What Radiologists Must Know About Meaningful Use

To hear four radiologists who have immersed themselves in the minutiae of the Health Information Technology for Economic and Clinical Health (HITECH) Act describe it, meaningful use—as it relates to radiologists—is an opportunity, a minefield, and a responsibility that could cost more than the $44,000 per radiologist that can be gained by demonstrating meaningful use of certified electronic health record (EHR) technology. Nonetheless, Ramin Khorasani, MD; David Avrin, MD, PhD; Keith Dreyer, DO, PhD; and David Mendelson, MD, attempted to cover the meaningful-use waterfront, as it relates to radiology, with a program description, clarifications, caveats, and tips in a session titled “Healthcare Reform Through Meaningful Use of Healthcare IT: Implications for Radiologists,” on November 29, 2010, at the annual RSNA meeting in Chicago, Illinois. A common thread that ran throughout the presentations was this: Every practice, in every setting, would be well advised to appoint someone to conduct a careful review of the 100-plus–page overview documents (if not the entire 900-page final bill) describing the program. Unless they are willing to risk penalties that will amount to 5% of Medicare payments by 2019, an estimated 90% of radiologists must demonstrate meaningful use of certified EHR technology by 2015. HITECH OverviewKhorasani, director, information management systems, Brigham & Women’s Hospital, kicked things off with an overview of the HITECH Act (approved by Congress in February 2009 as part of the broader stimulus act). The initial budget of more than $19 billion was bumped up to about $30 billion in July 2010, with the goal of reforming health care through the adoption of interoperable health records. “The HITECH law created a mechanism to use stimulus funds to enable a nationwide health-information infrastructure that promotes the electronic use and exchange of information, and it establishes incentive payments for eligible providers and hospitals participating in Medicare and Medicaid programs that meaningfully use certified EHR technology,” he explains. Khorasani emphasizes that it can’t be one without the other: meaningful use and certified EHR technology are both required.Eligible Providers and Qualified EHRsTo qualify to participate in the program, radiologists must be enrolled with CMS and must qualify for reimbursement under Medicare or Medicaid. The ACR® has estimated that 85% of radiologists qualify to participate under Medicare. Medicaid incentives have a slightly higher dollar amount associated with them, but 30% or more of each individual radiologist’s transactions must be billed under Medicaid—a hurdle that the average practice cannot meet. All presenters focused on eligible providers, as opposed to eligible hospitals. Khorasani emphasizes that an eligible provider is the individual radiologist, not the practice: The individual radiologist is the eligible provider who has to attest that he or she is a meaningful user of certified technology by applying to CMS. The number of individual radiologists who apply will determine how many dollars flow back to the practice. For radiologists to participate, more than 10% of their patient encounters (but not the dollars connected to them) must be outside inpatient or emergency-department sites. Radiologists who provide more than 90% of their patient encounters in emergency and inpatient settings are excluded from the program. For eligible providers working in multiple practices, 50% of all patient encounters must be in a practice that meaningfully uses certified EHR technology. Meaningful use will be implemented in a staged approach. Stage 1, beginning January 1, 2011, focuses on data capture and sharing; stage 2, which will be introduced in 2013, moves on to enable users to perform advanced clinical processes (such as disease management, medication management, decision support, and clinical decision making) through IT; and stage 3 will be rolled out at some future date, with a focus on improving outcomes. At present, the only requirements that have been published are for stage 1 meaningful use. Eligible providers must use certified EHR technology, either as complete solutions or as modules that enable an eligible provider to qualify for a component of meaningful use. Certifications will be announced by CMS and the Office of the National Coordinator for Health Information Technology (ONCHIT) and posted on their website. The intention of certification is to provide some insurance that the EHR technology being marketed has the features that allow users to qualify for meaningful-use incentives. Three authorized testing and certification bodies have been named: the Certification Commission for Healthcare Information Technology; Drummond Group Inc (Austin, Texas); and InfoGard Laboratories (San Luis Obispo, California). To demonstrate meaningful use of certified products, eligible providers have to meet 15 core objectives (there are two or three exclusions that radiologists may qualify for) and five out of 10 menu-set