Radiation Protection Dosimetry (2005), Vol. 114, Nos 1-3, pp.

126–130 INVITED PAPER

doi:10.1093/rpd/nch533

ICRP RECOMMENDATIONS ON ‘MANAGING PATIENT DOSE

IN DIGITAL RADIOLOGY’
E. Vano
San Carlos University Hospital, Radiology Department, Complutense University, 28040 Madrid, Spain

The International Commission on Radiological Protection (ICRP) approved the publication of a document on ‘Managing
patient dose in digital radiology’ in 2003. The paper describes the content of the report and some of its key points, together
with the formal recommendations of the Commission on this topic. With digital techniques exists not only the potential to
improve the practice of radiology but also the risk to overuse radiation. The main advantages of digital imaging: wide dynamic
range, post-processing, multiple viewing options, electronic transfer and archiving possibilities are clear but overexposures can

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occur without an adverse impact on image quality. It is expected that the ICRP report helps to profit from the benefits of this
important technological advance in medical imaging with the best management of radiation doses to the patients. It is also
expected to promote training actions before the digital techniques are introduced in the radiology departments and to foster
the industry to offer enough technical and dosimetric information to radiologists, radiographers and medical physicists to help
in the optimisation of the imaging.

INTRODUCTION the transition to digital equipment, patient doses

Committee 3 (Protection in Medicine) of the Inter-
national Commission on Radiological Protection
(ICRP) decided in 2001 to launch a task group
(TG) to produce a document on ‘Managing Patient
Dose in Digital Radiology’. The appointed members
of the TG were: E. Vano (chairman), R. Loose,
B. Geiger, B. Archer, K. Faulkner and the corres-
ponding members: M. Rosenstein, J. M. Fernandez,
H. P. Busch, M. Wucherer, B. Bergh, R. Gagne and
C. Sharp. The document was finished in 2003 and
approved for publication by Committee 3 and by
the Main Commission of ICRP in November 2003.
Previously, the draft was posted at the website of
ICRP (www.icrp.com) during a 2 month period for
public comments. The report has been published by
Elsevier in 2004(1).
The decision to start with this document was taken
considering that digital radiology (DR) represented
one of the greatest technological advances in medical
imaging over the last decade. With digital systems,
images can be taken, immediately examined, deleted,
corrected, cropped and sent to a network of com-
puters. Thus, the benefits are enormous. The refer-
ring physician often can view the requested image on
a desktop personal computer, usually accompanied
by the interpretation, just minutes after the examina-
tion was performed. In addition, the patients can
have all his/her X rays on a compact disc to take to
another physician or hospital.
Digital technology has not only the potential to
reduce patient doses, but also the risk to increase the
number of exposures and the dose required to obtain
images of enough quality. Experience has shown that
although many radiology departments have made
Corresponding author: eliseov@med.ucm.es
have not gone down but have measurably increased.
Most systems do not easily track unsatisfactory ima-
ges that were deleted from the system and although
the data are present, few systems display meaningful
dose or exposure factors for the patient record.
Attention needs to be given to many factors when
making the transition to digital systems. A few
examples of this are standardisation of equipment,
training, privacy and security concerns, quality con-
trol, diagnostic reference levels (DRLs), archiving,
compression algorithms and referral criteria.
If careful attention is not paid to the radiation
protection issues of DR, medical exposure of patients
will increase significantly and without concurrent
benefit. Conversely, if the radiation protection issues
are adequately addressed, medical exposures may
decrease without decreasing the diagnostic benefit
to the patient.
This paper describes the content of the ICRP
report and the formal recommendations of the
Commission to manage patient dose in DR.
CONTENT OF THE REPORT
The ICRP report is structured in four chapters and
three appendices. A glossary and an extensive list of
references are also included. Several figures help
to understand the fundamentals of DR influencing
image quality and patient doses and, in some cases,
show examples of some mistakes that can be made
using digital techniques. The report and all the chap-
ters start with a list of key points allowing the read-
ers to know in advance the most important aspects
of the different sections. Other digital techniques,
such as computed tomography (CT) and digital
subtraction angiography (DSA), are not included
in the document.

