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Matching Regulation to Practice
STATE CHAPTERS
Matching Regulation to Practice Robert J. Achermann, JD With the increasing prevalence of imaging equipment that combines both positron emission tomography (PET) and single photon-emission computed tomography (CT) with computed tomographic imaging, some users may encounter state licensing and regulation that cause practical staffing issues. The emergence of hybrid PET/CT combination units may encounter roadblocks with regard to the types of technologists who can operate this type of equipment. Depending on the status of your state’s structure for regulating radiologic and nuclear medicine technologists, the solution we sought in California may be appropriate. BACKGROUND In California, both radiologic technologists (RTs) and nuclear medicine technologists are licensed in their respective fields to operate diagnostic imaging equipment under appropriate physician or other health care practitioner supervision. The Bureau of Radiologic Health (BRH) has jurisdiction over both types of equipment and both types of technologists and thus similar control over any hybrid units. In 2000, the BRH issued an advisory that recognized that new technology was emerging that combined both nuclear medicine and radiologic technology [1]. Depending on the circumstances, this technology could be operated either separately or in dual mode. The state opined [1] that when such scanners were operated as standalone devices, only technologists who were licensed to operate specific technology could operate the equipment (ie, only a licensed nuclear medicine technologist could 844
operate a PET scanner, and only a licensed RT could operate a CT scanner). However, in dual mode, for attenuation correction and anatomic localization only, procedures were considered nuclear medicine. As the technology improved, these scanners became capable of providing computed tomographic scans of diagnostic quality. Referring physicians were expecting their patients to undergo both CT and PET/CT during a single visit, on the same piece of equipment. The 2000 advisory did not allow nuclear medicine technologists to perform diagnostic CT. The only individuals who could scan patients on hybrid PET/CT units to obtain PET, PET/CT, and CT would have to be licensed as both RTs and nuclear medicine technologists. An obvious alternative would be to have both types of technologists present to perform their respective portions of examinations, but that would be a costly and inefficient use of resources and personnel. A legislative change was necessary to eliminate this dual-licensure requirement for the use of this hybrid equipment. Many state legislatures have the difficult task of deciding the initial scope of practice for a variety of health care practitioners and then often end up being the umpires in resolving changes to those descriptions of scope. With the exception of physicians who have plenary licenses to practice medicine, almost all other types of health care personnel, from RTs to podiatrists, have specific descriptions of their training, roles, duties, and perhaps requirements for supervision. This is the legal framework in California, but some states do not even license RTs and simply require that physicians who use the equip-
ment be responsible for their personnel and competence. If there are scopes of practice in your state, you may witness some very nasty legislative battles over who can do what and also any changes to existing law. The relationship between the radiology community and RTs in California has always been a very supportive one. For example, when the radiology community wanted to change the law on the ability of RTs to inject contrast material and the level of radiologist supervision, we met with and obtained the support of the RT community. Similarly, when it was decided to pursue legislation in California to permit qualified RTs and nuclear medicine technologists to be cross-trained to operate hybrid PET/CT units, we sought out all the affected parties to achieve consensus. That consensus within the medical community was already created in 2002, with the convening and publication of a position document, “Fusion Imaging: A New Type of Technologist for a New Type of Technology” [2]. The conference generating that document included representatives from the American College of Radiology (ACR), the Society of Nuclear Medicine, the American Society of Radiologic Technologists, the Society of Nuclear Medicine Technologist Section, the Nuclear Medicine Technologists Society, the American Registry of Radiologic Technologists (ARRT), and the Nuclear Medicine Technology Certification Board (NMTCB). The document states that radiographers, nuclear medicine technologists, and radiation therapy technologists are qualified to operate PET/CT scanners, provided they meet specific
© 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.07.012
State Chapters 845
training and experience criteria. That document urged both the ARRT and the NMTCB to develop qualification guidelines to allow radiographers and therapists to sit for the PET examination and nuclear medicine technologists to sit for the CT examination. Both certification boards have met that goal, and by 2005, both were offering the respective technologists the opportunity to sit for specific examinations for certification. It was decided that we would follow a similar path of altering state law to allow RTs or nuclear medicine technologists to operate hybrid units either as a stand-alone modality or in dual mode, if they had obtained their respective cross-training. STEPS TAKEN The Society of Nuclear Medicine’s Pacific Southwest Technologist Chapter notified the BRH that PET/CT scanners were much more sophisticated than they had been in 2000, and that many were used as diagnostic computed tomographic scanners as well. They requested that the bureau issue another advisory that would allow appropriately trained and credentialed technologists, as described in the position document, to be recognized by the state to operate the hybrid scanners. Counsel for the BRH indicated that this would not be possible under the current statutes and that this type of change would be possible through only new legislation. The Pacific Southwest Technologist Chapter contacted the California Society of Radiologic Technologists to inform the society of the current regulatory climate and to ask the society to cosponsor a bill. They also contacted the respec-
