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					Final Report




DEVELOPMENT OF BEST PRACTICE
PROFESSIONAL SUPERVISION AND
REPORTING STANDARDS FOR
RADIOLOGISTS


JUNE 2006
2 June 2006

Ms Jane Grimm
Manager
Quality Use of Diagnostic Imaging Program
Royal Australian and New Zealand College of Radiologists
Level 9, 51 Druitt Street
Sydney NSW 2000


  Development of Professional Supervision and Reporting Standards for
                      Radiologists - Final Report


Dear Jane

In accordance with the project terms of reference, we are pleased to enclose
our Final Report in relation to the abovementioned project.

The report includes a summary of the information gathered during the
scoping stage of the project and includes the proposed Standards developed,
regarding professional supervision and reporting.

We would like to express our thanks for the assistance and support we have
received, from both the College and yourself, throughout the duration of this
project. We look forward to working with you again in the future.


Yours faithfully
AUSTRALIAN HEALTHCARE ASSOCIATES




Peter C Geary
Director
Final Report




DEVELOPMENT OF BEST PRACTICE
PROFESSIONAL SUPERVISION AND
REPORTING STANDARDS FOR
RADIOLOGISTS


JUNE 2006
Table of Contents

Acronyms ................................................................................................................................................4
1. Executive Summary.........................................................................................................................5
2. Introduction....................................................................................................................................10
   2.1 The Royal Australian and New Zealand College of Radiologists............................................10
   2.2 Project Task............................................................................................................................10
   2.3 What is a Standard? ...............................................................................................................10
   2.4 The Practice of Radiology.......................................................................................................11
   2.5 Assuring Quality .....................................................................................................................11
   2.6 Purpose ..................................................................................................................................11
   2.7 Scope .....................................................................................................................................11
3. Methodology ..................................................................................................................................12
   Stage 1 - Scoping Study ..................................................................................................................12
   Stage 2 - Development of Standards...............................................................................................13
   Stage 3 - Standards Testing and Implementation Requirements.....................................................13
4. Results............................................................................................................................................15
   4.1 Setting the Scene ...................................................................................................................15
               4.1.1     The Profession of Radiology....................................................................................................................15
               4.1.2     Medical Consultative Role in Patient Care ..............................................................................................15
               4.1.3     The Components of the Diagnostic Imaging Service...............................................................................16
               4.1.4     The Imaging Team – Role and Responsibilities ......................................................................................17
               4.1.5     Professional Supervision .........................................................................................................................18
               4.1.6     Taking a Quality Systems Approach........................................................................................................18
      4.2 Current Regulatory Requirements ..........................................................................................19
               4.2.1     Overview..................................................................................................................................................19
               4.2.2     Medicare Benefits Arrangements ............................................................................................................20
               4.2.3     Professional Supervision Requirements..................................................................................................21
               4.2.4     Radiation Protection – State and Territory Requirements .......................................................................24
               4.2.5     Views about Current Regulatory Requirements ......................................................................................26
      4.3 Recent Practice Guidelines, Standards and Requirements ....................................................27
               4.3.1     Review Method and Limitations...............................................................................................................27
               4.3.2     Professional Practice Guidelines and Standards – USA and Canada.....................................................28
               4.3.3     Professional Guidelines and Standards – United Kingdom and Europe .................................................32
               4.3.4     Health Insurance Remuneration Arrangements– Canada and USA .......................................................33
               4.3.5     Conclusions – Similarities, Differences and Lessons Learnt ...................................................................36

5. Discussion......................................................................................................................................38
6. Conclusions and Recommendations ...........................................................................................39
   6.1 Professional Competence - Qualifications of Personnel.........................................................39
               6.1.1     The Imaging Team...................................................................................................................................39
               6.1.2     For Radiologists.......................................................................................................................................39
               6.1.3     For Other Health Care Professionals in the Imaging Team.....................................................................40
      6.2 The Diagnostic Imaging Service Cycle ...................................................................................42


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Table of Contents
      6.3 Review of Request and Patient Preparation ...........................................................................43
              6.3.1      Objectives ................................................................................................................................................43
              6.3.2      Key Tasks ................................................................................................................................................43
              6.3.3      Key Considerations and Managing Associated Risks .............................................................................43
              6.3.4      Radiologist Responsibilities .....................................................................................................................44
              6.3.5      Relevant Existing Standards....................................................................................................................44
              6.3.6      Proposed Supervision Standard - Review of Request and Patient Preparation......................................45
      6.4 Performance of Imaging Examination.....................................................................................46
              6.4.1      Objectives ................................................................................................................................................46
              6.4.2      Key Tasks ................................................................................................................................................46
              6.4.3      Key Considerations and Managing Associated Risks .............................................................................46
              6.4.4      Radiologist Responsibilities .....................................................................................................................46
              6.4.5      Proposed Supervision Standard - Performance of Imaging Examination................................................47
              6.4.6      Risk Assessment .....................................................................................................................................48
      6.5 Interpretation and Reporting ...................................................................................................48
              6.5.1      Objectives ................................................................................................................................................48
              6.5.2      Key Tasks ................................................................................................................................................48
              6.5.3      Key Considerations..................................................................................................................................49
              6.5.4      Radiologist Responsibilities .....................................................................................................................49
              6.5.5      Relevant Existing Standards....................................................................................................................49
              6.5.6      Proposed Supervision Standard - Reports ..............................................................................................50
              6.5.7      Other Proposed Standard - Requestor Communication ..........................................................................51
      6.6 Summary of Proposed Standards...........................................................................................51
              6.6.1      Proposed Supervision Standard - Review of Request and Patient Preparation......................................51
              6.6.2      Proposed Supervision Standard - Performance of Imaging Examination................................................52
              6.6.3      Proposed Supervision Standard - Reports ..............................................................................................54
              6.6.4      Other Proposed Standard - Requestor Communication ..........................................................................54
      6.7 Implementation Requirements and Linkages..........................................................................54
              6.7.1      Implementation Requirements.................................................................................................................54
              6.7.2      Linkages ..................................................................................................................................................57

7. References .....................................................................................................................................60


APPENDICES
     A. Stakeholder Consultation
     B. Professional Supervision Requirements for in the MBS
     C. Intravenous Contrast Media Guidelines
     D. Organisations Consulted
     E. USA Professional Supervision
     F. Canada Professional Supervision
     G. Risk Management Framework




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Table of Contents
TABLES
Table 4-1: Components of the Diagnostic Imaging Service ...................................................................17
Table 4-2: Medicare - By or On Behalf of Provisions for Diagnostic Imaging Services ..........................21
Table 4-3: Medicare – Conditions for Services Rendered ‘On Behalf O” Medical Practitioners .............22
Table 4-4: Medicare – Professional Supervision Requirements for Diagnostic Imaging Services..........23
Table 4-5: State/Territory Licensing and Registration Conditions ..........................................................24
Table 4-6: Professional Supervision and Reporting Requirements for Radiologists - Canada and USA29
Table 4-7: Communication in Diagnostic Radiology - Key Principles and Practices, Canada and USA.30
Table 4-8: Professional Supervision and Reporting Requirements by Diagnostic Imaging
           Modality/Examination – Canada and USA ............................................................................31
Table 4-9: Professional Supervision and Reporting Requirements for Radiologists – Ontario, Canada 34
Table 4-10: US Medicare Program – Professional Supervision Requirements for Diagnostic Tests and
           Procedures............................................................................................................................35
Table 4-11: Definitions of Direct Supervision by Radiologists ................................................................36
Table 6-1: Radiologists’ Qualifications, Registration and Continuing Professional Development (CPD)
           Requirements........................................................................................................................39
Table 6-2: Additional Professional Competency Requirements for Radiologists Practicing MRI,
           Diagnostic Mammography and Diagnostic Ultrasound..........................................................40
Table 6-3: Competency Requirements for other Health Care Professionals in the Imaging Team ........41
Table 7-1: Individuals Consulted............................................................................................................65
Table 7-2: Written Submissions Received .............................................................................................66
Table 7-3: Canadian Association of Radiologists - Standards August 2005 ..........................................82




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Acronyms
ACRONYMS

 ACSQHC    Australian Council for Safety and Quality in Health Care

 ACR       American College of Radiology

 AHA       Australian Healthcare Associates

 AHMC      Australian Health Ministers’ Conference

 ARPANSA   Australian Radiation Protection and Nuclear Safety Agency

 CAR       Canadian Association of Radiologists

 CT        Computed tomography

 DoHA      Australian Government Department of Health and Ageing

 EAR       European Association of Radiology

 FDA       Food and Drug Administration

 HIC       Health Insurance Commission

 MoU       Radiology Quality and Outlays Memorandum of Understanding, June 2003

 MRI       Magnetic resonance imaging

 NHMRC     National Health and Medical Research Council

 QUDI      Quality Use of Diagnostic Imaging Program

 JCAHO     The Joint Commission on the Accreditation of Healthcare Organizations

 RANZCR    The Royal Australian and New Zealand College of Radiologists

 RCR       The Royal College of Radiologists, United Kingdom




                                         4               AUSTRALIAN HEALTHCARE ASSOCIATES
1. Executive Summary
This chapter provides a summary of this report.


1.    EXECUTIVE SUMMARY

This report represents the outcome of a project to developof professional supervision and reporting
standards for radiologists providing diagnostic imaging services. It has been prepared for the Australian
and New Zealand College of Radiologists (RANZCR) by Australian Healthcare Associates (AHA


About the Project

The project had two objectives:
      to review professional supervision and reporting requirements in the context of current radiology
      practice and knowledge, emergence of teleradiology and other developments; and
      to develop uniform best practice professional supervision and related reporting standards for all
      imaging services provided by radiologists incorporating the specific requirements of teleradiology.

The aim was develop professional supervision and reporting standards that promote safe and quality
patient care and radiology practice.

The project falls under the Quality Use of Diagnostic Imaging (QUDI) program, a four-year initiative to
support quality improvement in the use of diagnostic imaging services. One of the program’s priority
areas is the examination of the role of the current professional supervision requirements for radiologists.

The range of imaging services that the standards cover was set to those that fall within the scope of the
Radiology Quality and Outlays Memorandum of Understanding (MoU) June 2003 – namely, diagnostic
radiology, computed tomography (CT), ultrasound services (with certain exceptions) and magnetic
resonance imaging (MRI) services.


The Profession of Radiology

Radiology is the field of medicine that deals with the scanning of radiographic images of the body to
diagnose illness and disease and evaluate the effects of treatment (RANZCR 2005). It involves the use
of a variety of medical imaging techniques, advanced computer technology and complex equipment to
study human anatomy, pathology and physiology and to define disease processes.

Radiologists are medical specialists who provide imaging services to patients, referred to them by their
general practitioner (GPs) and specialist colleagues. Patients are referred to assist in both diagnosis
and to decide upon the best management of their health problems. Radiologists, therefore, provide a
medical consultative service to other doctors.


The Diagnostic Imaging Service

A diagnostic imaging service consists of three major parts:
      review of the request and patient preparation;


                                                     5              AUSTRALIAN HEALTHCARE ASSOCIATES
1. Executive Summary
      the performance of the procedure on the patient to capture the images; and,
      the reading and reporting of the images by the radiologist.

Within each part, there are various components and related tasks. The goal of the imaging service is to
maximise the information obtained from the examination, while minimising associated safety risks and
ensuring high quality patient care. The outcome of the service is a written report with a medical opinion
from the radiologist that addresses the medical problem and questions posed by the requesting doctor,
and assists patient care.


What is Professional Supervision and Reporting?

Diagnostic imaging services are provided in multi-disciplinary teams with members with the required
expertise drawn from various professional and other groups (e.g. radiographers, sonographers and
medical physicists). Teams are lead by radiologists who supervise the examination, read and interpret
results and are responsible for the service. The individual responsibilities of team members are
interdependent and collectively enable the effective delivery of the service

The radiologist is responsible for the medical imaging service. Responsibility covers selection of the
appropriate examination, the care of the patient, the performance of examination, the provision of the
interpretation of the images and written report to the referring doctor, and quality assurance of the
imaging service.

Certain tasks are delegated to team members with the required expertise who undertake these tasks
under the radiologist’s supervision. The performance of medical imaging services under the supervision
of the radiologist (or other medical practitioners) has become known as professional supervision.


Defining Professional Supervision Requirements – Problems and Controversies

What constitutes an appropriate set of professional supervision requirements for the range of modalities,
tests and examinations that comprise medical imaging has been the subject of much discussion and
debate in Australia and overseas. Much of the debate has focussed on the availability and participation
of the radiologist or other medical imaging specialist during the performance of the service on the
patient and defining levels of supervision.

A variety of approaches to defining professional supervision requirements have been developed.
Different levels of professional supervision have been defined depending on the nature of the test or
examination being performed. They range from general oversight and direction and having an on-site
presence to provide direct supervision through to personal attendance on the patient and personal
performance of the examination.


Current Regulatory Requirements – Overview

A range of State/Territory and Commonwealth laws deal with the diagnostic imaging sector. The two
main regulatory instruments that deal with professional supervision requirements for radiologists are the
Commonwealth Medicare benefits arrangements and State and Territory regulations for radiation
protection.



                                                    6               AUSTRALIAN HEALTHCARE ASSOCIATES
1. Executive Summary
In addition to this legislative framework, there are the policies and processes that organisations,
involved in the health service delivery, set to ensure safe and quality care. They include policies and
processes for credentialing and defining the scopes of practice of individual medical practitioners and
other health professionals, and for establishing standards of practice, clinical governance and clinical
risk management arrangements.


Medicare Benefits Arrangements and Requirements

The Medicare benefits arrangements incorporate a number of approaches to defining professional
supervision requirements for diagnostic imaging services. They focus on requirements for the
performance of the diagnostic imaging procedure on the patient to capture the required images.
Requirements have developed over time and vary to reflect differences in the nature of the modality and
test or examination being performed. Two sets of provisions are in place:
      general conditions that establish a base level professional supervision requirement; and
      modality or examination specific provisions, that establish higher level professional supervision
       requirements.

Combined, the general and modality/examination specific arrangements establish three levels of
professional supervision. They are based on the supervising practitioner’s degree of direct participation
in the performance of the procedure on the patient. The supervising practitioner is responsible for the
service, interprets the scans and compiles the written report. A variety of terms are used to describe the
different requirements including general supervision, direct supervision and personal attendance or
personal supervision.

There are a number of concerns about the appropriateness and relevance of current Medicare
requirements. Concerns centre on the lack of clarity in requirements; resulting administrative difficulties;
the current terminology with calls for a new conceptual framework for considering professional
supervision and reporting; continuing relevance given development in knowledge, technologies and
practice; and lack of attention given to the reporting side.


State and Territory Radiation Protection Requirements

In Australia, the regulation of radiation protection, like other areas of public safety, is undertaken through
national and State and Territory controls. Each jurisdiction administers their own radiation protection
legislation. Legislation typically covers the setting of minimum dose limits; licensing of people to
undertake practices in radiation; registration of radiation emitting equipment; safety procedures;
responsibilities; power of inspection; and enforcement provision and penalties.

Licensing requirements vary across jurisdictions. In some jurisdictions, they cover certain types of
medical imaging equipment and procedures with conditions applying to radiologist supervision.
Diagnostic imaging services funded under Medicare must be provided in accordance with any
State/Territory laws relating directly or indirectly to the use of diagnostic imaging procedures or
diagnostic imaging equipment. Consequently, if a jurisdiction sets higher professional supervision
requirements, they become the regulatory requirement for services rendered under Medicare in that
jurisdiction. Requirements vary widely across jurisdictions and, again, different terms are employed
across jurisdictions to define supervision requirements.




                                                      7               AUSTRALIAN HEALTHCARE ASSOCIATES
1. Executive Summary
There are moves to develop a uniform national framework for radiation protection with work being
undertaken through the Australian Health Ministers’ Conference (AHMC). States and Territories are at
different stages in reviewing their legislation and establishing new legislation that puts into effect the
agreed national framework. Licensing conditions, however, appear to remain a matter for each
jurisdiction to determine.


Recent Practice Guidelines, Standards and Requirements

A review of recent radiology practice guidelines, standards and requirements across countries and
agencies was conducted in order to understand the requirements in place and approaches used to
define the standards, and to consider similarities, differences and lessons learnt.

A mix of approaches has been used to define professional supervision and reporting requirements for
radiologists. They range from considering requirements in the context of good practice guidelines and
standards for a particular modality or examination and the setting of radiologist staffing requirements for
medical imaging facilities under accreditation arrangements, through to specifying requirements in
payment schedules. Each offers lessons.
      The American College of Radiology (ACR) and the Canadian Association of Radiologists (CAR)
      approaches place the radiologist’s professional supervision and reporting responsibilities within a
      broader quality assurance system approach for a particular modality or examination.
      They also provide examples of ways for considering principles of good practice in reporting and
      the report’s content.
      Payment approaches adopted in Canada show different ways of specifying the components of
      the imaging service and the radiologist’s roles and responsibilities for the service.
      Canadian approaches also provide ways for considering ideal requirements and managing the
      potential risks that occur when the ideal supervision requirement is unable to be met.
      The UK experience with clinical governance provides some principles to guide clinical risk
      management in radiology practice.


Discussion of Approaches

Australian and overseas approaches to professional supervision have traditionally varied according to
the modality, test or examination. Implicitly, therefore, resulting levels of supervision have sought to
provide ways of managing different levels of associated risk. Stakeholder consultations affirmed that
this was an important principle that should underpin professional supervision and reporting standards.

The amount and nature of radiologist participation should and will vary with the type and complexity of
the medical problem, the type of technology used and type of examination performed. Different
modalities and examinations have different technical profiles. For some, these technical requirements
can be managed usually through the use of imaging protocols (e.g. plain x-rays and CT scans). Other
imaging modalities (e.g. ultrasound) present a different set of technical challenges and are not as
protocol driven.

Many stakeholders indicated that ultrasound is a highly operator dependent imaging modality, where the
use of probes and transducers to produce an image where the probe is pointed, requires flexibility in
approach and high levels of expertise. The use of contrast media (e.g. in CT scans) and sedation (e.g.


                                                     8              AUSTRALIAN HEALTHCARE ASSOCIATES
1. Executive Summary
in MRI) changed the risk profile and required a medical practitioner (not necessarily a radiologist) to be
available to treat any adverse reactions or other events.

Consultations however have also indicated that radiologists operate in a range of operating
environments and the risks associated with each different environment varies significantly. These
Standards therefore call for an assessment of risk and development of a range of appropriate
procedures to manage this risk by individual radiologists and/or practices.


Proposed Standards

Most approaches to professional supervision in Australia and overseas have tended to focus on the
level and nature of radiologist availability during different types of examinations - for example, whether
they should be available on-site or be available to personally attend the patient. These approaches
implicitly suggest that radiologists will have appropriate input to the imaging service, if they are available
to do so.

This approach however, fails to recognise that in many cases, radiologist input to the request review,
patient preparation and examination components of the imaging service for example, are dependent on
other members of the imaging team, such as radiographers and sonographers, seeking such input.

The proposed Standards developed as part of this project and set out in Chapter 6 - Conclusions and
Recommendations, place a greater focus on ensuring the effective functioning of the imaging team as a
whole. This involves all members of the imaging team having a clear understanding of their roles and
responsibilities and involves radiographers and sonographers having a sound appreciation of the
circumstances and situations in which they should seek additional radiologist input to the imaging
service.


    The proposed professional supervision and reporting standards set out in this document,
  recognise that radiologists operate in a diverse range of unique imaging environments, each
     with their own risks, which should be appropriately managed. The proposed Standards
  therefore, take a flexible, protocol-based, quality systems approach, rather than a rigid rules-
             based approach, representing a significant shift in thinking on this topic.

  Recognising that the ultimate aim of these Standards should be to ensure radiologist input to
 the imaging service at the appropriate/critical times, the Standards have a focus on developing
    an effectively functioning team. This focus manifests itself in the requirement to develop
     protocols to guide technologists as to when they should seek the input of a radiologist.




                                                      9               AUSTRALIAN HEALTHCARE ASSOCIATES
2. Introduction
This chapter provides background to the project and details the purpose and scope of the
project.


2.    INTRODUCTION

2.1   The Royal Australian and New Zealand College of Radiologists

The Royal Australian and New Zealand College of Radiologists (RANZCR) is the leading organisation
for the promotion of the science and practice of the medical specialties of radiology and medical imaging
(diagnostic and interventional) and radiation oncology in Australia and New Zealand. It produces
standards documents for radiologists involved in the delivery of radiology services on aspects of
practice. The College’s Standards aim to define good practice, advance the practice of radiology and
promote the provision of a high quality service to patients. These Standards focus on the professional
supervision and reporting responsibilities of radiologists.


2.2   Project Task

The project’s task is to establish uniform professional supervision and related reporting standards for all
imaging services provided by radiologists including the specific requirements of teleradiology.
Specifically, the project requirements are to:
        1.       Review current regulatory requirements and the current literature (both local and
                 international) with regard to the professional supervision of imaging services.
        2.       Identify key policy issues that need to be addressed in relation to the use of
                 teleradiology and assess implications for professional supervision and reporting of
                 diagnostic imaging services.
        3.       Develop and test, in relation to procedures/examinations supervised by radiologists,
                 best practice standards of:
                         Professional supervision, or personal attendance, by the radiologist, according
                         to a particular modality or procedural group; and
                         Professional supervision of, or personal reporting by the radiologist of the
                         results of a particular modality or procedural groups.
        4.       Identify any changes that may be required to current regulatory requirements.
        5.       Identify, develop and test appropriate information for inclusion in relevant material for
                 consumers.


2.3   What is a Standard?

The Australian Council for Safety and Quality in Health Care (ACSQHC) defines a standard as agreed
qualities and processes, designed to ensure a product, service or method will perform consistently at a
designated level (2005). Standards, therefore, are a means of describing the level of quality, health
care providers are expected to meet and against which the level of quality performance can be
assessed. As such, the proposed Standards would set requirements for professional supervision and
reporting practice that radiologists are expected to meet.


                                                     10              AUSTRALIAN HEALTHCARE ASSOCIATES
2. Introduction
2.4   The Practice of Radiology

Radiology is the branch of medicine that deals with the scanning of radiographic images of the body to
diagnose illness and disease and evaluate the effects of treatment. Radiologists are medical specialists
trained in the use of medical imaging techniques to study human anatomy, pathology and physiology
and to define disease processes. Radiologists provide a medical consultative service. Medical
practitioners refer patients to radiologists with requests for imaging investigation, advice and opinion for
the purpose of diagnosis or management. Imaging services are provided in multi-disciplinary teams led
by radiologists. Radiologists are responsible for the medical care of the patient while in the radiology
practice or department. They supervise the conduct of the imaging examination, read and interpret
results, and prepare a report with examination results and professional opinion for the patient’s
requesting doctor. This set of responsibilities is termed professional supervision and reporting.


2.5   Assuring Quality

The quality of the imaging service provided is dependent on the interplay of many factors. Factors
include the knowledge, expertise and experience of the radiologist and other team members; the
equipment and facilities used; the capabilities of the imaging modality and test; the quality assurance
systems in place; good communication among health care participants, their clear understanding of their
responsibilities and how effective the team is in working together.

Professional supervision and reporting are concerned with the process of care provided to patients and
in assuring the quality of the imaging service. They are central to the roles, responsibilities and
accountabilities of radiologists in providing quality medical imaging services to patients and requesting
doctors.


2.6   Purpose

These proposed Standards define the principles and requirements of professional supervision and
reporting that radiologists are expected to meet. They are intended for practitioners in both the public
and private sectors working in small and large organisations. They aim to promote safe and quality
patient care and radiology practice.


2.7   Scope

They focus on diagnostic imaging, not interventional imaging, services provided by radiologists. They
cover professional supervision and reporting requirements for four types (or modalities) of diagnostic
imaging provided by radiologists:
          diagnostic radiology;
           computed tomography (CT);
           ultrasound (with certain exceptions); and
           magnetic resonance imaging (MRI).

Cardiac ultrasound, obstetrics and gynaecological ultrasound, cardiac angiography and nuclear
medicine services fall outside the scope of these Standards.



                                                     11              AUSTRALIAN HEALTHCARE ASSOCIATES
3. Methodology
This chapter provides an outline of the methodological approach adopted when undertaking the
project.


3.    METHODOLOGY
A three-stage development approach was adopted:
        Stage 1 - was a scoping study to research, identify and assess key issues, and establish
                  principles and options for standards development;
        Stage 2 - involved developing the standards;
        Stage 3 - focused on testing the standards and exploring the implementation requirements.


Stage 1 - Scoping Study

In broad terms, the first stage scoping study involved:
      examining current professional supervision and reporting requirements under the Medicare
      benefits and other regulatory arrangements;
      seeking views of key stakeholders;
      reviewing national and international experience and literature, related developments and trends;
      considering the use of teleradiology and implications for professional supervision and reporting;
      identifying and assessing key issues and their implications;
      considering options and future directions; and
      developing a discussion paper presenting findings and conclusions.

The intention was to provide a sound information base for considering project issues and options and
establishing future directions.


Consultations

A series of consultations were held during the first stage in order to advise key stakeholders about the
project, to gather information and to seek views. Consultations were targeted at TRG members and 46
government, professional, consumer and industry organisations, as agreed with the RANZCR. A mix of
consultation methods were used – face-to-face interviews, telephone interviews and written
submissions. In total, 47 consultations were been conducted during this stage. A list of individuals
consulted during the course of the project is provided at Appendix A.

Discussions were held with key RANZCR staff to discuss the project, context and approach and to
gather information and clarify issues. Information about the project was published in RANZCR
newsletters to advise Fellows of the project. The I-MED/MIA virtual reporting centre in Camberwell,
Victoria was also visited to gain an understanding of the operations and activities of such a facility.

At the conclusion of the consultation phase, a Standards Working Group (SWG) was formed to assist in
refining the Standards, once developed. Individuals approached to be on the group were those which
had shown a particular interest in the project during the consultation process. This small group included


                                                    12               AUSTRALIAN HEALTHCARE ASSOCIATES
3. Methodology
radiologists, radiographers, an ultrasonographer, a GP and specialist referrer, as well as a consumer
representative.

Information Gathering and Analysis

Information was gathered from a variety of sources including consultations, published reports and other
research. Reviews of the published literature on key areas were undertaken. Areas covered national
and international professional standards for diagnostic imaging and teleradiology; regulatory
requirements under health insurance arrangements across a selection of countries; role, use, and value
of teleradiology in delivery of diagnostic imaging; in the medical professional role and responsibilities of
radiologists; in standards development; and other imaging developments and trends. Published
literature on some of these topics was scant and of variable quality. These matters and their
implications are highlighted in subsequent chapters.


