Legislature(2005 - 2006)CAPITOL 17
03/02/2005 03:15 PM House LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Start | |
| HCR3 | |
| HB150 | |
| HB147 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HCR 3 | TELECONFERENCED | |
| += | HB 147 | TELECONFERENCED | |
| *+ | HB 150 | TELECONFERENCED | |
HB 150-LICENSING RADIOLOGICAL TECHNICIANS 3:45:58 PM CHAIR ANDERSON announced that the next order of business would be HOUSE BILL NO. 150, "An Act requiring licensure of occupations relating to radiological technology, radiation therapy, and nuclear medicine technology; and providing for an effective date." JON BITTNER, Staff to Representative Anderson, introduced the bill by first reading the following opening statement: House Bill 150 will establish educational and certification standards for the health care personnel in Alaska who perform medical imaging and radiation procedures. MR. BITNER then continued by reading the following: 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 Radiological 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. Thirty-eight 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 radiological 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. MR. BITNER concluded by stating the following: 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. REPRESENTATIVE ROKEBERG asked about the letter from the Alaskan Academy Of Physician Assistants and wondered if they were in favor of the bill. MR. BITNER stated that there is some confusion here. REPRESENTATIVE ROKEBERG stated that he believed there was a letter that was floating around in the past that said that they were supporting the bill. He then stated that there was current letter stating some kind of opposition to the bill. MR. BITNER then stated that this was sent recently. 3:49:55 PM DONNA RUFSHOLM, Chairman, Alaska Society for Radiological Technologists, stated that establishing state procedures for licensure has been an ongoing effort by this group. She indicated that it started ten years ago and only in the last 4 years has any progress been made. She then continued that currently there are no stipulations or standards for the regulation of radiological technicians. She revealed that anyone off the street can take a job as a radiological technician at a hospital or clinic. Radiologists in the state have some concern about the quality of these radiographs that they are receiving from villages that do not have properly educated personnel, as they are more often than not, bad images or images that are not viable for use in diagnosis. Furthermore, she said, there are huge concerns from radiologists about these poor efforts at imaging because of the high levels of radiation that result. This radiation, she said, impacts not only the villager getting the imaging but the uneducated technician as well. MS. RUFSHOLM stated that HB 150 would establish educational and certification standards for the healthcare personnel to perform the radiation imaging procedures. She pointed out that studies show that these kinds of efforts to educate the operator insure better work quality which leads to quality information being used for proper diagnosis. She continued by stating that it would also reduce healthcare costs since repetitive exposures would not be made due to inadequate knowledge of radiological science and technique. This bill will ensure that excellence in radiological imaging and better healthcare for Alaskans. MS. RUFSHOLM then outlined the history of this effort by stating that over the years the group had been working extensively with the Alaska State Hospital and Nursing Home Association (ASHNA), where we tried to address some of the issues that are being faced by the rural communities that do not have credentialed individuals performing radiological procedures. MS. RUFSHOLM then stated that there were some concerns about access to radiological facilities and services if there were some standardization and licensing put into effect. Nevertheless, there is support from ASHNA for this bill. 3:53:15 PM MS. RUFSHOLM indicated that her group does work with association of Physician Assistants, most recently last October, when we addressed some of their concerns. She indicated that the final outcome of this meeting was that they wanted to be listed under the definition of licensed practitioners. MS. RUFSHOLM pointed out that she did change the language to include them as licensed practitioners in what was then called HB 186. She continued to state that she had also worked with the association of nurses and resolved issues that they felt concerned about. Recently this week, the Physician Assistants have brought up new issues and she stated that they will be testifying to this today. 3:54:26 PM CHAIR ANDERSON pointed out that Ms. Rusholm is the technical person at the meeting. REPRESENTATIVE LEDOUX stated that she was a firm believer in not fixing something that did not seemingly need to be fixed, and asked what the problem was exactly with the radiological technician issue in the state of Alaska. MS. RUFSHOLM affirmed that there was indeed a huge problem that is obviated by her presentation and the one that will be given by Mr. Clyde Pearce, the state radiological inspector. MS. RUFSHOLM described this presentation as one that will include physical displays of terribly poor radiographs that will illustrate examples of radiographs that, because of faulty techniques, and because many contain both over exposure and under exposure, the radiographs were not viable for diagnosis or use in clinic evaluation. She then went on to say that these examples being shown today were actual 'x-rays' taken by village technicians that were sent to radiologists elsewhere in the state. REPRESENTATIVE LEDOUX expressed her nescience and asked what excessive doses of radiation meant. MS. RUFSHOLM carefully explained that radiation exposure is measured accumulatively and that excessive exposure can be hazardous. 