosphors: acquisition Basics - Storage of digital phosphors: image acquisition Basics of - digital Flat panel image detector: acquisition Differences - Flat panel in detector: image characteristics Differences in image characteristics 2.5.2 Digital fluoroscopy: Compared to the answers for digital radiography there is about the same impression regarding digital fluoroscopy, with Measures for quality control being one of the main aspects where additional education is found necessary. 2.5.3 Digital mammography: Again need for additional education in all aspects, with only slight differences in the percentage of individual aspects. 2.6 Use of monitor viewing: Besides digital acquisition, monitor viewing of digital radiographs is one of the problem areas in digital radiology. Authorities in the field still disagree on the possibility to display sufficient image information on monitors and on the type of monitors (resolution 6

requirements, luminance, etc.) to be used. Therefore the questioning on the experience with monitor viewing was found appropriate for the survey. Two questions were asked: Do you think that all relevant information for digital images is presented on the monitor in electronic format, which was stated with Yes by 40% to 67% of the answers and with No by 33% to 60% of answers. The specifications on the lack of information were almost identical with one third considering a Lack of dose information, Lack of kv/ma-values and Lack of Sensitivity-Value. 3. General considerations on the education and training of radiographers From a practical point of view the main impact of digital radiology on the work of radiographers lies in image acquisition. Therefore, a knowledge of the physical properties of the imaging system, their influence on image appearance and especially the image/dose relationship, as well as measures for quality control are main issues which have to be included in education and training for radiographers. Postprocessing of images according to the vendors workstation specifications and the underlying basic principles of image manipulation are further important issues. The technical aspects of digital radiology are mostly incorporated in the curricula of schools and academies for the education of radiographers. There seems to be a general lack of dedicated training programs for ongoing education in new radiological techniques. 4. General considerations on the education and training of medical physicists: With the continuing introduction of digital techniques into clinical practice the role of the medical physicist as a clinical partner for radiologists and radiographers is rising. Especially matters of quality control (technical quality) in image acquisition and postprocessing gain importance. From a general point of view therefore a profound knowledge of the basic physical properties of a digital modality, possibilities for quality testing and approval, statistical analysis of data and the institution of methods for continuous quality control are key issues in education and ongoing training of this staff group. As only few universities cover medical aspects in their curriculum most of the medical physicists acquire their knowledge on the job (see results of survey), whereas efficient and general available educational resources do not exist. As many of the essentials for the physicists work are theoretical in nature, the provision of a knowledge base, which may be accessed within the community would be helpful beside the institution of dedicated training programs. 5. General considerations on the education and training of radiologists and other medical doctors involved in X-ray diagnostics: Not only radiologists but various other medical specialists are involved in diagnostics or interventions, which use digital radiology equipment (dentists, cardiologists, surgeons...). If the equipment used relies on the delivery of radiation to the patient, a minimum of general knowledge on radiation protection, dose level, dose reduction and quality control is equally important for all professionals engaged in these procedures. In general sufficient knowledge of dose levels and measures of dose reduction, as well as measures for interpretation of image quality are mandatory regardless of the medical speciality involved and the type of radiographic equipment used. A basic knowledge on how the introduction of digital technology changes these general aspects of imaging should also be required in these disciplines. 7

Annexes: In these annexes examples of education/training issues to be included in some sort of official educational program are presented. The level of knowledge and coverage of special objectives depends on the group of professionals to whom this program will apply. Finally a structured concept on how to teach these issues to professionals in dedicated educational modules for basic and continuing education is suggested. 1. Outline for general education and training aspects in digital radiology: 1.1 X-ray systems for digital imaging 1.1.1 To discuss the difference between analogue and digital images 1.1.2 To have an up to date knowledge on the availability of clinical digital imaging systems for radiography, mammography and fluoroscopy 1.1.3 To discuss the physical properties of an X-ray digitizer 1.1.4 To explain the physical properties of storage phosphor radiography systems 1.1.5 To explain the physical properties of digital radiography systems: 1.1.5.1 Physical properties of direct and indirect systems 1.1.5.2 Basic principles of selenium detectors 1.1.5.3 Basic principles of detectors based on Caesium-iodide-amorphous silicon 1.1.5.4 Basic principles of CCD-detectors 1.1.6 To explain the physical properties of digital fluoroscopy 1.1.6.1 To explain the basic principles of the image intensifier 1.1.6.2 Discuss the difference between continuous and pulsed fluoroscopy 1.1.7 To explain the physical properties of digital mammography 1.2 Image acquisition 1.2.1 To explain the DQE and MTF of digital systems in comparison to film/screen systems 1.2.2 To discuss the dose level (speed class equivalent) of digital systems compared to film/screen systems 1.2.3 To explain how the image produced on a digital system will react on changes of exposure parameters (kv, mas) 1.2.4 To discuss the meaning and importance of various parameters for the control of adequate exposure ( Sensitivity-parameter, Level-Value, Hist-parameter, etc.) 1.2.5 To define the dose area product and its units 1.3 Image postprocessing 1.3.1 To discuss the rationale for postprocessing 1.3.2 To discuss the difference between an unprocessed and processed image 1.3.3 To discuss the possibilities of standard postprocessing and individual postprocessing 1.3.4 To discuss the situations in which additional postprocessing and/or changes in the standard postprocessing are necessary 1.3.5 To give an overview of postprocessing in computed/digital radiography 1.3.6 To give an overview of postprocessing in digital fluoroscopy 1.3.7 To give an overview of postprocessing in digital mammography 1.3.8 To give an overview of postprocessing on diagnostic workstations 1.4 Image transfer 1.4.1 To discuss the basic structure of PACS (image acquisition, distribution, storage, visualisation, archive) 1.4.2 To discuss basic aspects of image networks and teleradiology 8

