Radiology and Meaningful Use: Questions Loom As Attestation Begins
It was the radiology community’s version of the shot heard ‘round the world: in April 2010, the Continuing Extension Act of 2010 revised the Health Information Technology for Economic and Clinical Health (HITECH) Act’s definition of a hospital-based eligible professional to include hospital-based physicians practicing in outpatient settings, thereby rendering more than 90% of radiologists eligible for the meaningful-use program. Previously, imaging providers had believed that they would be exempted from the maze of attestation, incentives, and penalties prescribed by the HITECH Act, but suddenly, they (and their information systems) were in the loop. Radiologists have always been early adopters, when it comes to IT, but the stage 1 meaningful-use requirements were, predictably, written with a broader audience in mind. Therefore, they require the use of either an electronic health record (EHR) or a product certified by the Office of the National Coordinator (ONC) as a modular EHR—for instance, a RIS with additional capabilities worked into its millions of lines of code—for information aggregation and attestation. Keith Dreyer, DO, PhD, vice chair of radiology computing and information sciences at Massachusetts General Hospital in Boston, says, “We’re hoping that the stage 2 guidelines will be more attuned to radiologists. For many groups, there’s just too much money on the table to ignore this.” With stage 2 requirements pending, Michael Peters, director of legislative and regulatory affairs for the ACR®, says that radiologists should brace themselves for more of the same. “I’d expect to see more inclusion of specialists through exclusions, but overall, more continuation of the one-size-fits-all approach,” he explains, adding that the ACR has been pushing for more in Washington. “Everyone understands that CMS and ONC regulators cannot conceivably create unique participation and technology requirements for each and every medical specialty, but there has to be a middle ground between that paradigm and the current approach,” he says. The Lay of the Land In June 2011, the ONC working group tasked with developing the requirements for the meaningful-use program indicated to radiology stakeholders working on Capitol Hill—Dreyer and the ACR among them—that it was in the process of carving out separate recommendations for medical specialties, and hinted that these recommendations might be rolled out as early as stage 2. Peters, however, is not optimistic that the changes will be seen so soon. “I and my counterparts in the other specialty societies have been trying to make sure this stays on their radar, but those recommendations may not be available until the stage 2 proposed rules are out the door and going through the necessary review processes prior to publication for comment,” Peters says. In the meantime, attestation for stage 1, a 90-day process of collecting and reporting patient information to CMS, can begin in either 2011 or 2012 for eligible providers hoping to capitalize fully on the incentives offered by the HITECH Act. Totaling $44,000 per eligible provider for those who follow the agency’s timeline and begin with stage 1 before the end of 2012, the incentives are tempting—and, of course, they will be replaced with penalties in later years. Steven Fischer, CIO for the Center for Diagnostic Imaging (CDI), Minneapolis, Minnesota, says, “We did a financial assessment, and it makes sense for us to pursue this—not so much for the incentives, but because of the hammer coming down in 2015. The incentives do add up, however; it’s a pretty nice chunk of change, even after expenses.” Because the stage 1 requirements—and, if all indications prove true, the forthcoming requirements for stage 2—are geared toward physicians in general (not specific specialties), attestation can only be achieved using an EHR or an ONC-certified modular EHR. RIS vendors are scrambling to update their software to attain this certification, although the process is, obviously, a cumbersome one. At the June 2011 annual meeting of the Society for Imaging Informatics in Medicine in Washington, DC, vendors shared their progress on attaining the coveted certification, but for the most part, there was little to celebrate yet. “What I am telling people right now is get to your vendors and let them know what you need,” Dreyer says. “There’s not enough pull coming from radiologists yet, and as a result, the response from the vendor community has been inconsistent.” Weighing the Benefits As Dreyer suggests, one reason for the lack of response from vendors might be the lack of impetus from radiologists. David Mendelson, MD, is professor of radiology and chief of clinical informatics at Mount Sinai Medical Center (New York, New York), where the hospital is in the midst of its 90 days of continuous use. He says, “We’re waiting. We’re concerned CMS and ONC together might make some late-in-the-game changes in meaningful use for radiology, so we haven’t made any final decisions about technology.” This sentiment is echoed by Mike Hawkins, chief strategy officer at Zwanger-Pesiri