Meaningful Use: How Meaningful is it for Radiologists?

By Barbara F. Rubel, MBA 

Meaningful: to “have a meaning or purpose.” We have meaningful relationships, meaningful activities, meaningful events, and now we have “meaningful use.” The Centers for Medicare and Medicaid Services (“CMS”) have not defined the term “meaningful” specifically, however, meaningful is defined within the context of how certain technology is used to achieve patient health and provider efficiency goals. Thus, “meaningful use” is the use of this technology to achieve defined patient and provider outcomes.

CMS further clarifies this technology must be certified and it must be electronic, per the American Recovery and Reinvestment Act of 2009 (“ARRA”), more commonly known as the Stimulus Bill. The ARRA provides incentive payments to eligible professionals (“EP”), eligible hospitals (“EH”), and critical access hospitals (“CAH”) for participating in Medicare and Medicaid programs that adopt and successfully demonstrate “meaningful use of certified electronic health record (“EHR”) technology.

The vast majority of radiologists are defined as EPs under the Medicare and Medicaid EHR Incentive Programs as a result of Congress’ having revised the definition of a hospital-based EP in the proposed rule from an EP who provides 90 percent or more of his/her services in places of service classified under place of service codes (“POS”) 21, 22, or 23 to one who provides 90 percent or more of his or her services in places of service inpatient (POS 21) and emergency room (POS 23). This singular revision moved the traditional hospital-based radiologist from an excluded provider under the law to an eligible professional.

The determination of whether an EP is a hospital-based EP is made solely on the basis of site (place) of service and, because Congress directed that site of service be used, the fact an EP may rely solely upon the hospital’s EHR technology in fulfilling his or her clinical responsibilities and likely has no purchasing power with respect to the technology, cannot be used to determine eligibility.

The 90 percent calculation is based on an EP’s physician fee service data for the prior fiscal year and the percentages to determine eligibility are not determined by professional service payment dollars or number of claims, but rather "total number of Medicare allowed services for which the EP was reimbursed, with each unit of a CPT billing code counting as a single service." The question of eligibility with respect to professionals who have no prior year history has been submitted to CMS with no clarification as of the date of this article.

While successful reporting of meaningful use is determined by the EP’s total number of Medicare allowed services, the determination of eligibility for the incentive program must include an EP’s total patient population, regardless of the payor.

The ARRA provides for incentive payments to EPs who demonstrate meaning use of certified EHR technology and CMS’ Final Rule, titled Medicare and Medicaid Programs: Electronic Health Record Incentive Program, was published in the Federal Register on July 28, 2010. EPs who a) comply with the meaningful use objectives and measures, b) are able to exchange information electronically, and c) submit Clinical Quality Measures (“CQMs”) are eligible for up to a total of $18,000 in the first year they demonstrate compliance which can be either in 2011 or by October 1, 2012. This first year incentive payment is reduced to $12,000 for EPs whose initial year of reporting is 2013.

To qualify for the incentive payment in Year One, EPs need only demonstrate use of certified technology for a continuous 90-day period. However, all subsequent reporting must be for a full calendar year and payment years must be sequential for the full incentive payments to be realized (see Exhibit A). For example, if meaningful use is met no later than October 1, 2012, the EP is eligible for a payment incentive of up to $18,000. If, however, the same EP fails to demonstrate meaningful use in 2013, the second year incentive payment of up to $12,000 is forfeited. If the EP then demonstrates compliance with meaningful use again in 2014, the payment for which the EP is eligible is up to $8,000, since the second year payment of $12,000 has been forfeited.

Exhibit A: EHR Payment Incentives 

EPs who are not demonstrating meaningful use of certified EHR technology by 2015 will face penalties beginning with -1 percent of the EP’s total Medicare allowed fee compensation in 2015. This percentage penalty increases to -2 percent in 2016 and -3 percent in 2017. These penalties become more severe in 2018 and 2019 where a threshold of participating EPs must be reached. If it is determined in 2018 and subsequent years that less than 75 percent of EPs are meaningful users then the payment adjustment will decrease by one percentage point each year until the payment adjustment reaches 95 percent.

