SUBMISSION
8 July 2015
Consultation: Regulation Impact
Statement
Improving the quality and safety of Medicare
funded diagnostic imaging services through the
enhancement of regulatory and accreditation
requirements
The Peak Body Representing Chiropractors
www.chiropractors.asn.au
Contents
MAIN RECOMMENDATIONS .......................................................................................................... 4
INTRODUCTION .................................................................................................................................... 6
Identified matters from the RIS ........................................................................................... 6
Outcomes sort from this submission .................................................................................. 6
BACKGROUND ...................................................................................................................................... 7
Radiography an important and established part of chiropractic .................... 7
Clinical benefits of chiropractors’ performing radiography ................................ 7
WHICH HEALTH PRACTITIONER CAN ASSIST RADIOLOGIST OR OTHER
SUITABLY QUALIFIED SPECIALIST PROVIDING SERVICES?......................................... 7
Appropriately qualified health professional training, knowledge and
experience ....................................................................................................................................... 8
Quality of diagnostic images created by chiropractors ........................................... 8
Radiation risk .............................................................................................................................. 9
THE LEVEL OF SUPERVISION REQUIRED TO ENSURE THAT SERVICES ARE
OF A HIGH QUALITY, SAFE AND APPROPRIATE.............................................................. 9
Quality of images ........................................................................................................................ 9
RURAL ACCESS FOR PATIENTS ...................................................................................... 10
STORAGE AND EQUIPMENT MAINTENANCE. ......................................................... 10
APPENDIX 1- UNIVERSITY CURRICULUM FOR RADIOGRAPHY SUBJECTS IN
CHIROPRACTIC AND RADIOGAPHY
APPENDIX 2 - MONASH UNIVERSITY BACHELOR OF RADIOGRAPHY AND
MEDICAL IMAGING
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APPENDIX 3 - ARPANSA CODE OF PRACTICE - RADIATION PROTECTION
IN THE APPLICATION OF IONIZING RADIATION BY CHIROPRACTORS
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MAIN RECOMMENDATIONS
The aim of this submission is to ensure that Chiropractors’ Association of
Australia (CAA) is:
1. included in any dialogue related to this particular matter to ensure the
interests of both Chiropractors and their patients are not unfairly
disadvantaged by any proposed changes;
2. provided with an opportunity to make further submissions in areas
identified in this submission and arising during the course of the
consultation process;
3. kept informed throughout the consultation process and recognised as a
Stakeholder for the purpose of this review.
The CAA recommends that:
4. Chiropractors are entirely appropriate to assist a Radiologist in the
provision of a report by capturing the images. Chiropractors should be
accepted as a non-comprehensive practice without a Radiologist in
Attendance for Diagnostic Imaging within the scope of their licensing;
5. The current rural exemption clause should be maintained;
6. The inclusion of a DIAS standard that requires appropriate storage and
retrieval processes of images and reports and the strengthening of
equipment maintenance standards is supported.
CHIROPRACTORS’ ASSOCIATION OF AUSTRALIA
The Chiropractors’ Association of Australia (CAA) is the peak body
representing the interests of Australian chiropractors and their patients. The
CAA is a national organization with state and territory branches. The CAA
corporate structure is one of a company limited by guarantee. The
organization has over 3,000 members. The CAA is governed by a Board of
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Directors elected by representatives of all stakeholder groups within the
Association.
CONTACT CAA
Adjunct Associate Professor Matthew Fisher PhD DHlthSt (honoris causa)
PO Box 255, Parramatta NSW 2124
Tel: 02 02 8844 0400
Fax: 02 02 8844 0499
Email: ceo@caa.asn.au
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INTRODUCTION
1.
This submission is made by the Chiropractors’ Association of Australia (National) Ltd with respect to the
Consultation Regulation Impact Statement May 2015 and limits itself to information on Chiropractic as
relating to the stated Objective of the RIS; “a review of the existing requirements for the provision of
diagnostic imaging and to explore options for enhancing quality, minimising waste and reducing harm
caused by inappropriate, unnecessary and sub-optimal diagnostic imaging services.”
Identified matters from the RIS
2.
In summary, these submissions address the following matters:
(a)
Which Health Practitioner can assist Radiologist or other suitably qualified specialist providing
services?
(b)
The level of supervision required to ensure that services are of a high quality, safe and appropriate.
