Radiologists Take on Meaningful Use A KLAS-RSNA Report

November 2011 Radiologists Take on Meaningful Use A KLAS-RSNA Report

Radiologists Take on Meaningful Use: A KLAS-RSNA Report T A B L E O F C O N T E N T S PAGE SECTION 5 EXECUTIVE OVERVIEW RSNA Acknowledgement Worth Knowing Introduction Why Is This Important? Scope of the Project Information Exchange Patient Engagement Clinical Decision Support Measuring and Monitoring Clinical Quality Measures Electronic Image Storage and Display Conclusion EXPANDED RESULTS KLAS-RSNA Meaningful Use Study 2011 I 1

RSNA ACKNOWLEDGEMENT Dear RSNA Member, As you may know, the Office of the National Coordinator for Health Information Technology (ONCHIT) has been mandated by the U.S. Federal Government to draw up guidelines for the Meaningful Use of IT in healthcare. Meaningful Use requirements are meant to improve healthcare through the use of IT. They will be tied to reimbursement incentives for healthcare providers who are successful Meaningful Users. The development of these guidelines will directly impact the practice and reimbursement of radiology. RSNA has worked with KLAS, by providing them with a random sample of member email address, to conduct a survey that lets radiologists share their opinions about how to make Meaningful Use guidelines beneficial and applicable to radiology. A summary of the results of this survey is presented below. These results will be shared with ONCHIT to help that agency understand radiologists concerns and preferences for Meaningful Use. We encourage you to follow the unfolding of Meaningful Use guidelines and to keep letting your voices be heard on this critical issue. Sincerely, Sarah S. Donaldson, MD Chairman, RSNA Board of Directors 2 I KLAS-RSNA Meaningful Use Study 2011 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

Executive Overview RSNA was approached by KLAS to assist them in performing a survey on Meaningful Use (MU). Two components of assistance were requested: (1) A comprehensive list of what the RSNA Informatics Committee (RIC) believes to be the important and appropriate criteria for MU of Health Information Technology (HIT) in radiology; and (2) a representative cross section of the RSNA membership from both academia and private practice to be included in the survey. In contradistinction to the existing federal regulations for Phase I that are designed for internal medicine, family practice, and pediatrics, it is hoped and anticipated that specialty appropriate criteria will be included in Phase II for all specialties, not just radiology. Many of the knowledgeable RIC members involved in MU at the federal level provided valuable input to this list of criteria that we encourage you to read about in the following Summary/Executive Report being made available to RSNA members by RSNA and KLAS. David E. Avrin, M.D., Ph.D. RSNA Radiology Informatics Committee Chair KLAS-RSNA Meaningful Use Study 2011 I 3

WORTH KNOWING TWENTY-FIVE PERCENT OF RADIOLOGISTS said that they are very involved in making decisions regarding meaningful use (MU), but only 6% considered themselves very educated in MU. NEARLY 40% OF RADIOLOGISTS cited concerns about either lack of clarity in MU guidelines or decreased efficiency as the result of adopting MU guidelines. Other concerns were also mentioned, such as reimbursements and lack of hospital support or readiness. PATIENT ENGAGEMENT AND RADIATION DOSE TRACKING WERE SEEN AS THE LEAST IMPORTANT CRITERIA. In follow-up discussions, many providers reported that patient engagement would be most beneficial in mammography and interventional radiology. RADIOLOGISTS SAW CLINICAL DECISION SUPPORT AS IMPORTANT, ESPECIALLY FOR REFERRING PHYSICIANS. Most saw this as a means to ensure that the correct imaging test is ordered and to reduce the amount of unnecessary and costly imaging. Several physicians mentioned that clinical decision support would assist them while consulting with referring physicians. Planning to Qualify for MU Incentives (n=203) Knowledge of MU (n=196) 1-Not at all Familiar, 5-Very Familiar Yes 28% Considering It 27% 4 16% 5 6% 1 25% No 10% Don't know 35% 3 28% 2 25% 4 I KLAS-RSNA Meaningful Use Study 2011 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

