As the meaningful use process under the HITECH (Health Information Technology for Economic and Clinical Health) Act evolves forward, physicians practicing in different specialties face diverse situations, challenges, and questions. One specialty in which questions have been particularly heightened has been that of radiology. Many radiologists interact primarily with referring physicians, and thus their patient contact is limited compared to the vast majority of specialties; what’s more, radiologists’ workflow is in some ways quite unique; what’s more, until recently, most radiologists did not use electronic health records (EHRs) in their fullest sense. All that said, the Office of the National Coordinator for Health Information Technology (ONC) and Centers for Medicare & Medicaid Services (CMS) have made it clear that they expect virtually all physicians in private practice to participate in the meaningful use program—not only that, but also that radiologists are liable for reimbursement penalties under the program’s guidelines, as well as for its funding rewards.
One radiology group practice that has been striving forward on meaningful use is East River Medical Imaging, which has been participating in Stage 1 of meaningful use, and is simultaneously planning for Stage 2 participation. Its leaders have been partnering with the Fort Lauderdale-based IDS, which provides the group with its core electronic health record (EHR) solution, a product designed specifically with radiologists and orthopedic surgeons in mind.
Andy Wuertele, East River Medical Imaging’s chief administrative officer, and David Vazquez, its systems administrator, spoke recently with HCI Editor-in-Chief Mark Hagland. Below are excerpts from Wuertele’s comments to HCI.
Tell me about your participation in Stages 1 and 2 of meaningful use? Did you attest for all 12 radiologists for Stage 1?
That’s correct, yes; all 12 radiologists submitted their attestations in March 2013, and received their incentive payments at the end of March.
And can you share about Stage 2?
We’re in the midst of our second year of Stage 1 data-gathering and participation for this October-December quarter, and are preparing for Stage 2. We are still finalizing our plans and watching very closely what CMS is guiding the field to do, and are awaiting some further clarification on their expectations for 2015.
When are you thinking of attesting to Stage 2?
We believe we will need to begin as of January 1, so it will be a 365-day Stage 2 attestation process. We would be quite supportive of the discussion to transition that to a 90-day process.
Will it be a significant burden to do a 365-day period for a medical group your size?
Yes, if only because vendor preparedness has taken this much time. If we were attesting to Stage 1 for 365 days, that would not be a problem; it’s adding in the new technology right now that is challenging for so many.
You’d have to be doing that right now, correct?
Yes, that’s right, and very few vendors have implemented their 2014-approved technology. And one requirement is for patient participation. We’re very excited to develop a patient portal, but we need for it to be very patient-friendly to support it and meet the high expectations for service that are essential in our practice. And so to have so many question marks still in the atmosphere about what’s expected and for it to e this late in the game to have the 2014 versions of the EMR systems being approved, we’re still in a bit of a standby mode.
Your core solution is from IDS?
Yes, the Abbadox solution from IDS. It’s a cloud-based solution.
Is it particularly good for specialists?
It’s supportive of specialists’ workflow. I believe their client base supports radiologists and orthopedic surgeons; they have the capability of adapting it to the needs of other specialties as well.
What have been the special elements of meaningful use for radiology practices?
First and foremost, our conversion to a comprehensive electronic workflow had already happened more than ten years ago, driven by the efficiencies around PACS [picture archiving and communications system] use, and the large amount of data we’ve had to manage and turn into further information. So the vendors in radiology have legacy products and systems tailored to those sets of challenges, and their willingness to reinvent their products to add meaningful use capability has been limited. And the incentives that the government has put in place don’t recognize that radiology is a leader in accomplishing what they’re incentivizing. So we need to do even more than we have already done; we need to make technology investments on top of those made over the prior decade, so it’s a very unique situation. And in radiology, therefore, there has been skepticism about the impact of the meaningful use requirements. So all that is a historical note. But when you start to look at what we think the definition of meaningful use is, relative to driving better results and higher quality with each encounter, we recognize that a patient’s flow through radiology is different.
For one thing, the patient often doesn’t have direct contact with the radiologist.
Yes, that’s right; let me give you an example of a patient who comes in for an MRI of the brain and the cervical spine as well as a chest x-ray. That single visit could be a single encounter, or it could be two encounters. And that is determined by how many providers, how many radiologists, are involved interpreting the results of those exams. We happen to document the brain MR, the cervical spine MR, and the chest x-ray as three separate exams. But the neuroradiologist who reads the brain and cervical spine exams may be reading those together, even as separate exams. But because it’s the same radiologist and the same day of service, it will be counted as a single encounter. And then the chest x-ray will probably be counted as a separate encounter. We certainly don’t want the patient to have to answer questions like smoking cessation, three times. So it’s about workflow.
We happened to implement a kiosk technology for gathering information from patients, so that the patient doesn’t have to enter smoking information three times, for example. And rather than having an administrative worker go in afterwards to decide whether that was two or three encounters because the neuroradiologist read two and another radiologist read the third, we apply our CPT and ICD-9 coding data to populate the database and determine which encounters have been completed and can be closed.
How hard was it to make all of this work out?
It was a substantial challenge, but it was one that was accomplished within a five-month development window. We worked very closely and intensively, as did the IDS people, to define what we needed and to put into action.
Was the attestation for meaningful use Stage 1 in any way difficult?
The attestation itself was very straightforward. I think because there are so many different rules and guidelines, it was challenging at times to become comfortable that we were fully meeting al the expectations. For example, there has been great debate about whether or not a patient visit that doesn’t include face-to-face contact with the radiologist should count as an encounter. Our determination was that not only was it prudent to include all the encounters, whether a patient saw a radiologist or only technologist under the supervision of a radiologist, but that it was the safest approach, from a regulatory standpoint. We’re unusual in our setting in that the radiologists will spend time with patients more often than in an academic medical center. Certainly, there are kinds of patients and procedures where they’re not directly working with them; but there are certainly many times where the radiologist will sit down with the patient at the request of the referring physician. We have a very strong hands-on approach. But that itself creates another challenge. The last thing we want in terms of workflow is for our radiologists to take their eyes off the images in PACS and have them have to type in smoking history data.
So you would advise other radiology groups to facilitate kiosk-based or other information-gathering processes, to help physicians with workflow and to minimize patient frustration?
Yes, absolutely. Ironically, the biggest objection patients raise is around giving their weight more than once. Some patients question what we’ll be using their information for.
What have been your biggest learnings overall so far?
That’s a great question. One has clearly been to find a responsive and focused technology partner. We searched, starting in 2011, for the right combination of technologies to enable to participate in meaningful use. We started with an expectation that we would use our RIS, PACS, and practice management combination and would use a modular approach. After about a year, it was clear that our vendor would not be able to stitch all those together, and that we would need a dedicated HER vendor that would close all the gaps. The expectation was that we’d have to hire a substantial number of data entry clerks, because gathering the data was not an off-the-shelf prospect.
We happened to be working with IDS in a couple of other areas; this was our first EHR, in terms of what the federal government would classify as an EHR. But then again, ten-plus years ago, we were already in the electronic medical record realm with PACS. We weren’t able to participate in meaningful use in 2012 because we didn’t have the right technology combination, and it wasn’t until May 2013 that we finally signed off on the proposal to put these final pieces in place. So had we not had the confidence in and relationship with IDS to pull this off, we would have had to forego that participation last year and thereby lose out on the incentives and face penalties, and not have the move forward with expertise internally with meaningful use. And I think meaningful use attestation and achievement is an important indicator of our quality as a provider. It gives us credibility with sophisticated hospitals, payers, and employers, in the community we’re working in.