tive physician organizations (the California Radiological Society and the Society of Nuclear Medicine) to obtain their support. All requests were enthusiastically approved. Financial assistance was received from the above-mentioned groups, as well as imaging vendors. In a state such as California, with a full-time legislature and a fairly complex process for enacting legislation, it is advisable to obtain guidance and support from a lobbyist to assist in the passage of legislation. In this case, because there was support from the radiology community, it was decided to retain the services of the lobbyist for the state radiology society, who was knowledgeable of the issues and the process for this kind of legislation. We approached individual legislators, explained the problem, and eventually Assemblyman Spitzer introduced Assembly Bill 2720. The actual drafting of the bill was done with the support of the lobbyist, consultation with the BRH, affected medical specialties, and the technologist community. Assembly Bill 2720 would require that the BRH issue a permit to either RTs or certified nuclear medicine technologists to perform PET or CT, respectively, on the basis of their obtaining certification from either the NMTCB or the ARRT. The bill allows only crosstrained individuals to perform those procedures on hybrid PET/CT units. It would also allow either an RT or a nuclear medicine technologist to perform these procedures as part of training program to obtain certification. The bill moved through multiple committee hearings with little or no debate. There were amendments from time to time to make minor adjustments or clarifications
as the issue was reviewed by committee staff members. Because it was really a consensus approach, the major task was preparing the background on the reason for the bill and being available to resolve issues or concerns. Assembly Bill 2720 passed the legislature and was signed by the governor and took effect on January 1, 2007. SUMMARY AND NEXT STEPS If legislative change is needed, 5 elements must be present for an uneventful and successful process: 1. a good relationship with the agency that regulates radiation in your state, 2. the support of both the radiology and nuclear medicine communities, 3. radiologic and nuclear medicine technologist cosponsorship, 4. financial assistance, and 5. an experienced lobbyist familiar with your state’s legislative process as it relates to medical imaging. Once the bill is signed into law, the agency overseeing radiology issues will be able to recognize the ARRT (for CT) and NMTCB (for PET) credentials and can issue the appropriate license. However, to put the law into practice, the technologist societies must educate their constituents. Technologists must become competent and knowledgeable in hybrid imaging to pass the certification examinations and provide excellent patient care. REFERENCES 1. Radiation Safety Advisory 00-1. June 3, 2004. 2. Fusion imaging: a new type of technologist for a new type of technology. J Nucl Med Technol 2002;30:200-4.
Robert J. Achermann, JD, California Radiological Society, 1 Capitol Mall, Suite 320, Sacramento, CA 95814; e-mail: [email protected].
Matching Regulation to Practice Robert J. Achermann, JD With the increasing prevalence of imaging equipment that combines both positron emission tomography (PET) and single photon-emission computed tomography (CT) with computed tomographic imaging, some users may encounter state licensing and regulation that cause practical staffing issues. The emergence of hybrid PET/CT combination units may encounter roadblocks with regard to the types of technologists who can operate this type of equipment. Depending on the status of your state’s structure for regulating radiologic and nuclear medicine technologists, the solution we sought in California may be appropriate. BACKGROUND In California, both radiologic technologists (RTs) and nuclear medicine technologists are licensed in their respective fields to operate diagnostic imaging equipment under appropriate physician or other health care practitioner supervision. The Bureau of Radiologic Health (BRH) has jurisdiction over both types of equipment and both types of technologists and thus similar control over any hybrid units. In 2000, the BRH issued an advisory that recognized that new technology was emerging that combined both nuclear medicine and radiologic technology [1]. Depending on the circumstances, this technology could be operated either separately or in dual mode. The state opined [1] that when such scanners were operated as standalone devices, only technologists who were licensed to operate specific technology could operate the equipment (ie, only a licensed nuclear medicine technologist could 844
operate a PET scanner, and only a licensed RT could operate a CT scanner). However, in dual mode, for attenuation correction and anatomic localization only, procedures were considered nuclear medicine. As the technology improved, these scanners became capable of providing computed tomographic scans of diagnostic quality. Referring physicians were expecting their patients to undergo both CT and PET/CT during a single visit, on the same piece of equipment. The 2000 advisory did not allow nuclear medicine technologists to perform diagnostic CT. The only individuals who could scan patients on hybrid PET/CT units to obtain PET, PET/CT, and CT would have to be licensed as both RTs and nuclear medicine technologists. An obvious alternative would be to have both types of technologists present to perform their respective portions of examinations, but that would be a costly and inefficient use of resources and personnel. A legislative change was necessary to eliminate this dual-licensure requirement for the use of this hybrid equipment. Many state legislatures have the difficult task of deciding the initial scope of practice for a variety of health care practitioners and then often end up being the umpires in resolving changes to those descriptions of scope. With the exception of physicians who have plenary licenses to practice medicine, almost all other types of health care personnel, from RTs to podiatrists, have specific descriptions of their training, roles, duties, and perhaps requirements for supervision. This is the legal framework in California, but some states do not even license RTs and simply require that physicians who use the equip-