1.4.3 To give a rough estimate of the size of an uncompressed digital image for radiography, CT, MRI and fluoroscopy 1.4.4 To discuss the difference between short term and long term storage and the available storage media 1.4.5 To discuss the rationale for image compression 1.4.6 To give a basic explanation of the DICOM standard and its implications for digital radiology 1.4.7 To explain the term image header and its information content 1.5 Image analysis 1.5.1 To explain the meaning of a pixel matrix and the image depth 1.5.2 To discuss the influence of workstation resolution and luminance on image visualisation 1.5.3 To discuss the relationship of image resolution and display resolution 1.5.4 To discuss the influence of magnification on display resolution 1.5.5 To discuss the influence of different postprocessings on the diagnostic image content 1.5.6 To discuss the interference of image display mode on metric functions (full screen mode, 1:1 mode) 1.6 Quality control 1.6.1 To explain the rationale for technical quality control checks 1.6.2 To discuss the terms: 1.6.2.1 Image quality 1.6.2.2 Range of tolerance 1.6.2.3 Imaging system 1.6.2.4 Image acquisition system 1.6.2.5 X-ray producing system 1.6.2.6 X-ray test patterns 1.6.3 To discuss the basic possibilities for quality control in acquisition, postprocessing and display 1.6.4 To discuss the differences of acceptance testing and constancy testing 1.6.5 To discuss the organisation and meaning of a reject analysis 1.6.6 To discuss the commonly used digital radiology phantoms and their potential application for quality control 9

2. Outline for specific education and training aspects in computed and digital radiography 2.1 X-ray systems for computed/digital radiography 2.1.1 To have an up to date knowledge on the availability of clinical systems for computed radiography based on digital luminescence radiography as well as digital detectors 2.1.2 To discuss the physical properties of a storage phosphor plate/digital detector and its reaction to ionising radiation 2.1.3 To be able to give a narrow estimate of the resolution of a storage phosphor plate of a given cassette size 2.1.4 To be able to give a narrow estimate of the resolution of a digital detector system depending on its physical properties (CCD, Selenium detector, etc.) 2.1.5 To discuss the resolution of storage phosphor plates and digital detectors in relation to film/screen radiography 2.1.6 To explain the sensitivity range of computed and digital radiography in relation to film/screen radiography 2.2 Image acquisition 2.2.1 To discuss the process of image acquisition with computed radiography (identification of cassette, exposure, acquisition, postprocessing) in comparison with direct digital radiography 2.2.2 To know the dose level (speed class equivalent) of computed radiography and digital radiography compared to film/screen systems 2.2.3 To explain special applications of computed radiography and digital radiography such as whole spine or whole leg acquisition or digital tomography 2.3 Image postprocessing 2.3.1 To discuss the meaning of the image histogram 2.3.2 To explain the following techniques related to postprocessing and their influence on the image: 2.3.2.1 Edge enhancement 2.3.2.2 Unsharp masking 2.3.2.3 Dynamic range reduction 2.3.2.4 Multiscale processing 2.3.2.5 Image gamma 2.3.2.6 Noise reduction 2.3.2.7 Window/Level setting 2.3.2.8 look up table 2.3.3 To explain why different processings of the same image (i.e. chest in normal and edge enhanced mode) may be helpful 2.3.4 To discuss possibilities of image manipulation tools such as shuttering, magnification, electronic collimation 2.4 Image transfer 2.4.1 To discuss the process of image plate identification 2.4.2 To discuss error sources in identification and their consequences in a PACS 2.5 Image analysis 2.5.1 To discuss the observable differences in computed radiography/digital radiography and film/screen radiography on behalf of selected clinical examples 2.5.2 To explain the possibilities of further postprocessing on a diagnostic workstation 10

2.5.3 To discuss possible artefacts in digital radiographs 2.5.4 To explain the rationale for the use of workstation tools such as magnification and window/level settings and their implications on diagnostic performance in soft copy reading of computed/digital radiographs 2.6 Quality control 2.6.1 To discuss common error sources in computed and digital radiography systems 2.6.2 To give a rough estimate on the half life of storage phosphor plates 2.6.3 To explain the calibration process of digital detectors and its influence on image quality 2.6.4 To explain the use of the CDRAD phantom and its application to quality control 11

