Transcript Meaningful Use in Radiology: New Technologies for U.S.

•MGH Licensed Technology
•Nuance, Inc.
•Powerscribe, Commissure, RadWhere, RadCube
•Clinical Decision Support, RadPort , Leximer NLP
•LifeIMAGE, Inc.
•Image Sharing, Data Mining, Render
•Medical Advisory Boards
•McKesson
•Philips Medical
•General Electric
•Siemens
•Carestream
•Visage Imaging
•Vital Image
•Nuance
•LifeIMAGE




Federal Healthcare Reform
Preparing for Radiology Meaningful Use
Demonstration of New Technologies
Summary
“To lower health care cost, cut medical errors, and improve care,
we’ll computerize the nation’s health records in five years,
saving billions of dollars in health care costs and countless lives.”
Health Initiatives: To incentivize the ‘Meaningful Use’ of certified EHR technology

EHR


Certified


Electronic Health Record
Tested and Certified in accordance with the HHS Certification Program
Meaningful Use (MU)

Demonstrate the use of IT in the practice of medicine to:
 Enhance Quality
 Improve Patient Safety
 Decrease Costs
 Demonstrate Improved Outcomes
Technology Adoption
Time
Transformational
Change in Health Care
Delivery & Population
Health
2009
2011
2013
2015
HIT-Enabled Health Reform
2009 MU Criteria
HITECH Policies
2011 MU Criteria
Capture & Share Data
2013 MU Criteria
Clinical Decision Support
2015 MU Criteria
Improved Outcomes
*Report of Health IT Policy Committee
Meaningful
User
2011
2012
2013
2014
2009
2010
2016
Total
Incentive
2011
2012
2013
2014
2015
$ 18,000
$ 12,000
$ 8,000
$ 4,000
$ 2,000
$ 18,000
$ 12,000
$ 8,000
$ 4,000
$ 2,000
$ 44,000
$ 15,000
$ 12,000
$ 8,000
$ 4,000
$39,000
$ 12,000
$ 8,000
$ 4,000
$ 24,000
$ 44,000
1%-5%
Penalties
2015 +
$1.5B incentive opportunity for US radiologists
$10B annual penalty impact for US radiologists

Centers for Medicare and Medicaid Services (CMS)

Office of the National Coordinator (ONC) for Health IT
Branch of Health and Human Services (HHS)
 Dr. David Blumenthal, MGH - Chair
 Dr. John Glaser, PHS - Senior Advisor


Policy Committee
 Meaningful use (MU) of healthcare information technology (HIT)
 Certification and adoption of electronic health record (EHR) products
 Strategy for health information exchange (HIE)

Standards Committee
 Quality measurement
 Clinical operations
 Privacy and security
Communication
Management
Clinical
Support
ImageDecision
Management
Interpretation
Process
Radiation
Safety
& Quality
Management
Computerized
Physician
Order Entry
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Deployability
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Deployability
Deployability
Category
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Category
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
Centers for Medicare and Medicaid Services


Proposed Rule
Meaningful Use Requirements for:
 Eligible Hospitals (EH), Eligible Professionals (EP)
 EP - 25 Meaningful Use Objectives and Measures

Office of the National Coordinator for Health IT

Interim Final Rule
 Certification Criteria
 Standards
 Implementation Specifications
Each measure was reviewed and discussed in the context of a radiology practice

Office of the National Coordinator
 Interim Final Rule (IFR) of Standards and Certification Criteria
 End of Public Comment Period - March, 2010

Centers for Medicare & Medicaid Services
 Notice of Proposed Rulemaking (NPRM) on Meaningful Use
 End of Public Comment Period – March, 2010
The definition of EH and EP has been changed
CMS Eligible
Place of Hospital
Service Codes
Eligible Professional
84% of all Physicians
•POS: 11, Office
•POS: 20, Urgent Care Facility
•POS: 21, Inpatient Hospital
•POS: 22, Outpatient Hospital
•POS: 23, Emergency Room
•POS: 24, Ambulatory Sx Center
•POS: 49, Independent Clinic
Eligibility Determination:
If 10% (or more) of your CMS practice is from POS 11, 20, 22, 24, 49
you are considered an eligible professional.
Relaxed the requirements for 2011-12 in response to public comments

15 ‘Core Set’ Measures (5 are eligible for exclusion)


10 ‘Menu Set’ Measures (6 are eligible for exclusion)



Must meet 5 out of 10 measures
44 Clinical Quality Measures


Must meet all non-excluded measures
Must report 6 of the 44 measures (3 Core and 3 Non-Core)
To receive all incentives, must begin by 2012
Incentives will be single annual payments
Did NOT relax the requirements for 2011-12 as much as CMS

All products must be Certified
Full EHR Certification
 EHR Module Certification

 A module can measure one or more objectives

Certification is more stringent than CMS requirements


All EPs must be capable of measuring ALL objectives


CPOE: CMS Stage 1 for medications, Cert. requires radiology orders
Regardless of exclusions or menu selections
Testing and certification process will begin Sept. 2010.