ment be responsible for their personnel and competence. If there are scopes of practice in your state, you may witness some very nasty legislative battles over who can do what and also any changes to existing law. The relationship between the radiology community and RTs in California has always been a very supportive one. For example, when the radiology community wanted to change the law on the ability of RTs to inject contrast material and the level of radiologist supervision, we met with and obtained the support of the RT community. Similarly, when it was decided to pursue legislation in California to permit qualified RTs and nuclear medicine technologists to be cross-trained to operate hybrid PET/CT units, we sought out all the affected parties to achieve consensus. That consensus within the medical community was already created in 2002, with the convening and publication of a position document, “Fusion Imaging: A New Type of Technologist for a New Type of Technology” [2]. The conference generating that document included representatives from the American College of Radiology (ACR), the Society of Nuclear Medicine, the American Society of Radiologic Technologists, the Society of Nuclear Medicine Technologist Section, the Nuclear Medicine Technologists Society, the American Registry of Radiologic Technologists (ARRT), and the Nuclear Medicine Technology Certification Board (NMTCB). The document states that radiographers, nuclear medicine technologists, and radiation therapy technologists are qualified to operate PET/CT scanners, provided they meet specific
© 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.07.012
State Chapters 845
training and experience criteria. That document urged both the ARRT and the NMTCB to develop qualification guidelines to allow radiographers and therapists to sit for the PET examination and nuclear medicine technologists to sit for the CT examination. Both certification boards have met that goal, and by 2005, both were offering the respective technologists the opportunity to sit for specific examinations for certification. It was decided that we would follow a similar path of altering state law to allow RTs or nuclear medicine technologists to operate hybrid units either as a stand-alone modality or in dual mode, if they had obtained their respective cross-training. STEPS TAKEN The Society of Nuclear Medicine’s Pacific Southwest Technologist Chapter notified the BRH that PET/CT scanners were much more sophisticated than they had been in 2000, and that many were used as diagnostic computed tomographic scanners as well. They requested that the bureau issue another advisory that would allow appropriately trained and credentialed technologists, as described in the position document, to be recognized by the state to operate the hybrid scanners. Counsel for the BRH indicated that this would not be possible under the current statutes and that this type of change would be possible through only new legislation. The Pacific Southwest Technologist Chapter contacted the California Society of Radiologic Technologists to inform the society of the current regulatory climate and to ask the society to cosponsor a bill. They also contacted the respec-
tive physician organizations (the California Radiological Society and the Society of Nuclear Medicine) to obtain their support. All requests were enthusiastically approved. Financial assistance was received from the above-mentioned groups, as well as imaging vendors. In a state such as California, with a full-time legislature and a fairly complex process for enacting legislation, it is advisable to obtain guidance and support from a lobbyist to assist in the passage of legislation. In this case, because there was support from the radiology community, it was decided to retain the services of the lobbyist for the state radiology society, who was knowledgeable of the issues and the process for this kind of legislation. We approached individual legislators, explained the problem, and eventually Assemblyman Spitzer introduced Assembly Bill 2720. The actual drafting of the bill was done with the support of the lobbyist, consultation with the BRH, affected medical specialties, and the technologist community. Assembly Bill 2720 would require that the BRH issue a permit to either RTs or certified nuclear medicine technologists to perform PET or CT, respectively, on the basis of their obtaining certification from either the NMTCB or the ARRT. The bill allows only crosstrained individuals to perform those procedures on hybrid PET/CT units. It would also allow either an RT or a nuclear medicine technologist to perform these procedures as part of training program to obtain certification. The bill moved through multiple committee hearings with little or no debate. There were amendments from time to time to make minor adjustments or clarifications
as the issue was reviewed by committee staff members. Because it was really a consensus approach, the major task was preparing the background on the reason for the bill and being available to resolve issues or concerns. Assembly Bill 2720 passed the legislature and was signed by the governor and took effect on January 1, 2007. SUMMARY AND NEXT STEPS If legislative change is needed, 5 elements must be present for an uneventful and successful process: 1. a good relationship with the agency that regulates radiation in your state, 2. the support of both the radiology and nuclear medicine communities, 3. radiologic and nuclear medicine technologist cosponsorship, 4. financial assistance, and 5. an experienced lobbyist familiar with your state’s legislative process as it relates to medical imaging. Once the bill is signed into law, the agency overseeing radiology issues will be able to recognize the ARRT (for CT) and NMTCB (for PET) credentials and can issue the appropriate license. However, to put the law into practice, the technologist societies must educate their constituents. Technologists must become competent and knowledgeable in hybrid imaging to pass the certification examinations and provide excellent patient care. REFERENCES 1. Radiation Safety Advisory 00-1. June 3, 2004. 2. Fusion imaging: a new type of technologist for a new type of technology. J Nucl Med Technol 2002;30:200-4.
Robert J. Achermann, JD, California Radiological Society, 1 Capitol Mall, Suite 320, Sacramento, CA 95814; e-mail: [email protected].