Legislature(2005 - 2006)CAPITOL 120
04/11/2005 01:00 PM House JUDICIARY
| Audio | Topic |
|---|---|
| Start | |
| HB14 | |
| HB12 | |
| SB105 | |
| HJR9 | |
| HB150 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 246 | TELECONFERENCED | |
| = | HB 14 | ||
| * | HB 257 | ||
| + | HJR 9 | TELECONFERENCED | |
| += | HB 150 | TELECONFERENCED | |
| HB 53 | |||
| += | HB 12 | TELECONFERENCED | |
| += | SB 105 | TELECONFERENCED | |
| += | HB 96 | TELECONFERENCED | |
HB 150 - LICENSING RADIOLOGIC TECHNICIANS 2:08:32 PM CHAIR McGUIRE announced that the next order of business would be HOUSE BILL NO. 150, "An Act requiring licensure of occupations relating to radiologic technology, radiation therapy, and nuclear medicine technology; and providing for an effective date." [Before the committee was CSHB 150(L&C).] 2:08:51 PM REPRESENTATIVE GARA moved to adopt the proposed committee substitute (CS) for HB 150, Version 24-LS0470\S, Mischel, 4/11/05, as the work draft. There being no objection, Version S was before the committee. 2:09:26 PM REPRESENTATIVE ANDERSON, speaking as the sponsor, relayed that the concept embodied in HB 150 has been evolving since the 1990s. He paraphrased from the following written opening remarks [original punctuation provided]: House Bill 150 will establish educational and certification standards for the health care personnel in Alaska who perform medical imaging and radiation procedures. Any radiology procedure is only as effective as the person performing it. An underexposed chest x-ray cannot reveal pneumonia or a malignant lesion, just as an inadequate mammography technique cannot detect breast cancer. No matter what the procedure, the Radiologic Technologist's knowledge of anatomy, careful application of radiation and skillful operation of sophisticated medical equipment are the keys to its success. To be clinically useful, diagnostic imaging exams must be accurate. 38 states have adopted recommendations for state licensure of radiology personnel. Alaska is not one of those states. Establishing state standards will ensure that Alaskans will have access to safe and high quality radiologic care. Licensure will establish radiation protection measures as well as education and credentialing standards that will ensure the competency of persons operating medical equipment emitting radiation. To ensure that the citizens of the State of Alaska receive maximum protection from the harmful effects of excessive and improper exposure to radiation, licensure must be passed to establish standards. 2:12:28 PM REPRESENTATIVE ANDERSON opined that HB 150 is critical for the safety of Alaskans. Passage of HB 150 would make Alaska the 39th state to adopt legislation regarding the licensure of radiology personnel. He noted that although there might be arguments that personnel in rural Alaska have been performing radiologic procedures [without any problems to date], he can provide examples of over-radiated, under-radiated, and misdiagnosed cases that resulted from improperly trained personnel, generally in rural settings. The University of Alaska has worked to make it easier to enroll in its Radiologic Technology program, he remarked, and asked the committee to support the bill, particularly given the changes in Version S. 2:16:07 PM JON BITTNER, Staff to Representative Tom Anderson, Alaska State Legislature, sponsor, relayed that members' packets include a memorandum that outlines the changes in Version S, which now references "department" throughout rather than "division". He indicated that other changes include adding a new Section 1, which amends AS 08.01.010 to include the regulation of radiographers; removing dental hygienists from proposed AS 08.89.100(b)(2); adding schools of dentistry and dental hygiene to proposed AS 08.89.100(b)(4); adding the word "current" - with regard to certification - to proposed AS 08.89.140(2); adding the words, "or have demonstrated experience sufficient in the opinion of the department to waive the program", to proposed AS 08.89.150(a)(3); changing the words in proposed AS 08.89.170(c) from, "three out of five years preceding application", to, "two years preceding July 1, 2007". 2:21:00 PM MR. BITTNER indicated that still other changes include adding the word, "nonrenewable" - with regard to temporary permits - to proposed AS 08.89.170(d); changing the text in proposed AS 08.89.180(d) to say, "Sponsors approved by the American Registry of Radiologic Technologists are considered approved continuing education providers"; changing the time frame in proposed AS 08.89.210 from, "24 months", to, "one year", and adding the sentence, "The department may require an examination for reinstatement"; and adding, to proposed AS 08.89.220 - which pertains to fees - new paragraphs (8) and (9), which read: (8) adding an area of practice to an existing license; (9) program approval under AS 08.89.130. 2:24:12 PM MR. BITTNER indicated that further changes include changing proposed AS 08.89.340(c) to read: (c) The department may summarily suspend a license before final hearing or during the appeals process if the department finds that the licensee poses a clear and immediate danger to the public welfare and safety. A person is entitled to a hearing conducted by the office of administrative hearings under AS 44.64.010 with seven days after the suspension order is issued. A person may appeal an adverse decision after hearing to the superior court. MR. BITTNER also indicated [that proposed AS 08.89.340 no longer contains a subsection (e), which required waiting a year after license revocation before reapplying]; that proposed AS 08.89.990 no longer contains a definition for "division", and now defines "radiographer" rather than "radiologic technologist"; [that Version S no longer exempts proposed AS 08.89.340(c) from AS 44.64.030(a)(6); that the section pertaining to regulations no longer references the division; that Version S no longer contains revisor's instructions]; and that conforming changes have been made to section numbers. 2:25:46 PM REPRESENTATIVE DAHLSTROM referred to the new language in proposed AS 08.89.210 - "The department may require an examination for reinstatement" - and asked how it will be determined whether a person should take the examination. MR. BITTNER said his assumption is that the Division of Occupational Licensing will ultimately make the determination regarding whether an examination is warranted, and suggested that a representative from the division could better address that question. 