Federal Healthcare Reform
Preparing for Radiology Meaningful Use
•
Required: Technology probably does not exist in your department
1.
2.
3.
4.
•
Required: Technology may exist within your department
1.
2.
3.
4.
5.
6.
7.
8.
•
Implement one clinical decision support rule
Electronically exchange key clinical information among patient authorized providers
Report ambulatory clinical quality measures to CMS/States
Conduct annual Security Risk Analysis, HIPAA 45 CFR 164.308(a)(1)
Provide patients with an electronic copy of their health information, upon request
Provide clinical summaries for patients for each office visit
Drug-drug and drug-allergy interaction checks
Record demographics
Maintain active medication allergy list
Record smoking status for patients 13 years or older
Maintain an up-to-date problem list of current and active diagnoses
Maintain active medication list
Most radiologists excluded
1.
2.
3.
Computerized physician order entry (CPOE)
Record and chart changes in vital signs
E-Prescribing (eRx)
• Required: Two of the following seven
1.
2.
3.
4.
5.
6.
7.
Provide patients access to their health information via an electronic portal
Generate lists of patients by specific conditions
Drug-formulary checks
Incorporate clinical lab test results as structured data
Send reminders to patients for preventive/follow up care
Use of certified EHR to identify patient-specific education resources
Capability to provide electronic syndromic surveillance data
• Most radiologists excluded
1. Medication reconciliation
2. Summary of care record for each transition of care / referrals
3. Capability to submit electronic data to immunization registries/systems



Federal Healthcare Reform
Preparing for Radiology Meaningful Use
Demonstration of New Technologies
•
Technology
•
•
•
•
•
•
Implement one clinical decision support rule
Provide patients access to their health information via an electronic portal
Electronically exchange key clinical information among patient authorized providers
Generate lists of patients by specific conditions
Report ambulatory clinical quality measures to CMS/States
Security Audit
•
Conduct annual Security Risk Analysis, HIPAA 45 CFR 164.308(a)(1)

Decision Support At Point of Order
Appropriateness score (1-9) given selected exam and clinical indications
 Suggests alternatives to currently selected exam


Duplicate Exam Alert



Radiation Alert
Extra Decision Support for Primary Care



Prior related exam reports and images available
Headache and low back pain pathways
Hard Stop on Red (non clinicians)
Continuous User Feedback
Modification of indication check boxes
 Addition of new exam types
 Changes to rules by consensus of PCP, Specialists, Radiologists