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 ICRP PATIENT DOSE IN DIGITAL RADIOLOGY
In the chapter of introduction it is highlighted
that the diagnostic information provided by modern
digital detectors can be equal or superior to conven-
tional film-screen systems, with comparable patient
doses. Digital imaging has practical technical advan-
tages compared with film techniques, for example,
wide contrast dynamic range, post-processing
functionality, multiple image viewing options and
electronic transfer and archiving possibilities.
With digital systems, an overexposure can occur
without an adverse impact on image quality. Over-
exposure may not be recognised by the radiologist
or radiographer. In conventional radiography,
excessive exposure produces a ‘black’ film and
the digital imaging system makes it more difficult to
recognise overexposure or underexposure.
In digital fluoroscopy examinations, it is very easy
to obtain a large number of images because it is not
necessary to introduce cassettes or film changers,
as in conventional systems. In addition, a large
number of exposures per examination allow a larger
selection of images, with the potential to improve
clinical diagnosis. All these practices result in higher
absorbed dose for the patient.
Axelsson et al.(3) have demonstrated that in upper
gastrointestinal examinations, some centres with
digital fluoroscopy use a mean number of 68 expos-
ures per examination in comparison with 16 expos-

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inadequate exposure produces a ‘white’ film, both
with reduced contrast. In digital systems, image
brightness can be adjusted post-processing, inde-
pendent of exposure level.
The document is addressed to radiologists, radio-
graphers, medical physicists and all other interested
individuals who are familiar with conventional
film-based radiography and fluoroscopy. No specific
physics, electronic or computer knowledge is neces-
sary to understand the basic principles of digital
radiography and fluoroscopy or their clinical
applications described in the report.
PATIENT DOSE AND IMAGE QUALITY
The chapter dealing with patient dose and image
quality is the most practical one. Some parameters
that usually identify image quality (e.g. noise)
correlate well with dose. For digital detectors, higher
doses result in a better image quality (e.g. a less
‘noisy’ image) in a certain range of dose. Thus,
a tendency to increase doses can occur especially in
those examinations where automatic exposure con-
trol is not usually available (e.g. bedside applica-
tions). Lower doses would clearly result in some
adverse impact on image quality with regard to
noise, and probably would be noticed. However,
if the doses drift upward, the overexposure will not
be noticed because there will be no adverse effect on
image quality(2). The increase in dynamic range of
ures used in other centres with conventional systems.
Image quality criteria should be developed for
digital techniques, and should include the reasonable
number of images to be obtained per examination.
DRLs would be a useful tool for optimisation of
procedures, if an appropriate patient dose quantity
and the number of exposures per examination are
recorded(4).
The report highlights that DR allows obtaining
different levels of image quality (using different
patient doses) that can be adapted to the different
medical imaging tasks. The objective is to avoid
unnecessary patient doses, which have no additional
benefit for the clinical purpose intended.
The follow-up of a fracture does not require the
same level of image quality as that required for its
diagnosis. For tasks such as routine follow-up stud-
ies, assessment of instability or orthopaedic meas-
urements, a radiation dose reduction of up to 75%
with digital techniques in comparison with conven-
tional film-screen techniques (speed of 400) has been
demonstrated by Strotzer et al.(5).
Busch et al.(6,7) have proposed during the
European research programme DIMOND(8) a ‘three
band’ classification for image quality—high, medium
and low—depending on the clinical problem to be
solved. Table 1 presents some examples.
The ICRP document also summarises actions that
can influence image quality and patient doses and
includes an assessment of the impact of each action.
Table 2 presents some of these actions.

Table 1. Examples of clinical problems with their image quality classes.

Clinical problem Image Comment

quality class

Primary bone tumour High Image may characterise the lesion

Chronic back pain with no
pointers to infection or neoplasm
Pneumonia adults: follow-up
Medium Degenerative changes are common and non-specific. Mainly used
for younger patients (e.g. <20 y of age, spondylolisthesis, etc.)
or older patients, e.g. >55 y of age
Low To confirm clearing, etc. Also, not useful to re-examine patient at
<10 d intervals as clearing can be slow (especially in the elderly)

