Federal ambulatory meaningful use (MU) regulations provide potential bonus payments of $1.5B to radiologists over the next 4 years, with looming penalties for those eligible providers (EPs) that do not comply. Until recently, most radiologists thought that they were not included in the meaningful use regulations. However, the American College of Radiology now estimates that approximately 90% of radiologists are eligible providers

Radiology practices need to consider several questions:

  • Are you ready for meaningful use?
  • Given that radiologists must comply for at least 90 consecutive days within 2012 to receive the full Medicare incentive payment of $44,000 per radiologist, do you fully understand the technology, workflows, and reporting procedures required to receive a bonus?
  • Also, are you aware of the operational and marketing advantages that can be achieved through effective implementation of meaningful use technology?
Brief History

The core idea behind US government creation of meaningful use incentive payments was to promote the use of standards-based electronic health records and thus achieve several goals:

  • Less redundant testingn Fewer medical errors because of better communication between providers and computer-aided decision support
  • Better, prompter patient access to medical records
  • Infrastructure to promote national health care goals related to prevention

Under Stage 1, each EP who receives Medicare payments of at least $24,000/year is eligible for up to $44,000 in bonus payments over the next 5 years, provided that greater than 10% of services are performed in the outpatient setting.

Logical Pillars

Murray A. Reicher, MD, FACR

Several logical pillars form the foundation for strategic planning of meaningful use implementation.

  1. The ambulatory MU incentive payments are physicians-based, not facility-based. Since radiologists typically staff multiple locations, they must implement MU technologies and workflows that collect, aggregate, and act upon information at each place (or the preponderance of places) where they serve patients. This favors a vendor-neutral, cloud-based, Web service solution that can work in conjunction with any other existing information system. The solution must provide third-party RIS/PACS vendors and users with the capacity for single sign-on, as well as synchronization of the patient and exam context. The integration must be standards-based and low cost.
  2. The regulations are evolving, with final Stage 2 and Stage 3 rules yet to be announced. Therefore, one must implement a solution that can rapidly evolve independent of any existing RIS, HIS, or PACS, where rollout of new versions may take months or years. This also points toward the cloud, since cloud-based users could theoretically be upgraded all at once.
  3. The physician bonus payment is significant, but still not large enough to fund an onerous workflow burden among support staff, especially in view of the fact that administrative and technical staff will complete most of the required activities. Therefore, the ideal solution should not only facilitate compliance, but also do so in a way that improves the efficiency of clerical and technical personnel—including a Web-based patient portal for data entry by patients.
  4. The workflow in radiology departments and imaging centers is quite different from the workflow among general practitioners, internists, and other specialists. Ambulatory imaging patients are frequently seen in high volume with short examinations. The radiologist often does not directly see the patient. Therefore, the ideal technology should prompt compliance among front-desk staff and technologists, display compliance for the radiologist, provide the radiologist with the MU data that can benefit patient care, and efficiently provide the patient with required information.
  5. The regulations require the adoption of both technologies and workflows. The technological solutions must encompass all specifications provided and regulated by the Office of the National Coordinator (ONC) for ambulatory meaningful use compliance. It is important to note the ambulatory certification requirement, because a radiologist leveraging an inpatient certified HIS will not qualify.

A provider can achieve technological compliance by implementing a complete certified ambulatory electronic health record (EHR), or can use a combination of certified modules that together comprise a complete ambulatory EHR.

If your current vendor is certified or planning to get certified, research the details. If the vendor is certified as a “module,” then supplemental technology is required for compliance. In addition, the Centers for Medicare and Medicaid Services (CMS) regulates the workflows and metrics that define meaningful use of complete ambulatory EHRs. Given the size of the bonus, it seems unlikely that one can profitably implement numerous systems that must be interfaced and maintained over time. The goals of simplicity, accurate data collection, and standardization of workflows would logically best be served by each radiologist adopting one system throughout their scope of practice.