Stage 2 - Development of Standards

In broad terms this stage involved:
      examining the nature, uses, technical, clinical and practice requirements of each service modality
      and procedural group;
      identifying and assessing similarities, differences, key issues and implications for uniform best
      practice standards;
      establishing principles, attributes, concepts and definitions to underpin the standards;
      designing draft uniform best practice standards and identifying alternative approaches within and
      across standards;
      assessing identified alternatives against criteria based on guiding principles and attributes for
      best practice standards;
      considering how and where they differ to current requirements and implications for
      modality/procedural group, type of practice and aspects of RANZCR practice and accreditation
      standards;
      developing the proposed standards.

This stage was complex and time-consuming, due to the range of complicated issues which had to be
worked through. Consultation was on-going throughout this stage and a broad range of views continued
to be received from key stakeholders.


Stage 3 - Standards Testing and Implementation Requirements

This stage involved the testing of the proposed standards and the identification of issues associated
with their implementation. It also assisted in identifying linkages between this and other QUDI projects.

Due to the nature of the proposed Standards, testing focussed on consulting with radioloigists and other
members of the imaging team to identify the potential impact of the proposed standards on their practice
and imaging environment. As part of this process, we provided the draft Standards to a number of
stakeholders, along with the a questionnaire with a number of questions exploring these issues.



                                                     13              AUSTRALIAN HEALTHCARE ASSOCIATES
3. Methodology
Stakeholders provided with the draft Standards and questionnaire included members of the TRG as well
as the SWG formed specifically for this project.

The aim was to ensure that the standards are robust and that there are no unintended consequences.
Other issues explored via the process included:
      likely impacts across practices and locations;
      timing considerations;
      links to other initiatives;
      standards promulgation;
      ongoing review and evaluation arrangements
      links to other QUDI initiatives.

Following this final consultation process, the draft Standards were refined and finalised, and this final
report prepared.




                                                     14              AUSTRALIAN HEALTHCARE ASSOCIATES
4. Results
This chapter provides an outline of the key results and findings of consultation and research
activities undertaken during the project.


4.    RESULTS
4.1   Setting the Scene

4.1.1 The Profession of Radiology

Radiology is the field of medicine that deals with the scanning of radiographic images of the body to
diagnose illness and disease and evaluate the effects of treatment (RANZCR 2005). It involves the use
of a variety of medical imaging techniques, advanced computer technology and complex equipment to
study human anatomy, pathology and physiology and to define disease processes.

Imaging techniques (or modalities) range from familiar X-rays and ultrasound scans to magnetic
resonance imaging (MRI), computed tomography (CT) and nuclear medicine services.

Increasingly, radiology is taking on a treatment role through the use of newer imaging techniques to
undertake interventional and therapeutic procedures that range from image guided biopsy and drainage
procedures to the insertion of vascular stents.

Radiologists are medical specialists. They complete medical degrees, a period of at least two years in
general clinical training and then a five year specialist training program, that involves the successful
completion of examinations (RANZCR 2005).


4.1.2 Medical Consultative Role in Patient Care

Radiologists are medical specialists who provide imaging services to patients referred to them by their
general practitioner (GPs) and specialist colleagues. Patients are referred for assistance in both
diagnosis and deciding upon the best management of their health problems. Radiologists, therefore,
provide a medical consultative service to other doctors. The care path for patients requiring medical
imaging services is illustrated in the following Chart 4-1.




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Chart 4-1: Patient care path for diagnostic imaging services




Source: AHA adaptation of material presented by the Canadian Institute for Health Information (2001)



4.1.3 The Components of the Diagnostic Imaging Service

A diagnostic imaging service consists of two parts:
       the performance of the procedure on the patient to capture the images; and,
       the reading and reporting of the images by the radiologist.

Within each part, there are various components and related tasks. They are described in broad terms in
the following Table 4-1.




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Table 4-1: Components of the Diagnostic Imaging Service
                Key Component                                         Description
    Review of patient and request                  Review of request from doctor for an imaging service
                                                   Discussion with patient
                                                   Selection of appropriate test/procedure
                                                   Explaining the test/procedure and any associated
                                                   risks to patient
                                                   Obtaining patient’s informed consent
    Preparing the patient                          Preparing and positioning the patient for the
                                                   test/procedure
    Performance of imaging                         Performing the test/procedure
    test/procedure
                                                   Monitoring the patient
                                                   Obtaining images
                                                   Administering contrast media or sedation, as
                                                   necessary
                                                   Assuring image quality
                                                   Documenting tests/procedures performed
                                               All of this is done in accordance with agreed protocols,
                                               guidelines and regulations
    Interpretation                                 Review of images and interpreting results of the
                                                   imaging test/procedure including review of previous
                                                   scans, where available
    Reporting                                      Preparation and provision of written report to
                                                   requesting doctor
                                                   Other communication with requesting doctor as
                                                   situation requires

The goal of the imaging service is to maximise the information obtained from the examination, while
minimising associated safety risks and ensuring high quality patient care.

The outcome of the service is a written report with a medical opinion from the radiologist that addresses
the medical problem and questions posed by the requesting doctor, and assists patient care.


4.1.4 The Imaging Team – Role and Responsibilities

Diagnostic imaging services are provided in multi-disciplinary teams with members with the required
expertise drawn from various professional and other groups. Teams are lead by radiologists who
supervise the examination, read and interpret results and are responsible for the service.
Team members include radiographers and sonographers who operate the equipment to produce quality
images, perform examinations and ensure patient comfort and safety; medical physicists who ensure
optimum performance of the equipment; service engineers who maintain and service equipment; and
administrative staff who book appointments and undertake other clerical tasks. The individual
responsibilities of team members are interdependent and collectively enable the effective delivery of the
service (RCR 1998). The team mix varies depending on the type of examination or procedure being

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performed. Services are provided in accordance with agreed protocols and quality assurance
procedures.


4.1.5 Professional Supervision

The radiologist is responsible for the medical imaging service. Responsibility covers selection of the
appropriate examination, the care of the patient, the performance of examination, the provision of the
interpretation of the images and written report to the referring doctor, and quality assurance of the
imaging service.

Certain tasks are delegated to team members with the required expertise and undertaken under the
radiologist’s supervision. Radiographers and sonographers usually discuss the examination with the
patient, prepare and position the patient, perform the examination to capture the required images and
document the studies and procedures performed, with the radiologist selecting the appropriate
examination, interpreting the images and preparing the written report.

The performance of medical imaging services under the supervision of the radiologist (or other medical
practitioners) has become known as professional supervision. The Oxford English Dictionary defines
supervision as ‘to direct or watch with authority the work or proceedings or progress, to oversee’.

What constitutes an appropriate set of professional supervision requirements for the range of modalities,
tests and examinations that comprise medical imaging has been the subject of much discussion and
debate in Australia and overseas. Much of the debate has focussed on the availability and participation
of the radiologist or other medical imaging specialist during the performance of the service on the
patient and defining levels of supervision.

A variety of approaches to defining professional supervision requirements have been developed.
Different levels of professional supervision have been defined depending on the nature of the test or
examination being performed. They range from general oversight and direction and having an on-site
presence to provide direct supervision through to personal attendance on the patient and personal
performance of the examination.

This chapter reviews this experience in order to understand approaches used and requirements.


4.1.6 Taking a Quality Systems Approach

The project’s aim is to develop professional supervision and reporting standards that promote safe and
quality practice and patient care. It is important to place professional supervision and reporting within a
broader quality assurance system.

The broad framework of structure, process and outcomes that Donabedian (1998) developed to
describe the three components of quality health care provides a useful way of considering this:

      structure: includes material resources, human resources and organisation – for example, the
      knowledge and experience of the medical practitioner ordering and using the results of the
      examination of the patient; the knowledge, skills, expertise and experience of the personnel/
      team conducting the test and interpreting the images; continuing medical education and quality
      assurance; practices, facilities and equipment used; the capabilities of the imaging modality and


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      test; funding arrangements; and information available through standards, guidelines and
      protocols.
      process: concerns what is done in provision of the imaging service including the activities of the
      imaging team across the components of the service and professional supervision and reporting
      requirements for radiologists.
      outcomes: concerns what is achieved for patients, including the provision of a medical opinion to
      requesting doctor to assist patient care.

Within this framework, many important structural and process factors influence the quality of imaging
practice and patient care. Professional supervision and reporting requirements are two aspects of a
quality assurance system. They cannot be considered in isolation. At the same time, it is beyond this
project’s reach and scope to identify and examine all those factors. Instead, key factors and
connections are highlighted.


4.2   Current Regulatory Requirements

4.2.1 Overview

This section examines current regulatory requirements for professional supervision and reporting by
radiologists in Australia and summarises stakeholder’s views about their appropriateness and
effectiveness.

A range of State and Territory and Commonwealth laws deal with the diagnostic imaging sector. To set
the context for the current regulatory requirements for professional supervision, an overview of the
legislative framework is provided.

All States and Territories and the Commonwealth have some form of legislation dealing with radiation
protection. States and Territories also have regulatory controls over institutions in which diagnostic
imaging services are provided. They are responsible for the regulation and management of public
hospitals and other health services, the licensing of private hospitals and the registration of medical
practitioners and other health professionals.

At the Commonwealth level, the Health Insurance Act 1973 covers the major elements of the Medicare
program providing medical and hospital services and Commonwealth funding for services. The Act
governs the payment of Medicare benefits for diagnostic imaging services. The National Health Act
1953 covers the provision of certain medical, pharmaceutical and dental services. The Act provides the
basis for Commonwealth funding for the national breast cancer screening program, BreastScreen
Australia.

Other relevant Commonwealth legislation includes the Therapeutic Goods Act 1989 that provides a
national framework for the regulation of therapeutic goods (e.g. diagnostic imaging equipment) in
Australia to ensure their quality, safety and efficacy for marketing and use; and the Customs Act 1901
that covers the import and export of goods into and out of Australia, including restricted items, such as
medical radioisotopes.

There is also State/Territory and Commonwealth law that regulates the business management of
Australian companies incorporated under that legislation and the Trade Practices Act 1974 Act
(Commonwealth) that provides protection to consumers against unconscionable conduct, false



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representations, misleading or deceptive conduct and other ‘unfair practices’ in connection with the
supply of goods, services and land. All States and Territories have similar legislation.

In addition to this legislative framework, there are the policies and processes that organisations involved
in the health service delivery set to assure safe and quality care. They include policies and processes
for credentialing and defining the scopes of practice of individual medical practitioners and other health
professionals, and for establishing standards of practice, clinical governance and clinical risk
management arrangements.

The remainder of this section focuses on the two main pieces of legislation dealing with professional
supervision requirements for radiologists – the Commonwealth Medicare benefits arrangements and
State and Territory regulations for radiation protection.


4.2.2 Medicare Benefits Arrangements

Services Covered

Medicare benefits are provided for people who incur medical expenses in respect of clinically relevant
services provided by qualified medical practitioners, and certain dental practitioners and optometrists.
Professional services covered include diagnostic imaging services. All services and procedures for
which Medicare benefits are paid are contained in the Medicare Benefits Schedule (MBS). A new
edition of the MBS takes effect on 1 November each year and updates are issued throughout the year
as required.


Diagnostic Imaging Services

The Diagnostic Imaging Services Table (DIST) of the MBS sets the rules of interpretation, items of
diagnostic imaging services and associated schedule fees on which Medicare rebates are calculated.
The Table covers diagnostic radiology, computed tomography (CT), ultrasound, magnetic resonance
imaging (MRI) and nuclear medicine services. Each professional service is assigned a unique item
number. A service covers the performance of the imaging examination on the patient and the reading,
interpretation and reporting of the examination.


Request Requirements

Generally, Medicare benefits for diagnostic imaging services are only payable following the provision of
a written request from another medical practitioner. Several exemptions from the written request
requirements are provided by the Health insurance Act 1973. They include emergencies, remote area
exemptions and pre-existing diagnostic imaging practices. Diagnostic imaging services requiring a
written request are classified as R-type (requested) services while those not subject to the requirement
are classified as NR-type (not requested) services.




Providing Doctors


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Services are provided by medical practitioners who are specialists in medical imaging – diagnostic
radiologists and nuclear medicine physicians – and other consulting physicians who perform certain
types of imaging services in the practice of their speciality. The latter group includes cardiologists
performing procedures with cardiac catheters, gynaecologists and obstetricians performing ultrasound
examinations, urologists using ultrasound in the management of prostatic disease, and vascular and
other surgeons. A medical practitioner must be currently registered or licensed as a medical practitioner
under State/Territory law.


‘By Or On Behalf Of’ Provisions

As Table 4-2 indicates, diagnostic imaging services are defined as professional services that may be
rendered by or on behalf of a medical practitioner.

Table 4-2: Medicare - By or On Behalf of Provisions for Diagnostic Imaging Services
 Unless otherwise stated, a diagnostic imaging service specified in the DIST may be provided by:
      (a) a medical practitioner; or
      (b) a person, other than a medical practitioner, who:
               (i)      is employed by a medical practitioner; or
               (ii)     provides the service under the supervision of a medical practitioner in
                        accordance with accepted medical practice.
Source: MBS, 1 November 2004 - Category 5 - Diagnostic Imaging Services, Section DIC.

What constitutes an appropriate level of supervision that the medical practitioner should provide under
these on behalf of provisions has been the subject of much discussion and debate among professional
groups (providers and requesters), funders, payers and regulators. Resulting arrangements are known
as professional supervision requirements.


4.2.3 Professional Supervision Requirements

Approaches

Today, the Medicare benefits arrangements incorporate a number of approaches to defining
professional supervision requirements for diagnostic imaging services. They focus on requirements for
the performance of the diagnostic imaging procedure on the patient to capture the required images.
Requirements have developed over time and vary to reflect differences in the nature of the modality and
test or examination being performed. Two sets of provisions are in place:
       general conditions that establish a base level professional supervision requirement; and
       modality or examination specific provisions, that establish higher level professional supervision
       requirements.


General Conditions

General conditions are set out in the MBS. They are summarised in Table 4-3. They establish:


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       responsibility for the service - where the service must be billed in the name of the practitioner who
       must accept full responsibility for the service; and
       a general supervision requirement – where the supervising medical practitioner need not be
       present during the performance of the service on the patient but, as a minimum, has established
       consistent quality assurance procedures for the data acquisition and personally analysed the data
       and written the report.


Table 4-3: Medicare – Conditions for Services Rendered ‘On Behalf O” Medical Practitioners
 In order that a service rendered by an employee or under the supervision of a medical practitioner can
 attract a Medicare rebate, the service must be billed in the name of the practitioner who must accept
 full responsibility for the service.
 The Health Insurance Commission would need to be satisfied with the employment and supervision
 arrangements.
 In this regard, while the supervising medical practitioner need not be present for the entire service, he
 or she must have a direct involvement in at least part of the service.
 Although the supervision requirements would vary depending on the test or examination being
 performed, they would, as a general rule, be satisfied where the medical practitioner has:
          (i)       established consistent quality assurance procedures for the data acquisition; and
          (ii)      personally analysed the data and written the report.
Source: MBS General Explanatory Notes, 12.2.2.



Modality/Examination Specific Requirements

Professional supervision requirements have been specified in the DIST for certain:
       modalities – CT, ultrasound, MRI and nuclear medicine services; and
       examinations within modalities – diagnostic mammography and musculoskeletal ultrasound.

Approaches have concentrated on defining the types of medical practitioners able to provide (render)
imaging services and, therefore, act as the supervising medical practitioner, and associated professional
supervision requirements. In some cases, certain aspects of the service that the supervising
practitioner must undertake are specified. They are summarised in Table 4-4 while more detailed
information for each modality and examination is at Appendix B.

Since 2001, qualification requirements for sonographers performing ultrasound examinations on behalf
of a medical practitioner have been established for Medicare benefits purposes. Sonographers must be
suitably qualified and involved in a relevant and appropriate Continuing Professional Development
program and be enrolled on the Register of Accredited Sonographers administered by the HIC. In
addition, the sonographer’s name must be recorded in the report of the service; however, it is not
required to be included on the copy of the report given to the patient. These requirements are unique to
sonographers.




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  Table 4-4: Medicare – Professional Supervision Requirements for Diagnostic Imaging Services
                           Rendering/Supervising Medical
Modality/Examination                                                 Professional Supervision Requirements
                           Practitioner
Computed                   Specialist in the specialty of            Available to monitor and influence the conduct
Tomography                 diagnostic radiology                      and diagnostic quality of the examination and, if
                                                                     necessary, to personally attend on the patient.
Diagnostic
Mammography
Diagnostic                 Specialist or consultant physician in     Available to monitor and influence the conduct
Ultrasound                 the practice of his or her speciality     and diagnostic quality of the examination and, if
(excluding                                                           necessary, to personally attend on the patient.
musculoskeletal)
Musculoskeletal            Specialist or consultant physician in     Responsible for the conduct and report of the
Ultrasound                 the practice of his or her speciality     examination, personally attends during the
                                                                     performance of the scan and personally examines
                                                                     the patient. This is known as the personal
                                                                     attendance requirement.
Magnetic Resonance         Is a specialist in diagnostic radiology   Eligible provider is available to monitor and
Imaging                    who satisfies HIC that:                   influence the conduct and diagnostic quality of the
                                                                     examination including, if necessary, by personal
                           he or she is a participant of the
                                                                     attendance on the patient.
                           RANZCR’s Quality and Accreditation
                           Program; and
                           the equipment he or she proposes to
                           use for providing the services meets
                           eligible equipment requirements.
Nuclear Medicine           Credentialled specialists and             Personally supervise all components of the
                           consultant physicians in nuclear          service and perform personally certain
                           medicine with credentialling by the       components of components – namely, a
                           Joint Nuclear Medicine Credentialling     preliminary examination of the patient and the
                           and Accreditation Committee of the        estimation of the dosage, and compiling the final
                           Royal Australasian College of             report of the service. Supervising specialist,
                           Physicians (RACP) and the                 however, does not have to physically attend
                           RANZCR.                                   during the entirety of each component. This is
                                                                     often called a personal supervision requirement.
  Source: AHA analysis of MBS DIST 2005.
  Generally, services provided in emergencies and in remote locations are exempted from these
  professional supervision requirements. Some examinations may involve administration of contrast
  media (e.g. CT) and sedation (e.g. MRI). The RANZCR has established guidelines covering these
  situations and they are summarised at Appendix C.


  Three Levels of Professional Supervision

  Combined, the general and modality/examination specific arrangements described above establish
  three levels of professional supervision. They are based on the supervising practitioner’s degree of
  direct participation in the performance of the procedure on the patient. The supervising practitioner is
  responsible for the service, interprets the scans and compiles the written report. A variety of terms are
  used to describe the different requirements. For the purposes of this analysis, the following
  classification has been used:

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      General supervision requirement: where the supervising medical practitioner is not present
      during the performance of the service on the patient; has established consistent quality
      assurance procedures for the data acquisition; and has personally analysed the data and written
      the report.
      Direct supervision: where the supervising practitioner is available to monitor and influence the
      conduct and diagnostic quality of the examination including, if necessary, by personal attendance
      on the patient; has established consistent quality assurance procedures for the data acquisition;
      and personally analysed the data and written the report. It applies to CT, diagnostic
      mammography, MRI and most ultrasound services.
      Personal attendance requirement: where the supervising practitioner is on site and personally
      examines the patient and personally attends during the performance of the scan; has established
      consistent quality assurance procedures for the data acquisition; and personally analysed the
      data and written the report. It applies to musculoskeletal ultrasound and nuclear medicine
      services.

The MBS is silent on the use of teleradiology.


4.2.4 Radiation Protection – State and Territory Requirements

In Australia, the regulation of radiation protection, like other areas of public safety, is undertaken through
national and State and Territory controls. Each jurisdiction administers their own radiation protection
legislation. Legislation typically covers the setting of minimum dose limits; licensing of people to
undertake practices in radiation; registration of radiation emitting equipment; safety procedures;
responsibilities; power of inspection; and enforcement provision and penalties.


Licensing Requirements across Jurisdictions

Licensing requirements vary across jurisdictions. In some jurisdictions, they cover certain types of
medical imaging equipment and procedures with conditions applying to radiologist supervision.
Diagnostic imaging services funded under Medicare must be provided in accordance with any
State/Territory laws relating directly or indirectly to the use of diagnostic imaging procedures or
diagnostic imaging equipment. Consequently, if a jurisdiction sets higher professional supervision
requirements, they become the regulatory requirement for services rendered under Medicare in that
jurisdiction. Jurisdictions were surveyed to establish current conditions relevant to professional
supervision requirements for diagnostic imaging. Requirements are shown in Table 4-5. They vary
widely across jurisdictions and, again, different terms are employed across jurisdictions to define
supervision requirements.

Table 4-5: State/Territory Licensing and Registration Conditions
New South Wales
Conditions of the radiographer’s licence:

The licensee must only use fluoroscopic and fluorographic apparatus while working under the general
supervision and direction of a licensed radiologist; and/or while working under the direction of a
registered medical practitioner who requires fluoroscopy during surgical and other procedures.
The licensee must only use computed tomography apparatus while working under the general



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supervision of a licensed radiologist, or a registrar who is training in the discipline of diagnostic radiology
at a hospital.

Definitions
    'general supervision' means supervision by a qualified person who oversees the person being
    supervised and ensures that the person follows safe radiation work practices in relation to the use of
    radioactive substances or radiation apparatus.
Victoria
Condition of registration of radiating apparatus (CT only):

The registered person must ensure that the apparatus is only operated by a person who holds the
relevant operator licence prescribed in Regulation 11 of the Health (Radiation Safety) Regulations 1994.
A radiologist must be immediately available to supervise all stages of a CT procedure as required.
Supervision is taken to mean physical presence within the practice. This requirement is waived for
emergency inpatient examinations, patients at hospitals with a designated emergency centre, or for
urgent “out of hours” provided the radiologist is called immediately and is in attendance as soon as
possible, or is able to supervise the examination by an approved remote link teleradiology system.
Queensland
There are no special conditions regarding professional supervision by radiologists.
Western Australia
Condition of registration of radiating apparatus

The registrant is directed to ensure that fluoroscopic x-ray apparatus is used only by radiographers
using the apparatus as part of a procedure while working under the direction and personal supervision
of a licensed radiologist who is responsible for that procedure.
     “general supervision” means the exercise of control over radiation safety without the person
     exercising such control necessarily being present at the registered premises or field site
     “personal supervision” means the exercise of control over radiation safety by the person exercising
    such control being present on the registered premises or field site
South Australia
There are no special conditions regarding professional supervision by radiologists.
Tasmania
Conditions of the radiologist’s licence:

Licences hold no special conditions relating to professional supervision by radiologists, however, must
adhere to certain NHMRC guidelines, as indicated below.
Use of electronic products described as “X-ray” in Schedule 1 for diagnostic medical imaging must
comply with:
     NHMRC “Recommendations for Minimising Radiological Hazards to Patients (1985)”, except where
     a recommendation of that document conflicts with a specific condition laid down on this licence; and
     NHMRC “Code of Nursing Practice for Staff Exposed to Ionising Radiation (1984)”.
Use of electronic products described as “MRI” in Schedule 1 for the purpose of medical imaging must
comply with the NHMRC Safety Guidelines for Magnetic Diagnostic Facilities (1991), except where a
recommendation of this document conflicts with a specific condition laid down on the licence.
All use of the electronic products described as “X-ray” in Schedule 1, for diagnostic dental radiography,



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shall be in accordance with the NHMRC Code of Practice for Radiation Protection in Dentistry (1987).
ACT
There are no special conditions regarding professional supervision by radiologists.
Northern Territory
There are no special conditions regarding professional supervision by radiologists.
Source: State/Territory Radiation Safety Agencies 2005



Development of a National Framework for Radiation Protection

Since the late 1990s, work has been under way, through the Australian Health Ministers’ Conference
(AHMC), on the development of a uniform national framework for radiation protection. In July 2004,
Ministers endorsed the National Directory for Radiation Protection as the agreed framework for radiation
protection (ARPANSA 2004). States and Territories are at different stages in reviewing their legislation
and enacting new legislation that puts into effect the agreed national framework. For example, Victoria
has introduced a new Radiation Bill 2005 to cover the creation of a regulatory scheme that is consistent
with the national framework and with the recommendations of the national competition policy review of
the legislation completed in 2001 (Phillips Fox 2005). Licensing conditions, however, appear to remain
a matter for each jurisdiction to determine.


4.2.5 Views about Current Regulatory Requirements

Views on the appropriateness and relevance of the current professional supervision and reporting
requirements were canvassed as part of consultations. Views centred on several key issues.


Lack of clarity in current requirements

A recurring theme in consultations was the lack of clarity in current Medicare requirements. Many
respondents referred to the problems encountered in developing a clear, practical and workable
definition for being ‘available to monitor and influence the conduct and diagnostic quality of the
examination and, if necessary, to personally attend on the patient’. Many used the example of the
proposed ‘15 minute walk rule’ to highlight the problems involved. There were also differing views about
whether this requirement meant the on-site physical presence of the supervising radiologist.


Resulting administrative difficulties

Respondents from the government sector highlighted the resulting problems they faced in monitoring
compliance with the current Medicare professional supervision requirements.


Inadequacies in current terminology

Many respondents commented on the variety of terms used to define different levels of professional
supervision (general supervision, personal supervision, direct supervision) with many of them used
interchangeably. This resulted in confusion and misunderstandings. There were calls for the


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development of a new conceptual framework for considering professional supervision and reporting
requirements with a clear and concise nomenclature.


Continuing relevance

Many respondents questioned the continuing relevance of aspects of the current requirements given
developments in knowledge, technologies and practice. Some respondents focussed on the
appropriateness of particular requirements – e.g. personal attendance requirements for musculoskeletal
ultrasound services given developments in this field, arguing that they should be treated in the same
way as the rest of diagnostic ultrasound services. Others consider that current ways of viewing
professional supervision are no longer appropriate given developments in communications technologies
and teleradiology and the changes they bring to the way radiology is organised, delivered and practised.

There were mixed views about the current role, place and benefits of teleradiology. Some respondents
questioned the notion that there is a single rendering practitioner, indicating that it does not accurately
reflect the way diagnostic imaging services are delivered in practice.


Lack of focus on reporting side

Many respondents commented on the tendency for attention to focus on the professional supervision
aspects of the diagnostic imaging service, and not the reporting side. The radiologist’s role and
responsibility is to supervise, interpret and report the on the service, and ensure quality patient care.
The report represents one of the key outcomes of the service. Currently, the content of the report is not
specified in the Medicare rules for diagnostic imaging. Standards that set out good practice in reporting
and supervision are needed.


4.3   Recent Practice Guidelines, Standards and Requirements

4.3.1 Review Method and Limitations

The review covered recent practice standards and guidelines set by peak national and international
radiology professional bodies and requirements set for reimbursement purposes under publicly funded
health insurance schemes. It focussed on diagnostic radiology and guidelines, standards and
requirements set since 2000.

