February was a lucrative month for health care providers and
physicians who attested to their compliance with federal “meaningful
use” regulations. Many cashed in on their reimbursement for meeting the
objectives set by the Medicare and Medicaid EHR Incentive Programs,
commonly known as “meaningful use.”
According to the Centers for
Medicare & Medicaid Services (CMS), 27,500 Medicare physicians
received $425 million in reimbursements, 5,500 Medicaid clinicians and
eligible professionals (EP) received $100 million, and 90 hospitals in
either program deposited $200 million, for a grand total of $725 million
in reimbursements to 33,090 providers in one month.1
is the cut for radiologists? For the 90% of radiologists who qualify
as EPs, a total of nearly $1.5 billion in incentive payments is
available—if they take action now.
“This is an important year for
radiology and meaningful use. By complying with the program this year,
radiology can receive the maximum available incentive and avoid future
costly penalties,” said Bob Cooke, co-founder and CEO of
ImagingElements. “Radiologists qualify for incentives of up to $39,000
over the next 3 years, but as the total incentive cap drops annually
through 2016, this incentive is only available if you start this year.”
up a meaningful use strategy requires some advance work, and the clock
is ticking. Radiologists must first meet the Stage 1 requirements of the
EHR Incentive Programs for a 90-day period in their first year of
participation and a full year in their second year of participation
before they need to attest to Stage 2 requirements.2
program employs a carrot-and-stick approach to drive compliance, with
the maximum $39,000 incentive representing the carrot. The stick:
Beginning in 2015, EPs who fail to attest to meaningful use will be
subject to payment reductions. The reduction starts at 1% and increases
each year that a Medicare EP does not demonstrate meaningful use, up to a
maximum of 5%.
However, according to data recently published by
CMS and the ONC, only about 4,000 of the approximately 30,000 eligible
radiologists attested in 2012.2
Can you afford to wait?
small percentage of radiologists see the program as an opportunity to
advance their practice and use it as an early competitive advantage;
they want to take advantage of the incentives to upgrade their
“The financial incentive encouraged us to get in, and
we wanted to be the first ones in our area to attest to meaningful use.
We are looking at promoting to referring physicians and patients the
fact that we attested to meaningful use,” said Jennifer Staley, RT,
Technical Director, Tri-City Radiology in Kenneweck, WA, where they
attested using an EHR module provided by RamSoft.
Nonetheless, most radiology practices have yet to embrace meaningful use, begging the question: Why not?
part, it may be that the program takes a “one-size-fits-all” approach;
many of the requirements are more geared toward primary care physicians
and don’t apply directly to radiology. However, in September 2012, CMS
released the final rule for meaningful use Stage 2, which integrates
imaging into the process in ways that Stage 1 did not. Imaging will be
one of 6 menu objectives for EPs in the Stage 2 final rule, of which 3
must be met. Stage 2 also contains 17 core objectives for a total of 23;
20 must be met for Stage 2 compliance.4
new updates to Stage 2, many experts say it’s unwise to procrastinate,
and that radiologists must take the time now to see how the changes
affect their practices.
According to Cooke, “Radiologists can use
the language in the measures related to a radiologist ‘seeing the
patient’ to dramatically reduce the number of patient encounters in
scope for meaningful use attestation. It’s an opportunity to be
compliant with the program, without having to do things that have little
clinical benefit—this can really ease the entry into the program.”
cause for delay is the program gives radiologists who can show hardship
a 5-year exemption from using EHRs to collect and communicate patient
data. Yet there are no guarantees that the exemption will stay in
“Some radiologists close to retirement may take a
hardship exemption (if eligible) to avoid Medicare penalties starting in
2015, and as Stage 3 comes along, some of the criteria may change, such
as exemptions that may be even more favorable to specialty
practitioners, such as radiologists,” noted Douglas Rufer, Director,
Technical Marketing and Sales Engineering at Carestream Health.
consequences of not complying with the meaningful use requirements will
still impact those radiology practices that deliberately choose not to
“They will still be affected,” said Keith Dreyer,
DO, PhD, Vice Chair of Computing and Information Sciences in the
Department of Radiology at Massachusetts General Hospital, Boston, MA,
in an interview with the Daily Bulletin.5 “[Referring
physicians] will use their certified EHR to order from us, and we will
need to be able to serve them,” said Dr. Dreyer, noting that in Stage 2,
referring physicians will have to fulfill requirements for ordering
images and receiving results electronically.
“It also takes
radiologists off the road that the rest of health care is quickly moving
down, so I would only consider this exemption if complying with the
program is not an option,” he added.