3:57:33 PM MS. RUFSHOLM went on to explain that a radiation burn can be evidenced by the manifestation of erythema in a few days, which is followed by the deterioration of the skin. This, she said, culminates in an ulcer. However, she said, the connection between overexposure and radiation and the resultant manifestation is not something that happens overnight. This takes months, sometimes years. REPRESENTATIVE LEDOUX asked that if 38 states require licensing, would there be any stats that illustrate that these difficulties happened more in the states without licensing. MS. RUFSHOLM answered that no, she did not know about any documentation that would illustrate this. CHAIR ANDERSON asked how Ms. Rusholm was able to reconcile the issue of rural Alaska not having access to educated technicians and the fact that if it were the case of either not having any radiology abilities and poor quality radiology services, that they would rather have the latter. 3:59:27 PM MS. RUFSHOLM explained that the exemptions do exist for this bill and there would be not problem for them to obtain technical education and continue doing what they are doing, provided that they are able to sit for a national registry examination, after which they would receive a limited scope license. They can sit in their homes and do this test online. The costs are nominal. CLYDE PEARCE, Chief Inspector, Radiological Health for the State of Alaska, Department of Health, stated that he performed inspections at over 360 facilities, which includes about 800 sources of radiation. He then indicated that currently he worked on scientific equipment, and in the past, he worked on airport screening machines. He began by first referring to Representative Ledoux and her earlier question about examples of radiation exposure leading to hospitalization and stating very affirmatively that there was several examples of documentation in prestigious medical journals. He cites the American Society of Radiological Technologists, which conducted a longitudinal study that continues to the present, looked at various diseases that were suffered by people working as radiological technicians. One example he said, was that they found they suffered three times the national rate of breast cancer in non operators before licensing began in other areas. REPRESENTATIVE LEDOUX asked if these statistics were done when the equipment emitted more radiation than modern equipment. MR. PEARCE answered that that the actual x-ray was discovered in 1895 and the first biological injury from radiation occurred in this country the following year. He then continued discussing the morbidity factors, primarily the loss of fingers and hands that dentists and other medical professionals suffered. He pointed out that the first death of radiation exposure took place in the United States in the late part of the 19th century by a man who worked for Thomas Edison. He then talked about the use of radiation for cosmetic hair removal and how it resulted in arm amputations for women in large numbers. The dangers were seen right away and safety measures were put into place. MR. PEARCE continued by saying that the discovery of the CAT scan in 1971 changed this trend. He announced that the exposure rate of this type of imagery was 10 to 100 times higher than the normal x-ray dose. This is justified medically, since many life-threatening conditions can be found quickly and mitigated before things get worse. An example, he offered, would be sub dural hematoma inside the skull, that would increase in pressure and cause major damage to the brain if left undetected. He then stated that a real concern is the level of exposure to children using adult doses of radiation. 4:06:37 PM MR. PEARCE stated that most of the burns that we have seen has occurred with stints and fluoroscopy and has been done by uneducated and non-radiological technicians and doctors. This indicates, he said, that education and training make the difference and this lack of training is directly related to the injuries that are documented. REPRESENTATIVE LEDOUX asked if this bill allowed doctors to perform x-rays. MR. PEARCE answered by stating that this bill is specific to technicians and excludes licensed healings arts professional practitioners. REPRESENTATIVE LEDOUX answered that she believed, based on previous testimony that the issue was one between trained radiologists and doctors, albeit, general practitioners who do not have the training in radiation science. MR. PEARCE answered plaintively that this bill had nothing to do with radiologists but it does address safe versus hazardous exposure. 