Radiology, Lindenhurst, New York. “In the past, I’ve been burned by changes like this,” he says. “When it comes to government regulation, if you start preparing too early, you may find the change never actually happens or that the issue was overblown. From our perspective, it’s wait and see when our vendor delivers the software and implements it.” University Radiology Group of East Brunswick, New Jersey, on the other hand, found the incentives too high to resist, and is currently in the middle of attestation for stage 1. Tom Dunlap, MBA, the group’s CEO, says, “We have 90 radiologists, of whom 70 or so are candidates for this. When you’re doing this 70 times, twice a day, multiplied by the number of measures, it’s a fair amount of effort.” He adds, “This is an exercise, but with close to a million dollars in incentives on the table, it’s attractive enough that I think we’d be making a mistake if we didn’t try to get this done. Our hope is that everybody who is qualified under the rules is going to pass, and we’ll get the incentive by the end of this year.” The attestation is made possible by University Radiology’s electronic medical record (EMR), a product designed for private practices and sold by the practice’s RIS vendor. Alberto Goldszal, MBA, PhD, the group’s CIO, says, “We had the vision to choose a vendor that was well attuned to the requirements coming down the pike.” At CDI, the team took another approach to meeting the electronic requirements for attestation by developing (with its vendor) additional modules for the RIS that can fill in the gaps. “Things like drug interactions, computerized provider order entry, and HL7 continuity of care record (CCR)/continuity of care document (CCD) capabilities—things a RIS doesn’t usually have—the vendor put together as separate modules, and it bundled that software for us,” Fischer says. “We were already requesting it because we probably would have gone ahead and done it ourselves, otherwise.” Whose IT to Use Demonstrating meaningful use poses a challenge to small radiology practices, for which the total incentive dollars will not be nearly enough to offset the IT investment required. “At the end of this, in 2015, some radiologists might still eat the penalty because they’re not in the position to do this,” Dreyer notes. Larger, hospital-based practices, on the other hand, face a different challenge: carving out who is responsible for supplying the necessary IT solutions. Sean McClure, clinical information system administrator for ProMedica (Toledo, Ohio), says, “We have four different radiology professional groups serving our seven hospitals. We have a common RIS and PACS, but one of our radiology groups owns its own PACS, so we have an interface with it. Every time you divvy it up like that, you diminish your central authority.” For the time being, McClure and his team have decided to allow the radiology groups to pursue the incentive dollars independently—but he has not ruled out the possibility of supporting them with data from the health system’s hospital information system, if necessary. “If they need support from us, we will certainly assist and comply, but we have not specifically done anything to assist any of those professional groups,” he says. “We thought they would ask, if they were interested, but if somebody needs information from us to help his or her practice, we’d be ready for it. One of our goals is to be ready for people to request information from us.” At Mount Sinai Medical Center, Mendelson’s responsibilities for clinical informatics extend well beyond the walls of the radiology department. He reports that the hospital’s EMR is likely to be leveraged to fill in the gaps not covered by the radiology group’s RIS, but for the time being, the hospital is focusing its efforts on the CMS Electronic Prescribing (eRx) Incentive Program. Because CMS prohibits collecting eRx incentives and the initial meaningful-use incentives during the same year, Mendelson says, “At this point, there’s nothing lost in delaying collecting the meaningful-use data until next year,” he says. “Once we get a handle on what modules exist for radiology and where the gaps are, we’ll decide if we want to build an interface from our EMR to our RIS.” Mendelson adds that an emerging IT product category might prove to be the best solution for hospital-based radiology, providing an alternative to linking to the hospital EMR. “There are beginning to be announcements of products that will sit on top of your RIS, pick up what information your RIS already has, and then interface with an EMR product and use it to fill in the gaps,” he says. “A couple of companies have said they are developing this. We’re trying to determine which route to take, and we have the luxury of making that decision in early 2012.” Preparing for Attestation At University Radiology, where the 90-day stage 1 attestation is well underway, a period of intense planning preceded the commencement of the project. “What was critical, for us, was an early start,” Goldszal says. “A multidisciplinary team is needed to make sure you have technology that’s been certified—that’s the invitation to the party—and then to look at what you’ll