By Matthew Jones, BS, RT(R)(CT)
December 2009 — The long debated topic of using non registered technologists versus registered technologists (RTs) comes up time and again. If this article assists a single imaging administrator in winning the argument to use RTs instead of non registered technologists, it is well worth the read.
To date, only 38 states require the use of RTs.1 This opens potential for non registered personnel to perform diagnostic imaging exams in the remaining 12 states. This lack of state regulation is often interpreted as acceptance of this practice as safe. Nothing could be further from the truth.
Properly educated and experienced RTs provide numerous hard and soft benefits, including radiation safety for patients and staff; assurance of competency provided by registry credentials and required continuing education resulting in standard of care compliance and higher quality patient care; lower image repeat rate resulting in dollar savings in film and resources, lower radiation dose, and higher quality images with fewer missed pathology; compliance with numerous accrediting bodies including The Joint Commission, CMS, third party insurance payors, ACR, and Certificate of Need requirements; reduced exposure to legal liability; and improved public perception of service.
Individuals can become registered by meeting the requirements and testing from various licensing bodies. The largest of these is the American Registry of Radiologic Technologists (ARRT). The ARRT provides advanced registry credentialing for numerous imaging modalities including radiography, mammography, computed tomography (CT), sonography, and magnetic resonance imaging (MRI).2 There are several recognized credentialing bodies for medical imaging including Nuclear Medicine Technology Certification Board (NMTCB) and American Registry for Diagnostic Medical Sonography (ARDMS). Each of these registries requires successful completion of specific didactic and clinical experience to qualify for registry testing.
The majority of diagnostic imaging procedures use ionizing radiation to produce an image of the internal structures and/or physiology of the body. Ionizing radiation is a high energy particle that is able to penetrate various materials and interact with them at the atomic level. These interactions produce ions (charged particles) in matter creating unstable atoms. This instability or radioactivity can increase the occurrence of cancer as well as other potential negative genetic effects.3 Radiation dose (and the damage it causes) is cumulative over one’s lifetime. There is an adage in the x-ray community: “An x-ray lasts a lifetime.”
In 2006, medical radiation accounted for nearly half of the total radiation exposure of the U.S. population. This is 7 times the amount of medical radiation exposure as was present in the early 1980s.4 Ionizing radiation used in medical imaging has the potential to cause great physical damage if used incorrectly.5 Cases of radiation burns have been recorded in multiple instances.6Exposure to ionizing radiation is insidious as ionizing radiation cannot be seen nor felt and can go undetected. Used appropriately, radiation in diagnostic imaging is an incredible tool to diagnose and manage disease. However, radiation exposure always carries a potential health risk.
RTs are specifically trained and educated in the effects of ionization radiation and radiation safety. They receive advanced education in protecting the patient, themselves, and their coworkers from unnecessary exposure. The registry examination and subsequent required continued education (CE) assures the proper training and responsibility.
RTs are educated in the “As Low As Reasonably Achievable” (ALARA) principle. This principle is applied to all situations where ionizing radiation is used and states that every effort should be taken to keep radiation doses “as low as reasonably achievable.”7, 8 This principle, along with the alarming increase in patient dose due to large increases in utilization of advanced medical imaging procedures, has also spawned the Image Gently campaign, designed to reduce the dose to pediatric patients.9 Armed with ongoing education, RTs are able to keep doses low by using situation specific exposure techniques, proper patient positioning, and knowledgeable operation of imaging equipment.
Standard of Care
Standard of care can be defined as a benchmark of care in a specific community.10 This benchmark outlines the best practice for a given provider based on what the average, prudent provider in the area would give.11
The standard of care for an imaging organization could be determined by the standard set forth by the surrounding facilities offering the same service. If all surrounding facilities offer a specific level of service (ie, RTs to perform imaging procedures), the imaging organization could be found in breech of the local standard of care. Similarly, if an organization offers similar services at multiple locations in the same organization, a potential for the standard of care to not be met could occur if the same level of care was not available at all locations.
A breech in the standard of care can be described with the “calculus of negligence” (also knows as the Hand Rule).12 In short, a breech occurs when the cost of avoiding harm is actually less than the cost of allowing the harm to happen and simply paying for the harm.
