Yesterday, the American College of Radiology (ACR) published a new statement from its Drugs and Contrast Media Committee on the supervision of diagnostic tests that make use of contrast media. With it, the ACR could be dashing the efforts of ACR accredited facilities to use mid-levels in the providing remote direct supervision of MRI and CT studies using contrast should this statement become incorporated into ACR's accreditation standards. But one cannot say that definitively. 

The committee's statement prescribes that there must be on-site when contrast is administered either a radiologist or other physician (including radiology residents and fellows) OR “another qualified person” who is acting under the general supervision of a physician. 

Referring to the other qualified person (or perhaps even the radiologist or other physician), the onsite individual (including, perhaps the direct supervising physician/practitioner or even the radiologic technologist?) must: 

1. Have received training and meet institutional periodic competency guidelines at evaluating patients and diagnosing and differentiating different types of adverse reactions to contrast. 
2. Be able to recognize when medical intervention is required for a hypersensitivity immediate reaction or physiology adverse event due to contrast administration. 
3. Be trained and legally permitted to administer prescription medications (e.g. antihistamine, intravenous fluid, beta agonist inhalers, epinephrine) and other appropriate interventions independently or under a standing orders/algorithmic approach under state law or regulations, and under local, institutional, site, and facility policies, guidelines and rules.  
4. When qualified to act under general supervision of a physician, be able to consult with the supervising physician within an appropriate time frame. (Query, does the committee refer to consultation with the general supervising physician or the direct supervising physician?)
5. Has minimum BLS certification. 
6. Understand when to call for assistance and how to activate emergency response systems. 

These are excellent standards. But I find the statement quite confusing by not making clear who can be the other qualified individual.  Also, one must wonder why the statement focuses only on the  physician who has general supervision duties, but not the direct supervisor of the contrast studies. Or the qualifications and training of the radiologic technologists.  I have some questions.

First, is the committee not be satisfied with even Board certified radiologists performing direct supervision of a contrast study by being present using real-time audio and video communications technology? 

Second, a big question is whether the other “qualified person” can be a radiologic technologist? This is a key question and important for ACR accredited centers whose contrast studies are virtually supervised. It makes sense that a technologist can be the “other qualified individual," but that is unsaid.

Third, why does the statement says nothing whatsoever about the roles and responsibilities of the direct supervising physician/practitioner? The statement envisions a larger role for the general supervising physician. “This remote general supervision should be available whenever contrast material is administered and include the standard post administration monitoring…” Does this make the role of the direct supervising physician superfluous and redundant? 

It may be possible that for so long as the “general” supervising physician has overall responsibility, the committee is more flexible regarding direct supervision.  Unfortunately, we just have to attempt to just infer that meaning. The statement does not speak at all about the who and the how of providing remote direct supervision of contrast studies.

This is a very puzzling document. I wish the committee had been much more clear.