2:27:30 PM DONNA J. RUFSHOLM, R.T., Chair, Licensure Committee, Alaska Society of Radiologic Technologists (AKSRT), relayed that the AKSRT asked Representative Anderson to sponsor HB 150. She explained that in 1981, Congress passed the Consumer-Patient Radiation Health and Safety Act of 1981, which established minimum standards for state licensure of personnel who administer ionizing radiation. The goal of establishing those standards was to minimize unnecessary exposure to radiation. Since then, 41 states have adopted licensure laws, though Alaska has yet to do so. Currently, pending legislation in Congress would require all states to either meet or exceed federal standards or else risk losing Medicaid and Medicare reimbursement for imaging procedures. Thus, HB 150 is important, she remarked, because it would establish state standards and thereby remove the risk of losing federal reimbursement; in lieu of having its own state standards, Alaska would have to comply with whatever standards the federal government imposed. MS. RUFSHOLM then posed the question, "Why establish minimum standards for personnel who perform medical imaging procedures?" and responded by saying that basically, it all boils down to quality; safety to the patient, the operator; and the cost. She went on to say: We all know that radiation is a carcinogen; operators of medical x-ray equipment deliver the largest portion of manmade radiation to the general public. Radiation is safe if properly applied, but it can be harmful or even deadly if it's ... [maladministered]. I think that's [a] really important factor ..., that radiation ... has been recognized as one of the leading carcinogens. ... Delays [of] diagnosis or misdiagnoses caused by poor imaging exams can drive up health care costs, [and] inaccurate ... imaging can delay diagnoses. Accurate diagnosis depends on a good and useful medical image; the quality of [a] medical imaging exam is only as good as the person performing it. Right now ..., in Alaska, anyone can take x-rays; [even] anyone who's sitting on the committee ... right now could go into an office, if someone would hire them, and take x-rays without any training. We require hairdressers to be licensed, but ... we don't require people delivering radiation to patients to have any sort of licensing or educational requirements. ... There is a report that's just out ... [by] the Medical Payment Advisory Commission (MedPAC) - which is an agency that advises Congress on health care policy - regarding what they called the overuse, under use, and misuse of imaging services. And on March 17 of 2005, the [federal] House Ways and Means Committee's subcommittee on health conducted a hearing to address the MedPAC recommendations that Congress set standards for those ... who perform or interpret diagnostic imaging examinations. ... [A synopsis indicates that] Medicare has an interest in ensuring that imaging studies are done by skilled, technical staff using appropriate equipment, and that the "CMS" - which is Medicare - strongly should consider setting standards for at least the following areas: imaging equipment, qualifications of the technicians performing the studies, the technical quality of the images produced, and procedures for ensuring patient safety. So this is Medicare, and they're really going to be setting some guidelines and standards for those individuals who perform radiology procedures. MS. RUFSHOLM added: With HB 150, we have recognized the fact that the rural areas of the state have different needs than what the urban areas do, and I think that in writing [HB 150] and working with the different groups around the state, we've tried to address those needs. We surely do not want those services to be discontinued - that's not the intent of the bill - we know that those services need to be there, especially in the very, very remote areas; it's really imperative that they be able to provide radiology services for patient care, and our concern is that we don't want to see those services discontinued but we would like to see the people [who] deliver those services have some sort of training. And we've worked with the University of Alaska, in Anchorage, to provide an online course for those individuals; there are other online courses also available on the Internet for individuals to receive a minimum of training so that they can protect themselves as well as the patient from unnecessary radiation. We've kept the cost down, [and] we've made accommodations in the bill ... so that people who are currently taking x-rays can ... probably be tested out - they would be looked at for competency, and would actually forgo the program ... if they can prove competency. MS. RUFSHOLM concluded: We've allowed ... a very long period of time - a four- year period - for individuals to be able to participate in the course if [that requirement] ... was something that they would have meet ..., and we've also made accommodations [such] that individuals who are new coming into the field would be able to take x- rays as they're taking the first module at the [University of Alaska Anchorage (UAA)] so that they could go to work immediately as long as they had a mentor - someone working at the facility with them. So we're doing our best to try to meet all those needs and still recognizing the fact that people do need to be educated for their own safety and the safety of the public, which is what the whole intent of this bill is. 2:34:55 PM REPRESENTATIVE GARA said he's heard concerns that even if the UAA offers a program, it will only have a certain number of openings available, as well as concerns regarding what courses are going to satisfy the bill's training requirements. He also relayed that he's been told that many of the people currently being exempted from the bill's requirements don't have any experience in taking x-rays, and so is wondering why such people should be exempted. MS. RUFSHOLM first offered her belief that the UAA will make enough courses available so that people can meet the bill's requirements, and so meeting those requirements won't be a problem, particularly given that if the bill passes this year, it will be 2007 before it's enacted; also, people will have another two years to fulfill their education requirements. And once people fulfill their education requirements, the state will send in their names to the American Registry of Radiologic Technologists (ARRT), which, as a courtesy to states with limited-scope licensure, offers an examination that individuals can take, and passage of that examination would then qualify a person as a "limited-scope" radiographer; additionally, online courses [currently] available on the Internet also allow an individual to sit for that examination. 2:39:20 PM REPRESENTATIVE GARA relayed that he's been told by some people that they believe the UAA might only be able to accommodate about 20 students per year, and that it could take as many as three semesters to complete the educational requirements proposed by the bill. MS. RUFSHOLM suggested that UAA staff might be better able to address that issue. She acknowledged, however, that she, too, has been told that the UAA might only be able to accommodate 20 people during the upcoming fall semester, but only because it is a new program. She explained that the program will consist of three modules, the first to be completed in a minimum of four weeks, with the second and third modules perhaps being completed at the same time should UAA staffing levels allow. Thus the educational requirements could be completed in as few as eight weeks or as many as twelve weeks. She mentioned, though, that she is not familiar with how much time the online courses take to complete. 2:41:23 PM MS. RUFSHOLM, in response to the question of why certain groups of people have been exempted from the bill, said it is because those groups have their own boards and practice standards, including standards related to radiology procedures. She also mentioned that concerns offered by those practicing in rural areas and in small clinics in urban settings regarding a possible interruption of services for training purposes have prompted the change in Version S that allows a person to begin the first module of the UAA's program while he/she is working. So as long as a person has a mentor, an employer who is willing to oversee the person while he/she is taking x-rays, then he/she can take module one of the program and be working at the same time. That person would, of course, also have to continue on with module two [and three] of the program. REPRESENTATIVE ANDERSON mentioned that his son was x-rayed at a clinic after a bicycle accident and was told by the person taking the x-ray that his arm was probably broken, but further x-rays at a hospital revealed that his arm wasn't broken. He indicated that this experience has furthered his belief that certification of those taking x-rays would eliminate such misdiagnoses. REPRESENTATIVE GARA said he supports the concept of the bill, but some of its aspects still raise questions. For example, should those groups of people currently being exempted from the bill really be exempted? Is the training such people currently get really sufficient? 