Developing Imaging Reporting by Radiology Practitioner Assistants - Term Paper Example

Developing imaging Reporting by Radiology Practitioner Assistants Introduction and Background Developments in the role of Radiology Practice Assistants (RPAs) can be traced to more than four decades back. A review of literature shows that the main issues that led to the increased responsibilities RPAs stemmed from the shortage of radiologists, the increased demand for quick radiology assessment as diagnostic aids for diagnosis and initiation of therapeutic interventions, and the discontent among radiographers with their limited responsibilities (Rudd, 2003). This led to the concept of creating additional knowledge and skills among experienced radiology technicians and providing them with certification to take up additional responsibilities in procedural base studies. However, as with any change there was resistance to the changing developments on the role of RPA’s and minimal acceptance of the benefits in speeding up radiology reporting, with particular emphasis in radiology reporting in the case of accidents and emergencies that came from the increased role of RPA assistance in radiology reporting (Williams et al, 2005). The advent of imaging technology as a diagnostic aid is nearly a century old and certain practices evolved with the reporting traditions in radiology. These practices have created the requirement of a medical report. Statutes relating to the medical report to accompany radiological findings have made it essentially the domain of radiologists, negating any intrusion on the medical report by radiographers. This has led to a situation, wherein radiographers find that despite developments in their role whereby they are encouraged to point out their imaging findings, they are forced to avoid making any comments on the medical significance of their imaging findings. In short this makes their imaging findings deficit in supporting clinical decisions (Robinson, 1998). In the United States of America this practice in radiological reporting has led to a limited role in the advanced functioning of RPAs to three key areas under the supervision of a radiologist. These key areas are responsibility for the assessment of patients, patient management and education of patients; evaluation of image quality, initial image observations, and the communication of these observations to the supervising radiologist, and performing certain selected radiology procedures that include fluoroscopy. RPAs are not allowed to interpret images, make diagnosis, and prescribe medication or therapies, which remain in the realm of radiologists (The Radiologist Assistant: Improving Patient care While Providing Workforce Solutions). Thus under the Technological, Technicians & Other Technical Service Provider Type under which the RPA classification was added, the RPA is a health professional, who is certified as a registered radiographer with the American Registry of Radiologic Technologists (ARRT) with the limited role of providing certain aspects of health under the supervision of the radiologist (New Code Values). Rudd 2003, points such a limitation in the role of RPA’s does not completely address the two key issues of the increased demand for quick radiology assessment as diagnostic aids for diagnosis and initiation of therapeutic interventions, and the discontent among radiographers with their limited responsibilities. It is in the light of this that an expansion of the role of RPAs to take in plain film interpretation of the chest, abdomen, spine, skull, and extremities needs to be considered seriously. Rationale for the Expansion of the Responsibilities of the RPA to Plain Film Interpretation The ACR PRACTICE GUIDELINE FOR GENERAL RADIOGRAPHY 2007, p.17, specifies that “the goal of radiography is to establish the presence or absence and nature of disease by the demonstration of the disease process itself or the effects of the disease process on the normal anatomy.” Plain film interpretation one imaging technique in radiography and in recommending a role for plain film interpretation for RPAs it becomes essential to justify this recommendation in keeping with the goals of radiology. A clear cut set of standards for plain film interpretation is absent. In the absence of such clear cut standards for plain film interpretation, the only way forward in ascertaining the capability for RPAs to take on the responsibility of plain film interpretation is to use the medico-legal benchmark of the comparison of the RPAs interpretation of plain film interpretation with that of the average performance of the health practitioner currently responsible for this function in the health care sector (Robinson et al, 1999). In the United Kingdom radiographers have been provided with an expanded role, with particular reference to plain film interpretation and reporting in trauma and skeletal radiography, and this extended role of the radiographers has been established or is in the process of being established all over the United Kingdom as identified by the Audit Commission (2002), the NHS Modernisation Agency (2003), and the NHS Improvement Plan (2004) (Request for New/Amendment to an Existing Module). An evaluation of radiographic reporting was conducted at four trusts of the NHS with regard to four parameters. These parameters were accuracy of the radiographers’ reports in terms of sensitivity