If Radiologists Ran the MU Program: KLAS/RSNA Survey
David ArvinHow much would an extra $44,000 government stipend mean to your radiology practice? Would it be enough to cover the hassle of diving into the attestation to meaningful use of health IT? To date, many practices have declined to participate, according to David Avrin, MD, PhD, of the University of California–San Francisco. On September 9, in San Francisco, at the 2012 Annual Meeting & Leadership Summit of the California Radiological Society, Avrin presented “Meaningful Use 2013: Phase II and Radiology.” He says, “Only 10% of large private practices [reported] investing themselves in meaningful use because it is such a poor fit.” The other 90% of radiologists who responded to a survey cosponsored by the RSNA and the KLAS research group believed “the juice wasn’t worth the squeeze,” he says, when the survey was taken in November 2011. Despite the fact that there is still a finite window of opportunity to get in on the good side of meaningful use—before incentives turn into penalties and the dollars start heading the other way—radiologists surveyed felt that the program has some big holes that take the sweetness right out of the bargain. They also had some strong feelings about how the program could be tailored to add meaning for radiologists. Avrin, who chaired the RSNA Radiology Informatics Committee, says that the group agreed to work with KLAS on the study because it “wanted to have something to pass back to the feds to say, ‘This is what radiology really needs,’” he explains. To give a sense of the environment in which these questions are being asked, Avrin recounts an anecdote about a colleague who was taken aside after delivering a grand-rounds talk on the subject and told that meaningful use is not about radiology. Practices either have a plan in place, have researched the program and decided to take no further action at this time, or have not considered the issue at all, Avrin says, calling the attitude that many have adopted one of watchful waiting. “You do have to worry about the penalties. If you wait, meaningful use is not going to go away,” he says. Framing the Question KLAS asked the RSNA Radiology Informatics Committee to provide a comprehensive list of what it believes to be the important and appropriate criteria for meaningful use of health IT in radiology. More than 200 RSNA members responded when asked to rate the importance of the committee’s suggested features to their practices, on a scale of 1 to 5. The questions were grouped under five capabilities: • digital image storage and display; • information exchange among referring physicians, radiologists, and health-care institutions; • patient engagement; • clinical decision support for referring physicians and radiologists; and • measurement and monitoring of clinical quality. In response to the first capability category, Avrin says, the survey respondents agreed that digital image storage/display was very important. Likewise, radiologists considered of high importance the ability to accept outside imaging studies into a PACS and the ability of physicians to launch a Web viewer to access images and reports from the electronic medical record (EMR), even if the patient did not have a record at the physician’s institution. Nonetheless, all practices are still working to eliminate patient-mediated electronic exchange (carrying around a CD), he says, adding, “There’s a lot of commercial activity in that area.” Surveyed radiologists universally agreed that outside images don’t bring with them any legal liability, although none had any system in place that allowed out-of-network images to be stored in their host PACS. “It’s good for patient care to store outside images, but you’ve got to make sure you have the right patient,” Avrin says, referring to patient identification as our next major federal problem. “The Social Security number doesn’t work well because babies aren’t born with Social Security numbers,” he notes, adding that adult patients from outside the United States can also lack Social Security numbers. “In many countries, they have a separate ID,” he says. On the subject of information exchange between radiologists and referring physicians, the survey participants rated as important the ability to transmit imaging reports electronically to the EMR. The ability to receive imaging orders electronically was also considered important. It’s something that Avrin says is on the horizon, but is a bigger challenge for freestanding imaging centers. Regarding patient engagement, Avrin believes that patients who have engagement with their own studies don’t typically burden physicians with additional questions. The ability to send patients reminders to take further steps after nonroutine findings was considered somewhat important by radiologists. A good system can issue reminders to patients with all the hassle of purchasing an airline ticket, Avrin notes. The radiologists who participated in the survey were more enthusiastic about the ability to provide decision support to the referring physician than they were about the ability to share radiation-dose reporting with referrers. Incentives, Then Penalties Noting that the American Recovery and Reinvestment Act of 2009 greatly increased penalties on HIPAA violations, Avrin expresses frustration with meaningful-use adoption guidance migrating so quickly from incentives to penalties. For radiologists, there are too many flaws in the system as designed, he says, and the products that exist to address them are too limited in scope. “If they didn’t make an effort to accommodate the important things in our practice, why should we be subject to such penalties?” he asks. Complicating matters, Avrin points out, is the fact that very few RIS and PACS vendors offer systems certified for meaningful use as a complete electronic health record (EHR); he says, “Modular certification is not a valid route.” He adds, “If you’re going to choose a vendor, make sure it is certified,” Avrin says. “I would be cautious about component certification.” Certification status of individual products can be verified at the website of the Office of the National Coordinator for Health IT. Looming challenges in the system, for radiologists, also include questions about the transition of care from small offices to hospitals, Avrin says, including how patient handoff is charted from system to system and what happens to patients’ records across those boundaries. “We can move DICOM images around the world . . . but we can’t even identify the patient between our office and the hospital,” Avrin says. “You can see that very few of these things—except maybe computerized provider order entry and physician support—apply to radiology.” He adds, “If you have a joint-venture imaging center with your hospital and have significant inpatient activities, you can use the EHR route” to demonstrate physician compliance with meaningful-use statutes, “but you’re going to get into a little discussion with your hospital about where the $44,000 goes because it is not interested in providing you with funds to invest in IT for your stand-alone practice. That’s the conundrum we’re in,” he says. Matt Skoufalos is a contributing writer for Radinformatics.com.