One of the most misunderstood, murky and maligned healthcare terms is meaningful use. The concept is particularly vexing for radiology departments as medical imaging represents the apex of meaningful deployment of IT, yet the specialty was overlooked in preliminary meaningful use (MU) discussions. That’s all changed. “We can’t have an effective electronic health information system that can’t move images,” says David Blumenthal, MD, chair of the Office of the National Coordinator for Health IT. Now is the time for radiology to tune in to get in on the incentives.

Last fall when the Centers for Medicare & Medicaid Services (CMS) released the MU final rule, the agency modified its requirements so that more than 90 percent of radiologists could meet the definition of eligible providers (EPs), and thus will qualify for incentives of up to $44,000 over five years beginning in 2011 (October 1). To be eligible for incentives, radiologists must be enrolled in CMS and qualify under Medicare or Medicaid.

The aggregate financial impact is tremendous, with more than $1.5 billion in incentives available for radiologists. Large practices could reap nearly $10 million.

However, six and seven figure incentives don’t come without strings attached, and in the case of MU, the requirements, permutations and complexities are staggering. That’s partly because the EMR is the sole component of MU compliance for most providers. However, unlike other eligible providers, radiologists do not interact with the EMR, which means radiology practices need to rely on other, less straightforward paths to MU. Most practices will focus on modular certification of multiple systems.

Eligibility for incentives depends upon the individual radiologist’s practice scenario, but, regardless of the practice setting, each radiologist will be required to purchase and attest to the use of certified technology that meets each of the 25 MU measures or file for an exclusion of individual measures.

Vendors are responsible for certifying IT systems. Practices considering an MU application should check with vendors regarding their certification plans and anticipated timelines. Lists of certified systems can be found on the website of the Office of the National Coordinator for Health IT. In addition, healthcare organizations need to certify any homegrown systems that will be used to meet specific measures. Finally, physicians need to individually attest to MU in year one.

Some capabilities to meet MU measures may reside with existing infrastructure such as RIS, PACS and reporting systems. “We’re confident that our integrated RIS/PACS technology will enable us to meet 60 to 70 percent of meaningful use measures. We’re looking at additional systems to bring us the rest of the way,” explains Andy Wuertele, COO of East River Medical Imaging, a 12-radiologist practice serving five locations in New York City. He anticipates leveraging the CD burning capacity of the practice’s PACS to meet the requirement to provide patients with an electronic copy of health information. RIS, on the other hand, is a veritable MU powerhouse, facilitating compliance with recording demographics and smoking status, issuing patient reminders and much more.

In many instances, the practice may need to invest in additional systems such as decision support, data mining, image sharing or patient portals to meet one or more MU measures. East River Medical Imaging plans to upgrade its RIS to include a patient portal feature that provides patient-specific education resources, thus meeting an additional MU measure.

Clearly, there’s no one-size-fits-all solution, but some savvy and forward-thinking radiology stakeholders are putting the pieces of the puzzle together.

Certification pathways

Center for Diagnostic Imaging (CDI), a Minneapolis-based outpatient imaging provider with 51 owned clinics and nine managed centers, started considering MU nearly two years ago in combination with a proposed clinical decision support project.

As CIO Steve Fischer and his team consider the certification process, a few certainties stand out. The practice’s billing system has been certified, and its RIS vendor has started the certification process, allowing CDI to tick off a handful of measures such as patient demographics and medication lists.

Meaningful Use: An Online Guide

Tracking all of the various components of the meaningful use puzzle represents a massive undertaking. A few of the most helpful sites include: cmio.net Health Imaging & IT’s sister publication CMIO provides a wealth of information in its meaningful use portal. onc-chpl.force.com/ehrcert The Office of the National Coordinator for Health IT provides weekly updates to its master list of certified software. radmu.org The website features radiology resources including practice analyzers to help organizations determine their eligibility for incentives.

Another way to break the process into manageable elements is to review exclusions. Radiology providers are eligible for multiple exclusions. That is, certain measures may not apply to outpatient imaging. Instead of precluding a practice’s eligibility, the practice can opt out of selected measures. For example, CDI will opt out of smoking cessation and immunization data measures.

A homegrown patient portal presents more of a challenge, offers Fischer. The Certification Commission for Health Information Technology (CCHIT) has developed a certification pathway for homegrown hospital systems, but has not yet announced a similar strategy for ambulatory providers, which leaves Fischer and CDI with two options. The practice may seek certification for its homegrown portal or package its systems together and pursue comprehensive certification for its software portfolio.

Such vagaries have deterred other providers from developing systems internally. Meaningful use has impacted the technology planning process at East River Medical Imaging, says Wuertele. Initially, the practice had considered developing its own patient portal; however, after examining MU requirements, the practice has modified its strategy. “It’s our intent to meet the October 1 deadline, and we don’t want to certify a homegrown system. We’ll utilize a portal that is already certified or well on its way,” offers Wuertele. Another requirement for the new system? It will integrate or interface with the practice’s RIS/PACS.

Exponential complexities

Integration among systems represents a major issue for radiology practices as they need to rely on modular certification of multiple systems. J. Raymond Geis, MD, medical director, imaging informatics at Advanced Medical Imaging Consultants, a Fort Collins, Colo.-based outpatient radiology practice that serves a broad mix of 28 sites including large and small hospitals, physicians’ offices and the Veterans’ Administration, explains that interfaces are one of the few aspects of MU that are within the practice’s control.

Geis believes that the practice meets the law’s intent and hopes to meet the October 1 deadline, but whether or not it can dot all of the i’s remains up in the air. That’s because the radiologists interact with myriad software applications including three or four different EMRs and an equal number of RIS and dictation systems and cannot guarantee which will be certified by October.