Quality of Care
RTs provide quality patient care that is achieved by a combination of their registry exam and the CE credits need to maintain their registry. The maintenance of the registry via CE can be looked upon as ongoing and documented competency in safety, patient care, and all areas related to medical imaging.
Attempting to achieve and maintain competency of non registered personnel in imaging and safety practices is a daunting and expensive task. A large number of man hours would go into the initial training, not to mention the hours that it would take to maintain and track competence for each non registered technologist in use.
The state of Michigan was a forerunner in the late 1980s to bring about strict regulation of mammography requiring advanced education for technologists performing mammography. Today, the Mammography Quality Standards Act (MQSA) requires that all technologists performing mammography studies be registered specifically in mammography. Requiring the use of RTs in mammography resulted in a 35% decrease in repeat rates.13 This improvement is attributed to the use of RTs.
Image Repeat Rates
The use of RTs helps ensure a low image repeat rate. Patients needing repeat images require registration personnel, technologist, radiologist, and administration time to process these repeated images. The physical resources used (ie, film, gown laundering, contrast, etc) must also be taken into account, as well as the fact that if a repeat is being done, the facility is unable to do an exam that would generate revenue.
RTs undergo training in advanced imaging positioning and proper image evaluation to acquire the highest possible quality images. This training greatly reduces the number of repeat images that must be taken on the patient, thus reducing the patient’s (and everyone’s) radiation dose and ensuring a prompt and accurate diagnosis allowing the continuation of the patient’s treatment plan.
Without the experience that comes with an RT, the likelihood of poor quality images is very high. Poor quality images are likely to result in incorrect diagnosis, repeat visits for testing, and delays in patient care.
Organization Weigh In
There are many organizations that have a vested interest in medical imaging and offer guidelines, recommendations, and requirements for the practice of medical imaging.
Currently, Centers for Medicare and Medicaid Services (CMS) has specific requirements for the use of RTs in specific circumstances in an independent diagnostic testing facility.14 Facilities not meeting these requirements laid out in §410.33 of Title 42 are not eligible to bill for medical imaging procedures. In short, most non hospital facilities must use an RT for reimbursement.
Effective January 1, 2012, CMS will require accreditation of imaging facilities to allow for payment. In 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (H.R. 6331) passed. This requires accreditation for specific advanced imaging modalities, such as CT, MRI, and nuclear medicine/PET in order to receive payment for the technical component. This specifically excludes x-ray, ultrasound, and fluoroscopy. Since Section 135 of MIPPA deals with physician schedules only, it does not pertain to hospital services. At this time, MIPPA affects only non hospital services where advanced imaging services are offered.
Along with specific quality assurance programs, the American College of Radiology (ACR) includes the use of RTs to perform many exams, depending on the modality.15 The ACR states in Section 3, Part D of their Practice Guideline for General Radiography a requirement that RTs be used.16 There are similar recommendations for other imaging modalities.
Many other third party payors including Blue Cross and United Health are expected to follow suit. The changes in the requirements for third party payors happen on a daily basis, but the trend is clear. It would appear that third party payors are grasping for any reason to avoid paying. The preemptive use of RTs in all settings would be prudent to assure meeting these ever changing requirements.
Currently the RadCARE Bill (Consumer Assurance of Radiologic Excellence Act of 2006) is being promoted to set a national standard.17 This national standard will require that all individuals performing medical imaging be certified in their medical imaging discipline of practice.
Thirty-six states and the District of Columbia require a Certificate of Need (CON) for the installation and operation of certain medical devices.18 These devices include advanced imaging devices such as CT, MRI, etc. The state of Michigan, for example, has strong verbiage in their operation requirements for the CT CON, citing the use of properly qualified personnel complete with proof of CE. Registry with the ARRT is listed as a satisfactory assurance that an operator meets the requirements laid out.19
The potential for harmful litigation can also not be overlooked. By employing RTs who have the documented competency provided by their registry, the chance of litigation is reduced by avoiding compromising situations before they happen. Should a situation arise that does involve the courts, the use of an RT is much more defensible than the alternative.
The financial cost of any litigation, win or lose, far exceeds the modest increase in expense of using RTs versus a lower paid, non registered technologist. One might say that you get what you pay for.
