At the Intersection of Radiology and the EHR
The heightened interest in electronic medical records (EMRs) and electronic health records (EHRs) can be attributed, in part, to the recent announcement that federal funds under the American Recovery and Reinvestment Act (ARRA) would be made available to qualified medical practices commencing in 2011. Though radiology continues to question its eligibility for the funding of imaging informatics projects, the benefits (both direct and indirect) of PACS integration with health care records are numerous.
D. Scott Jones, CHC, LHRM
These include enhanced access to medical records, greater availability of imaging studies and reports generated at other imaging facilities, mitigation of medicolegal and risk-management matters through improved access to medical information, and the ability to communicate results and follow-up recommendations more closely. In addition, integrated medical records have the potential to improve billing performance and collection and to enhance cash flow. Whether radiology has a direct financial stake in the federal funding for wiring US hospitals is unclear, but the indirect benefits of integrating PACS with the EMR and the EHR are indisputable. EHR and EMR The EHR is a longitudinal electronic record of the patient’s health information generated by one or more encounters in any care-delivery setting. Included in this record are patient demographics, progress notes, problems, medications, vital signs, medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. It also has the ability to generate a complete record of a clinical patient encounter, as well to support other care-related activities (including evidence-based decision support, quality management, and outcomes reporting) either directly or indirectly via interface.
Howard B. Kessler, MD
It is important to recognize that an EHR is generated and maintained within an institution, such as a hospital, integrated-delivery network, clinic, or physician’s office. An EHR is not a longitudinal record of all care provided to the patient, in all venues, over time. Considerable uncertainty exists regarding the differences between EHRs and EMRs. The confusion is pervasive at all levels of health care delivery. In many instances, the terms are used interchangeably by experts, users, and vendors. According to the National Alliance for Health Information Technology, however, there is a distinct difference between the entities. The EMR is the electronic record of an individual’s health-related information created, gathered, managed, and consulted by licensed clinicians and staff, from a single organization, who are involved in the individual’s health and care. The EHR differs from the EMR in that it is the aggregate electronic record of an individual’s health-related information created and gathered cumulatively across more than one health care organization. It is managed and consulted by licensed clinicians and staff involved in the individual’s health and care. Professional Medical Liability A frequently mentioned reason for the use of EMRs is the perceived impact on professional medical liability or medical malpractice claims. Professional medical liability companies have long emphasized that complete and consistent medical-records documentation aids in defense against claims, and in particular, those that are considered frivolous or without medical merit. Logically, the ready availability of complete patient health information, in an easy-to-use and readable format, should improve the ability of the physician or nonphysician provider to review and use that health information. By extension, better medical judgments should be possible, and certain types of medical malpractice claims might be avoided. Data also exist to support this contention. For example, a survey¹ of 1,140 Massachusetts physicians published in the Archives of Internal Medicine indicated a significant difference in the number of malpractice claims brought against those who did not use an EMR system, compared with those who did. According to the study, 6% of those respondents using EMRs reported malpractice claims; in comparison, 11% of physicians who did not use an EMR reported claims. It is important to note that the study methodology used was logistic regression analysis of reported malpractice claims among respondents, compared with paid-claims data from the Massachusetts Board of Registry in Medicine Internet site. Obviously, this excludes data on settled claims that might not have been reportable. The report concluded that results were inconclusive, and that studies are needed to confirm these results before they can have policy implications. Statistical data supporting the efficacy of EMR or EHR use in reducing malpractice claims are limited at present, but are expected to become more readily available as the use of electronic records matures and as claim history is established. The frequently extended time period between a medical injury and the closure of a legal case currently limits the availability of usable data. Although EMR and EHR statistics are not individually available, a relevant review of the largest national database of closed medical malpractice claims has been conducted using the Data Sharing Reports2 generated by the Physician Insurers Association of America (PIAA), Rockville, Maryland. PIAA consists of more than 70 physician insurers; collectively, they provide coverage for approximately 60% of the private-practice physicians in the United States. PIAA data include information on 239,756 closed claims from 1985 to 2008. Claims that involved a failure in the informed-consent process (including breach of contract) were among the most prevalent claims reported in the 2009 PIAA Data Sharing Report. In all medical specialties, 14,985 closed claims from 1985 through 20082 reported an issue related to these concerns, and 39% of those claims resulted in a payment to the plaintiff. To the extent that EMRs can document and record patient-education and informed-consent processes, for example, it is logical that some of these claims might be mitigated.

