MU Roadmap: Choices, Mandates, and Decisions in the Age of Meaningful Use

Detours notwithstanding, radiology is making slow progress toward the demonstration of meaningful use of health IT

The 2014 technology-acquisition roadmap looks a lot like the map from last year, which is to say that it resembles a bare-bones diagram that often fails to show road closures and detours. Many radiology directors in hospitals and private practices have nonetheless navigated the IT/workflow roadblocks, realizing that many of the hurdles have come courtesy of meaningful use. 

For some, the largely perfunctory collection of data for stage 1 of meaningful use has been anything but business as usual, with many radiologists contending that because they never did it in the past, they do not see the logic behind doing it now. Safwan Halabi, MD, director of imaging informatics at Henry Ford Health System (Detroit, Michigan), admits that this attitude initially caused some anxiety stemming from a disagreement as to whether radiologists should attest to stage 1 of meaningful use. 

Radiology and health-system administrators at Henry Ford Health System are finalizing the decision for radiologists’ attestation to stage 1 of meaningful use. The plan is to come to a decision by the end of the first quarter of 2014. “It takes 90 days to attest, so we must get on that—because the monies are dwindling for the incentives,” Halabi says. “Pretty soon, the meaningful-use incentive transitions to meaningful-use penalties, beginning in 2015 and 2016. That is why it is becoming more urgent for radiologists to attest to stage 1 of meaningful use.” 

From a raw-technology standpoint, Halabi and his staff members encountered many challenges in their efforts to prepare four hospitals and more than 20 satellite sites for meaningful use. Henry Ford Health System had flourished with a homegrown electronic health record (EHR) for decades, and it served the health system well. As the Health Information Technology for Economic and Clinical Health Act and other legislative actions standardized the EHR for meaningful use, however, the homegrown system needed to be overhauled or enhanced.

“They were going to put modules on top of the homegrown system to be able to certify the EHR and attest to stage 1 of meaningful use,” Halabi recalls. “After some struggles with that, the health system decided to adopt an EHR system that was certified for meaningful use and vetted at other large health-care institutions. Ultimately, the health system opted to forgo further development of the homegrown EHR due to the uncertainty of certifying the system for stage 1 of meaningful use.” 

Henry Ford Health System’s detour on the technology-acquisition road was not inexpensive. Millions of dollars were initially spent on refreshing the storage and server infrastructure of the homegrown EHR and on retrofitting it with modules intended to let it attain meaningful-use certification. 

As that activity proceeded, it became evident that there were still numerous holes to fill before the homegrown system could be certified. This endeavor became insupportable, and the health system decided to replace its EHR with a certified commercial system—at a cost of approximately $350 million. This figure includes additional full-time employees, the necessary operating capital, and training time. 

Denominator Reduction

The occasionally painful transition led to standardization across the health system, and Halabi believes that this will eventually put the system in good stead to collect incentives, avoid penalties, and comply with future meaningful-use requirements for the good of patients. Issues involving appropriate EHR compatibility and technology proved less troublesome at Imaging Healthcare Specialists (IHS), San Diego, California. Jon M. Robins, MD, chair and CEO, oversees an operation with 28 radiologists in San Diego County and South Riverside County. He reports that the 11-location private practice added an integrated meaningful-use module to its existing RIS/PACS. 

The challenge, for IHS, revolved around adapting the meaningful-use workflow into its large-volume practice—particularly in locations that saw multiple walk-in patients—without adding significant overhead burdens. “We knew we would be sharing a certain component of the meaningful-use dollars with the vendor to get the software,” Robins says, “but we didn’t want to negate what we were going to be seeing in meaningful-use incentive dollars with too much practice overhead.” 

His decision to be an early stage 1 adopter proved fruitful, despite initial concerns. “We realized that we weren’t going to be doing anything different from what any of us experience when we go to our own physicians—which is filling out forms,” he says. “The words meaningful use created organizational consternation and resistance when it was just the acquiring of some basic information to be entered into the RIS.” 