A two-stage review process was adopted. The first stage involved scanning and assessing the range of
information available across countries and international bodies while the second stage involved targeted
analysis for a selection of countries and bodies. A wide variety of information was found in the first
stage, however, much of it represented broad policy statements and position statements about the
practice of radiology. Consequently, detailed analysis was confined to Canada, the USA, the UK and
the European Association of Radiology (EAR). Appendix D provides further information on the
professional bodies covered in the review’s first stage search strategy.

Making comparisons across countries is inherently difficult given differences in national policies; in the
organisation, funding and management of national health programs, diagnostic imaging services and
radiology sectors; and in practice. The results of this review are useful for highlighting similarities and
differences in approaches to and requirements for radiologist professional supervision and reporting,


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and considering lessons learnt. However, they tell us little about the factors that contributed to the
setting of practice requirements and their effectiveness.


4.3.2 Professional Practice Guidelines and Standards – USA and Canada

The American College of Radiology (ACR) and Canadian Association of Radiologists (CAR) use similar
approaches to practice guidelines and standards development with the Canadian standards drawing on
those developed by their US counterparts.


Purposes and Scope

Both peak bodies aim to develop guidelines and standards to provide assistance to practitioners
performing examinations and procedures. Resulting documents address the practice of a particular
diagnostic imaging modality (diagnostic radiography, CT, MRI, ultrasound) or particular clinical
applications within a modality (diagnostic mammography, ultrasound examinations of female pelvis,
breast and antepartum obstetrics), supporting requirements (e.g. administration of contrast media), and
reporting requirements. They aim to assist practitioners in delivering effective and safe medical care.
They are developed by expert advisory panels through a consensus process. They are reviewed
periodically.

The resulting radiology practice documents are described in several ways. CAR calls its documents
‘standards’ while the ACR uses the term ‘practice guideline’. Both describe them as representing policy
statements that attempt to define principles of practice that should generally produce safe and effective
radiological care. They are not intended as rules, nor are they designed to establish a legal standard of
care or conduct.


Principles and Approaches

Both ACR and CAR approaches are based on the principle that safe and effective use of diagnostic
(and therapeutic) radiology requires specific training, skills, and techniques. Consequently, practice
documents address the required qualifications and responsibilities of the radiologist (or medical imaging
specialist); the required qualifications and responsibilities of other team members (e.g. technologists,
medical physicists); examination and patient safety considerations; equipment; quality control and
improvements; documentation; and reporting. Professional supervision and reporting responsibilities of
the radiologist, therefore, are placed within a broader quality assurance system approach for a particular
modality or examination. Practice guidelines/standards are supported by technical standards that
together have formed the basis for accreditation programs for particular imaging modalities.


What Do They Say About Professional Supervision and Reporting?

The ACR and CAR practice guidelines and standards emphasise the role and responsibilities of the
radiologist in supervising, interpreting and reporting diagnostic imaging examinations. They distinguish
between two broad levels of professional supervision - general supervision and direct supervision with
the latter requiring the radiologist to be present on-site and immediately available to furnish assistance
and direction throughout the performance of the procedure.




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Principles and practices for radiologist reporting are addressed through separate practice guidelines or
standards for communication for diagnostic radiology, with the Canadian standard drawing heavily on
the US reporting guideline. Communication covers the written report and direct communication with the
referring doctor. They highlight the central importance of the written report as the final product of the
imaging service and recommend a minimum set of items that a report should include. In some
instances (e.g. breast imaging), additional reporting requirements are set in line with mandatory national
standards.


Table 4-6 summarises the key features of general and direct supervision and reporting requirements
recommended by the peak Canadian and US radiology professional bodies, while Table 4-7 sets out the
key principles and practices recommended for effective communication in diagnostic radiology.

Table 4-6: Professional Supervision and Reporting Requirements for Radiologists - Canada and
           USA
          General Supervision and Reporting                          Direct Supervision and Reporting
      Examinations undertaken under the supervision              Examinations undertaken under the supervision
      of and interpreted by the appropriately trained            of and interpreted by the appropriately trained
      and credentialed radiologists with radiologist             and credentialed radiologists.
      responsible for all aspects of the study.
                                                                 Supervising radiologist is present and
      Trained and certified technologist, under overall          immediately available to furnish assistance and
      supervision of radiologist, responsible for patient        direction throughout the performance of the
      safety and comfort, examination preparation and            procedure.
      performance, technical and quality evaluation of
                                                                 Trained and certified technologist responsible
      images and relevant QA.
                                                                 for patient safety and comfort, examination
      Reporting in line general standards/guidelines             preparation and performance, technical and
      set for Communication: Diagnostic Radiography.             quality evaluation of images and applicable QA.
                                                                 Reporting in line general standards/guidelines
                                                                 set for Communication: Diagnostic Radiography
                                                                 with additional national requirements for
                                                                 screening and diagnostic mammography.
Source: AHA analysis of ACR Practice Guidelines and CAR Practice Standards 2005




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Table 4-7: Communication in Diagnostic Radiology - Key Principles and Practices, Canada and
           USA
  Purpose
  An official interpretation should be generated following any examination, procedure or officially requested
  consultation. An official interpretation is defined as that written report (and any supplements or amendments
  thereto) that attach to the patient’s permanent record (ACR).
  The effective transmission of radiographic information from the radiologist’s mind to the clinician constitutes
  the report’s purpose (CAR).

  Diagnostic radiology report
  A final written report shall be provided with all radiologic studies regardless of site of performance (e.g.
  hospital, imaging centre, physician office, mobile units).
  Report should contain the following minimum items:
       A. Demographics
       B. Relevant clinical information
       C. Body of report – procedures and materials, findings, patient limitations, clinical issues and
          comparative data
       D. Impression – conclusion or diagnosis that relates to the patient’s health problem and clinical
          questions posed by the referring doctor.
  Report shall be clear and concise.
  Other forms of communication
  Final written report is the definitive means of communicating results to referring physician. Other methods of
  direct or personal communication of results are encouraged in certain situations.
  Timeliness of reporting
  Timeliness of reporting varies with the nature and urgency of clinical problem. The written radiological report
  should be made available in a clinically appropriate, timely manner.
Source: Source: AHA analysis of ACR Practice Guideline for Communication: Diagnostic Radiology. Effective January 2002
and CAR Practice Standard for Communication in Diagnostic Radiology, first approved in June 1997 and reviewed in
September 2001.



What are the Modality and Examination Specific Requirements?

Table 4-8 compares the policy positions of the ACR and CAR on professional supervision and reporting
requirements across the main diagnostic imaging modalities and for diagnostic mammography.

The ACR recommends general supervision by the radiologist for all the imaging modalities with the
exception of diagnostic mammography, which should be performed under the direct supervision of the
radiologist qualified in mammography. The latter requirement is to ensure that the examination is
planned and tailored to a patient’s individual needs.

There are two key areas where CAR differs from the ACR recommendations. They relate to CT studies
and diagnostic ultrasound examinations where CAR refers to ideal requirements.




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Table 4-8: Professional Supervision and Reporting Requirements by Diagnostic Imaging
           Modality/Examination – Canada and USA
             Requirements                             Canada                                 USA
    General supervision and              General (plain) radiography            Diagnostic radiology
    reporting
                                         MRI                                    Diagnostic CT
                                                                                Diagnostic ultrasound
                                                                                MRI
    Direct supervision and               Diagnostic ultrasound – on site        Diagnostic mammography
    reporting                            availability ideal requirement for
                                         case-by-case consultation
                                         CT – direct monitoring of each
                                         study an ideal requirement
                                         Diagnostic mammography and
                                         problem solving breast
                                         evaluation


Source: AHA analysis of ACR Practice Guidelines and CAR Practice Standards 2005


       For CT studies, CAR recommends that the ideal requirement is for the interpreting radiologist to
       monitor directly the performance of each study (CAR 2002). However, it acknowledges that this
       ideal is often unable to be met because of time constraints and limitations on radiologist
       availability. In settings where on-line monitoring is not possible, development of an appropriate
       CT protocol based on careful review of clinical indications, as well as the availability of prior
       imaging studies, is recommended.
       For diagnostic ultrasound examinations, CAR recommends that a sonologist must be available for
       consultation with the sonographer on a case-by-case basis and that this is best achieved by
       having the sonologist on site and available to participate actively in the ultrasound examination
       when required (CAR 2001 to 2005). This is because ultrasound is highly operator-dependent
       imaging modality that requires a radiologist’s availability to ensure quality examinations. At the
       same time, CAR acknowledges that the geographic realities in Canada do not permit the
       presence of an on-site sonologist in all locations. Consequently, CAR recommends strategies to
       risk manage situations, where a sonologist is not available on site to directly supervise the
       examination. Strategies include ensuring adequate documentation of each examination with a
       videotape record as an adjunct to the hard copy images in difficult cases; having a sonologist
       available by telephone for consultation with the sonographer and the referring physician; and
       regular sonologist visits to remote facilities to provide on site review of ultrasound procedures and
       sonographer supervision.

The latter has been CAR’s policy position over a number of years and it has been restated in the
release of its latest draft practice standard that covers the performance of musculoskeletal ultrasound
examinations (2005). As noted already, both ACR and CAR develop practice guidelines and standards
through consensus approaches.

Appendix E and Appendix F provide further information about the practice guidelines and standards of
the ACR and CAR.




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4.3.3 Professional Guidelines and Standards – United Kingdom and Europe

The Royal College of Radiologists (RCR) has adopted a different approach to establishing good practice
in clinical radiology. The approach adopted reflects the nature of the UK health system, the
organisation and delivery of radiology services and the clinical governance framework set by the UK
Government under which National Health Service (NHS) organisations operate to improve the quality of
care.


Clinical Governance Framework of the NHS

Clinical governance is the process whereby individual practitioners are responsible for developing and
maintaining standards within their local NHS organisation (Department of Health 1999). Organisations
are accountable for continuously improving the quality of their services and maintaining high standards
of care. This includes action to ensure risks are avoided; adverse events are detected rapidly, openly
investigated and lessons learned; good practice is rapidly disseminated; and systems are in place to
support continuous improvements in clinical care. The UK Government has created a series of national
initiatives to support local activities. Initiatives include provision of best practice advice in use of new
and existing treatments through the National Institute of Clinical Excellence (NICE), clinical guideline
development, and national standards and service models for particular services or care groups.


Royal College of Radiologists – Defining Criteria for Good Radiological Practice

It is against this national policy backdrop and national agenda that the activities of the RCR need to be
considered. The RCR has developed and issued a series of guidance documents that define the
principles for the delivery of a high quality imaging service and high standards of clinical care in
radiology within the NHS and its departments of clinical radiology. They focus on contemporary issues
in the NHS. Documents have included advice on reporting (1995), delegation in departments of clinical
radiology (1996), inter-professional roles and responsibilities ( 1998), good practice for clinical
radiologists (1999), skills mix in clinical radiology (1999), clinical governance and revalidation for
radiologists (2000), risk management in clinical radiology (2002), making the best use of a department
of clinical radiology (2003) and individual responsibilities – a guide to good medical practice (2004).
Together, these documents define the criteria for good radiological practice and the competence, care
and conduct expected of a radiologist, in all aspects of their professional work. Professional
supervision and reporting responsibilities of the radiologist are set within a broader context of practice
within a department of radiology, under the clinical governance framework.


European Developments

At the European level, the European Association of Radiology (EAR) has issued several good practice
guides for European radiologists – Good Practice Guide for European Radiologists (2004) and Risk
Management in Radiology in Europe (2004). Both guides draw extensively on the principles set by the
RCR. Within Europe there are moves towards the development of uniform standards for radiology
training through the EAR (Diagnostic Imaging 2004). In the area of radiation safety, the roles and
responsibilities of the radiologist have been enhanced with the setting of a European Union directive for
the justification of radiation exposure (EURATOM 1997). Each radiation exposure must be justified and
a clinical evaluation of the outcome of each medical exposure documented (ARC 2000, EAR 2004).




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4. Results
Clinical radiologists are also required to monitor their requests for investigation to reduce overall
radiation exposure and to assess the risks and benefits of a radiological examination.

4.3.4 Health Insurance Remuneration Arrangements– Canada and USA

Review of professional supervision and reporting requirements for radiologists, under publicly funded
health insurance schemes in Canada and the USA, has provided mixed results. This outcome reflects
in part the variety of approaches adopted, the information available in the public domain, and
government health policies and priorities. This section provides an overview of requirements while
Appendix E and Appendix F provides additional information.


Accredited Facilities Approach

In Canada, some provincial government health plans address professional supervision and reporting by
radiologists through accreditation requirements for imaging facilities for reimbursement purposes
(Alberta and British Columbia). Provincial professional bodies set the guidelines and standards against
which facilities are accredited. Professional supervision and reporting are addressed through the
establishment of radiologist staffing requirements for a facility and the range of imaging services
provided. Remote sites without full-time radiologist coverage are provided for with a series of
requirements set to manage possible risks and ensure safe and quality care. Specific requirements
may be set for a particular imaging modality and these appear to reflect, in part, the funding policies of a
provincial government.

For example, in Alberta accredited MRI facilities require the MRI radiologist being on-site for at least
50% of studies in a day and being immediately available (in person or by telephone) during all studies
(College of Physicians and Surgeons of Alberta 2005). The MRI radiologist is responsible for approving
all protocols on a case-by-case basis and for interpreting all studies in a timely fashion. Accreditation
arrangements allow for remote MRI facilities that do not have an on-site radiologist with a series of
requirements to manage associated risks and ensure safe and quality care. Requirements include
having remote services linked to at least one other fully supervised full-time MRI facility; having an MRI-
approved radiologist available to the imaging technologist by telephone during imaging sessions (or by
tele-imaging in certain cases) and to review all requisitions, prescribe all imaging protocols and interpret
all studies. MRI studies, where direct supervision is the accepted practice standard, are not performed
by remote MRI facilities.


Physician Payment Schedule Approach

Other Canadian provinces specify supervision and reporting requirements through physician payment
schedules (Manitoba, Ontario and Saskatchewan). Generally, fees have two components –
professional and technical – with descriptors specifying each element of the diagnostic imaging service
that a particular fee component covers. The descriptor of the professional fee covers supervision and
reporting requirements that the radiologist (or other physician) is expected to perform in claiming the
service. It therefore sets out the elements of the service and the roles and responsibilities of the
radiologist in providing the service. The level of specification varies across the three provinces with
Ontario having the most detailed.

Generally, the level of supervision required is specified in the professional fee descriptors for a modality
and/or examination. Two levels of professional supervision tend to be used – general clinical


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4. Results
supervision and oversight, and an on-site professional supervision requirement where the radiologist is
required to be present in the facility to provide clinical supervision. Radiologist reporting requirements
are built into the professional fee through the setting of an element for interpreting the results of the
diagnostic procedure. Some elements of the professional component may be delegated to another
physician. However, interpreting the results of the diagnostic procedure must be performed personally
by the physician who claims the service.

The approach used in Ontario is illustrated in Table 4-9.

Table 4-9: Professional Supervision and Reporting Requirements for Radiologists – Ontario,
           Canada
                Professional component                                      Technical component
         A. Providing clinical supervision including                 A. Preparing the patient for the procedure
            approving, modifying and/or intervening                  B. Performing the diagnostic procedure or
            in the performance of the procedure                         assisting in the performance of the
            where appropriate, and quality control of                   procedure
            all elements of the technical component                  C. Making arrangements for any appropriate
         B. Performance of any clinical procedure                       follow-up care
            associated with the diagnostic procedure                 D. Providing records of results of the
            which is not separately billable.                           procedure to the interpreting physician
         C. Where appropriate, post procedure                        E. Discussion with, and providing
            monitoring, including intervening except                    information and advice to, patient or
            where this constitutes a separately                         patient’s representatives(s), whether by
            billable service.                                           telephone or otherwise, on matters
         D. Interpreting the results of the diagnostic                  related to the service.
            procedure.                                               F. Preparing and transmitting a written,
         E. Providing premises for any aspect(s) of A                   signed and dated interpretation of the
            and D that is (are) performed at a place                    procedure to referring physician
            other than the place in which the                        G. Providing premises, equipment, supplies
            procedure is performed.                                     and personnel for all specific elements of
                                                                        the technical and professional
     If the physician claiming the fee for the service is               components.
     personally unable to perform elements A, B and C,
     these may be delegated to another physician who
     must personally perform the service.

     Element D must be personally performed by the
     physician who claims the service.
Source: AHA analysis of Ontario Health Insurance Plan (April 2005)



US Medicare Program Requirements

The US Medicare program sets physician supervision requirements that apply during the performance
(technical component) of diagnostic x-ray, diagnostic laboratory and other diagnostic tests and
procedures in physicians’ offices and non-hospital free standing centres. Tests have to be performed
under the supervision of a physician. Requirements do not apply to Medicare hospital inpatients or
outpatients. They were implemented in 2001 after much discussion with professional and industry
bodies about the requirements, their definitions and coverage.

There are three levels of supervision that apply to diagnostic tests and procedures provided by
radiologists – general, direct and personal. Each item of service in the Medicare Physician Fee


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4. Results
Schedule is assigned a professional supervision level code (e.g. 1 for general, 2 for direct and 3 for
personal supervision) that applies for reimbursement purposes. Definitions for each level are set out in
Table 4-10, together with examples of the types of imaging examinations covered.


Table 4-10: US Medicare Program – Professional Supervision Requirements for Diagnostic
           Tests and Procedures
               Level                             Definition                     Examinations/Procedures
    General supervision           Means the procedure is furnished under      X-rays (except where contrast
                                  the physician’s overall direction and       is required)
                                  control, but the physician’s presence is
                                  not required during the performance of
                                  the procedure. Under general                CT without contrast
                                  supervision, the training of the non-       MRI without contrast
                                  physician personnel who actually
                                  performs the diagnostic procedure and       Most ultrasound
                                  the maintenance of the necessary
                                  equipment and supplies are the
                                  continuing responsibility of the
                                  physician.


    Direct supervision            Means the physician must be present in      CT with contrast
                                  the office suite and immediately
                                                                              MRI with contrast
                                  available to furnish assistance and
                                  direction throughout the performance of     Certain ultrasound
                                  the procedure. It does not mean that
                                  the physician must be present in the
                                  room when the procedure is performed.
    Personal supervision          Means a physician must be in                X-rays with contrast procedures
                                  attendance in the room during the
                                                                              Certain CT procedures
                                  performance of the procedure.
                                                                              Certain MRI procedures
                                                                              Certain ultrasound procedures
Source: US Department of Health & Human Services Centers for Medicare & Medicaid Services, Medicare Carriers Manual
2005

Hospital and mammography services are excluded from the supervision requirements with hospitals
regulated through the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) while
mammography is regulated by the US Food and Drug Administration (FDA).

Practices are required to staff their facilities accordingly, in order to comply with the supervision
requirements. General supervision means that the physician is not necessarily on-site. In the case of
direct supervision, the physician must be present in the office suite and immediately available. This is
defined as within earshot (not just reachable by beeper, and not merely in the same building) whereas
with personal supervision the physician must actually be present in the room with the patient during the
performance of the procedure (Murray 2001). Documentation is required to be kept in order to show
compliance.




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4. Results
4.3.5 Conclusions – Similarities, Differences and Lessons Learnt

A mix of approaches has been used to define professional supervision and reporting requirements for
radiologists. They range from considering requirements in the context of good practice guidelines and
standards for a particular modality or examination and the setting of radiologist staffing requirements for
medical imaging facilities under accreditation arrangements, through to specifying requirements in
payment schedules. Each offers lessons.
      The ACR and CAR approaches place the radiologist’s professional supervision and reporting
      responsibilities within a broader quality assurance system approach for a particular modality or
      examination.
      They also provide examples of ways for considering principles of good practice in reporting and
      the report’s content.
      The payment approaches adopted in Canada show different ways of specifying the components
      of the imaging service and the radiologist’s roles and responsibilities for the service.
      Canadian approaches also provide ways for considering ideal requirements and managing the
      potential risks that occur when the ideal supervision requirement is unable to be met.
      The UK experience with clinical governance provides some principles to guide clinical risk
      management in radiology practice.

In terms of establishing appropriate radiologist supervision requirements, across the range of modalities
and examinations that make up diagnostic imaging, all have sought to define levels of supervision,
however, that there are differences in the number of levels, in terminology and in definitions:
      The US Medicare program has set three levels – general, direct and personal while other bodies
      tend to focus on two levels – general and direct.
      Under the Australian Medicare arrangements, three levels apply – general, direct and personal
      attendance.
      Supervision levels are focussed on establishing the radiologist’s responsibilities and the degree of
      direct participation (the assistance and direction they provide) during the performance of the
      examination on the patient.
      Much attention has focussed on where the radiologist is physically located – off site, on the
      premises, or in the room where the procedure is being performed.
      Much of the debate has centred on defining availability and whether it requires on-site presence.
      The types of assistance and direction required of the radiologist during the performance of an
      examination, for direct supervision purposes, have been defined in different ways as Table 6-6
      illustrates.

Table 4-11: Definitions of Direct Supervision by Radiologists
              Organisation                                          Definition
      ACR and CAR                    Supervising radiologist is present and immediately available to
                                     furnish assistance and direction throughout the performance of the
                                     procedure.
      Ontario                        An on-site professional supervision requirement where the
                                     radiologist is required to be present in the facility to provide clinical
                                     supervision. Providing clinical supervision including approving,
                                     modifying and/or intervening in the performance of the procedure


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              Organisation                                     Definition
                                    where appropriate, and quality control of all elements of the
                                    technical component.
      Australian Medicare           Where the supervising radiologist is available to monitor and
      Program                       influence the conduct and diagnostic quality of the examination.
      US Medicare Program           The physician must be present in the office suite and immediately
                                    available to furnish assistance and direction throughout the
                                    performance of the procedure. It does not mean that the physician
                                    must be present in the room when the procedure is performed.
    Source: AHA analysis 2005

In terms of the requirements for different modalities and examinations, some broad observations can be
made:
      For diagnostic radiology, CT and MRI examinations, there is a trend towards general supervision.
      There appears to be agreement that diagnostic mammography requires a higher level of
      supervision with the term direct supervision often used; however, direct supervision is defined in
      different ways and it is unclear to what extent the establishment of national programs for the
      prevention and management of breast disease across countries has contributed to this situation.
      In ultrasound, there are different views about the appropriate level of professional supervision that
      the radiologist should provide. Those advocating higher levels of radiologist involvement and
      input, during the performance of the examination on the patient, are doing so because of the
      operator-dependent nature of ultrasound and the consequent need to ensure quality
      examinations.

However as noted, drawing comparisons across countries and agencies is inherently difficult and little is
known about the factors and circumstances that contributed to the setting of a particular requirement.




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5. Discussion
This chapter includes a brief discussion of the results, to set the scene for the approach adopted
in developing the proposed professional supervision and reporting standards, as set out in
Chapter 6 - Conclusions.


5.    DISCUSSION
Australian and overseas approaches to professional supervision have traditionally varied according to
the modality, test or examination. Implicitly, therefore, resulting levels of supervision have sought to
provide ways of managing different levels of associated risk. Stakeholder consultations affirmed that
this was an important principle that should underpin professional supervision and reporting standards.

The amount and nature of radiologist participation should and will vary with the type and complexity of
the medical problem, the type of technology used and type of examination performed. Different
modalities and examinations have different technical profiles. For some, these technical requirements
can be managed usually through the use of imaging protocols (e.g. plain x-rays and CT scans). Other
imaging modalities (e.g. ultrasound) present a different set of technical challenges and are not as
protocol driven.

Many stakeholders indicated that ultrasound is a highly operator dependent imaging modality, where the
use of probes and transducers to produce an image where the probe is pointed, requires flexibility in
approach and high levels of expertise. The use of contrast media (e.g. in CT scans) and sedation (e.g.
in MRI) changed the risk profile and required a medical practitioner (not necessarily a radiologist) to be
available to treat any adverse reactions or other events.

Consultations however have also indicated that radiologists operate in a range of operating
environments and the risks associated with each different environment varies significantly. These
Standards therefore call for an assessment of risk and development of a range of appropriate
procedures to manage this risk by individual radiologists and/or practices.

Most approaches to professional supervision in Australia and overseas have tended to focus on the
level and nature of radiologist availability during different types of examinations - for example, whether
they should be available on-site or be available to personally attend the patient. These approaches
implicitly suggest that radiologists will have appropriate input to the imaging service, if they are available
to do so. This approach however, fails to recognise that in many cases, radiologist input to the request
review, patient preparation and examination components of the imaging service for example, are
dependent on other members of the imaging team, such as radiographers and sonographers, seeking
such input.

It is therefore appropriate that supervision standards place a greater focus on ensuring the effective
functioning of the imaging team as a whole. This involves all members of the imaging team having a
clear understanding of their roles and responsibilities and involves radiographers and sonographers
having a sound appreciation of the circumstances and situations in which they should seek additional
radiologist input to the imaging service.




                                                      38              AUSTRALIAN HEALTHCARE ASSOCIATES
6. Conclusions and Recommendations
This chapter summarises our conclusions and sets out the proposed standards associated with
professional supervision and reporting. In addition, it discusses implementation issues
associated with the proposed standards and linkages between this and other QUDI projects.


6.     CONCLUSIONS AND RECOMMENDATIONS

6.1     Professional Competence - Qualifications of Personnel

6.1.1 The Imaging Team

Diagnostic imaging services are provided in multidisciplinary teams with members with the required
expertise drawn from various professional and other groups. The following table identifies the members
of the imaging team and details their key role.

         Team Member                                                       Key Role
Radiologists                           Team leader with overall responsibility for the radiology service
Radiographers/Sonographers Prepare patient, operate equipment, perform examinations
Medical Physicists                     Ensure optimum performance of equipment
Service Engineers                      Maintain and service equipment
Nurses                                 Provide clinical support
Administrative Staff                   Book appointments, type reports undertake other clerical staff

The team mix varies depending on the type of examination performed. The individual responsibilities of
team members are interdependent. Collectively, they enable the effective delivery of the service (RCR
1999).


6.1.2 For Radiologists

Radiologists, and the teams they lead, must be appropriately qualified, trained and experienced to
provide the requested services.

Radiologists providing imaging services must meet certain competency requirements as specified in
Table 6-1. Additional requirements apply for radiologists practising MRI, diagnostic mammography and
diagnostic ultrasound.