2:48:41 PM REPRESENTATIVE PEGGY WILSON, Alaska State Legislature, said she is concerned that the bill could create a hardship for small businesses, particularly in rural areas. She mentioned that [as a registered nurse], she used to work in a very small clinic in Tok, and that both nurses and the laboratory technician working at that clinic were trained, on the job, to use the x-ray machine and were then monitored to ensure that safety procedures were followed. In such settings, there is a need to have more than one person trained in the use of the x-ray equipment, since it wouldn't possible to have a trained technician brought in should the person who regularly takes the x-rays be unavailable. Another of her concerns centers on the fact that because the machines in rural areas of the state are older models, the educational modules may not addresses the specifics of all the different types of machines - particularly the older, more complex types - that are currently being used in various areas of the state. Additionally, she opined, the cost of the proposed educational requirements are quite prohibitive, particularly given that many small clinics operate with limited funds. 2:53:42 PM REPRESENTATIVE WILSON mentioned that in Tok, the chief emergency medical technician (EMT) also knew how to take x-rays, and this saved clinic employees from having to come to work in the middle of the night in emergency situations. She pointed out that many small communities and places in rural Alaska aren't on the road system, and opined that the bill is much needed when it comes to the issue of radiation therapy, but questioned whether the restrictions the bill imposes are really necessary with regard to normal, everyday x-rays. Referring to Representative Anderson's example regarding his son, she noted that in most situations, the person who takes the x-ray is not the person who reads it; the x-ray must still be sent off to be read by a trained radiologist. So just because a person hasn't been taught to read an x-ray and so perhaps misdiagnoses a condition doesn't mean that the x-ray itself wasn't a good x-ray. She said she questions whether the state really has a problem with regard to those taking x-rays, particularly given that she has not been shown any evidence of or been given a listing of mishaps. CHAIR McGUIRE said she would provide Representative Wilson with the testimony from those that believe problems are occurring. Noting that Representative Wilson believes that those performing radiation therapy should be licensed, Chair McGuire asked her whether believes that there are other types of radiation use that ought to only be performed by licensed individuals. REPRESENTATIVE WILSON opined that anytime one is performing a procedure that is "all inclusive" - such as a mammogram, magnetic resonance imaging (MRI), or computerized axial tomography scan (CAT scan) - that person should be licensed because the procedure is so specialized, adding that usually such people receive special training in the use of that equipment anyway. She surmised that such persons and procedures are already covered and so she is not as concerned about them. 2:59:53 PM REPRESENTATIVE GARA said he is wondering whether the bill should perhaps focus on procedures other than x-rays. He asked whether CAT scans and MRIs expose one to more radiation than regular x- ray machines. REPRESENTATIVE WILSON suggested that others could perhaps better respond to that question. REPRESENTATIVE GARA asked whether registered nurses, as part of their course work, receive training in the taking of x-rays. REPRESENTATIVE WILSON said no. She added that she is not saying that one couldn't "give too many rads" with an x-ray machine, though newer models make doing so difficult because they are more sophisticated and thus much safer. She said she has a concern regarding exempting licensed practitioners, since most of them often don't have the expertise needed to operate x-ray machines. Relying on the fact that licensed practitioners are held accountable by their boards is simply offering a false sense of security, she concluded. 3:03:32 PM CHAIR McGUIRE characterized the distinction between the operation of x-ray equipment and the diagnosis of x-rays as an important one. REPRESENTATIVE WILSON noted that even in Wrangell, all x-rays are sent to a certified radiologist for formal diagnosis, and the doctors only offer their belief regarding what the x-rays truly shows. She then noted that page 2, line 16, says in part, "(A) the direct supervision of a licensed practitioner", and pointed out that in remote areas, a person could be under the direct supervision of someone in another town. Referring to page 4, line 22, she noted that the language says in part, "or have demonstrated experience sufficient in the opinion of the department to waive the program", and asked whether department personnel are actually going to go to a remote site to determine whether a person is capable of operating the equipment in question. Referring to page 9, regarding disciplinary actions and administrative hearings, she noted that [lines 28-29] say in part, "within seven days after the suspension order is issued", and pointed out that some areas of the state only get mail every other week, and so as much as a month could pass before a response is received by the department regarding a person's wish to have an administrative hearing take place; therefore, the seven-day time frame is very unfair to those residing in some parts of the state, she opined. 3:07:47 PM PAMELA LaBOLLE, The Mulder Company, Lobbyist for the Alaska Society of Radiologic Technologists (AKSRT), noted that consumers are not testifying on this bill, and opined that this is because the public has been led to believe that anyone who delivers healthcare to them is trained, certified, and maintains safety for the patient utmost in his/her mind. She added, "Won't they be surprised when they find out that the people who are dealing with radiation, delivering doses of radiation to these patients, have no training," particularly given that even food service workers, beauticians, cosmetologists, barbers, hairdressers, and truck drivers are required by the state to have training and become licensed. REPRESENTATIVE GARA noted that he has heard both arguments, that x-ray equipment can be dangerous, and that x-ray equipment - as used in a dentist's office - delivers almost no radiation. MS. LaBOLLE remarked that that dentists, dental assistants, and nurse practitioners have their own boards and proficiency tests. 