Table 1. Significant US Malpractice Claims (All Specialties) for 1985–2008
Other significant claims that might be affected by electronic-record use include problems with patient history, exam, or work-up; medical records; imaging performance/interpretation; and communication between providers² (Table 1). PIAA notes that across all medical specialties, almost 30% of claims result in payment to plaintiffs.² By extension, issues that appear to be fertile ground for improvement by EMRs and EHRs have a much higher percentage of payment; in some cases, double that of all other types of claims. EMR Status On February 17, 2009, the ARRA was signed into law, committing $19.2 billion to health care IT to promote its use by all providers of health care. Beginning in 2011 and continuing through 2014, $17.2 billion in incentive payments will be distributed to eligible health care providers Providers using a certified EMR will be eligible for substantial government cash incentives, and providers may be penalized if they have not adopted a certified EMR by 2015. To be eligible for the incentives, you must meet three requirements. First, you must be an eligible professional who is a meaningful user of certified EMR technology. Eligible professionals include doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry, as well as chiropractors and physician assistants. Hospital-based professionals, such as pathologists, emergency-department physicians, and anesthesiologists, are excluded. The law only requires physicians to be Medicare providers; it does not mandate that they see a certain percentage of Medicare patients.

Table 2. Bonuses per Physician for the Meaningful Use of Electronic Health Records
Second, the three requirements for meaningful use must be met. According to the Certification Commission for Healthcare Information Technology, these are having an electronic-prescribing function; furthering the electronic exchange of health information in a manner designed to improve the quality of health care (specifically, the EMR must connect with other EMRs, such as those at hospitals and other providers’ practices); and providing for the submission of statistical information on quality of care to the government, so that it can determine whether EMRs are, in fact, improving the health care system. Possible benchmarks for the last requirement include attestation from a witness statement, submission of claims with appropriate coding, a survey response, or a report. Third, to be eligible for funds under the ARRA, medical personnel will be required to use an EMR that is certified. To be considered certified, the EMR must:
  • include patients’ demographic and clinical health information, such as medical history and problem lists;
  • have the capacity to provide clinical decision support that includes physician order entry (to capture and query information relevant to health care quality); and
  • exchange electronic health information with, and integrate such information from, other sources.
Once these three criteria have been met, the ARRA allows up to $44,000 in bonus payments to individual physicians who demonstrate meaningful EHR use before 2015 (Table 2). The earmarked federal funds will not be released in advance to help purchase the systems, but will be released beginning in 2011, after facilities have implemented electronic records and met the meaningful-use criteria. Total funds released per practice are directly related to the number of health care professionals within the medical enterprise who adopt electronic records. Radiology and the EHR It is unlikely that radiology practices and radiology departments in acute care settings will embark on initiatives to obtain EHR systems. An enterprise-wide system for collecting and archiving relevant data (including imaging information) is usually the responsibility of the institution, with appropriate input from physicians, departments, and other key individuals. Radiologists and radiology administrators can play a critical role in software selection and must be cognizant of the features that have a direct impact on diagnostic imaging. This is particularly important with regard to features and to the necessary interfaces required to link the PACS/RIS meaningfully with EHRs and EMRs. One cannot overstate the importance of these key links. HL7 interfaces affect everything from the communication of results and follow-up recommendations to billing, coding, and compliance.³ Fortunately, radiology is somewhat ahead of the curve; its growing experience with PACS and RIS should position imaging well for its role of making images and RIS data available to an enterprise-wide EHR.