Table 6-1: Radiologists’ Qualifications, Registration and Continuing Professional Development
         (CPD) Requirements
Radiologists’ qualification

A radiologist must be qualified by a recognised training body to practice diagnostic radiology through one of the following
academic awards:
             Diploma of The Royal Australian and New Zealand College of Radiologists (DRACR)/Fellow of The Royal
             Australian and New Zealand College of Radiologists (FRANZCR); or
             National Specialist Qualification Advisory Committee (NSQAC)/Specialist Recognition Advisory Committee


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6. Conclusions and Recommendations
             (SRAC) equivalent. (Standard P.1.1.1)


Registration

In Australia, a radiologist must be registered with the relevant State or Territory Medical Board which has jurisdiction over the
location in which that radiologist carries out his/her practice. In New Zealand, a radiologist must be registered with the
Medical Council of New Zealand. (Standard P.1.2.1)
A radiologist must hold a current radiation operator’s licence. In Australia, the radiologist must hold a current State or
Territory radiation Operator’s Licence, while in New Zealand the radiologist must hold a current Annual National radiation
Laboratory Licence. (Standard P.1.2.2)


Continuing professional development (CPD)

A radiologist shall participate in the RANZCR CDP Program and maintain his/her participation in each triennium of the
RANZCR CDP Program. (Standard P.1.3)
Source: RANZCR Accreditation Standards for Diagnostic and Interventional Radiology (Version 7 - 2005)

Radiologists practising MRI and diagnostic mammography must meet additional qualification and CPD
requirements, while radiologists practising ultrasound must meet additional qualification requirements as
specified in Table 6-2.

Table 6-2: Additional Professional Competency Requirements for Radiologists Practicing MRI,
         Diagnostic Mammography and Diagnostic Ultrasound
MRI

MRI Supervising Radiologists of MRI facilities must have evidence of competence in the techniques and application of
magnetic resonance imaging. (Standard P1.1.3)
Each radiologist interpreting MR images must have accumulated 30 MRI specific CPD points/hours I the past three years.
MRI Supervising Radiologists must accrue a minimum of 60 MRI specific CPD points over three years. The MRI CPD
activities undertaken must be those recognised by the RANZCR CPD Program. (Standard P.1.3.3)


Diagnostic mammography

Each radiologist must interpret mammograms on a regular basis. (Standard P.1.1.5)
Each radiologist interpreting mammograms must have accumulated 15 mammography specific CPD points/hours in the past
three years in Mammography CPD activities recognised by the RANZCR CPD Program. (Standard P.1.3.2)


Diagnostic ultrasound

A radiologist practising Diagnostic Ultrasound must comply with RANZCR Guidelines For Medical Practitioners Performing
and Interpreting Diagnostic Ultrasound – Intercollegiate Consensus Statement (June 1998). (Standard P.1.1.4)
Source: RANZCR Accreditation Standards for Diagnostic and Interventional Radiology (Version 7- 2005)



6.1.3 For Other Health Care Professionals in the Imaging Team

Other health care professionals who are members of the medical imaging team must meet certain
qualification, registration and CPD competency requirements as specified in Table 6-3.




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6. Conclusions and Recommendations
Table 6-3: Competency Requirements for other Health Care Professionals in the Imaging Team
Radiographers

A radiographer:
            Must be qualified by a recognised training body to practice radiography ((Standard P.2.1.1)
            Must hold a current State, Territory or New Zealand Radiographers Board registration, where available
            (Standard P.2.2.1)
            Must hold a current State or Territory Radiation Operator’s licence, where available (Standard P.2.2.2)
            Shall participate in a radiographer’s CPD Program, such as or equivalent to the Australian Institute of
            Radiography (AIR) CPD Program. (Standard P.2.3.1)


Diagnostic mammography radiographers

A diagnostic mammography radiographer:

            In addition to compliance with the requirements of P.2.1.1, possession of a Certificate of Clinical Proficiency
            from the AIR or equivalent would be an advantage. (Standard P.2.1.2)
            Within the general requirements for Radiographer CPD, each radiographer performing services in diagnostic
            mammography must participate in at least 15 hours of mammography-specific CPD every three (3) years. CPD
            activities include formal programs such as conferences, seminars and meetings of professional bodies; and self-
            instruction by way of the study of publications, books and exhibits. (Standard P.2.3.2)
Sonographers

A sonographer:

            Must either be on the Register of Accredited Sonographers or Student Sonographers as administered by the
            Australian Sonographer Accreditation Registry Ltd (ASAR) or be registered directly with the DHA or be eligible
            for registration with the ASAR/DHA (Standard P.3.1.1)
            Shall participate in the ASAR CPD Program. (Standard P.3.2.1)
MRI radiographers

Radiographers who perform MRI examinations:

            Must have completed or be undertaking training and gaining experience in MRI which is approved by the
            supervising radiologist (s) (Standard P.5.1.1 – Under Review)
            Shall participate in a program of MRI-specific CPD activity such as the AIR CPD Program. (Standard P.5.2.1 –
            Under Review)
Nurses

Nurses employed in medical imaging practices:

            Shall hold current State, Territory or New Zealand nursing registration (Standard P.7.1.1)
            Shall have adequate training/experience in Medical Imaging practice. (Standard P.7.2.1)
Source: RANZCR Accreditation Standards for Diagnostic and Interventional Radiology (Version 7- 2005)




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6. Conclusions and Recommendations
6.2    The Diagnostic Imaging Service Cycle

Usually, a diagnostic imaging service is initiated by a written request from a medical practitioner
(requester) and comprises several stages before the radiologist provides a written report with results
and opinion to the requester. The stages of the diagnostic imaging cycle are illustrated in Figure 6-1.

Figure 6-1: Diagnostic Imaging Service Cycle




Adapted from the Royal College of Pathologists of Australasia Chain of Information Custody for Pathology Request - Test -
Report Cycle in Australia (Guidelines for Pathology Requestors and Pathology Providers), 2004.

The patient’s clinician determines on clinical grounds that a diagnostic imaging service is required for
patient care and communicates the request for imaging. The responsibility of radiologists commences
with the receipt of the request for an imaging test/examination and continues until the outcomes are
communicated to the requester.

The goal of the imaging service and imaging team is to maximise the information obtained from the
examination while minimising associated safety risks and ensuring high quality patient care. The
outcome of the service is a written report with a medical opinion from the radiologist that addresses the
medical problem and questions posed by the requesting doctor, and assists patient care.

Within each stage there are a variety of tasks to be performed with the mix and complexity varying
depending on patient, disease, clinical and other factors and body system under investigation and
imaging examination required. The quality of the report depends on the stages and steps that comprise
the imaging service as illustrated in Figure 6-1.

Not all of the tasks will be undertaken by the radiologist personally, however at a minimum, the
radiologist should provide appropriate supervision and/or input for each task. The following section


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6. Conclusions and Recommendations
discusses each of the stages comprising a diagnostic imaging service and sets out standards for
supervision and input by radiologists.


6.3    Review of Request and Patient Preparation

6.3.1 Objectives

This stage of the imaging service covers the review of the request for imaging and preparation of the
patient for the examination. Its objectives are to:
          Ensure adequate assessment of the patient’s condition and symptoms and clear
          understanding of the nature of the medical problem and questions to be investigated - based
          on the information provided by the requesting medical practitioner and, where appropriate,
          discussions with the patient.
          Arrange the appropriate investigations for the patient in order to minimise risk and maximise
          the effectiveness of diagnosis.


6.3.2 Key Tasks

It involves:
          Reviewing request from doctor for imaging service and clinical indications
          Discussion with patient - including obtaining and recording relevant information on allergies,
          pregnancy status and previous studies and in the case of MRI examinations, whether the
          patient has a pacemaker, aneurism clips or any surgically inserted metallic device
          Reviewing any previous test results where relevant and available
          Advising on appropriateness of examination
          Explaining test/procedure and any associated risks to patient and/or requester
          Obtaining the patient’s informed consent
          Determining imaging protocol to be followed
          Preparing and positioning of patient for test/procedure.


6.3.3 Key Considerations and Managing Associated Risks
          Patients present with a variety of medical problems and complexity.
          Imaging may be requested for a variety of purposes - e.g. as a non-specific screen, to exclude
          a specific diagnosis, to confirm specific diagnoses, to narrow a differential diagnosis, to stage
          a known condition or to monitor a known condition.
          Information provided on the request may include signs, symptoms or suspected condition(s)
          pointing to a particular diagnosis or a range of diagnoses or enumerate the possible diagnoses
          that are being considered and suspected condition(s), the test(s) to be used.
          Imaging modalities and examinations, and the body systems to be imaged, have different
          technical and risk profiles. For some, these technical requirements can be managed usually
          through the use of radiologist-specified imaging protocols. Other imaging modalities or


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6. Conclusions and Recommendations
           examinations are not as protocol-driven. The use of contrast media (e.g. in CT scans) and
           sedation (e.g. in MRI) alters the risk profile.
           The patient should always be informed of the name and status of the person performing a task
           that forms part of an imaging service.


6.3.4 Radiologist Responsibilities

The radiologist is responsible for ensuring:
           Requests received are in line with RANZCR Standard P.1.5.1
           Consulting with patients as clinically necessary, as per RANZCR Standard A.2.1.1
           Advising on appropriate imaging investigation, methods and preparation, as per RANZCR
           Standard P1.5.1 and P1.5.3
           Receipt of patient’s informed consent
           Quality of the review and patient preparation stage.


6.3.5 Relevant Existing Standards

A number of existing RANZCR Standards are relevant to this component of the imaging service. These
Standards, to which reference is made in Section 6.3.4 above, have been included in this section for
ease of referral.


Standard P.1.5.1 - Requests
A diagnostic imaging procedure shall be undertaken upon receipt of a request made by a medical practitioner, or by one of
the following practitioners where the imaging procedure requested is directly related to the practitioner’s specialty groups’
recognised field of expertise: a Chiropractor, Dental Practitioner, Oral and Maxillofacial surgeon, Osteopath, Physiotherapist,
Podiatrist or Prosthodontist or licensed under State or Territory laws.

A request shall be made in a format whereby sufficient information is provided on the clinical indications for the procedure
requested.

Before undertaking the requested diagnostic imaging procedure, a radiologist shall consider the appropriateness of the
procedure requested based on the clinical information provided for diagnosis of the patient’s condition.



Standard P.1.5.3 - Additional and Substituted Tests
Should the Radiologist determine from the clinical information provided in a request that a different diagnostic imaging
procedure or modality would be more appropriate for the diagnosis of the patient’s condition, and where the substituted
procedure or modality is one that would be accepted by diagnostic imaging specialists as more appropriate to the clinical
information provided, the radiologist shall substitute that diagnostic imaging procedure or modality. The Radiologist shall
take all reasonable steps to contact the requesting practitioner before providing the substituted procedure or modality and
shall notate this determination in his/her report along with all efforts made to contact the requesting practitioner.
Should the radiologist determine on the basis of the results obtained from a requested procedure that an additional service is
necessary for the diagnosis of the patient’s condition, the radiologist shall undertake the additional service and notate his/her
report accordingly.




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Standard A.2.1.1 - Needs Assessment
Information relevant to the studies being performed must be obtained and recorded prior to the examination by clerical staff,
radiographer, sonographer, nuclear medicine technologists and/or radiologist. Relevant information shall include allergies,
pregnancy status and previous studies. Additional specific information must be obtained and recorded prior to patients
undergoing special examinations such as MRI, angiography, prostate biopsy.



6.3.6 Proposed Supervision Standard - Review of Request and Patient Preparation

The radiologist should have appropriate input and supervision, such that they may be certain all of their
responsibilities in relation to the review of the service request and patient preparation, have been
adequately met. This may be ensured through at least one of the following:
1.   Personally conducting each of the components associated with this stage of the imaging service; or
2.   Direct (face to face) supervision of the other members of the imaging team, as this stage of the
     imaging service is undertaken; or
3.   Ensuring the implementation and adherence to appropriate written protocols, to be followed by
     members of the imaging team, under the radiologist’s direction.
     The protocols should outline the responsibilities of other members of the imaging team when
     undertaking components of this stage and the circumstances/situations under which, different
     members of the team should seek further guidance and/or input from a radiologist. Additional
     radiologist input, for different circumstances/situations may involve the radiologist:
           − conducting aspects of this component themselves
           − providing verbal advice
           − providing a practical assistance/direction/demonstration
           − conducting a review of clinical information/diagnoses.
     Circumstances/situations which may be specified as triggers for seeking additional radiologist input
     may relate to:
           − the type/nature of the referral received - emergency, insufficient clinical information,
             conflicting indications
           − the type of examination requested - modality/body system or inappropriate or unwarranted
             examination requested based upon accepted diagnostic imaging algorithms
           − patient characteristics - age, condition, complicating factors.
     The protocols may also provide for different triggers for seeking radiologist input, depending on the
     specific imaging team member undertaking a particular component of this stage of the service,
     based upon the team member’s:
           − qualification
           − experience
           − specialisation.




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6.4    Performance of Imaging Examination

6.4.1 Objectives

This stage of the imaging service deals with the performance of the examination on the patient. Its
objectives are to:
          Ensure the patient’s comfort and safety
          Assure a quality examination
          Obtain images of diagnostic quality.


6.4.2 Key Tasks

It involves:
          Performing the agreed examinations(s)
          Monitoring the patient for any complications or adverse effects
          Obtaining images
          Administering contrast media or sedation as necessary
          Documenting test/procedures performed
          Monitoring and reviewing images to ensure their quality and suitability.


6.4.3 Key Considerations and Managing Associated Risks

          Quality of report depends on a quality imaging examination
          Performance of examination requires skilled and appropriately trained staff


6.4.4 Radiologist Responsibilities

The radiologist is responsible for:
          Medical care of the patient
          Setting standards for performance of tests/ examinations including selection of numbers and
          types of views to be used
          Meeting those standards for performing examinations where this is the case
          Monitoring the quality of the examination
          Managing complications and adverse effects that may arise
          Providing advice and support
          Quality assurance of the completed examination - evaluation of technical adequacy (i.e. is the
          examination complete and adequate for diagnostic purposes?) and clinical relevance (does
          the examination contribute to solving diagnostic dilemma?)
          Safety of working environment.


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6.4.5 Proposed Supervision Standard - Performance of Imaging Examination

The radiologist should have appropriate input and supervision, such that they may be certain all of their
responsibilities in relation to the examination stage, have been adequately met. This may be ensured
through at least one of the following:
1.   Personally conducting each of the components associated with this stage of the imaging service; or
2.   Direct (face to face) supervision of the other members of the imaging team, as this stage of the
     imaging service is undertaken; or
3.   Ensuring the implementation and adherence to appropriate written protocols, to be followed by
     members of the imaging team, under the radiologist’s direction.
     The protocols should outline the responsibilities of other members of the imaging team when
     undertaking components of this stage and the circumstances/situations under which, different types
     of team members should seek further guidance and/or input from a radiologist. The protocols
     should do this while ensuring service quality and patient safety and being cognisant of patient
     access issues, in areas with a limited radiologist workforce.

     The types of circumstances/situations which should be specified in the protocols as triggers for
     seeking additional radiologist input may relate to:
         − the type/nature of the examination being undertaken - modality/body system
         − difficulties obtaining an image of the type/quality required
         − unusual or unexpected imaging results
         − examination findings requiring urgent reporting
         − receipt of additional critical verbal information provided by the patient and not included on
           the request/referral
         − concerns regarding the proper functioning of imaging equipment
         − patient characteristics - age, condition, complicating factors, medical history, clinical
           indications.

     The protocols should indicate for each circumstance/situation, the additional input a radiologist
     should be available to provide. The protocols should specify, for example, that for each specified
     circumstance/situation that a radiologist should be available to either:
         − immediately personally attend the patient
         − personally attend the patient within a specified set timeframe
         − provide immediate verbal advice
         − provide verbal advice within a specified set timeframe.

     The protocols may also provide for different triggers, depending on the imaging team member
     undertaking a particular component of this stage of the service, based upon the team member’s:
         − qualification
         − experience
         − specialisation.



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6. Conclusions and Recommendations
      Other members of the imaging team should not proceed with an examination where it is known the
      radiologist would not be available to provide appropriate additional input, as detailed in the
      protocols. The protocols should also ensure that:
          − all regulatory requirements are met (MBS, State/Territory Radiation Protection legislation)
          − examinations which require the administration of contrast media are not undertaken unless
            a radiologist or other appropriately credentialed medical practitioner would be available to
            immediately personally attend the patient
          − examinations which require sedation of the patient are not undertaken unless a radiologist
            or other appropriately credentialed medical practitioner would be available to immediately
            personally attend the patient
          − examinations of critically ill patients should only be undertaken by, or under the direct (face
            to face) supervision of, a radiologist or other appropriately credentialed medical practitioner
          − patients are not required to wait for an excessive period during an examination for
            additional radiologist input to be sought
          − an excessive proportion of patients are not required to be called back and re-examined to
            obtain an image and report of appropriate quality.


6.4.6 Risk Assessment

When developing written protocols for the examination component of the diagnostic imaging service,
radiologists should have due regard to the relative risk to patient safety and service quality of each type
of examination. These risks may be considered by modality and by body system. A basic framework
for the consideration of the relative risk of different examinations by body system and modality has been
included as Appendix A to this report.


6.5    Interpretation and Reporting

6.5.1 Objectives

This stage of the imaging service deals with analysis and interpretation of the images produced and
reporting of the results to the requesting doctor. Its objective is to produce a timely written report that
provides an answer to the clinical questions posed, together with an assessment of the whole image for
relevant and/or unexpected findings (RCR 2006).



6.5.2 Key Tasks

It involves:
          Reviewing images to evaluate their quality and suitability
          Reviewing and analysing images to establish findings
          Interpreting results of imaging test/procedure by correlating findings of image analysis with
          patient, disease, clinical and other factors



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6. Conclusions and Recommendations
            Reviewing previous studies where available
            Preparing and providing written report to requesting doctor
            Seeking a second opinion where appropriate – e.g. where diagnosis may be difficult or
            specialist knowledge is required
            Other communication with requesting doctor as the situation requires


6.5.3 Key Considerations

The accuracy and timeliness of the report are a key component of the patient’s care. Interpretation and
reporting are central to responsibilities of radiologists. It requires a wide medical knowledge and
awareness of the likely accuracy of the examination in the particular patient related to published
accuracy of the technique and its applicability to a particular examination (RCR 2006). Accuracy of
image interpretation is crucial.


6.5.4 Radiologist Responsibilities

Radiologists are responsible for ensuring that reports issued should be accurate, explicit and
understandable reports, which record the relevant findings and provide clear guidance to the requester
on likely diagnosis and supplementary investigations. Where uncertainty exists, this should be made
clear within the text of the report.

Reports should contain the following minimum items – demographics; relevant clinical information; body
of report that details procedures and materials, findings, patient limitations, clinical issues and
comparative data; and impression – conclusion or diagnosis that relates to the patient’s health problem
and clinical questions posed by requesting doctor (ACR 2002).

The current RANZCR Standard for reports is provided in the following Section 6.5.5 along with the
Standard relating to trainee radiologists and their supervision. It should be noted that the current
RANZCR report Standard is classified as an administrative standard, rather than a professional
standard.


6.5.5 Relevant Existing Standards

A number of existing RANZCR Standards are relevant to this component of the imaging service. These
Standards, have been included in this section for ease of referral.


Standard A.1.4.1 - Reports
All studies shall be interpreted and reported by a radiologist or a trainee in a RANZCR accredited training position.

All reports shall include:
            A title;
            The name and address of the practice, and location/site where the imaging procedure(s) was performed;
            Referrer’s name;
            Date of issue of report;


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6. Conclusions and Recommendations
            Unique identification of the patient i.e. Full name and date of birth or medical record number;
            Date of imaging procedure(s);
            Identification of the modality used;
            Imaging procedure(s) results and, where appropriate, the units of measurement;
            Opinions and interpretations where relevant;
            Name of reporting radiologist.

Note: Practice sites shall refer to the ACR Standard for Communication (Diagnostic Radiology) as a guideline for further
detail.

The radiologist or medical specialist who signs or co-signs a report created by a colleague shall satisfy him/herself that the
content of the report has been checked for grammatical errors only but not as to clinical content or accuracy. In addition,
practices shall apprise themselves of the relevant legislation in regard to electronic signatures.

The written and confirmed report shall be sent to the referrer or other health care provider providing clinical follow-up. The
patient may act as a courier for this purpose.



Standard P.1.4.1 - Supervision of Trainee Radiologists
A qualified radiologist must be available to provide on-site direct supervision of Trainee Radiologists at all times in hours, and
be available to provide advice and backup at all times out of hours.



Standard A.1.4.5 - Supervision of Trainee Radiologists
  The timeliness of reporting any radiological study varies with the nature and urgency of the clinical problem. The written
                           report shall be made available in a clinically appropriate, timely manner.


ACHS Clinical Indicator for the reporting of in-patient films (24) shall apply to n-patient examinations.
Regular QA reviews to be carried out at least once every three years shall be performed on the time between the
performance of the study and the issuing of the written report.


Note: Practice sites shall refer to the ACR Standard of Communication (Diagnostic Radiology) as a guideline for further
detail.



Standard A.1.4.6 - Urgent Reports
If there are urgent and significant unexpected findings, the radiologist shall use reasonable endeavours to communicate
directly with the referrer or an appropriate representative who will be providing clinical follow-up. A record of actual or
attempted direct communication shall be maintained.
Note: Practice sites shall refer to the ACR Standard for Communication (Diagnostic Radiology) as a guideline for further
detail.



6.5.6 Proposed Supervision Standard - Reports

All studies must be interpreted and reported by a qualified radiologist or a trainee radiologist under
specialist supervision. The radiologist should ensure that an appropriate protocol is in place to ensure
that the level of supervision of trainees is adequate. This protocol should include arrangements for


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6. Conclusions and Recommendations
conducting an appropriate number of validation checks of imaging reports prepared by trainee
radiologists, the extent of which, may vary depending on the trainee’s experience and expertise.


6.5.7 Other Proposed Standard - Requestor Communication

Radiologists provide a medical consultative service. Communication with requesting doctors should not
simply conclude with the issuing of the report. Radiologists should ensure that there are mechanisms in
place to enable the requester to discuss imaging findings with the radiologist in order to better
understand the implications and reliability of the findings or to provide further clinical information that
may affect interpretation. These mechanisms, should also allow radiologists to provide advice to their
general practitioner and specialist colleagues regarding imaging strategies, appropriate for particular
clinical problems.


6.6    Summary of Proposed Standards

This section provides a summary of the proposed Standards set out in this document.

These Standards are designed to promote safe and quality patient care and radiology practice. The
Standards recognise that professional supervision is only one aspect of ensuring an effectively
functioning imaging team and that a diagnostic imaging service includes multiple components, of which,
the examination is but one. They recognise that radiologists work in a range of environmental settings
and that there is no one best approach to supervision, suitable for all circumstances. The development
and adherence to a set of practice-based protocols is but one aspect of ensuring service quality and
should be seen as one part of an overall quality system encompassing all of the RANZCR Standards.

The Standards therefore, focus on ensuring that radiologists assess the risks associated with delivering
radiology services in their unique environment and that they provide clear guidance and direction for
other members of the imaging team, as to when they should seek radiologist input to the service. The
proposed Standards will require individual radiologists or radiology practices to undertake a systematic
analysis of the risks associated with each type of imaging service they undertake. A suggested
framework to assist in undertaking this risk profiling is attached at Appendix G. This framework requires
consideration of the risks, in terms of service quality and patient safety, associated with different types
of examinations, by body system and modality.


6.6.1 Proposed Supervision Standard - Review of Request and Patient Preparation

The radiologist should have appropriate input and supervision, such that they may be certain all of their
responsibilities in relation to the review of the service request and patient preparation, have been
adequately met. This may be ensured through at least one of the following:
1.    Personally conducting each of the components associated with this stage of the imaging service; or
2.    Direct (face to face) supervision of the other members of the imaging team, as this stage of the
      imaging service is undertaken; or
3.    Ensuring the implementation and adherence to appropriate written protocols, to be followed by
      members of the imaging team, under the radiologist’s direction.
      The protocols should outline the responsibilities of other members of the imaging team when
      undertaking components of this stage and the circumstances/situations under which, different


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6. Conclusions and Recommendations
     members of the team should seek further guidance and/or input from a radiologist. Additional
     radiologist input, for different circumstances/situations may involve the radiologist:
          − conducting aspects of this component themselves
          − providing verbal advice
          − providing a practical assistance/direction/demonstration
          − conducting a review of clinical information/diagnoses.
     Circumstances/situations which may be specified as triggers for seeking additional radiologist input
     may relate to:
          − the type/nature of the referral received - emergency, insufficient clinical information,
            conflicting indications
          − the type of examination requested - modality/body system or inappropriate or unwarranted
            examination requested based upon accepted diagnostic imaging algorithms
          − patient characteristics - age, condition, complicating factors.
     The protocols may also provide for different triggers for seeking radiologist input, depending on the
     specific imaging team member undertaking a particular component of this stage of the service,
     based upon the team member’s:
          − qualification
          − experience
          − specialisation.


6.6.2 Proposed Supervision Standard - Performance of Imaging Examination

The radiologist should have appropriate input and supervision, such that they may be certain all of their
responsibilities in relation to the examination stage, have been adequately met. This may be ensured
through at least one of the following:
1.   Personally conducting each of the components associated with this stage of the imaging service; or
2.   Direct (face to face) supervision of the other members of the imaging team, as this stage of the
     imaging service is undertaken; or
3.   Ensuring the implementation and adherence to appropriate written protocols, to be followed by
     members of the imaging team, under the radiologist’s direction.
     The protocols should outline the responsibilities of other members of the imaging team when
     undertaking components of this stage and the circumstances/situations under which, different types
     of team members should seek further guidance and/or input from a radiologist. The protocols
     should do this while ensuring service quality and patient safety and being cognisant of patient
     access issues, in areas with a limited radiologist workforce.

     The types of circumstances/situations which should be specified in the protocols as triggers for
     seeking additional radiologist input may relate to:
          − the type/nature of the examination being undertaken - modality/body system
          − difficulties obtaining an image of the type/quality required



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6. Conclusions and Recommendations
      − unusual or unexpected imaging results
      − examination findings requiring urgent reporting
      − receipt of additional critical verbal information provided by the patient and not included on
        the request/referral
      − concerns regarding the proper functioning of imaging equipment
      − patient characteristics - age, condition, complicating factors, medical history, clinical
        indications.

  The protocols should indicate for each circumstance/situation, the additional input a radiologist
  should be available to provide. The protocols should specify, for example, that for each specified
  circumstance/situation that a radiologist should be available to either:
      − immediately personally attend the patient
      − personally attend the patient within a specified set timeframe
      − provide immediate verbal advice
      − provide verbal advice within a specified set timeframe.

  The protocols may also provide for different triggers, depending on the imaging team member
  undertaking a particular component of this stage of the service, based upon the team member’s:
      − qualification
      − experience
      − specialisation.

