Mining for Clinical Gold in Government Red Tape

In dissecting stage 2 of meaningful use, Alberto Goldszal, PhD, summarizes the meaningful-use challenge for radiologists: “In the meaningful-use rules, you are going to see some specific examples of things that are changing the radiology workflow that are perceived as a contraindication for radiology efficiency,” he says. “Overall, it does improve patient care—at least, that is the intended goal.”

Goldszal is CIO of University Radiology (East Brunswick, New Jersey), an 83-radiologist practice. On December 3, 2013, at the annual meeting of the RSNA in Chicago, Illinois, he was a copresenter of “Impact of Legislative Policy and Regulations in Imaging Informatics.”

With meaningful use here to stay, Goldszal’s approach has been to roll up his sleeves and get to work. University Radiology attested to stage 1 in 2011 and is deep in preparations to attest to stage 2 in 2014. 

Complying with stage 2 will add considerable complexity to the radiology practice’s IT infrastructure, but it also will protect the practice from penalties scheduled to commence in 2015. Ultimately, Goldszal suggests, the universal adoption of electronic health records (EHRs) could lead to the simplification of information exchange.

With meaningful use rolling out in three (or more) stages, early adopters are on the cusp of the transition to stage 2. About 40% of the nearly 1 million US physicians have implemented certified EHR technology and received incentive payments. Just 14% of radiologists can say the same. 

Of radiologists who have earned incentives, most are in stage 1, but some are transitioning to stage 2, Goldszal says. No matter when a radiologist begins attesting to stage 1, he or she must do so for two years.

“The initial stage is actually quite boring because it focuses on data collection, and you do not see the benefit of it—just the labor,” Goldszal says. “The hope is that future stages will provide improvements in clinical processes and will benefit clinical outcomes.”

The focus, in stage 2, is on advanced clinical processes, with rigorous information exchange, transmission of patient-care summaries across settings, and increased family/patient engagement. For stage 1, eligible professionals had to implement a 2011 edition of certified EHR technology; for stage 2, there is a 2014 edition, and some EHRs already comply. To earn incentives, eligible professionals must meet core, menu-set, and clinical-quality measures. These have been modified—with implications for radiology. 

Core Measures

In stage 1, there were 15 core measures (six of which have been folded into other measures in stage 2); there are 17 core measures in stage 2. Some stage 1 menu-set measures have been moved to the core objectives. Eligible professionals may request exemption from some (but not all) core measures. In this list, the percentage following the name of the measure refers to the number of patients to whom the measure must apply.

• Computerized Provider Order Entry (CPOE), 60%/30%/30%, and Electronic Prescribing (50%): Objectives 1 and 2.—Every certified EHR must be capable of both CPOE and electronic prescribing, but physicians can claim exemptions from both. In stage 1, physicians had to prescribe medication for 30% of patients using CPOE, and in stage 2, that jumps to 60%, and 30% of radiology orders have to be entered electronically—in the referring physician’s electronic medical record system. 
• Drug/Allergy Interaction.—Physicians will continue to be required to do drug–drug and drug-allergy checks before they dispense a medication, but the measure will be folded into the clinical decision-support measure. 
• Problem List (80%).—Compiling patient problem lists is straightforward, but is no longer a separate measure because it has been merged into the transition-of-care record. 
• Patient Demographics (50%): Objective 3.—“Every patient who comes into our hospital or clinic gets registered in our system, so this is not very challenging,” Goldszal notes. 
• Medication List and Allergy List.—This has been merged into the transition-of-care measure and is therefore mandatory. Goldszal hopes that as certified EHR technology is universally adopted, the referring physician will electronically transmit this information to the radiologist. 
• Vital Signs (50%): Objective 4.—“You can elect to be excluded if you believe that collecting vital signs is not an essential part of the radiology service,” Goldszal says. “We believed it was not meaningful for all exams. We do collect vital signs on special occasions, and we audit these measures; this was accepted by CMS.”
• Smoking Status (50%): Objective 5.—Some physicians can elect to be exempted, but Goldszal says that radiologists have to collect these data.
• Clinical Decision Support (Five Rules): Objective 6.—There are no exemptions from this measure, which moves from one rule in stage 1 to five rules in stage 2. “In stage 1, you could use a very simple algorithm,” Goldszal says. “If the patient is female and more than 40 years old, see if the patient has had a mammogram in the past year (anywhere in your practice). If the answer is no, recommend that the patient have a mammogram, following the ACR® guidelines.” These five rules need to be inside the EHR or interfaced with another system (such as ACR Select) that would return the results to the EHR.
• Results Portal (50%–5%): Objective 7.—More than 50% of unique patients must be provided with online access to their health information within four business days, and more than 5% must view the information, download it, or transmit it to a third party.
• Clinical Summaries (50%): Objective 8.—Physicians provide summaries of what was performed for the patient during the visit. Eligible professionals may exempt themselves.
• Exchange Clinical Information.—This was incorporated into the transition-of-care record.
• Protect Health Information (Risk Analysis): Objective 9.—No physician may claim an exemption from performing a risk analysis for patient information created or maintained by certified EHR technology. Electronic health information must be encrypted.
• Drug Formulary.—This measure has been folded into the definition of certified EHR technology and is mandatory.
• Laboratory-test Results (55%): Objective 10.—“Typically, we do not order a lot of laboratory tests, but if we do so, we have to do it electronically,” Goldszal says, unless the practice chooses to exempt itself from this measure. 
• Patient Lists: Objective 11.—This is a list of patients by specific condition, and there are no exemptions. “That’s for mining your database,” Goldszal says.
• Patient Reminders (10%): Objective 12.—This includes annual reminders for mammograms, as well as reminders for other screening procedures. “We do 1.5 million exams a year, so 10% is a lot,” Goldszal says. Physicians may exempt themselves from this measure—with justification.
• Access to Electronic Health Information (10%).—This was merged with the view, download, and transmit results portal measure. Physicians may exempt themselves from this function.
• Education Resources (10%): Objective 13.—There is no exemption from this measure. Physicians must provide patients with educational resources.
• Reconcile Medications (50%): Objective 14.—When a patient comes from another physician with a list of medications, those need to be incorporated into the EHR (and reconciled to make sure that they are up to date) when a new medication is prescribed. Physicians may exempt themselves.
• Transition of Care (50%): Objective 15.—The measure requiring eligible professionals to provide a summary of care for each transition or referral case is the most challenging, Goldszal believes, but it is the one that yields the most benefit. For every patient received from (or referred to) another caregiver, providers must encapsulate and send electronically all of the data collected related to the meaningful-use measures. “It’s a beautiful thing, if you fast-forward five years down the road, and everybody is doing this,” Goldszal says. Physicians may exempt themselves.
• Immunization Registry: Objective 16.—“This is really for pediatric clinics and does not apply to radiology,” Goldszal says. “Elect to be excluded.”
• Secure Messaging (5%): Objective 17.—This requires eligible professionals to use the secure-messaging capability of certified EHR technology to communicate with patients. “They may have questions on the radiology report, they may contest a finding, or they may want more information,” Goldszal suggests. “You have to provide a mechanism for that. You are going to have to have the resources to deal with patient questions. You only have to do this for 5% of your patients, but if your numbers are high, 5% could be an absolute nightmare.”