Table 3. US Malpractice Claims in Radiology for 1985–2008
Although malpractice case-tracking systems do not yet differentiate between physicians who do and do not use electronic records, there are several statistically supportable quality targets for electronic systems, based on analysis of PIAA data. Separate national malpractice-claims data (Table 3) are available for radiology from PIAA’s 2009 Data Sharing Reports.¹ Clearly, national medical malpractice information demonstrates that significant concerns continue to exist in the areas of informed consent, provider communications, patient history and work-up, and medical-records documentation. EMR and EHR systems should address these issues and provide enhanced means to improve performance. Implications for Radiology Among the most important direct benefits of the integration of radiology into the EMR is the ability to use direct migration of radiology studies and reports. Reports have been readily available for years, but the ability to embed actual studies (including key images) is valuable to the physician and patient. This will be particularly beneficial in specialties such as oncology, where physicians’ access to all medical imaging studies and reports is essential. Areas that radiologists need to keep in mind include studies requiring further evaluation, notification of critical results, reporting of unexpected findings, and the use of automated systems to interface with screening programs, such as initiatives for breast-cancer detection. The responsibilities of the radiologist (and the institution where the study was performed) include the observation of relevant findings and the making of recommendations for follow-up care. Greater system integration enhances the tools, inherent in notification systems, that can inform all patients of the results of their procedures. From a risk-management perspective, this can document poor or noncompliant behavior, especially when recommendations for future studies are ignored. Other areas of risk that can be mitigated using electronic documentation include informed consent (a cumbersome and time-consuming process) for interventional radiology procedures, particularly in the event of a complication. In many instances, access to key information might have been lacking. For example, knowledge (or its absence) can represent potential risk-management issues in the areas of allergic reactions, reactions to contrast media, renal-function studies, and glomerular filtration rates. Documenting risks, benefits, and potential adverse outcomes is a critical step in the risk-management process. A tight interface between the PACS and the EHR will provide many indirect additional benefits, including access to more meaningful information on patients (including patient history, current medical status, and imaging results from prior studies performed at outside institutions). Communication between the RIS and the EHR also has the potential to enhance revenue opportunities and improve collections. Some analysts estimate the costs of lost revenue and revenue-recovery efforts as 3% to 5% of annual collections. Electronic records, when closely integrated with the PACS and the RIS, provide greater accuracy and less uncertainty for diagnostic and interventional radiology. Electronic ordering using a database of procedures provides two data-entry points for accurate ordering. The correct CPT® codes are automatically entered in conjunction with the ICD-9 codes. In addition, any preauthorization requirements automatically cross over an interface to the RIS/PACS, thus avoiding denial of payment based on an absent or incorrect precertification procedure. Access either to a transcribed report or to a final report generated using voice-recognition software facilitates the submission of complete records necessary for payment through third-party carriers. Carefully integrated programs minimize the risks of overcoding and underbilling, improving compliance with federally funded programs (where the consequences of incorrect billing and claims submission can be time consuming and costly). For the EHR and the EMR, penetration into the marketplace is likely to accelerate as companies vie for a market increased by almost $20 billion in government funding to support this initiative. The benefits to all stakeholders in health care could also include an as-yet-unproven impact on professional-liability claims (which should be tracked, if possible). Although the logic supporting the use of electronic records to enhance the quality of care is convincing, today’s limited use of EMR and EHR systems in most medical specialties limits cause-and-effect analysis. The emphasis on improving quality of care and on enhancing medical efficiency is a key element of the ARRA incentives for implementing electronic records. Based on its experience in PACS implementation, radiology is well prepared to provide leadership and guidance. Howard B. Kessler, MD, is medical director, Radiology Solutions, New Jersey and Pennsylvania divisions, Philadelphia, Pennsylvania. D. Scott Jones, CHC, LHRM, is vice president, corporate compliance and risk management, Healthcare Providers Insurance Exchange and American Healthcare Providers Insurance Services, Philadelphia, Pennsylvania.