In the interim, the practice is assessing its interfaces and how data are exchanged. “We’re figuring out if we are collecting data correctly, so once systems are certified, the practice can move forward,” Geis offers.

Rads and EMRs

Many radiology practices will use EMR-like functions of radiology systems, rather than EMRs, to comply with meaningful use. Healthcare behemoth Massachusetts General Hospital (MGH of Boston), however, is approaching compliance from a different angle. The hospital, which internally developed its EMR technology, is planning to certify the system and the radiology department will use it as a cornerstone of radiologists’ compliance.

A Meaningful Use Snapshot

RIS PACS Reporting System Image Sharing & Patient Portal Decision Support Record demographics (preferred language, gender, race, ethnicity, date of birth); Maintain an up-to-date problem list of current and active diagnoses; Maintain active medication list; Maintain active medication allergy list Electronic copy of health information; Patient electronic access Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request; Issue patient reminders Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule The above chart is a sample of how a practice might meet various MU measures. Actual compliance will differ by practice and will be assessed by CMS.

“Because the EMR is internally developed, it gives us the ability to create flexibility to pull out measures such as blood pressure readings and smoking cessation and create specific modules or a dashboard [to demonstrate compliance],” says Keith Dreyer, MD, vice chairman of radiology. Such flexibility could be a tremendous boon to radiology departments that typically don’t gather data on criteria like smoking cessation. Because the data are captured in the EMR, radiologists can use it to qualify even though they don’t interact with the EMR as long as there is a pathway that connects the radiologist to the EMR.

MGH will create a system to query the EMR and pull the data on behalf of radiologists and map it into the radiology reporting system. “We’ll see other EMRs develop these types of tools,” predicts Dreyer.

Many questions, few answers

For many radiology practices, even those on track to meet the October 1 deadline, MU remains a moving target with a plethora of unanswered questions in the balance. Dreyer confides that some Partners Healthcare-affiliated hospitals are non-academic organizations that contract with private practice radiologists. “We are working with them to obtain certification, but there are some key differences.” The physicians may not have to buy technology if the hospital owns it; however, the organizations have not determined how to disperse incentive payments. “There may be a sharing arrangement, especially if the hospital has to turn on seat licenses for an EHR for radiologists,” offers Dreyer.

Other radiology practices are grappling with an approach to exclusions. Fischer of CDI indicates that the practice has not yet decided if it will invest in a package to meet the computerized physician order entry (CPOE) criteria or apply for an exclusion as the practice would fall under the exclusion. One of the benefits of an early application is seeing which exclusions CMS accepts and how it handles them, notes Geis.

CDI plans to contract with a consultant as it answers this and a panoply of other questions. Radiologists, however, are key to the practice’s success. It’s important to gain physicians’ buy-in early in the process, says Fischer, because if they don’t participate the process could morph into an unsustainable uphill battle. Educating radiologists about requirements and confirming that incentives convert to penalties in 2015 could help gain their support.

One of the final questions every practice needs to consider is the timing of an application. Early applicants stand to gain maximum incentives, but there is a considerable investment of time and dollars associated with an early application. Practices that wait may be well-positioned to learn from early adopters. Geis recommends that all radiologists start learning as much as possible because of the looming penalties.

The carrot beyond $44,000

Although the prospect of six and seven figure payoffs is luring some practices and departments into the murky realm of meaningful use, there may be additional advantages to an early application. These include gaining a competitive edge and developing potentially saleable portfolios.

“We view this as potential opportunity,” offers Geis. “If we get the PACS, RIS, transcription and patient portal certified, we may be able to package it as a product that we can sell as a service to other providers.” What’s more, the point of the data collection is to demonstrate that a practice is efficiently contributing to better patient outcomes. “If we can prove that, it’s good for our business,” he says.

Indeed, opportunity is the operative term as Wuertele characterizes MU as “an opportunity to further cement our relationships with the referring physician community.” As an early applicant, East River Medical Imaging hopes to serve as a resource for the local medical community as it develops technical and policy know-how and learns to implement electronic processes without losing the human touch.

The final word

Meaningful use, particularly among radiologists, may spur more questions than solutions. However, a few items are clear. Although rules and requirements are still being formulated, MU is here to stay. The advantages to an early application include maximizing incentive dollars, establishing a role as a local leader and potentially developing a saleable portfolio of MU services. On the flip side, there’s no defined formula or best practices for certification. Each department needs to forge its own path—which represents a substantial challenge and a unique opportunity to revisit and reconfigure informatics infrastructure.

Meaningful Use Means New Model for Hospitals & Radiology Groups

Montgomery County Memorial Hospital, a critical access hospital in Red Oak, Iowa, had an early lead on meaningful use. CIO Ron Kloewer enacted a blackout on IT investments shortly after passage of the American Recovery and Reinvestment Act (ARRA) in 2009. “We were reluctant to move forward because we knew standards were going to change,” recalls Kloewer. He insisted that any technology investment include a rider that hold the hospital harmless from future upgrade costs related to MU compliance. Although the hospital’s radiology group, Heartland Radiology Consultants of Grand Island, Neb., was not involved in early MU conversations, the decision had an immediate impact on the practice because it was eyeing a RIS/PACS upgrade. After a year of waiting, the hospital, vendor and radiology group agreed to a complimentary RIS/PACS upgrade that did not include an MU rider. The experience illustrates a critical point for hospitals. Even if the radiology practice does not intend to pursue incentives, radiology systems like RIS/PACS need to be considered in the institutional application. In other words, the hospital needs to approach the situation as if the radiology practice were applying. For example, Heartland Radiology is in a wait and see mode, prepping for an application in 2014, but Montgomery County Medical Center is aiming for full institutional compliance by October 1, and plans to assist all physicians connected with the hospital, which means it is assessing systems such as RIS/PACS as it prepares its application.