Meeting the Challenges of Stage 1 Meaningful Use

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While the news crews have moved on to coverage of the final rule for stage 2 meaningful use, the reality is this: The vast majority of radiology practices still has not met the stage 1 requirements. Their greatest challenge is likely to be understanding how the rule applies to their practice setting, and radiology practices are interpreting that in radically different ways, according to Reynold Yordy, director of marketing, information systems, for FUJIFILM Medical Systems.
Reynold Yordy“The biggest challenge for them is understanding how it actually applies to them—and the bigger part is finally coming to the realization that, for the most part, it doesn’t.”
— Reynold Yordy, FUJIFILM Medical Systems
Nevertheless, with 90% of radiologists thought to be eligible to participate in the program, practices stand to lose 1% of their Medicare billings in 2015 if they do not attest. This figure can escalate to as much as 5% over the subsequent five years, if they can’t qualify for a hardship exemption. For this reason, Yordy expects to see many practices get into the game in 2013 and attest to stage 1 meaningful use. Customers are following a fairly standard pattern, Yordy explains: They review the objectives and the measures and then say, “‘We don’t do this.’ We then have to go through it with them and explain that stage 1 is really more focused on family practice,” Yordy says. “Stage 2 looks like it will be getting closer.” The objective is to craft a way to make it through the attestation process without adversely affecting workflow—so that they can come into compliance, receive their incentive payments, and guard against penalties in 2015. A Significant Balancing Act One decision practices must make is determining how to interpret the phrase seen by eligible provider, which is present in many of the measures. Because only a few radiology subspecialists regularly see patients, practices must decide how many of their patient encounters fall under the rule. “Nine of the measures have that language in it, and CMS has been great at being vague about what they tell people,” Yordy says. “Their response has been that it is up to providers to determine what that means to them.” Some groups that Yordy is working with are interpreting that literally and excluding all studies except those that involve a physical encounter with patients. Others are interpreting it broadly to include all patient images. The practices that are using the seen-by-eligible-provider language to exclude many of the studies that the practice performs find that if they exclude too many studies, some radiologists will have zero studies to report. “If you have physicians that don’t do mammography and don’t do outpatient interventional work, then they probably are not going to see a patient,” Yordy says. “Then, they have to figure out which studies they are going to count, because if they use that rule, then a lot of their radiologists will not be able to attest. We found that it has become a significant balancing act of how they are going to do it. I think that will continue to evolve over the next year.” One practice that will attest to meaningful use of its Fujifilm Synapse RIS in the coming weeks intends to cover its bases by including every study, but intends to work toward a more selective approach. Decision Support Finding expert opinions on the subject has not been easy for radiology practices. Where they typically might turn to a lawyer to answer such questions, Yordy says, many lawyers do not consider themselves expert in the meaningful-use regulations, and consultants do not want to be held accountable for definitive answers. “Probably the biggest challenge for practices is that no one wants to be committal about these questions,” Yordy says. Nonetheless, he advises that practices engage with someone whose job it is to stay on top of the meaningful-use regulations, primarily because the rules continue to change. “The rules change, making it difficult to understand when an exclusion counts and when it doesn’t count,” he says. Yordy cites the following example: Previously, practices could exclude themselves from the syndromic surveillance and immunization measures. A clarification of the rules disallows practices from excluding themselves from both measures at the same time. CMS has provided a forum [link to: for physicians and health IT personnel to use in staying abreast of changes, and the agency has advised that practices can use the answers and information provided there to justify their decisions. “The problem is that a lot of those answers on the forum resemble the whole seen-by-eligible-provider thing: It’s up to your practice to determine things,” Yordy says. Because of these changes, Yordy has seen some groups choose to comply with more than the minimum five menu-set measures required by stage 1 regulations. He’s also seen the exact opposite, he says: “’I am going to do as little as I can,’ some practices say. They ask, ‘How many exclusions can I claim, and what little do I need to do after that?’” Meeting the Menu-set Measures Fujifilm’s approach has been to provide software that will give practices the flexibility to attest in the way that they choose—and to provide guidance on which measures are most relevant—but the practice must decide to what it wants to attest. “We’ll give some guidance as to what menu-set measures seem to make sense,” Yordy says. “Patient lists and patient reminders are part of your practice today. You send out reminders for mammograms, but at the end of the day, you need to get a professional who deals with meaningful use on a daily basis to confirm that this is right.” To meet the patient-lists measure, practices can generate, for instance, a list of all of the women in the system who have had a mammogram in the past 12 months. The other three measures are up for grabs. Yordy says, “We haven’t seen any consistency; it is just what people decide to do.” Looking ahead to stage 2, Yordy recommends that practices begin to build a patient portal now and train patients to access their information electronically. “Our customers would be well served to start doing that now,” he advises. “In stage 2, 5% of your patients must access their electronic health records. It’s not that you provide it to them electronically; 5% actually have to decide to access them. Going ahead and getting the patients involved in that process now will serve practices down the line in stage 2, when it gets so much more intense.” A Process-oriented Approach Fujifilm has taken a process-oriented approach both to software development and to implementation and customer training. The first step was making sure it had a certified product for Synapse RIS users, and—because the rule was not particularly relevant to radiology—one with the right touchpoints and integration points. “When they do need to collect those data, they can do it with the least amount of interruption to their workflow,” Yordy says. When customers are ready to beginning planning for attestation, a Fujifilm representative sits down with them and asks them to identify the objectives—both core and menu set—and quality measures to which they plan to attest. “Then, we take each of those objectives and step through it with them: ‘You can do it here, in this process, or here—in this part of the process. Who do you see doing this?’” Yordy explains. “Based on that, we come up with a training regimen for their users.” One of the ways that Synapse RIS optimizes the process is by giving the practice the ability to modify registration forms to collect data such as patients’ smoking and medication histories as part of the registration process. “Users have to input the data when they are registering patients, but the onus is on the patient to capture the data,” he notes. Understanding a practice’s unique workflow and adapting the software to the practice are the primary objectives. “We understand that this is new and difficult for people. We understand that it will change the way that they do business. Our goal is to sit down with them and understand how they work today, and taking those steps has been well received by customers. We have one customer who has been using the RIS for quite a while. When we turned on the meaningful-use piece for that customer, it was a nonevent—which is what we hoped for,” Yordy says. He expects to see many practices begin the attestation process next year, and even though they might not begin attesting until October 2013, he encourages those practices to begin thinking about what the rule means to them and how they need to go about implementing the measures. He says, “We definitely found that the people who thought about it and planned for it had a much easier time going through the process.” Cheryl Proval is editor of