From the Chair of the Commission on Economics
Gregory N. Nicola, MD, FACR

Some radiology practices across the country are now supervising contrast administration virtually rather than with on-site radiologists. Radiologists (including myself) have mixed feelings about this brave new world of virtual contrast supervision. 

From a regulatory standpoint, this development is on solid footing. In April 2020, CMS altered the definition of direct supervision to include virtual presence through real-time audiovisual technology — when allowed by state supervision requirements. The agency reaffirmed this expanded definition of direct supervision in the 2024 Medicare Physician Fee Schedule final rule, extending the policy until at least the end of 2024. Experts believe there is a good chance the changed definition will be made permanent. So perhaps this isn’t as much of a brave new world as it may seem; radiology groups have been supervising contrast remotely for several years. In fact, companies will provide remote contrast coverage for your center independent of the radiology group that bills the professional services. CMS has previously concluded that advanced practice providers can provide direct supervision of contrast administration in all imaging settings except independent diagnostic testing facilities. One might argue that radiologist-led and supported remote contrast coverage is necessary to ensure high-quality patient care and to protect relationships with hospital and imaging center partners.

Radiologists (including myself) have mixed feelings about this brave new world of virtual contrast supervision.

In this and all endeavors, patient safety must be our top priority. Radiologists who provide remote contrast supervision must develop and test the process relentlessly. This is necessary to ensure that the radiologist response is immediate, redundancies are built-in and that the on-site technologists are trained in applying ACR algorithms for managing adverse reactions. 

My practice has recently begun a pilot program providing remote supervision for contrast coverage at one of our rural imaging centers located four hours away. Finding on-site radiologist staffing for the center proved impossible. Without remote contrast coverage, the imaging center would have been forced to close, removing access to imaging for the patient community. We partnered with center leaders and local technologists to develop a process that ensured the safety of our patients. Three concepts emerged as key to our success: redundancy, vigilance and collaboration. 

Since the direct supervision requirement mandates that the supervisor be “immediately available,” building redundancies into our system was non-negotiable. We brainstormed everything that could fall through or go wrong and built a backup for those scenarios. Then we created a backup for the backup. We also enforced vigilance in the form of uncompromised commitment to process. Much like the airline industry and other high-reliability organizations, we committed to rigorous and routine testing even when the probability of a bad event is mercifully low. Finally, we knew from the beginning that we’d never be successful without cooperation and buy-in from the on-site technologists. 

And while radiologists have mixed feelings about remote contrast supervision, technologists understandably have much more trepidation when faced with this change. A strong working relationship and reassurance that radiologist supervision may be packaged differently but is otherwise unchanged go a long way in establishing a comfort level among the team. In our center, we review and rehearse the ACR algorithms for managing contrast reactions together, resulting in a level of comfort with these guidelines that has surpassed what existed when we were staffing on site. 

With no solutions to the national radiologist workforce shortage on the horizon, remote contrast supervision may protect access to care and allow short-staffed radiology groups to better use limited manpower resources. It could reduce burnout and improve morale as we reduce the requirement for an on-site presence after hours. Done in the appropriate settings, for the right reasons, and with meticulous attention to quality assurance, virtual supervision could benefit our members and our patients. Does remote contrast coverage nudge radiology down the slippery slope of commoditization? Maybe. But that ship has sailed, and having radiologists lead this effort is a better strategy than allowing it to evolve without us.