4:09:07 PM MR. PEARCE continued by stating that clarification of the bill over time had led to many who once opposed the bill to come forward with support. He then said that a lot of things have been changed including a change in how the bill treated geographical location. He clarified this by stating that this was not a rural versus metropolis issue. As an example, he pointed to the worst problem that he had encountered which was found in downtown Anchorage. He explained that the problem that occurred was exposing patients to great amounts of radiation. MR. PEARCE pointed out to the committee several examples, and [pointing to several radiographs], said that the flaws that were found in Anchorage were evidence of too much exposure and yet, he said, this technician's supervisor explained to her that there was not enough exposure. In other words, there was not enough radiation. This was, he said, completely opposite of reality. MR. PEARCE then described an experiment that he and a colleague did at the University of Alaska. They produced a perfect radiograph that was medically diagnostic. He then explained that they did a series of exposures that exponentially doubled the radiation each time. The first doubled the normal optimal radiograph which made tissue observation impossible and left bone analysis okay. He indicated that to get a full black radiograph, the dummy patient had received 60 times the optimal level of radiation. This is close to what is happening here in Alaska. MR. PEARCE warned that the reason these technicians must be trained and be required to operate at higher caliber than they currently are required to do. He pointed out that current state regulations stipulate that technicians must be trained but it does not say for what duration. The people that have gone to professional schools are excluded by this bill and are left untouched, but those so-called technicians that operate radiological equipment that are no trained will be affected. MR. PEARCE ended by bluntly stating that this bill really has to do with people that are exposing other people to unsafe levels of radiation. He then exhibited several other examples of bad radiography including a cervical spine shot, which exposed the occipital and temporal aspects of the skull with huge amounts of unneeded radiation, in addition to the chest and the thyroid gland, which is very sensitive to radiation. He also pointed out an example that showed a patient receiving a cervical spine shot, not being asked to lower his shoulders to minimize exposure to the chest. MR. PEARCE pointed out that depending on what part of the body you are trying to image, the techniques will vary and it is important not to visualize radiography like one would photography, since they are very different approaches to imaging physical reality. 4:15:41 PM MR. PEARCE stated that getting an overdose does not mean you are mortally injured. He pointed out that there are some medical standards of practice regarding acceptable radiation exposure limits. However, the state regulations do not specify radiation exposure limits and decisions regarding radiation exposure are left to the clinician. However, this responsibility that is levied towards the health care provider, does not mean that radiation-imaging go beyond what is a medically sound exposure. MR. PEARCE then referred back to his previous example and said that exposing the patient 60 times the optimal level is not acceptable. He ends by stating that it does require a modicum of intelligence. CHAIR ANDERSON gave his appreciation gave a succinct summation to the speaker by stating that whether it is over or under the medically appropriate radiation exposure, the problem lies in having to repeat the procedure due to first time technical difficulties. He then asked if getting these people licensed and educated was the quintessential thing to do so that this would not ever happen. MR. PEARCE stated that this would not occur if these people were educated. He concurred with the Chair and then offered the reasonable assertion that if there was an accident, it would be a salvageable radiograph. The whole idea here is that this is not photography and this tool is not comparable to the camera [in that the former is passive]. The x-ray is an active administration of radiation. He mentioned also that even diagnostic radiation levels have been linked to diminished capacity in intelligence development, and to breast cancer. CHAIR ANDERSON stated that MR. PEARCE had made the point that the sponsor was trying to make and asked if he would stand by for questioning. ED HALL, legislative liaison for the Alaskan Academy of Physician Assistants, stated that there has not been a flip-flop on our position and have always thought that some of the language on the bill could be changed so that it appealed to the group. Basically this would have been the inclusion of physician assistants and nurses practitioners as part of the excluded group not affected by the new bill. 4:21:11 PM MR. HALL indicated that as PA's, they recognize that his group works for our physician within their specific specialties. However, he said, that one of his concerns was why the bill was not being hear in the HES committee instead of the Labor and Commerce committee. MR. HALL continued by noting that the language was changed and that upon further reading he pointed out that in section 8.89.120, beginning on page 2, line 29, and ending on page 3, line 12, section C, the bill never states whether or not out his profession can do radiology. 