Meaningful Use & Radiology: Can a Square Peg Fit in a Round Hole?

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square-peg_1331735778.jpg - Square Peg
Since the initial meaningful use (MU) rule was published in fall 2010, MU has excluded, confounded and confused radiologists. As the imaging community ponders the notice of proposed rulemaking (NPRM) for Stage 2, many practices are caught between the proverbial rock and a hard place.

On one side is the need to invest capital and staffing resources to purchase certified technology to collect data that are not useful or meaningful, such as smoking cessation and immunization history. On the other side, the threat of penalties looms, beginning with a 1 percent reduction in Medicare payments in 2015, which increases to 3 percent in 2017.

The government is not out to target radiology, says Robert M. Tennant, MA, senior policy advisor of Medical Group Management Association (MGMA) in Washington, D.C. MU was designed to incentivize primary care providers to adopt EHRs, he says. The gap between primary care providers’ IT needs and radiologists’ is large. “It is not logistically reasonable for the vast majority of radiologists to be meaningful users,” says Tennant.

Three strikes?

The problem boils down to semantics and math, says Barbara F. Rubel, MBA, senior vice president of the Radiology Business Management Association (RBMA) in Fairfax, Va. “Our surveys show many hospitals interpret the regulations incorrectly and tell radiologists they are ineligible; or they limit access to certified ambulatory technology to employed physicians.”

Another challenge is the relative inconsequence of imaging informatics in the eligible hospital program, says David Avrin, MD, PhD, vice chair of informatics at the University of California, San Francisco. “PACS and RIS get trumped by the EHR. Hospitals are not going to live or die for MU dollars based on radiology systems.”

The Stage 2 NPRM, issued Feb. 23, gives a slight nod to the use of radiology across the enterprise. One proposed measure adds radiology orders to the computerized physician order entry (CPOE) objective and another would require accessibility to image results and information through the EHR. Neither is set in stone, as the Office of the National Coordinator for Health IT (ONC) will consider comments on the 125 potential Stage 2 measures for several months before publishing the final rule—a process that may last until the end of 2012.

Hospital-based radiologists also must contend with a mismatch between how the Centers for Medicare & Medicaid Services (CMS) defines their business and their actual practice. “The program defines a hospital-based radiologist differently from how it occurs in the community,” says Rubel. CMS states that a hospital-based physician should provide 90 percent or more of his or her studies, procedures or encounters in the  inpatient or emergency department setting.

When RBMA and Management Services Network (MSN) of Columbus, Ga., surveyed radiology practices, the organizations found the vast majority of hospital-based radiologists provide approximately half of their services in the outpatient setting, explains Rubel. However, these radiologists don’t maintain independent information systems and rely on the hospital for technology.

The hitch is inpatient and outpatient MU requirements differ. Either the inpatient system would need to be re-certified as outpatient technology, or the practice would need to invest in a separate, redundant outpatient system.

A third option is equally difficult. “We thought practices could build an interface to the hospital system and download the required data,” says Rubel. However, if the hospital is not populating an ambulatory system, it would not be collecting the appropriate data, forcing radiologists to gather the data from referring physicians—an unwieldy, unlikely prospect.

The upshot? Many practices face the prospect of a 1 percent reduction in Medicare payments in 2015. The NPRM offers a glimmer of hope. Also, ONC is soliciting comments on an exception for eligible providers who lack:
  • Face-to-face contact with patients;
  • Follow-up with patients; or
  • Control over EHR technology.

The NPRM cites radiology as a specialty in which providers might meet this hardship exemption, which could be applied for a maximum of five years.

Tennant outlines another challenge. In many cases, radiology practices do not have direct access to MU measures, such as body mass index or smoking cessation.

In a KLAS-RSNA survey, titled “Radiologists' Take on Meaningful Use,” nearly 40 percent of the 203 radiologist respondents expressed concerns about MU and noted the potential decreased efficiency that might result from compliance.

The respondents cited relatively modest benefits to some MU criteria and noted potential difficulties providing patients access to images and reports over the web. Although the respondents acknowledged the importance of clinical decision support for referring physicians, "clinical decision support for radiologists was viewed as relatively unhelpful," the authors wrote.

One of RSNA’s objectives with the report, says Avrin, was to demonstrate the need for specialty-specific criteria. “ONC has not done anything to address actual EHR use cases in each specialty. The interim rule for Stage 2 provides some flexibility, but it is still far from what RSNA and KLAS identified as a true radiology specialty list.” The hope, and goal, is that the final rule for Stage 2 includes specialty-friendly language, such as greater flexibility in the use of EHR and alignment with existing quality programs and for Stage 3 to be specialty-specific. Avrin recommends that ONC develop specialty-specific documents that address EHR use cases for each of the nearly 30 medical specialties.

A final wrench in the process is the variability in practice sizes and configurations in radiology. A handful have extensive IT resources and can develop an internal system to meet MU, but most have limited IT resources and depend on the vendor market. Few vendors have focused on radiology. “Each practice has to evaluate if vendors can help and how the system fits with their existing patterns and workflow,” says Roger S. Eng, Jr., MD, president of Golden Gate Radiology in San Francisco.

Stakeholders Rally

Since April 2010, multiple organizations lobbied to educate ONC about the challenges that radiology faces. In October 2011, the American College of Radiology (ACR), the Healthcare Billing & Management Association (HBMA), the Society of Interventional Radiology (SIR), MGMA and RBMA drafted a letter detailing concerns and recommendations to CMS and ONC.

To correct for radiologists’ reliance on hospital technology, the organizations recommended that the agencies implement a program to dual-certify technology for inpatient and ambulatory use.

The organizations protested the lack of specialty-specific criteria and measures, urging CMS and ONC to develop specialty-specific measures in Stage 2, or exclude specialists from penalties. The groups met with CMS and ONC in December 2011 and again in January, to review the issues affecting hospital-based radiologists and suggested that the agencies either develop a hardship exemption category or provide additional guidance to address the identified issues. The proposed exemption criteria in the NPRM seem to acknowledge the barriers specialists face.

“The government understands the issues," says Tennant. “We are cautiously optimistic there will be a positive resolution.”  

In the interim, the optimal strategy for many radiologists may be "wait and see." Avrin says, “Stage 1 of MU is a poor fit for radiology. Radiologists should not bend over backwards to fit into a program that isn’t appropriate for radiology and should to see how Stage 2 addresses specialty-specific measures.”

Rubel sees the NPRM as “a bit of a lifeline,” but emphasizes that many radiology practices have no choice other than to wait and see the final criteria for Stage 2 and beyond.

Tennant adds, “The message is clear: If you have a pathway to meaningful use which is reasonable and cost-effective then you should proceed. However, for the vast majority of radiologists, that pathway does not exist.”