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Obligations of the On-Call Radiologist

Obligations of the On-Call Radiologist

One of the thorniest — and more contentious — issues in the imaging sciences today centers on the role of the on-call radiologist. Questions swirl around two key issues:

• Must on-call radiologists be physically present inside their hospitals to do readings, or can they fulfill their obligations by teleradiology?
• Who has, or what is, the final word regarding call coverage — federal mandate, hospital policy, medical staff bylaws, group contract, radiologist availability, or individual availability or preference?

Getting a clear reading on the call coverage issue is key, given the accelerating movement toward teleradiology, the shortage of radiologists, and the threat of stiff sanctions should a physician fail to meet his or her obligations.

ACR Associate General Counsel Thomas Hoffman notes that no national consensus has emerged. "This is a dynamic area, particularly where you have the broad outlines of a legal government mandate and all solutions seem to be local," he says.

A look at the current law is in order.

EMTALA and CMS

Both the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Medicare Interpretive Guidelines from CMS outline a hospital's broad obligations regarding the provision of emergency radiology care, but both leave hospitals to negotiate with medical staff the critical who, what, when, where, and how. Hoffman calls the Medicare Interpretive Guidelines "the flesh on the bones of the law" but notes that, like EMTALA, they "do not mandate a particular method of on-call coverage."

CMS further says: "No physician is required to be on call at all times. On-call coverage should be provided for, within reason, depending on the number of physicians in a specialty. The determination about whether a hospital is in compliance with these regulations must be based on the facts in each individual case. If a staff physician is on call to provide emergency services, or to consult with an emergency department (ED) physician in his or her area of expertise, that physician would be considered to be available to the hospital. A determination as to whether the on-call physician must physically assess the patient in the emergency department is the decision of the treating emergency physician."

This last point bears repeating. The ED treating physician has ultimate authority to call a radiologist into the hospital for an image consultation. In certain cases, Hoffman says, the treating physician can call in a radiologist, even if the radiology practices teleradiology in compliance with EMTALA and CMS guidelines.

A case in point: An ED physician and radiologist differ in their interpretations. The ED physician insists they look at the images together, believing it clinically crucial.

Another example might see a radiologist required to come into the hospital to use a work station to give the ED physician a definitive diagnosis. Barry Pressman, M.D., FACR, chair of the Department of Imaging and Chief of Neuroradiology and Head and Neck Imaging at Cedars-Sinai Medical Center in Los Angeles, notes that "teleradiology generally does not allow for sophisticated 2-D and especially 3-D reformations, as are required to interpret CT angios."

Hoffman says there used to be a common misunderstanding that a hospital that held itself out as a provider of certain subspecialties — such as diagnostic imaging — had to have three or more appropriately subspecialized physicians on staff or on call. Medicare subsequently denied having ever said that, or even having implied it.

Contractual or Bylaw Obligations

Even though CMS or EMTALA do not require a radiologist at a major hospital to participate in 24/7 call coverage, the hospital itself — or its radiology department — may do so by contract, policy, or medical staff bylaws. Similarly, a radiology group's contract may spell out call coverage terms in the absence of a formal requirement by a hospital. When in doubt about call coverage, Hoffman says, consult with those in the know. A medical staff's call obligations are typically detailed in hospital policy or medical staff bylaws.

Penalties

Failure to fulfill EMTALA's responsibilities can trigger stiff penalties against the hospital and radiologist alike. The applicable EMTALA statute prescribes, "any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital, including a physician on call for the care of such an individual, and who negligently violates a requirement [of the EMTALA law]" is subject to a civil penalty of up to $50,000 per violation. If the violation is gross and flagrant, or is repeated, then the physician may face exclusion from participating in Medicare and Medicaid programs. Hoffman calls this threat of exclusion EMTALA's "ultimate hammer."

Hoffman describes the ACR Practice Guideline on Hospital Emergency Coverage "as the only official resource we have on point for radiologists covering emergency departments." But there's a key caveat. The guideline — first adopted in 2000, then revised and amended in 2003 and 2006 — outlines generally accepted standards but doesn't carry the weight of law.

In short, the guideline specifies "timely coverage" of imaging examinations for ED patients. This can be accomplished in one of two ways:

1. A qualified radiologist is available to interpret imaging studies in accordance with criteria determined by collaboration between the radiology department, the ED, and the medical staff of the hospital, depending on resources available in the applicable geographic locality.

2. A qualified radiologist with acceptable teleradiology link to the hospital is available.

On-Call Responsibilities in a 24/7 World

Smaller hospitals or rural hospitals that hold themselves out as providers of imaging services may find it difficult to comply with EMTALA's provisions. When a hospital is short-staffed or has not yet perfected its teleradiology coverage, Hoffman says "it may have no choice but to rely on an off-site teleradiology practice, or to make an arrangement with a radiology group that they be available for immediate consultation."

The 2003 Medicare regulations also allow physicians to perform call coverage at more than one location, which raises logistical issues. Again, CMS places the responsibility squarely on the backs of hospital administrators. By being proactive and adopting sound call-coverage policies early on, hospitals can effectively anticipate such scenarios as an on-call radiologist working at another hospital or being tied up in surgery, or circumstances in which no radiologist is available for call.

Hoffman notes that the ACR and other key groups have spent many years trying to hammer out these complex issues. Among the difficult questions: Should call coverage in a hospital be selective, based on status, or based on something else? Also: Would physicians who do not have active staff privileges be exempt from call? Hoffman says these are "as much hospital issues as they are physician issues."

At present, Hoffman says, the clinical and technology curves are probably ahead of the regulatory curve. CMS continues to assess how teleradiology fits into the overall picture — and into a myriad of settings.

The bottom line, Hoffman says, is that hospitals and physicians should communicate their needs and expectations, and ensure that everyone knows what their legal responsibilities are, so there are no surprises.