Implementing meaningful use
and understanding how to use the EHR and the specific modules may take
additional time, reported Ajay Bhatnagar, MD, MBA, a radiation
oncologist practicing at Cancer Treatment Services Arizona Adjunct, and
an Assistant Professor of Radiation Oncology, University of Pittsburgh
School of Medicine. “You have to create patient-care visits, end-of-care
summaries after they leave, and quality indicators. All of these
requirements are typically outside of the doctors’ workflow,” said Dr.
Ultimately, what has motivated early adopters is the
belief that it’s better to reap the rewards today for what is inevitable
tomorrow. “We thought we should do it while it is a bonus and might as
well start participating now,” said Dr. Bhatnagar.
Where are the gaps?
Stage 1, the gaps in existing radiology platforms relate mainly to data
capture, including specific demographic information, medications, and
vital signs. Some vendors have already extended their systems to support
With recent changes to CMS’ final rule for Stage 2
objectives, radiologists should look for gaps in their current system,
as things get more complicated.
One change to the Stage 2 rule
reduces the percentage of radiology procedures that must be ordered
using a computerized provider order entry (CPOE) to 30% of the ordered
radiology exams. In particular, the measures related to CPOE and the
ability to view images in certified EHR technology will be critical
factors to achieving compliance, and will be critical in maintaining the
relationship between the hospital and imaging provider.
ups the ante for radiology specific applications in terms of meaningful
use compliance, and having a solution designed with radiologists needs
in mind will be critical,” noted Cooke.
Radiologists will still
have to address the issue of employing clinical decision support (CDS)
when using CPOE. Although the Stage 2 rules do not include CDS in the
definition of CPOE, radiology groups should still consider adopting CDS,
since the American College of Radiology (ACR) continues to push for
inclusion of CDS in Stage 3 requirements.
At a higher level,
radiologists need to maintain visibility through educating clinicians on
appropriateness and quality. “Implementing CDS will add value to the
care delivery process by reducing unnecessary costs and radiation
exposure. Radiologists now have an opportunity to lead and shape policy
through aggressively promoting the adoption of CDS as part of any
shared-savings arrangement,” said Michael Mardini, founder and CEO, the
National Decision Support Company (NDSC), the exclusive distributor of
ACR Select represents an evidence-based national
standards set of criteria developed by expert panels at the ACR and
collaboration with over 20 medical specialty organizations.
NDSC has integrated ACR Select with major EHR and CPOE vendors to make
using CDS a seamless part of ordering workflow.
The threshold for
the imaging results accessibility objective was also lowered to
requiring that just 10% of imaging tests be accessible through a
certified EHR via an active link to the images. Yet radiology practices
will still need to implement technology, such as XDS-I and XDR-I, or an
image sharing platform to securely exchange the images.
change to Stage 2 rules involves inputting vital signs into the EHR. If,
for example, an EP determines blood pressure is not relevant, but
height and weight are, common in CT, MR imaging or PET examinations, the
EP may opt out of recording blood pressure.
In general, Rufer says other gaps a radiology practice should look for are the following:
- Multiple systems that don’t comply with meaningful use;
- Aggregating data across multiple certified modular solutions for attestation;
- Real-time dashboards (or reports) to monitor compliance;
- Workflow analysis and design to determine how/where in the workflow the data will be captured;
- Education and training to address patient complaints about providing additional medical data.
groups have a number of options to achieve meaningful use, and the
number of options is growing. It does take some planning, but the
incentives are worth it, and with the right help, achieving it can be a
manageable task,” said Mardini.
What technology do you need?
An EP must use an EHR or
module that is certified specifically for the EHR Incentive Programs to
make sure it offers the necessary technological capability,
functionality, and security to help them meet the meaningful use
criteria. In the past couple of years, the market has been inundated
with certified image-enabled EHRs designed to support radiologists in
achieving meaningful use standards, complete and modular certified RIS
solutions, and other meaningful use modules, but there is no silver
What EPs want to know is: What is the most efficient path
to meeting meaningful use criteria? The first thing to know is every
case is different.
Radiologists need to consider their service
model and referring relationships in relation to the available IT
infrastructure in order to make the right decision about the best path
to getting on the road to meaningful use. Radiologists who are part of
an integrated delivery network can often utilize the hospital’s
deployment of Ambulatory EHR to attest.
It gets more complicated
when you consider a large radiology practice that provides service to
multiple locations. “Often, in the case of radiologists serving multiple
hospitals, leveraging the hospital’s technology can be unwieldy,” said
Complete certified solutions
certified solution contains all the functions in a single place and
automatically tracks, records, and reports on the achievement of the
meaningful use objectives.