and specificity; impact on the care given to the patient and patient management with respect to the volume of reporting activity and the ready availability of thee reports; costs incurred in the implementation of radiographer reporting; user satisfaction. The evaluation demonstrated that radiographers displayed high accuracy and maintained these high levels of accuracy over time, particularly with regard to musculo-skeletal trauma examinations. Users of the radiographer service were also very satisfied at these high levels of accuracy. There was increased speed in the availability of radiological examination reports, which had its impact on improved patient care. However, there were costs attached to these benefits, which ranged between forty to sixty pounds per radiographer per week (The Implementation of a Radiographic Reporting Service for trauma examinations of the skeletal system, 1999). According to the Implementation of a Radiographic Reporting Service for trauma examinations of the skeletal system, in 4 National Health Service Trusts, 1999, p. 109, impediments to the functioning of the radiographic reporting service did not arise from accuracy issues of the reports, but instead stemmed from “institutional politics, poor inter-departmental relationships, and attitudes of senior staff. Further evidence of the accuracy and benefits of radiographer reporting experience in the United Kingdome can be seen from the several studies that have evaluated these factors from different perspectives. Piper, Paterson and Godfrey, 2005, evaluated the results in Objective Structural Examinations (OSE) of radiographer reporting in 6796 cases, where the radiographers had acquired additional knowledge and skills by successfully completing a post-graduate qualification in clinical reporting of the appendicular and axial skeleton. The mean values calculated from OSE scores were very high in terms of sensitivity, specificity, and accuracy. A similar finding was made with regard to A/E and non-A/E examinations with negligible differences in between A/E and Non-A/E examination accuracy. Brealey et al, 2005, compared the reporting of plain film radiographs between selectively trained radiographers and consultant radiologists for accident and emergency departments as well as general practitioners in hospital environments. Though there was only a limited variance in the accuracy between the reporting of plain film radiographs, which did not impact significantly on diagnosis and therapeutic decisions, both in the accident and emergency department and among the general there was greater confidence shown in the plain film reports of consultant radiologists than in the plain film reports of selectively trained radiographers. This however did not deter the authors from concluding that there was potential to use selectively trained radiographers in accident and emergency departments and for general practitioners in hospital settings (Brealey et al, 2005). Brealey et al, 2005, evaluated the cost and impact of using selectively trained radiographers for reporting accident and emergency radiographs of the appendicular skeleton. The authors found a slight reduction in the accuracy of the reporting, which however did not have a significant impact on patient outcomes. The authors also found that the use of selectively trained radiographers for such reporting of plain films led to a cost saving of three hundred and sixty-one pounds to the X-ray department (Brealey et al, 2005). Brealey, King and Warnock, 2002, evaluated the acceptance of different health care professionals of reporting of accident and emergency plain film reporting of selected areas of the body by radiographers. Their evaluation showed there was near unanimous agreement among radiologists that radiographic reporting of accident and emergency plain films of selected body areas could be accepted and it was useful on alleviating their workload with regard to reporting. This appreciation of radiographer reporting of plain film reporting however was not shared by the other health care professionals, who were either in disagreement or were uncertain of the accuracy and utility of radiographer reporting of accident and emergency plain film reporting (Brealey, King & Warnock, 2002). Four themes emerge from the studies that have evaluated radiographer reporting of plain films, which are that radiographer plain film reporting is accurate and useful, provides costs saving, lays an emphasis on increased knowledge and skills requirement in radiographers, and is hindered only by the politics, culture and attitudes within the healthcare institution. Another factor that supports the enhanced role of radiographers in plain film reporting is the changes that have in expanded roles to other disciplines within the health care sector to provide for more satisfactory outcomes to patients. This can be seen in the expanding role of nursing professionals is several areas of health care, which were essentially the domains of clinicians earlier. Nurse-led therapeutic interventions and nurse prescribing and nurse reporting of radiographs are some of the expanded roles in nursing professionals, who have acquired the necessary additional knowledge and skill sets to perform these roles satisfactorily (Culpan, 2006). . This suggests that the roles of other health care professionals can be expanded suitably after the acquisition of