(c)
Rural Access for Patients
(d)
Image Quality, Storage and Equipment maintenance.
Outcomes sort from this submission
3.
The CAA (National) in summary seeks the following:
(a)
To provide information consistent with the objectives so that all decisions are made in an informed
environment.
(b)
To be part of the dialogue over the coming process to ensure the interests of both Chiropractors and
their patients are not unfairly disadvantaged by any proposed changes.
(c)
The opportunity to make further submissions in areas identified in this submission and arising during
the course of the consultation process.
(d)
To be kept informed throughout the consultation process and recognised as a Stakeholder for the
purpose of this review.
(e)
Chiropractors are entirely appropriate to assist a Radiologist in the provision of a report by capturing
the images. Chiropractors should be accepted as a non-comprehensive practice without a Radiologist
in Attendance for Diagnostic Imaging within the scope of their licensing.
(f)
That the current rural exemption clause should be maintained.
(g)
The inclusion of a DIAS standard that requires appropriate storage and retrieval processes of images
and reports and the strengthening of equipment maintenance standards is supported.
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BACKGROUND
Radiography is an important and established part of chiropractic
4.
Diagnostic radiography has played an important part in chiropractic practice since the early 20th century.
Many chiropractors in Australia carry out their own radiography, and training in radiography and radiology
is an important part of all chiropractic courses in Australia. The CAA has a Radiology Committee, whose
members include the heads of the radiology departments of 3 of the 4 Australian chiropractic teaching
institutions as well as a number of field practitioners with a strong interest in the area of chiropractic
radiography.
5.
Because Chiropractors apply unique management protocols and interventional techniques which carry
inherent relative contraindications, diagnostic radiology may significantly improve patient safety where a
clinical indication for x-ray is established. Chiropractors who take their own x-rays provide an added-value
service to the patient, enabling earliest possible care in an acute setting.
Clinical benefits of chiropractors performing radiography
6.
7.
There are significant benefits to patients in having their chiropractor do the x-rays.
(a)
Appropriate image: The chiropractor, trained in radiography and radiology, is the person best placed
to ensure that the image meets the diagnostic requirements for which it is being made.
(b)
Immediate reading and response: While the patient is still present in the premises the chiropractor
can read the image, make diagnostic decisions, and immediately begin treatment on the basis of the
diagnosis, informed by the diagnostic image. (This is not to minimise the role of the specialist
radiologist, which we shall address below.)
The treating chiropractor, with relevant expertise in radiography and radiology, is the person who can serve
the patient best by performing the radiography. It is a strong case of “The right test at the right time on
the right patient for the right clinical condition”. This point is summed up concisely in comments of a CAA
member and chiropractor who notes:
“There is an x-ray machine down the hall from my consulting room. This means I can directly
influence x-rays as they are taken and alter the examination as new information comes to
hand with each x-ray. I can also combine this with the information I have gained in the exam
room. This means the experience and quality of care afforded to my patients is exceptionally
efficient and minimises fragmentation of care.”
WHICH HEALTH PRACTITIONER CAN ASSIST RADIOLOGIST OR
OTHER SUITABLY QUALIFIED SPECIALIST PROVIDING SERVICES?
8.
To identify the Health Practitioner to assist the Radiologist in the provision of services we will use the
criteria from the objective:
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Objective: Medicare benefits are currently claimed and paid for diagnostic imaging services that are
provided by appropriately qualified professionals, who have the training, knowledge, and experience
required to provide quality outcomes for patients and that patients receive services that are clinically
appropriate, safe and provide benefit (emphasis added).
Appropriately qualified health professional training, knowledge
and experience
9.
Given the rationale provided in points 10-13 below, it is our position that members of the public who use
chiropractic services should not be disadvantaged by the 2012 changes to the DIST which removed their
rights to a Medicare rebatable Radiologist Report at the primary point of care. That evidence supports that
chiropractors are entirely appropriate to assist the Radiologist in the provision of a report by capturing the
images.
10.
Chiropractors have move extensive training in radiography and radiology than dentists and medical
practitioners; and their training compares favourably with that given to radiographers with respect to
conventional radiographic technique and safety.
11.