4:24:20 PM MR. HALL indicates that he is mostly speaking on behalf of people who have the radiological equipment and will be kept from using it for simple radiology. He agreed thought that the bill dealing with higher end imaging like cat-scans, and fluoroscopy, do need to regulated, but putting simple radiology into the same class would be a detriment to healthcare. He also said that requiring this amount of training for the number and type of imaging that is done annually does not balance itself. MR. HALL then described the actual process that goes on between a clinic and the radiologist that actually reads the film. He said that if the radiologist makes a comment about the film, i.e., that it is too dark or too light, then that is noted. The radiologist makes a qualified read or they refuse to look at it if is very poor quality. MR. HALL then indicated that he understood the passion behind this bill, however, he announced that what the academy would support is changing the bill so that there is a requirement for certification for anyone doing high end imaging including nuclear medicine, MRI, Cat-scans, and any process that might result in higher than normal radiation exposure, but not impact the day-to-day routine use of low grade radiation used with normal x-rays. CHAIR ANDERSON announced that at first he was not going to support this bill but after receiving several examples of the problem and experiencing a radiological over exposure in his own family, he changed his mind. He indicated that his son had fallen and hurt his arm and after listening to a clinic PA exclaim that the arm was broken, it was re-shot at the hospital where the radiologist said that it was not broken. He said that this was a perfect example of double exposure. MR. HALL asked if the film was read at the hospital and asked if the radiologist indicated what was wrong with the first film. CHAIR ANDERSON answered that he was just following orders and did not get a reason for the problematic film. MR. PEARCE stated that he heard something in the previous speakers speech that gave him some concern. He pointed out that the bill simply is not centered on physician assistants at all. He then indicated that in AS 8.89.100, the bill is talking about who is impacted by the bill and who is not, as found in subsection (b). He stated that what a PA knows or doesn't know is irrelevant. This bill does not concern this profession. CHAIR ANDERSON announced that he was going to obtain a legal opinion on this and get back to the committee. MR. HALL asked if the two nurses that work underneath him were going to have to be licensed. MR. PEARCE answered that yes, any healthcare worker that does not have a professional degree will have to be licensed. MR. HALL then asked if he were going to be forced to do all the shots until these women were certified. 4:32:18 PM MR. PEARCE answered that the training administered by Mr. Hall can be evaluated and take the place of certification. He then said that the bill is a platform and refinement will certainly take place. He then again said that it does not matter what the PA does or does not know and that this lack of knowledge is dealt with by the board and not this bill. MR. HALL asserted that the medical board would rely heavily on this bill and pointed out that this is why diligence was being paid to the passage of the bill now. REPRESENTATIVE ROKEBERG stated that it may be possible to apply for temporary permits as a transitional phase, and that this may have to be determined while the bill is in committee. CHAIR ANDERSON indicated to Mr. Hall that this bill is a work in progress. BARBARA HUFF-TUCKNESS, Director, Governmental Affairs, Teamsters Union 159, indicated that in representing radiological technologists, she was surprised that certification in radiological science was not required. She said that training and certification of this training is a must ubiquitously around the state, and that the South Peninsula and Kodiak Island Hospital already require certification. She then said that if you don't have a properly trained worker and as the equipment becomes more technical, the lack of certification will affect job performance. The workers that are being utilized as radiological technicians should be encouraged to go to school and become experts in their field. MS. HUFF-TUCKNESS then changed course to voice an objection to the fact that truck drivers to be certified since they haul the equipment around the state, yet radiology technicians are not required by state law to be certified. She describes this oversight as appalling. She asked the committee to please pass the bill through. 4:36:35 PM STEVE GAGE, physician assistant, Sitka, Alaska, announced that he was Chair of the Community Health Care Directors Association and representative SE Alaska Healthcare Consortium. He indicated that he had some concern about the bill and how it affects mid-level practitioners, or Nurse Practitioners and Physician Assistants. He agreed with Mr. Hall that this is not communicated effectively or explicitly. MR. GAGE stated that his chief reason for testifying is the concern he and others have about access to basic radiological services in the villages and deep in the bush, for basic extremity care. He described the community health aid program as a collection of 500 clinics that are headed by mid-level providers, such as nurse practitioners and physician assistants. He continued by stating that these clinics are the backbone of healthcare in the rural areas and without the clinics, there would be no modern healthcare. He then stated that the main thing that these clinics are in need of are radiological services. Unfortunately, he said that native communities do have to take a plane ride into a larger town to get the same services that Representative Anderson used for his son in Anchorage. Weather and daylight play a factor in transportation to the hospital since flight to and from there from the village is the only way to get the patient to the services that they do not have in the bush. Things of this nature could be taken care of in the village and the trip would not be necessary. 