3:11:08 PM CLYDE E. PEARCE, Radiologic Health Specialist II, Radiologic Health, Laboratories, Division of Public Health, Department of Health and Social Services (DHSS), relayed that the DHSS supports the bill and hopes that the concerns raised by "small and rural providers" can be addressed. With regard to the question of why people in the health care field who've been identified as not being trained [to take x-rays] are being exempted from the bill while other operators are not, he acknowledged that such is of concern; for example, physician's assistants (P.A.s) must do everything through, or report to, their collaborative physician, and so if a P.A. is actually taking x-rays, then his/her collaborative physician would have good reason to be concerned, though the bill does not specifically address that issue. He offered his understanding that the purpose of the bill is to address situations in which no one is trained. From the time a patient enters a facility and the decision to take an x-ray is made and that x-ray is then taken and read, there ought to be at least one person in that chain of healthcare services who is trained, he opined. CHAIR McGUIRE asked Mr. Pearce to comment regarding what levels of radiation exposure can be expected to occur in various situations. MR. PEARCE relayed that one of his duties is to [measure the radiation levels]of the various types of equipment being used around the state, and said he does see differences. He went on to say: The problem is that it's not just the output capability of the machine that we need to be concerned about, it's how the machine is used. And I like to use the example of a driver of an automobile: when you look at the automobile with seatbelts, and safety bags, and tinted windshields, and power brakes and steering, and all of [these kinds] ... of safety features, why is [it] that 40,000 people die every year? It's because of how it's used. And when I do inspections, I actually rarely find a problem with the machine even though I find many problems with how it's used. I was in Fairbanks recently, and 42 percent of the repeated films [and errors] were due to positioning. Now that's not something you normally even cover in a radiation safety course, but the person doing the x- rays had no knowledge of topographic anatomy, and so they didn't know exactly where internal structures were and they were guessing with the positioning. ... So there is a real concern there about excessive exposures, due to how the equipment's used, but in terms of procedures in general, we have the routine films - (indisc.) abdomen, chest, skull x-ray; there's a certain amount of radiation there, and we can think of that as a unit of one - whatever it might be. When you look at a [computed tomography (CT) scanner], the exposure level can increase substantially; however, there are some real diagnostic advantages to a CT scanner, and also earlier treatment can be critical in saving a patient. When you look at bone densitometers, exposures are very low. [With regard to] nuclear medicine, surprisingly, ... the patient receives less exposure than a corresponding ... medical x-ray exam. But all that aside, as far as a comparison, it depends on how they're used. So in the statistics that have [been] published recently, ... one of those shows [that] about a 1 percent rate of all cancers in the U.S. are due to diagnostic x-rays. Another one was showing a diminished intellectual capacity as a result of the very young being exposed to ... diagnostic levels of radiation. Now these are ... up in the upper level of CAT scan. However, in my experience, in certain areas of Alaska, I have seen those levels exceeded by ordinary radiography simply because of how the equipment was used. And I agree with [Representative Wilson] that the older machines do present a special challenge; [however,] newer machines don't guarantee a lower dose - in fact, there are concerns about the doses getting higher. But the older machines, in my opinion, require even better foundation in the principles of how to use them safely. ... 3:16:33 PM MR. PEARCE, in response to a question, explained that anytime one uses radiation, there is risk, but the physician is trying to strike a balance between benefit and risk. Although newer machines, when used properly, result in lower exposure, because they are digital and produce an x-ray that compensates automatically for overexposure, they also have the potential to result in higher exposure to the patient without the operator being aware that such is occurring. In response to a further question, he said it is not true that new x-ray machines don't produce any more radiation than the x-ray machines used at airports for security purposes; rather, medical x-ray equipment deliberately exposes patients to radiation, and does so with a much larger beam "and a lot of scatter from the patient." Additionally, because of that "scatter", those who operate x-ray machines have an incidence of breast cancer three times higher [than those who do not]. MR. PEARCE, in response to a comment, said, "I do have a concern, as a radiation inspector, [regarding] ... the fact that [new equipment] ... may conceal the exposures and actually allow even higher exposures to occur." 3:19:54 PM ED HALL, P.A., Legislative Liaison, Alaska Academy of Physician Assistants (AKAPA), indicated that many of the AKAPA's concerns have already been addressed through Version S. He said that although there have been accusations that there are people using radiological equipment without any training, none of his medical colleagues have heard of any such instances. He went on to say: We don't just [pull] people off the street and point them to the x-ray machine and say, "Go start shooting x-rays." ... There's a guide book out that addresses anatomy, we make sure that people have an understanding of anatomy, [and] most of the clinics that I know of [that] ... are using "techs" ... to shoot their films are [using somebody who is] ... either a community health aide [or] ... somebody who has had some exposure to anatomy - big, gross anatomy. And then there's the text that shows positioning, and, yes, ... it is much easier nowadays to use [modern equipment] and have the technique of a certain exposure that one would need to use. So I would like everybody to recognize that this is just not ... blindly giving authority to anybody to shoot x-rays; they do have some training. As far as training goes, I know that particularly in the P.A. programs that I'm aware of and several of the medical school programs that I'm aware of, there is not a specific course on how to shoot x-rays, but there are courses on reading radiography, and so indirectly sometimes you may get some knowledge about shooting x-rays. But, yes, I think if this bill is directed at safety, ... then you probably shouldn't exempt any provider because ..., even though we do have a licensing board that oversees us, it is not within most of our training to know how to shoot x- rays; this is all knowledge that is acquired once we get into certain situations. In my clinic I've got two nurses and myself who shoot x-rays, and ... one of my nurses has been through the training at the [Alaska] Native Medical Center [ANMC], and she, basically, trained the other nurse and myself as far as the appropriate techniques and positioning and all the important things that we do to try to keep things safe. I am happy to see the changes that Representative Anderson and his staff have incorporated; however, ... ultimately, I think that this bill would be best if they could separate out basic radiography from the other procedures such as MRI and CT testing and things where you have to inject - I think all of those things defiantly need to have some certification. MR. HALL concluded: And lastly, in [regard] to that certification, there has been talk about, if we have a licensing board that we respond to or that we are accountable to, [since] nurses ... and nurse practitioners ... all answer to the nursing board, ... the question has to be raised [whether they can] then be exempt because they're under a different licensing board, and, then, can a CNA [certified nursing assistant] - who also is a licensee of the nursing board - ... be exempt too. So I think the more we talk about this bill, I think there's a lot of unanswered questions, but I think it's heading in the right direction, personally. And I think, professionally, around the state, ... it's heading in the right direction, but I still think that [there are] limitations [that's] going to make this very costly for medicine in Alaska. And just because 42 other states do it ... is not a good ... [reason] for us to do it if we are interested in access to care. Thank you for your time. ... 