  Other members of the imaging team should not proceed with an examination where it is known the
  radiologist would not be available to provide appropriate additional input, as detailed in the
  protocols. The protocols should also ensure that:
      − all regulatory requirements are met (MBS, State/Territory Radiation Protection legislation)
      − examinations which require the administration of contrast media are not undertaken unless
        a radiologist or other appropriately credentialed medical practitioner would be available to
        immediately personally attend the patient
      − examinations which require sedation of the patient are not undertaken unless a radiologist
        or other appropriately credentialed medical practitioner would be available to immediately
        personally attend the patient
      − examinations of critically ill patients should only be undertaken by, or under the direct (face
        to face) supervision of, a radiologist or other appropriately credentialed medical practitioner
      − patients are not required to wait for an excessive period during an examination for
        additional radiologist input to be sought
      − an excessive proportion of patients are not required to be called back and re-examined to
        obtain an image and report of appropriate quality.




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6.6.3 Proposed Supervision Standard - Reports

All studies must be interpreted and reported by a qualified radiologist or a trainee radiologist under
specialist supervision. The radiologist should ensure that an appropriate protocol is in place to ensure
that the level of supervision of trainees is adequate. This protocol should include arrangements for
conducting an appropriate number of validation checks of imaging reports prepared by trainee
radiologists, the extent of which, may vary depending on the trainee’s experience and expertise.


6.6.4 Other Proposed Standard - Requestor Communication

Radiologists provide a medical consultative service. Communication with requesting doctors should not
simply conclude with the issuing of the report. Radiologists should ensure that there are mechanisms in
place to enable the requester to discuss imaging findings with the radiologist in order to better
understand the implications and reliability of the findings or to provide further clinical information that
may affect interpretation. These mechanisms, should also allow radiologists to provide advice to their
general practitioner and specialist colleagues regarding imaging strategies, appropriate for particular
clinical problems.


6.7   Implementation Requirements and Linkages

6.7.1 Implementation Requirements

This section provides a brief summary of the requirements associated with the implementation of the
Standards regarding professional supervision. Some of these are requirements to be addressed by the
College, while others will need to be addressed by individual radiologists or radiology practices.


Implementation requirements for the RANZCR

Key requirements for the College, associated with the implementation of these Standards, are detailed
in this section, including requirements to:
         ensure the sector is aware of the proposed new Standards
         assist radiologists through the implementation process
         implement ongoing review and evaluation processes

Ensure the sector is aware of the proposed new Standards

A key requirement for the College is to ensure the diagnostic imaging sector is aware of the proposed
new Standards regarding professional supervision. This is not a requirement unique to this project
however, and will be relevant to a number of QUDI projects.

While radiologists should be the focus of the College’s information and communication efforts, it may
also be appropriate to inform other stakeholders of the new Standards. These stakeholders may
include:
         The Department of Health and Ageing
         Medicare Australia


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6. Conclusions and Recommendations
         related professional and industry organisations, such as:
            − The Australian Diagnostic Imaging Association
            − The Australian Sonograhers Association
            − Australian Society of Ultrasound in Medicine
            − The Australian Institute of Radiography
            − The Australian and New Zealand Society of Nuclear Medicine
         relevant consumer groups.

Information may be provided to radiologists and other stakeholders via a number of methods including:
          direct communication
          posting information on the RANZCR website
          including information in RANZCR newsletters and circulars
          making announcements at RANZCR conferences, workshops and meetings.

It may be more efficient and effective to implement all new Standards developed under the QUDI
Program at the one time, to ensure radiologists and stakeholders do not feel overwhelmed by the
amount of quality improvement information being received from the College. A singular announcement
of a new set of RANZCR Standards would likely be most effective in generating interest and therefore,
prompting radiologists to obtain and implement the new Standards.

All communications should include detail regarding how the new Standards may be obtained and should
include the name and contact details of the person within the College that may be contacted for further
information.


Assist radiologists through the implementation process

The implementation of new Standards regarding professional supervision will involve the development
of protocols for radiologist input by individual radiologists and radiology practices. Written practice
based protocols, regarding radiologist input may be a new concept for a large segment of the diagnostic
imaging sector and the College will, therefore, be required to support radiologists and radiology
practices through the implementation process.

College support may include facilitating information exchange between radiologists, to allow them to
share ideas and ultimately assist them in the development of their individual practice-based protocols.
Depending on demand from College members, and if feasible, it may also be beneficial for the College
to conduct a series of information sessions and workshops in relation to all of the new Standards,
developed under the QUDI Program.

In addition, the College may also be able to post good practice examples of protocols on the RANZCR
website to allow Radiologists to gain a clearer understanding of what might be included in their own
practice’s protocols.




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6. Conclusions and Recommendations
Implement ongoing review and evaluation processes

The College should ensure the new Standards are implemented in conjunction with processes to review
and evaluate their relevance, impact and outcomes, on an ongoing basis. It is therefore recommended
that prior to the implementation of these proposed Standards, and other Standards to be developed as
part of the QUDI Program, that the College develop and implement formal review and evaluation
processes. The College’s review and evaluation processes may include:
         establishing mechanisms for receiving ongoing feedback from radiologists and other
         stakeholders
         implementing formal, periodic feedback processes, including:
            − surveys of relevant stakeholders
            − forums to discuss impacts, outcomes and potential shortcomings

In addition, the College may consider commissioning a formal external review and evaluation of all new
Standards implemented as part of the QUDI Program after they have been in place for a period of time.

Findings and outcomes resulting from evaluation and review processes, should inform future
refinements and/or developments in relation to the Standards.


Implementation requirements for radiologists

Key requirements for radiologists are detailed in this section, including requirements to:
         conduct a risk assessment and develop practice-based protocols
         educate the imaging team, in relation to the protocols and ensure adherence


Conduct of risk assessment and develop practice-based protocols

The implementation of the new Standards regarding professional supervision will require that
radiologists undertake a risk assessment of their unique imaging environment and develop appropriate
practice-based operating protocols.

Many radiologists and radiology practices will have previously undertaken risk assessments and may
already have unwritten protocols in place, regarding the effective functioning of the imaging team. In
these circumstances, radiologists will need to develop written protocols in order to codify existing
unwritten practices and protocols.
For some radiologists and radiology practices, these Standards will require comprehensive review of the
functioning of the imaging team, involving a detailed risk analysis of the practice and its operation. The
key focus of the risk assessment should be to identify potential risks to patient care, safety and service
quality. Risk assessment should take into account key characteristics of the practice, and may
encompass, the:
         type of imaging examinations undertaken at the practice (modality and body system)
         number and nature of staff employed at the practice (qualifications, training, experience,
         specialisation)
         proportion of services undertaken using teleradiology


                                                    56              AUSTRALIAN HEALTHCARE ASSOCIATES
6. Conclusions and Recommendations
          practice patient mix (if there are any unique or particular characteristics).

Following the conduct of a comprehensive risk assessment, practice based protocols will need to be
developed. These protocols should ensure the delivery of quality services and mitigate risks where they
exist, through the facilitation of appropriate involvement of radiologists in the delivery of the diagnostic
imaging service. Protocols will need to provide direction to the members of the imaging team, regarding
radiologist input, to encompass a range of circumstances, as detailed in the Standards.

The Standards also require that radiologists consider how protocols impact on patients. Issues such as
patient waiting times and/or the need for patients to return to the practice for follow-up or second
examinations will need to be addressed. This applies particularly where practices service patients
which may be required to travel long distances to reach the practice. It may therefore, be appropriate
that protocols include measures to identify patients travelling long distances to reach the practice and to
implement practices that minimise the risk of these patients having to return to the practice for a second
examination.


Educate the imaging team in relation to the protocol and ensure adherence

Following the development of appropriate practice-based protocols, radiologists will be required to
educate the members of the imaging team based at their practice, in relation to the protocols. This will
include providing the protocols to team members and educating and explaining the implications of the
protocols for them and their work practices.

Subsequent to the protocols being implemented, it will also be the responsibility of the radiologist to
ensure all members of the imaging team conduct themselves in accordance with the protocols. This
may require radiologists to implement appropriate monitoring and reporting mechanisms in their
practice, associated with additional education, where adherence issues are identified.


6.7.2 Linkages

This QUDI project, regarding professional supervision and reporting (QS1), has linkages with a number
of other QUDI projects. Awareness of these linkages will assist in the overall understanding of how this
particular project fits within the broader QUDI context. The identification of the nature of these linkages
is also important in ensuring the results, findings and outputs of individual QUDI projects, feed into one
another.

The following table identifies other QUDI projects with linkages to this project and provides a brief
description of this link.

      QUDI Project                                                 Link
 CS3 - Develop              The findings of project CS3 may inform risk assessments undertaken by
 evidence based             radiologists and the development of appropriate practice-based protocols.
 diagnostic imaging and
 intervention guidelines    The professional supervision Standards contained within this document
 and alternative            suggest that protocols for radiologist input take into account patient
 management options         characteristics such as age, condition, complicating factors, medical history
 with particular            and clinical indications. An outcome of Project CS3 may include the
 reference to significant   identification of specific patient characteristics which give rise to greater


                                                      57              AUSTRALIAN HEALTHCARE ASSOCIATES
6. Conclusions and Recommendations
     QUDI Project                                              Link
patient characteristics   risks, which should therefore, be addressed in protocols developed in
                          response to these professional supervision Standards.
CS4 - Develop, pilot      As indicated in this report, one of the responsibilities of radiologists is to
and recommend             ensure patients are informed about the diagnostic imaging procedure for
consumer information      which they have been referred, to ensure the patient can provide informed
strategies to address     consent for the procedure.
consumer awareness
of diagnostic imaging
and promote informed      The outcomes of project CS4, have included the identification of strategies
choice, financial         which are effective in promoting awareness and informed choice for
consent and the           consumers. These strategies may be adopted by radiologists in exercising
consumer benefits of      their responsibility to obtain informed consent from patients. Radiologists will
accredited service        need to be aware however, that if radiologists delegate responsibility for this
provision                 aspect of the imaging service to other members of the imaging team, they
                          may need to include provisions in their practice-based protocols for seeking
                          radiologist input in certain circumstances. These circumstances may include
                          those for example, where:
                             a patient requires more clinical or technical information about the imaging
                             service and/or associated risks, which other members of the imaging
                             team are not able to provide
                             it is not clear whether informed consent has been obtained (due to
                             language or other issues)
QR3 - Develop best        The outcomes of project QR3 will potentially impact on the nature of the
practice standards        protocols developed, associated with reviewing patient referrals. Higher
and guidelines for        quality referrals, for example, will enable members of the imaging team, to
referral and clinical     identify at an early stage, patients/examinations which may require
notes for radiology       radiologist input.
QS3 - Establish roles     Project QS3 has a direct link with, and impact upon this project, particularly if
and standards for non-    project QS3 results in the roles of non-medical diagnostic imaging
medical diagnostic        professionals, such as radiographers and sonographers, being extended.
imagers and develop a
strategy to attract and
retain non-medical DI     Should the roles of these members of the imaging team be extended, it may
professionals through     be necessary to revise aspects of these Standards, to include the
tole extension            requirement for the development of protocols encompassing aspects of the
                          imaging service, which were not previously able to be delegated, to other
                          members of the imaging team.

QS7 - Establish           The Standards set out in this document, treat teleradiology as a normal
technical and practice    component of imaging practice, which is safe and effective, provided
standards for             appropriate protocols are in place for its use and provided appropriate
accreditation             equipment and technology are used.
requirements for
clinical teleradiology
                          Project QS7 is critically important in developing appropriate technical
                          Standards for teleradiology and in identifying the type of equipment and
                          technology appropriate for the delivery of these services, in the context of


                                                   58              AUSTRALIAN HEALTHCARE ASSOCIATES
6. Conclusions and Recommendations
    QUDI Project                                                Link
                          providing timely, safe, high quality services. The Standards set out in this
                          document assume that all teleradiology services are provided in accordance
                          with the minimum technical Standards to be developed as part of project
                          QS7.
QS8 - Develop             It may be appropriate, that protocols developed by radiologists, to meet the
credentialing             supervision Standards set out in this document, be reviewed in light of any
requirements and          changes to credentialing requirements resulting from project QS8.
applications consistent
with QUDI Program
objectives
ES4 - Evaluate the        This project represents one component of the QUDI Program and the
QUDI Program and          findings and outcomes of this project will therefore, need to be examined as
identify program          part of project ES4 as it evaluates the entire QUDI Program.
outcomes,
effectiveness and
impact



   The proposed professional supervision and reporting standards set out in this document,
 recognise that radiologists operate in a diverse range of unique imaging environments, each
    with their own risks, which should be appropriately managed. The proposed Standards
 therefore, take a flexible quality systems approach, rather than a rigid rules-based approach,
                     representing a significant shift in thinking on this topic.

 Recognising that the ultimate aim of these Standards should be to ensure radiologist input to
the imaging service at the appropriate/critical times, the Standards have a focus on developing
   an effectively functioning team. This focus manifests itself in the requirement to develop
    protocols to guide technologists as to when they should seek the input of a radiologist.




                                                  59             AUSTRALIAN HEALTHCARE ASSOCIATES
7. References
This chapter details the references utilised during the conduct of this project.


7.    REFERENCES
Articles

Adam E.J., Is direct radiologist supervision of abdominal computed tomography (CT) scans necessary?,
Clinical Radiology, Vol 60(7), 2005, pp 756–757.

Ashcroft R.E., Goddard P.R., Review Article: Ethical issues in teleradiology, The British Journal of
Radiology, Vol 73, 2000, pp 578-582

Baerlocher M.O., Asch M.R., The future interventional radiologist: clinician or hired gun?, Journal of
vascular and interventional radiology, Vol 15(12), Dec 2004, pp1, 385-1,390.

Burgul R., Gilbert F.J., Undrill P.E., Methods of measurement of image quality in teleultrasound, The
British Journal of Radiology, Vol 73, 2000, pp 1,306-1,312

Chow, K.W., Reflections of a septuagenarian - radiology: past, present and future, Annals of the
Academy of Medicine, Singapore, Vol 33(5), Sep 2004, pp 671-675.

Ditchfield M.R., Fink A.M., Role of supervision in a radiology practice, Australasia Radiology, Vol 47,
2003, pp 1-7

Dixon G.D., Current status and issues of concern in diagnostic radiology, Missouri medicine, Vol 102(2),
Mar-Apr 2005, pp 110-115.

Dunnick N.R., Applegate K.E., Arenson R.L., The Inappropriate Use of Imaging Studies: A Report of the
2004 Intersociety Conference, American College of Radiology, Vol 2(5) May 2005, pp 401-406

Farrow B.R.H., Diagnostic accuracy in the new millennium, Australian Veterinary Journal, Vol 83(1-2),
Jan-Feb 2005, pp 30-31.

Goh V., Halligan S., Anderson J.M., Hugill J., Leonard A., Is direct radiologist supervision of abdominal
computed tomography (CT) scans necessary?, Clinical Radiology, Vol 60, 2005, pp 758–761

Goyan M., Debatin J.F., The future of hospital - based radiological imaging, World hospitals and health
services: the official journal of the International Hospital Federation, Vol 40(2), 2004, pp 27-31, 42.

Grosvenor L.J., Verma R., O'Brien R., Entwisle J.J., Finlay D., Does reporting of plain chest radiographs
affect the immediate management of patients admitted to a medical assessment unit?, Clinical
Radiology, Vol 58(9), 2003, pp 719–722

Hailey D., Ohinmaa A., Roine R., Study quality and evidence of benefit in recent assessments of
telemedicine, Journal of Telemedicine and Telecare; Vol 10(6), 2004, pp 318-324.

Hailey D., Roine R., Ohinmaa A., Systematic review of evidence for the benefits of telemedicine, Journal
of Telemedicine and Telecare, Vol 8 (Suppl. 1): S1, 2002, pp 1–7.




                                                    60              AUSTRALIAN HEALTHCARE ASSOCIATES
7. References
Hobbs W.C., Taking digital imaging to the next level: challenges and opportunities, Radiology
management, Vol 26(2), Mar-Apr 2004, pp 16-20.

Kouri B.E., Parsons R.G., Alpert H.R., Physician Self-Referral for Diagnostic Imaging: Review of the
Empiric Literature, American Journal of Roentgenology, Vol 179, Oct 2002, pp 843-850

Mildenberger P, Eichelberg M., Martin E., Introduction to the DICOM standard, European radiology, Vol
12, 2002, pp 920-927.

Mozumdar B.C., Jones G., Medico-legal issues in radiological consultation, Radiology management, Vol
25(5), Sep-Oct 2003, pp 40-43.

Reiner B.J., Siegel E.L., Siddiqui K., Evolution of the digital revolution: a radiologist perspective, Journal
of digital imaging: the official journal of the Society for Computer Applications in Radiology, Vol 16(4),
Dec 2003, pp 324-330.

Roine R., Ohinmaa A., Hailey D., Assessing telemedicine: a systematic review of the literature,
Canadian Medical Association or its licensors, Vol 165(6), 18 Sep 2001, pp 765-771.

Siegle R.L., Nelson L., Changing roles: The radiologist in management, Academic radiology, Vol 6(5),
May 1999, pp 307-313.

Struber J., Tichon J., Minimum technical requirements and evaluating effectiveness of teleradiology,
Technology and Health Care, Vol 11(6), 2003, pp 391–398.

Williamson E.E., Williamson B. Jr, Radiologist-Patient Interactions: Implications for Picture Archiving
and Communications Systems and Teleradiology, Journal of digital imaging: the official journal of the
Society for Computer Applications in Radiology, Vol 12(2 Suppl 1), May 1999, pp 137-138.

White P., Legal issues in teleradiology—distant thoughts!, The British Journal of Radiology, Vol 75,
2002, pp 201–206.


Internet Articles

Cannavo M.J., Cost-justifying the purchase of a teleradiology system, Jan 1999
http://www.auntminnie.com/index.asp?Sec=ref&sub=wht&pag=dis&ItemId=608

Murray, C., Medicare's Radiology Supervision Rules, Sep 2001
http://www.imagingeconomics.com/library/200109-13.asp

Page D., Teleradiologists must tread carefully in legal mine field, GE Healthcare & EMC, Jun 2005
http://www.diagnosticimaging.com/scar2005/news/?id=164300349

Page D., Legislation tackles offshore teleradiology, May 2005
http://www.diagnosticimaging.com/pacsweb/printer_friendly/?articleID=163105354

Ridley E.L., ACR international teleradiology task force releases white paper, Feb 2005
http://www.auntminnie.com/index.asp?Sec=sup&Sub=pac&Pag=dis&ItemId=65397

Ruth Pollard Health Reporter, Turf war as nurses eye bigger role, May 2005

                                                      61              AUSTRALIAN HEALTHCARE ASSOCIATES
7. References
http://www.smh.com.au/text/articles/2005/05/08/1115491047100.html?oneclick=true

Thompson T.L., Radiologists (mostly) cheer as insurers set imaging rules, Nov 2004
http://www.auntminnie.com/index.asp?Sec=sup&Sub=imc&Pag=dis&ItemId=63469

Williams C.D., Radiologist Assistants Prepare to Enter the Workforce, May 2005
http://www.rsna.org/publications/rsnanews/may05/ra0505.html


Documents – USA

ACR Practice Guideline For Communication: Diagnostic Radiology, American College of Radiology, Jan
2002

ACR Practice Guideline For General Radiography, American College of Radiology, Jan 2003

ACR Practice Guideline For Performing And Interpreting Magnetic Resonance Imaging (MRI), American
College of Radiology, Jan 2003

ACR Practice Guideline For Performing And Interpreting Diagnostic Computed Tomography (CT),
American College of Radiology, Jan 2003

ACR Practice Guidelines And Technical Standards, American College of Radiology

ACR Practice Guideline For Radiologist Coverage Of Imaging Performed In Hospital Emergency
Departments, American College of Radiology, Jan 2003

ACR Practice Guideline For The Use of Intravascular Contrast Media, American College of Radiology,
Jan 2002

ACR response to 2001 CMS US Medicare Supervision rules, ACR 2001 Bulletin
http://www.acr.org

Breast Ultrasound Accreditation Program Requirements, American College of Radiology, Apr 2005

CT Accreditation Program Requirements, American College of Radiology, Oct 2004

Medicare’s Physician Supervision Requirements, American Society for Therapeutic Radiology and
Oncology, Jul 2004

MRI Accreditation Program Requirements, American College of Radiology, Apr 2005

Nuclear Medicine/PET Accreditation Program Requirements, American College of Radiology, Dec 2004

Quality Imaging - MEDIC, the Medical Excellence in Diagnostic Imaging Campaign
http://www.qualityimaging.org


Documents – Canada




                                                 62             AUSTRALIAN HEALTHCARE ASSOCIATES
7. References
CanMEDs Role Definitions for Diagnostic Radiologists, Jul 2005

Independent Diagnostic Testing Facility (IDTF), HGS Administrators, Nov 2003

Manitoba Physician's Manual, The Minister of Health, Canada, Apr 2005
http://www.gov.mb.ca/health/index.html

Pascale Lehoux, University of Montreal, Discussion paper No. 37: Could New Regulatory Mechanisms
Be Designed after a Critical Assessment of the Value of Health Innovations?, Commission on the Future
of Health Care in Canada, Nov 2002

Saskatchewan Health Payment Schedule for Insured Services Provided by a Physician, Saskatchewan
Health, Canada, Apr 2005

Schedule of Benefits for Physician Services under the Health Insurance Act – amended Sep 2003,
Ministry for Long-Term Care, Government of Ontario Canada


Documents – Australia and New Zealand

A National Standard for credentialling and defining the scope of clinical practice of medical practitioners,
for use in public and private hospitals, Australian Council for Safety and Quality in Health Care, Jul 2004

Accreditation Standards for diagnostic and Interventional Radiology Ver 6.2, The Royal Australian and
New Zealand of Radiologists - The Accreditation Guidelines and Quality Committee, Feb 2004

Clinical Teleradiology Background Paper Draft 1.0, The Royal Australian and New Zealand College of
Radiologists

Clinical Teleradiology Background Paper Draft 2.0, The Royal Australian and New Zealand College of
Radiologists

Guidelines for professional conduct for Radiographers, Radiation Therapists and Sonographers,
Australian Institute of Radiography, Apr 2003

Guidelines on Mammographic Screening for Cancer for Women with Prostheses, Royal Australian and
New Zealand College of Radiologists, Aug 2001

Health Insurance Act 1973 (volume 1), Commonwealth Government

Health Insurance Amendment (Diagnostic Imaging, Radiation Oncology and Other Measures) Bill 2002,
Commonwealth Government

Intravenous Contrast Media Guidelines, The Royal Australian and New Zealand College of Radiologists,
Aug 2001

Jones N., Radiologist Workloads, RANZCR Workforce Advisory Board, Apr 2003

Medicine Carriers Manual, Department of Health & Human Services (DHHS) Centers for Medicare &
Medicaid Services, Sep 2001


                                                     63              AUSTRALIAN HEALTHCARE ASSOCIATES
7. References
Medicare Benefits Schedule: Diagnostic Imaging Services – Category 5, HIC

National Accreditation Standards, National Quality Management Committee of BreastScreen Australia,
Jul 2002

Policy on Breast Cancer Screening, Royal Australian and New Zealand College of Radiologists, Nov
2002

Policy on the use of thermography to detect breast cancer, Royal Australian and New Zealand College
of Radiologists, Aug 2001

Report on the Curriculum Development Project for the Diagnostic Radiology Education Board of the
Royal Australian and New Zealand College of Radiologists, Diagnostic Radiology Education Board, Jul
2005

Results of 2004 Royal Australian and New Zealand College of Radiologists Workforce Surveys – 2004
Diagnostic Radiologists and Radiology Trainee Report, Australia, presented to RANZCR Council
Meeting: 11 Feb 2005

Review of Victorian radiation safety legislation Discussion Paper, Department of Human Services, State
Government of Victoria, Dec 2003

Standards for Accreditation of Nuclear Medicine Practices, Australian and New Zealand Association of
Physicians in Nuclear Medicine Inc, Nov 2000

Statement on Mammographic Changes Following Surgical Intervention in the Breast, Royal Australian
and New Zealand College of Radiologists, Feb 2004


Documents – UK

Good Medical Practice, General Medical Council, May 2001

Quality Assurance Guidelines for Breast Cancer Screening Radiology, NHSBSP Publication No 59, Jan
2005


Documents – Other

Guidelines On Teleradiology In Malaysia, Radiology Malaysia

Telehealth - delivering health care from a distance, International Organization for Standardization, Oct
2004




                                                    64              AUSTRALIAN HEALTHCARE ASSOCIATES
   Appendix A – Stakeholder Consultation
   This Appendix provides a summary of the consultations undertaken as part of this project.


   A STAKEHOLDER CONSULTATION
   In total, consultations were conducted with 44 individuals and submissions were received from 3
   organisations, as detailed in the following tables.

   Table 7-1: Individuals Consulted
Name                     Organisation
Ms Jane Grimm            Royal Australian and New Zealand College of Radiologists (RANZCR)
Ms Sandra Keogh          Royal Australian and New Zealand College of Radiologists (RANZCR)
Dr Matthew Andrews       Project Technical Reference Group (TRG)
Dr Michael Carr          Project Technical Reference Group (TRG)
Dr Winston Chong         Project Technical Reference Group (TRG)
Dr Nick Ferris           Project Technical Reference Group (TRG)
Dr Stacy Goergen         Project Technical Reference Group (TRG)
Dr Laurence Lau          Project Technical Reference Group (TRG)
Dr Gary O’Rourke         Project Technical Reference Group (TRG)
Dr Nick Stephenson       Project Technical Reference Group (TRG)
Dr Mark Tie              Project Technical Reference Group (TRG)
Dr Allan Wycherley       Project Technical Reference Group (TRG)
Dr Liz Wylie             Project Technical Reference Group (TRG)
Dr Neil Jones            RANZCR Fellow – Chair, Workforce Advisory Board


Dr George Koperski       ACT Health - Radiation Safety Section
Dr Fraser Brown          Australian and New Zealand Society of Nuclear Medicine (ANZSNM)
Mr Matthew Swain         Australian Diagnostic Imaging Association (ADIA)
Mr Emile Badawy          Australian Institute of Radiography (AIR)
Mr Geoffrey Dick         Australian Institute of Radiography (AIR)
Ms Marcia Fleet          Australian Institute of Radiography (AIR)
Mr Alan Melbourne        Australian Radiation Protection and Nuclear Safety Agency (ARPANSA)
Dr Matthew Andrews       Australian Society for Ultrasound in Medicine (ASUM)
Dr David Davies-Payne    Australian Society for Ultrasound in Medicine (ASUM)
Dr Glenn McNally         Australian Society for Ultrasound in Medicine (ASUM)
Ms Robyn Tantau          Australian Sonographers Association (ASA)
Ms Elaine Trevaskis      Australian Sonographers Association (ASA)
Mr Andrew Wilmot         Australian Sonographers Association (ASA)




                                                        65             AUSTRALIAN HEALTHCARE ASSOCIATES
   Appendix A – Stakeholder Consultation
Mr Michael Irvine         Department of Health - Environmental Health Directorate (Western Australia)
Dr David Barton           Department of Health and Ageing (DoHA)
Mr Dale Brooker           Department of Health and Ageing (DoHA)
Ms Margaret Curran        Department of Health and Ageing (DoHA)
Mr Chris Sheedy           Department of Health and Ageing (DoHA)
Mr Russell Robinson       Department of Health and Community Services - Radiation Protection (Northern Territory)
Ms Joy Batchelor          Department of Health and Human Services - Radiation Advisory Council (Tasmania)
Dr Gabby Bright           Department of Human Services - Radiation Advisory Council (Victoria)
Mr Edmund Arozoo          Environmental Protection Authority (South Australia)
Dr Peter Charlton         Health Insurance Commission (HIC)
Ms Elizabeth Low          Health Insurance Commission (HIC)
Dr Paul Davis             Industry Advisor - I-Med / MIA
Dr John Stubbe            Industry Advisor - I-Med / MIA
Mr Barry Field            New South Wales Environment Protection Agency (EPA)
Dr Gary Cohen             Practicing Radiologist
Ms Kim Osborne            Queensland Health - Radiation Health
Dr Robert Gibson          Royal Melbourne Hospital




   Table 7-2: Written Submissions Received
Organisation                                                                               Date
Australian College of Rural and Remote Medicine (ACRRM)                                    August 2005
Breast Cancer Network of Australia (BCNA)                                                  August 2005
The Royal Australasian College of Physicians (RACP)                                        August 2005




                                                           66            AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix B – Professional Supervision Requirements in
             the MBS
This Appendix describes the professional supervision requirements that apply for particular
imaging modalities and examinations listed in Diagnostic Imaging Services Table (DIST) of the
Medicare Benefits Schedule (MBS). A description of each modality is also provided.