3. Outline for specific education and training aspects in digital fluoroscopy 3.1 X-ray systems for digital fluoroscopy 3.1.1 To have an up to date knowledge on the availability of clinical digital imaging systems for fluoroscopy 3.1.2 To explain the physical properties of digital fluoroscopy 3.1.3 To explain the operation of continuous and pulsed fluoroscopy modes 3.1.4 To explain the different modes in grid controlled pulsed fluoroscopy 3.1.5 To give a rough estimate on the differences in dose between the LIH (last image hold) and the single shot image 3.1.6 To explain the serial shot modes 3.1.7 To discuss the differences between different time resolutions (2 images/s, 3 images/s, etc.) in relation to dose 3.1.8 To discuss the videocinematographic technique and its dose range compared to normal serial mode 3.2 Image acquisition 3.2.1 To discuss the influence of variations in the distance from object to image intensifier on dose and image quality 3.2.2 To discuss the influence of magnification modes on dose 3.2.3 To explain the influence of additional filtration and semitransparent collimators on dose and image quality 3.2.4 To discuss the difference between continuous and pulsed fluoroscopy with respect to dose level and resolution 3.2.5 To give an explanation for the use of pulsed fluoroscopy in various clinical settings 3.2.6 To explain the rationale for LIH (last image hold) technique and its use in clinical settings 3.2.7 To give an overview of the use of serial shot mode application in various clinical settings 3.2.8 To discuss the use of delays in acquisition of contrast enhanced fluoroscopy and give a rough estimate on delays used for angiography of the lower leg vessels and the brain vasculature 3.2.9 To discuss measures for radiation protection related to patients and staff (additional shielding, etc.) 3.2.10 To describe deterministic effects which may be observed in digital fluoroscopy 3.2.11 To discuss dose limits for staff in fluoroscopy 3.3 Image postprocessing 3.3.1 To explain the following techniques related to postprocessing and their influence on the fluoroscopic image: 3.3.1.1 Image subtraction 3.3.1.2 Pixel Shifting 3.3.1.3 Remasking 3.3.1.4 Road mapping 3.3.2 To explain the possibilities of 3D reconstruction in biplane fluoroscopy 3.4 Image transfer 3.4.1 To give a rough estimate of the size of an uncompressed digital fluoroscopy image 3.5 Image analysis 3.5.1 To discuss the technique and application of cine-mode 12

3.5.2 To discuss the difference in subtracted and not subtracted images 3.5.3 To discuss image artefacts in digital fluoroscopy 3.6 Quality control 3.6.1 To explain the use of common fluoroscopy phantoms 3.6.2 To discuss the application of moving phantoms for quality control 3.6.3 To discuss the importance of simple criteria for the control of patient and staff doses 3.6.4 To explain differences in patient and staff doses in diagnostic and interventional digital fluoroscopy 13

4. Outline for specific education and training aspects in digital mammography 4.1 X-ray systems for digital mammography 4.1.1 To have an up to date knowledge on the availability of clinical digital imaging systems for computed and digital mammography including systems for mammography controlled intervention ( biopsy tables ) 4.1.2 To explain the physical properties of digital mammography and current differences/limitations in relation to conventional mammography 4.1.3 To explain differences of mammography systems based on DLR and digital detectors 4.1.4 To describe the different anode/filter combinations available in modern digital mammography units 4.2 Image acquisition 4.2.1 To know the dose level of digital mammography compared to film/screen systems 4.2.2 To discuss the influence of different anode material (Rh, Mb, etc.) and filters on the dose level and image quality of digital mammograms 4.2.3 To discuss the influence of breast compression on image quality 4.2.4 To discuss limitations of digital mammography in clinical settings i.e. large breasts) 4.2.5 To discuss possible dose reductions in digital mammography compared to film/screen mammography 4.2.6 To discuss the importance of low dose exposure in screening mammography 4.3 Image postprocessing 4.3.1 To discuss relevant image quality features in digital mammograms 4.3.2 To discuss current postprocessing algorithms in digital mammography 4.3.3 To discuss the influence of postprocessing on the image quality features defined in 4.3.1 4.4 Image analysis 4.5 To explain the image quality criteria for clinical digital mammography images 4.5.1 To discuss differences in the image content of digital and conventional mammograms 4.5.2 To discuss the influence of workstation resolution and luminance on image visualisation 4.5.3 To discuss the influence of 1K and 2K monitor workstations on diagnostic performance in mammography reading 4.5.4 To explain special workstation features needed for soft copy reading of mammography 4.5.5 To discuss available methods for CAD (computer aided diagnosis) in digital mammography analysis 4.6 Quality control 4.7 To describe methods for definition of image quality in mammography 4.7.1 To discuss the ACR mammography test phantom and its application 4.7.2 To discuss the CDMAM phantom and its application 4.7.3 To explain the differences in results gained with the two phantom types and their implications on quality control 14

5. Outline for specific education and training aspects in digital visualisation and reporting 5.1 Workstations 5.1.1 To explain basic features of diagnostic workstations and comment on the differences between workstations for reporting, viewing and postprocessing 5.1.2 To explain the physical properties of cathode tube monitors and liquid crystal monitors 5.1.3 To discuss implications of monitor design on clinical use 5.1.4 To discuss physical differences in current high resolution grey scale and colour monitors and their implications on clinical use 5.2 Image presentation 5.2.1 To discuss different display modes and their usefulness for softcopy reporting 5.2.2 To explain the rationale for display of images in tile or stack mode 5.2.3 To discuss the relationship of image resolution and display resolution 5.2.4 To discuss the influence of magnification on display resolution 5.3 Image postprocessing 5.3.1 To explain differences in 2D and 3D rendering techniques 5.3.2 To explain the technical background of maximum intensity projections and their clinical use 5.3.3 To explain the technical background of volume rendering techniques and their clinical use 5.4 Image transfer 5.4.1 To discuss the differences between lossy and loss-less image compression 5.4.2 To discuss the workflow concepts in digital environments (HIS-RIS-PACS) 5.4.3 To explain differences in short term and long term archival and comment on implications for the workflow 5.4.4 To discuss legal issues concerning electronic archival of medical images 5.4.5 To explain methods available for image transfer in teleradiology 5.4.6 To discuss legal issues concerning teleradiology applications 5.4.7 To discuss legal and safety issues relevant for PACS and teleradiology 5.5 Image analysis 5.5.1 To explain inherent differences between soft copy and hard copy reporting 5.5.2 To discuss necessary PACS workstation software features 5.5.3 To discuss the folder and worklist concept 5.5.4 To discuss the differences in image content between conventional and digital image studies 5.5.5 To discuss methods for digital report generation such as speech recognition systems and comment on their integration in digital radiology 5.5.6 To comment on structured reporting 5.6 Quality control 5.6.1 To discuss possible methods for quality control regarding imaging workstations 5.6.2 To explain the use of an SMPTE-test pattern 5.6.3 To explain the use of a photometer for constancy checking of workstation luminance 5.6.4 To give an estimate on the schedule for continuous checking of workstations 5.6.5 To give a short overview on administration issues in digital radiology and PACS 15