3:25:40 PM RONALD L. DEIS relayed that his background is one of teaching radiologic technology at universities, and that he came to Alaska to manage a radiology department [at an Anchorage hospital]. Shortly after his arrival, he began receiving requests to train those who were taking x-rays at various local offices. Many of those requesting the training said that they hadn't any knowledge of how to take x-rays before getting hired at those local offices and had often ended up repeating an x-ray five, six, or even seven times without being able to get it right. He said that eventually he approached the University of Alaska with the concept of teaching an introduction to radiography course, and has since been teaching that course for the last 18 years; additionally, he has been teaching a [similar] course at the ANMC, for the last 9 years, to P.A.s, nurse practitioners, and community health aides. MR. DEIS said that in spite of these efforts, he still runs across those who've been hired to work in an office or clinic and have been told that their duties include taking x-rays regardless of the fact that they hadn't any training. Again, such people often end up repeating x-rays multiple times in an attempt to get an adequate x-ray. He said that as a person who is very familiar with the radiology procedures currently practiced in the state, he thinks that the state needs to know who is administering ionizing radiation and institute minimum educational and clinical standards. 3:28:52 PM BARBARA HUFF TUCKNESS, Director, Governmental and Legislative Affairs, Teamsters Local 959, relayed that her organization supports both HB 150 and its members who work in the industry, for example, those who work at South Peninsula Hospital, which does require certification of its radiological technologists, and Providence Kodiak Island Medical Center, adding that she was quite surprised to find out a couple of years ago that such certification was not already a state requirement. She pointed out that not only are the state's certified nursing assistants and phlebotomists required to be certified - regardless of whether they are in rural or urban settings - but so are the state's truck drivers. MS. HUFF TUCKNESS surmised that a lot of people believe that the [bill pertains to] just x-rays and mammograms, and noted that since she has become aware of the fact that the state does not require certification of those using radiologic equipment, she has begun asking those who are performing those services for her whether they are certified. She added: I do not believe that the public, in general, realizes the degree and the type of work that these individuals are performing. And ... while we supported the original version of the bill, I think that there have been some somewhat reasonable compromises - there are probably some areas that I would say we've probably gone a little bit too far the other direction - but having something on the books and moving in the right direction I think, both from an employee perspective working in the industry as well as a public health safety issue, I would encouraged the committee to move the bill forward. 3:33:52 PM B.J. ANDERSON, Anchorage Neighborhood Health Center (ANHC), first relayed that she is the ANHC's x-ray manager, and then referred to the provision in the bill addressing temporary permits, and said that they [at the ANHC] have been led to believe that a person who wants to begin training [and] get a limited license only needs be enrolled in a program. However, she pointed out, proposed AS 08.89.170(a)(1) and (2) say that a person must have first completed the program and taken an examination. Therefore, she opined, the wording in the bill should be changed to reflect that once a person is enrolled in a training program and has a mentor, then the person can begin working under a temporary permit. MS. ANDERSON then pointed out that using mammography as an example of the type of x-ray that [this bill would address] is inappropriate because mammography technicians in Alaska are already certified by the ARRT, are already working under the umbrella of the Food and Drug Administration's (FDA's) Mammography Quality Standards Act of 1992 (MQSA) program, and are required to have American College of Radiology (ACR) certification. She went on to say: Any clinician or clinic has a huge liability providing healthcare services, and ... they have taken that seriously by using a mentoring approach to teach staff how to safely perform radiologic procedures. And so I think ... this is one of the reasons why this is a very difficult bill in that we're requiring certification but we're forgetting that in the rural areas they are drawing people from the community and teaching them, on the job training, how to perform x- ray radiologic examinations. And ... I would say for the most part, most clinicians and clinics are very conscientious about that. Perhaps ... I can't speak for everyone, but I think that if this bill goes through, it definitely needs to make allowances for that mentoring-type of approach to continue, as well as the professional training that we could get through [the] UAA. I don't believe that this bill is ready to progress until some of these changes have been implemented. REPRESENTATIVE GARA asked how many hours of on-the-job training are given to a person before he/she can operate an x-ray machine. MS. ANDERSON said that is hard to estimate, given that when a person is hired, he/she may have had previous training and the training specific to that facility's radiologic equipment may not occur all at once. However, if she were to be training someone from the ground up, she relayed, she would be looking to enroll that person in the type of program that the UAA is proposing to provide. 