MEANINGFUL USE FOR RADIOLOGISTS: Perspectives from a Vendor and Radiologist

Transcription

1 MEANINGFUL USE FOR RADIOLOGISTS: Perspectives from a Vendor and Radiologist By Murray A. Reicher, MD, FACR DR Systems Chairman and Co-founder Tom Gibbings, MBA DR Systems Associate Product Manager

2 Meaningful Use for radiologists: 2 Contents Introduction... 3 Brief History... 3 Logical Pillars:... 4 Core and Menu Requirements... 7 Clinical Quality Measures... 9 Other important questions: Registration to Obtain Payment...11 Conclusions...11 About the Author and Company...12 About Murray A. Reicher, MD, FACR, Chairman DR Systems, Inc About DR Systems, Inc

3 Meaningful Use for radiologists: 3 Introduction Federal ambulatory meaningful use regulations provide potential bonus payments of $1.5B to radiologists over the next four years, with looming penalties for those eligible providers (EP) that do not comply. Until recently, most radiologists believed that they were not included in the meaningful use regulations, but the American College of Radiology now estimates that approximately 90% of radiologists are eligible providers. So the question is, are you ready for meaningful use? Understanding 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 required technology, workflows, and reporting procedures required to receive a bonus? Furthermore, do you understand the competitive marketing and operational advantages achievable through effective implementation? So the question is, are you ready for meaningful use? Do you fully understand the required technology, workflows, and reporting procedures required to receive a bonus? Brief History Meaningful use incentive payments were introduced into federal law as part of the American Recovery and Reinvestment Act of The core idea was to promote the use of standards-based electronic health records and thus achieve several goals: Less redundant testing Less medical errors because of better communication between providers and computer-aided decision support Better, quicker patient access to medical records Provide the infrastructure to achieve national healthcare goals related to prevention These all seem to be reasonable and noble goals, especially given that we live in a nation with high health care expenditures and non-ideal outcomes, such as high obesity rates (up to 38% in some States), non-diagnosed hypertension in million Americans, high tobacco-related healthcare costs (as much as $170 B per year), poor immunization compliance (30-35,000 flu-related deaths per year), poor compliance with well-understood screening measures (mammography, colonoscopy, skin cancer screening), etc.

4 Under Stage 1 of the federal law, each EP who receives Medicare payments of a minimum of $24,000/year is eligible for up to $44,000 in bonus payments per physician over the next five years, provided that more than 10% of services are performed in the outpatient setting as defined by the following Center for Medicare and Medicaid Services (CMS) place of service (POS) codes 1 : POS: 11, Office POS: 20, Urgent Care Facility POS: 22, Outpatient Hospital POS: 24, Ambulatory Surgery Center POS: 49, Independent Clinic For an EP that receives Medicare payments totaling less than $24,000/year, the incentive payments are reduced on a sliding scale basis. Prior to lobbying efforts, the POS 22 code was not included in the proposed ambulatory physician incentive payment criteria, and as a result, most radiologists staffing hospitals would have been excluded from participation, but when POS 22 was including among the outpatient criteria, the vast majority of radiologists became eligible providers. Logical Pillars: In order to build a logical case for appropriate implementation of meaningful use (MU) technologies and workflows, one must first understand a series of logical pillars that form the foundation for strategic planning (Figure 1). 1. The ambulatory MU incentive payments are physicians-based, not facility based. Since radiologists typically staff multiple locations of service, one must implement technologies/workflows that collect, aggregate, and act upon information at each place or the preponderance of places where each physician encounters patients. This logical pillar 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 the capacity for single sign-on, as well as synchronization of the patient and exam context. Furthermore, 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 without dependence on any existing RIS, HIS, or PACS, where roll-out of new versions may take months or years. This logical pillar also points toward the cloud, since the nation of cloud-based users could theoretically be upgraded all at once. In addition, for radiologists to achieve wide-scale compliance, there simply isn t the time to upgrade all of the legacy RIS/PACS in use today. 3. The physician bonus payment is significant, but still not large enough to fund an onerous workflow burden among support staff, especially since most of the required activities will be completed by