5.6.6 To discuss media for digital storage of radiographic images and inherent security issues 16

Structure and content of specific training sessions for education in Interventional and Digital Radiology 5.7 Training of Radiographers: This outline represents the minimum requirements of basic and continuing education which we consider necessary for radiographers not previously engaged in digital radiology. If and to which extent especially aspects included in the basic modules are/or should be part of the curricula of official institutions for the education of radiographers, of teaching centres and academies is beyond the scope of this draft, although there may be similar requirements. From a general point of view the content of training modules for radiographers should mainly focus on aspects related to image acquisition and basic quality control. Special focus should be drawn on changes in daily routine resulting from application of digital instead of conventional technology. Aspects of radiation protection are included in this guideline, but they are covered in more detail in the EC guideline Radiation Protection 116 Guideline on Education and Training in Radiation Protection for Medical Exposures. The basic education may be organised in form of a weekend workshop including all basic modules with a total duration of 20 working hours, or in single workshops focused on an individual basic modules content (but with the obligation to attend all of them). The follow up modules would probably be better organised in single sessions focusing on an individual subtask. 5.7.1 Basic education (20 hours) 5.7.1.1 Basic module for general digital radiology Theoretical overview (lecture type presentation) of currently available CR/DR-systems, their technical concept and physical properties. Theoretical comparison (lecture type presentation) of conventional and computed/digital radiography in relation to DQE and MTF, as well as differences in the dose level. Image appearance 1 : Introductory lecture on image appearance in computed/digital radiography: Effect of choice of kv/ma and dose on image appearance. Simple measures for the control of correct exposure (HIS-values, sensitivity, etc.). Image appearance 2 : Effect of postprocessing on image appearance. Typical postprocessing techniques such as edge enhancement, unsharp masking, dynamic range reduction, noise reduction, etc. should be discussed in relation to their effect on the final image. Medical information technology : Overview (lecture type presentation) of medical information technology (HIS, RIS, PACS) relevant for the digital radiology department and the integration of image acquisition systems into the digital workflow. Practical workshop 1 Image acquisition : Practical training in computed/digital radiography with exposure of antropomorphic phantoms. Practical workshop 2 Image postprocessing : Practical training on workstations with postprocessing of patient images and discussion of resulting images. 17

5.7.1.2 Basic module for digital mammography Theoretical overview (lecture type presentation) of currently available systems for digital mammography (Storage Phosphors, CCDs, Flat Panels), their technical concept and physical properties. Special focus should be put on differences between the technologies. Theoretical comparison (lecture type presentation) of conventional and computed/digital mammography in relation to DQE and MTF, as well as differences in the dose level. Image appearance (lecture type presentation): Comparison of image appearance in conventional and digital mammography and influences of postprocessing. Practical workshop Digital mammography : Acquisition of phantom images, image analysis in relation to dose, influence of compression and postprocessing on image appearance. 5.7.1.3 Basic module for digital fluoroscopy and interventional radiology Theoretical overview (lecture type presentation) of currently available systems for digital fluoroscopy, their technical concept and physical properties. Image acquisition : Aspects of image acquisition in digital fluoroscopy affecting dose and image quality (such as influence of object intensifier distance on dose, use of additional filtration, road mapping, continuous versus pulsed fluoroscopy). Radiologic risks in interventional radiology (deterministic effects as a function of dose, stochastic risks and age dependence, measures for risk minimisation). 5.7.1.4 Basic module for radiation protection and quality assurance Radiation protection 1: National and international regulations for radiation protection of patients and staff. Measures for patient and staff dosimetry. Radiation protection 2: Repetition of basic dosimetric quantities in radiology (Dose Area Product, Entrance Dose, Surface Dose, etc) and their interrelation. General dose level in digital radiography, fluoroscopy and mammography compared with conventional acquisition and measures for further dose reduction (pulsed fluoroscopy). Quality assurance 1: Introductory lecture Aspects of radiological quality assurance rationale for quality assurance, national and international regulations, documentation. Quality assurance 2: Methods for quality control constancy testing, reject analysis, use of phantoms for quality control in computed/digital radiography, digital fluoroscopy and computed/digital mammography; special aspects in interventional radiology. Quality assurance 3: Introduction to guidelines such as the European Guidelines on Quality Criteria For Diagnostic Radiographic Images (as far as they apply will be substituted by a special guideline for computed/digital radiography in the near future) and their implication for daily practice. Quality assurance 4: The image chain quality aspects related to information technology (RIS, PACS) such as patient identification, data care, quality control of display systems. 18

