Dr. Shrestha is Vice President, Medical Information
Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and
Medical Director, Interoperability & Imaging Informatics,
You cannot escape the responsibility of tomorrow by evading it today.
Geographic Kids has a series called “Animal Myths Busted.” The top myth
they address is that ostriches bury their heads in the sand when
they’re scared or threatened. While this is in reality an optical
illusion with the ostriches, it seems some in our radiology community
have indeed chosen to bury their heads in the sand when it comes to
confronting and dealing with the challenges, and opportunities,brought
to us by Meaningful Use (MU).
MU1 is the set of standards
defined by the Centers for Medicare & Medicaid Services (CMS) EHR
Incentive Programs that governs the use of electronic health records
(EHR) and allows eligible providers and hospitals to earn incentive
payments by meeting specific criteria.MU is divided into 3 palatable
- Stage 1 focuses on capturing health information in a coded format to
track key clinical conditions and communicate information for care
coordination and 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. Image viewing is supported as an
- Stage 3 (starting in 2016) will focus on
achieving improvements in outcome-based metrics: quality, safety and
efficiency, decision support, patient access to self-management tools,
and population health.
The sins of procrastination
In total, the federal
government has already paid out $14.6 billion in EHR incentive payments.
Physicians performing < 90% of their service in inpatient or in
emergency care settings at hospitals are eligible for incentive payments
under the Medicare EHR Incentive Program.The vast majority of
radiologists are defined as “eligible professionals” (EPs) under the
Medicare and Medicaid EHR Incentive Programs.The ACR estimates that an
estimated 90% of radiologists are eligible for incentive payments.
However, out of the approximately 30,000 radiologists in the United
States < 10% have successfully attested to Stage 1 Meaningful Use.2
radiology groups have already implemented certified ambulatory EHRs and
have even received their first installment of $18,000out of a maximum
$44,000 expected incentive payment. But most continue to procrastinate
or consider the processes “too much of a hassle.2”
the clock is ticking—radiologists only have until October 1, 2013, to
qualify for a bonus of $39,000 per radiologist. Radiologists must first
demonstrate that they have met the MU Stage 1 requirements for 90 days
in their first year of participation, and a full year in their second
year of participation, before they need to attest for Stage 2
Beginning in 2015, the sins of procrastination start
catching up and penalties start kicking in. The later you start, the
more requirements you have to meet in a shorter period of time. EPs who
fail to attest to MU will be subject to payment reductions starting at
1% and increasing each year that a Medicare EP does not demonstrate
meaningful use, up to a maximum of 5%.
But it is not just the
fines that should convince radiology groups to take their heads out of
the sand and face MU. They should in MU because it provides a unique
opportunity for the medical community to leverage federal funding to
implement and embrace technologies that truly drive forward the
meaningful use of the EHR. Nonetheless, some radiologists are
unfortunately choosing to opt-out or to adopt a “wait and see” approach.
One size fits all is a problem
When it comes to
demonstrating MU, it is clear that one size does not fit all. The
requirements around MU were clearly not written with radiologists in
mind, or for that matter, other specialists that have limited or no
direct patient interaction, such as pathologists or anesthesiologists.
“meaningful use” of EHR technology for a primary care practitioner in
an ambulatory clinic differs quite a bit from the way radiologists
interact with the core set of imaging-related clinical applications,
such as picture archiving and communication systems (PACS), radiology
information systems (RIS), and advanced visualization tools.
Radiologists, by virtue of what they do, are rightfully more concerned
about knowing data elements, such as the ‘reason for exam,’ than
educating patients on smoking cessation.
Hardship exemption: A possible loophole?
that certain specialties like radiology do not have regular direct
interaction with patients, CMS included in the Stage 2 Meaningful Use
regulations a hardship exception clause that would essentially help
avoid penalties in 2015. This would allow for some to skip meeting the
requirements for 5 years without penalty. But the matters around this
perceived loophole are far from clear, and CMS may endup revisiting the
specialty codes to determine which of the codes would qualify for
automatic exception in future rule making.
The hardship exemption
seems to be an unreliable excuse to procrastinate. The ACR has made it
clear that this exemption is temporary and radiologists could still end
up facing penalties after 5 years, or sooner if CMS decides to modify
the specialty-based hardship exemption.
Radiologist as a physician consultant
The evolving role
of the radiologist should be that of a physician consultant: an active
and value generating contributor to the care team around the patient.
Value-based health care pushes for collaborative care and measures the
interactions among clinicians engaged in the care of the patient. MU
essentially sets the foundation to move from a fee-for-service model to a
fee-for-value model that emphasizes bundled payments and accountable
care. Stage 2 measures incorporate referring clinicians specifically in
terms of orders and results. Thirty percent of radiology orders created
by the EP during the EHR reporting period should be recorded using CPOE.
Starting as early as 2014, if radiology orders cannot make it from the
referring clinicians’ EHR to the radiology group, the business may
simply shift elsewhere.
Fortunately, these referring clinicians
have been busy trying to meet MU requirements. These same clinicians
will come to expect to sendus a clinical summary and in return receive a
radiology report, possibly even with access to images directly from
their systems. Indeed, the clinical summary from the ordering physicians
would provide a much more complete patient history and would be a boon
towards a more patient-centric approach to imaging. As radiologists are
increasingly perceived as physician consultants, they can more directly
educate clinicians on imaging appropriateness, radiation dose, and
MU Stage 2 also pushes for patients to be able to view,
download, and transmit their health information online. With this,
patient engagement is now a core measure. Engaging the patient in their
own care will only help everyone and may aid in highlighting the value
of imaging and of the specific role of the radiologist.
Did someone say meaningful use 3?
While the frenzy continues for Stages 1 and 2, requirements for Stage 3 continue to push the needle forward. For example,3 the requirement to use CPOE to record radiology reports by the EP jumps from 30% in Stage 2 to a proposed 60% in Stage 3.
ACR is pushing the Office of the National Coordinator for Health Care
Technology (ONC) to make sure that radiologists and other specialists
get a decent shot at the incentives, and the hope is that Stage 3 will
not just be a one size fits all but much more malleable to thes pecific
needs of specialists. The ACR is also pushing for its appropriateness
criteria to be used as the basis for the radiology order entry systems
Stage 3 could also see a major push for clinicians to
have access to imaging results and images directly through the EHR
technology.Stage 3 should ideally encourage health care providers to
give patients at least the option to have their images and related
information (such as dose) transmitted to other health record systems.
Image-enabling the health information exchange (HIE) should be a
priority driven by clinical needs, technology readiness, and regulatory
incentives—with the aim to reduce inappropriate utilization, while
controlling radiation dose exposure to patients and decreasing waste and
Overall, MU essentially sets the stage for
better-coordinated patient care. While meeting the specific requirements
of MU may seem quite daunting, especially given how primary
care-centric the requirements are, not starting with MU should not be an
option. We should get rid of any self-pity, cynicism, and self-doubt,
and march on, for we have always been a specialty that has been at the
forefront of technology innovation and adoption.
- Shrestha R. Meaningful Use: What it means to radiologists. Applied Radiology. 2012;41:24-26.
- Bresnick, J. Is meaningful use too much of a hassle for radiologists? EHR Intelligence.
Updated February 11, 2013. Accessed June 1, 2013.
PH. Comments of the American College of Radiology on the ONC Health IT
Policy Committee’s Request for Comments Regarding Stage 3 Meaningful
Use. American College of Radiology.
January 14, 2013.