objectives. Eligible providers also must report on six of 44 quality measures. The ACR’s radiology-specific summary of meaningful use, which can be accessed on the college’s website, contains detailed descriptions of the 15 core objectives, 10 menu objectives, and 44 clinical quality measures.Mind the GapsIt is ironic that despite substantial investments in health IT, RIS, and PACS, many radiologists will still have gaps in their current practice when it comes to demonstrating meaningful use, Khorasani says. For instance, 50% of an eligible provider’s patients must have a smoking status entered into a certified EHR product. Fortuitously, in stage 1, it doesn’t matter how the information gets into the EHR: Anyone can enter these data, or the records can be automatically populated from another electronic source (medication entry is an exception). “This is about documentation, rather than forcing an individual physician—in this case, a radiologist—to interact with a certified EHR technology,” Khorasani notes. Nonetheless, even if all of the products currently in use in a radiology department or practice receive certification, radiologists will not be able to meet all of the meaningful-use requirements in stage 1, Khorasani warns, adding that in stage 2, those gaps will become even more substantial. He says, “It’s safe to say that many or most radiologists will have to leverage their hospital-based EHR to qualify for meaningful use’s many, many requirements.”Incentives and PenaltiesRadiologists who start reporting in 2011 or 2012 can qualify for up to $44,000 in total payments over five years. If they start reporting in 2013, they can qualify for up to $39,000, and if they do not participate until 2014, the most that eligible providers can qualify for is $24,000. “The concept is that these dollars are here to help you acquire the products that are certified to help you meet meaningful-use requirements,” Khorasani says. “This is not to pay for the investments you already made because most of those are not going to get you there. The fundamental concept here is you need to get new stuff to meet these requirements. We are hoping that existing technologies get certified that will qualify for a number of those measures—but certainly not all of them.” Each qualifying eligible provider does not automatically receive the maximum payment for each year that he or she participates: Payment is 75% of Medicare charges in the year in which the eligible provider is attempting to qualify, or the maximum for that year, whichever is less. “If you start reporting in 2011 and you bill Medicare $10,000 in 2011, you will get $7,500 in incentives if you were a meaningful user of certified EHR technology,” Khorasani explains. Physicians will receive the maximum $18,000 if they bill Medicare in excess of $24,000. Furthermore, when eligible providers start reporting, they must report for successive years or risk losing the Medicare incentive for the year they miss. “Here’s the downside: Medicare’s fee reductions begin in 2015,” he notes. “If you haven’t become a meaningful user of certified EHR technology by 2015, you will get a 1% hit on your collections from CMS; in 2016, it becomes 2%; in 2017, it becomes 3%; and it becomes a maximum of 5% by 2019.” Eligible providers who choose to begin reporting meaningful use in 2011 may choose any consecutive 90-day period that they want to report, the latest start date being October 1, 2011 In subsequent years, eligible providers must report for the entire year. “Even if you want to take maximal advantage of the incentive program, you can begin reporting late in 2012 and still qualify for most of the dollars, which may not be a bad plan,” Khorasani suggests. Electronic Reporting ProcessTo report meaningful use, providers must log into a CMS website with their national provider-identification numbers, attest that that they are meaningful users of certified EHR technology by answering relevant questions, and (at the end of the session) designate which of their employers will receive their incentive payments. That employer will receive the checks, totaling a maximum of $44,000 over five years for a radiologist who begins reporting in 2011 or 2012. Those dollars are unlikely to make it into the pocket of the individual radiologist, Khorasani believes. How they will be spent is likely to be decided by the designated employer, be it hospital or practice. Implementation, including modification of existing processes and data-input methods, will probably require a large share of those funds, according to Khorasani. “What that actually means is you may have to pay a bunch of those dollars to get your EHR in your hospital to meet the requirements of meaningful-use certification,” Khorasani explains. “I would be amazed if they actually end up in the pocket of any radiologists where I work.” In conclusion, Khorasani alludes to the many ambiguities that remain regarding how radiology will demonstrate meaningful use, and he suggests that the incentives being offered by the government are unlikely to fund the requisite change fully.

