Table 5.

Allocation of Responsibilities: Deciding Nonphysician Roles in Clinical Exercise ECG Tests

Medical director

• Establishes and documents policies: provides standing orders to specify duties and limits of exercise testing responsibilities for each nonphysician delegate; specifies clinical risk categories of patients eligible to be tested. Does not delegate authorities reserved for licensed physicians

• Directly supervises sufficient tests with each nonphysician to confirm his/her competencies with clinical classes of patients to be tested; requires individual to be credentialed or provide alternative evidence of qualifications (ie, ACSM CES or RCEP credentials or equivalent)

• Establishes, regularly rehearses, and documents capability for emergency response; ensures capability for rapid activation of a physician-directed advanced cardiac life support team for all tests; requires each nonphysician delegate to maintain training in AHA BLS or equivalent and to participate in these emergency rehearsals

• Provides substantive physician oversight with regard to policy supervision for informed consent; indications/contraindications for testing; immediate pretest physical examination by a physician; confirmation of anticipated test end points; diagnosis, prognosis, or treatment decisions; final clinical interpretation; and report to referring physician

• Makes certain that provisions in the medical malpractice policy do not preclude insurance coverage for delegation of patient care duties to nonphysicians

Nonphysician test supervisor

• Demonstrates evidence of competency related clinical exercise testing (eg, appropriate credentialing and evidence of continuing education)

• Establishes and maintains competency for cardiovascular emergency response capability, AHA BLS, or equivalent

• Performs only procedures, supervisory duties, and initial interpretations as delegated and documented in written policies from the medical director of the testing facility

• Accepts only responsibilities consistent with competencies and credentialing

• Does not perform duties that might be characterized as the practice of medicine

Institutional administrator(s)

• Reviews institutional implications of nonphysician roles in clinical exercise testing relative to institutional liability insurance coverage, Medicare regulations and policies of private healthcare insurers that would affect eligibility for reimbursement of services, and the conduct of any clinical exercise testing performed as part of IRB authorized research

Legal counsel

• Provides guidance on framing policies and practices so that proposed practices will comply with federal and state statutes, local laws, and health insurance mandates

ACSM indicates American College of Sports Medicine; AHA, American Heart Association; BLS, basic life support training, including automated external defibrillator; CES, certified Clinical Exercise Specialist; IRB, Institutional Review Board; and RCEP, Registered Clinical Exercise Physiologist.