have to change in your day-to-day behavior to capture these new elements. It’s all attainable, but attention to detail is crucial. One critical factor here is that there’s no partial credit—you pass or fail, so good planning and communication are needed from the get-go to the end.” Mendelson concurs that additional training will be a must for any radiology group that hopes to participate in the program. “There’s no radiology department I know that would naturally be able to fulfill these requirements,” he says. “You’ll have to change your workflow, and that may mean you have to hire some new collectors of information.” The Mount Sinai team plans to evaluate whether fulfilling the measures will have a significant impact on radiologists’ workflow and productivity. If so, Mendelson says, “My guess is we’ll come up with a number of FTEs we need to hire, and we’ll carefully look at how many dollars we have to gain versus how many we have to spend. My guess is it will still be worthwhile for us to participate.” To determine how best to meet the measures without interfering with productivity and quality, Goldszal and his colleagues established a multidisciplinary team that included the practice’s managers, its general counsel, an administrative technologist, an office manager, and a front desk manager. Dunlap says, “We started last November and met once a week, and we’re still meeting once a week. This is not a trivial exercise: It requires the group to be fully engaged because there is a big investment of time and effort.” Staff members at University Radiology were retrained to populate the new data fields for each patient, and in anticipation of patients’ resistance to answering certain questions, role-playing sessions were used to develop ideal responses. “You have to make sure everyone is saying the same thing, and saying it in a way that fits what we’re trying to do, without offending the patient,” Dunlap says. “It’s a fine line, and at the end of the day, if they don’t want to give the information, you’re not going to get it. What we say is, ‘This is part of the new health-care initiative to capture information to help set policy.’” Looking Forward While some radiology practices have jumped into the meaningful-use program with both feet, Dreyer estimates (based on anecdotal evidence) that they represent a small percentage of groups nationwide. “When I give a talk about this and I ask how many are doing something, it’s 10%; how many have a plan to do something, 10%; how many plan to make the attempt, 10%; and how many need more information, 70%,” he says. “People just don’t have the tools.” Dreyer adds, however, that he expects the landscape to change rapidly as RIS vendors get their products certified for the program. “Once that happens, thousands of radiology groups that couldn’t get anywhere with this before can upgrade,” he says. “To the radiologists, I would say that this is real, and it’s going to be a big deal. You need to buy a product based on what the federal government is telling you to do.” As providers await the stage 2 recommendations, Peters reiterates that the ACR and other groups have the radiology community’s back. “The ACR is meeting again with pertinent CMS and ONC regulators to discuss imaging considerations for stage 2, in the absence of specialist recommendations from the meaningful-use work group,” he says. “We are also continuing to work with other specialty societies and the AMA to try to enhance the clinical relevance of the program requirements for specialists.” Peters adds that the specialty societies might have more to do before the program is updated to reflect their constituents’ needs better. “It has been an uphill battle, breaking through on this issue,” he says. “All indications are that the ACR’s efforts—and those of the rest of specialized medicine—will need to continue for the foreseeable future.” Looking even further ahead, however, Fischer is optimistic about the foundation being laid by the meaningful-use measures, in spite of their lack of specificity. “If you dig deeply enough, there’s some good that comes out of this, in terms of connectivity and exchanging CCD/CCR in stage 2 and later (which we see as very beneficial),” he says. He continues, “One of the challenges we have, right now, is that integration between, for example, the specialist and the orthopedist isn’t very easy. If we can get to where there’s a standard for exchange of patient demographics and history, that will be a home run—and I think that’s one of the things the program is aiming to accomplish.” Dreyer concludes on a note of caution for radiology. “If anyone out there is thinking this is going to go away, he or she is wrong,” he says. “I cannot imagine anything, based on the countless hours I’ve spent at the federal level, that’s going to change this—not a change in political party, not a change in support for the Patient Protection and Affordable Care Act, and not a change in having more radiologists at the table. I spend all of my time doing this, and radiologists are not going to be made exempt.” Additional Reading - Ready Set—Attest Cat Vasko is associate editor of Radiology Business Journal.