127
 E. VANO
Image quality can also be compromised by
inappropriate levels of data compression and/or
post-processing techniques. Data compression and
post-processing requirements should be defined by
modality and the medical imaging task.
If patient dose parameters are displayed at
the operator console (and inside the X-ray room
for interventional procedures), radiographers and
medical physics specialists can better manage patient
dose to agreed protocols.
Real-time collection of dose data, that is, an easily
visible indication on the control panel, would allow
comparison with DRLs, facilitate management of
dose and help to prevent excessive patient doses(10).
An outline of training topics for DR is presented
in one of the Annexes of the ICRP report(1).
REGULATORY ASPECTS AND QUALITY
MANAGEMENT
Commissioning of digital systems, or introduction of
new techniques, should ensure that imaging capabil-
ity and radiation dose management are integrated to
achieve acceptable clinical image production using
appropriate patient doses.
Justification criteria should be one of the key
components considered in the update of a quality
assurance programme when a facility converts to

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The display, recording and management of radio-
graphic and geometric parameters used during
procedures should be quite easy in DR and this
would help in the optimisation. Table 3 describes
the present and the desired situation in the future
for the different digital technologies for data on
patient doses.
Specific training in DR is necessary for radiolo-
gists, medical physicists and radiographers involved
in the use of digital techniques. This training should
include basic aspects of radiation protection for
patients and staff, details of the operation of the
installed X-ray systems, use of visualisation units
and post-processing capabilities and the operation
of the ‘picture archiving and communication system’
(PACS).
digital imaging.
Increases in the number of examinations could
occur because of the relative ease of obtaining and
archiving images with digital imaging.
Reiner et al.(11) have reported a substantial increase
in the number of radiological examinations per-
formed in some centres following a conversion from
conventional to DR. That study was done in several
US hospitals and demonstrated that the ‘inpatient
utilisation’ (i.e. the number of examinations per
in-patient day) increased by 82% (from 0.265 to
0.483 examinations per patient day) after a transition
to film-less operation. This is substantially greater
than the increases of 11% (from 0.190 to 0.211
examinations per patient day) nationally at
film-based hospitals. Outpatient utilisation (i.e. the

Table 2. Examples of actions influencing patient dose and image quality or diagnostic information.

Action Influence on Influence on image quality

patient dose or diagnostic information

Reduction of noise perception in the image Increase Improvement

(i.e. the perception of the signal-to-noise ratio)
Loss of images in the network or in the PACS Increase Retakes
due to improper identification or other reasons(9)
Deletion of image files at the viewing or Increase Loss of (perhaps) some useful information.
workstation of apparently non-useful images Difficult to control repeated exposures

Table 3. Present and the desired situation in the future for the different digital technologies for data on patient doses.

Digital technology Available now Desired in the future

CR (computed radiography)
DR (digital radiography
with flat panel)
Fluoroscopy
Dose or exposure index
Radiographic technique, patient
data and patient dose estimation
Radiographic technique, radiation
field geometry and dose
parameters per series
Link with radiographic technique, patient dose
estimation and patient data. Archive in the RIS
(Radiological Information System)
Automatic extraction of the information from
the DICOM header. Archive in the RIS
Fluoroscopy information. On-line skin dose maps
and automatic extraction of information from
DICOM header. Archive in the RIS