3:40:19 PM SUSAN MASON-BOUTERSE, Executive Director, Sunshine Community Health Center, provided written testimony, which was paraphrased by Beth Little-Terry; Ms. Mason-Bourterse's written testimony read [original punctuation provided; contains some formatting changes]: My name is Susan Mason-Bouterse, and I am testifying in opposition to HB 150. I am the Executive Director of Sunshine Community Health Center, located in Talkeetna. We are a federally qualified health center, serving the upper Susitna Valley. We serve a population of about 6,000 people, including a significant number of visitors to our state with the tourism activities in this area. We are located 75 miles from the nearest hospital in Palmer. After hours care is a significant part of our practice. Our provider staff includes one family practice physician, 3 physician assistants, and 2 nurse practitioners. We offer digital radiology at our center and have a contract with AK Imaging Associates to provide our radiology reads, which we are able to do through tele-radiology. We are able to obtain stat reads; our normal turn-around time is 48 hours. In the past year, we performed a total of 52 X-Rays, the majority of which were of extremities. We also perform a number of chest X-Rays. Our X-Rays are performed by either our providers or our medical assistants. We do NOT require our MA's to be licensed radiology technicians. We DO provide thorough, hands on training for our MA's, including the areas of patient and practitioner safety, positioning, equipment operation and maintenance. And none of our MA's perform X-Rays without the provider being assured they are competent and fully qualified. I do not oppose this bill in its proposed purpose, which is to ensure quality of care for patients. However, I do not believe that simply requiring licensure will ensure that purpose is achieved. And the very likely impact of this bill is reduced access to care for people in rural parts of Alaska and for people who are already challenged in accessing health care, those without insurance. In a rural health center such as ours, we often are the first point of contact for individuals seeking health care. Being able to offer radiology services provides the following: Opportunity to catch severe and life-threatening diagnoses early Ensuring that uninsured patients will be follow through with specialty care, such as orthopedic referrals (we provide the referring X-Ray and are able to offer it at discounted fee) Reduced costly emergency transports and admissions to ER MS. MASON-BOUTERSE'S written testimony continued: I would like to give you a couple of real life examples of how our ability to offer radiology provides immense benefits to our patients: (these are scenarios - you will need to ad lib a bit) Chest X-Ray revealed lung carcinoma in an elderly gentleman in our community. He was not willing to see a specialist or pursue any type of referral for treatment. The diagnosis of the cancer is allowing our staff to explore options with him and is allowing him and his family to prepare for the difficult and challenging times ahead. A woman called our after hours services. She had fallen and needed X-Rays. Unfortunately, our X-Ray was down at that time and she did not follow up and go to the hospital for X-Ray. She also didn't come back when we called her the following week to have her come in for X-Rays once our equipment was functional. She called 3 weeks later, complaining of pain and was X- rayed at that time. Unfortunately, her treatment course by that time was much more complex and painful due to her delay in seeking care - the bones were fractured and had begun to heal unaligned - had to be re-broken and re-set, with resultant poorer outcome than should have been. This bill, though intended to improve quality of care and ensure safety, actually could severely curtail access to care. It could very likely have the effect of making radiology the sole domain for a privileged few, mostly urban sites. With the ever-increasing costs of health care, I would prefer to see legislation that reduces barriers to care rather than increasing them. If ensuring quality is truly the goal of this proposed legislation, then requiring continuing education and periodic proficiency testing of non-licensed personnel seems a much more effective way to ensure quality and safety without reducing access to care. Thank you for your consideration of this testimony. 3:45:27 PM LORREN J. WEAVER, M.D., Medical Director, Camai Community Health Center, said he is testifying in opposition to HB 150 on behalf of the Bristol Bay Borough, which is the owner of the Camai Community Health Center. He said: I believe having licensed radiological technologists at our clinic will not significantly increase safety, raise the standard of care, or improve security of diagnosis in our setting. I understand that bad things happen and that people can be damaged by people that do things wrong. We have always trained our people; I think it always has been incumbent upon the primary care providers to oversee the quality of the films that are read - radiologists read them - as well as [offer] oversight. Even though [Mr. Pearce] says that there are people that are getting radiated, I'm sure that may be happening, but I think passing a bill does not change that necessarily. For example, a chest x-ray is touted to have the radiation equivalent to one day's sunlight. ... In a limited scope clinic, I don't believe that the amount of radiation, even though there may have to be a few repeats, is carcinogenic; I don't think that there's any evidence presented that extremity films and skull films and spine [films] produce enough radiation for carcinogenic [results]. ... I don't think anyone argues against the fact that CT, MRI, mammography, arteriography, and ... multiple ... other radiation therapy [modes] all should be heavily governed and do have risk, [but] I believe that [with regard to] simple scope procedures done in rural areas, the benefits far outweigh the risks and the costs [the procedures] may actually obstruct. We're [home to] the largest wild salmon fishery in the world ..., and we see a lot of trauma. ... And in fact, our population may grow from ... 1,200 to well over 10,000 in the summertime. ... Most Alaskans know that [the] fishing industry is dangerous and has a lot of injuries. [I've] heard a certain amount of anecdotal stories where people's lives have been saved by radiology, and I can voice that this is true - I can give you any number of cases where that happened. For example, someone with a pneumothorax, which means a ruptured lung, if that diagnosis is not made here and a chest tube [inserted] ..., the person will die before (indisc.) we're approximately 289 air miles from anchorage, which is a tertiary care [facility]. DR. WEAVER continued: So stabilization and radiology go hand in hand for trauma cases, and I think it's important that we maintain that. I think that having radiologic technologists will not improve that situations and, in fact, we have tried to recruit registered technologists out here and we usually get the guffaw: "You mean go to rural Alaska? I don't think so." So ... we need to face the reality here and do the best we can. Obviously patients need to be safe, [but] I don't think giving the [American Radiologic Technologists] the responsibility for how we do x-rays in rural Alaska is helpful. No one's arguing against [certification for] more complex procedures. I think that the other thing that would happen is, ... if we're not able to use in-house people to do the radiology, it will cost us approximately twice the amount of money it would cost to operate; this would probably mean that we would have to cut back our services. We are ... currently at ... 24/7/365 day operations, ... [and] we have no other hospital facility nearby; ... we're barely able to keep our doors open with the amount of technology that we have. We are a community health center which is funded through the same federal grants that the [Sunshine Community Health Center] in Talkeetna is. We have to think about the cost to patients. If patients have to go to Anchorage ... [facilities] for simple x-ray procedures, this will cost in the hundreds of thousands of dollars for them; that doesn't mean that they can't be safe with what we do here, but passing the bill will not improve that percentage. 