5.7.2 Continuing education 5.7.2.1 Follow up module for digital radiography (3 hours) Update on currently available systems for computed/digital radiography, their technical concept and physical properties as well as ongoing developments. Special focus should be put on differences between the new technologies and previously available systems ( such as DR versus CR). Update on image analysis: Image appearance, artefacts, dose dependence, image quality concepts. Practical workshop with acquisition of phantom images and image quality analysis. 5.7.2.2 Follow up module for digital mammography (2 hours) Update on currently available systems for computed/digital mammography, their technical concept and physical properties as well as ongoing developments. Special focus should be put on differences between the new technologies and previously available systems (such as DR versus CR). Influence of acquisition parameters on dose and image quality in digital mammography. 5.7.2.3 Follow up module for digital fluoroscopy and interventional radiology (2 hours) Update on x-ray systems for digital fluoroscopy and interventional radiology. Update on interventional procedures and risk estimation according to complexity of the procedure. 5.7.2.4 Follow up module for radiation protection and quality assurance (2 hours) Radiation protection: Practical protection of patients and staff (discuss dose limits and regulations, influence of shielding, use of personal protection, basic dosimetry). Quality assurance: Implication of periodical control (constancy testing) on image quality and patient protection. Simple measures for image quality analysis in digital radiography and dose estimation in different procedures (radiography, fluoroscopy, interventional procedures). 19

5.8 Training of Radiologists This outline represents the minimum requirements of basic and continuing education which w e consider necessary for radiologists not previously engaged in digital radiology. If and to which extent especially aspects included in the basic modules are/or should be part of the curricula of medical schools is beyond the scope of this draft, although there may be similar requirements. From a general point of view the content of training modules for radiologists should mainly focus on aspects related to application of digital technology to various clinical problems and image analysis. Special focus should be drawn on changes in daily routine resulting from application of digital instead of conventional technology. Aspects of radiation protection are included in this guideline, but they are covered in more detail in the EC guideline Radiation Protection 116 Guideline on Education and Training in Radiation Protection for Medical Exposures. The basic education may be organised in form of a weekend workshop including all basic modules with a total duration of 20 working hours, or in single workshops focused on an individual basic modules content (but with the obligation to attend all of them). The follow up modules would probably be better organised in single sessions focusing on an individual subtask. 5.8.1 Basic education (20 hours) 5.8.1.1 Basic module for general digital radiology Theoretical overview (lecture type presentation) of currently available CR/DR-systems, their technical concept and physical properties. Theoretical comparison (lecture type presentation) of conventional and computed/digital radiography in relation to DQE and MTF, as well as differences in the dose level. Image appearance 1 : Introductory lecture on image appearance in computed/digital radiography: Effect of image appearance on the visualisation of clinically important anatomical structures. Image appearance 2 : Effect of postprocessing on image appearance. Typical postprocessing techniques such as edge enhancement, unsharp masking, dynamic range reduction, noise reduction, etc. should be discussed in relation to the clinical problem to be solved with a radiology examination and their effect on the final image. Soft copy reporting : Introductory lecture on differences between hardcopy and softcopy reading, influence of workstation design/specification and ambient light on reader performance, rationale for the use of different workstation features for image analysis (magnification, postprocessing). Medical information technology : Overview (lecture type presentation) of medical information technology (HIS, RIS, PACS) relevant for the digital radiology department and the integration of image acquisition systems into the digital workflow. Practical workshop Image analysis : Practical training in reading of storage phosphor/digital radiographs (hardcopy and softcopy reading) with special focus on differences compared with conventional imaging and the recognition of artefacts. 20

5.8.1.2 Basic module for digital mammography Theoretical overview (lecture type presentation) of currently available systems for digital mammography (Storage Phosphors, CCDs, Flat Panels), their technical concept and physical properties. Special focus should be put on differences between the technologies. Theoretical comparison (lecture type presentation) of conventional and computed/digital mammography in relation to DQE and MTF, as well as differences in the dose level. Image appearance (lecture type presentation): Influences of acquisition technique (conventional/digital) on the appearance of anatomical and pathological structures in the mammogram. Typical artefacts. Practical workshop Digital mammography : Hard- and softcopy reading of normal and pathological digital mammograms in comparison with conventional counterparts, and discussion of differences in the image appearance. 5.8.1.3 Basic module for digital fluoroscopy and interventional radiology Theoretical overview (lecture type presentation) of currently available systems for digital fluoroscopy, their technical concept and physical properties. Image acquisition : Aspects of image acquisition in digital fluoroscopy affecting dose and image quality such as pulsed fluoroscopy. The fluoroscopic examination : Use of different acquisition features (continuous/pulsed fluoroscopy, road mapping, magnification, postprocessing) in relation to the procedure (diagnostic and interventional) and clinical question. Discussion of current interventional techniques and their risk estimation in accordance with the complexity of the procedure, as well as methods for risk reduction. 5.8.1.4 Basic module for radiation protection and quality assurance Radiation protection 1: National and international regulations for radiation protection of patients and staff. Measures for patient and staff dosimetry. Radiation protection 2: Repetition of basic dosimetric quantities in radiology (Dose Area Product, Entrance Dose, Surface Dose, etc) and their interrelation. General dose level in digital radiography, fluoroscopy and mammography compared with conventional acquisition and measures for further dose reduction (pulsed fluoroscopy). Radiation protection 3: Deterministic effects in diagnostic imaging with special focus on interventional radiology. Consequences for daily clinical practice (indication, technical realisation of exams). Quality assurance 1: Introductory lecture Aspects of radiological quality assurance rationale for quality assurance, national and international regulations, documentation. Quality assurance 2: Introduction to the image quality concept and guidelines such as the European Guidelines on Quality Criteria for Diagnostic Radiographic Images (as far as they apply will be substituted by a special guideline for computed/digital radiography in the near future). Quality assurance 3: The image chain quality aspects related to information technology (RIS, PACS) such as patient identification, data care, quality control of display systems. Practical Workshop Quality control : Image quality assessment with the use of clinical examples. Recognition of image artefacts in digital acquisition technologies. Basic quality control in digital visualisation. 21