Executive Overview INTRODUCTION The Office of the National Coordinator for Health Inf ormation Technology (ONCHIT) has been mandated by the federal government to draw up guidelines for the meaningful use (MU) of IT in healthcare. MU requirements are meant to improve healthcare through the use of IT. They will be tied to reimbursement incent ives for healthcare providers who are successful meaningful users. 6% Percent of responding providers who say they are very familiar with MU requirements The development and interpretation of these MU guidelines will directly impact the practice and reimbursement of radiology. Qualifying organizations stand to gain up to $44,000 per physician if they attest. However, those providers that are eligible for incentives but that do not meet the MU standards by 2015 will be hit with penalties through cuts in Medicare reimbursements. Although most radiologists are considered eligible providers (EPs), under current requirements, MU will be hard for radiologists to meet. This is because the guidelines are geared primarily toward primary care physicians. In conjunction with RSNA, KLAS has provided a forum for radiologists to share their opinions about how to make these guidelines beneficial and applicable to radiology. KLAS and RSNA have come together to assess these opinions in an attempt to inform the discussion happening in Washington about how to accommodate subspecialist needs in Stage 2 of MU. WHY IS THIS IMPORTANT? Almost 60% of surveyed radiologists said they are planning to qualify for MU or they are considering it. Many of the radiologists surveyed reported that they are very involved in making decisions regarding MU for their practice; however, only 5% of participants said they are very familiar with MU. One radiologist said, It is not very clear what steps or process the radiologists need to follow in order to become an eligible provider. They have to hunt for it quite extensively, if they can make any sense of it at all, and spend a lot of time trying to sort it out. Considering these numbers, a brief review of MU is called for. MU has five main goals intended to be met with the adoption of the proposed guidelines. The first goal is to improve healthcare quality, safety, and efficiency. Second is to engage patients and their families in patient care. Third is to improve care coordination. Fourth is to improve public health and reduce health disparities. Last is to ensure privacy and security protections for patients. The Stage 1 MU guidelines proposed by the federal government are meant to promote these goals, and providers must adopt the guidelines in order to qualify for the incentives. While the current requirements are not friendly to radiology, radiologists must still meet guidelines in order to avoid penalties by the 2015 cutoff. KLAS-RSNA Meaningful Use Study 2011 I 5

Figure 1: Study Participants n=208 Figure 3 SCOPE OF THE PROJECT Many radiologists are concerned that in order to attest for MU dollars, they will be forced to adopt rules that are not applicable to their practice of radiology or beneficial to patients. As one radiologist pointed out: We don t want to spend more money just for the sake of fulfilling meaningful use criteria on things that aren't really going to affect patient care. It seems like meaningful use might be good for certain areas of medicine, but I am not sure it is tailor-made for radiology per se. In light of this fact, KLAS and RSNA gathered feedback from over 200 radiologists who took an online survey where they were asked to rate criteria in terms of benefit to the radiology practice on a scale of one to five (one = not at all beneficial; five = very beneficial). Respondents covered a wide range of backgrounds, from small private practices to large radiology groups to hospitalbased radiologists. Private 60% Academic 18% Hospital 22% For this study, KLAS developed some questions with a focus on vendor preparedness to help providers meet MU. RSNA was not involved in the measurement of any vendors or in developing any vendor-focused questions in this study. The results of those vendorrelated inquiries can be found in the expanded report. RSNA developed questions regarding MU needs and requirements for radiology, which focused on five main areas: (1) information exchange between referring physicians, radiologists, and healthcare institutions; (2) patient engagement; (3) clinical decision support for referring physicians and radiologists; (4) measuring and monitoring clinical quality measures; and (5) electronic image storage and display. Each section will be addressed in this executive summary. INFORMATION EXCHANGE Overall, information exchange is seen as something that would benefit radiology and facilitate better care. One participant said, We are improving patient outcomes as we improve the communication between the physicians who ordered the tests and the physician who reads the test. There are a lot of ways that we can improve it. Although we are low tech, we have an automatic fax to our physicians, and physicians have online access to the images, as well as to the reports. It is not that difficult to do, but it is very important to the future of our field that we stay on top of that." 6 I KLAS-RSNA Meaningful Use Study 2011 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

