US Healthcare Reform Opportunities for Radiology ABR Foundation Summit

US Healthcare Reform Opportunities for Radiology ABR Foundation Summit
2010 Dr. Keith J. Dreyer Vice Chairman of Radiology, Massachusetts General Hospital Assistant Professor of Radiology, Harvard Medical School Corporate Director, Enterprise Medical Imaging, Partners HealthCare Chairman, ACR Government Relations Committee Co-Chairman, ACR Informatics Committee

Conflict of Interest MGH Licensed Technology Medical Advisory Boards
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

Objectives Federal Healthcare Reform
Preparing for Radiology Meaningful Use Demonstration of New Technologies Summary

President Obama’s First Weekly Address - January 24th, 2009
“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.”

American Recovery and Reinvestment Act (ARRA)
Health Initiatives: To incentivize the ‘Meaningful Use’ of certified EHR technology

Meaningful Use of Certified EHR Technology
Electronic Health Record Certified 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

Envisioning a “Tipping Point” -- Health IT as an Enabler
Technology Adoption Transformational Change in Health Care Delivery & Population Health Time

Meaningful Use is Being Defined To Follow an “Ascension Path” Over Time*
2009 2009 MU Criteria HITECH Policies 2011 2011 MU Criteria Capture & Share Data 2013 2013 MU Criteria Clinical Decision Support 2015 2015 MU Criteria Improved Outcomes HIT-Enabled Health Reform *Report of Health IT Policy Committee 8

Meaningful Use Incentives by Adoption Year
Meaningful User 2009 2010 2011 2012 2013 2014 2015 2016 Total Incentive $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000 $ 15,000 $39,000 $ 24,000 2015 + 1%-5% Penalties $1.5B incentive opportunity for US radiologists $10B annual penalty impact for US radiologists