5.8.2 Continuing education 5.8.2.1 Follow up module for digital radiography (3 hours) Update on available systems for computed/digital radiography, their technical concept and physical properties as well as ongoing developments. Special focus should be put on differences between the new technologies and previously available systems (such as DR versus CR). Update on image appearance and analysis: Influence of digital acquisition and postprocessing on image appearance and dose level, recognition of artefacts, dose dependence and image quality concepts. Application of digital techniques to clinical situations. Practical workshop Image analysis : Practical training in reading of storage phosphor/digital radiographs (hardcopy and softcopy reading) with special focus on differences compared with conventional imaging and the recognition of artefacts. 5.8.2.2 Follow up module for digital mammography (3 hours) Update on available systems for digital mammography (Storage Phosphors, CCDs, Flat Panels), their technical concept and physical properties. Special focus should be put on differences between the technologies especially regarding differences in the dose level. Image appearance (lecture type presentation): Influences of acquisition technique (conventional/digital) on the appearance of anatomical and pathological structures in the mammogram. Typical artefacts. Practical workshop Digital mammography : Hard- and softcopy reading of normal and pathological digital mammograms in comparison with conventional counterparts, and discussion of differences in the image appearance. 5.8.2.3 Follow up module for digital fluoroscopy and interventional radiology (3 hours) Update on currently available systems for digital fluoroscopy and interventional procedures. Special focus should be drawn on differences in image appearance as well as differences in the way a fluoroscopic (interventional) procedure may be performed using new technical properties. Image acquisition : Aspects of image acquisition in digital fluoroscopy affecting dose and image quality such as pulsed fluoroscopy with special focus on new technical developments. Discussion of radiation risks derived from new technical developments or interventional procedures, as well as methods for risk reduction. 22

5.8.2.4 Follow up module for radiation protection and quality assurance (3 hours) Update on national and international regulations for radiation protection of patients and staff and their implication on clinical practice. Update on deterministic effects in diagnostic imaging with special focus on interventional radiology. Consequences for daily clinical practice (indication, technical realisation of exams). Update on quality assurance: Rationale for quality assurance, national and international regulations, documentation, introduction to the image quality concept and guidelines, quality control in digital visualisation. 23

5.9 Training of Medical Physicists This outline represents the minimum requirements of basic and continuing education which we consider necessary for medical physicists not previously engaged in digital radiology. If and to which extent especially aspects included in the basic modules are/or should be part of the curricula of universities or dedicated academies is beyond the scope of this draft, although the re may be similar requirements. From a general point of view the content of training modules for physicists should mainly focus on aspects related to digital technology as well as radiation protection and quality assurance. Aspects of radiation protection are included in this guideline, but they are covered in more detail in the EC guideline Radiation Protection 116 Guideline on Education and Training in Radiation Protection for Medical Exposures. The basic education may be organised in form of a weekend workshop including all basic modules with a total duration of 20 working hours, or in single workshops focused on an individual basic modules content (but with the obligation to attend all of them). The follow up modules would probably be better organised in single sessions focusing on an individual subtask. 5.9.1 Basic education (20 hours) 5.9.1.1 Basic module for general digital radiology Theoretical overview (lecture type presentation) of currently available CR/DR-systems, their technical concept and physical properties. Theoretical comparison (lecture type presentation) of conventional and computed/digital radiography in relation to DQE and MTF, as well as differences in the dose level. Medical information technology : Overview (lecture type presentation) of medical information technology (HIS, RIS, PACS) relevant for the digital radiology department and the integration of image acquisition systems into the digital workflow. Introduction to networks for medical image transfer and teleradiology applications. Medical viewing workstations : Technical specifications of reporting workstations and monitors (greyscale, colour, cathode monitors, LCD monitors) and their influence on observer performance and digital workflow. Medical standards : Overview of relevant medical standards (HL7, DICOM, DIN 6856-2, DIN 6868-56/57, etc.) and national/international regulations (ICRP 73, 97/43 EURATOM, etc.). Practical workshop 1 Measurements : Theory and practice in measurement of output and half-value layer attenuation of x-ray beams, beam Energy (kvp), focal spot sizes of x-ray sources, image focus of receptors, operation of Automatic Exposure Controls, surface dose, entrance surface air-kerma, backscatter, etc. with the use of different measurement instruments. 5.9.1.2 Basic module for digital mammography Theoretical overview (lecture type presentation) of currently available systems for digital mammography (Storage Phosphors, CCDs, Flat Panels), their technical concept and physical properties. Special focus should be put on differences between the technologies. Theoretical comparison (lecture type presentation) of conventional and computed/digital mammography in relation to DQE and MTF, as well as differences in the dose level. 24