B PROFESSIONAL SUPERVISION REQUIREMENTS FOR MEDICARE BENEFITS
  ARRANGEMENTS – DIAGNOSTIC IMAGING SERVICES

1. Ultrasound

Ultrasound imaging (also known as ultrasound scanning or sonography) is a method of obtaining
images from inside the human body through the use of high frequency sound waves. The sound waves’
echoes are recorded and displayed in real time, visual image (RSNA 2005). No ionising radiation is
involved in ultrasound imaging.

Ultrasound services funded under the Medicare benefits arrangements cover general, cardiac, vascular,
urological, obstetric and gynaecological, and musculoskeletal.

Generally, ultrasound services must be performed under the professional supervision of a:

 specialist or consultant physician in the practice of his or her speciality who is available to monitor
 and influence the conduct and diagnostic quality of the examination and, if necessary to personally
 attend on the patient.
Source: MBS DIST DIK.1

Ultrasound services provided in emergencies and in remote locations are exempted from this
professional supervision requirement.

Different professional supervision requirements apply to musculoskeletal ultrasound services (items
55800 to 55854). They are known as personal attendance requirements. Services must be provided
by a specialist or consultant physician in the practice of their own speciality with Medicare benefits only
payable where:

 The medical practitioner responsible for the conduct and report of the examination personally
 attends during the performance of the scan and personally examines the patient.
Source: MBS DIST DIK.9.1.

Services performed because of medical necessity in a remote location are exempted from the personal
attendance requirement.

The Medicare benefits arrangements also set qualification requirements for sonograhers performing
ultrasound examinations on behalf of a medical practitioner. Under these accreditation requirements,
sonograhers must be suitably qualified and involved in a relevant and appropriate Continuing
Professional Development program and be enrolled on the Register of Accredited Sonographers
administered by the HIC (MBS DIST DIK.2). In addition, the sonographer’s name must be recorded in
the report of the service; however, it is not required to be included on the copy of the report given to the
patient (MBS DIST DIK.2).



                                                     67              AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix B – Professional Supervision Requirements in
             the MBS
2. Computed Tomography Services

Computed tomography (CT) is a diagnostic technique that involves imaging anatomical information from
a cross-sectional plane of the body with each image generated by a computer synthesis of x-ray
transmission data obtained in many different directions in a given plane (RSNA 2005). CT scans reveal
both bone and soft tissues including organs, muscles and tumours. In some CT examinations, contrast
medium is injected into the patient to provide visual contrast in pictures of different tissues or organs.

Under the Medicare benefits arrangements, CT services must be performed:

 under the professional supervision of a specialist in the specialty of diagnostic radiology who is
 available:
 (i)    to monitor and influence the conduct and diagnostic quality of the examination; and
 (ii)    if necessary to personally attend on the patient.
Source: MBS DIST DIL.2

CT services provided in emergencies or of medical necessity in a remote area location are exempted
from this professional supervision requirement.

3. Diagnostic Mammography Services

Medicare benefits are available for diagnostic mammography, a radiographic examination that uses low
dose X-ray with high contrast, high resolution film to create detailed images of the breasts. Diagnostic
mammography is used to provide additional information about patients who have signs and/or
symptoms of breast disease. Mammography screening services are funded jointly by the
Commonwealth, State and Territory governments through for the national breast cancer screening
program, BreastScreen Australia.

Professional supervision requirements for diagnostic mammography services (items 59300 to 59318)
are the same as those for CT services. Diagnostic mammography services must be performed under
the professional supervision of a:

 specialist in the specialty of diagnostic radiology who is available to monitor and influence the conduct
 and diagnostic quality of the examination and, if necessary, to personally attend on the patient.
Source: MBS DIST DM.6.2

Diagnostic mammography services provided in emergencies or because of medical necessity in a
remote location are exempted from this professional supervision requirement.

4. Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses a large magnet, radio waves and computer to scan inside a
patient’s body and produce detailed images of tissues and organs. MRI scans are used to diagnose
and evaluate conditions. As with ultrasound, MRI does not use ionising radiation.




                                                    68              AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix B – Professional Supervision Requirements in
             the MBS
Under the Medicare benefits arrangements, MRI services must be performed under the professional
supervision of an eligible provider at an eligible location where:


       Eligible provider                Is a specialist in diagnostic radiology who satisfies HIC
                                        that:
                                        (a) he or she is a participant of the RANZCR’s Quality and
                                            Accreditation Program; and
                                        (b) the equipment he or she proposes to use for providing
                                            the services meets eligible equipment requirements.
       Professional                     The eligible provider is available to monitor and
       supervision
                                         influence the conduct and diagnostic quality of the
                                        examination including, if necessary, by personal
                                        attendance on the patient.
      Source: MBS, DIST DIO.5 & DIO.6

MRI services provided in emergencies or by medical necessity in a remote area are exempted from this
professional supervision requirement.


5. Nuclear Medicine Services

Nuclear medicine is a medical speciality where organ function and structure are examined by
administering small amounts of radioactive contrast materials to the patient and taking scans with a
gamma camera or other device for the purpose of diagnosing or treating disease.

Medicare benefits for nuclear medicine services are limited to services provided by specialists and
consultant physicians credentialled in nuclear medicine. Credentialling is by the Joint Nuclear Medicine
Credentialling and Accreditation Committee of the Royal Australian College of Physicians (RACP) and
the RANZCR.

The nuclear medicine service may be performed by a credentialled nuclear medicine specialist or on
their behalf. The nuclear medicine specialist is responsible for all components of the service. They
must perform personally certain components – namely, a preliminary examination of the patient and the
estimation of the dosage, and compiling the final report of the service. They are required to personally
supervise all other components; however, they do have to physically attend during the entirety of each
component.

These requirements are defined as personal supervision (MBS 2004, ANZAPNM 2000). They are set
out in the Standards of Accreditation of Nuclear Medicine Practices (ANZAPNM 2000). They were
developed to reflect the nature of nuclear medicine services with procedures vary in length and
complexity and to ensure quality practice.




                                                       69              AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix C – Intravenous Contrast Media Guidelines
This Appendix provides guidelines for use of Intravenous Contrast Media, as set out by
RANZCR. Of particular interest is Section 5, which outlines which staff are authorised to
administrator intravenous injection of contrast media.


C INTRAVENOUS CONTRAST MEDIA GUIDELINES
1. When used for intravenous and other forms of parenteral injection, contrast media infrequently cause
   adverse drug reactions and very rarely cause patient death.

2. In determining the need for contrast media in the circumstances of the examination, specific risk
   factors can be identified, including:
      a. previous reactions to contrast media;
      b. asthma;
      c. significant allergic disease;
      c. cardiac disease;
      d. renal insufficiency particularly associated with insulin dependent diabetes;
      f. sickle cell disease, polycythemia and myeloma;
      g. phaeochromocytoma

  The practice must have a clear protocol for each of these conditions.

3. Severe hypotension, bronchospasm, cardiac arrhythmia, even anaphylaxis may occur. Staff should
   be trained and equipped to recognise and deal with all these problems which may require different
   forms of therapy.

4. Before injecting contrast material, the person performing the injection must check the name of the
   agent, its concentration and its expiry date. Additional measures to ensure injection of the correct
   material must be in place. These may include checking of the same details by another person or the
   implementation of systematic measures to prevent inappropriate injections.

5. A practice or department may decide whether appropriately trained radiographers, nurses and/or non-
   radiologist doctors may administer intravenous injection of contrast media, taking full consideration of
   relevant state and territory legislation and any implications for medical malpractice, medical
   negligence or professional indemnity insurance cover.

  Radiographers, nurses and/or non-radiologist doctors must not be compelled to perform this
  procedure.

  Any liability for an adverse event arising from an intravenous injection of contrast media lies with the
  radiologist as the employer and/or as the supervising specialist.

  Documented procedures for the administration of contrast media by radiographers, nurses and/or
  non-radiologist doctors must be included in the practice procedures manual and must include the
  following minimum requirements:




                                                    70              AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix C – Intravenous Contrast Media Guidelines
  Radiographers and Nurses
      radiographers and nurses must be trained in venipuncture and resuscitation and receive
      certification of their competence from the practice;
      protocols must be confirmed by the radiologist prior to each injection;
      the practice should limit the number of unsuccessful venipuncture attempts allowed per
      examination;
      the practice must identify those patients who are not suitable for injection by radiographers and
      nurses, eg children, patients with a history of difficult injections or contrast reactions;
      the supervising radiologist must remain immediately available for 20 minutes following injection in
      case of any subsequent reactions.

  Non-radiologist Doctors
      protocols must be confirmed by the radiologist prior to each injection;
      non-radiologist doctors injecting patients must remain immediately available for 20 minutes
      following injection in case of any subsequent reactions.

Adopted by RANZCR Council: August 2001




                                                   71              AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix D – Organisations Consulted
This Appendix provides a list of organisations consulted during the course of this phase of the
project.


D ORGANISATIONS CONSULTED


        Organisation                                                        Abbr.
        ACT Health - Radiation Safety                                       -
        American College of Radiology                                       ACR
        American Institute of Ultrasound in Medicine                        AIUM
        Association of University Radiologists                              AUR
        Australian and New Zealand Society of Nuclear Medicine              ANZSNM
        Australian College of Rural and Remote Medicine                     ACRRM
        Australian Diagnostic Imaging Association                           ADIA
        Australian Institute of Radiography                                 AIR
        Australian Radiation Protection and Nuclear Safety Agency           ARPANSA
        Australian society for ultrasound in Medicine                       ASUM
        Australian Sonographers Association                                 ASA
        Breast Cancer Network of Australia                                  BCNS
        British Institute of Radiology                                      BIR
        British Medical Ultrasound Society                                  BMUS
        Canadian Association of Radiologists                                CAR
        Department of Health - Environmental Health Directorate (Western
                                                                            DoH
        Australia)
        Department of Health and Ageing                                     DoHA
        Department of Health and Community Services - Radiation
                                                                            DHCS
        Protection (Northern Territory)
        Department of Health and Human Services - Radiation Advisory
                                                                            DHHS
        Council (Tasmania)
        Department of Human Services (Radiation Advisory Council
                                                                            DHS
        (Victoria)
        Environmental Protection Authority (South Australia)                EPA
        European Association of Radiology                                   EAR
        European Congress of Radiology                                      ECR
        European Society for Neuroradiology                                 ESN
        European Society of Gastrointestinal and Abdominal Radiology        ESGAR



                                                  72             AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix D – Organisations Consulted
    Organisation                                                      Abbr.
    European Society of Nuclear Medicine                              ESNM
    European Society for Therapeutic Radiology and Oncology           ESTRO
    Health Insurance Commission                                       HIC
    Hong Kong College of Radiologists                                 HKCR
    International Cancer Imaging Society                              ICIS
    International Congress of Radiology and the ISR                   ICR
    International Organization for Medical Physics                    IOMP
    International Society of Radiology                                ISR
    International Radiology Quality Network                           IRQN
    Japan Radiologist Society                                         JRS
    Joint Commission on Accreditation of Healthcare Organisations     JCAHO
    National Health Service                                           NHS
    National Institute of Clinical Excellence                         NICE
    New South Wales Environment Protection Agency                     EPA
    Queensland Health -Radiation Health                               QH
    Radiological Society of North America                             RSNA
    Royal Australasian College of Physicians                          RACP
    Royal Australian and New Zealand College of Radiologists          RANZCR
    Royal College of Radiologists                                     RCR
    Scottish Radiological Society                                     SRS
    US Food and Drug Administration                                   FDA




                                                73         AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix E – USA Professional Supervision
This Appendix provides a summary the professional supervision in United States of America.


E UNITED STATES OF AMERICA PROFESSIONAL SUPERVISION
American College of Radiology Practice

The American College of Radiology (ACR) is the principal organisation of radiologists, radiation
oncologists and clinical medical physicists in the United States. The ACR develops practice guidelines
and technical standards for radiologic practice. Practice guidelines and technical standards represent
policy statements by the College. They are developed through a consensus and review process. They
recognise that safe and effective use of diagnostic and therapeutic radiology requires specific training,
skills and techniques. They aim to assist practitioners in delivering effective and safe medical care.

Types of Guidelines and Standards
ACR policy statements fall into three types:
      Practice guidelines – for a specific modality, examination or procedure;
      Technical standards - e.g. equipment, teleradiology;
      Accreditation standards – that draw together aspects of practice guidelines and technical
       standards.

Accreditation Programs
The ACR develops and administers accreditation programs that assess the quality of imaging facilities.
The programs aim to set quality standards for practices and help them continuously improve upon
quality of care they give to patients.

The Mammography Accreditation program was introduced in 1987 on a voluntary participation basis and
in 1992 the federal government mandated that all mammography facilities be accredited. The ACR has
developed other, modality-specific accreditation program including:
      Radiation oncology (1987);
      Ultrasound (1992);
      Stereotactic breast biopsy (1996);
      MRI (1996);
      Breast ultrasound (1998);
      Nuclear medicine (1999); and
      CT (2002).

ACR accreditation programs evaluate the qualifications of personnel, equipment performance,
effectiveness of quality control measures, and quality of clinical images. These are considered the
primary factors that affect the quality of clinical images and ultimately the quality of patient care.

Professional Supervision and Reporting – What Guidelines and Standards Say
Key features of ACR practice guidelines that relate to professional supervision and reporting of
radiologists are summarised below. Guidelines vary in format and content. Generally, they cover




                                                    74              AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix E – USA Professional Supervision
qualifications and responsibilities of personnel; examination considerations, equipment; quality control
and improvements; documentation and reporting.

General Radiography
Team                            Physician, medical physicist and radiologic technologist
Physician – qualifications      Radiographs must be obtained under the supervision of, and interpreted by, a
and responsibilities            licensed physician who meets specified criteria for:
                                          Certification and training qualifications
                                          Maintenance of competence
                                          Continuing medical education (CME).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME) and should include CME in diagnostic radiography as
                                is appropriate to his/her practice.
Medical physicist -             Certification and continuing education in appropriate sub-fields in medical
qualifications and              physics (e.g. therapeutic radiological physics, diagnostic radiological physics,
responsibilities                medical nuclear physics and radiological physics).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME).
Radiologic Technologist -       Certification by the American Registry of Radiologic Technologists (ARRT) or an
qualifications and              unrestricted state license.
responsibilities
Reporting                       Reporting should be in accordance with ACR Practice guideline for
                                Communication: Diagnostic Radiology.
Source: ACR Practice Guideline for General Radiology. Effective January 2003.



Diagnostic Computed Tomography
The Team                        Physician, medical physicist and radiologic technologist
Physician – qualifications      All examinations should be performed under the supervision of and interpreted
                                by a licensed physician who meets specified criteria for:
                                          Certification and training qualifications
                                          Maintenance of competence
                                          Continuing medical education (CME).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME) and should include CME in CT as is appropriate to
                                his/her practice.
Physician - responsibilities    Physician shall have the responsibility for:
                                          Reviewing all indications for the examination
                                          Specifying the use, dosage and rate of administration of contrast
                                          agents
                                          Specifying the imaging technique including appropriate windowing and
                                          levelling
                                          Interpreting images
                                          Generating written reports
                                          Maintaining the quality of both the images and interpretations.
Medical physicist –             Certification and continuing education in appropriate sub-fields in medical



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Appendix E – USA Professional Supervision
qualifications and              physics (i.e. radiological physics and diagnostic radiological physics).
responsibilities
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME).
Radiologic technologist -       Certification by the American Registry of Radiologic Technologists (ARRT) or an
qualifications                  unrestricted state license with documented training and experience in CT.
Radiologic technologist -       Radiologic technologist responsible for:
responsibilities
                                          patient comfort
                                          preparing and positioning the patient during examination
                                          obtaining CT data in a manner prescribed by supervising physician
                                          performing regular quality control testing of CT system under
                                          supervision of medical physicist.
Use of Contrast Media           By certified and/or licensed radiologic technologists and radiologic nurses, under
                                the direction of a radiologist or his/her physician designee who is personally and
                                immediately available, if the practice is in compliance with institutional and state
                                regulations. See ACR Practice Guideline for Use of Intravascular Contrast
                                Media.
Reporting                       Not covered specifically in guideline. See ACR Practice Guideline for
                                Communication: Diagnostic Radiology.
Source: ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT). Effective January
2003.

Diagnostic Ultrasound
General                         Diagnostic ultrasound examinations should be supervised and interpreted by
                                trained and qualified physicians.
                                Studies should be performed by qualified and knowledgeable physicians and/or
                                sonographers using appropriate equipment and techniques.
The Team                        Physician and diagnostic medical sonographer.
Physician – qualifications      Physicians who perform and/or interpret diagnostic ultrasound should be
and responsibilities            licensed and meet specified criteria for:
                                          Certification and training qualifications
                                          Maintenance of competence
                                          Continuing medical education (CME).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME) and should include CME in ultrasonography as is
                                appropriate to his/her practice.
Diagnostic medical              When a sonographer performs an examination, they should be qualified by
sonographer                     appropriate training to do so. This qualification can be demonstrated by a
                                nationally recognised certifying body.
Reporting                       Not covered specifically in guideline. See ACR Practice Guideline for
                                Communication: Diagnostic Radiology.
Source: ACR Practice Guideline for Performing and Interpreting Diagnostic Ultrasound Examinations. Effective January
2001.

Magnetic Resonance Imaging (MRI)
The Team                        Physician, medical physicist/MR scientist and technologist
Physician - qualifications      Physician should be licensed and meet specified criteria for:
                                          Certification and training qualifications



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Appendix E – USA Professional Supervision
                                          Maintenance of competence
                                          Continuing medical education (CME).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME) and should include CME in MRI as is appropriate to
                                his/her practice.
Physician - responsibilities    Physician has responsibility for all aspects of the study including, but not limited
                                to:
                                     reviewing all indications for the examination
                                     specifying pulse of sequences to be performed
                                     specifying the use and dosage of contrast agents
                                     interpreting images
                                     generating written reports
                                     assuring the quality of both the images and interpretation
Medical physicist/MR            Certification and continuing education in appropriate sub-fields in medical
scientist – qualifications      physics (i.e. radiological physics and diagnostic radiological physics).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME).
Medical physicist/MR            Medical physicist/MR scientist to carry out acceptance testing and monitoring of
scientist –responsibilities     MRI equipment
Technologist - qualifications   Certification as an MRI technologist and licensed in the jurisdiction where he/she
                                practises, if state licensure exists. To assure competence, all technologists
                                must be evaluated by the supervising physician.
Technologist –                  Technologist to participate in:
responsibilities
                                          assuring patient comfort and safety
                                          preparing and positioning the patient for MRI examination
                                          obtaining MRI data in a manner suitable for interpretation by physician
                                          performing daily quality control testing of MRI system.
Administration of contrast      In accordance with institutional policy and state and federal law by a physician, a
and sedation                    nurse or technologist with training in cardiopulmonary resuscitation. See ACR
                                Practice Guideline for Use of Intravascular Contrast Media and ACR Practice
                                guideline for Adult Sedation/Analgesia. An appropriately equipped emergency
                                cart must be immediately available to treat serious adverse reactions.
Reporting                       Not covered specifically in guideline. See ACR Practice guideline for
                                Communication: Diagnostic Radiology.
Source: ACR Practice Guideline for Performing and Interpreting Magnetic Resonance Imaging. Effective January 2003.

Screening Mammography
General                         All mammography must be performed in concordance with the Mammography
                                Quality Standards Act (MSQA) regulations.
The Team                        Interpreting physicians, medical physicists and radiological technologists.
Interpreting physician -        All physicians interpreting mammograms shall meet the MSQA final rule criteria
qualifications                  for:
                                          Initial qualifications
                                          Continuing experience and education.
Radiologic technologist -       All mammographic examinations shall be performed by radiologic technologists



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Appendix E – USA Professional Supervision
qualifications                 who meet:
                                         General requirements
                                         Mammography requirements
                                         Continuing education and experience requirements
                               as specified in MSQA final rule.
Medical physicist -            All medical physicists conducting surveys of mammography facilities and
qualifications                 providing oversight of the facility quality assurance program shall meet:
                                         Initial qualifications requirements
                                         Alternative initial qualifications requirements
                                         Continuing education and experience requirements
                               as specified in MSQA final rule.
Performance of examination     The examination should be performed by a qualified radiologic technologist with
                               or without a physician present.
Reporting – documentation      Requirements specified. Final reports should include the FDA-approved final
and communication of           assessment categories defined in the ACR Breast Imaging Reporting and Data
results                        System (BI-RADS Atlas) 4th edition, 2003. Reporting should be in accordance
                               with ACR Practice Guideline for Communication: Diagnostic Radiology and
                               consistent with MSQA Final Rule.
Follow-up imaging studies      Follow-up imaging studies should be done under the direct supervision of a
                               qualified mammography physician.
Source: ACR Practice Guideline for the Performance of Screening Mammography. Effective January 2004.

Diagnostic Mammography
Definition                     Diagnostic mammography is a radiologic examination performed to provide
                               additional information about patients who have signs and symptoms of breast
                               disease, radiographic findings, or in situations where direct supervision of the
                               imaging is deemed appropriate by the interpreting physician.
                               Direct supervision is defined as physician being present and immediately
                               available to furnish assistance and direction throughout performance of
                               procedure.
The Team                       Same as for screening mammography.
Qualifications and             Same as for screening mammography.
responsibilities of
personnel
Reporting – documentation      Requirements specified. ACR BI-RADS provides a framework for reporting,
and communication of           lesion assessment, imaging-pathologic correlation, and quality improvement.
results                        Reporting should be in accordance with ACR Practice Guideline for
                               Communication: Diagnostic Radiology and consistent with FDA final rule for
                               MSQA that took effect from April 1999.
Source: ACR Practice Guideline for the Performance of Diagnostic Mammography. Effective January 2003.

Diagnostic Procedures using Radiopharmaceuticals
The Team                       Physician, nuclear medicine technologist and qualified medical physicist or other
                               qualified scientist
Physician – qualifications     Physicians providing nuclear medicine services must meet specified criteria for:
                                         Certification and training
                                         Continuing medical education (CME)



                                                           78                  AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix E – USA Professional Supervision
                                          Authorised user of radioactive materials.
                                CME should be specifically related to diagnostic procedures using
                                radiopharmaceuticals, in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME).
                                Physician may also be required to hold current advanced cardiac life support
                                certification if monitoring patients undergoing cardiac stress studies.
Physician - responsibilities    Physician is responsible for ensuring:
                                          appropriate use of services
                                          quality of procedures
                                          all aspects of patient and facility safety
                                          compliance with applicable government and institutional regulations
                                          regarding use of radiopharmaceuticals.
                                The nuclear medicine physician is ultimately responsible for all safety and
                                appropriate utilisation of all radiopharmaceuticals prepared and/or used under
                                his/her direction.
Nuclear medicine                The technologist performing nuclear medicine services should meet specified
technologist - qualifications   Certification, licensing and continuing education criteria.
Medical physicist or            Certification, training and continuing education in appropriate sub-fields in
Scientist - qualifications      medical physics (i.e. radiological physics and nuclear medicine physics).
                                CME should be in accordance with ACR Practice Guideline for Continuing
                                Medical Education (CME).
Medical physicist or            A medical physicist should be responsible for overseeing the equipment quality
Scientist - responsibilities    control program and for monitoring performance upon installation and routinely
                                thereafter. See ACR Technical Standard for Nuclear Medicine Performance
                                Monitoring of Nuclear Medicine Imaging Equipment. Daily testing and evaluation
                                of nuclear medicine equipment may be performed by the technologist under the
                                supervision of the physician.
Reporting                       Appropriate technical data should appear in the report of the procedure. These
                                include, at a minimum, the radiopharmaceutical, dosage, route of administration
                                and views obtained. Pharmacologic enhancement and other interventions
                                should be documented. Reporting should be in accordance with ACR Practice
                                Guideline for Communication: Diagnostic Radiology.
Source: ACR Technical Standard for Diagnostic Procedures Using Radiopharmaceuticals. Effective January 2002.

Radiologist Coverage of Imaging Performance in Hospital Emergency Departments
Policy                          ACR policy is that radiologists provide comprehensive imaging services to
                                patients seen in the emergency department (ED) and provide timely consultation
                                services for a patient’s physician.
Radiologist responsibilities    Services of radiologists in ED setting include:
                                          design and standard of safe and effective radiologic procedures
                                          continuing supervision of technical performance and control of quality
                                          interpretation of examinations
                                          reporting of results
                                          appropriate consultation with referring physician.
Recommended coverage            Timely coverage of imaging examinations for ED patients can be accomplished
                                in one of the following ways:
                                          By qualified radiologist available to interpret imaging studies in
                                          accordance with criteria determined by collaboration between


                                                             79                   AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix E – USA Professional Supervision
                                         radiology departments, ED, medical staff of hospitals depending on
                                         resources available in applicable geographic locality.
                                         By qualified radiologist with acceptable teleradiology link to the
                                         hospital (see ACR Technical Standards for Teleradiology)
Monitoring preliminary         Each facility should have a defined mechanisms for:
review
                                         monitoring of any preliminary imaging study review performed by an
                                         ED physician
                                         timely notification to ED physician and/or primary care physician when
                                         there is a substantive discrepancy between the preliminary review and
                                         radiologist’ official interpretation.
Source: ACR Practice Guideline for Radiologist Coverage of Imaging Performed in Hospital Emergency Departments.
Effective January 2003.