Appendix 1 (attached) details the Chiropractic curriculum relating to radiation physics and protection,
radiography and radiologic interpretation from three established Universities. For comparison, Appendix 2
(attached) details the course modules relating to the above as taught at Monash University Bachelor of
Radiography and Medical Imaging.
12.
To summarise, a typical amount of dedicated and structured educational training by chiropractors in the
areas of radiation physics and safety would be 40-50 hours; in radiographic positioning would be 40–50
hours; and in clinical radiography would be 45–60 hours, with a minimum of 30 patient procedures
required under accreditation standards.
13.
This is further augmented by the education provided in anatomy, interpretive, and reporting aspects of
their training, which is substantial.
14.
Chiropractors, as qualified health professionals, should have the same access to Medicare funded
Diagnostic Imaging opinions from Medical Radiologists as dentists and medical practitioners on the basis of
their education and training in radiation safety and radiographic technique.
Quality of diagnostic images created by chiropractors
15.
If it is suggested that diagnostic images created by chiropractors are generally inferior to those created by
medical practitioners, dentists or other health professionals, we are unaware of any foundation for such a
suggestion. We would submit that such a suggestion is in fact unfounded. The chiropractic profession
invites open and regular dialogue with other stakeholders and radiation bodies regarding this and any
related issues.
16.
If images submitted for radiological report are not up to standard, presumably the radiologist would refer
them back to the radiographer or the referring practitioner. Furthermore, any significant shortfall in
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standards would be reflected in reporting under the DIAS and in reports to the Chiropractic Board of
Australia.
Radiation risk
17.
Specific recognition is provided within the Chiropractic Board of Australia Code of Conduct for
Chiropractors in the radiology appendix. This specifically states:
“Chiropractors use radiography for several purposes following the identification of various history and
examination
findings, including: confirmation of diagnosis/pathology; determining appropriateness
of care; identifying contraindications or factors that would affect or modify the type of
treatment/care proposed.”
18.
It further addresses the key radiation protection principles of the ARPANSA Code (Appendix 3 - attached)
regarding—

Justification:
“No practice involving exposure to radiation should be adopted unless it produces sufficient benefit to
the exposed individuals or to society to offset the radiation detriment it causes”
The procedure must be justified for that individual patient.

Optimisation:
“Radiation doses must be kept ‘as low as reasonably achievable’ (ALARA)”

Dose limits
“All applications of ionizing radiation must be managed in a way to not exceed dose limits specified in
RPS1”
19.
In Appendix 2, chiropractors’ training includes, in its core curriculum, substantial training about radiation
risk. This exceeds that of medical practitioners and dentists.
THE LEVEL OF SUPERVISION REQUIRED TO ENSURE THAT
SERVICES ARE OF A HIGH QUALITY, SAFE AND APPROPRIATE.
Quality of images
20.
We would suggest that Chiropractors be accepted as a non-comprehensive practice without a Radiologist in
Attendance for Diagnostic Imaging within the scope of their licensing.
21.
We are unaware of any current or previous quality failings as a profession, which would become very
evident due to the DIAS Standards. Furthermore, accepted “Medical Practice” requires images submitted
for radiological report, which are considered not up to standard by the radiologist, to be referred back to
the radiographer or the referring practitioner. Once again, any significant shortfall in quality would be
reflected in records under the DIAS and reports to the Chiropractic Board of Australia.
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RURAL ACCESS FOR PATIENTS
22.
23.
While we could support a simplification of the rural exemption clause, we would advise that any reduction
in Chiropractic access in these areas will result in a hardship to Rural Patients for the following reasons:
(a)
Increased waiting time prior to the commencement of care. We have been advised that waiting
times can be as great as 3 weeks for what is deemed at Country Hospitals as non-urgent imaging.
(b)
Increased financial hardship by removing a Medicare funded Radiologist Report from Rural
Chiropractors.
For this reason we recommend that current rural exemption clause be maintained.
STORAGE AND EQUIPMENT MAINTENANCE.
24.
The CAA (National) would support the inclusion of a DIAS standard that requires appropriate storage and
retrieval processes of images and reports. As a part of the Patient Health Record, this should be currently
occurring but inclusion in the DIAS will reinforce this important requirement, including a doubleredundancy off-site back-up for all digital health records.
25.
The CAA (National) would support the strengthening of the equipment maintenance standard to hold with
the objectives of the RIS to provide Quality Images.
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