Executive Overview Figure 2: Information Exchange between Referring Physicians and Radiologists (1-Least Beneficial, 5-Most Beneficial) Ability of radiology practices to send imaging reports to EMR electronically 4.56 Ability of radiology practices to receive imaging orders electronically 4.30 Ability to maintain database of nonroutine findings and a record of contacts between radiology department and referring physicians for each finding 4.26 Ability to send electronic reminders to referring physicians for imaging follow-up of nonroutine findings (follow-up needed but not critical to finding) 4.22 Ability to transmit structured clinical data as part of the radiology report 3.86 Regarding image exchange with referring physicians, radiologists felt that the ability to send imaging reports to the EMR electronically would be most beneficial criterion. On the other hand, what seemed least beneficial to this group of radiologists was the ability to transmit structured clinical data as part of the report. Looking at information exchange between healthcare institutions, the ability to share prior reports across institutional boundaries was viewed as very beneficial. Information exchange between healthcare institutions would be huge. That would obviously create some areas where it would dramatically reduce the number of radiology studies and the overall number of unnecessary exams, blood work, and pathology performed on individuals. Also important to radiologists were the ability to share images across institutional boundaries, the ability to share prior exam history, and the ability to determine if patient records at two different institutions correspond to the same individual. The ability to share patientspecific radiation dose information across institutional boundaries was clearly considered the least beneficial criterion. PATIENT ENGAGEMENT Overall, patient engagement was not viewed as a hot-button issue and was seen as less beneficial than other criteria discussed in this study. Out of the criteria KLAS-RSNA Meaningful Use Study 2011 I 7

Figure 3: Patient Engagement presented in this area, the one viewed as most beneficial was the capability to send reminders to patients for imaging followup of nonroutine findings. Many noted that outside of mammography and interventional radiology, radiologists are fairly removed from patient contact. Radiologists are conflicted in that while patients have a right to their images and reports, it is not medically beneficial for them to have access to that information. One radiologist described the potential difficulties for the patient this way: I think that engaging patients is a double-edged sword. Radiologists are not caregivers. We give a service. I rarely interact with patients, and I think that primary care doctors and others who order images would agree that they want to discuss results with their patients and that patients having access to their images will result in a huge amount of unnecessary concern on the part of the patients. I think physicians (1-Least Beneficial, 5-Most Beneficial) would end up spending too much time on the phone with patients explaining normal chest x-rays or things that are non life threatening. On the other hand, maybe patients have a right to see their images, and maybe that could save a life in some rare cases. Some also noted that their referring physicians might not consider this as a benefit. Driving this point home, one radiologist said, I have a slight opinion on making reports available to patients. It is probably not going to make my life too miserable, but I am just thinking of the poor referring doctor. When the patient gets a report full of verbiage, they understand every other word because it is not written for them. It has been a massive headache in the mammography field to get all these sixth grade level letters written to send out to people, which never can really describe the whole situation in all of its appropriate degrees of complexity.... I am all for Capability to send reminders to patients for imaging follow-up of nonroutine findings Use of a reporting system that can store structured clinical information as part of the report 4.04 3.84 Provide patients with the ability to schedule routine imaging exams online 3.66 Use of a reporting system that enables selection from a preselected set of structured options to fill a report field 3.42 Provide patients access to electronic images and reports over the web 3.01 8 I KLAS-RSNA Meaningful Use Study 2011 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

