On September 28th, the Ministry of Health of the Government of Alberta announced plans to reinstate public funding for claims for diagnostic imaging (DI) referred by physiotherapists and other health-care practitioners.1 This planned change will enable physiotherapists who refer patients for approved forms of DI to once again have those imaging service costs covered by Alberta Health funding.
So, all physiotherapists can order diagnostic imaging now?
No. Authorization to order DI is granted by the College of Physiotherapists of Alberta and is a restricted activity.
In order for a physiotherapist to become authorized to order DI, they must meet the requirements found on the CPTA website under Ordering Diagnostic Imaging. This includes a minimum of five years clinical experience in Canada, being registered in Alberta, completing the appropriate coursework and have an understanding of the practice standard on Performance of Restricted Activities.
If you meet the authorization requirements, you can apply for authorization.
You will also need a Practitioner Identification Number (Prac ID) to be able to order DI. The Prac ID enables the radiologist’s reimbursement for reviewing the images and completing the DI report. Prac ID’s are separate from the College of Physiotherapists of Alberta authorization process and can be obtained through Alberta Health here.
Does this mean everyone gets a DI referral?
One of the issues with DI is that waitlists build quickly when unnecessary DI referrals occur and this interferes with timely access to DI for those in need. One of the arguments made when physiotherapists initially advocated for gaining authorization was that a physiotherapist’s knowledge and skill set would allow for appropriate DI referrals specific to musculoskeletal issues.
It is important to recognize that DI is not free. The money to pay for services comes from somewhere, whether it is privately from a person’s own pocket or publicly from taxpayer monies. The Alberta Health Care Insurance Plan (AHCIP) foots the bill for publicly funded DI services which comes from you as an Alberta taxpayer. Physiotherapists must be cognizant of all the issues pertaining to DI referral rates. One of the main identified issues that has been well documented with DI is the expanded costs to our health-care system that comes with over ordering. 2
There is also the potential negative cascade of effects on the patient from ordering DI such as patient anxiety from getting the imaging, incidental findings, over diagnosis, and the risk from repeated exposure to radiation.2,3
Physiotherapists are responsible to use DI judiciously keeping in mind several factors such as necessity, risk to the patient, and impact on the health-care system.
When does this take effect?
The most recent update indicated that as of October 7th the information systems needed to enable reimbursement for diagnostic images referred by physiotherapists through AHCIP are now in place. So, physiotherapists with authorization to order DI should be able to refer their patients using the appropriate referral forms and their Prac ID.
What if my colleague has authorization and I ask them to order my patient an x-ray?
In alignment with the DI requirements found in the Performance of Restricted Activities Standard of Practice, the physiotherapist with the authorization to order DI “Orders diagnostic imaging for their own clients only, for the purpose of assisting in the management of their physiotherapy care.”
Physiotherapists should not be referring patients for DI unless they are involved in the patient’s care delivery and have assessed the patient themselves to determine if the referral is necessary, safe and will answer the clinical question it is intended for. This is a serious responsibility that should not be treated lightly.
If I am authorized, what can I order?
On September 28, 2022, the Government of Alberta, Ministry of Health announced that public funding would be made available through the Alberta Health Care Insurance Plan (AHCIP) for DI referrals from physiotherapists, chiropractors and audiologists. This funding for referrals is currently limited to x-ray, ultrasound, and fluoroscopy.
In accordance with the wording of the Physical Therapists Profession Regulation (Section 14), fluoroscopy is not an imaging technique that physiotherapists can refer patients for.
But what about MRI?
At this point in time, the College has been advised that the Schedule of Medical Benefits does not include fee codes for Magnetic Resonance Imaging services, meaning that public funding for Magnetic Resonance Imaging referred by physiotherapists will not be provided through the Alberta Health Care Insurance Plan.
Physiotherapists can still refer for MRI’s if the patient is willing to access an MRI through privately funded means.
Questions regarding access to public MRI funding through Alberta Health Services should be directed to Alberta Health Services.
Does this announcement mean I can use Point of Care Ultrasound (POCUS) in my practice?
The Physical Therapists Profession Regulation only permits physiotherapists to order ultrasound imaging and does not include “to apply.” So no, physiotherapists cannot apply Point of Care Ultrasound Imaging.
For those of you who aren’t sure what POCUS is I will give you brief rundown.
This is a form of ultrasound examination provided in clinical practice settings with the intent to clarify uncertain findings of the clinical examination or to enhance the quality and effectiveness of interventions. As noted by the College of Physicians and Surgeons of Alberta (CPSA), POCUS is an application of ultrasound imaging technology distinct from the more extensive investigation undertaken during a Consultative Diagnostic Ultrasound examination conducted by a radiologist.
