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Radiology meaningful use defined by exclusions, image exchange

Meaningful use compliance for radiologists means two things: knowing which criteria do not apply and enabling data exchange via PACS. Even with a certified EHR system, it's tough.

Given their intimate role in health care, radiologists generally see a large volume of patients, whether they're in a hospital setting or small practice. Therefore, there's much exposure to treating Medicare and Medicaid patients.

Initially, though, radiologists were not included in the original HITECH Act. The 2010 Continuing Extension Act paved the way for radiologists and other medical specialists to qualify as eligible professionals (EP). As a result, Keith Dreyer, D.O., vice chairman of radiology informatics at Massachusetts General Hospital, believes about 90% of radiologists are eligible for Medicare incentive payments. (Dreyer's remarks come from an interview with and a podcast posted on the Carestream Health blog.)

However, many radiologists remain uncertain about which stage 1 meaningful use criteria apply to them. There are 15 core (required) measures and 10 menu (optional) measures, from which EPs can choose five.

However, there are exclusions from some measures for many specialties. Specifically, note the Centers for Medicare and Medicaid Services (CMS) and, radiologists are exempt from six core and eight menu requirements.

Radiology meaningful use criteria core set exclusions

Objective Stage 1 Measure Exclusion
Use a computerized physician order entry (CPOE) system. Use CPOE for at least 30% of unique patients with at least one medication in their medication list. Any EP who writes fewer than 100 prescriptions during the EHR reporting period.
Generate and transmit permissible prescriptions electronically (e-prescribing). Using certified EHR technology, write and transmit electronically at least 40% of all permissible prescriptions. Any EP who writes fewer than 100 prescriptions during the EHR reporting period.
Record and chart changes in vital signs. For at least 50% of all unique patients 2 years old and older, record height, weight and blood pressure; calculate and display body mass index, and plot and display growth charts for patients. 2 years old to 20 years old, including BMI. Any EP who sees no patients 2 years old and older. Also, any EP who believes that height, weight, and blood pressure have no relevance in their scope of practice.
Record smoking status for patients 13 years old or older. Record for at least 50% of all unique patients. Any EP who sees no patients 13 years old and older.
Report clinical quality measures to CMS or the states. For 2011, submit summary information for clinical quality measures to CMS based on the attestation methodology of reporting clinical data. N/A. However, if an EP has zero denominator for all core and alternate core measures, they are able to report zeros to satisfy the requirements of the measure.
Provide patients with an electronic copy of their personal health information (PHI) upon request. Provide information (including diagnostic test results, problem list, medication lists, allergies) to at least 50% of all patients within three business days. Any EP who has no requests from patients or their agents for an electronic copy of PHI during the EHR reporting period.
Provide clinical summaries for patients for each office visit. Provide clinical summaries for at least 50% of all office visits within three business days. Any EP who has no office visits during the EHR reporting period.

Radiology meaningful use criteria menu set exclusions

Objective Stage 1 Measure Exclusion
Incorporate clinical lab-test results into EHRs as structured data. Incorporate into certified EHR technology more than 40% of all clinical lab results that are given in a positive/negative or numerical format. An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period.
Send reminders to patients per patient preference for preventive or follow-up care. Send reminders to at least 20% of all unique patients seen by the EP who are under 5 years of age or over 65. An EP who has no patients under 5 years of age or over 65 with records maintained using certified EHR technology.
Provide patients with timely electronic access to their health information. Provide electronic access to the health information of at least 10% of all unique patients (including lab results, problem list, medication lists and allergies) within four business days of that information being made available to the EP. Any EP who neither orders nor creates any of the information listed at 45 CFR 170.304(g) during the EHR reporting period.
Perform medication reconciliation at relevant encounters and each transition of care. Do so for at least 50% of encounters and transitions. An EP who was not the recipient of any transitions of care during the reporting period.
Provide summary care record for each transition of care and referral. Do so for at least 50% of transitions and referrals. An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period.
Submit electronic data to immunization registries and actual submission where required and accepted. Test the EHR system's capacity to submit electronic data to immunization registries. An EP who administers no immunizations during the EHR reporting period or is in an area where no immunization registry has the capacity to receive the information electronically.
Provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice. Test the EHR system's capacity to provide electronic syndromic surveillance data to public health agencies unless none have 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.

For radiologists, EHR implementation depends on resources

Depending on a small radiological practice or a hospital, the amount of resources will ultimately vary in implementing a certified EHR system.

A small practice should consider allocating one person to take charge of meaningful use requirements, Dreyer said. That point person would calculate how much the practice stands to lose or gain, find out if any providers decline to engage in meaningful use, learn what technology changes are needed, decide how to cope with workflow changes and, ultimately, make well-informed decisions.

Large practices and hospitals, generally ones that are multispecialty, will likely have more resources. Dreyer advises those facilities to speak with stakeholders about EHR implementation, and also to determine if the CIO will be applying for meaningful use.

Of course, this is all contingent on three things, Dreyer said -- having certified EHR technology, using it in meaningful ways, and documenting the measures necessary to complete meaningful use attestation

Even if all three things are possible, stakeholders still need to know that capturing and maintaining patient data will take time and affect workflow. That, at least, is New Jersey-based University Radiology's advice for achieving meaningful use.

It should be noted that, while radiologists are exempt from a handful of measures, EHR technology must be able to support all 25 meaningful use objectives, regardless of which ones radiologist attests to. As Dreyer said in a recent Radiological Society of North America (RSNA) News piece, this could force radiologists to invest in technology they will not actually use.

HIE via PACS key to radiology meaningful use

Considering radiologists do not often create EHR documents, image sharing and health information exchange are among meaningful use staples for radiology, especially as stages 2 and 3 draw near.

Digital Imaging and Communications in Medicine, or DICOM, is the standard for transmitting medical images. DICOM enables the assimilation of numerous technologies -- such as printers, scanners and network hardware -- into picture archiving and communication systems (PACS).

Guy Pastena, M.D., a second year neuroradiology fellow at Massachusetts General Hospital, uses a certified PACS system from Agfa HealthCare. While it supports DICOM images, Pastena said sending radiologic images is done internally.

"There is no process for sending images around per se except the Intranet and/or VPN," he said. "Once images are acquired they go into our PACS system and are accessible through both that and a Web-based image viewer the clinicians use called Amicas. They are viewable by anyone with privileges as soon as acquired."

Pastena also noted that there are no unique features in the EHR system he uses. "Our reports show up in the radiology section, but I use lab data, notes, pathology, EEG records all to put together a picture of the patient as a whole to either make a clinical decision or to help me read the scan more accurately."

The lack of unique EHR features is one reason radiologists often have to purchase additional technology -- which can be thorny, given financial constraints. It is more efficient to have an EHR system that covers all meaningful use criteria instead of piecing together disparate technology, according to an article in the September issue of Journal of the American College of Radiology.

The article also noted that radiologists must either deploy an EHR system at the location where they treat more than 50% of their patients or work more than 50% of the time at a practice with a certified EHR system. One way to mitigate concerns over how much time a radiologist spends at a particular practice is to use a cloud EHR system, since that lets radiologists log data from any location.

Let us know what you think about the story; email Craig Byer. Assistant Editor.

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