“Most hospitals are concentrating on
meeting the eligible hospital requirements for their overall
organization, not specifically the ambulatory requirements that most
radiologists fall under,” said Rufer. “Therefore, most hospitals will
have a full EHR that will drive their priority for meaningful use
compliance.” Moreover, the reimbursement for maintaining hospital
compliance is higher than that for maintaining radiology compliance,
Radiologists can use a radiology information system
(RIS) certified as an Ambulatory EHR, or a system that contains a
certified EHR to comply with meaningful use. In radiology, these systems
collect data and provide reporting specific to an EP, the department or
practice (Figure 1). They can be used to augment the existing systems,
or completely replace legacy, noncertified technology.
cloud-based meaningful use service that integrates with existing imaging
IT solutions is ElementMU by ImagingElements. Based on a fully
certified ambulatory EHR, the service is specific to the needs of
radiology, and is designed to augment existing IT platforms. Using this
solution, radiologists can participate in the meaningful use program
without replacing technology or burdening the ordering health care
system with extra work. The service is designed for radiologists who
would not otherwise have access to certified technology, or for those
that want to exploit denominator reduction opportunities by minimizing
the set of exams in scope for meaningful use.
“Using the ‘as seen
by EP’ workflow reduction opportunities, we were able to use only 3% of
our overall patient volume and still comply with the program,” said
Frannie Joseph, Practice Administrator at Raleigh Radiology, a practice
with several locations in North Carolina.
Ramsoft offers a
complete ambulatory EHR add on to its RIS solution. PowerServer 5.1 is
2011/2012 compliant, which means the software is capable of supporting
providers with Stage 1 meaningful use measures.
“Once we added
the meaningful use module, all we had to do was adjust our paperwork. We
needed to add the demographic information to meet the meaningful use
criteria. It was seamless for us, and it wasn’t hard to attest,” said
Staley. “We like that we can electronically send patients their
information. As soon as a report is signed by the radiologist, it goes
to the referring physician, and then it’s automatically sent to the
In fact, Tri-City Radiology is taking its reimbursement
dollars from attesting to meaningful use to upgrade other electronic
portals it shares with its clients. “We have had a lot of requests from
clinics to create an HL7 interface with them, and with the reimbursement
from meaningful use, we are putting that money toward implementing the
HL7 interfaces with other clinics,” Staley added.
meaningful use Stage 2 rules include image-enabling EHRs as a menu set
measure, organizations like Huntington Hospital are looking to quickly
and easily image-enable their enterprises for compliance,” said Jeff
Surges, CEO, Merge Healthcare. Merge’s iConnect Enterprise Clinical
Platform solution enables health care organizations to collect, archive,
view, share, and exchange any type of image anywhere, any time. It
includes iConnect Access, a zero-download DICOM image and XDS server,
iConnect Share, a gateway for image sharing across the enterprise and
iConnect Enterprise Archive, a vendor-neutral archive to create an
enterprise imaging strategy. It works with existing applications,
leveraging widely-used web and health care technology standards, to
provide a vendor neutral interoperable environment.
An example of a complete certified RIS system, Fujifilm’s Synapse RIS
Version 6.1 is a fully certified EHR for radiologists to meet multiple
criteria. Version 6.1 includes an enhanced dashboard that aids the user
in managing performance in real time (Figure 3). Version 6.1 also
includes Synapse Financials for RIS, which provides an option for
incorporating the billing process into the system and a feature that
alerts the user to dose management concerns for the patient. As with
Fujifilm’s complete medical informatics product portfolio, version 6.1
for Synapse Information Systems is designed to run in a virtual
Carestream’s Vue RIS is a dual-certified EHR. It
provides a complete EHR for radiology groups and a modular certification
for hospitals to connect with their EHR.
The complete EHR
certification means that imaging centers, radiologists, orthopedists,
and other EPs with Vue RIS do not need to purchase an EHR to capture and
report data required to satisfy Stage 1 rules, such as an active
patient medication list and ambulatory clinical quality measures. “Our
RIS tracks and displays dose history by capturing exposure information
from the modality. In the future, we will be able to allow physicists at
user sites to enter formulas that can be used to calculate dose and
ultimately track cumulative dose for each patient,” said Cristine Kao,
Carestream’s Global Marketing Manager for Healthcare Information
Solutions. Vue RIS provides embedded voice recognition, critical results
reporting, centralized patient scheduling, and management reports that
track patient referrals by physician and modality reading by each
With a dual-certified EHR, one product could drive
both hospital and ambulatory requirements, depending on the scenario.