Menu-set Objectives

In stage 2, eligible professionals must choose to meet three of the six menu-set objectives. Some are new, and all will have a direct impact on radiology practices, whether they participate or not.

• Collect Patient History (More Than 20%).—More than 20% of patients seen by the eligible professional during the reporting period must have structured data entry for one first-degree relative or more.
• Imaging Results (10%).—The requirement that 10% of imaging results must be accessible from the EHR will affect radiologists, whether or not they want to participate. “The rest of the community will be adopting this, and radiology will have to be driving,” Goldszal says, adding that there are several solutions on the market.
• Progress Notes (30%).—Goldszal believes that radiology practices will benefit by having progress notes from referring physicians in their EHRs. There are no exemptions.
• Cancer Registry.—Eligible pro-fessionals electronically submit cancer cases to a public-health cancer registry on a continuing basis.
• Syndromic Data.—This entails submitting electronic syndromic surveillance data to public-health agencies.
• Specialized Registry.—Eligible professionals report specific cases to a specialized registry (such as the ACR’s Dose Index Registry) associated with a specific disease or sponsored by a national specialty society.

Clinical-quality Measures

These are mandatory for all physicians, but they are no longer tied to a stage. The list published in 2011 has been replaced by a new list. “Even if you start attesting to meaningful use for the first time next year, you are going to use the 2014 measures, regardless of the attestation stage,” Goldszal says. 

Eligible professionals have several options with regard to meeting the clinical-quality measures. They can choose to meet nine of the 64 clinical-quality measures; they can meet the clinical-quality measures by participating in the Physician Quality Reporting System; and if they are participating in the Medicare Shared Savings Program or the Pioneer ACO Model, they can use those programs’ quality requirements to meet the clinical-quality measures. 

New Technical Challenges

Goldszal makes it clear that radiology-practice CIOs will be living in a much larger world when they undertake the demonstration of stage 2 of meaningful use. Radiology interfaces RIS with PACS, PACS with the EHR, and RIS and PACS with voice recognition, as well as coding and billing systems. “We have been doing that for 25 years, but something has changed,” he says.

Radiology will need to become conversant in using HL7 infobuttons for integrating clinical decision support; HL7 Clinical Document Architecture for sending problem lists, smoking status, and family histories; and SNOMED CT (or some other lexicon) for the purpose of coding all of that information. Laboratory-test orders also “need their own interface (HL7 ELINCS) and use their own terminology, LOINC,” Goldszal notes. “We are used to DICOM and HL7, but these are new players.”

In summary, there is a net increase in the number of measures to be tracked in stage 2, Goldszal says. “It’s a challenge for practices, vendors, and hospitals alike,” he adds. “There are more interfaces and greater interoperability demands.”

Hardship exemptions can be used to avoid payment adjustments for noncompliance, and physicians registered with the Provider Enrollment, Chain, and Ownership System, or PECOS—including radiologists, anesthesiologists, and pathologists—can be granted an exemption for up to five years. “The caveat is that the government can suppress that exemption at any time,” Goldszal says.