“This is not a windfall. This is not a gift to radiology. This is, at best, a partly funded mandate,” he says. “Becoming a meaningful user of health IT, however, is our professional responsibility. As we have done many times in the past in radiology, we will lead health IT transformation of the country, and this is sorely needed to reform the health-care system.”

Khorasani recommends these actions: Become educated and follow the meaningful-use pathway; identify the meaningful-use champion in your practice; assess your current IT capabilities to identify gaps; and hold on to your dollars very tightly. “It looks as though everyone is going to want a piece of it before you even qualify,” Khorasani advises. “Hold on tightly, don’t spend much, and watch for these clarifications.”Maintenance of Certification and Meaningful UseDavid Avrin, MD, PhD, vice chair of informatics at the University of California–San Francisco, took on the even more nebulous task of discussing maintenance of certification as it relates to meaningful use. While this might not be a top-of-mind concern at the moment for radiologists, it is likely to play into future meaningful-use measures. The American Board of Medical Specialties, which has the American Board of Radiology as one of its 24 members, signed a contract with ONCHIT in October 2010 to explore ways in which health IT and the maintenance-of-certification programs of the various member boards can be coordinated. “It is that synergy that will make both more valuable, and ultimately, more successful,” Avrin notes. “The concept of maintenance of certification is two things: One, that we are committed to lifelong learning, and two, that we are committed to continuous quality improvement of our practices and institutional systems.” Radiologists can expect to see the development of knowledge self-assessment modules for health IT to ensure basic knowledge of EHRs and how they can improve care; a greater interest in decision support, both at order entry and at the time of interpretation; the development of new tools for analysis and reporting; and simulations to demonstrate quality-improvement activities.By the Skin of Our Teeth: The Private PracticePerhaps this falls into the category of being careful what you wish for, but radiologists would not be in the predicament of trying to solve the puzzle of meaningful use if it weren’t for the Continuing Extension Act of 2010 passed by Congress in April 2010. The law had nothing to do with meaningful use, but had a dramatic effect on which physicians would not be considered eligible to participate in the program—namely all of those physicians billing over 90% of their encounters under place-of-service codes 21 (inpatient) and 23 (emergency). In ensuring the eligibility of physicians billing under code 22 (outpatient hospital), Congress invited radiologists to the meaningful-use party. Keith Dreyer, DO, PhD, vice chair of informatics at Massachusetts General Hospital (MGH) in Boston, offers the perspective of the private practice.

“If this didn’t pass, we probably would not be having this lecture today. Remember, it’s not your group, it’s every individual, so if you have one person reading ICU films all day long, or an emergency-department radiologist, he or she may opt out,” he notes.

Dreyer advises practices to have a conversation with their hospital CIOs because some of them might be operating under the misconception that radiology is not eligible for the incentives. For the MGH radiology practice, the incentives could add up to $8 million. Be advised, however, that the 24 meaningful-use measures for eligible hospitals are quite different from the 25 measures for eligible providers. “If your hospital goes for an eligible-hospital status and meets all 24 measures, that does not mean you get a free ride,” Dreyer explains. “They also have to consider that the technology they have in the hospital is going to meet your needs as well.”Where Imaging IT Can Get YouWhether the private practice wishes to assign the hospital or the practice as employer (and therefore, the recipient of the incentive), it will face the same challenge: There currently are no existing products certified for radiology that meet all 35 EHR criteria, meaning that radiologists probably will need to pursue modular certification of their EHR solutions. It is important to know, Dreyer points out, that while radiologists are likely to be able to exempt themselves from meeting some of the 25 provider measures, their EHR solutions will still have to be able to meet all 35 criteria. Dreyer’s guess is that imaging-informatics solutions can, at best, meet 27 of 35 EHR criteria: five to 15 for RIS (0, if it’s a poor one); 0 to three for PACS; two to five for a reporting system; one to three for an image-sharing portal; and one measure for decision-support software. “Regarding decision support, it’s decision support for us, not decision support for the people who are ordering,” Dreyer clarifies. “We have to have decision support at the time we make the diagnosis.” How do you determine whether your multimodular EHR system meets all of the criteria? “That’s a good question,” Dreyer says.Leveraging the Hospital EHRDreyer believes that both hospital-employed and private-practice radiologists will need to leverage the hospital EHR through integration of certified radiology IT products to demonstrate meaningful use of health IT. Another challenge will be developing systems to measure (and therefore prove) that you are meeting meaningful use. For instance, eligible providers must collect blood-pressure readings on 50% of all patients, so if a radiologist is reporting on 10,000 patients, a system must be in place to show that 5,000 blood-pressure readings are being measured. No matter what your relationship is with the hospital, it is important to raise the subject of meaningful use with the hospital. “If you are all private practice, the hospital may say, ‘You are not our problem,’” Dreyer notes. “If you are employed by the hospital, it will be a lot easier, but you really want to make sure you are regarded in that plan.” Dreyer urges private practices to analyze their billings and place-of-service distribution to assess the potential amount of incentives and the exclusions that might apply before approaching the hospital CMO or CIO. He recommends using two practice-analyzer tools on the Meaningful Use for Radiologists website (sponsored by FUJIFILM Medical Systems USA, Inc, Stamford, Connecticut) to assess eligibility, as well as to identify the meaningful-use measures that individual practices will be required to meet. Dreyer notes that MGH has the added pain of writing its own software, so it began the certification process in December 2010 and expects it to take four months. In conclusion, he urges practices to get in the game now, while incentives are being offered: New meaningful-use and clinical quality measures for stage 2 are currently being determined for release in the first quarter of 2011, and stage 3 is being discussed. “There will be more specialty focus; they are coming to us and asking, ‘What should we include for radiology?’” Dreyer says. “We are telling them computerized provider order entry, clinical decision support, image management, image sharing, and radiation-dose management.” The price of not participating, Dreyer believes, is too great. “There are short- and long-term penalties, but the private payors also are supporting it,” he reports. “Medical boards are working with this for maintenance of certification, and the states are considering including meaningful use for increased requirements for medical licensure.” In Massachusetts, a law was floated, but not passed, that would have required eligible providers to demonstrate meaningful use before they could get a license in that state by 2015.Meaningful Use for the Academic PracticeAs both director of medical informatics for radiology and chief of clinical informatics at Mount Sinai Medical Center, New York, New York, David Mendelsohn, MD, has lived and breathed meaningful use, on behalf of the clinical staff, for the past year. He notes that meeting meaningful-use requirements for any specialty other than internal medicine will be a challenge. “That’s not to tell you not to do this,” Mendelson says, “but if you are going to pursue this, you need to take a very detailed look.” He passes on some key points to consider as you build your strategy. Tip one: If you are part of a large practice, carefully consider how many Medicare patients each radiologist sees—because that is how they will qualify for incentive money. A practice might need to restructure the distribution of work to maximize and optimize the incentive dollars that each individual radiologist can capture. Tip two: Within the 500-plus pages of the original rule, CMS identifies reasons for physicians to exclude certain of the measures. For instance, eligible providers writing fewer than 100 prescriptions during a reporting period can be excluded from the electronic-prescribing measure (contrast media are not considered medications).

