Pushing ahead with Meaningful Use

You cannot escape the responsibility of tomorrow by evading it today.

—Abraham Lincoln

National 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).

Palatable stages

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 stages:

• 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 optional item.
• 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

Some 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”

And 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 requirements.

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.

The “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?

Recognizing 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 quality.

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.

The 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 with CDS.

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 associated costs.

Conclusion

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.

References

1. Shrestha R. Meaningful Use: What it means to radiologists. Applied Radiology. 2012;41:24-26.
2. Bresnick, J. Is meaningful use too much of a hassle for radiologists? EHR Intelligence. http://ehrintelligence.com/2013/02/11/is-meaningful-use-too-much-of-a-hassle-for-radiologists/. Updated February 11, 2013. Accessed June 1, 2013.
3. Ellenbogen 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. http://www.acr.org/~/media/ACR/Documents/PDF/Advocacy/Fed%20Relations/Meaningful%20Use/acrcomments_hitpc_rfc_1142013.pdf. January 14, 2013.