Q & A With ACR’s Michael Peters: Portals and Beyond in MU 1, 2 and 3

On January 29, 2014, Michael Peters, senior director of legislative and regulatory affairs, for the ACR^®, presented a webinar—Navigating the MU Pathway: Stages 1 and 2—sponsored by FUJIFILM Medical Systems. The 30-minute question period following the presentation proved too short to answer all of the questions, so Peters generously prepared answers to the questions that follow.

Radinformatics: Radiology practices have the option of including all patients, or just those with direct radiologist contact, in the so-called denominator. Can you talk about the pros and cons of each option?

Peters: For any meaningful-use objectives with measures that use a denominator of unique patients seen by the eligible professional, the physician is able to define what it means to see patients, as long as all physical encounters and telemedicine encounters with patients are included; the definition is consistent for all such measures, and throughout the reporting period; and the definition does not result in a zero denominator. This is optional, so whether or not a participant uses this flexibility is entirely up to that individual.

On the positive side, this flexibility allows radiologists to have a degree of control over their denominators for those particular measures, and I know of certified products that are specifically designed to codify and leverage this flexibility. Some radiologists, however, might decide not to use this optional flexibility because it could conceivably be more complicated to implement, in an automated fashion, if they are not using products that can easily take advantage of it.

Radinformatics: Stage 2 of meaningful use requires new functionality from an electronic health record (EHR), and vendors are required to be recertified. Is a patient portal one of those requirements, and if so, what functionality must it have?

Peters: First, note that the editions of certification criteria for health IT products used by participants are independent from the stages of meaningful use. In other words, everyone participating in stage 1 and stage 2 of meaningful use this year must use 2014 edition certified products.

Regarding the patient-portal issue in particular, beginning this year, there is a stage 1 and stage 2 meaningful-use objective related to providing patients with the ability to view, download, and transmit certain health information within four business days of the information being available to the physician.

The health information required by CMS for the view/download/transmit objective consists of patient name, provider’s name and contact information, current and past problem list, procedures, laboratory-test results, current medications and medication history, current medication allergies and medication-allergy history, vital signs, smoking status, demographics, care-plan fields, and any known care-team members. You will notice that radiology reports and images are not on that list, but nothing in meaningful use prevents participants from making additional data available to patients through the portal.

Most of these data elements are captured, along the way, for other meaningful-use objectives. When data are not available—because there is no information to record or because the radiologist is excluded from it by another meaningful-use objective (for example, the participant has invoked the exclusion for the vital-signs objective)—the participant is allowed to indicate, in the portal, that the information is not available.

The measure for stage 1 and stage 2 is that more than 50% of unique patients seen by the eligible professional are given this online access to the health information in question within four business days. There is a second measure, for stage 2 participants only, that requires that more than 5% of unique patients seen by the eligible professional (or authorized representatives) either viewed this health information, downloaded it, or transmitted it to a third party.

There is an important exclusion from both measures of this objective if the radiologist neither orders nor creates any of the specific health information that must be available to view/download/transmit (except for patient name and provider’s name), so certain radiologists might conceivably be able to meet that exclusion. If (and only if) they meet that exclusion, they would not need to implement technology certified for the corresponding view/download/transmit certification criterion because view/download/transmit is not in the base EHR list of criteria. In other words, if you are excluded from view/download/transmit requirements, you wouldn’t actually need the certified patient-portal functionality in your certified EHR technology.

Radiologists who are not excluded from view/download/transmit requirements, and therefore must meet the measures, need a product that is specifically certified for the view/download/transmit certification criterion. I won’t go into the lengthy technical details of that particular criterion, but know that if a given piece of software is certified for the Office of the National Coordinator (ONC) for Health IT’s view/download/transmit criterion, it inherently has the functionality needed to facilitate one’s compliance with the CMS view/download/transmit objective.

Radinformatics: If a radiologist opts for the Provider Enrollment, Chain, and Ownership System (or PECOS) exclusion, how long can he or she avoid the penalties? What is the downside?

Peters: The underlying law does not currently give CMS the authority to grant an eligible professional a significant-hardship exception from meaningful-use penalties for more than five total years, throughout that individual’s career. Unless something changes, then, the downside of an eligible professional’s use of those five years, up front, is that the payment reductions will already be at the maximum penalty level when he or she first sees penalties, in 2020.

Radiology’s participation in carrot-and-stick incentive programs like the Physician Quality Reporting System (PQRS) and meaningful use has been relatively low, so it appears that many are willing to risk future payment adjustments (or they are in situations without viable compliance options). The ACR has advocated long-term relief for individuals who fall into the latter category.

Radinformatics: My practice has done nothing so far. Do you have any suggestions for jump-starting the process?

Peters: The first step toward making a decision about whether or not to participate is learning about the regulations. Decision makers in the practice should read up on the materials and guidance on the CMS EHR Incentive Program site and the ONC’s HealthIT.gov site. They can also access the ACR’s educational resources about the subject in our meaningful-use resource center.

Radinformatics: Do you have a sense of what practices are spending, per radiologist, on compliance?

Peters: There isn’t a common number. Physicians are not required by the Medicare version of the EHR Incentive Program to own certified EHR technology to be meaningful-use compliant, but they do need access to certified EHR technology. Moreover, if you are purchasing your own software, you should know that depending on what you’re going for, prices vary wildly. Also note that the ONC’s latest set of regulations implemented a certain degree of price transparency for 2014 edition certified products, so it should be easier to shop around than it was in previous years of the program.

Radinformatics: Many of the partners in our practice would rather take the penalties than jump through the hoops. How can those of us who want to participate convince the others?