Public Perception of Service
There is a competitive advantage to offering high quality care provided by RTs. Most local physician or chiropractor offices may not utilize RTs. The community’s perception of quality service and care must be considered.
The poor reputation garnered by and the reduction in quality of care from the use of non registered technologists is not worth the short term financial gain. Patients and their families expect and deserve the highest quality of care available. They will expect credentialed RTs to perform their imaging exams, especially from hospital based organizations. Public perception of the overall quality of service provided at a facility using non credentialed personnel could suffer, resulting in their choosing another facility for their healthcare needs.
The primary perceived benefit of using non registered personnel to perform medical imaging is lower labor costs and the lack of RT availability.20
1 Medical Radiation Exposure of the U.S. Population Greatly Increased Since the Early 1980s. National Council for Radiation Protection and Monitoring. March 3, 2009. Available at: click here . Accessed July 21, 2009.
2 Koenig T, Wolff D, Mettler F, Wagner L. Skin Injuries from Fluoroscopically Guided Procedures. American Journal of Roentgenology. December 12, 2000. Available at: click here . Accessed July 21, 2009.
3 FDA Public Health Advisory: Avoidance of Serious X-Ray-Induce Skin Injuries to Patients During Fluoroscopically-Guided Procedures. U.S. Food and Drug Administration. September 30, 1994. Available at: click here . Accessed July 22, 2009.
4 State Licensure or Certification by Discipline. American Society of Radiologic Technologists. 2009. Available at: click here. Accessed July 20, 2009.
5 Certifications Offered. American Registry of Radiologic Technologists. 2009. Available at: click here. Accessed July 23, 2009.
6 Radiation Basics. Health Physics Society. May 9, 2009. Available at: click here. Accessed July 21, 2009.
7 Regulatory Guide 8.18 Information Relevant to Ensuring That Occupational Radiation Exposures at Medical Institutions Will Be as Low as Reasonably Achievable. NRC Regulatory Guide. October 1982. Available at: click here. Accessed July 22, 2009.
8 Joseph N, Phalen J. Part 4 Principles of Patient Radiation Protection & ALARA, Section 4.6: Concept and federal regulation of ALARA. CE Essentials Online. 2006. Available at: click here. Accessed July 22, 2009.
9 Image Gently. Available at: click here. Accessed July 22, 2009.
10 Torrey T. Definition: Standard of Care. About.com. July 28, 2008. Available at: click here. Accessed July 22, 2009.
11 Definition of Standard of Care. MedicineNet.com. June 12, 2004. Available at: click here. Accessed July 22, 2009.
12 Calculus of negligence. Wikipedia. June 13, 2009. Available at: click here. Accessed July 22, 2009.
13 Fintor L, Brown M, Fischer R, et al. The Impact of Mammography Quality Improvement Legislation in Michigan: Implications for the National Mammography Quality Standards Act. The American Journal of Public Health. April 1998. Available at: click here . Accessed July 23, 2009.
14 Title 42, Part 410, Subpart B, 410.33 Independent diagnostic testing facility. GPO Access. July 21, 2009. Available at: click here. Accessed July 23, 2009.
15 Accreditation Programs. American College of Radiology. Available at: click here. Accessed July 22, 2009.
16 Practice Guideline for General Radiography. The American College of Radiology. 2008. Available at: click here. Accessed July 23, 2009.
17 S.2322. American College of Medical Physics. Available at: click here. Accessed July 22, 2009.
18 Certificate of Need. American Health Planning Association. Available at: click here. Accessed on October 18, 2009.
19 §19 (1) Certificate of Need (CoN) Review Standards for Computed Tomography (CT) Scanner Services. The State of Michigan, Michigan Department of Community Health. 2009. Available at: click here. Accessed July 29, 2009.
20 The personnel crunch: a crisis in the radiologic technology work force. American Society of Radiologic Technologists. 2009. Available at: click here. Accessed on October 18, 2009.
Matthew Jones, BS, RT(R)(CT) is PACS administrator and manager of diagnostic imaging for Memorial Healthcare of Owosso in Owosso, MI. He can be reached at firstname.lastname@example.org