5.9.1.3 Basic module for digital fluoroscopy and interventional radiology Theoretical overview (lecture type presentation) of currently available systems for digital fluoroscopy, their technical concept and physical properties. Image acquisition : Aspects of image acquisition in digital fluoroscopy affecting dose and image quality such as pulsed fluoroscopy. 5.9.1.4 Basic module for radiation protection and quality assurance Staff and patient dosimetry : National/international regulations, methods for patient and staff dosimetry, deterministic effects, reference levels for medical exposures, Monte Carlo Simulations. Introductory lecture on acceptance and constancy testing: Rationale for quality assurance, planning and organisation of a quality assurance programme, national and international regulations. Basic concepts for digital radiography, fluoroscopy and mammography. Introduction to image quality assessment : Definition of technical and clinical image quality, biophysics of perception, description of phantoms for image quality assessment (Leeds-phantom, CDRAD/CDMAM phantom, etc.) and quantitative/semi-quantitative methods for image quality evaluation (DQE/MTF-measurement, observer performance: forced choice experiments, ROC-analysis, etc.). Introduction to quality assurance in digital reporting : Aspects of monitors influencing image quality and perception of details (luminance, resolution, image depth, etc.). Measures for quality assessment (SMPTE-test phantoms). Quality in medical IT-applications : Error sources in image networks (PACS) and radiological software, methods for performance testing and continuous quality control. Workshop Quality Control : Practical training in the use of phantoms and measurement instruments used in quality control. 5.9.2 Continuing education 5.9.2.1 Follow up module for digital radiography (4 hours) Update on available CR/DR-systems, their technical concept and physical properties with comparison in relation to DQE and MTF, as well as differences in the dose level. Update on medical information technology (HIS, RIS, PACS) relevant for the digital radiology department and the integration of image acquisition systems into the digital workflow including networks for medical image transfer and teleradiology applications as well as the medical viewing workstations. Update on relevant medical standards (HL7, DICOM, DIN 6856-2, DIN 6868-56/57, etc.) and national/international regulations (ICRP 73, 97/43 EURATOM, etc.) with special focus on changing standards and regulations (i.e. newly released amendments). Practical workshop Measurements : Theory and practice in measurement of output and half-value layer attenuation of x-ray beams, beam Energy (kvp), focal spot sizes of x-ray sources, image focus of receptors, operation of Automatic Exposure Controls, surface dose, entrance surface air-kerma, backscatter, etc. with the use of different measurement instruments. 25

5.9.2.2 Follow up module for digital mammography (2 hours) Update on available systems for digital mammography (Storage Phosphors, CCDs, Flat Panels), their technical concept and physical properties. Special focus should be put on differences between the technologies. Theoretical comparison (lecture type presentation) of conventional and computed/digital mammography in relation to DQE and MTF, as well as differences in the dose level special focus should be drawn on differences resulting from new technologies. 5.9.2.3 Follow up module for digital fluoroscopy and interventional radiology (2 hours) Update on available systems for digital fluoroscopy, their technical concept and physical properties, as well as new acquisition and postprocessing techniques Image acquisition : Aspects of image acquisition in digital fluoroscopy affecting dose and image quality. 5.9.2.4 Follow up module for radiation protection and quality assurance (4 hours) Update on national/international regulations as well as reference levels and the implication of changes in these matters on daily practice, such as quality control programs. Update on acceptance and constancy testing including aspects of digital visualisation as well as reporting: Rationale for quality assurance, planing and organisation of a quality assurance program. Update on image quality assessment: Repetition of technical and clinical image quality, biophysics of perception, description of phantoms for image quality assessment and quantitative/semi-quantitative methods for image quality evaluation with special focus on new developments. Workshop Quality Control : Practical training in the use of phantoms and measurement instruments used in quality control. 26

5.10 Training of medical doctors (non radiologists) involved in any kind of radiography or radiography assisted procedures This outline represents the minimum requirements of basic and continuing education which we consider necessary for medical doctors (non radiologists) involved in any kind of radiography (i.e. dental systems, etc.) or radiography assisted procedures and not previously engaged in digital radiology. If and to which extent especially aspects included in the basic modules are/or should be part of the curricula of medical schools is beyond the scope of this draft, although there may be similar requirements. From a general point of view the content of training modules should mainly focus on practical aspects related to application of digital radiology and radiation protection in daily clinical practice. Special focus should be drawn on changes resulting from application of digital instead of conventional technology. The basic education may be organised in form of a weekend workshop including all basic modules with a total duration of 10 working hours, or in single workshops focused on an individual basic modules content (but with the obligation to attend all of them). Due to the limited schedule the follow up modules would probably be integrated in a single workshop. 5.10.1 Basic education 5.10.1.1 Basic module for digital radiology Introduction to digital radiology : Imaging systems for digital radiography, fluoroscopy and mammography, their basic physical/technical specifications and clinical application. Radiation dose : Definition of commonly used dosimetric quantities (surface dose, entrance dose, etc) and their implication for clinical practice. Radiation dose in digital compared to conventional acquisition on behalf of typical examples. Information technology : Basic overview on PACS and teleradiology as well as the digital workflow. 5.10.1.2 Basic module for interventional radiology Overview of digital technology suited for interventional radiology and its application to special clinical situations. The application of different acquisition techniques in interventional procedures and their influence on dose and image quality. Complexity of different interventional procedures, its influence on the radiation burden of staff and patient as well as implications for dose reduction strategies. 5.10.1.3 Basic module for radiation protection and quality assurance Patient and staff protection : National and international regulations regarding the protection of patients and staff against the risks of ionising radiation. Methods for reduction of radiation exposure (time, distance, shielding, etc.). Risk assessment : Deterministic and stochastic effects and their dose (age) dependence. Reference values for commonly performed radiological procedures and comparison with environmental radiation exposure. Dosimetry : Basic dosimetric quantities in digital radiology, simple measurements and estimations of surface dose and radiation risks. 27

Workshop Digital radiology : Practical training in reading of digital images (radiographs, mammograms, fluoroscopy) with special focus on assessment of image quality and recognition of artefacts. 5.10.2 Continuing education 5.10.2.1 Follow up module for digital radiology Update on digital radiology: New developments in digital acquisition, image transfer and storage and their application to clinical practice. 5.10.2.2 Follow up module for interventional radiology New developments in technology suited for interventional radiology and their influence on clinical practice regarding image quality and possible dose reductions. 5.10.2.3 Follow up module for radiation protection and quality assurance Update on regulations regarding the protection of patients and staff against the risks of radiation special focus should be put on changing regulations and their implication for daily clinical practice. Repetition of radiation risks and measures of radiation protection for staff and patients. 28