5 Meaningful Use for radiologists: 5 administrative and technical staff. Therefore, the ideal solution should not only facilitate compliance, but do so in a way that improves the efficiency of clerical and technical personnel. This pillar mandates the automated collection of MU data from upstream systems and/or from the patient. Given the incomplete market penetration of upstream MU systems today, a webbased patient portal wherein patients can complete their MU data from home or using a tablet in a waiting room seems essential. 4. The workflow in radiology departments and imaging centers is unique, quite different from the workflow among general practitioners, internists, and other specialists. Ambulatory imaging patients are frequently seen in high volume with short examinations, such as a patient undergoing an outpatient chest radiograph. The radiologist often does not directly see the patient. Therefore, in a radiology setting, 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 very efficiently provide the patient with required information. Simply stated, the technology and workflow must serve the spirit/detail of the law, the specific needs of imaging patients/specialists, and the critical need to work efficiently. Simply stated, the technology and workflow must serve the spirit/detail of the law, the specific needs of imaging patients/specialists, and the critical need to work efficiently. 5. The regulations require the adoption of both technologies AND workflows. The technological solutions must encompass all of the 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 won t 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 currently certified or planning to get certified, research the details of the certification; if your current vendor is certified as a module then supplemental technology is required for compliance. Module certification alone will not qualify you for the meaningful use incentives. In addition, the Center for Medicare and Medicaid Services (CMS) regulates the workflows and metrics that define meaningful use of such 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. Imagine, for example, a radiologist who must collect and aggregate data from multiple systems at multiple sites in order to collect a bonus that averages $11K per year. Imagine the complexity of upgrading multiple systems that are interfaced together when the next set of regulations are announced. The goals of simplicity, accurate data collection, and standardization of workflows would logically best be served by each radiologist adopting one system throughout his or her scope of practice. 6. Independent of meaningful use legislation, today s radiologists are threatened by commoditization caused, in part, by their lack of

6 Meaningful Use for radiologists: 6 direct contact with patients. Therefore, the ideal solution should strengthen both the clinical input that radiologists receive from referring providers and the direct communication between radiologists and their patients. Figure 1 graphically shows the logical pillars discussed above and the resultant conclusions regarding key must-have features of the required technology. Key Features Web plug-in to any RIS/PACS Single sign-on Synchronization of patient/exam context Receive data from upstream systems PHR for pre-registration Compliance wizard for techs/others Real-time data aggregation for compliance tracking and reporting Cloud-based, Imaging-Centric, Vendor-Neutral, Complete, Certified, Ambulatory ehr, Aggregator & Reporting Tool Data Collection/Patient Interaction Must be Very Efficient Because of High-Volume, Short-Duration Imaging Exams Need to Increase Clinical Input to and Clinical Relevance of Radiologists, Yet Most Patient Interactions Involve Techs and Other Support Staff Physician-centric Incentives Rapidly Evolving Rules Implementation Must Be Profitable Unique Radiology Workflow Dual Need for Both Technologies and Workflows Radiologists Frequently Staff Multiple Locations with Disparate RIS/PACS No Time or Ability to Replace or Upgrade Every RIS/PACS Figure 1: Logical pillars leading to the conclusion that the most viable solution is a cloud-based, vendor-neutral, imaging-centric, complete ambulatory EHR that can aggregate data from the patient, RIS, PACS, and other upstream systems. The system must prompt support staff to complete workflow, display data to radiologists, while aggregating data for all places of service and providing real-time compliance metrics.