Alberta Health has confirmed in the past that the application of POCUS is currently not authorized to physiotherapists because of the specific wording of the Physical Therapist Profession Regulation. Any physiotherapist independently using POCUS in Alberta is, therefore, currently in breach of the legislation, and the Legislative Responsibilities Standard of Practice.
The College of Physiotherapists of Alberta is aware of practice settings in which physiotherapists are assigned the application of POCUS under the supervision of a duly authorized health professional. For example, some physiotherapists working in hospital-based incontinence clinics perform assessments and treatments using POCUS under the supervision of radiologists located within the same building.
It’s been a while since I have been regularly referring patients for diagnostic imaging, what do I need to keep in mind?
Regardless of your authorization to refer for DI, physiotherapists are required to practice in a manner consistent with all of the Standards of Practice, including the Competence Standard of Practice which states that physiotherapists must practice within their level of competence and take appropriate action when they do not have the required competence to deliver quality care. If a physiotherapist has not provided referrals for DI in recent months, they are advised to spend some time brushing up on their knowledge and skills before they start to refer for DI again.
It is also highly recommended that for those physiotherapist who haven’t been ordering imaging frequently in the last two years to review the Performance of Restricted Activities Standard of Practice and the performance expectations specific to DI. It is important to remember that you are responsible for the imaging you order. That means if a referral is lost along the way and you get a phone call from the patient seven weeks later wondering why they haven’t been contacted yet that is on you and your staff to manage and accept responsibility for. That also means that if you haven’t received imaging back from a provider and an important finding gets lost in the shuffle, you are accountable. Be diligent and construct a good system with your clinic and/or staff to track referrals made and results from those referrals.
Imaging can produce urgent findings and it is up to you to ensure you are aware of the findings and take action as you are the practitioner that ordered the DI in the first place. Emergency contact information must be on all imaging orders in the event that emergent notification must occur. If any findings are critical to the patient, it is your responsibility to work with the patient to ensure they are able to access appropriate care. You must also adhere to the appropriate privacy legislation as you carry out these tasks.
Communication and collaboration are imperative
To build on the previous point communication and collaborative practice is essential as a member of a patient’s health-care team. Physiotherapists should be communicating with other members of that health-care team to reduce the occurrence of redundancy or duplication of ordering images. It is potentially harmful to the patient to expose them to more radiation than necessary as well as wasteful to the health-care system to duplicate imaging services. Prior to ordering DI, you may have the patient sign consent forms to pull their DI history for you in order to avoid duplication of imaging.
It often occurs that the patient has booked appointments with both you and the physician to discuss results, but this can be a duplication of services if there is no requirement for the patient to continue with the physician. It is important to communicate to the physician the imaging you have referred for, the purpose of the imaging, and that you will follow-up with the patient once the results are back. Once images you ordered are discussed you have the option to send the patient back to the doctor to get a referral for further medical care or treatment if it is required.
The authority to order DI comes with taking on the potential risk of harm to your patient. Incidental findings on imaging vary depending on the type of imaging and patient factors but they are common across all forms of DI.4 Patients that receive an imaging report with incidental findings can find themselves caught in a cascade of care where they are sent for more medical tests, more DI, unnecessary medical procedures and even unnecessary surgical procedures.3,4 All of this comes at the cost to the patient and their overall wellbeing. In a paper authored by Ganguli et. al. they reported “cascades had caused their patients harm (86.7%), including psychological harm (68.4%), treatment burden (65.4%), financial burden (57.5%), dissatisfaction with care (27.6%), physical harm (15.6%), disrupted social relationships (8.7%), and death (0.2%). They reported that they personally experienced wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). More than two-thirds (68.9%) of all respondents reported experiencing at least one of these harms in the past year."3,5
Be intentional when you are ordering DI. What is the specific reason you are ordering it? Will this change the management of this injury? Is the patient a surgical candidate? What are the potential unintended consequences of ordering DI for this patient? These are questions you should be asking yourself when you are trying to decide if you should refer your patient on for DI or not.
So, what is the key message from this?
If you have the authorization to order DI through the College of Physiotherapists of Alberta and have a Prac ID then you are able to once again refer patients for DI, some of which is now covered through public funding. You must remember the responsibilities that come with this authorization in regards to patient safety, patient needs, and your due diligence to the health-care system.
- Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open. 2019 Oct 2;2(10):e1913325. doi: 10.1001/jamanetworkopen.2019.13325. Erratum in: JAMA Netw Open. 2019 Nov 1;2(11)
- Lumbreras B, Donat L, Hernández-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Br J Radiol. 2010 Apr;83(988):276-89.