Applied Radiology

Dr. Shrestha is the Vice President of Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA, and the Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.

Wouldn’t we all like to have a slice of the $1.5 billion incentives payment pie available for eligible radiologists? Imaging was given the cold shoulder in the first phase of the meaningful use program (MU), but the Stage 2 MU proposal gives more credit to radiology. The question is, is it enough? And what are providers to do now? The recommendations incorporated into the proposed rules by the Centers for Medicare &Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health IT include a menu set measure for diagnostic image accessibility, clinical quality measures relevant to radiology, and more flexibility on defining encounters. But for a clinical specialty that isso integral to the running of a health system, radiology measures are only deemed optional.

Personally, I find this bittersweet. While we are happy that imaging is finally getting a decent mention, it’s only that – a decent mention.Many in the industry had been hoping that imaging would be deemed ‘required,’ and not just ‘optional.’

Background

The Health Information Technology for Economic and Clinical Health (HITECH) Act is a key component of the 2009 American Recovery and Reinvestment Act (ARRA) – more fondly known as the ‘Stimulus Bill.’ This Act seeks to improve American healthcare delivery and patient care through an unprecedented investment in health information technology (David Blumenthal, 2010). MU aims to improve health outcomes, patient engagement, care coordination, and efficiency of the healthcare system by promoting the adoption and meaningful use of health information technology electronic health records (EHR) incentive programs. MU is divided into 3 stages:

• Stage 1 focuses on capturing health information in a coded format to track key clinical conditions, to communicate information for care coordination, and to identify some clinical quality measures.
• Stage 2 (starting in 2014) expands on Stage 1 criteria and encourages use of captured data and exchange of key electronic information in a structured format. Viewing of images will be supported as an optional item.
• Stage 3 (starting in 2015) would focus on achieving improvements in quality, safety, and efficiency, emphasizing decision support, patient access to self-management tools, and population health.

Get with the program

The establishment of incentive payments to eligible professionals (EPs) and hospitals to promote the adoption and MU of interoperable health information technology and qualified EHRs is seen as a boon to the evolving digital healthcare enterprise. As we all strive to move the needle toward transformed healthcare, the challenge often is in achieving true MU of health data amid a sea of information systems and data repositories comprising structured data, unstructured data, and imaging data.

MU has had a series of positive impacts in the effective use of information to support better decision making and more effective care processes that improve health outcomes and result in robust quality measurement and improvement.

However, with reports that half of U.S. hospitals are at risk of failing to meet federal requirements for achieving MU of electronic medical records and may incur penalties by 2015 (Accenture, 2012), much still needs to be done.

So, indeed, MU does have direct applicability to radiologists, and embracing this is not just an option. At stake is more than just the$44,000 per physician for achieving MU before 2015. The benefits of creating a more integrated imaging workspace with richer interaction around patient-centric data are critical to an efficient radiology workflow regardless of MU mandates. Just as critical is that, starting in 2015,the carrot turns into a stick, and actual Medicare payment reductions will be put in place for not demonstrating MU.

Meaningful Use

MU and radiology:Objectives and measures

It is important to understand the objectives, thresholds for compliance, and the clinical quality measures associated with MU. For example, Stage 1 of MU has 25 MU objectives or goals, 15 of which are core objectives and 10 are menu set objectives. Twenty objectives in all must be satisfied or determined not applicable. Each MU objective has an associated measure and reporting requirement. Some also have potential exclusions. Radiologists will find that some CMS prescribed objectives do not apply to outpatient imaging.

Core objectives that many will find appropriate include drug and allergy interaction checks, demographics, active medication allergy list, providing patients with electronic copies of their health information, the capability to exchange key clinical information and protect electronic health information.

As for Menu set objectives, 5 objectives must be chosen from the 10 menu set objectives (eg, lab results, patient specific education, etc).Not all objectives are relevant for radiology (eg, drug formulary checks) and 5 menu set objectives may be excluded if they do not apply.

Then there are the measures. Ambulatory quality measures are typically referred to as “clinical quality measures” or CQMs. There are44 CQMs, and CMS requires reporting on 3 core or alternate core measures and 3 menu set measures. Most of the Stage 1 core and menucriteria are preserved in Stage 2, although several are combined and modified. For example, in Stage 2, EPs will need to meet 12 out of 125clinical quality measures.

