Next-Generation Remote Console Operations & Radiology Informatics

Over the past several years, the healthcare industry has been challenged with unstable work environments, pressures on productivity, and shrinking reimbursements. The radiology workforce shortage experienced these stressors long before COVID-19. In the ASRT Workforce Survey 2019, the industry began to see an increase in vacancies in 2015 — five years before the pandemic began.

At RSNA 2023, Dr. Jocelyn Chertoff shared that by 2030, the world will face a shortage of about 10 million healthcare workers. Despite the future healthcare shortage forecast, as of 2023, there has been an increase in the total number of students entering radiography programs by 1,444 people. Specific to MR, there has been a decrease in the number of students enrolled in MR programs, moving from 720 students to 555. Out of the 60 ARRT-recognized MR programs, 62.5% are not at full capacity.

Remote scanning offers the potential to learn multiple vendors, be more versatile in the workplace, and rotate shifts for a healthier work/life balance. Healthcare leadership interested in remote scanning for workforce shortages should be cognizant that current accreditation organizations and guidelines vary in the industry and must be fully reviewed to determine their applicability within their own organizations.

The benefits of MR as an effective and essential clinical diagnostic tool have been demonstrated during more than 35 years of use. However, the exigencies of the MR environment — including the static magnetic field (B0), time-varying radiofrequency magnetic field (B1), and time-varying gradient magnetic field (dB/dt), as well as the use of gadolinium-based contrast agents (GBCAs) — make proper implementation and supervision of all clinical and research MR systems essential for the prevention of potential related hazards.

The use of GBCAs results in additional patient risk with a reported potential for significant adverse drug reactions of approximately 0.01%. These severe reactions, if unsupervised and left untreated, could result in patient death.

Development of models for remote scanning implementation must ensure that the safety of those being scanned and of the staff is always maintained to at least the same level as for standard scanning with the MR Technologist on site.

When considering the implementation of remote imaging, an organization should research the applicable standards set forth by the facility's accrediting body. The four accreditation bodies approved by CMS for advanced diagnostic imaging are:

• American College of Radiology (ACR)
• Intersocietal Accreditation Commission (IAC)
• RadSite
• The Joint Commission (TJC)

A certified and registered MR Technologist should perform the exam, whether remote or onsite. Accrediting bodies state a facility's MR Technologist should be licensed in the jurisdiction in which they practice if state licensure for MR Technologists exists. When exams are performed remotely and crossing state lines, it is important to obtain and follow all applicable state requirements where the technologist is physically located and the state where the patient is receiving the scan.

All accreditation, certification, and licensing documentation must be monitored and tracked through the healthcare organization caring for the patient in the event of an audit — inclusive of outsourcing remote scans to third parties.

The Food and Drug Administration (FDA), an agency within the Department of Health and Human Services (HHS), is responsible for regulating the safety and effectiveness of medical devices. FDA's Center for Devices and Radiological Health (CDRH) regulates radiation-emitting electronic products used for both medical and non-medical applications.

Medical device manufacturers must submit documentation for pre-market submissions for FDA's evaluation of the safety and effectiveness of device software functions. This clearance process involves thorough evaluation of the device design, performance, and manufacturing processes to ensure that it meets regulatory standards for quality, safety, and efficacy.

Remote scanning capabilities are designed to:

• Enable healthcare professionals to operate imaging equipment remotely addressing the shortage of radiologic technologists and advanced imaging expertise.
• Standardize imaging protocols and practices across different locations for accurate patient diagnosis and management.
• Leverage the expertise of technologists across multiple locations, facilitating knowledge sharing and training, and ultimately improving patient care.

Facilities using remote scanning should ensure that the equipment manufacturer has appropriate FDA clearance for the intended use and develop policies and procedures ensuring that the use of remote technology is safe for patients.

Vendor Selection

Facilities should decide if they would like to set up remote scanning on more than one vendor specific MR machine, both now and in the future. Purchasing vendor agnostic equipment will give the flexibility to scan with more than one vendor. Most vendors only control the MR scanner but there are some that will allow control of the contrast injector.