4:39:23 PM MR. GAGE then stipulated that even though the mid-level practitioners are grandfathered in, the medical workers that work for them are not and that he wondered what kind of training is going to be required by the state for education and training. He pointed out there are 20 hours of continuing education and that these workers were busy people and could not be bothered with this type of requirement, since it would not be feasible financially. He then added that it leaves the clinics shorthanded while they are gone. He then stated that the clinics have been utilized the protocol already put into place by the Alaskan Native American Healthcare Diagnostic Training. This is augmented by the fact that all of the films that are taken are overseen by an actual radiologist and there is dialog that takes place immediately. He ended by stating that he was concerned about the fees and that the training not be overkill. 4:42:49 PM CHAIR ANDERSON stated that he would try to work on the cost factors in rural Alaska and trying to keep the fees reasonable. 4:43:25 PM ANN DAILY, physician assistant, regional clinic, Illiama, Alaska, pointed out that the 7 remote clinics in her region do not have ready access to high end radiological diagnostic care provided by trained, educated technicians, and lack the ability to have the native workers directly supervised by a certified technician. She indicated that they also lack the ability to effectively certify all of these uneducated native workers. She then pointed out that the physician assistants working in these clinics are well qualified to do simple radiological procedures and that the radiographs that are created by the physician assistants are reviewed by radiologists and there is discussion between the two professionals. She indicated that there are measures of protection in the clinics that measure the amount of radiation exposure that occurs. MS. DAILY made it a point to mention that she had worked with radiological technicians that were certified, and that she actually experienced on occasion, both over and under exposed films created by credentialed staff. MS. DAILY ended by stating that House Bill provided no additional safety assurances and in some instances, will negatively impact the ability to provide decent healthcare to some Alaskans. She asked the committee to consider the financial impact on these remote villages. 4:47:09 PM REPRESENTATIVE LEDOUX pointed out that Ms. Daily operates the sub regional class of village healthcare, but those serving underneath her are not medical professionals and that they certainly were not physician assistants. MS. DAILY agreed and answered that this was correct. GUMENSINDO ROSALES, registered radiological technologist, indicated that the current medical system in Alaska is broken, especially based on the testimony of Clyde Pearce. He then pointed out that testifiers that have come before are coming at this from a weak and unrelated issue, primarily that being access and the inability for the native workers to be able to afford to leave and get training and certifications. He then pointed out that by investing $70 a year, and $140 dollars for two years, they can continue their education (CE) and not be burdened with the travel expenses or the time spent away receiving the training in a classroom. He ended by stating that the only financial impact here is the initial training which all uneducated workers will have to manage, and updating this training can be as simple as reading a magazine provided by the American Society for Radiological Technology, which they will be a part of when they are certified. 4:49:27 PM MR. ROSALES referring to Article 1, Section 8.89.150, stated that this bill is primarily pointed at ionizing radiation and not magnetic energy. He then referred to Article 3, Section 8.89.990, where it defines the work of the limited technician as one that is primarily concerned with the "the axial-appendicular skeleton". He said, from his experience, that the axial- appendicular aspect of the human skeleton includes the head and neck, and spine and that these areas are not touched by the inexperienced technicians, since the eyes and the abdomen are very vulnerable to radiation exposure. He indicated that this work is reserved for the radiologist or a certified technician. CHAIR ANDERSON asked if Mr. Rosales would memorialize his testimony and make a concrete argument that is definitive. MR. ROSALES stated that in the industry, the nationwide standard consisted of 24 hours of continuing education exams (CEE), and changing the bills stipulation of 20 to the national standard of 24, which would make it easier for people who are transferring from other states to work in Alaska. CHAIR ANDERSON asked the speaker to contribute this in written form. He then closed public testimony. [HB 150 was held over.]
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