Use of Intravascular Contrast Media
Goal                           Radiologist and other personnel administering IV contrast media should use
                               these agents appropriately and properly so that imaging studies are optimised
                               and risk to patient is minimised.
Policy – administration        ACR approves injection of contrast material and diagnostic levels of
                               radiopharmaceuticals by certified and/or licensed radiologic technologists and
                               radiologic nurses under the direction of a radiologist or his/her physician
                               designee who is personally and immediately available, if the practice is in
                               compliance with institutional and state regulations. There must be prior written
                               prior approval by the medical director of the radiology department/service of
                               such individuals; such approval process having followed established policies and
                               procedures, and the radiologic technologists and radiologic nurses who have
                               been so approved maintain documentation of CME related to the materials being
                               injected and to the procedure being performed.
The Team                       Supervising physician, physician designee and radiologic technologist
Supervising physician -        Supervising physician should be licensed and meet specified criteria for
qualifications                 certification and training.
                               CME should be in accordance with ACR Practice Guideline for Continuing
                               Medical Education (CME).
Supervising physician –        The supervising physician has responsibility for:
responsibilities
                                         reviewing all indications for the examination
                                         specifying type, use, dosage and rate of administration of contrast
                                         agents.
Responding to adverse          The supervising physician or his/her physician designee must be immediately
effects                        available to respond promptly to an adverse effect.
                               Training and proficiency in cardio-pulmonary resuscitation are recommended for
                               those who attend patients undergoing contrast-enhanced examinations.
                               May be administered by technologist or registered nurse with qualifications for
                               performing IV injection of contrast material should be in compliance with current
                               ACR policy standard and existing operating procedures/management of the
                               imaging facility.
Radiologic technologist –      The technologist should have responsibility for:
qualifications and
                                         patient comfort
responsibilities
                                         preparing and positioning patient for examination.
                               Technologist performing IV injections of contrast material should have
                               qualifications that comply with current ACR policy statements and existing



                                                           80                  AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix E – USA Professional Supervision
                                 operating procedures or manuals at the imaging facility.
Reporting                        Reporting should be in accordance with ACR Practice Guideline for
                                 Communication: Diagnostic Radiology.
Source: ACR Practice Guideline for the use of Intravascular Contrast Media. Effective January 2002.

Reporting: Diagnostic Radiology
Policy                           An official interpretation should be generated following any examination,
                                 procedure or officially requested consultation.
Written report - definition      An official interpretation is defined as that written report (and any supplements or
                                 amendments thereto) that attach to the patient’s permanent record. In health
                                 care facilities with a privilege delineation system, such a written report is
                                 prepared only by a qualified physician who has been granted specific delineated
                                 clinical privileges for that purpose by the facility’s governing body upon the
                                 recommendation of the medical staff.
Diagnostic radiology report      A final written report shall be provided with all radiologic studies regardless of
                                 site of performance (e.g. hospital, imaging centre, physician office, mobile units).
                                 Report should contain the following minimum items:
                                      E.   Demographics
                                      F.   Relevant clinical information and ICD 9 codes as available
                                      G. Body of report – procedures and materials, findings, patient limitations,
                                         clinical issues and comparative data
                                      H. Impression – conclusion or diagnosis.
                                 There are specific requirements under MQSA regulations for mammography
                                 reporting.
Other forms of                   Final written report is the definitive means of communicating results to referring
communication                    physician. Other methods of direct or personal communication of results are
                                 encouraged in certain situations.
Timeliness of reporting          Timeliness of reporting varies with nature and urgency of clinical problem.
Source: ACR Practice Guideline for Communication: Diagnostic Radiology. Effective January 2002.

Interventional Clinical Practice
The ACR has developed practice guidelines for interventional clinical practice in collaboration with the
American Society of Interventional and Therapeutic Neuroradiology (ASITN) and the Society of
Interventional radiology (SIR) – Practice Guideline for Interventional Radiology. Effective January 2004.
The guidelines focus on developing an interventional clinical practice for inpatient and outpatient clinical
services. They provide recommendation about processes for handling referrals, the physician-patient
relationship, scheduling of invasive procedures, staffing, clinical space, time dedicated to clinical duties,
equipment needs, clerical service and continuous quality improvement programs. They have not been
analysed further given their service development focus.




                                                             81                  AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix F – Canada Professional Supervision
This Appendix provides a summary the professional supervision arrangements in Canada.


F CANADA PROFESSIONAL SUPERVISION
Canadian Association of Radiologists

The Canadian Association of Radiologists (CAR) is the national peak organisation for radiologists in
Canada. It develops standards to provide assistance to practitioners performing examinations and
procedures.

Standards Development

Standards are developed by expert advisory panels through review of evidence and consensus process
involving clinicians and experts in the field. In some cases, standards are based on those published by
other national bodies. For example, CAR standards for ultrasound are based on those developed by
the American College of Radiology (ACR) and the American Institute of Ultrasound. Standards are
reviewed periodically.

The standards are described in several ways. They are seen as representing a policy statement by
CAR. They are “guidelines that attempt to define the principles of practice that should generally
produce radiological care”. They are not rules or “intended to establish a legal standard of care or
conduct”. “The ultimate judgment regarding the propriety of any specific procedure or course of conduct
must be made by the physician and medical physicist in light of all circumstances presented by the
individual situation.”

Current Standards

The current standards of the CAR are listed in Table 7-3.

Table 7-3: Canadian Association of Radiologists - Standards August 2005
       Modality                                  Topic                        Date Approved
General (Plain)         Skeletal Surveys in Children                     June 1998
Radiography
                        General (Plain) Radiography                      June 2000
                        Chest Radiography                                First adopted in 1994 and
                                                                         revised in June 2000
                                                                         June 2000
                        Cervical Spine in Children and Adults
                                                                         June 2000
                        Lumbosacral Spine
Computed Tomography     Diagnostic CT Scans                              March 2002
(CT)




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Appendix F – Canada Professional Supervision
        Modality                                    Topic                              Date Approved
Ultrasound                 Diagnostic Antepartum Obstetric Examination            September 2001
                           Female Pelvis Examination                              March 2002
                           Abdomen and Retroperitoneum Examination                March 2002
                           Scrotum Examination                                    March 2002
                           Thyroid and Parathyroid Examination                    March 2002
                           Specific Anatomical Areas – Vascular Ultrasound        March 2002
                           Breast Examination                                     October 2003
                           Musculoskeletal Examination                            2005 Draft - awaiting
                                                                                  approval
Magnetic Resonance         MRI                                                    June 1999
Imaging (MRI)
Breast Imaging             Screening and Diagnostic Mammography                   June 1998
Other                      Myelography                                            March 2002
                           Diagnostic Angiography                                 September 2002
                           Performance of Percutaneous Nephrostomy                September 2002
                           Performance of Adult Dual - or Single-Energy X-Ray     November 2002
                           Absorptiometry
                           Ultrasound Guided Percutaneous Breast Interventional
                                                                                  October 2003
                           Procedures
Contrast Media             Pharynx and Oesophagus in the Adult                    June 1994
                           Small Bowel in Adults                                  June 1996
                           Upper Gastrointestinal Tract                           First approved in June
                                                                                  1995 and reviewed in
                                                                                  2000
Reporting                  Communication in Diagnostic Radiology                  First approved in June
                                                                                  and reviewed in
                                                                                  September 2001
Source: CAR 2005 http://www.car.ca/ethics/standards/index/htm

The standards vary in approach and format. They recognise that the safe and effective use of
diagnostic and therapeutic radiology requires specific training, skills, and techniques as described in
each document.

Review of Standards
CAR standards were reviewed in order to identify professional supervision and requirements relating to
radiologists across imaging modalities. Analysis focussed on diagnostic radiology where the radiologist
provides a medical consultative role rather than interventional procedures where the radiologist
becomes the treating physician. Key features and principles are summarised below.




                                                            83               AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix F – Canada Professional Supervision
General (Plain) Radiography
Physician –                Physicians involved in the performance, supervision and interpretation of standard
Qualifications and         radiographs should be Diagnostic Radiologists and must have a Fellowship or
Responsibilities           Certification in Diagnostic Radiology with the Royal College of Physicians and
                           Surgeons of Canada and/or the Collège des Médecins du Quebec. Also acceptable
                           are foreign specialist qualifications if the Radiologist so qualified holds an
                           appointment in Radiology with a Canadian University.
                           As new imaging modalities and interventional techniques are developed additional
                           clinical training, under supervision and with proper documentation, should be
                           obtained before radiologists interpret or perform such examinations or procedures
                           independently. Such additional training must meet with pertinent provincial/regional
                           regulations. Continuing professional development must meet with the requirements of
                           the Maintenance of Certification Program of the Royal College of Physicians and
                           Surgeons of Canada.
Technologist -             The medical radiation technologist must have Canadian Association of Medical
Qualifications and         Radiation Technologist (CAMRT) Certification or be certified by an equivalent
Responsibilities           licensing body recognized by the CAMRT.
                           Under the overall supervision of the radiologists, the technologist will have the
                           responsibility for:
                                     patient comfort and safety
                                     examination preparation and performance
                                     image technical evaluation and quality and applicable quality assurance.
                           The training of technologists engaged in specialty activities shall meet with applicable
                           and valid national and provincial specialty qualifications.
                           Continued education of technologists is encouraged by the CAMRT and should meet
                           pertinent provincial regulations.
                           The technologist should have training in fluoroscopy either in his/her training
                           curriculum or through special courses and must perform fluoroscopy on a regular
                           basis.
Quality Control and        This section of the standard sets out principles and requirements for quality control
Improvement                and improvement designed to minimise patient, personnel and public radiation risks
                           and maximise the quality of the diagnostic information. It covers safety and operation
                           of imaging equipment, assuring image quality, quality control procedures for
                           radiographic examinations, procedures and policies, and monitoring and evaluation of
                           procedures and policies including accuracy of radiological interpretation and
                           appropriateness of examination.
Reporting                  Results will be communicated to referring physician in accordance with CAR
                           Standard on Communication: Diagnostic Radiology.
Source: CAR Standards for General (Plain) Radiography. First adopted: June 2000.


Computed Tomography (CT)
General                    CT studies should be performed by qualified and knowledgeable physicians and/or
                           technologists using appropriate equipment and technique.
                           Examinations should be supervised and interpreted by appropriately trained and
                           credentialed medical imaging specialists.
Physician –                Physicians involved in the performance, supervision and interpretation of CT should
Credentials Criteria       be Diagnostic Radiologists and must have a Fellowship or Certification in Diagnostic
                           Radiology with the Royal College of Physicians and Surgeons of Canada and/or the
                           Collège des médecins du Québec. Also acceptable are Radiologists qualified in other
                           jurisdictions who hold special licenses within a Canadian University.
                           As new imaging modalities and interventional techniques are developed additional


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                           clinical training, under supervision and with proper documentation, should be
                           obtained before radiologists interpret or perform such examinations or procedures
                           independently. Such additional training must meet with pertinent provincial/regional
                           regulations. Continuing professional development must meet with the requirements of
                           the Maintenance of Certification Program of the Royal College of Physicians and
                           Surgeons of Canada.
Technologist –             The Medical Radiation Technologist must have Canadian Association Medical
Credentials Criteria       Radiation Technologist certification or be certified by an equivalent licensing body
                           recognized by the CAMRT.
                           Under the overall supervision of the Radiologist, the Technologist will have the
                           responsibility for:
                                     patient comfort and safety
                                     examination preparation and performance
                                     image technical evaluation and quality, and applicable quality assurance.
                           The training of Technologists specifically engaged in CT shall meet with applicable
                           and valid national and provincial specialty qualifications.
Performance of             Ideally each study would be monitored directly by the interpreting physician.
Examination: Role of       However, realities of time constraints and potential limitations on physician
Interpreting Physician     availability necessitate that many scans be performed without on-line monitoring. In
in On-line Monitoring      this setting, optimisation of the CT examination requires development of an
                           appropriate CT protocol based on careful review of clinical indications as well as all
                           prior available imaging studies.
Contrast Media             Choice of whether or not to administer IV contrast will depend on clinical
                           indication of study. Operators should be knowledgeable concerning
                           various means of administering IV contrast.
Source: CAR Standard for Performing and Interpreting Diagnostic CT Scans. Adopted: March 2002.


Magnetic Resonance Imaging (MRI)
Physician –                Physicians involved in the performance, supervision and interpretation of magnetic
Qualifications and         resonance imaging should be Diagnostic Radiologists and must have a Fellowship or
Responsibilities           Certification in Diagnostic Radiology with the Royal College of Physicians and
                           Surgeons of Canada and/or the Collège des médecins du Québec. Also acceptable
                           are foreign Specialist qualifications if the Radiologist so qualified holds an
                           appointment in Radiology with a Canadian University.
                           As new imaging modalities and interventional techniques are developed additional
                           clinical training, under supervision and with proper documentation, should be
                           obtained before radiologists interpret or perform such examinations or procedures
                           independently. Such additional training must meet with pertinent provincial/regional
                           regulations. Continuing professional development must meet with the requirements
                           of the Maintenance of Certification Program of the Royal College of Physicians and
                           Surgeons of Canada.
                           The final judgment regarding appropriateness of a given examination for a
                           particular patient is the responsibility of the radiologist.
Medical Physicist –        A medical physicist (on-site or contracted part-time) shall have the
qualifications and         responsibility for the initial acceptance testing and for conducting and
responsibilities           overseeing quality control testing of the MR scanner.
                           The medical physicist shall be certified by the Canadian College of
                           Physicists in Medicine and shall have specific training and experience in
                           MRI. Training and experience shall include detailed knowledge of the
                           physics of MRI, system components and performance, safety procedures,
                           acceptance testing, and quality control testing.
Technologist –             The medical radiation technologist must have Canadian Association of


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qualifications and        Medical Radiation Technologists (CAMRT) certification in magnetic
responsibilities          resonance (RTMR) or be certified by an equivalent licensing body
                          recognized by the CAMRT.
                          Under the overall supervision of the radiologists, the technologist is
                          responsible for:
                                     patient comfort and safety
                                     examination and preparation of patients
                                     performing the MRI scans
                                     technical and quality evaluation of images and relevant quality
                                     assurance.
                          Continued education of technologists is encouraged by the CAMRT and
                          should meet pertinent provincial regulations.
Service Engineers –       The service engineer shall be responsible for system installation,
qualifications and        calibration, and preventive maintenance at regularly scheduled intervals.
responsibilities          The service engineer's qualification will be ensured by the corporation
                          responsible for service and the manufacturer of the MR equipment used at
                          the site.
Administration of         When necessary, contrast and sedation shall be administered in
contrast and sedation     accordance with institutional policy and provincial and federal law by a
                          physician, who has trained in cardiopulmonary resuscitation. An
                          appropriately equipped emergency cart must be immediately available to
                          treat serious adverse reactions. MR compatible ventilators, and appropriate
                          patient monitoring should be available at those sites undertaking general
                          anaesthesia and sedation studies.

Quality control and       Safety guidelines, practices, and policies shall be written, enforced, documented, and
improvement               reviewed at least annually by the supervising radiologist and the MR charge
                          technologist.
                          Quality control testing of system performance should be conducted routinely under
                          the supervision of the medical physicist (if present on site), with review at least every
                          six months by the supervising radiologist.
Source: CAR Standards for Magnetic Resonance Imaging (MRI). Approved: June 1999.


Ultrasound – Diagnostic
General                   Diagnostic ultrasound examinations should be supervised and interpreted by trained
                          and credentialed physician imaging specialists.
                          Studies should be performed by qualified and knowledgeable physicians and/or
                          sonographers using appropriate equipment and techniques.
Sonologist Credentials    Physicians involved in the performance, supervision and interpretation of
Criteria                  ultrasonography should be Diagnostic Radiologists and must have a Fellowship or
                          Certification in Diagnostic Radiology with the Royal College of Physicians and
                          Surgeons of Canada and/or the Collège des Médecins du Québec. Also acceptable
                          are equivalent foreign Radiologist qualifications if the Radiologist so qualified holds
                          an appointment in Radiology with a Canadian University.
                          As new imaging modalities and interventional techniques are developed additional
                          clinical training, under supervision and with proper documentation, should be
                          obtained before radiologists interpret or perform such examinations or procedures
                          independently. Such additional training must meet with pertinent provincial/regional
                          regulations. Continuing professional development must meet with the requirements
                          of the Maintenance of Certification Program of the Royal College of Physicians and
                          Surgeons of Canada.
Sonographer               Sonographers should be graduates of an accredited School of Sonography or have



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Credentials Criteria       obtained certification by the American Registry of Diagnostic Medical Sonographers
                           (ARDMS) or the Canadian Association of Registered Diagnostic Ultrasound
                           Professionals (CARDUP). They should be members of their national or provincial
                           professional organization. Continuing medical education should be mandatory
                           consistent with the requirements of ARDMS or CARDUP.
                           CARDUP will have a national exam process for sonographers in place by 2004. At
                           that time, this will become the accepted standard for sonographers. As an interim
                           measure, individual consideration of training and qualifications by a Task Force
                           consisting of members of relevant societies can be recommended for all those whose
                           training does not fall within appropriate guidelines.
Supervision and            A sonologist must be available for consultation with the sonographer on a case by
interpretation             case basis. Ideally the sonologist should be on site and available to participate
                           actively in the ultrasound examination when required.
                           It is recognized however that the geographic realities in Canada do not permit the
                           presence of an on-site sonologist in all locations. Adequate documentation of each
                           examination is critical. A videotape record may be useful as an adjunct to the hard
                           copy images in difficult cases. Despite the geographic isolation of a community the
                           reports must be timely. Furthermore, the sonologist must be available by telephone
                           for consultation with the sonographer and the referring physician. The sonologist
                           should visit the facility on a regular basis to provide on site review of ultrasound
                           procedures and sonographer supervision.
Sources: CAR Standards for:
         Performing and Interpreting Diagnostic Antepartum Obstetric Ultrasound Examination. Approved: September 2001
         Ultrasound Examination of the Female Pelvis. Approved: March 2002
         Ultrasound Examination of the Abdomen and Retroperitoneum. Approved: March 2002
         Ultrasound Examination of the Scrotum. Approved: March 2002
         Ultrasound Examination of the Thyroid and Parathyroid. Approved: March 2002
         Specific Anatomical Areas (Vascular Ultrasound). Approved: March 2002.
         Performance of Breast Ultrasound Examination. Approved: October 2003
         Performing Musculoskeletal Ultrasound Examination. Draft released in 2005, awaiting approval.



Breast Imaging – Screening Mammography
Radiologist –              Physicians involved in the performance, supervision and interpretation of
credentials criteria and   mammography should be Diagnostic Radiologists and must have a Fellowship or
responsibilities           Certification in Diagnostic Radiology with the Royal College of Physicians and
                           Surgeons of Canada and/or the Collège des Médecins du Québec. Also acceptable
                           are foreign Specialist qualifications if the Radiologist so qualified holds an
                           appointment in Radiology with a Canadian University.
                           As new imaging modalities and interventional techniques are developed additional
                           clinical training, under supervision and with proper documentation, should be
                           obtained before radiologists interpret or perform such examinations or procedures
                           independently. Such additional training must meet with pertinent provincial/regional
                           regulations. Continuing professional development must meet with the requirements of
                           the Maintenance of Certification Program of the Royal College of Physicians and
                           Surgeons of Canada.
                           Radiologists practising mammography should participate regularly in mammography
                           continuing education programs. They should adhere to the requirement for CAR
                           mammography accreditation.
Technologist -             The medical radiation technologist must have Canadian Association of Medical
credentials criteria and   Radiation Technologist (CAMRT) Certification or be certified by an equivalent
responsibilities           licensing body recognized by the CAMRT.



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                           Under the overall supervision of the radiologist, the technologist will have the
                           responsibility for:
                                     patient comfort and safety
                                     examination preparation and performance
                                      image technical evaluation and quality and applicable quality assurance.
                           The technologist should receive continuous supervision on image quality from the
                           interpreting radiologists.
                           The training of technologists engaged in specialty activities shall meet with applicable
                           and valid national and provincial specialty qualifications.
                           Continued education of technologists is encouraged by the CAMRT and should meet
                           pertinent provincial regulations.
                           The technologist should have training in mammography either in his or her training
                           curriculum or through special courses and must perform mammography on a regular
                           basis.
Radiation physicist -      A medical physicist shall have the responsibility for the initial acceptance testing and
credentials criteria and   for conducting and overseeing quality control testing of the mammographic unit.
responsibilities
                           The medical physicist shall be certified by the Canadian Organization of Medical
                           Physicists or possess equivalent qualifications from the Canadian College of
                           Physicists in Medicine.
                           Training and experience shall include knowledge of the physics of mammography,
                           systems components and performance, safety procedures, acceptance testing,
                           quality control and CAR Mammography Accreditation Program requirements.
Free Standing and          Screening mammography may be performed in non-traditional settings where a
Mobile Settings            physician may not be in attendance. Essentially, the examination offered must follow
                           all of the described standards and guidelines cited here as documented protocols.
                           The radiologic technologist should work under the same rules whether in a fixed or
                           mobile setting.
                           The radiologist supervising the facility should be available for consultation and must
                           visit the facility at least monthly to observe the performance of mammograms and
                           assure that safe operating procedures are adhered to.
Screening                  Reporting should be according to the CAR Standards for Communication. As well, the
Mammography Report         American College of Radiology (ACR) document "Breast Imaging Reporting Data
                           Systems" (BIRADS) has been adopted as a reference document and is available on
                           request from the ACR office. A description of abnormalities detected at screening and
                           recommendations for work up should be included in the report. For abnormalities
                           which are in the highly suspicious category suggestive of malignancy, the report
                           should be communicated to the referring physician directly in a manner that ensures
                           receipt and documentation of the reports, such as by telephone, fax or registered
                           mail.
Quality Control            A documented quality control program with procedure manuals and logs should be
                           maintained in accordance with the CAR Mammography Accreditation Program's
                           quality control specifications.
                           1. Radiologist
                           The radiologist will be responsible for ensuring that technologists have adequate
                           training and maintenance of competence; he/she or a designate must ensure that the
                           technologists and physicists perform the appropriate tests on schedule, and that all
                           records are properly maintained and that the quality of clinical images is acceptable.
                           2. Technologist
                           The radiology technologist will be responsible for various routine tests including
                           darkroom cleanliness, processing quality control, screen cleanliness, viewboxes and
                           viewing conditions, phantom images, visual checklist, repeat analysis, analysis of


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                          fixer retention in film, darkroom fog, screen film contact and compression.
                          3. Physicist
                          The medical physicist will be responsible for the mammographic unit evaluation,
                          collimation assessment, focal spot size measurements, kVp accuracy and
                          reproducibility.

                          The American College of Radiology (ACR) Committee on Mammography Quality
                          Assurance has published a document entitled "Mammography Quality Control"
                          addressing, specifically, radiology technologists' and physicists responsibilities. This
                          document has been reviewed and acknowledged by the Task Force on
                          Mammography and is recommended as a reference document.
Source: CAR Standard for Breast Imaging. Approved: June 1998

Diagnostic Mammography and Problem Solving Breast Evaluation
Qualifications of         The same criteria apply as for screening mammography.
Personnel

Supervision               The diagnostic mammogram is planned and tailored for the needs of the individual
                          patient. It should be done under the direct supervision of a radiologist qualified in
                          mammography.
Report                    All areas of clinical or radiologic concern should be acknowledged in the report. The
                          report should describe the pertinent observations, establish a level of suspicion
                          based upon the imaging findings and provide specific recommendations for patient
                          management. The report should also document any other breast imaging studies or
                          procedures which have been performed and should correlate these results with the
                          mammographic findings. Screening recommendations may be included.
                          The same criteria for reporting and communication as for screening mammography
                          apply.
Source: CAR Standard for Breast Imaging. Approved: June 1998


Communication in Diagnostic Radiology
General                   The final product of any consultation is the submission of a report on the results of
                          the consultation. In addition, the diagnostic radiologist and the referring physician
                          have many opportunities to communicate directly with each other during the course of
                          a patient's case management. Such communication should be encouraged because it
                          leads to more effective and appropriate utilization of Diagnostic Radiology in
                          addressing clinical problems and focuses attention on such concerns as radiation
                          exposure, appropriate imaging studies, clinical efficacy, and cost-effective
                          examinations. These principles apply to all radiology consultations irrespective of the
                          technology used including teleradiology and PACS.
                          In order to afford optimal care to the patient and enhance the cost-effectiveness of
                          each diagnostic examination, radiological consultations ought to be provided and
                          radiographs interpreted within known clinical settings. The CAR supports radiologists
                          who insist on clinical data with each consultation request.
The Diagnostic            An authenticated written interpretation shall be performed on all radiographic
Radiology Report          (imaging) procedures. The report should include the following items:
                                    Name of patient and another identifier, such as gender, birth date, pertinent
                                    ID number or hospital or office identification number
                                    Name of referring (attending) physician
                                     Name of most responsible physician
                                    Names of other physicians
                                    Name or type of examination




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                                     Date of dictation
                                     Date of examination and transcription
                                     Time of the examination (for ICU-CCU patients)
                                     Body of the report
                                     The effective transmission of radiographic information from the radiologists
                                     mind to the clinician constitutes the purpose of the report. The report should
                                     be clear and concise. Normal or unequivocally positive reports can be short
                                     and precise. Whenever indicated, the report should include:
                                          -    procedures and materials
                                          -    findings
                                          -    limitations
                                          -    clinical issues
                                          -    comparative data
                                          -    assessment and recommendations.
Written Communication      The timeliness of reporting any radiologic examination varies with the
                           nature and urgency of the clinical problem. The written radiological report
                           should be made available in a clinically appropriate, timely manner.
                           The final report should be proofread carefully to avoid typographical errors,
                           deleted words, and confusing or conflicting statements, and authenticated
                           by a radiologist, whenever possible. Electronic and rubber-stamp signature
                           devices, instead of a written signature, are acceptable if access to them is
                           secure. If this is not possible, the name of the radiologist who dictated the
                           report should appear on the report.
                           A copy of the final report should accompany the exchange of relevant radiographic
                           examinations from one health professional to another health professional.
Direct Communication       Radiologists should attempt to co-ordinate their efforts with those of the referring
                           physician in order to best serve the patient's well-being. In some circumstances, such
                           co-ordination may require direct communication of unusual, unexpected or urgent
                           findings to the referring physician in advance of the formal written report. Examples
                           include:
                                     The probable detection of conditions carrying the risk of acute morbidity
                                     and/or mortality which may require immediate case management decisions.
                                     The probable detection of disease sufficiently serious that it may
                                     require prompt notification of the patient, clinical evaluation or
                                     initiation of treatment.
                                     In these circumstances, the radiologist, or his or her
                                     representative, should attempt to communicate directly (in person
                                     or by telephone) with the referring physician or his or her
                                     representative. The timeliness of direct communication should be
                                     based upon the immediacy of the clinical situation.
                                     Documentation of actual or attempted direct communication is
                                     appropriate in accordance with department policy, legal
                                     advisability, understanding with the referring physician, and
                                     individual judgement.
                                     Any discrepancy between an emergency or preliminary report
                                     and the final written report should be promptly reconciled by
                                     direct communication to the referring physician or his or her
                                     representative.
Source: CAR Standard for Communication in Diagnostic Radiology. First approved in June 1997 and reviewed in
September 2001.