7 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. An eligible provider (EP) must comply and report all 15 core items and also comply with five of the 10 items from the menu set. EP s 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 an exclusion counts, this EP would then comply with the requirement to meet five of the 10 menu set items. The table below shows the core items, menu items, and exclusions: Table 1 Clinical Objective Exclusion Criteria Compliance Threshold Stage (d)(1) - CPOE 495.6(d)(2) - Drug/Drug, Drug/Allergy Any eligible professional (EP) who writes fewer than 100 prescriptions during the EHR reporting period No exclusion 30% Must be enabled Core Set(All required unless specific exclusions apply) 495.6(d)(3) - Maintain problem list 495.6(d)(4) e-prescribing 495.6(d)(5) - Maintain active medication list 495.6(d)(6) - Maintain active medication allergy list 495.6(d)(7) - Record demographics 495.6(d)(8) - Record changes in vital signs 495.6(d)(9) - Record smoking status 495.6(d)(10) - Report clinical quality measures No exclusion 80% Any EP who writes fewer than one hundred prescriptions during the EHR reporting period 40% No exclusion 80% No exclusion 80% No exclusion 50% Any EP who sees only patients 2 years old or younger or who believes that all three vital signs of height, weight and blood pressure have no relevance to their scope of practice may attest and be excluded Any EP who sees only patients younger than 13 years old No exclusion 50% 50% 495.6(d)(11) - Clinical decision support 495.6(d)(12) - Provide patient with electronic copy of their health info No exclusion Any EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period one rule 50%

8 Meaningful Use for radiologists: (d)(13) - Provide clinical summaries for patients for each visit 495.6(d)(14) - Capability to exchange key clinical information 495.6(d)(15) - Conduct Annual Security Risk Analysis 495.6(e)(1) - Drug formulary checks 495.6(e)(2) - Incorporate clinical lab test results into EHR 495.6(e)(3) - Generate patient lists by specific conditions Any EPs who have no office visits during the EHR reporting period No exclusion No exclusion Any EP who writes fewer than 100 prescriptions during the EHR reporting period Any EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period No exclusion 30% one test one report 40% one report Menu Set (5 of 10 required in Stage 1) 495.6(e)(4) - Send reminders to patients for follow up care 495.6(e)(5) - Provide patients with timely electronic access 495.6(e)(6) - Identify patientspecific educational resources via EHR 495.6(e)(7) - Medication reconciliation Any EP who has no patients 65 years old or older or 5 years old or younger Any EP that neither orders nor creates lab tests or information that would be contained in the problem list, medication list, medication allergy list (or other information as listed at 45 CFR (g)) during the EHR reporting period 20% for pts that are >65yrs or <5yrs 10% No exclusion 10% An EP who was not the recipient of any transitions of care during the EHR reporting period 50% 495.6(e)(8) - Summary of care for each transition of care or ref 495.6(e)(9) - Submit electronic data to immunization registries 495.6(e)(10) - Submit electronic syndromic data Any EP that does not transfer a patient to another setting or refer a patient to another provider during the EHR reporting period An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically 50% one test one test

9 Meaningful Use for radiologists: 9 Clinical Quality Measures One of the core items requires the EP to Report Clinical Quality Measures (CQMs). This one measure requires the EP to report three core CQMs, up to three alternative CQMs (one alternative CQM for each core CQM, wherein the EP has no relevant encounters), plus three additional CQM s. Each CQM is very precisely specified by CMS with regard to numerators and denominators the numerators essentially provide the definition of a compliant event, and the denominators specify the population of encounters that are relevant. Each CQM specifies the ratio of numerator to denominator that is acceptable. But for radiologists, many of the CQMs have a denominator of zero because the type of encounter codes uses by radiologists do not fall within the definition of the CQM. For example, let s take a closer look at the three core CQMs. Each CQM can be classified according to its National Quality Forum (NQF) or Physician Quality Reporting Initiative (PQRI) specification. In some cases, a particular CQM may be classified by both NQF and PQRI numbers. The table below shows the three core measures, three alternative core measures, and their descriptions. Classification Title Description CORE NQF 0421 PQRI 128 CORE NQF 0013 CORE 0028 ALTERNATIVE CORE NQF 0041 PQRI 110 Adult Weight Screening and Follow-Up Hypertension: Blood Pressure Measurement Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded. Percentage of patients aged 18 years and older who have been seen for at least 2 office visits who were queried about tobacco use one or more times within 24 months b. Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention. Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February). ALTERNATIVE CORE NQF 0024 ALTERNATIVE CORE Weight Assessment and Counseling for Children and Adolescents Childhood Immunization Percentage of patients 2-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio(ipv), one measles,,mumps and rubella