Stage 2 of MU has incorporated many of the American College of Radiology’s (ACR) recommendations, acknowledging the average radiologist’s lack of regular patient contact and creating more flexibility in the way radiologists can demonstrate MU of certified EHR technologies.

Interoperability and access

One of the main themes of MU Stage 2 is interoperability – the demonstration of actual connection to outside systems rather than just establishing the capability to connect. There is a greater push for collaboration between EHR vendors, and for improvement in care coordination, especially during transitions of care or referrals. Also emphasized is enabling patients to access their health information online,which may give personal health records (PHR) and patient portals a much needed shot in the arm. Stage 2 proposes that eligible providers(EP) must show that 10% of patients “view, download or transmit” their electronic personal health information (ePHI). The proposed Stage2 optional imaging menu set rule will require that more than 40% of all scans and tests ordered by EPs or hospitals are accessible through certified EHR technology.

What do I do next?

While CMS regulates healthcare providers, the ONC regulates the technology and the certification process. CMS states that the EHR incentive payments will be made available to eligible professionals who meaningfully use qualified EHRs that have been certified by an organization recognized by the ONC.

If you have not started looking at how MU would affect you, then you should hurry up. The later you start, the more requirements you have to meet in a shorter period of time. Remember, Medicare payment penalties begin in 2015 for eligible professionals that fail to achieve MU status.

Also remember as you read this that providers across the country have already started to see payments come through. The earlier you become certified, the more time you have to develop compliance with various criteria to move through the stages. Early adopters gain more immediate and longer-term benefits for participating in the Medicare EHR program. One can, however, begin as late as 2014 and still receive incentives for Stage 1 compliance. The last date to attest without penalties will be Oct.1, 2014.

Keep in mind, however, that Certification and MU are not the same thing. Certification is what the EHR can do; MU is how the EHR is used – and this is the responsibility of providers and facilities. You will not achieve MU and obtain the incentives only by implementing a certified EHR. You must show you are using the certified EHR technology in a meaningful way.

Eligibility

Physicians performing <90% of their service in in-patient or in emergency care settings at hospitals are eligible for incentive payments under the Medicare EHR Incentive Program. Most radiologists are defined as eligible providers under the Medicare and Medicaid EHR Incentive Programs.

Certification

Radiologists must use technology certified by the Authorized Testing and Certification Body (ATCB) to collect and disseminate health information electronically. If you have not done so already, check with your radiology information system (RIS) and picture archiving and communication system (PACS) vendors, as well as with any EMR solutions you may access regularly to see where your vendors are in the certification process. Remember, too, that the technologies can be certified as complete or modular, and there are provisions that allow for a shopping cart of modules as opposed to using a complete EHR, which may be beneficial to some radiologists. A radiologist must demonstrate MU for 90consecutive days in the first reporting year and full years for subsequent periods to qualify for the incentive payments. MU Stage 2 proposals include changes to certification for EHRs sold by vendors or self-developed by healthcare providers and new patient safety criteria for certification.

Registration and attestation

Complying with the program costs time and money. You must register with CMS and attest to MU to receive any incentive payments. Although certified EHR technology need not be in place before registering, it must be in place before attesting. Assembling the reporting datais no small feat, but make sure you enter the data in the Meaningful Use Attestation Calculator first (http://www.cms.gov/apps/ehr/) to see if attestation passes CMS criteria. The registration and attestation system can be found at https://ehrincentives.cms.gov.

RadiologyMu.org has a “practice analyzer,” among a host of other useful information. Based on information entered about the practice, it calculates eligibility, incentive payments, and penalties.

Conclusion

It is critical to plan your MU strategy thoroughly. Create a cross-functional team of key stakeholders that includes EP radiologists as well as administrators, business, and IT leads. Radiology technologists also play a key role in defining the workflows and bridging the perceived or actual gaps in data collection and access. This is true, too, for front office staff and PAs. As mentioned earlier, make sure your existing (or new) RIS, PACS, and EMR vendor is also heavily engaged. As with all major projects, ensure you create a thorough project and communications plan, and engage all stakeholders actively.

Farzad Mostashari, MD, National Coordinator for Health Information Technology, calls 2012 the “Year of Meaningful Use” – with the aim to get 100,000 healthcare providers paid under the incentive programs by year’s end (Mostashari, 2012). Increasing the adoption andMU of healthcare IT is crucial to moving the needle toward safer, better-coordinated patient-centered care.

MU should not be seen as just a financial incentive but rather as a major milestone that helps define a successful EHR implementation.

Bibliography

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