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Alberta
Introduction
In Alberta, reimbursement for medical services is available under the Alberta Health Care Insurance
Plan. The Schedule of Medical Benefits sets out the services that are insured under the Alberta Health
Insurance Act and associated Plan. Claims for services under the radiology (and pathology) sections
are not payable unless the physician has been accredited by the Alberta College of Physicians and
Surgeons of Alberta to provide these services.

The Medical Profession Act provides for the regulation of physicians and practice of medicine in Alberta.
This Act gives the College the authority and responsibility to regulate diagnostic and treatment facilities
in Alberta except facilities operated by government (local, provincial and federal) and facilities approved
under the Hospitals Act. The College provides this service to facilities operating under the Hospitals Act
through a contract with Alberta Health and Wellness.


Accreditation Standards and Guidelines
The College administers an accreditation program for all medical diagnostic imaging in Alberta. It sets
the standards and guidelines for diagnostic imaging against which services are accredited. The latest
edition is Diagnostic Imaging Standards and Guidelines, Alberta. The College of Physicians and
Surgeons of Alberta. June 2005. The College’s Advisory Committee on Radiology and Diagnostic
Imaging develops the standards and guidelines for accredited facilities. Its role is to advise the
College’s Medical Facility Assessment Committee on medical imaging matters. The aim is to set a high
standard of medical practice in diagnostic imaging for Alberta. The standards and guidelines set out the
role of the College in accreditation of facilities and cover physician approval, personnel, facility, medical
record, quality assurance, manuals, safety, procedures, remote MRI and teleradiology and digital image
data management, mobile X-ray equipment and supervision of ultrasound studies. Standards and
guidelines fall into three broad groupings - requirements for accreditation (where “shall” is used),
recommendations (“should”), and discretionary (“may”). Mammography facilities are accredited through
CAR Mammography Accreditation Program (CAR – MAP).

Key Features

Medical Director
The College requires all accredited medical imaging facilities/departments to have a Medical Director
(i.e. a practitioner who is registered with the Alberta College of Physicians and Surgeons and licensed to
practise medicine in Alberta) who is accountable for the practise of medicine within the facility.

A medical imaging facility/department shall be under the complete direction and supervision of a
medical director.

Medical Directors have to be satisfied as to the standing of other professionals with their respective
regulatory bodies and to the safety of their practices.

Ideally, the medical director should be an imaging specialist.

For facilities where the Medical Director does not have the expertise in the particular imaging modality,
the services of a consultant are required.

Consultant Physician


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When the medical director is not an imaging specialist, there shall be a consultant physician who is
approved for modalities not within the scope of practice of the medical director.

The consultant shall be licensed to practise in medicine in Alberta and be a specialist in the modalities
for which he/she provides consultative services.

MRI Facilities
MRI radiologist is a radiologist approved by the College either to interpret studies or direct an MRI
facility.

The medical director of an MRI facility shall be a radiologist with full approval in MRI and licensed to
practise in medicine in Alberta.

A physician with full MRI approval shall review a minimum of 20% of the studies performed each month
in the facility.

All MR protocols shall be approved by an MRI radiologist on a case-by-case basis.

All MRI studies shall be interpreted by an MRI radiologist and reported in a timely fashion.

An MRI radiologist shall be on site for the majority of the studies performed each day n the facility.

An MRI radiologist shall be immediately available (i.e. in person or by telephone) during all studies.

Supervision requirements for fully-supervised facilities include an MRI qualified radiologist being on site
for at least 50% of studies and the Medical director on site for at least 20% of studies.

Liaison physician
In hospital facilities that do not have an on site imaging specialist, there shall be a liaison physician who
is a local member of the medical staff and appointed to act in concert with the administration and the
radiology consultant.

Technical personnel
Radiological examinations shall be performed by an imaging specialist or technologist or technician who
has current registration with their professional association.

Areas specified include radiology, technologists and technicians; ultrasound; mammography; MRI;
nuclear medicine; and bone densitometry.

Provision shall be made for technologists/technicians to regularly attend relevant continuing education
programs.

Physician Approval
Physicians providing services in echocardiography, MRI, nuclear medicine, PET and ultrasound are
required to have prior College approval. Cover full approval, restricted approval, re-approval and active
practice requirements.

Request for consultation
Requests for imaging consultations shall be completed for all imaging procedures.




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Reports
All examinations shall be reported by an appropriately approved imaging specialist as soon as possible
after the images are available.

Unusual, unexpected or urgent findings which may require immediate case management decisions shall
be communicated immediately to the referring practitioner.

Report of the interpretation of imaging procedures shall include as per CAR Standards for
Communication: Diagnostic Radiology – A. the Diagnostic Radiology Report.

All reports should be signed or electronically verified by the interpreting radiologist prior to being issued.

Ultrasound – supervision of studies
An ultrasonologist shall be on site at the facility for consultation, supervision and interpretation of all
ultrasound examinations unless otherwise approved by the College.

Teleultrasound is an approved exception subject to specific accreditation standards for teleultrasound
services.

In unusual circumstances, approval for ultrasound examinations without an ultrasonologist available
either on site or be teleultrasound will be considered only upon application and only for specified studies
and locations where the absence of ultrasound services could harm patients.

Approvals are subject to adequate arrangements for the prompt interpretation of studies by an
ulatrsonologist and a process for immediate referral of complex cases. Interpretation of studies by
ultrasonographers or others who are not an ultrasonologist is not acceptable.

Procedures – fluoroscopy
Fluoroscopy shall be performed under the direction and supervision of a radiologist or physician
approved by the College.

Procedures – Intravascular iodinated contrast agents
The use of contrast shall adhere to a policy approved by the radiologist/imaging specialist responsible
for imaging in the facility.

A physician shall be immediately available during the examination in which an IV contrast agent is
administered.

All images shall be reviewed and interpreted by a radiologist/imaging specialist.

Remote MRI services
Remote MRI services are subject to accreditation by the College as a separate imaging facility.

The Medical Director of a remote service shall be a Medical director of a least one other accredited fully
supervised full time MRI facility.

An Alberta MRI-approved radiologist shall review all requisitions, prescribe all imaging protocols and
interpret all studies, and be available to the imaging technologist by phone during imaging sessions.

The technologist performing studies shall be a qualified MRI technologist.


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MRI studies requiring preliminary view before discharging patients in accordance with generally
accepted standards of practice in Alberta shall have and use tele-imaging technology for review by the
radiologist of such cases performed at the remote facility.

MRI studies with the use of gadolinium shall be performed only under the direct supervision of an
appropriately qualified physician and within close proximity of a hospital ED.

MRI studies under intravenous sedation or on patients requiring monitoring of vital signs during the
imaging procedure are not permitted.

Studies for which the generally accepted standard of practice in Alberta is the direct supervision by a
radiologist shall not be performed by remote MRI.

Teleradiology and Digital Image Data Management
Standards have been adapted from the CAR national Standards for Teleradiology. They include
requirements and recommendations for the accreditation of teleradiology facilities and digital image data
management by the College of Physicians and Surgeons of Alberta. They define qualifications of
personnel, equipment guidelines, record storage, quality control and quality improvement for digital
image data management and teleradiology.

The Alberta Health Care Insurance Plan covers telehealth services. Telehealth service is defined as a
physician delivered health service provided to a patient at a designated RHA telehealth site, through
use of video technology including store and forward. The patient must be in attendance at the site at
the time of video capture. Teleradiology services are not claimable against these telehealth items.




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BRITISH COLUMBIA

Introduction
The British Columbia Medical Services Plan (MSP) insures medically required services provided by
physicians and supplementary health care, prostheses, laboratory services and diagnostic procedures.
The Medical Services Commission administers the plan. To practise and be paid by the MSP,
practitioners and diagnostic facilities require approval by the Medical Services Commission and
accreditation by the Diagnostic Accreditation Program of the College of Physicians and Surgeons of BC.
Arrangements cover diagnostic radiology, diagnostic ultrasound, CT, CAT and nuclear medicine
scanning. Fees for billing MSP-insured diagnostic services are listed in the Medical Services
Commission Payment Schedule. Standards and guidelines for accreditation of providers and facilities
have been requested from the College.

MSP Payment Arrangements for Diagnostic Imaging Services – Key Features
Key features of the payment arrangements relating to diagnostic imaging services are summarised
below.

General
Benefits are limited to services which are medically required for the diagnosis and/or treatment of a
patient, which are not excluded by legislation or regulation, and which are rendered personally by
medical practitioners or by others delegated to perform them in accordance with the Commission’s
policies.

Delegated procedures
These are set out and require performance of procedure under direct supervision of the physician or a
designated alternative physician with equivalent qualification. However, these limitations do not apply to
approved procedures rendered in approved “diagnostic facilities” and which are subject to accreditation
under the Diagnostic Accreditation Program.

Diagnostic facility services
These are “medically required services performed in accordance with protocols agreed to by the
Commission, or on the order of the referring practitioner, who is a member of a prescribed category of
practitioner, in a approved diagnostic facility by, or under the supervision of, a medical practitioner who
has enrolled, unless the services are determined by the Commission not to be benefits”.

The MSC designates certain diagnostic procedures as diagnostic facility services under the MSC
Payment Schedule. Current services include diagnostic radiology, diagnostic ultrasound, nuclear
medicine scanning, computerised axial tomography technical fee (CT, CAT), MRI and PET.

Diagnostic radiology – use of telemetry
Radiology fees or nuclear medicine fees may only be claimed for studies performed by telemetry when:
      The service meets existing MSC policy on the use of telemetry
      The use of telemetry will not negatively affect the existing on-site visit schedules of the radiologist
       or nuclear medicine specialist.




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Diagnostic ultrasound – on-site supervision
Real time ultrasound fees may only be clamed for studies performed when a physician is on-site in the
laboratory for the purpose of diagnostic ultrasound supervision.

Diagnostic ultrasound – use of telemetry
Real time ultrasound fees may only be claimed for studies performed by telemetry when:
      The service meets existing MCS policy on the use of telemetry.
      The facility currently holds a remote site designation from MSC (facilities should recognise that
       once the volume of services justifies full-time radiologist coverage, remote site designation may
       be removed).
      The use of telemetry will not negatively affect the existing on-site visit schedules of the
       radiologists.
      The majority of scans will continue to be scheduled when the visiting radiologist is on-site for the
       purpose of ultrasound supervision.

Nuclear medicine – use of telemetry
Radiology fees or nuclear medicine fees may only be claimed for studies performed by telemetry when:
      The service meets existing MCS policy on the use of telemetry
      The use of telemetry will not negatively affect the existing on-site visit schedules of the radiologist
       or nuclear medicine specialist.




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MANITOBA

Introduction
Manitoba reimburses patients through the Health Services Insurance Fund. The schedule of services
and fees is set out in the Manitoba Physician’s Manual issued by the Minister of Health. The Manual
sets out the fees/benefits payable under the Manitoba Health Services Insurance Act for the cost of
insured medical services. The latest version relates to April 2005. In order to be eligible, specialists
must be registered with the College of Physicians and Surgeons of Manitoba.

Physician Fees – Three Components
The schedule separates physician fees into three components:
      Technical (Column Tec) – benefit for radiographic examinations, including the production of
       radiographs, supply of contrast media, equipment maintenance, capital cost of replacement
       equipment, fixed and variable overhead costs of the premises, technical services
       administration, production of one or more copies of the report by the certified radiologist and
       collection costs.
      Professional (Column Pro) – the benefit for supervision of imaging services, advising the
       referring physician as to the most appropriate imaging modality, maintenance of quality control,
       imaging interpretation and fluoroscopic assessment.
      Procedural (Column C) – are intended to cover the procedural portion of the examination and
       are separate and distinct from the professional supervisory and interpretative fees of
       professional component (Column Pro.) They represent the additional benefit for the professional
       procedural portion of the examinations. They are intended to cover compensation for the
       professional service of placing an instrument and introducing contrast media (except in
       excretion studies of the biliary and renal tracts, and oral and rectal administration for study of
       the alimentary canal). The same fees may be charged for similar services associated with
       diagnostic physiological studies of non-radiological nature, for example – catheterisation for
       physiological sampling or the transmission of pressure, sound or electrical waves or the
       therapeutic injection of drugs. They apply to interventional and procedural services only.

Itemisation
Generally, the itemisation is modality or procedural based with services grouped under body part or type
of examination to be performed (e.g. in the case of MRI multi-slice T2 (1or 2 echoes), multi-slice I.R. or
T1. or repeat).

Radiologist/physician supervision, performance, interpretation and reporting requirements are generally
not covered in the itemisation of services. Instead, they are covered in the three fee components.

Exceptions are:
      Breast ultrasound where the itemisation distinguishes between sonologist performed sonography
       and non-sonologist performed sonography for breast unilateral and bilateral real time studies
       with the sonologist performed services attracting a higher benefit (97% and 87% more
       respectively).
      Items for sonologist performed procedures where sonologist performs all examinations due to
        particular circumstances – e.g. rural Manitoba no technician available, after hours no technician
        available, and new or complex procedure no qualified technician. These items are set out in the
        following table.



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Appendix F – Canada Professional Supervision
Table: Sonologist Performed Procedures – Manitoba Canada
      Item                 Descriptor
      7362                 Portable ultrasound examination performed by sonologist [or the first full thirty
                           (30) minute period and for each additional thirty (30) minute period or portion
                           thereof]
      7363                 Sonologist performs part of examination for a minimum of ten (10) minutes or
                           less where the sonologist’s input revises the technologist’s initial or provisional
                           finding or changes the management of the patient’s care
      7365                 Sonologist performs all of examination
      7367                 Hysterosonography
      7368                 Sonography, intraoperative real time study performed by radiologist [for the first
                           full thirty(30) minute period and for each additional thirty (30) minute period or
                           portion thereof]
  Source: Manitoba Physician’s Manual. April 1, 2005. Issued by the Minister of Health.
  www.gov.mb.ca/health/index/html


     Special other radiological procedures - where a sonologist provides interventional and/or invasive
      procedures, he/she shall be eligible to claim tariffs from the Diagnostic Radiological Procedures
      Schedule regardless of imaging modality.
      Nuclear Medicine – In Vivo where two fees apply:
     -       Technical: includes fees for the technical and physical aspects of the services rendered.
             The cost of the material is additional.
     -       Professional: is the fee for the professional services only, performed by the physician.




                                                        98                 AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix F – Canada Professional Supervision
SASKATCHEWAN

Introduction
The Saskatchewan Medical Care Insurance Plan provides health insurance cover for services provided
by physicians, chiropractors and optometrists as well as some services provided by dentists.
Saskatchewan Health administers the plan. The plan pays for insured services on a fee-for-service
basis in accordance with medical care insurance payment schedule. The latest schedule came into
effect from April 2005.

The Saskatchewan Health Payment Schedule for Insured Services Provided by a Physician - April 1,
2005 provides some information on professional supervision and reporting requirements for radiologists
practising in the province. Some are radiologist specific while others apply to physicians generally.
Key features are summarised below.

General – services supervised by a physician
A service which is insured by Saskatchewan Health when provided by a physician is also insured when
provided under the supervision of a physician. Payments can be made to the physician for this
supervision as long as the physician is available to intervene promptly if necessary.

Supervised services are provided by:
   (a) a person during the period of registration on the educational register of the College of
        Physicians and Surgeons as an intern, a resident, an undergraduate junior rotating intern
        (JURI) or as a person taking other post graduate training in Saskatchewan as a physician,
        where that service is provided as part of the course of training being undertaken;
   (b) another physician providing the service as part of a course of instruction being administered by
        the College of Medicine of the University of Saskatchewan and where that physician does not
        charge for the service;
   (c) a person employed by a physician in the physician’s office and for whose work the physician
        assumes overall responsibility and provides intermittent daily personal supervision, and the
        service is:
            (i)      a laboratory service;
            (ii)    a diagnostic X-ray procedure;
            (iii)   a diagnostic procedure involving a tracing;
            (iv)    an intra-muscular, intra-dermal, or sub-cutaneous injection;
            (v)     a specimen collection.
    (d) a person in training as a health care worker under the supervision of the physician for a specific
        procedure and the worker does not have privileges through either independent licensure or
        transfer of function to independently perform the procedure (e.g. advanced clinical nurse,
        respiratory technologist).
    (e) A person employed by a physician whose practice is restricted to dermatology may provide
        ultraviolet B therapy when the physician assumes overall responsibility and provides intermittent
        daily personal supervision.

Payment for a supervised service may only be made to the physician providing the supervision.




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Appendix F – Canada Professional Supervision
Radiology
Radiology is not insured when:
   (a) provided in hospital or any facility funded by the District Management Branch, Saskatchewan
       Health
   (b) performed by other than a radiologist


Diagnostic Ultrasound
Ultrasound is an insured service where:
      it is provided outside a hospital and is not provided to a hospital in-patient or a patient in the
         Emergency Department
      it is provided by a physician who is listed by the College of Physicians and Surgeons of
         Saskatchewan as having qualified to receive payments
      a hard copy of the diagnostic ultrasound examination (s) plus a written signed interpretation of the
        report of that examination is retained by the physician providing the service.

Payment schedule distinguishes between technical component and interpretation component.


Diagnostic Radiology
      A diagnostic x-ray procedure is an insured service where it is entirely provided outside a hospital
       by a radiologist.
      Payment to the radiologist will be made only where he has performed the procedure personally or
       the technical component was performed by qualified staff for whom he assumes responsibility
       and provides daily supervision.
      Payment for diagnostic x-rays of any one region includes payment for a sufficient number of films
       to establish diagnosis in the average case. Payment includes the customary media and its
       administration, but not specialist clinic procedures listed in Section A of the Payment Schedule
       for which an additional payment may be made.

Payment schedule distinguishes between technical component and interpretation component.


Radiologist Clinical Procedures
      Certain procedures are insured where provided by a radiologist.
      Payment is to radiologist is made only where the radiologist has performed the procedure
       personally.
      Procedures include angiography, transluminal angioplasty, procedures under fluoroscopic, CT or
       ultrasonic guidance and selective catheterisation of renal vein by Seldinger technique or cut
       down.
      Cardiologists have applicable angiography services in another section (A Section) of the payment
       schedule.
      Other procedures (600X to 663X) may be charged by other physicians recognised by the College
       of Physicians and Surgeons as having adequate training in radiology and confining their
       practice to radiology.



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Appendix F – Canada Professional Supervision
Therapeutic Radiology, Nuclear Medicine
     Therapeutic radiology services are not listed in the Payment Schedule because in Saskatchewan
      these procedures are performed in facilities funded through other government programs.
     Therapeutic radiology or isotope procedure is an insured service where it is entirely provided
      outside a hospital and it is provided by a qualified specialist in Therapeutic Radiology.




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Appendix F – Canada Professional Supervision
ONTARIO

Introduction
The Ontario Health Insurance Plan (OHIP) provides residents of Ontario with coverage for medically
necessary services. The Ministry of Health and Long-Term Care administers the plan. The OHIP
Schedule of Benefits and Fees sets out services covered, associated requirements, fees and benefits
including those relating to diagnostic imaging. Some are general relating to all physician services while
others are imaging specific. Key features are summarised below.

General - Delegated Procedure
When a procedure(s) is carried out by a physician’s employee(s), under the direct supervision of the
physician in his/her office, the usual claims can be made for the procedure(s) which are generally and
historically accepted as those which may be carried out by the nurse or other medical assistant in the
employ of the physician.

Procedures in this context do not include such services as assessments, consultations, psychotherapy,
counselling etc.

Direct supervision requires that, during the procedure, the physician be physically present in the office
or clinic at which the service is rendered.

While this dies not preclude a physician from being otherwise occupied, he/she must be in personal
attendance to ensure that procedures are being performed competently and he/she must at all times be
available immediately to approve, modify or otherwise intervene in a procedure as required in the best
interests of the patient.

Some procedures may not require the physical presence of a physician for direct supervision. These
exceptions to the physical presence of the physician requirement for direct supervision may be made
upon recommendation of the Ontario Medical Association and the College of Physicians and Surgeons
of Ontario.

Only the simple office procedures listed below may be performed by the non-physician without the
physical presence of a physician in the physician’s office.

The procedure must be rendered in accordance with accepted professional standards and practice [Sec
18 (2) of the Health Insurance Act].

The non-physician performing the procedure must have been properly trained and report to the
physician.

Professional and Technical Components

Procedures are divided into a professional component (P) and a technical component (H)

Technical component may only be billed for a service provided in the out-patient department at a
hospital or in an off-site premise, operated by the hospital corporation.

Some procedures (e.g. diagnostic ultrasound, nuclear medicine) have two levels of professional
component – P1 and P2.




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Appendix F – Canada Professional Supervision
Diagnostic Radiology, MRI and Nuclear Medicine

                                                                                                 Nuclear
                                                             Diagnostic
                                                                                   MRI          medicine in
                                                             Radiology
                                                                                                  Vivo
   Professional component (P or P1)
        F.   Providing clinical supervision including
             approving, modifying and/or intervening in
             the performance of the procedure where
             appropriate, and quality control of all
             elements of the technical component
        G. Performance of any clinical procedure
           associated with the diagnostic procedure
           which is not separately billable.
        H. Where appropriate, post procedure               Applicable        Applicable       Applicable
           monitoring, including intervening except
           where this constitutes a separately billable
           service.
        I.   Interpreting the results of the diagnostic
             procedure.
        J.   Providing premises for any aspect(s) of A
             and D that is (are) performed at a place
             other than the place in which the
             procedure is performed.


   If the physician claiming the fee for the service is
   personally unable to perform elements A, B and C,
   these may be delegated to another physician who
   must personally perform the service.


   Element D must be personally performed by the
   physician who claims the service.
   Professional component (P2)
        A.   Interpreting the results of the diagnostic
             procedure.
        B.   Providing premises for any aspect(s) of the
                                                           Not applicable    Not applicable
             specific elements, that is (are) performed
             at a place other than the lace in which the
             procedure is performed.


   Element A must be personally performed by the
   physician who claims for the service.
   Technical component (H)
        A.   Preparing the patient for the procedure.
        B.   Performing the diagnostic procedure or
             assisting in the performance of
                                                                             Not applicable
             fluoroscopy.
        C. Making arrangements for any appropriate
           follow-up care.



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Appendix F – Canada Professional Supervision
        D. D. Providing records of results of the
           procedure to the interpreting physician.
        E.   Discussion with, and providing information
             and advice to, patient or patient’s
             representatives(s), whether by telephone
             or otherwise, on matters related to the
             service.
        F.   Preparing and transmitting a written,
             signed and dated\ interpretation report of
             the procedure to the referring physician.
        G. Providing premises, equipment, supplies
           and personnel for all specific elements of
           the technical and professional components
           except for the premises for any aspect9s)
           of A and D of the professional component
           that is (are) not performed at the place in
           which the procedure is performed.



Diagnostic Ultrasound

Professional Component P1
    A. Being physically present in the ultrasound department or facility to provide clinical supervision,
        including approving, modifying and/or intervening in the performance of the procedure where
        appropriate, and quality control of all elements of the technical component of the procedure.
    B. Either
             a.      the performance of some or al of the procedure; or
             b.      the review of the images obtained before the patient leaves the department/office,
                     so as to be able to modify the examination while the patient is still in the
                     department office.

    C. Where appropriate, post procedure monitoring, including intervening except where this
       constitutes a separately billable service.
    D. Interpreting the results of the diagnostic procedure.
    E. Providing premises for any aspect of D that is performed at a place other than the place in
       which the procedure is performed.

Elements A, B, C and D must be personally performed by the physician who claims the service.

Professional Component P2
    A. Interpretation of the results if the physician’s only contact with the examination is a review of its
        recording by video methods or multi-format images, after the patient has left the
        department/office.
    B. Providing the premises for any aspect of A of P2 that is performed at a place other than the lace
        in which the procedure is performed.

Element A must be personally performed by the physician who claims the service.


Technical Component H
   A. Preparing the patient for the procedure.


                                                          104        AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix F – Canada Professional Supervision
    B. Performing the diagnostic procedure(s).
    C. Making arrangements for any appropriate follow-up care.
    D. Providing records of results of the procedure to the interpreting physician.
    E. Discussion with, and providing information and advice to, patient or patient’s representatives(s),
       whether by telephone or otherwise, on matters related to the service.
    F. Preparing and transmitting a written, signed and dated\ interpretive report of the procedure to
       the referring physician.
    G. Providing premises, equipment, supplies and personnel for all specific elements of the technical
       and professional components except for the premises for any aspect(s) of A of the P2
       professional component that is (are) not performed at the place in which the procedure is
       performed.

Where the only professional component provided is P2, the specific elements A and C listed for the
professional component P1are included in the specific elements of the technical component.




                                                   105             AUSTRALIAN HEALTHCARE ASSOCIATES
Appendix G – Risk Management Framework
This appendix provides an example of a risk management framework radiologists may use in the development of their practice-based protocols.

G RISK MANAGEMENT FRAMEWORK


                                                                    Cardio-                                        Female           Musculo-
                   Nervous                                                         Digestive     Genitourinary
                                    Neck            Chest          vascular                                      Reproductive       skeletal
                   System                                                           System         System
Modality                                                           System                                          System            System


  General
                    Risk?           Risk?            Risk?           Risk?           Risk?           Risk?           Risk?           Risk?
Radiography



 Ultrasound         Risk?           Risk?            Risk?           Risk?           Risk?           Risk?           Risk?           Risk?


 Computed
Tomography          Risk?           Risk?            Risk?           Risk?           Risk?           Risk?           Risk?           Risk?
   (CT)

  Magnetic
 Resonance          Risk?           Risk?            Risk?           Risk?           Risk?           Risk?           Risk?           Risk?
Imaging (MRI)




                                                                      106                                     AUSTRALIAN HEALTHCARE ASSOCIATES

				
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