Health and Human Services
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

Meaningful Use Matrix ONC Policy Committee

Radiology MU Submission to ONC

Radiology Meaningful Use Matrix American College of Radiology
Communication Management Concept Function Priority Care Goal Deployability Category 1. Distribution of Images and Reports to ordering providers All imaging and report data will be immediately available for consumption by authorized healthcare providers through secure Internet or Intranet access. Care Coordination Exchange meaningful clinical information among professional health care team I. Mature Technology 2. Distribution of Images and Reports to patients All imaging and report data will be available for consumption by patients through secure Internet access or PHR providers. II. Ready for Introduction 3. Critical Findings Management All urgent and critical findings will be communicated directly with the ordering provider. These findings and their associated communications will be tracked and recorded in a local database. Improve quality, safety, efficiency and reduce health disparities Generate lists of patients who need care and use them to reach out to patients (e.g., reminders, care instructions, etc.) 4. Recommendation tracking and reconciliation All recommendation for further imaging will be monitored. In cases where the recommendation was not performed within the time specified, communication to the ordering provider will be performed and recorded. III. Well Developed Computerized Physician Order Entry Concept Function Priority Care Goal Deployability Category 1 Computerized Physician Order Entry Orders for outpatient diagnostic imaging are entered electronically by the referring provider at the point of order. These orders contain enough standardized and codified information about modality, body region, contrast, clinical application, and other details to allow the exact study protocol to be determined by imaging facility personnel. Improve quality, safety, efficiency and reduce health disparities Use CPOE II. Ready for Introduction 2 Imaging protocol standardization Examinations will be defined in a standardized format detailing the examination acquisition and protocol performed in RADLEX format. Provide access to comprehensive patient health data for patient’s health care team 3 Imaging protocol selection Implies articulation of 'orderables' and 'performables' and a process by which the specific imaging protocol is selected or tailored to the level of specificity required at each point in the process (e.g., pre-authorization, scheduling, scanning) Use evidence-based order sets III. Well Developed 4 Exam scheduling and reconciliation by ordering physician Exposing examination resource availability to referring physicians for remote scheduling Care Coordination Exchange meaningful clinical information among professional health care team 5 Exam scheduling by patient Exposing examination resource availability to patients for remote scheduling Enagage Patients Provide patients and families with timely access to data, knowledge, and tools to make informed decisions IV. In Development Radiation Safety & Quality Management Concept Function Priority Care Goal Deployability Category 1. Radiation Dose All patient radiation exposure will be recorded at the examination level in a local database and submitted to national registries. Improve quality, safety, efficiency and reduce health disparities Report to registries for quality improvement, public reporting, etc II. Ready for Introduction 2. Peer Review 2% of all interpretations will be reviewed by a second interpreter and scored for accuracy. Egregious discrepancies will be internally reviewed and transmitted to a national registry. I. Mature Technology 3. Ordering physician outcomes feedback Digital capture of ordering physician feedback regarding the quality of the interpretation and its usefulness in the process of patient care and effectiveness on patient outcome. Provide access to comprehensive patient health data for patient’s health care team III. Well Developed Interpretation Process Concept Function Priority Care Goal Deployability Category 1. Report Throughput 100% of all reports will be rendered in digital format and made available for distribution within the prescribed timeframe. Improve quality, safety, efficiency and reduce health disparities Exchange meaningful clinical information among professional health care team I. Mature Technology 2. Common reporting format Reports will be rendered and distributed in a single format that is common to the health provider organization regardless of individual interpreter styles. Care Coordination 3. Standardized reporting format Reports will be rendered and distributed in a single format that conforms with the national standard for structured reporting of radiology information. Use evidence-based order sets III. Well Developed 4. Structuring and Coding of Key Components Standard codification of key reporting elements including Procedure performed, Pertinent Findings and Recommendations. Report to registries for quality improvement, public reporting, etc Clinical Decision Support Concept Function Priority Care Goal Deployability Category 1. Clinical Decision Support for ordering physician This is distinct from normative appropriateness feedback and consists of guidelines and diagnostic pathways linked directly from the ordering client. May also include assistance in protocol selection and notification about prior studies on the same patient that may be relevant Improve quality, safety, efficiency and reduce health disparities Apply clinical decision support at the point of care III. Well Developed 2. Ordering physician appropriateness feedback retrospectively If facility has implemented ROE with prospective DS about appropriateness of outpatient imaging, can use these existing scores for aggregation and feedback. If facility does not employ ROE with DS at point of order, appropriateness scores may be generated retrospectively for each examination based on the study modality/type and clinical indications for that study. Most likely, this would be done by a standardized and CMS authorized automated method that applies authorative appropriateness criteria to electronic administrative data about the examinations. Would have to determine if want to allow facilities to try and do the appropriateness scoring by hand/chart review. However, probably would want to stick to the SAME requirements for percent of providers and studies included. Report to registries for quality improvement, public reporting, etc 3. Ordering physician appropriateness feedback at point of order Give ordering providers immediate normative feedback (ordinal categories or numeric scores) about the appropriateness of requested imaging exams based on their assertions of clincal scenario/indications during computerized order entry. These categories and/or scores should be drawn from authoritative sources. This depends on having one or more authorative, transparent, public sources of appropriateness scores such as ACR-AC or ACC-AC. Also depends on Computerized Radiology Order Entry (ROE) with coded capture of both standard procedure descriptions AND clinical scenario (signs, symptoms, know diagnoses, demographics, co-morbidities) assertions. 4. Report ordering physician case-mix adjusted imaging utilization information Exact methods for aggregating, case-mix adjusting, and reporting radiology resource use data to outpatient referring providers are somewhat controversial, in constant flux, and under development. It is insufficient to simply report raw numbers of examinations ordered by individual providers without some reference to normative criteria based on data from relevant peers. Further, providers with relatively high absolute use rates are likely also those with busier practices and sicker patients. Therefore, any feedback to referring providers about their utilization of imaging must, at least, be corrected for practice size and mixture. In outpatient settings, this implies access to 'denominator' data for each provider and the most obvious is outpatient visits rendered by them. It is important to note that the denominator (visits) and numerator (imaging tests) must derive from the same population of patients. IV. In Development Image Management Category Function Priority Care Goal Deployability Category 1. Image Storage in Digital Format Storage of all acquired image data using DICOM standards in a certified image archive for a period of time mandated by state and federal requirements. Care Coordination Exchange meaningful clinical information among professional health care team I. Mature Technology 2. Image Sharing via standard media in DICOM format Capable to export and import standard media (eg CD, DVD) to transfer any stored patient image data. 3. Image Sharing via media-free electronic transfer Capability to export and import all patient image data amongst providers and PHRs using IHE protocols via secure Internet connectivity. II. Ready for Introduction 4. Image Display for interpretation Must use certified software on qualified hardware for the visualization of image data. Display systems must be capable of displaying current as well as all prior and shared image data. Improve quality, safety, efficiency and reduce health disparities 5. Image Display for referring physicians Must provide a software application for referring physicians to see current image data as well as relevant prior, including shared image data. Computerized Physician Order Entry Clinical Decision Support Image Management Interpretation Process Communication Management Radiation Safety & Quality Management

Proposed Rulemaking January, 2010
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

Combined Key Radiology Society Response
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

CMS Final Rule July, 2010 POS: 11, Office
The definition of EH and EP has been changed CMS Place of Service Codes Eligible Hospital 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
CMS Final Rule July, 2010 Relaxed the requirements for in response to public comments 15 ‘Core Set’ Measures (5 are eligible for exclusion) Must meet all non-excluded measures 10 ‘Menu Set’ Measures (6 are eligible for exclusion) Must meet 5 out of 10 measures 44 Clinical Quality 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

ONC-HIT Final Rule July, 2010
Did NOT relax the requirements for 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 CPOE: CMS Stage 1 for medications, Cert. requires radiology orders All EPs must be capable of measuring ALL objectives Regardless of exclusions or menu selections Testing and certification process will begin Sept

Preparing for Radiology Meaningful Use

Radiology MU 15 Core Objectives
Required: Technology probably does not exist in your department 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 (a)(1) Required: Technology may exist within your department 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 Computerized physician order entry (CPOE) Record and chart changes in vital signs E-Prescribing (eRx)