Peters: There are pros and cons to participating in the EHR Incentive Program, and participation is technically voluntary. I think that if you collectively learn about the program’s requirements and explore your options, as a practice, you are likely to come to a shared conclusion about whether or not to participate. I do not believe that a truly informed decision not to participate in the program is any more or less valid than a decision to participate. You just need to do your homework before making that decision.

Radinformatics: How has stage 2 of meaningful use changed what to look for in an EHR for a radiology practice?

Peters: There are two ways to look at this question. First, all participants need access to 2014 edition certified products beginning this year. Simply put, prior 2011 edition certified products are no longer usable for meaningful-use compliance in 2014 and beyond.

Second, meaningful use’s existence, as an economic-stimulus program, has been successful at pushing referring providers off paper, particularly in primary-care fields. This, in turn, has led to those physicians doing more electronically and wanting more out of their systems, in terms of making electronic orders possible and closing the loop.

Regardless of meaningful-use participation or nonparticipation—in fact, regardless of the program’s existence at all—if radiologists are not exploring how modern EHR technology’s ubiquity influences what referring providers demand from them, in terms of interoperability and connectivity, they are probably missing out on ripe opportunities. You don’t need to be a meaningful-use EHR user to make smart technology decisions.

Radinformatics: While meaningful use stage 2 has more relevance to radiology than stage 1 has, it also requires new competencies from radiology IT. Where can imaging IT professionals get further education in HL7, lexicon use for coding family histories, and laboratory terminology?

Peters: As a government-affairs guy, I can’t speak in an informed manner about educational opportunities for IT experts. EHR Incentive Program participants themselves, however, do not need to know anything about standards to be meaningful-use compliant. The purpose of the certification criteria and certification process for products is to assure participants of the ability of those products to make the tasks for which they are certified possible.

Radinformatics: How is recertification going among radiology vendors? What is a reasonable amount of time to wait for that to happen, and how can a practice protect itself from EHR technology’s obsolescence, in that respect?

Peters: All meaningful-use participants need to be using 2014 edition certified products beginning this year. According to reports from the ONC, about half of vendors whose products were used as the primary component of certified EHR technology by radiologists in prior years of meaningful use do not yet offer 2014 edition certified versions of those products. That’s a pretty striking statistic.

Some EHR vendors have concerns about the 2014 edition certification criteria that I won’t go into here, but note that the ONC is coming out with an optional 2015 edition later this year to help resolve those concerns. I believe that the 2015 edition certification criteria proposed rule from the ONC will be published for public comment very soon. My understanding, based on ONC staff reports, is that the 2015 edition certification will be entirely optional, and that 2014 edition certified products will still be acceptable for use in the program after the 2015 edition is finalized.

Radinformatics: Can you provide an example of how radiology practices are complying with the requirement for clinical decision support?

Peters: The stage 1 and stage 2 clinical decision-support objectives are somewhat different, but the commonality between them is that the measures for those two objectives are entirely made possible by certified EHR technology—and nearly impossible to fail if you are equipped with certified EHR technology. You basically just need to make sure the functionality (which is inherent in all certified EHR technology because the clinical decision-support criterion is in the base EHR list) is active for the duration of the reporting period. There is no minimum number of decision-support alerts that must pop up or anything like that.

Radinformatics: What is the ACR pushing for in stage 3? Can you make any predictions about what it will include?

Peters: As someone who works with many different radiology-related federal agencies on a variety of issues and initiatives, I’d rather not try to predict the outcome of a rulemaking before the final rules have been written. I think the rulemaking ahead is going to be more difficult for CMS and the ONC than past rulemakings have been because radical framework changes are, frankly, needed (as the penalty phase looms).

The Health IT Policy Committee, which advises the ONC (and indirectly, CMS) on meaningful use, plans to finalize its recommendations for stage 3 objectives next month. Based on how those recommendations read (in current draft form) and based on conversations over the past year, I am not expecting anything less than the status quo from that committee. It is sticking to its guns, in terms of building up the current framework instead of overhauling it. That said, federal agencies commonly deviate from the advice of their advisory committees, and the CMS/ONC staff is under no obligation to implement those recommendations in full.

In fact, we’ve seen massive deviations, in the past two rulemakings, between what CMS/ONC staff actually implement and what their advisory committees originally recommended. In other words, predicting the future stage 3 meaningful-use regulatory requirements based on next month’s advice of the Health IT Policy Committee is not something I would ever recommend.

CMS and ONC staff members will begin drafting their proposed rules very shortly. They are planning to publish the stage 3 meaningful use and 2017 edition EHR certification criteria proposed rules around fall 2014, with final rules planned for mid-2015.

ACR’s platform of meaningful-use requests has not changed over the years, in terms of appropriateness-criteria–based clinical decision support, imaging data exchange, alternative pathways to compliance, more scope-based exclusions from objectives, less prescriptiveness, more flexibility, and so forth. We (together with the RBMA) added a new request, late last year,  for an alternative process through which hospital-located physicians in unhelpful facilities could obtain hospital-based status (and therefore, ineligibility). It’s kind of a long shot, but we feel strongly about helping those who can’t do meaningful use because of where they work.

Legislatively, our Congressional Affairs team is working hard on issues surrounding the bill currently in play that would provide a permanent fix for the sustainable growth rate, which includes the merit-based incentive payment system (MIPS) concept. The way that the MIPS proposal looks now, it would significantly affect the financial aspects of meaningful use, PQRS, and other quality-incentive programs, as well as encouraging the creation of alternative pathways for non–patient-facing eligible professionals. This will have a huge impact on Medicare, if Congress gets this thing done, so stay tuned.

Cheryl Proval is editor of Radinformatics.com.