5.11 Training of other staff (i.e. nursing staff, technical staff) involved in any kind of radiography or radiography assisted procedures This outline represents the minimum requirements of basic and continuing education which we consider necessary for other staff (nursing staff, etc.) involved in any kind of radiography (i.e. dental systems, etc.) or radiography assisted procedures and not previously engaged in digital radiology. If and to which extent especially aspects included in the basic modules are/or should be part of the curricula of nursing schools etc. is beyond the scope of this draft, although there may be similar requirements. From a general point of view the content of training modules should mainly focus on practical aspects related to application of digital radiology and radiation protection in daily clinical practice. Special focus should be drawn on changes resulting from application of digital instead of conventional technology. The basic education may be organised in form of a weekend workshop including all basic modules with a total duration of 10 working hours, or in single workshops focused on an ind ividual basic modules content (but with the obligation to attend all of them). The follow up modules would probably be better organised in single sessions focusing on an individual subtask. 5.11.1 Basic education 5.11.1.1 Basic module for digital radiology Introduction to digital radiology : Imaging systems for digital radiography, fluoroscopy and mammography, their basic physical/technical specifications and clinical application. Radiation dose : Definition of commonly used dosimetric quantities (surface dose, entrance dose, etc) and their implication for clinical practice. Radiation dose in digital compared to conventional acquisition on behalf of typical examples. Information technology : Basic overview on PACS and teleradiology as well as the digital workflow, with special focus on administration of patient/exam data and common error sources. 5.11.1.2 Basic module for interventional radiology Characterisation of interventional procedures, radiological risks in intervention (deterministic effects, stochastic effects, etc.), care and follow-up for interventional patients. Measures for dose estimation in interventional procedures and influence of acquisition factors on dose. 5.11.1.3 Basic module for radiation protection and quality assurance Patient and staff protection : National and international regulations regarding the protection of patients and staff against the risks of ionising radiation. Risk assessment : Reference values for commonly performed radiological procedures and comparison with environmental radiation exposure. Patient and staff protection : Rationale for the use of shielding, reduction of radiation time, distance from radiation source, staff dosimetry. Rationale for continuous quality control with practical training in constancy testing. 29

5.11.2 Continuing education 5.11.2.1 Follow up module for digital radiology Update on digital radiology : New developments in digital acquisition, image transfer and storage, with special focus on changes in clinical practice resulting from introduction of new technologies. Update on medical information technology and administration of patient and exam data. 5.11.2.2 Follow up module for interventional radiology Update on radiological equipment used for intervention and new interventional procedures. Changes in daily routine due to new developments. Measures of dose estimation in interventional procedures and influence of acquisition factors on dose. 5.11.2.3 Follow up module for radiation protection and quality assurance Update on national and international regulations regarding the protection of patients and staff against the risks of ionising radiation, with special focus on changes relevant for clinical practice. Update on reference values and dose estimations. Update on patient and staff protection. 30

7. Sample of Questionnaire: Training and education: When new digital modalities were introduced, which educational resources were used? Workshop with vendor Training on the job (assisted by vendor) Training on the job (learning by doing) Visit to other hospital Workshop at scientific meeting Dedicated educational program Others Which additional resources did you use? Literatu re Video/CD-Rom Internet Others specify: Which ongoing training measures do you use? In house training (continue below) Presentations,... Workshops, scientific meetings... Visits by specialists Others How many training hours do you consider reasonable? Educational program On the job 5 10 15 20 25 more For initial training For continuous education on a 2-3 year basis Is there a training resource of any kind for digital radiology offered by a national society in your country? Yes No When computed/digital radiography was introduced, which of the following did you encounter? Different image CR: DR: appearance Different image/dose relationship Need for new quality criteria When digital mammography was introduced, which of the following did you encounter? Different image appearance Different image/dose relationship 31

Need for new quality criteria When digital fluoroscopy was introduced, which of the following did you encounter? Different image appearance Different image/dose relationship Need for new quality criteria Is there a continuous program of evaluation/quality control for digital radiology? Technical quality Staff Monitor-viewing: Do you think that all relevant information for digital images is presented on the Monitor in Yes No If "No" please continue: Lacking dose info rmation Lacking KV/mAs values Lacking "Sensitivityvalue" Other: Please state 3 most important skills for each professional in digital radiology: Radiolo gist Technic ian Physici st 32

The following list includes educational and training issues relevant for digital radiology. State for each if you think you have sufficient knowledge about it, or if you might need additional education. (If you have no experience with the system give no marks) 1) Digital sufficient need additional education radiography: knowledge Dose level compared to conventional radiography Image/dose relationship Potential for dose reduction Postprocessing capabilities Measures for quality control Physical properti es of imaging system Basics of digital image acquisition Storage phosphors: Flat panel detector: Differences in image characteristics 2) Digital sufficient need additional education fluoroscopy: knowledge Dose level compar ed to conventional fluoroscopy Image/dose relationship Potential for dose reduction Pulsed fluoroscopy Dose in relation to magnification Postprocessing capabilities Measures for quality control Physical properties of imaging system Basics of digital image acquisition Differences in image characteristics 3) Digital sufficient knowledge need additional education Mammography: Dose level compared to conventional mammography Image/dose relationship Potential for dose reduction Dose in relation to magnification 33

Postprocessing capabilities Measures for quality control Physical properties of imaging system Basics of digital image acquisition Differences in image characteristics Room for additional comments: 34

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