Radiology and the Economic Stimulus Act
The authors believe that the ARRA largely leaves the specialty out in the cold This year saw the most significant event in the history of health care IT: the passage of the American Recovery and Reinvestment Act of 2009 (ARRA). This legislation provides financial incentives for hospitals and physicians to adopt and use electronic medical records (EMRs). For CIOs of hospitals and physician practices that have struggled to estimate the benefits of investing in the EMR, this is a blessing. For the first time, there is a guaranteed return if hospitals and physicians meet the requirements of the legislation and the regulations that will follow. This act puts dollars on the table for hospitals and physicians to collect if they meet the requirements. The detailed requirements are being formulated, and there is some room for interpretation of the legislation that the regulations will need to address. The intent of this part of the ARRA is to address a deficiency in the health care delivery system that was identified decades ago and has continued to exist. That deficiency is fundamentally the use of paper records in the delivery of health care and the failure to embrace IT. The act encourages the active adoption of IT in creating EMRs, the sharing of information through health networks, and the use of information to improve the quality of care. The fact that the federal government has gotten behind this is a very good thing because it provides the kick in the pants needed to get this process moving faster. Looking back in time, the government’s mandate of the use of the DICOM standard in the original Digital Imaging Network-PACS, or DIN-PACS, contract awards ensured that DICOM would become the industry-wide standard for interoperability in images. We can anticipate that this level of federal-government interest in the interoperability of health care information may trigger the adoption of other industry-wide standards, such as patient-identification criteria. Unfortunately, the ARRA has no direct incentives for radiology (unless you want to be creative and go after some grants). Radiologists who are hospital based are ineligible because it is only the hospital that can collect the benefit. While radiologists who own and practice in outpatient imaging centers may have invested in sophisticated IT (including PACS, RIS, and speech-recognition systems), these systems, by themselves, fail to meet the criteria of an EMR, as certified by the Certification Commission for Healthcare Information Technology (CCHIT). The CCHIT requirements for Ambulatory Functionality are 46 pages long. The fundamental reasons that RIS and PACS do not meet CCHIT requirements is that they do not track and order medications or maintain problem lists. It is not inconceivable that a RIS vendor might try to include those capabilities in a future release to make the product CCHIT certified, but then there is the issue of meaningful use. Radiologists rarely prescribe drugs. The major inpatient requirements stressed by CCHIT are physician ordering and e-prescribing, followed by interoperability. If the hospital has all of the pieces, then it will be eligible for some incentive dollars. This is an unfortunate oversight in the legislation. Radiology, as a specialty, has embraced IT more than any other medical field has. Radiologists were early adopters of digital imaging and teleradiology. Radiology has led the way in using technology to improve workflow by creating filmless and paperless imaging centers and radiology departments. Radiology is better positioned to participate in networks to share health information than other specialties because of having made the investment in PACS and RIS. Radiologists are in a position to demonstrate leadership because of their technical expertise. One particularly critical area where radiology has expertise is interoperability. The RSNA, together with the Healthcare Information and Management Systems Society, collaborated in 1998 to create the Integrating the Healthcare Enterprise (IHE) initiative. IHE promotes improving the way that computer systems in health care share critical information. IHE has had an important role in driving the adoption of standards to address specific clinical needs, and radiologists have played a critical part in the IHE initiative. Radiologists were the drivers behind creating the DICOM standard in the 1990s. As a specialty, radiology has the most expertise in this area. The ARRA is going to push interoperability issues to the forefront; radiology has an opportunity, once again, to show leadership in this area. Another area where radiology’s experience can prove valuable is in understanding the relationship between technology and workflow. When radiology moved from being a film-based specialty in which images were interpreted using lightboxes into a digital world where powerful workstations display stacks of images that can be manipulated, it had to make major changes in its fundamental processes. Radiologists have been faced with a shortage of physicians in the specialty, coupled with imaging equipment that creates many more images. They have had to find ways to maximize their efficiency, out of necessity. Radiology, therefore, has done more to study the relationship between the technology and the workflow than any other specialty has. The body of knowledge that has been created around workflow issues in radiology is extensive and detailed, and it has been published in scientific journals. Radiology is also showing leadership in using technology to improve quality. At the University of Maryland, the department of radiology is doing some exciting things with quality indicators, dashboards, and improvement measurements. The technology and techniques developed there can be adapted for use in other departments. There has been some criticism of the entire economic stimulus program, with critics stating that money is being spent to reward bad behavior in the past. It is ironic that the ARRA will reward hospitals and physicians who have been laggards in adopting technology, but it provides no incentives to the specialty that has been the leader in this area. Nevertheless, radiology should continue to show leadership in using technology. Our entire health care delivery system will benefit from it.