February 1, 2010
RADIOLOGY PERSONNEL AND EQUIPMENT
By: John Kasprak, Senior Attorney
You asked for information on state law addressing the training of technicians who use radiology equipment. You also want to know if there are accreditation standards for radiology equipment.
Connecticut requires licensure as a “radiographer” in order to operate a medical x-ray system. The Department of Public Health (DPH) licenses individuals based on successful completion of (1) a recognized course of study in radiologic technology and (2) an examination in radiography or radiation therapy technology.
A 2009 act recognizes a new category of “radiologic assistants” in two different ways. One approach is to carve out a radiologic assistant category within the existing radiographer licensing law; the other is to create a separate license for them, but only if DPH has the funding available.
The state Department of Environmental Protection (DEP) is responsible for a registration and inspection program of medical x-ray machines to ensure their safety. The federal government recently selected the American College of Radiology (ACR) as a designated accrediting organization for medical imaging facilities. The ACR will be able to satisfy all accreditation requirements for providers of advanced medical imaging mandated by a 2008 federal law concerning Medicare.
State law prohibits anyone from operating a medical x-ray system unless he or she is licensed as a radiographer by DPH (CGS § 20-74bb). There are some exceptions to this, including one addressing nuclear medical technologist (see below). A “medical x-ray system” is one designed for the irradiation of any part of the human body for diagnostic or therapeutic purposes (CGS § 20-74aa). PA 09-232 (§ 49) specifies that operating such systems includes energizing the beam, positioning the patient, and positioning or moving equipment in relation to the patient.
A Connecticut-licensed radiographer may operate a medical x-ray system under the supervision and upon the written or verbal order of a state-licensed physician, chiropractor, natureopath, podiatrist, dentist, or veterinarian (CGS § 20-74bb(b)).
An applicant for licensure must successfully complete:
1. a course of study in radiologic technology in a program which, at the time of completion, was accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association, or a course of study deemed equivalent to such accredited program by the American Registry of Radiologic Technologists (ARRT); and
2. ARRT's radiography or radiation therapy technology examination (CGS § 20-74bb (a)).
The licensure applicant must have (1) official verification of the course of study in radiologic technology, forwarded directly to DPH from the institution where study was completed and (2) an official verification form, sent directly from ARRT to DPH, of completion of the required exam. Also, if applicable, the licensure applicant must provide verification of any licenses or certificates ever held in other jurisdictions.
Nuclear Medical Technologist. Under Connecticut law, a radiographer license is not required of a nuclear medical technologist certified by the Nuclear Medicine Technology Certification Board or the ARRT, provided the individual is engaged in the operation of a bone densitometry system under the supervision, control, and responsibility of a Connecticut-licensed physician (CGS § 20-74ee(a)(4)).
PA 09-232 (§§ 68, 83-90) takes two approaches to recognizing a category of health professional known as a “radiologist assistant.” One is to carve out a radiologist assistant category within the existing radiographer licensing law; the other is to create a separate license for radiologist assistants, but only if DPH has the funding available. This law took effect October 1, 2009 for the new radiologist assistant category and takes effect July 1, 2011 for licensure.
New Radiologist Assistant Category. The act enables a licensed radiologic technologist (someone who operates x-ray equipment, also known as a radiographer) to perform more advanced radiologic procedures as a radiologist assistant. In addition to the existing licensing requirements, to be a radiologist assistant a radiologic technologist must:
1. graduate from a radiologist assistant education program recognized by the ARRT and passed that group's radiologist assistant examination;
2. maintain a current Connecticut license in good standing as a radiologic technologist (radiographer);
3. hold current certification (a) in advanced cardiac life support and (b) as a radiographer and a radiologist assistant from the ARRT; and
4. maintain professional liability insurance or other indemnity against liability for professional malpractice for at least $500,000 for one person, per occurrence, with an aggregate of at least $1. 5 million.