Doing away with the meaningful-use nomenclature in favor of patient-data collection eased the transition, and patient-data collection was introduced across the practice without disrupting workflow. “When you look at the requirements for meaningful use, it is possible to attest for only face-to-face interactions between physicians and patients,” Robins explains. “Once we became aware of that, it became possible for us to attest under the seen-by requirements.”

He adds, “We ended up attesting to those procedures where radiologists were in direct contact with patients for the majority of our 26 radiologists. Those tended to be injections, biopsies, or interventional procedures. That made our life considerably easier.” 

Patient Portals and Decision Support

Stage 2 of meaningful use has helped to spur decision support and the creation of patient portals at IHS, at least in part, but Robins also credits an overall awareness, within radiology, that government pressures are moving the profession from volume-based to value-based payment models. Through meaningful use or otherwise, he says, the IT transition was going to happen. 

IHS is using a patient portal to demonstrate stage 2 of meaningful-use compliance; the portal gives patients an opportunity to view, download, and transfer information—as well as to view their reports. “We’re making EHR purchases this year to establish a referring-physician portal, strengthen our patient portal, and establish metrics and analytics within our practice that make decision support possible—both with computerized provider order entry (CPOE) and in the radiologists’ reports (when we are making imaging recommendations),” Robins says.

Alberto Goldszal, PhD, MBA, is CIO of 83-radiologist University Radiology Group (New Brunswick, New Jersey). He implemented a pilot program for his patient portal, giving access to employees and their families. “By the time that stage 2 came, in 2014, we only had to amplify that relatively constrained population of users to all of our patients,” he says. “We now have some experience in how to deploy this technology, how to support it, and how to promote value (for the patient and the practice) by establishing a mechanism for patients to look at their records and give us feedback.” 

The effort has been expensive—in terms of both technology and staff time. “It requires time to answer questions and time to communicate electronically with others,” Goldszal explains. “It adds tremendous value for patients, but it does not come free. You must account for people, processes, and systems to establish a direct relationship with patients. One of the major downsides is that radiology reports, except for mammography and dual-energy x-ray absorptiometry, are not created in a language for public consumption; rather, they are meant to be physician-to-physician communication tools, and that can create confusion for patients reading their reports.” 

When it came to complying with the stage 2 clinical decision support objective, Goldszal’s team began by implementing specific aspects—such as looking for the records of all women 40 or more years old. The algorithm would look for the date of the last mammogram and send a reminder, when necessary. “That’s the type of decision support that benefits patients,” Goldszal says. “That was a win–win relationship for the practice and the patients, but these things take resources.” 

CPOE Accelerator

At the University of Pittsburgh Medical Center (UPMC) in Pennsylvania, administrators immediately pushed for meaningful use, at an enterprise level, as soon as the requirements came to light. The meaningful-use mandate accelerated activities involving decision support and CPOE. 

“The same thing can be said of the patient-portal activities,” according to Rasu Shrestha, MD, MBA, vice president of medical IT at UPMC. “The meaningful-use carrot-and-stick approach works, but for a $10 billion organization such as ours, decision support, CPOE, and patient portals are journeys that we are already on; meaningful use is great, but it just reinforces what we’re already doing.” 

Prior to the meaningful-use edict, Shrestha and UPMC executives had worked toward the holy grail of interoperability for many years, with the aid of a task force. Shrestha and the UPMC task force’s members believed, early on, that interoperability at the 22-hospital organization (with a payor arm that has more than two million members) was not just nice to have, but was a must-have feature. Prioritizing IT acquisitions at UPMC continues to be done with interoperability firmly in mind, and that philosophy is expected to continue for the foreseeable future. 

Goldszal and his team also jumped on the meaningful-use train fairly quickly, with interoperability as the primary consideration. “Early on, we asked, ‘Should we spend this extra effort and collect data that may be marginally relevant for the patient, but in practicality, is not?’”

Goldszal says. “We determined that while the data collection may not benefit patients now, it is the beginning of something that is happening industrywide. We hope that downstream (perhaps not even in stage 1 or stage 2, but in a future stage), we will already be in a place to participate in the interoperability environment.” 