A certified EHR is defined as "an electronic record of health-related information on an individual that: (a) includes patient demographic and clinical health information, such as medical history and problem lists; and (b) has the capacity: (i) to provide clinical decision support; (ii) to support physician order entry; (iii) to capture and query information relevant to health care quality; and (iv) to exchange electronic health information with, and integrate such information from other sources.'' Certified EHR technology must meet certain criteria as adopted by the Department of Health and Human Services (“DHHS”) and it must be tested and certified by an Office of the National Coordinator for Health Information Technology (“ONC”) -Authorized Testing and Certification Body (“ATCB”). The companies that have been authorized as testing and certification bodies are Certification Commission for Health IT (“CCHIT”), Drummond Group, Inc. (“DGI”), InfoGard Laboratories, Inc., SLI Global Solutions, ISCA Labs, and SureScripts. All have been certified as complete EHRs and EHR modules with the exception of Surescripts LLC which is certified for e-prescribing, privacy and security modules only.

Hundreds of vendors have certified products listed at http://onc-chpl.force.com/ehrcert and, as of the date of this article, three companies have achieved “complete” EHR certification for radiology RIS and practice management products.

The meaningful use “objectives and measures” are the data EPs are required to report and reference the 15 mandatory “core” set objectives and 10 discretionary “menu” set objectives (from which five must be chosen). Each objective has an associated measure which quantifies the threshold required for successful reporting. For example, to satisfy the core objective “record patient demographics,” EPs must record patient demographics for at least 50 percent of their total patient population.¹ 

The certification “criteria” apply to the requirements for vendors' products as set forth by the ONC. The ONC has defined three categories of certification criteria, General, Inpatient, and Ambulatory. The criteria that apply to radiologists as EPs are the “Ambulatory” and the “General” criteria as these are the categories that apply to the technology needed for the EP version of the program.

Exhibit B is a sample of the Ambulatory and the General criteria and how they correspond to the core and menu set objectives (in parentheses). For example, Clinical Decision Support, a core objective, is included under the Ambulatory criteria. This information is especially important to radiologists who practice in a hospital setting and who rely upon the hospital’s technology in the performance of their clinical responsibilities. The reason is hospitals are also expected to comply with meaningful use of certified EHR technology and must satisfy the General and Inpatient criteria. Clearly, the General criteria are the same for EPs and EHs, but the Ambulatory and Inpatient are somewhat different; more precisely, there are four ambulatory criteria (Electronic prescribing ("Core"), Generate patient reminder list ("Menu"), Timely electronic access to health information ("Menu"), and Clinical summaries ("Core")) that are not included in the Inpatient criteria. Conversely, there are two Inpatient criteria (Reportable lab results and Advance directives ("Menu") that are not in the Ambulatory criteria. There are also subtle differences between some of the similar Ambulatory and Inpatient criteria. So a radiologist who practices in a hospital setting and relies upon the hospital’s EHR technology in the performance of his or her clinical responsibilities cannot necessarily comply with meaningful use simply because the hospital has invested in certified EHR technology - unless the hospital has implemented the technology that is certified as “Ambulatory."

Exhibit B: Meaningful Use Criteria 

One of the top health policy outcome priorities associated with meaningful use is to improve the quality and efficiency of care for Medicare and Medicaid populations. So eligible hospitals and providers that are applying for Stage One meaningful use incentives are required to also capture and report on Clinical Quality Measures (“CQMs”) using certified EHR technology. Clinical quality measures are measures that relate to one or more of the Institute of Medicine’s domains of health care quality. Certified EHR technology must be able to calculate numerators, denominators and exclusions for each of the CQMs listed in the Final Rule and EPs are required to submit information using certified EHR technology on three core or alternate core clinical quality measures and three additional clinical quality measures. Although CMS requires all EPs to report core measures, there is no requirement to satisfy a minimum value for any of the numerator, denominator or exclusion fields for CQMs, thus the value for any or all of these fields, as reported to CMS, may be zero.