Supervision. Each radiologist assistant must have a clearly identified supervising radiologist who has final responsibility for patient care and the assistant's performance. A radiologist may concurrently supervise no more than two full-time radiologist assistants, or their part-time equivalent. An assistant can perform services only at the supervising radiologist's primary medical practice location or in a health care facility where the supervising radiologist holds staff privileges.
A radiologist assistant who meets the above criteria may perform radiologic procedures delegated by and under the direct supervision of a supervising radiologist if:
1. the supervising radiologist is satisfied of the assistant's ability and competence;
2. the delegation is consistent with the patient's health and welfare and in keeping with sound medical practice;
3. the supervising radiologist assumes full control and responsibility for all procedures the assistant performs;
4. the procedures are performed under the oversight, control, and direction of the supervising radiologist; and
5. the supervising radiologist establishes written protocols for implementing the delegated procedures.
The act defines supervision to include the ability for direct communication between the radiologist and the assistant, active overview to assure the assistant is following directions, personal review of an assistant's practice at least weekly, and regular chart review. It defines “direct supervision” as a radiologist's presence in the office suite and immediate availability to furnish assistance and direction throughout the performance of the procedure.
The act specifies certain procedures that must be performed while the supervising radiologist is in the same room with the assistant (i.e., personal supervision). These are: (1) contrast media administration; (2) needle or catheter placement; (3) lumbar puncture under fluoroscopic guidance; (4) lumbar myelogram; (5) thoracic or cervical myelogram; (6) nontunneled venous central line placement, venous catheter placement
for dialysis, and breast needle localization; and (7) ductogram. In addition, the act permits a supervising radiologist to determine other procedures that are appropriate to be performed under personal supervision.
The act prohibits an assistant from (1) interpreting images, (2) diagnosing, (3) prescribing medication or therapy, or (4) administering anesthesia.
The act specifies that it does not apply to students in a radiologist assistant program recognized by the ARRT who are performing activities and services that are part of the course of study.
New License for Radiologist Assistants. Beginning July 1, 2011, the act creates a new license category for radiologist assistants, but only if DPH has appropriations available to implement it. The license and license renewal fee is $150. The licensure criteria is the same as the “carve-out” criteria. The act prohibits anyone who is subject to pending disciplinary action or an unresolved complaint in Connecticut or elsewhere from obtaining a license.
The act permits DPH to take disciplinary action against, and impose the same penalties on, a radiologist assistant for the same reasons it can against most health professionals.
STANDARDS FOR RADIOLOGY EQUIPMENT
DEP conducts a registration and inspection program for medical x-ray equipment, while the federal government is involved in the accreditation of medical imaging facilities.
In Connecticut, there are approximately 3,000 facilities that use x-ray tubes in medical diagnostic and radiation therapy devices, according to DPH. DEP conducts a registration and inspection program of medical x-ray machines to ensure that:
1. exposure to the general public and employees are at safe levels,
2. the facilities are in compliance with state regulations, and
3. exposure is kept as low as reasonably achievable while delivering the lowest practicable patient dose with the highest possible image quality.
All facilities must register their medical x-ray devices prior to use or when there is a change in the number or location of the devices (CGS § 22a-149).
(More detailed information on DEP's inspection program is attached.)
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA; H.R. 6331) calls for providers of advanced diagnostic imaging services (CT, MRI, PET and nuclear medicine) to be accredited, by January 2012, in order to receive payment for the technical component of those services. The legislation requires that (1) accreditation programs ensure that physicians and staff maintain the proper level of training and education, (2) facilities use imaging equipment that adheres to strict standards of performance and operates under proper safety guidelines, and (3) all imaging providers establish and maintain a quality assurance program.
The federal centers for Medicare and Medicaid Services (CMS) recently selected the ACR as a designated accrediting organization for medical imaging facilities. ACR accreditation assesses the overall quality of a practice, including personnel, equipment, quality assurance activities, and ultimately the quality of patient care. (For more information, see http://www.acr.org).