Following the Sound and the Fury: Meaningful-use Attestation
After government officials revised the Health Information Technology for Economic and Clinical Health (HITECH) Act to include hospital-based physicians practicing in outpatient settings, radiology practices began scrambling to determine what it will mean to them. IT adjustments take time and money, and practices waiting for stage 2 meaningful-use requirements are keen to start preparing.
Alberto Goldszal, PhD, MBA, is one CIO who decided to dive in early. On November 3, 2011, Goldszal presented “Implementation Experiences” as part of the broader “Meaningful Use” session that began the ACR® Imaging Informatics Summit in Washington, DC. Sharing part of his ongoing odyssey, Goldszal reports that the carrot-and-stick scenario is still firmly in place—with government holding the stick. For imaging providers, the now well-known carrot is the opportunity to receive $44,000 per physician for achieving meaningful use prior to 2015, when penalties (in the form of Medicare reimbursement reductions) begin.
At University Radiology (East Brunswick, New Jersey), where Goldszal is CIO, about a million procedures per year are handled by more than 90 radiologists, and this adds up to potential meaningful-use incentives that are too large to ignore. The partners read images generated at 10 imaging centers and six hospitals, and all of these arrangements now comfortably fall under the HITECH Act. “The purpose of the legislation is to lower health care costs, reduce medical errors, and improve care,” Goldszal says, “but the devil is in the details, and it does not come free.”
Despite the lack of stage 2 guidelines (still pending), Goldszal outlines three development stages to help administrators get started. Stage 1 focuses on electronically capturing health information in a coded format, tracking key clinical conditions, communicating health information for coordination of care, implementing decision-support systems for disease and medication management, and reporting clinical quality measures and public-health information.
Stage 2 will expand on stage 1, but also includes health information exchanges and electronic orders and results. Stage 3 will expand on quality, safety, and efficiency; decision-support systems; and patient access to self-management tools.
Prior to partnering with a reliable vendor, Goldszal and University Radiology’s administrators made sure they had what he calls an invitation to the party, which essentially entailed a thorough eligibility check. Specifically, a physician is eligible if he or she provides more than 10% of his or her interpretations for outpatients, without regard to where the interpretations are rendered. “While radiology is 85% of what we do, we also perform cardiovascular tests, apply radiation therapy, and perform interventional procedures,” Goldszal explains. “Because of that, three years ago, when we decided to buy a new RIS, we determined that we needed something with lots of flexibility—more like an electronic health record (EHR) for radiology operations and related businesses.” This purchase gave University Radiology a head start in meeting stage 1 requirements.
Collect, Record, and Repeat
Collecting data in a systematic and efficient way is crucial if radiology groups are to have the necessary data to demonstrate meaningful use. “For example, there are six to nine clinical quality measures out of a menu of 44, and they overlap with the Physician Quality Reporting System and HIPAA security measures,” Goldszal says. “We went back and measured who did what and the workload impact on the workforce (see figure).” Where the group could not find ways to use clinical data already being captured in the EHR or RIS to show meaningful use, front-desk staff and technologists bore the primary burdens of data collection. 
Figure Distribution of responsibility for collecting additional data needed to demonstrate meaningful use. Taken in isolation, it is easy to collect data for most measures, and it can even appear trivial. The complexity comes in trying to meet too many criteria at once without disturbing patients. “One measure that is foreign to radiology groups is the use of electronic prescribing,” Goldszal adds. “It is not common for radiologists to prescribe medication. If you do less than 100 prescriptions a year, then you are excluded. Interventionalist groups prescribe more.” Another easy-to-implement measure, usually managed at the front desk, is the collecting and reporting of extended demographic data. It is relatively simple to add a few more data points, and radiology groups must do that for more than 50% of patients. “An additional difficult one for radiology is to record vital signs because we usually don’t do that,” Goldszal says. “You may think you meet the exclusion, but document your rationale.” Reserve another dataset for an active medication list, also new to radiology, but now required for more than 80% of patients (with no exclusions). It’s not yet necessary to document dosage (which will be required in a later meaningful-use stage), but office personnel might want to develop this habit now. For many radiology groups, including University Radiology, the complexity lies in trying to achieve all objectives and measures at once. It’s a tall order, but it ultimately comes down to effective change management. Whatever information you happen to be capturing, Goldszal says, any bonus payment from CMS carries the possibility of an audit. To that extent, Goldszal advises, “Radiology practices must develop policies and procedures documenting what needs to be accomplished by each different working group/department, which data points need to be recorded for each and every patient encounter, and which protocols need to be followed to achieve compliance on all meaningful-use measures being tracked.” He continues, “As one example, blood pressure may not be as relevant in the diagnosis of a hand fracture; however, your EMR should capture the dataset, or at least have the ability to get these data. Your RIS should have the ability to collect, display, analyze and exchange these data.” Thanks to data collection via kiosks, handheld computers, and electronic tablets, collecting relevant information is easier than ever. The same technologies can be used to establish patient portals that conveniently maintain provider communications at an acceptable level. The role of IT professionals seems to grow every year, and the risk-analysis elements of meaningful use ensure that this will only continue. “Get a hacker to break into your system,” Goldszal says. “Do not take this lightly, because this is where I have seen a lot of audits come from—HIPAA security breaches are taken seriously.”
Figure Distribution of responsibility for collecting additional data needed to demonstrate meaningful use. Taken in isolation, it is easy to collect data for most measures, and it can even appear trivial. The complexity comes in trying to meet too many criteria at once without disturbing patients. “One measure that is foreign to radiology groups is the use of electronic prescribing,” Goldszal adds. “It is not common for radiologists to prescribe medication. If you do less than 100 prescriptions a year, then you are excluded. Interventionalist groups prescribe more.” Another easy-to-implement measure, usually managed at the front desk, is the collecting and reporting of extended demographic data. It is relatively simple to add a few more data points, and radiology groups must do that for more than 50% of patients. “An additional difficult one for radiology is to record vital signs because we usually don’t do that,” Goldszal says. “You may think you meet the exclusion, but document your rationale.” Reserve another dataset for an active medication list, also new to radiology, but now required for more than 80% of patients (with no exclusions). It’s not yet necessary to document dosage (which will be required in a later meaningful-use stage), but office personnel might want to develop this habit now. For many radiology groups, including University Radiology, the complexity lies in trying to achieve all objectives and measures at once. It’s a tall order, but it ultimately comes down to effective change management. Whatever information you happen to be capturing, Goldszal says, any bonus payment from CMS carries the possibility of an audit. To that extent, Goldszal advises, “Radiology practices must develop policies and procedures documenting what needs to be accomplished by each different working group/department, which data points need to be recorded for each and every patient encounter, and which protocols need to be followed to achieve compliance on all meaningful-use measures being tracked.” He continues, “As one example, blood pressure may not be as relevant in the diagnosis of a hand fracture; however, your EMR should capture the dataset, or at least have the ability to get these data. Your RIS should have the ability to collect, display, analyze and exchange these data.” Thanks to data collection via kiosks, handheld computers, and electronic tablets, collecting relevant information is easier than ever. The same technologies can be used to establish patient portals that conveniently maintain provider communications at an acceptable level. The role of IT professionals seems to grow every year, and the risk-analysis elements of meaningful use ensure that this will only continue. “Get a hacker to break into your system,” Goldszal says. “Do not take this lightly, because this is where I have seen a lot of audits come from—HIPAA security breaches are taken seriously.”