“Hospitals that own an outpatient-imaging center could capture and send
the eligible hospital data directly into their certified hospital EHR or
submit the data directly to the CMS from Vue RIS to comply with the
hospital eligibility requirements, while also using the same RIS
solution. This would drive their ambulatory radiology practice and
collect the incentive money available for the radiologists as EPs in the
outpatient setting,” said Rufer.
Other available modules include
the Intelerad Meaningful Use Module 2012 by the Intelerad Medical
Systems, which is also capable of supporting providers in meeting
Stage 1 meaningful use measures.
Modular certified solutions and others
modular certified product is designed to work in concert with other
certified technologies to meet all the required measures for meaningful
“A modular certified RIS cannot be used to achieve
meaningful use on its own, although some of the functions can contribute
to the achievement of the objectives,” Cooke indicated. “Typically,
several modular certified products would be combined together to achieve
the required meaningful use functionality, or a modular product would
augment a complete certified product. One or more modular certified
products, or complete certified products, can be combined to achieve
100% certification. In the case of modular certified RIS, it’s generally
designed to be used in conjunction with a certified EHR for
radiologists who are part of the health system; it won’t get you there
on its own.”
RIS can enable certain radiologists to meet meaningful use requirements by operating as a modular EHR.
of the ambulatory sites already have a practice management system that
is certified as a complete EHR. However, the system may not offer the
complete functionality a traditional RIS offers. Therefore, some sites
may choose to add a RIS and only use the billing functionality of the
practice management system,” said Rufer. “Other sites may still be
looking for a RIS to meet certification criteria or solve workflow
issues not currently being addressed by their existing solutions.”
HealthCare’s IMPAX RIS/PACS, offering extensive integration with EHRs
and other medical record solutions, can aid providers in meeting
meaningful use requirements. Part of Agfa HealthCare’s RIS/PACS product
is Impax Business Intelligence, which monitors clinical data against
thresholds outlined in Stage 1 and reporting them through the IMPAX RIS
solution. Facilities can select to monitor demographic data on patients
with individual monitoring on patient-preferred language, gender, race,
ethnicity, and date of birth; record vital signs on patients with
individual monitoring on patients between the ages of 2 to 20 for
height, weight, blood pressure, and body mass index (BMI); plot growth
charts for patients between the ages of 2 to 20 for both height and
weight against national statistics; and lastly, record smoking status on
patients age 13 and older. This can be used as a reporting dashboard in
conjunction with certified technology.
Siemens Healthcare recently introduced a new cloud-based option for its RIS, which is called syngoWorkflow (Figure 2). syngoWorkflow
can be configured to directly capture meaningful use data (via data
entry screen), receive (via interface), store, and transmit text-based
patient information related to the procedure including, but not limited
to, demographics, medications, allergies, and diagnostic reports. This
solution can aid in attesting when used in conjunction with certified
GE Healthcare also released its Modular Certified
meaningful use-ready software, Centricity Enterprise 6.9, a 2011/2012
Wave of the future: Radiology compliance
When can radiology expect the next big wave of meaningful use compliance? Some say it will land when Stage 3 is implemented.
is going to be based on the final outcome for Stage 3, specialty
exclusions, overall adoption and continued funding for the program, plus
whether there will be further stages to the program beyond Stage 3,”
In the overall scheme of things, meaningful use is
one more step toward a larger goal—health care reform—another reason why
radiologists should consider today how to prepare for what’s coming
More information on “meaningful use” core and menu
measures and on the changes to the Stage 2 rule is available in the
online edition of Technology Trends at appliedradiology.com.
- Mosquera M. CMS: Meaningful use EHR incentives hit $12.3B in
February. Government Health IT.
Updated March 15, 2013. Accessed March 22, 2013.
- Meaningful use. Policy making, regulation and strategy.
Accessed April 8, 2013.
- Meaningful Use. CMS.gov. The Center for Medicare & Medicaid Services. Updated September 20, 2012. Accessed March 22, 2013.
- Stage 2 Overview Tipsheet. RSNA.
Updated August 2012. Accessed March 25, 2013.
- Experts urge radiology to embrace meaningful use now. Daily
Bulletin. RSNA 2012. http://db2012.rsna.org/index.cfm?pg=12mon05.
Updated November 26, 2012. Accessed March 25, 2013.
- Certified EHR Technology. CMS.gov. The Center for Medicare &
Medicaid Services. Updated February 12, 2012. Accessed March 22, 2013.