CNY Prepares for Stage 1 Attestation

Like many people, Chris Tirabassi has watched the political parties duke it out over the relative merits of the Health Information Technology for Economic and Clinical Health (HITECH) Act. As practice administrator for CNY Diagnostic Imaging Associates LLC (Liverpool, New York), however, he has little time for philosophical discussion. Instead, Tirabassi is knee-deep in the meaningful-use mandates of the HITECH Act, as they apply to CNY’s Syracuse-area private practice of six radiologists.

Five years after widely embracing PACS, the four-location, radiologist-owned practice decided to pursue stage 1 of the meaningful-use provision. Avoiding penalties, Tirabassi, says, was certainly part of the rationale.

Chris Tirabassi“Meaningful use is a pure carrot-and-stick program. It’s better to take the carrot than to get punished by the stick.”

—Chris Tirabassi, CNY Diagnostic Imaging Associates

The decision to pursue the carrot took shape in early 2013. At that time, Tirabassi began assembling the pieces needed to collect the appropriate data for a government-mandated 90 consecutive days. CNY planned to attest to stage 1 meaningful use prior to the end of 2012.

Getting to the brink of attestation has been neither easy nor inexpensive. Tirabassi estimates that software, support, and operational costs of preparation have probably cut into about half of the anticipated incentive payment. “From an administrative standpoint, we’ve consumed about 160 hours of administrative time to meet and to develop the policies and procedures,” he says. “For training time, we’re in the range of 60 to 80 hours, across the company.”

Beginning the Journey

In stage 1, the government’s goal is to foster the capture of additional data to promote better health-care utilization. It’s a tall order, and Tirabassi hopes that the result will be greater practice efficiency.

The journey started with the naming of a lead team consisting of Tirabassi, the practice’s assistant administrator (a workflow expert), and two people from FUJIFILM Medical Systems USA, the software provider that powers most of CNY’s electronic health record (EHR) solution. CNY uses the Fujifilm Synapse® RIS (version 6.x), its integrated billing module, and its meaningful-use module; it interfaces with the local regional health-information organization and MEDENT, a regional EHR vendor—enabling the practice to communicate directly with several referring offices.

An outside consultant familiar with the Fujifilm RIS also joined the team. The consultant, the Fujifilm people, and the internal team started working together in early spring 2013 to begin the planning process.

Tirabassi purchased a module from Fujifilm that included additional software and a five-year maintenance agreement. “Internally, we had to consume additional resources for office managers to be involved,” Tirabassi says. “We had to get more input from our internal IT department, as well as our outside IT support system. Everything we needed to comply with the meaningful-use requirement was part of the Fujifilm system. The other resource was the time needed to train staff in how to capture the data.”

Doing the Homework

After the team had been assembled, each member pored over the fine print on the CMS website, which included the instructions and guidelines needed to comply with meaningful use. “The first steps (after we formed the team), which really drove the entire process, were to decide which core items we would measure and which we would exclude—and to decide which menu items were most related to our practice,” Tirabassi explains.

He adds, “There are 14 core items you have to account for; you have to deal with each of the 14, but you have the latitude to decide which ones you can measure and which ones can be excluded, based on the specific nature of your practice.” CNY chose to be excluded from using computerized provider order entry (CPOE) for medication orders, from prescribing electronically, from recording and charting vital signs, from providing patients with an electronic copy of their health information, and from providing clinical summaries for each office visit.

Stage 1 meaningful use essentially relates to primary care and patient-centered services—and not as much to “ancillary radiology, pathology, anesthesiology, and the types of practices that are more exam oriented,” Tirabassi reports. Of the 10 menu-set objectives in stage 1, CNY team members picked the five that were most relevant to the practice: drug-formulary checks, patient lists, patient-specific education resources, transition-of-care summaries, and syndromic-surveillance data submissions.

Preparing for Attestation

Tirabassi and the team started meticulously accumulating relevant data on September 16, 2013, in preparation for the formal attestation 90 days later. Prior to September 16, they had passed milestone number one by determining core and menu items in early summer. From there, they planned a workflow and ran several tests to make sure that nothing went wrong during the crucial 90-day data-accumulation period.

Prior to attesting, Tirabassi met with the radiologists (as a group) to walk them through the process of attestation. As a delegated official acting on behalf of the radiologists, Tirabassi was able to complete the attestation himself.

“It’s a process where I’ll answer a series of questions that follow the meaningful-use core and menu items,” Tirabassi continues. “One by one, through each of the 10 core items, I will say, ‘We are doing this measurement,’ ‘We have the capabilities to do what you are asking for,’ or ‘We are going to be excluded from this item.’”

Managing Change

Even in a relatively small practice such as CNY, the entire process represents change, and change can be difficult—in any organization. To ease the transition to meaningful use, Tirabassi and his team met with each staff member and radiologist as early as 2012, when they first pondered meaningful use.

Ultimately, the impact of the new data-collection requirements primarily affected those who greet and receive patients. “They were responsible for the input of all of the new data,” Tirabassi explains. “That new requirement in workflow caused a lag in the patient-flow cycle, which would then have an impact on our technical staff. That meant that the turnaround time lagged a bit, at least temporarily. In hindsight, this was the biggest challenge in the adjustment to meaningful use.”

From the radiologists’ point of view, the compliance challenge boils down to the obligations of participating in a federal program that has the potential to be audited. “When they sign off and attest, they have to be comfortable that the work that has been done is audit proof,” Tirabassi says. “If there is a challenge, downstream, from the federal government, we must demonstrate that we have complied with the rules. Their biggest challenge is trusting that all the work we’ve done has been consistent with the requirements of the meaningful-use rules.”

The Next Steps

Meaningful-use stage 1 requirements have been in place for two years, and CNY’s successful attestation for 2013 applies to all of 2014. In preparation for 2015, members of CNY’s meaningful-use team will be investigating stage 2. The government has hinted at stage 3, but guidelines have not been published, and now that stage 2 has been extended a year, those guidelines are not likely to be published soon.

While Tirabassi is not exactly looking forward to stage 2, he mentions that at least the second stage is more applicable to the world of radiology. As such, it might yet prove to be more beneficial to the business aspects of the practice.

“Overall, we felt that being proactive with meaningful use would be a way of mitigating looming cuts,” he says. “We’d like to think that meaningful use will enhance our data collection and our ability to react to health changes with our patients. For example, one of the meaningful-use menu items is called patient lists. We can create patient lists based on the condition and treatment the patient received. We think of it as data mining that can help the practice and improve patient care.”

Greg Thompson is a contributing writer for