3:51:47 PM KAREN FAGERSTROM, Director, Village Health Services, Community Health Services Division, Norton Sound Health Corporation (NSHC), relayed that she is trained as an advanced family nurse practitioner, and that she is in opposition of HB 150 as currently written. She went on to say: We are currently in the process of introducing radiology equipment in our area. We have one machine that is currently in use and we have three more that we'll be bringing on line in the next several years. Anytime new technology is introduced, obviously training has to take place so that the equipment can be operated safely for the patient and the operator. Currently we have a P.A. who's been doing x-rays over a number of years, and he's the one that's been operating the machine. We now have a [person associated with Community Health Aide Practitioners (CHAP)] who is learning to ... take x-rays; we sent her to the class offered by [Mr. Deis] along with another "midlevel" ..., and now they're back in Unalakleet working [under] the tutelage of the other P.A. and learning how to take x-rays. In the villages, number one, as far as the Bush goes, we're basically going to be doing simple films. The idea of mammography, that only takes place in Nome, and there is a licensed, registered technician who simply does mammography. As far as radiation treatment, MRI, CT, none of that even exists for Nome, let alone is it ever going to exist in a village. Potentially we're looking at [having] a CT, eventually, here in Nome, and that person, who would come in ... [and] operate that [would] have licensure and everything needed. I'm speaking ... to the portion of this bill [pertaining] ... to the people who would take limited radiology. What we did, in order to get this person on line, was started looking [at] writing policies and procedures, and ... [limit] their scope of practice ... as it ... would be in the bill; ... they would only take radiology of the chest, abdomen, and axial- appendicular skeleton, and that's basically what [we] would have them do out in this area - we're not looking to have them do any more than that [aside from] also learning how to operate the new digital equipment. I went online trying to find information about the classes taught at [the] UAA, and I cannot locate any information to be able to download exactly what's included in that class except [to find out that] ... the first credit hours [consist of] anatomy and physiology, [and that] the second portion of the ... classes that can be taken - section two and three - can be taken concurrently. ... I've requested information, [but] I've not received any, and I have great hesitation about being approved for that class, [given that we] can't even find out exactly what's being taught in it. MS. FAGERSTROM continued: One of the things, also, that would make it a great hardship, is [that] in this bill, in [proposed AS 08.89.160], it says, for the limited person, that they have to have a certain amount of clinical instruction ..., [which is defined as] hands-on experience in a health care setting, under the direct supervision of a practitioner or fully licensed radiological technologist. I have a problem with that because ... there would obviously be a certain number of hours that we would need to be able to train that person in Nome, but also we have a limited number of x-ray procedures [that] are going to take place. ... How long is that person going ... to have to [be] out of their villages, here in Nome getting x-rays? ... Is there a place that we can send it to the ANMC? What, creatively, can we do to get that person in [and] get the training that they need to safely do the procedures but not be out of their village for X number of weeks to months while obtaining that, because [the] CHAPs are the direct care providers. So I agree with the idea that there has to be training, but how can we make it more Bush friendly to get that training without making it [an] extreme hardship on the people who are here in the Bush. Also, with the [continuing medical education (CME) requirements], how does that relate ... specifically for the CHAPs when they're doing a limited amount of CME? Is that CME going to [be] written for them as applicable to their practice? That's one of the questions I have that's not really addressed here. ... So ... while I agree with the area of needing the training, there's a number of specific issues ... [that have] not been adequately addressed for the Bush and [would] potentially make [it] a real hardship for us [to] try to meet this bill as it stands. CHAIR McGUIRE asked Ms. Fagerstrom to provide the committee with any specific suggestions she has for improving the bill with regard to its educational and mentoring provisions, suggestions other than to simply exempt all those in rural settings. MS. FAGERSTROM relayed that she would pass on Chair McGuire's request to the CHAP directors at their next meeting. CHAIR McGUIRE said she will suggest to the sponsor that he work with [CHAP and NSHC] on an individualized basis. 4:00:35 PM LOUISE REED, Diagnostic Imaging Director, Yukon-Kuskokwim Health Corporation (YKHC), relayed that the aspects [of HB 150] that the YKHC is most interested in are the training provisions. She said she understands the concerns expressed by those in Bush communities regarding being able to acquire the training required to do the jobs they've been assigned. She mentioned that the YKHC has four outlying clinics that provide x-ray services, and that the YKHC set up its own [training] program a few years back when it started to set up x-ray equipment in places like Emmonak, Saint Marys, Aniak, and Toksook. The goal of that training program was to ensure that those taking x-rays would have the training to do a good job and not over-radiate the patients; the students in that program came in from their village clinics to the hospital in Bethel, and the trainers subsequently kept in daily contact with them as they were taking x-rays. MS. REED referred to a book titled, Radiography Essentials for Limited Practice, and characterized it as an invaluable tool, which anyone can order and then take the exams that come with the book in order to obtain CME credit, adding that this is the same book that is being used in the UAA class. Additionally, the UAA has just started a limited radiography program using the YKHC's hospital and students from the YKHC's outlying clinics as a beta test station for the rest of the state. The program, which started in January, is delivered through "distance education" and so students are able to meet once a week and then proceed at their own pace. MS. REED relayed that the YKHC has great hopes that this program will set the standard for the rest of the state, adding that the YKHC is very interested in seeing the bill pass; considers it to be doable; believes that training, particularly with regard to safety and radiobiology, is much needed; and is concerned both about its patients and the levels of radiation they are exposed to, and about staff's ability to take x-rays that lead to accurate diagnoses. She concluded by saying that the YKHC's concern is that its employees have the training they need to do the job that's expected of them, and feels that it is in a good position to help get a statewide program instituted. 