128
 ICRP PATIENT DOSE IN DIGITAL RADIOLOGY
number of examinations per visit) increased by 21%
(from 0.108 to 0.131 examinations per visit)
compared with a net decrease of 19% (from 0.148 to
0.120 examinations per visit) nationally at film-based
hospitals.
These increases most likely result from the relative
ease of obtaining and archiving images with digital
systems. Thus, justification criteria should be one
of the key components considered in the update
of a quality assurance programme when a facility
converts to digital imaging.
Once digital systems are in use, comprehensive
quality control programmes are required to ensure
that image quality and patient dose management are
maintained. Quality control programmes should det-
ect any significant changes in image quality or patient
dose management and therefore prevent upward
‘drift’ in doses, without additional clinical benefit.
It is especially important that DRLs be applied
to the acquisition of digital images because of the
potential for high-quality images to be produced
using excessive levels of exposure.
FORMAL ICRP RECOMMENDATIONS
The document includes eight formal recommenda-
tions by the Commission for DR:
(1) Appropriate training, particularly in the aspects
of patient dose management, should be under-
taken by radiologists, medical physicists and
radiographers before the clinical use of digital
techniques.
(2) Local DRLs should be reviewed when new
digital systems are introduced in an operational
facility.
(3) Frequent patient dose audits should occur when
digital techniques are introduced in an opera-
tional facility.
(4) The original image data should be made available
to the user not only for objective testing in a
rigorous quality assurance programme but also
for other types of independent tests of the
performance of digital-imaging systems.
(5) When a new digital system or new post-
processing software is introduced, an optimisa-
tion programme (for radiation dose) and con-
tinuing training should be conducted in parallel.
(6) Quality control in DR requires new procedures
and protocols. Acceptance and constancy tests
should include aspects concerning visualisation,
transmission and archiving of the images.
Specialists dedicated to maintaining the network
and the PACS should be available.
(7) As DR images are easier to obtain and to
transmit in modern communication networks,
referring physicians should be fully conversant
129
with the justification criteria for requesting
medical X-ray imaging procedures.
(8) Industry should promote tools to inform radi-
ologists, radiographers and medical physicists
about the exposure parameters and the resultant
patient doses. The exposure parameters and the
resultant patient doses should be standardised,
displayed and recorded.
APPENDICES
The three appendices incorporated deal with
fundamentals of DR, patient dosimetry: quantities
and units and the training outline.
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The appendix on fundamentals is an excellent
compendium on DR, which allows familiarisation
with some of the complex terminology after reading
a few pages.
It is highlighted that it is a characteristic for any
digital radiography device that the X-ray detection
stage, the final storage of the digital information and
the means for displaying the image (e.g. a work-
station with adequate viewing software connected
to a monitor providing diagnostic quality) are phys-
ically separate components.
For the field of medical-image communication,
the protocols in the Digital Imaging and Commu-
nications in Medicine (DICOM) standard has been
established. However, due to the rapid development
of new technologies and methods, the compatibility
and connectivity of systems from different manufac-
turers is still a great challenge.
Storage-phosphor systems use a storage-phosphor
plate to record as latent information the image from
the X-ray exposure. The systems are cassette based,
so that existing X-ray equipment can be used with-
out modifications. However, exposure parameters
cannot automatically be stored together with the
image data.
The most recent developments are the ‘flat-panel’
detectors. X-ray detection and image read-out is
performed in one step. An integrated assembly con-
sisting of an X-ray converter and the read-out elec-
tronics is a common feature of these detectors. X-ray
equipment with ‘flat-panel’ detectors is able to store
exposure parameters together with the image data.
One of the advantages of digitising the image
information is the application of image processing
to improve visualisation. As a consequence of these
processing capabilities, there is no longer a strict
correlation between the brightness (or blackening)
of the image and the exposure.
A function available in all the work stations is
‘windowing,’ which allows specification of only a
subset of the full range of pixel values for display.
All image information outside the window range
is no longer visible. Window centre and width are
usually transferred as part of the DICOM header of
 E. VANO
an image. An incorrect window setting may also be
interpreted as an underexposure or overexposure by
mistake.
A poorly performing image display device can
compromise the quality of the acquired data. The
user should have complete information with respect
to a minimum set of requirements for the image-
display device either by physical specification of
important display parameters or by reference to
specific models of image-display devices.
SECTION OF GLOSSARY AND ACRONYMS
The glossary and acronyms list included at the end of
the report is a very helpful section for readers not
familiar with digital terminology.
This section is also useful to differentiate between
some terms that are not always used correctly such
as ‘raw image’ and ‘original image’.
The term ‘raw data’ (related to ‘raw image’ ¼
read-out signal of flat-panel detector or storage-
phosphor system) is often used to emphasise that
they are unprocessed. The term ‘original image’ is
used for the obtained image after all device-specific
corrections. Image conditioning consists of all pro-
cessing steps necessary to transform the raw image
into the original image.
CONCLUSIONS
It is expected that the ICRP report on DR helps to
profit from the benefits of this important techno-
logical advance in medical imaging with the best
management of radiation doses to the patients.
It is also expected to promote training actions
before the digital techniques are introduced in radi-
ology departments and to allow the industry to offer
enough technical and dosimetric information to
radiologists, radiographers and medical physicists
to help in the optimisation of the imaging.
130
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