Wednesday, December 1, 2010

Meaningful Use or Mis-Use for Radiology?

If you scan all the marketing materials, press releases, and announcements of healthcare device and IT companies, the term Meaningful Use (MU) would be one of the most used (followed closely by cloud storage, vendor neutral archive, and dose reduction). For obvious reasons, healthcare providers are rushing to implement Electronic Health Records (EHR) that comply with MU requirements in order way to receive a share of the multibillion dollar subsidy for these products from the American Recovery and Reinvestment Act. If they don't have a system in place, procedure reimbursement will be cut—so there's a strong incentive to implement an EHR.

As would be expected, creative marketing for these products has kicked into high gear, stretching the meaning of MU. Radiology, in particular, is difficult to define in terms of MU, at least in a first pass at the recent Phase 1 Rule on Medicare and Medicare EHR incentive payments. 

What is the impact of MU on radiology? As a start, the word radiology appears only once in the entire Phase 1 Rule description, which doesn't give diagnostic imaging much to go on. The emphasis is on medication interactions, errors, and public health. Even the Phase 1 Rule requirement for Computerized Physician Order Entry (CPOE) does not include radiology tests. 

What is puzzling is that radiology has led the way in the development and implementation of IT in healthcare. Digital imaging, PACS, voice recognition-based reporting have been mainstream technologies for radiology the past decade. As film has been phased out, so have errors due to missing, lost, or misplaced images. Turnaround times for reports have been slashed from a day or longer to less than an hour at many facilities. And teleradiology has permitted the expertise of specialty radiologists to be available in remote areas, and allowed all-day, every-day coverage at any facility. 

This is not to say that there is not still work to be done. The integration among radiology, cardiology and other ologies is still in its infancy. Most radiology images are distributed via somewhat cumbersome API's in EMR’s. The implementation of images of for anyone everywhere at any time is still a challenge. 

IHE has addressed integration by offering a set of standards that makes this available, and its 2010 Connectathon has shown that vendor implementation is feasible. Unfortunately, vendors typically don’t choose to voluntarily implement standards; they tend to be biased toward using proprietary solutions that lock users into their architecture and products. And this is where the Phase 1 Rule for MU could have drawn a line in the sand by mentioning some of these efforts. 

The Medical Imaging and Technology Alliance (MITA), a lobbying organization for diagnostic imaging, attempted to bring this to the attention of the Dr. Blumenthal, the Director of the Office of the National Coordinator for Healthcare Information Technology (ONC) earlier this year--without any noticeable impact on the Phase 1 Rule. 

So, where and how does the MU regulation address radiology? First, it shows up in the requirement to use a CPOE; however, for radiology this is probably not to be expected until the Phase 2 Rule. Second, drug-to-drug and drug-allergy checks are required, which impacts the modalities that use contrast agents. 

DICOM has defined the capability for substance administration at a modality that allows queries for verification of the supplies to be used. There is an impact on the recording of certain demographic information, such as race and ethnicity, which might impact the data that will be sent to remote readers. Problem lists and diagnosis have to be encoded. 

Also, patients will have to be provided with a copy of their health information, which is a somewhat regular practice as many patients currently are requesting a copy of their images on portable media. Eventually, this data will be automatically uploaded to their Personal Health Record (PHR). There are also privacy and security requirements to protect electronic health information, which is already addressed in radiology via the widespread implementation of audit trails in PACS. 

It will be interesting to see what the Phase 2 and 3 MU ruling will say; hopefully radiology will be addressed in greater detail--in particular the requirement for interconnectivity standards, which are needed to make EHR’s that include imaging a success.