the additional and necessary skill sets for better patient outcomes. Additional Curriculum & Education Recommendations for RPA’s The current curriculum for certification of RPA’s in the United States of America is based on role of the RPA’s functioning under the supervision of radiologists with no medical reporting functions. However, the CBRPA [5] role delineation for RPA’s is flexible in that permits and expansion and progression of the role to incorporate a certain degree of independence in the clinical performance and decision-making by RPAs (Ellenbogen, et al, 2007). This role flexibility can take place only when the curriculum of the RPAs is expanded to provide the appropriate knowledge and skill sets required for plain film reporting as an expanded responsibility for RPAs as these reports have to stand up the legal requirements of the heath care sector (Culpan, 2006). In the expanded curriculum needs of RPA, with regard to the expanded role of reporting on plain film radiography, there is the need for the curriculum to provide greater depth of anatomy and physiology of the human body in the undergraduate programmes that lead to RPA certification. The undergraduate programmes should also incorporate image interpretation and clinical reporting knowledge and skill sets at the appropriate level so that the RPA is equipped to provide informed comments on radiographic examinations of using plain film with and without contrast agents. The clinical reporting of plain films have to stand up to the legal standards and so a part of the expanded curriculum needs for undergraduates planning to become RPAs will have to incorporate issues that cover all the medic-legal aspects that will have an impact on the expanded role RPA practice of plain film reporting. Plain film radiography reporting is not a role done in isolation. It has a specific clinical function. This link between the plain film reporting and its clinical implications makes it essential that the RPA pre-registration undergraduate programmes are embedded with imparting knowledge and skills to provide the ability to take into consideration the clinical context for which the radiographic image has been sought and to understand the essential aspects of the diagnostic questions that need to be answered. Such an understanding does not lie only in the image being considered, but also in the clinical history, laboratory test results and the patient’s previous radiographs. This calls for the curriculum to incorporate the ability of understanding patient history and laboratory examination reports. In other words the curriculum should impart knowledge and skill sets that include the ability to make clinical assessments (Freeman, 2006). Literary References ACR PRACTICE GUIDELINE FOR GENERAL RADIOGRAPHY. 2007. General Radiography, p.17-21. Brealey, S. D., King. D. G., Hahn, S., Crowe, M., Williams, P. Rutter, P. & Crane, S. (2005). Radiographers and radiologists reporting plain radiograph requests from accident and emergency and general practice. Clinical Radiology, 60(6), 710-717. Brealey, S. D., King. D. G., Hahn, S., Godfrey, C. Crowe, M. T. I., Bloor, K., Crane, S. & Longsworth, D. (2005). The costs and effects of introducing selectively trained radiographers to an A&E reporting service: a retrospective controlled before and after study. British Journal of Radiology, 75, 499-505. Brealey, S., King, D. &Warnock, N. (2002). An assessment of different healthcare professionals’ attitude towards radiographer reporting of A&E films. Radiography, 8(1), 27-34. Culpan, G. (2005). Development of radiographer reporting into the 21st century. Imaging & Oncology, 38-45. Ellenbogen, H. P., Hoffman, R. J., Short, W. B. & Gonzalez, A. (2007). The Radiological Assistant: What Radiologists Need to Know Now. Journal of the American College of Radiologists, 4, 461-470. Freeman, C. (2006). Medical Image Interpretation and Clinical Reporting by Non-Radiologists. London, The College of Radiographers. New Code Values. 2008. Retrieved September 19, 2008, from WPC Web Site http://www.wpc-edi.com/custom_html/tax_new.htm Piper, K. J., Paterson, A. M. & Godfrey, R. C. (2005). Accuracy of radiographers’ reports in the interpretation of radiographic examinations of the skeletal system: a review of 6796 case. Radiography, 11(1), 27-34. Request for New/Amendment to an Existing Module. 2008. Faculty of Health and Social Care. University of West England, Bristol. Robinson, A. J. P. (1998). Pattern recognition and radiographer reporting. Radiography, 4, 155-157. Robinson A. J. P. Wilson, D., Coral, A., Murphy, A. & Verow, P. (1999). Variation between experienced observers in the interpretation of accident and emergency radiographs. The British Journal of Radiology. 72, 323-330. Rudd, P. D. (2003). The development of radiographer reporting 1965-1999. Radiography, 9(1), 7-12. The Implementation of a Radiographic Reporting Service for trauma examinations of the skeletal system. 1999. Department of Radiography. Canterbury Christ Church University College. NHS Executive – South Thames Funded Research Project. The Radiologist Assistant: Improving Patient care while providing Workforce Solutions. 2002. Consensus Statements from the Advanced Practice Advisory Panel, Washington D.C. Williams, O. C., Bhawna, O., Abraham, J. & Hail, L. V. (2005). The Progression of Advanced Practice of RPA-RAs (CBRPA). Professional Life, 22- 28. Read More