Executive Overview privacy and all for [patients] owning [clinical data],... but the idea of the patient getting this thing and then calling to the poor primary care office and driving him nuts is wrong. CLINICAL DECISION SUPPORT Clinical decision support was seen as important, especially for referring physicians. The overall goal is to make sure the correct imaging test is ordered, based on clinically relevant data, and to reduce the amount of unnecessary radiation patients receive. One radiologist spoke to the possible benefits of adopting clinical decision support. We are all really excited about getting clinical decision support for the radiologists, but at the same time, without the support from referring physicians, we will really be under the gun. There has to also be a way to provide radiology-related decision support for the referring physicians. However, if there is strong clinical support for something, that will at least give us more leverage so that we aren't continually fighting the referring physicians. Radiologists felt that clinical decision support would be helpful for referring physicians in two ways. First and seen as most beneficial would be the ability to provide evidence-based advice on appropriate imaging tests to the referring clinician at the time of the imaging order. Following closely behind was the ability to display the patient s imaging history to the referring physician at the time of the imaging order. Reporting of patientspecific radiation dose to the referring clinician at the time of the order was not seen as beneficial. Clinical decision support for radiologists was viewed as relatively unhelpful, with Figure 4: Clinical Decision Support for Referring Physicians Ability to provide evidence-based advice on appropriate imaging test to the referring clinician at the time of the imaging order Ability to display patient imaging history to the referring clinician at the time of imaging order 4.32 4.47 Ability to display patient-specific radiation dose reporting to the referring clinician at the time of imaging order 3.54 2.5 3.0 3.5 4.0 4.5 5.0 KLAS-RSNA Meaningful Use Study 2011 I 9

Figure 5: Measuring and Monitoring Clinical Quality Measures (1-Least Beneficial, 5-Most Beneficial) Percentage of critical findings that are communicated to the referring clinician Percentage of exams for which clinically relevant and appropriate history and reason for examination are included in the original electronic order Median time between exam order received and report finalization for stat inpatient orders Median time between exam completion and report finalization 3.82 4.26 4.26 3.94 Median length of delays for scheduling inpatients and outpatients 3.60 Median patient waiting times in the radiology department 3.50 Percentage of studies undergoing study-specific peer review 3.24 Percentage of studies interpreted by a radiology subspecialist 2.91 Percentage of studies double read 2.69 the exception of a few criteria. Radiologists would like to have access to pertinent recent history, physical and progress notes, as well as lab results and other patient information. However, viewing patient medication lists was not seen as beneficial for radiologists. MEASURING AND MONITORING CLINICAL QUALITY MEASURES There are two measures that radiologists felt would be most beneficial to track. One was the percentage of critical findings that are communicated to the referring physician. The other was the percentage of exams for which clinically relevant and appropriate history and reason for examination are included in the original electronic imaging order. Though radiologists felt that these items would be beneficial, one participant pointed out the difficulty of the task. Measuring and monitoring clinical quality measures are really tough to do in radiology because, frequently, patients go back to their primary care providers and we don t know what happens to them unless we are involved in their care at a later stage. We do get some callbacks, like if patients have to go to the OR, the general surgeon will sometimes call and tell us. But there is no official follow-up for a lot of our clinical studies. We are so busy as consulting physicians that we don t have time to look at old studies and look at patients histories and see what happened. We do that sometimes but not for every patient. 10 I KLAS-RSNA Meaningful Use Study 2011 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