Core and Menu Requirements

For Stage 1 (the only fully defined stage at this moment), there are 15 “core” requirements and 10 “menu set” requirements. With credit for exclusions (see below), an eligible provider must comply with and report all 15 core items and also comply with five of the 10 items from the menu set.

The 15 core set items are:

Drug/drug, drug/allergy
Maintain problem list
Maintain active medication list
Maintain allergy list
Record demographics
Record changes in vital signs
Record smoking status
Report clinical quality
Clinical decision-support
Provide patient with electronic copy of health info
Provide clinical summaries for patients for each visit
Capability to exchange key clinical information
Conduct Annual Security Risk Analysis

The 10 menu set items are:

Drug formulary checks
Incorporate clinical lab test results into EHR
Generate patient lists by specific conditions
Send reminders to patients for follow-up care
Provide patients with timely electronic access
Identify patient-specific educational resources via EHR
Medication reconciliation
Summary of care for each transition of care or referral
Submit electronic data to immunization registries
Submit electronic syndromic data

Tom Gibbings, MBA

EPs may be granted exclusions for several of the items from both the core and menu set, and the excluded items “count” toward compliance. For example, an EP may hypothetically have legitimate exclusions for five of the menu set items, and since exclusion “counts,” this EP would then comply with the requirement to meet five of the 10 menu set items.

Other important questions and answers:

  • Does MU require you to include the radiology report when providing patients their “health information” or “clinical summaries”? Federal guidance indicates that it is acceptable for the provider to set an automatic withhold on certain information at their discretion.
  • Does MU require you to take a blood pressure on all of your outpatients? No. Any EP who believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice may attest to that and be excluded.
Registration to Obtain Payment

Radiologists, as well as any eligible physician specialist, can register now at ehrincentives.cms.gov. You can register even if you don’t employ a complete certified ambulatory EHR. But you cannot qualify for the incentives until after you have used a complete certified ambulatory EHR for at least 90 days.

The first deadline is October 3, 2012—the very latest that a physician can begin using certified technology to qualify for the maximum incentives. If this date is missed, the maximum incentive drops from $44,000 over 5 years per physician to $39,000 over 4 years per physician, and progressively decreases thereafter.

Prepare Now

If you think you might be ready for meaningful use, you aren’t ready. Close your eyes and imagine it is October 2, 2012. Do you completely understand the technology and workflow you will be using when you go to work the next morning?

If not, and you are a radiologist, you’ll be missing out on a chance to obtain a bonus payment while also increasing your clinical relevance. If you are a hospital administrator, you’ll be facing some upset radiologists who aren’t achieving what some of their friends have, and who aren’t helping you collect the data you need for inpatient compliance.

So if you are not ready, how do you get ready? Here are some suggestions:

  1. Set aside a few hours for a radiology MU retreat and include all of the key leaders needed to achieve success. Decide who will pay and who will be rewarded. When an EP registers with CMS, the EP designates the tax ID number of the recipient of the money. This means that an employing institution can collect the payments associated with their EPs.
  2. If you are in a radiology group practice, assign a physician MU champion to work with your staff and your hospital or imaging center owners. Assign responsibility, accountability, and a deadline.
  3. Determine your technology direction. Do you agree with our reasoning in favor of a vendor-neutral, cloud-based Web service, or do you believe you can achieve MU via an upgrade of your RIS/PACS or use of another EMR? Whatever your belief, diagram the precise workflow, appropriately alter job descriptions, and complete the “thought experiment” to validate your conclusion.
  4. Get started early. There’s an old saying, “When you are early, you are on time and when you are just on time, you are late.” The best way to guarantee your success by October 3, 2012, is to succeed before then.

Murray A. Reicher, MD, is a board-certified diagnostic radiologist and Fellow of the American College of Radiology. He is Chairman of DR Systems Inc, a leading provider of information and image management solutions for health care enterprises, which he co-founded in 1992. Tom Gibbings, MBA, is an associate RIS product manager at DR Systems.