The problem, Robins says, is the lack of a clear standard for interoperability. “One of the insanities of meaningful use is the absence of an interoperability standard,” he says. “The government has mandated that we do things, but it hasn’t mandated a communication capability, so we’re all left as islands—needing to communicate with one another.” 

Decision-support Validation

Despite the lack of clarity, administrators at Henry Ford Health System have forged ahead, and meaningful-use guidelines have essentially validated the direction of their early initiatives to pursue decision support and a vital patient portal. While they have already pursued many of the meaningful-use goals, meaningful use has “definitely pushed our patient portal to another level. More patients than ever are going to the portal, where they can access laboratory reports and imaging results,” Halabi notes.

Henry Ford Health System participated in the Medicare Imaging Demonstration (a project that assessed clinical decision support for CMS), and stage 2 of meaningful use “just emphasized that, or at least allowed us to continue pursuing that,” Halabi says. “We already do clinical decision support, but we are looking forward to taking it to the next level.” 

With an accredited EHR firmly in place, the stage 1 and 2 attestations will go smoothly, Halabi believes. “We have a closed physician group, so we can control the workflow, and the physicians can all be in line with the meaningful-use requirements,” he says. “We have a robust architecture to implement decision support in the order-entry process. We’re able to mix in clinical decision support for radiology orders, and there’s also clinical decision support for some of the common pathways—for pneumonia or surgical follow-up, let’s say.” 

A central-umbrella IT structure at Henry Ford Health System is believed to be critical to the successful implementation of meaningful use, with the EHR serving as the essential mainstay. “The EHR is crucial for the meaningful-use success of the different hospitals and business units throughout the health system,” Halabi says.

He continues, “The EHR is the core, where all the meaningful-use requirements are going to be deposited. Through all of this, we are supporting radiology to be able to bring up clinical decision support, to send reports to the patient portal, and (in the future) to communicate directly with patients—for them to be able to download and share their imaging in the health system.” 

Getting on Board

IHS is the largest outpatient-radiology provider in its area, and it also staffs several hospitals in the community. In working with these hospitals and in the community, IHS found that nonradiologist physicians were more likely to be involved in meaningful use. 

“When I heard this at last year’s annual meeting of the RSNA, it was stunning to me: Only 14% of radiologists across the country have attested to meaningful use, versus about 60% of other physicians,” Robins says. “I think the impediment to attestation, for many radiologists, has been their hospitals. Since we are an independent outpatient provider, we don’t have to rely on systems made available through the hospital. We were able to make a decision to participate in meaningful use, acquire the capability, and implement everything entirely on our own.” 

The problem, Robins says, is that radiologists must have cooperation from their hospitals. “Hospitals either have been reticent about providing what radiologists need or are slow in doing it,” Robins says. “Unless hospitals are willing to provide the technology and systems for radiologists, meaningful use isn’t going to happen. Radiologists would be willing to participate, but they are not the owners of the systems: The hospitals are.” 

Will hospitals and private practices ultimately be ready for stage 3 of meaningful use? At this point, Robins is taking no chances, deciding to beef up his internal IT department in preparation for whatever might come to pass. In addition to gaining a higher level of IT expertise in his senior-management team, he has invested in RIS/PACS technology that is flexible enough to meet future needs. 

“Align with technologies and vendors that have the resources and the system flexibility to make the required steps in the next two to five years,” he says. “We’ve had to commit capital to get where we are, and to be ready for where we need to go. All stages of meaningful use have accelerated IT capital expenditures and RIS/PACS expenditures within our practice.” 

When the requirements of stage 3 eventually are unveiled, Shrestha believes, the entire radiology world will be a bit more ready. With no details yet released, though, he and the UPMC system will proceed with educated guesses, at least for now. 

“Nothing has been put on the back burner that can be specifically attributed to stage 3 of meaningful use, and all systems are go,” Shrestha says. “Stage 2 will be extended to 2016, and then stage 3 will begin in 2017, for those providers that have completed at least two years in stage 2. We believe that stage 3 of meaningful can only make things better. It’s ultimately all about improving care, decreasing costs, and improving outcomes.”