Final Meaningful Use Rule Throws Radiology Some Curves

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CMS and the Office of the National Coordinator scaled back their requirements for demonstrating meaningful use of information technology in an 864-page final rule released yesterday, trimming by 20% the criteria physicians and hospitals are required to meet in order to receive HITECH funds for electronic health record system purchases.
In the process, they may have dashed or at least delayed radiology community hopes that the rule would propel the adoption of radiology decision support and computerized order entry systems (CPOE) with a final rule that made the CPOE requirement apply to medications only, eliminating imaging and laboratory. “It seems so short-cited: Here we have all of these grandiose IT goals, and the places where we should be focusing, or could be focusing, for quick success gets caught in the sludge,” says Liz Quam, executive director of the Quality Institute at the Center for Diagnostic Imaging in Minneapolis and a founding member of the Imaging e-Ordering Coalition. In the final rule, physicians must meet 20 of 25 criteria, 15 mandatory and 5 selected from a choice of 10; hospitals must meet 19 of 23 criteria, and they also have flexibility to choose 5 additional criteria from 10 options. More flexibility also is built into meeting the requirement for measuring clinical quality: eligible professionals and hospitals now need to follow six total, including three core clinical quality measures, and three others from a list of 44. In revising the rule, the Office of the National Coordinator (ONC) and CMS acknowledged that the previous all-or-nothing rule would have placed too great a burden on healthcare providers. “The DHHS received many comments that this approach was too demanding and inflexible, an all-or-nothing test that too few providers would be likely to pass,” wrote David Blumenthal, MD, MPP, in a commentary in the latest issue of the New England Journal of Medicine. The rule also backpedals on the requirement that physicians would have to run at least 80% and hospitals 10% of orders through the CPOE during a 90-day period in the first year of the program. “Our intent in the proposed rule was to capture orders for medications, laboratory or diagnostic imaging,” the rule stated. “However, after careful consideration of comments, we are adopting an incremental approach by only requiring medication orders for Stage 1.” The final rule requires all providers to hit a threshold of 30% of medication orders in Stage 1. “In terms of the CPOE, obviously the ACR would like to see a bigger push toward CPOE with integrated clinical decision support for radiology services,” says Michael Peters, assistant director of regulatory and legislative portfolio, the American College of Radiology “That is something the ACR has been pushing for not only in meaningful use but in many other areas. It was a little disappointing that the CPOE focused on medications. All is not gloom and doom, however.” Peters points out that there will be two more rule-makings over the next five years, so the window of opportunity remains open, in addition to these points of interest for radiology: • Eligibility requirements remain virtually identical to the proposed rule: all physicians are eligible except for those hospital-based physicians who provide >90% of their total Medicare (or Medicaid) services in POS Codes 21 (inpatient hospital) or 23 (ER hospital) locations. CMS is expecting only 14% of all Medicare physicians to be hospital-based. • Contrast media/drug-to-drug and drug-allergy tests: CMS said they are not linking these checks to specific drugs or agents. The rule notes: “It is common practice in radiology to identify a patient's past drug and food allergies and take appropriate interventions if necessary. Therefore, the drug-drug, drug-allergy, and drug formulary checks would be appropriate prior to administration of contrast media and imaging agents to patients." • In the ONC certification criteria final rule, released last week, the ONC specifically discussed the issue of RIS and some other HIT as EHR modules, verifying that EHR modules can be anything: They simply must be able to be certified as covering at least one of the certification criteria. The rule also specified the calculation payment amounts; payment adjustments for eligible professionals and hospitals that fail to demonstrate meaningful use of EHR technology; and other program participation requirements. Ongoing Frustration Quam expressed continuing frustration with the rule’s apparent focus on technology as opposed to interoperability, leaving private practice radiology, which has invested so heavily in informatics and interoperability, on the outside of the federal effort. “One would think that in a world where we want value for heath care that we would be demanding interoperability, so that the radiology module that is our RIS can hook up to any electronic medical record, any place,” Quam says. “That is the goal, but no one is pushing for it. Until we push for that and achieve that, absolutely, private practice radiology is going to be hurt as it relates to getting those subsidies.” She notes that the Center for Diagnostic Imaging, which owns and operates 55 imaging centers, continues to integrate its PACS with many different EMRs or practice management systems. “It could be so much faster if the federal government absolutely demanded interoperability, which is the best thing for the patient,” she comments. “It’s not there, and it is hard not to think there are some big pushers in the background to keep those electronic fences up. You have to fence in patients within certain health systems, which is absolutely not what patients want either. The electronic fence piece still hast to be taken down in order for radiology to flourish in the new world order.” Nonetheless, Quam believes the HITECH act may have some secondary benefits for imaging providers in that it will encourage eligible providers and hospitals to hook up with RIS and PACS. "Now we are going to be talking about MU [meaningful use] modules, because that is what a RIS is in the new world order," she says. She also says that the e-ordering Coalition will not back off of its mission to promote radiology CPOE and decision support as a way to address over-utilization of imaging. “There still is pressure on utilization and there will continue to be so, and if the choice is RBMs or clinical decision support, the provider community, I hope, will choose and advocate for clinical decision support,” Quam notes. “The e-ordering coalition is not going away and the provider roundtable of the coalition will continue to suggest what steps we can take to get there.”