Cameras

The use of cameras is not required but could add value, depending upon how an organization implements remote scanning. Areas in which a camera may add value include:

• On the injector, should your remote vendor not offer injector control.
• In Zone III looking down the bore of the magnet.
• In Zone III looking at the door to Zone IV.

All cameras should be physically secured to standard internet and phone connections that are needed to support the remote scanning equipment reliably. Facilities should consider developing a written standard operating procedure (SOP) that addresses management of situations in which communication connections go down during a scan.

Remote Operator Setup

Careful consideration should be given to not only what the remote operation control center will look like but also where it is located. A site should consider the same guidance used for a radiologist reading station: eliminating or significantly reducing distractions, optimizing ambient lighting, improving ergonomics, and providing adequate work surfaces.

Risk management, within MR, is an overarching term that encompasses the forecasting and evaluation of potential hazards within the MR environment to assist with mitigating or minimizing potential impact. When evaluating remote MR scanning, risk management is a key aspect that should not be ignored.

As remote MR scanning is still being developed, there is considerable debate as to who should be responsible for what. When implementing a remote MR scanning program, the delineation of roles both at the bedside and the remote technologist must be thoroughly vetted. In his editorial, "Divided Liability Remote MR Scanning," Emanual Kanal, M.D., divides the duties and responsibilities between the staff at the bedside and those at the remote facility.

Training and education of staff for any remote MR scanning program is essential for the success of the program and for the safety of everyone involved, including the patient. The duties and responsibilities of all roles charged with ensuring patient and staff safety should be clearly defined with considerations to format and frequency so that roles, duties, responsibilities, and liabilities are clearly set and understood.

As with any program, it is critical to have well-written and defined policies and procedures. All facilities utilizing MR technologies should maintain and regularly update MR safety policies. To mitigate potential risks for the remote MR scanning program, policies and procedures should be well-written, incorporating all aspects of the remote scanning program to ensure processes have been scrutinized and vetted to safeguard against potential threats.

Prior to implementation it is important to research the most up-to-date education and training guidelines maintained by state laws and regulations, certification agencies, accreditation agencies, and the standards of practice of nationally recognized professional associations.

On-site and remote MR technologists, along with all designated MR Level 2 personnel, will need to have proper training and documentation of remote scanning technology/equipment after initial implementation. All MR Level 2 personnel should be trained in how to use the software, ranging from securely logging in to troubleshooting if there is a lost connection.

Formal Workflow Policies Should Include:

• Communication Workflows: When and how remote technologists are notified of patient scans.
• Patient Safety: Who is responsible for the patient screening form if there is an on-site MR technologist? How is the screening form shared with remote technologist?
• Contrast Injections: How is contrast injection timing communicated? Via phone or chat? If the remote technologist is an external employee, are they familiar with the contrast policies of your facility?
• Image Quality: Who is responsible for verifying the patient exam is complete and all images are acquired? Do radiologists need to be involved to verify if using advanced imaging?
• Exam Protocol: Under supervision of the radiologist, who decides which protocol to use?

Compliance with required supervision, credentialing, and licensure guidelines are required for billing based on the site of service. Special technologist qualification requirements exist for Independent Diagnostic Testing Facilities (IDTF), including meeting the licensure and/or certification standards of the state in which tests are performed at the time of the IDTF's enrollment and/or at the time any tests were performed.

The technologists can either be employees of the IDTF or be contracted by the IDTF. All enrolling IDTFs must meet the applicable licensure, certification, or credentialing requirements at the time of their enrollment.

Key Regulations:

• 42 CFR §410.33 — Non-physician personnel requirements
• CMS IOM Pub. Chapter 10 — Medicare Enrollment Section 10.2.2.4 for IDTFs
• Local Coverage Article A53252 — IDTF supervising physician and non-physician personnel credentialing requirements

Facilities should verify coverage of services by liability insurance for the use of offsite technologists to ensure current coverage will remain in effect and not be considered an exclusionary service. Compliance with CMS guidelines and regulations, state laws, and individual payer requirements is required.