10 Meaningful Use for radiologists: 10 NQF 0038 Status (MMR); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. At first glance, this seems to present a daunting compliance task for radiologists, whose scope of practice seems disjointed from these requirements. But dig deeper and one learns that the denominator for each of these CQMs requires a particular collection of encounter codes that are not among the CPT s or HCPC codes that are used by radiologists in the ambulatory environment. Therefore, the typical radiologist will report zeroes for all of these items and will thus comply. The same can be said for many of the other 38 available CQMs, so that the vast majority of radiologists who don t see patients for primary care or psychiatric encounters can comply with the CQM requirement with no administrative burden. Other important questions: 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. An EP should be able to withhold information if its disclosure would cause substantial harm to the patient or another individual. A radiologist or radiology practice would seem justified in concluding that providing the patient their clinical report, especially before it s viewed by the referring physician, would cause more harm than good, given the technical nature of radiology reports and the need to integrate imaging findings with other clinical findings. 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 and be excluded. A common concern is since height and weight are commonly used in contrast calculations, the vital signs would then be considered within the scope of the practice. However, those contrast calculations are based on patient reported values of height and weight. Since the triage nurse is not taking the measurements, the vital signs meaningful use clinical objective remains outside the scope of radiology.

11 Registration to Obtain Payment Radiologists, as well as any eligible physician specialist, can register now at Even if you don t employ a complete certified ambulatory EHR, you can register, but be aware that 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; this is 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. Conclusions If you think you might be ready for meaningful use, you are not ready. Close your eyes, and imagine it is September 30, Do you completely understand the technology you will be using and the workflow tomorrow morning when you go to work? If not, and you are a radiologist, you ll be missing out on a chance to obtain a bonus payment while 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 are, 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 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 believe 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 ontime, 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.

12 Meaningful Use for radiologists: 12 About the Author and Company About Murray A. Reicher, MD, FACR, Chairman DR Systems, Inc. Dr. Reicher is a board-certified diagnostic radiologist and Fellow of the American College of Radiology. He is known for his numerous scientific publications, inventions, and presentations in the fields of neuroradiology, musculoskeletal MRI, and health information technologies. In 1992, he co-founded DR Systems, Inc., a leading provider of information and image management solutions for health care enterprises. In addition to serving as Chairman of DR Systems, he is the co-founder/chairman of Health Companion, Inc., co-founder/board member of Health Beacons, LLC, and councilor for the California Radiological Society, as well as the past President of Radiology Medical Group, Inc., and past CEO of Imaging Healthcare Specialists, LLC. Dr. Reicher received his undergraduate degree at UCLA in Biochemistry and his medical degree at UCSD. About DR Systems, Inc. DR Systems is the leading independent provider of enterprise imaging and information management systems for integrated healthcare networks, hospitals, and diagnostic imaging centers. Since 1992, the company has helped over 600 hospitals and imaging centers lower their cost of operation by improving management of patient information, eliminating ancillary IT systems and interfaces, and increasing workflow speed, while also providing better clinical quality and patient care. KLAS has recognized DR Systems and its Unity RIS-CVIS-PACS-Reporting platform as the leading PACS vendor and product in its 2011 Top 20: Best in KLAS Awards: Software & Services report. DR Systems, Inc Mesa Rim Road San Diego, CA Toll Free: (800) Tel: (858) Fax: (858) info@drsys.com Copyright DR Systems, Inc. All rights reserved. Various DR Systems product modules are protected by one or more of U.S. Patent # 5,452,416; 7,660,488; 7,787,672; 7,885,440; 7,953,614; 7,970,625; 8,019,138; 8,094,901; and other patents pending. Specifications are subject to change without notice. Other trademarks used herein are the property of their respective owners. MKT A Template: MKT H