Selecting a Patient
Doctor or Staff
Can Log In
Head CT Page1
Selecting A Study To Order
Considerations / Protocols
(here for Head CT)
Indications Specific To Study Type
(here for Head CT)
Duplicate Exam / Radiation Warning
Decision Support Feedback Screen
Here user chose
Head CT with indication
of dementia only
Screen To Proceed On Red
Exam Ordered But Not Yet Scheduled
Office staff can schedule the exam
Automatically select the first available time slot
Or, pursue web scheduling calendar
View, Cancel, Reschedule, Print Instructions
Patient Instructions
Directions To Imaging Center
MGPO actual imaging tests per 1000 members
(MRIs, CT Scans, Nuclear Cardiology)
395.0
390.0
actual tests per 1000 members
385.0
380.0
375.0
370.0
365.0
360.0
355.0
19% Decrease
(2005 – 2008)
350.0
345.0
340.0
335.0
Adjusted
Annual Compound
Composite:
Growth RateBCBS,
HPHC,
1%
TAHP
330.0
Adjusted
325.0
Annual Compound
320.0
Growth Rate
12% 315.0
310.0
2004
2005
2006
2007
2008
•
Technology
•
•
•
•
•
Implement one clinical decision support rule
Provide patients access to their health information via an electronic portal
Electronically exchange key clinical information among patient authorized providers
Generate lists of patients by specific conditions
Report ambulatory clinical quality measures to CMS/States
•
Initially created technology to manage patient’s outside imaging exams
•
•
•
From incoming CDs to the department, ER, OR, clinics and physician offices
Electronically from other institutions via secure dropboxes
Directly from registered patients
ROE
CD Import Workflow
2.
1.
Physician’s office receive CDs from
patients, upload images & reports
`
Physician review images &
reports directly using any PC or
Mac on the network
`
5.
Gatekeeper reconciles patient
and study information, and push
to RIS / PACS / EMR
Enterprise
RIS / PACS / EMR
`
3.
4.
Physician can nominate to
PACS for distribution and/or
interpretation by radiology
`
Physicians can share studies with
other physicians with access to the
facility’s network
Main Login
Initiate Study Upload
Locate Image Files
Confirm Upload
Upload in process
View Images using Inbox
Confirm Demographics for Import to MGH
Importing of Study to MGH complete
Request Interpretation
PACS and EMR Outside Exam Notification
PACS and EMR Outside Images
•
Progress to secure, cloud-based distribution of patient imaging exams
•
•
•
•
To transfer to patient authorized providers*
To patients directly via secure web portal*
For patients to transmit to their preferred authorized providers
To national registries (accreditation, dose monitoring, etc)
Secure Internet Distribution
ROE
* Stage I - Meaningful Use Objective
•
Technology
•
•
•
•
•
Implement one clinical decision support rule
Provide patients access to their health information via an electronic portal
Electronically exchange key clinical information among patient authorized providers
Generate lists of patients by specific conditions
Report ambulatory clinical quality measures to CMS/States
Clinical Findings
Bilateral subdural hemorrhages with
subarachnoid hemorrhage.
This study is reviewed with Dr Smith. Standard protocol was used to obtain an MRI of the
A follow up MRI of the brain is
brain with MRA of the circle of Willis and DWI imaging.
Phrase Isolation
LP
Recommendations
recommended within 7 days to assess
Dizziness and recurrent syncope. Please evaluate the posterior circulation. progression
Comparisonofis hemorrhage.
to a
CT of the head performed 3 September 99. Comparison is also to a CT performed the day after
the MRI on 5 September 1999. Bilateral subdural hemorrhages are present. The
right sided
SNOMED-Terms
RadLex-ID
Noise Reduction
L
N
subdural hemorrhage appears improved when compared to the prior CT. It has a component
Findings:
57003
extending further posteriorly than appreciated on the CT, appearing to involve the
occipital lobe
Hemorrhage
30005
on the right side. The left subdural hemorrhage is worse than it appeared on the
initial CT.
Locations:
18720
There is extensiveL
subarachnoid
hemorrhage better appreciated on MRI than onSubdural
CT.
36230
Signal Extraction
S
36231
There is no evidence of tentorial subdural hematoma. The subsequent CT didSubarachnoid
show such a
Side:
18235
bleed, this must have occurred in the interval between studies. DWI imaging of the brain
Bilateral
51444
parenchyma is normal in appearance.
There is no evidence
The circle of
Structured
Briefof acute infarction.Etiology:
64573
Willis was imagedL
with particular attention to the posterior circulation. The right vertebral artery
Classification
Unspecified
31564
C
appears prominent. The posterior circulation appears entirely normal. Because imaging was
39115
centered on the posterior circulation, the MCA's are not completely evaluated.Recommendation:
The ventricular
Brain MRI
29567
system and CSF spaces do not show evidence of abnormal dilation. The visualized extracranial
Time:
41066
structures are normal
LDin appearance.
Discretization
Days
25870
Impression. No evidence of acute infarction on diffusion weighted imaging.Quantity:
Bilateral
24620
7
subdural hemorrhages with subarachnoid hemorrhage. The posterior circulation 7appears entirely
normal. A follow up MRI of the brain is recommended within 7 days to assess progression of
hemorrhage.
STRUCTURED OUTCOMES
•
Technology
•
•
•
•
•
Implement one clinical decision support rule
Provide patients access to their health information via an electronic portal
Electronically exchange key clinical information among patient authorized providers
Generate lists of patients by specific conditions
Report ambulatory clinical quality measures to CMS/States



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Federal Healthcare Reform
Preparing for Radiology Meaningful Use
Demonstration of New Technologies
Summary
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Meaningful Use will definitely impact radiology (Billions at risk)
MU is moving rapidly, but with a visible trajectory
Next up for Radiology (Stage II, III):
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Radiology Structured Reporting
•
Imaging Technique
–
Time of image acquisition
• Administrative Information
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Imaging device
–
Imaging facility
 Structured
Reporting
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Image acquisition parameters, such as device settings, patient
–
Referring provider
positioning, interventions (e.g., Valsalva maneuver)
– Radiological
Society of North America (RSNA)
- Structure Reporting Initiative (SRI)
Date of service
–
Contrast materials and other medications administered
Time ofof
service
name, dose,
route, and time of administration)
– Use
RadLex for approved terminology and (including
Procedure
Mapping
–
Radiation dose
• Patient
Identification
 Standard
Library of Reports freely available from RSNA.org
• Comparison
Name
– Implementation
of RSNA SRI into industry
products has occured
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Identifier (e.g., medical record number or
–
–
•
Social Security Number)
Date of birth
Gender
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•
Observations
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Clinical History
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Medical history
Risk factors
Allergies, if relevant
Reason for exam, including medical necessity
•
Narrative description or itemization of findings, including
measurements, image annotations, and identification of key
images
Summary (or Impression)
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•
Date and type of previous exams reviewed, if applicable
An itemized list of key observations, including any
recommendations.
Signature
–
The date and time of electronic signature for each responsible
provider, including attestation statement for physicians
supervising trainees, if applicable
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Meaningful Use will definitely impact radiology (Billions at risk)
MU is moving rapidly, but with a visible trajectory
Next up for Radiology (Stage II, III):
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Radiology Structured Reporting
Radiology Order Entry
Radiology Clinical Decision Support - ACR Appropriateness Criteria
NHIN - Image Sharing
National Registries – Radiation Dose Monitoring
Stay tuned, stay informed!