The core CQMs that must be met are 1) Adult weight screening & follow-up, 2) Hypertension: blood pressure measurement, and 3) Preventive care & screening measure pair: Tobacco use assessment Tobacco cessation intervention. There is a high probability that most radiologists, if not all, will be reporting zeros for these core CQMs. The alternate core measures are 1) Preventive care & screening, including Influenza immunization for patients 50 years & older, and 2) Weight assessment & counseling for children & adolescents, and 3) Childhood immunization status. A complete list of the 44 CQMs is available at http://www.acr.org/SecondaryMainMenuCategories/GR_Econ/FeaturedCategories/federal/hhs/ACR-Summary-CMS-and-ONC-Stage-1-Meaningful-Use-Final-Rules.aspx.

Online registration for the EHR Incentive Program opened January 3, 2011 and EPs do not have to be using certified technology in order to register. It is important to note that registering for the payment incentive program has no impact on an EP’s eligibility for the payment penalties which begin in 2015. That is, all eligible EPs as determined by CMS, will be subject to the penalties regardless of if they have registered for the program or not. CMS plans on notifying physicians of their eligibility and EPs must be enrolled in PECOS in order to register.

In April 2011, CMS implemented the functionality which allows EPs to designate a third party to register and attest on their behalf and while the ONC is considering adding a group reporting option allowing group practices to demonstrate meaningful use at the group level in Stage Two, the current program requires EPs to register and attest individually.

EPs who work in more than one practice or in several locations must have at least 50 percent of their total patient encounters take place at locations that are using certified EHR technology; and they must base all of their meaningful use objectives only on patient encounters that take place at those locations. So if an EP provides 45 percent of his/her total volume of CPTs at Hospital A, another 40 percent at Hospital B, and the balance of 15 percent in an outpatient imaging center, using certified EHR technology at Hospital A alone will not meet the required 50 percent threshold. However, Hospital A and the outpatient imaging center, with a combined CPT volume of 60 percent, will meet the requirement and it is not necessary to also be using certified EHR technology at Hospital B.

On December 15, 2010 the American College of Radiology (“ACR”), the College of American Pathologists (“CAP”), and the American Society of Anesthesiologists (“ASA”) sent a joint letter to Kathleen Sebelius, DHHS, strongly supporting the expansion of health information technology in the medical field and acknowledging the contributions of radiology, pathology, and anesthesiology. However, the letter also noted that because many of the meaningful use requirements are not applicable, it would be impossible and unduly burdensome at best for these three specialties to meet the criteria and to avoid future penalties. The letter highlighted how the objectives and the criteria focus on the clinical and administrative needs of primary care or office-based providers and that fully functional EHR systems as defined by the ONC are not used in radiology, pathology and anesthesiology.

There are some success stories with respect to “hospital-based” physicians successfully demonstrating meaningful use in settings where they rely solely on the hospital’s technology in the performance of their clinical responsibilities. One example is where the system feeds the radiologists’ RIS interpretations as patient encounters into the hospital’s meaningful use dashboard and attestation system. All activities of the radiologists are tracked in the same system with other EPs and the meaningful use measurement activities on radiology patients are recorded throughout the entire system, i.e., the system is tracking patients enterprise-wide. For example, anyone recording a BMI on a patient will contribute to the radiologist's meaningful use thresholds. A relevant question with this scenario is, are hospitals likely to invest in solutions that are certified for EH and EP meaningful use compliance thus facilitating the compliance of their radiologists.

Radiology groups may opt to purchase their own “standalone” certified technology, a strategy that relies upon the hospital’s cooperation in capturing the required data elements to allow the radiologists to attest to meaningful use of certified technology.

Possible Solutions for Radiology
There are possible solutions for resolving the question “how meaningful is meaningful use to radiologists?” There is a significant hardship exception for EPs which states: (i) The Secretary may, on a case-by-case basis, exempt an EP who is not a qualifying EP from the application of the payment adjustment if the Secretary determines that compliance would result in a significant hardship for the EP. (ii) The Secretary’s determination to grant an EP an exemption may be renewed on an annual basis, provided that in no case may an EP be granted an exemption for more than 5 years. There may be the option to remove the annual application requirement and allow it to encompass applicants who indicate they do not have technology-purchasing power/influence in their respective practices/locations, revisions which only requires action by CMS.