Radiology MU 10 Menu Objectives
Required: Two of the following seven 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 Medication reconciliation Summary of care record for each transition of care / referrals Capability to submit electronic data to immunization registries/systems

Preparing for Radiology Meaningful Use Demonstration of New Technologies

Radiology MU Required New Functionality
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 (a)(1)

MGH Radiology Clinical Decision Support ROE-DS
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 Prior related exam reports and images available Radiation Alert Extra Decision Support for Primary Care 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

ROE-DS Secure Web Site

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

ROE DS Effect On Imaging Volumes

OP Visit Volumes

Effect of Decision Support on HCI
19% Decrease (2005 – 2008) Adjusted Annual Compound Growth Rate 1% Adjusted Annual Compound Growth Rate 12%

radiology Order entry and decision support
19% Decrease (2005 – 2008)

ROE-DS Results In Minnesota

Radiology MU New Required Functionality
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

Wide Area Image Sharing
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 1. Physician’s office receive CDs from patients, upload images & reports 2. 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. Physicians can share studies with other physicians with access to the facility’s network 4. Physician can nominate to PACS for distribution and/or interpretation by radiology

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

Wide Area Image Sharing
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

Render

Lexicon Mediated Entropy Reduction LEXIMER *Radiology 2005;234:323-329
Bilateral subdural hemorrhages with subarachnoid hemorrhage. Clinical Findings Phrase Isolation LP This study is reviewed with Dr Smith. Standard protocol was used to obtain an MRI of the brain with MRA of the circle of Willis and DWI imaging. Dizziness and recurrent syncope. Please evaluate the posterior circulation. Comparison is 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 Bilateral subdural hemorrhages are present. The right sided subdural hemorrhage appears improved when compared to the prior CT. It has a component extending further posteriorly than appreciated on the CT, appearing to involve the occipital lobe on the right side. The left subdural hemorrhage is worse than it appeared on the initial CT. There is extensive subarachnoid hemorrhage better appreciated on MRI than on CT. There is no evidence of tentorial subdural hematoma. The subsequent CT did show such a bleed, this must have occurred in the interval between studies. DWI imaging of the brain parenchyma is normal in appearance. There is no evidence of acute infarction. The circle of Willis was imaged with particular attention to the posterior circulation. The right vertebral artery appears prominent. The posterior circulation appears entirely normal. Because imaging was centered on the posterior circulation, the MCA's are not completely evaluated. The ventricular system and CSF spaces do not show evidence of abnormal dilation. The visualized extracranial structures are normal in appearance. Impression. No evidence of acute infarction on diffusion weighted imaging. Bilateral subdural hemorrhages with subarachnoid hemorrhage. The posterior circulation appears entirely normal. A follow up MRI of the brain is recommended within 7 days to assess progression of hemorrhage. A follow up MRI of the brain is recommended within 7 days to assess progression of hemorrhage. Recommendations STRUCTURED OUTCOMES Noise Reduction LN SNOMED-Terms RadLex-ID Findings: Hemorrhage Locations: Subdural Subarachnoid Side: Bilateral Etiology: Unspecified Recommendation: Brain MRI Time: Days Quantity: Signal Extraction LS Classification LC Structured Brief Discretization LD

Render with RadLex via Leximer

Appendicitis

Ectopic Pregnancy

Pancreatitis

Cirrhosis

Abdominal Aortic Aneurism

Osteoblastoma

Preparing for Radiology Meaningful Use Demonstration of New Technologies Summary

Radiology MU Summary 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): Radiology Structured Reporting

Radiology Structured Reporting
Imaging Technique Time of image acquisition Imaging device Image acquisition parameters, such as device settings, patient positioning, interventions (e.g., Valsalva maneuver) Contrast materials and other medications administered (including name, dose, route, and time of administration) Radiation dose Comparison Date and type of previous exams reviewed, if applicable Observations Narrative description or itemization of findings, including measurements, image annotations, and identification of key images Summary (or Impression) 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 Administrative Information Imaging facility Referring provider Date of service Time of service Patient Identification Name Identifier (e.g., medical record number or Social Security Number) Date of birth Gender Clinical History Medical history Risk factors Allergies, if relevant Reason for exam, including medical necessity Structured Reporting Radiological Society of North America (RSNA) - Structure Reporting Initiative (SRI) Use of RadLex for approved terminology and Procedure Mapping Standard Library of Reports freely available from RSNA.org Implementation of RSNA SRI into industry products has occured

Radiology MU Summary RadiologyMU.org Stay tuned, stay informed!
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): 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! RadiologyMU.org

US Healthcare Reform Opportunities for Radiology ABR Foundation Summit
2010 Dr. Keith J. Dreyer Vice Chairman of Radiology, Massachusetts General Hospital Assistant Professor of Radiology, Harvard Medical School Corporate Director, Enterprise Medical Imaging, Partners HealthCare Chairman, ACR Government Relations Committee Co-Chairman, ACR Informatics Committee

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