“The way radiologists will meet some of these measures is to exclude them, but you are going to have to justify the reason you have chosen to exclude a measure,” Mendelsohn advises.

Tip three: Someone in the practice should sit down and read summary documents that will start at 100 pages, Mendelson insists. “If you are the one responsible for your practice, it might behoove you to sit down and read the final 900-page CMS rule,” he says. “There is no way around it: You need to understand the detail.” Tip four: If your group practices in a geographic area considered by CMS to have a shortage of health professionals, you can qualify for a 10% bonus. Tip five: Large academic departments might have to redistribute cases among their radiologists to ensure that as many group members as possible meet the place-of-service requirements. If most of a radiologist’s work is in the inpatient environment, the key is to put that radiologist in the ambulatory environment for a percentage of time that gets the radiologist below the 90% inpatient threshold. Tip six: Whether you are in an academic or private practice, you might have to leverage your hospital’s EHR, which will encompass what Mendelson calls dramatic and traumatic workflow changes. While many radiology IT vendors are starting to look at getting their systems approved on a modular basis, it is unlikely that any of them will satisfy more than 20 of the 35 criteria of a certified EHR, he believes. Even though radiologists probably can exclude themselves from meeting certain measures, the systems that they use still must have the capability to meet all criteria. “Dreyer estimates that $8 million is on the table here for MGH radiologists,” Mendelson explains. “It might be worth some pain to capture that $8 million. If you are a much smaller practice, you have to consider the cost-benefit ratio of the pain that’s encompassed by invoking an electronic record in your environment—something you have never contemplated, before this, because you had no reason to do this before. Do you want to record vital signs on patients? Who’s going to do that in your practice? Does it cost you more than the $44,000 you get as an eligible provider to extend that service across your entire practice, to hire a nurse to sit there and measure vital signs on patients?” Another issue is the recording of demographics, including both race and ethnicity (many admission/discharge/transfer systems collect one or the other, a shortcoming that is likely to be rectified quickly by vendors). If your practice is hospital based, the best solution might be to migrate the data out of that system and into your RIS. “Your certified system has to house the system; it doesn’t have to be the original source of the data,” Mendelson notes. Tip seven: Develop systems to show compliance. Because there is no exclusion for implementing drug–drug and drug–allergy interaction checks, eligible providers must demonstrate that they are trying to comply. “If the denominator and numerator are both 0, that’s OK, but you have to have a system to show, at least, that for the few prescriptions you do write, you are tracking this,” Mendelson notes. “Is a RIS likely to do this? It might do allergy checking, but it is not going to do drug-to-drug interaction checking. Here is where you may need to invoke an EHR product, unless you can convince your RIS vendor to put this functionality into a product.” In conclusion, Mendelson urges practices to examine the measures one by one, look at the systems that they currently possess, and decide which measures they can meet easily and which ones present problems to be solved. “If you believe that your practice has a lot of money at stake here, and you want to pursue it, you need to immerse yourself in a lot more detail, go through each measure one by one, and decide how you are going to address it,” Mendelson concludes.Cheryl Proval is editorial director of Radinformatics.com and vice president, publishing, imagingBiz, Tustin, California.