David Blumenthal, M.D., National Coordinator for Health Information Technology
When David Blumenthal, M.D., National Coordinator for Health Information Technology wrote in the New England Journal of Medicine1, “Information is the lifeblood of modern medicine. Health information technology (HIT) is destined to be its circulatory system,” he clearly drew a connection between digital medical data and the delivery of care.
Still, his comment may have left radiologists scratching their heads, wondering if the reference to “information” included medical imaging.
Since the Office of the National Coordinator’s (ONC) released the preliminary definition of “meaningful use” on June 16, 2009, “the only mention of medical imaging in the matrix was a reduction in inappropriate imaging,” noted Nancy Koenig, president of Merge Healthcare’s Fusion division, and a founding member of the e-Ordering Coalition, a group advocating the adoption of decision-support tools for ordering diagnostic imaging tests.
The exclusion of medical imaging under the “meaningful use” matrix prompted the e-Ordering Coalition to form a representative voice in the national dialogue on the adoption of HIT and “meaningful use.” The Coalition then formed the Provider Roundtable that would work directly with the ONC and the American College of Radiology (ACR) to represent radiology’s views on how “meaningful use” should be defined.
“The Provider Roundtable is predominantly outpatient imaging centers and ACR. We did networking via the Coalition around what’s the best way to take the message to the ONC, to help the ONC tackle this large job of properly drafting meaningful use,” explained Koenig.
But has their voice been heard in Washington?
Apparently, the voice of the Provider Roundtable has been heard.
A proposed regulation released December 30, 2009, by the Department of Health and Human Services (DHHS) defined the first stage of the criteria. As Dr. Blumenthal explained2, “The first, a notice of proposed rule-making (NPRM), describes how hospitals, physicians, and other healthcare professionals can qualify for billions of dollars of extra Medicare and Medicaid payments through the meaningful use of electronic health records (EHRs). The second, an interim final regulation, describes the standards and certification criteria that those EHRs must meet for their users to collect the payments.”
According to the interim final rule (IFR), for an electronic health record system to qualify as “certified EHR technology” the product must include patient demographic and clinical health information (such as medical history and problem lists), and have the capacity to:
1) electronically capture health information in a coded format, using that information to track key clinical conditions and communicate that information for care coordination purposes
2) implement clinical decision support tools to facilitate disease and medication management
3) report clinical quality measures and public health information.
Room for Outpatient Centers?
What does “meaningful use” mean to a radiologist at an outpatient-imaging center?
Within the ARRA there is the Health Information Technology for Economic and Clinical Health Act, or the “HITECH Act.” The Act includes programs that provide incentive payments for the “meaningful use” of certified EHR technology.
However, it is questionable whether non-hospital-based radiologists will meet the threshold for these Medicaid incentives.
Instead, non-hospital-based radiologists may qualify for Medicare programs, which are restricted to non-hospital-based physicians. The logic is that hospital-based physicians are expected to use the facilities and equipment, including the EHR technology, provided to them by the hospital.
Radiology Left Out?
Where does this leave radiology information systems (RIS) and picture archiving and communications systems (PACS)? Can RIS and PACS qualify as certified EHRs?
Most RIS and PACS today would not qualify under the “meaningful use” criteria, says the ACR on its Web site. “It is unlikely that most existing RIS and/or PACS products would meet the necessary requirements, although the legislative language gives a certain degree of flexibility to regulators as to what constitutes EHR technology.”
There is still hope as the ONC may develop one or more modular/component HHS certification pathways for non-comprehensive EHR technologies. “Some type of modular/component certification could prove to be important to a specialty like radiology, which may not utilize all the functionalities and options of comprehensive EHR products,” wrote the ACR.
To qualify for federal dollars, EHRs will have to exchange data in a meaningful way. This boils down to EHRs providing computerized physician order entry (CPOE) and electronic medication administration capabilities (eMAR), including related clinical decision support.
But why is the exchange of data within RIS and PACS not considered meaningful, rendering radiology systems ineligible for stimulus monies?
e CMS Office of Media Affairs if “meaningful use” would include the exchange of medical imaging data, and if radiology IT systems, PACS and RIS, would fall under the meaningful use criteria?
“Not for 2011,” responded Nancy Szemraj, communications and outreach, CMS Office of Media Affairs. “It’s possible that this will be the case in 2013 or 2015. The meaningful use workgroup is still early in their deliberations for the 2013 recommendations.”
While the issue is pending, medical imaging is already cited in Stage 2 of the “meaningful use” definition.
Stage 2 encourages the use of health IT...in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results, such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease.”
Imaging within CPOE
In line with Provider Roundtable’s point, radiology, cardiac imaging, and nuclear medicine tests fall under the CPOE section.
But why is CPOE the key for diagnostic imaging’s inclusion in the Act? Simply put — CPOE is critical to reducing costs.
“An electronic ordering system for radiology can reduce costs and becomes more effective and efficient as the database becomes
greater,” explained Nick Christiano, chair of the Meaningful Use Committee. “The more data you have, the more ordering patterns you have, and the more you can develop predictive ordering patterns that should improve outcomes, while lowering utilization and costs.”
He added, “We can only base this theory on models already in place, such as CPOEs in the hospital environment. They have seen costs reduced between 12-18 percent. As a result of hospital-based CPOE, revenue enhancements of 2-3 percent have been reported.”
However, CPOE and decision support have not been widely adopted in radiology. Why? According to Christiano, “It’s not the technology, it’s due to the cultural adaptation of the providers.”
“In the previous hospital-based CPOE model, there has been 10-15 years of experience with CPOE. [Yet], it has a very low penetration rate. Less than 15 percent of community-based hospitals have adopted CPOE, and there is also low adoption on EMRs in physician practices. This can be traced to physician reluctance to embrace these technologies that will change their workflow and ordering habits.”
He noted, “With more computer literate physicians coming on the scene, the momentum for technology adoption will improve.”
Is Radiology Underrepresented?
As the ONC moves closer to defining “meaningful use,” non-hospital-based-radiologists and outpatient imaging centers have not been made a priority — at least not at the initial stage.
“Radiology has the unfortunate situation of being the only discipline in medicine that does not have a direct relationship with the patient. The only area where there is direct patient contact is in women’s care,” noted Christiano. “Radiology has become the target in terms of over-utilization and inappropriate practices since it is the one group that can’t go back to its patient population and ask for that population’s support with its governmental officials. Plus, RBMs literally broker radiology groups within their insurance network. This has commoditized radiology.”
It is still uncertain as to whether RIS and PACS will satisfy the “meaningful use” criteria and qualify for incentives. But a step in that direction would be for radiology to adopt CPOE and decision support solutions — a critical step to ensuring that the role of radiology is considered meaningful.
1. Blumenthal, D. Launching HITECH. NEJM • December 30th, 2009.