4:06:28 PM CHRIS DEVLIN, Executive Director, Eastern Aleutian Tribes, Inc., testified in opposition to HB 150, opining that the bill will negatively impact access to [health] care in rural Alaska and increase the cost of that care without guaranteeing safety. He noted that his organization has nine clinics, four of which have x-ray [equipment], out in the Aleutian Islands, and that x-rays are an essential diagnostic tool in the treatment of injuries resulting from accidents in the area's fishing industry. MR. DEVLIN said his organization ensures that its employees get some training in the use of x-ray equipment, and so to have to go through another state regulatory process and licensing will only increase costs and perhaps result in no x-rays being given because the current in-house training will no longer be considered sufficient. Without providing for either a rural exception or a "remote safety-net exception," the bill, which he characterized as premature, probably won't work for rural Alaska, he remarked, reiterating his belief that the bill will have a negative impact in terms of access to health care. 4:08:01 PM CHERYL KILGORE, Executive Director, Interior Community Health Center (ICHC), relayed that she and Tammy Wilkerson, Clinic Nurse Manager for the ICHC, believe in the importance of quality of care and the safety of all those who are involved with radiology. She said that one of the ICHC's concerns is that the bill could potentially create barriers to healthcare access, and therefore the ICHC's hope is that the originators of the bill will take into account certain aspects of the bill, one of those being that currently the testing provision is lacking in detail. She elaborated: If it's equivalent to a radiology/radiologic tech program, then it isn't appropriate for somebody that has a limited scope. I don't think it is. However, ... it's clear in the testimony so far today that there is some concern about the capacity of our existing system, whether it's [the] UAA or other online courses, to provide access to the number of students that might potentially need to have access to ... the online courses or get the minimal education that's required. That should be addressed. It may be that the course itself can be changed, although if it's dependent upon [the] UAA getting a certain amount of funding in order to meet the requirements of the students, I can tell you what our experience thus far - although we're moving in the right direction - has been with nursing, and that is [that] there are huge amounts of demand and very limited slots, the competition is fierce, and the funding will never be there - [funding] that is required in order to get all the students that want to get through, done. So I'd like there [to be] some consideration there, in this bill, to look at that further, because even if you have the best case scenario, where you had 20 students going to [the] UAA every 12 weeks - which I think everyone would agree would be very aggressive - we probably couldn't meet the demand. And, again, since we don't want to create insurmountable barriers to care, that area needs to be looked at. MS. KILGORE continued: The work experience requirement, i.e., three years, may be too rigorous as well, and when we look at, really, what our workforce issues in this state are in terms of recruiting healthcare professionals - including radiology techs - we ... don't want to make something worse than it currently is, which is, frankly, in my opinion, already a fairly grim situation. We need to provide, and I'd like the bill to consider the bill providing, funding - and ... this is really a legislative issue - funding for training for these limited radiology imagers, which I think is a good conceptual model and might very well be the fix to remote, rural areas that have difficulty. And frankly, even in Fairbanks, which we'd consider an urban area, we have difficulty attracting the radiologists and the radiology techs. In fact, that's why we have this collaboration going on, locally, where we have a school for radiology techs, and even then the demand exceeds the capacity of the system to get them through. We're pleased that the bill recognizes the need for limited radiology imagers, and we'd like to see, perhaps, in the bill itself, some "tiering" of activities to accommodate these issues of education and experience. For example, if you're a level one, that's the basic; ... you're scope is very limited. And then as you move up [to] level two, level three, you might have ... a broader scope, and be working towards ... potentially getting up to where you might even go to radiology tech school. That might be a way to deal with some of these issues that are definitely going to affect those of us that provide care in remote and rural areas. And we thank you very much for your consideration of that approach. The other thing I'd like to just say ... [is, from the perspective of] being involved in healthcare in both a rural and urban area for quite a long time, even in the best of situations with the best of technology and the most skilled people, radiology imaging is not an exact science. And we all know that. And that's where having qualified people is part of it, but also having a quality assurance program. And even with that in place, you can have films that don't detect things. So really we are partners in the delivery of healthcare. And we had a situation where we had a film of a hip taken in the emergency room with the radiologist, and the interpretation of the film - even with a good film - was accurate, but it was limited in that you couldn't visualize the hip fracture on the film. And that's where, working as a team, you really provide the very best, state-of-the-art care. And I'd really like to see more focus ... on CME and relationships between different healthcare providers and boards, because it would really improve care in the long term for Alaskans in this state. MS. KILGORE concluded: The other piece that I just would like to put out there for your consideration is looking at potentially focusing ... on providing funding for continuing medical education, in this regard, to those professions that don't have this as part of their [usual] background training. And also, if you look at this as a system of care, and you're looking at providing these limited radiology imagers as part of the system, then you would want to feed that film, from wherever it's being taken, through the system - ideally digitally, but you could still manually send films, because we know there's a wide variety of equipment out in the state of Alaska - into a radiologist, and get a radiologist to interpret it in its finality. So thank you so much; we appreciate your consideration of our comments, and are very glad that you're looking at providing quality of service and safety. 4:16:24 PM TIMO SAARINEN relayed that he is a registered x-ray technologist and CAT scan technologist and is registered in nuclear medicine, and noted that he started his radiological career in the military, via a limited license, and so understands about maintaining standards and fulfilling limited licensure requirements. He said he supports HB 150 because it sets minimal standards for safe, quality, diagnostic practices, adding that he believes all Alaskans deserve the same standard of healthcare. Additionally he noted that in the DHSS's recently released eleventh edition of its report on carcinogens, it listed x-rays as a known carcinogen. Patient safety is the main concern, and so a minimal standard ought to be provided for. He relayed that if it were left up to him, only fully registered x-ray technologists would be taking x-rays, though such could be a major problem in rural areas; therefore, he concluded, HB 150 is very good bill that sets minimal standard requirements. CHAIR McGUIRE, after ascertaining that no one else wished to testify, closed public testimony on HB 150 [Version S], and relayed that the bill would be held over.
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