Executive Overview Considered the least beneficial criterion was tracking the percentage of studies that are double read and tracking the percentage of studies interpreted by a radiology subspecialist. ELECTRONIC IMAGE STORAGE AND DISPLAY Due to the fact that the vast majority of radiologists have already adopted the criteria in this section, the radiologists in this study found them to be beneficial. For instance, digital storage and display of imaging studies (e.g., PACS) was considered to be the most beneficial criterion in the entire study. Also considered to be very beneficial were the ability of referring physicians to launch a web viewer of images and reports from the EMR and the ability to accept outside imaging studies into the PACS in the corresponding patient folder, when requested by the referring physician. CONCLUSION Radiologists believe that they have been overlooked when it comes to the current MU legislation, and nearly 20% mentioned concerns about the clarity of the regulations. Radiologists began using advanced information technology long before most primary care physicians and are concerned that they are now being asked to adopt technology and workflows that neither benefit their patients nor apply well to the practice of radiology. The results of this study indicate that radiologists have some concerns as they get ready for MU. Concerns include lack of clarity in the actual guidelines, decreased efficiency as a result of adopting MU guidelines, and lack of hospital support. A few radiologists feel confident and Figure 6: Electronic Image Storage and Display Digital storage and display of imaging studies When requested by a referring physician, accept outside imaging studies into the PACS in the corresponding patient folder 4.53 4.78 Ability of referring physician to launch web viewer of images and reports from EMR 4.49 Ability to create annotated image libraries for use in interdisciplinary conferences, QC activities, teaching, and research 4.01 2.5 3.0 3.5 4.0 4.5 5.0 KLAS-RSNA Meaningful Use Study 2011 I 11

knowledgeable about the process, but many are still waiting to see if there will be radiology-specific guidelines announced in Stage 2 or Stage 3 rules. It may be appealing to wait and see what happens, but now is the time for radiology as an industry to become informed and active in this process. 12 I KLAS-RSNA Meaningful Use Study 2011 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

Executive Overview Emily Crane REPORT AUTHOR emily.crane@klasresearch.com Holly Wallace CHIEF EDITOR TO VIEW OTHER TEAM MEMBERS CLICK HERE: FOR QUESTIONS OR COMMENTS ON THIS REPORT, CONTACT: KLAS 630 E Technology Ave. Orem, UT 84097 Ph: 800-920-4109 Fax: 801-377-6345 Web: www.klasresearch.com TO PURCHASE THE FULL VERSION OF THIS REPORT, LOG ON TO OUR STORE READER RESPONSIBILITY: This report is a compilation of data gathered from websites, healthcare industry reports, interviews with healthcare provider executives and managers, and interviews with vendor and consultant organizations. Data gathered from these sources includes strong opinions (which should not be interpreted as actual facts) reflecting the emotion of exceptional success and, at times, failure. The information is intended solely as a catalyst for a more meaningful and effective investigation on your organization s part and is not intended, nor should it be used, to replace your organization s due diligence. KLAS data and reports represent the combined opinions of actual people from provider organizations comparing how their vendors, products, and/or services performed when measured against participants' objectives and expectations. KLAS findings are a unique compilation of candid opinions and are real measurements representing those individuals interviewed. The findings presented are not meant to be conclusive data for an entire client base. Significant variables including organization/hospital type (rural, teaching, specialty, etc.), organization size, depth/breadth of software use, software version, role in the organization, provider objectives, and system infrastructure/network impact participants opinions, preclude an exact apples-to-apples vendor/product comparison or a finely tuned statistical analysis. We encourage our clients, friends and partners using KLAS research data to take into account these variables as they include KLAS data in their other due diligence. For frequently asked questions about KLAS methodology, please refer to the KLAS FAQs. COPYRIGHT INFRINGEMENT WARNING: This report, and its contents, are copyright protected works and are intended solely for your organization. Any other organization, consultant, investment company or vendor enabling or obtaining unauthorized access to this report will be liable for all damages associated with copyright infringement, which may include the full price of the report and/or attorney s fees. For information regarding your specific obligations, please refer to the KLAS Data Use Policy. ABOUT KLAS: For more information about KLAS, please visit our website. OUR MISSION: KLAS mission is to improve the delivery of healthcare technology by independently measuring and reporting on vendor performance. KLAS-RSNA Meaningful Use Study 2011 I 13