The law was changed such that CMS no longer has the option of including POS 22 under the hospital-based determination; however, the option to use “or” terminology, e.g., “or relies exclusively upon the hospital’s technology” may be a viable strategy to pursue. Removing the comprehensiveness requirement such that the technology could be certified for only the measures with which the EP must comply is a possible strategy that would require an ONC rule change. If successful, this could eliminate the need for functionality for objectives EPs are excluded from, e.g., the e-prescribing function for radiologists. Allowing EPs to use Inpatient certified EHR technology as currently written would likely require a correction notice or rule change as would requiring hospitals to certify for General, Inpatient, and Ambulatory criteria.

The online Attestation Program was made available April 18, 2011 and is a written confirmation from the EP attesting to his/her meaningful use of certified EHR technology. EPs must attest to the numerators, denominators, and exclusions for all meaningful use measures and the CQMs, it requires the EP’s National Provider Identifier (“NPI”) and Tax Identification Number “(TIN”), beginning/end dates of EHR reporting period and other administrative information. CMS has also launched the Meaningful Use Attestation Calculator which is designed to help EPs and eligible hospitals determine if they have met all of the objectives and their associated measures for meaningful use prior to completing an attestation. The Calculator may be found at http://www.cms.gov/apps/ehr.

What To Do Now
There are a number of things radiologists can do now to determine if/how they will comply with meaningful use. Those who practice in hospital settings are wise to ask their hospitals what is being done at the hospital level and if the hospitals are intending to comply as EHs. If yes, a subsequent question is will the hospitals be purchasing the technology required for EP compliance and if so, on what timetable? The radiologist is not required to "own" the technology in order to comply so a hospital-supported solution is a viable one. If the answer is no, a follow-up question is will the hospitals provide the radiologists access so that meaningful use elements may be downloaded to a radiology group-supported solution? Radiologists in free-standing imaging centers will want to talk with their vendors about product certification and applicable implementation timelines and it is important to ask if upgrades to accommodate any changes resulting from Stage Two and Stage Three implementation will result in additional costs to the radiologists.

And some are pursuing a strategy of listening and learning without taking any immediate definitive actions. There are a number of stakeholders, including the RBMA, who are actively pursuing ways of making meaningful use more meaningful and more relevant to radiology and to radiologists. The results of these efforts may change the meaningful use landscape as we know it today, and a conservative approach to implementation may prove more fruitful in the long term. And at the end of the day, in the words of Kevin Henkes, “Sometimes all you can do is say ‘Wow’.”

¹ The 50 percent threshold for the core objective “record patient demographics” applies for Stage One of the program. The proposed thresholds for Stages Two and Stage Three are 80 percent and 90 percent respectively.

Barbara F. Rubel
Senior Vice President
Marketing & Client Services

Barbara F. Rubel, MBA, Senior Vice President, Marketing and Client Services, provides comprehensive support services for MSN Clients from the Request for Proposal (“RFP”) process through contract implementation. She holds the Master of Business Administration degree in Marketing from Mercer University Atlanta, as well as a Master of Music from Ohio University. Barbara’s expertise is in health care marketing, managed care contract negotiations, strategic planning, and market research. Prior to joining the MSN team, she provided health care marketing services to statewide radiology networks, sole physician practitioners, physician groups, and specialty physician networks as a marketing consultant. Barbara is a Past President of the Radiology Business Management Association (“RBMA”), an organization she current serves as Chair, Technology Task Force. She has also served as RBMA’s Southern Director (2003-2005), Secretary (2005-2007), and President-Elect (2006-2008). She is a Past President of the Georgia Radiology Business Management Association (“GRBMA”), an active member of the Healthcare Billing & Management Association (HBMA), and a contributor to the Journal of the American College of Radiology (“JACR”), the RBMA Bulletin and Imaging Economics.Barbara can be reached at brubel@msnllc.com or 770.431.9783.