The U.S. government should make major changes to its draft proposal for stage 2 meaningful use requirements for healthcare IT stimulus funding, according to comments submitted by the American Medical Association (AMA), the American College of Radiology (ACR), and 38 other specialty medical organizations.
They had the following messages for the Health IT (HIT) Policy Committee Meaningful Use Workgroup of the Office of the National Coordinator for HIT (ONC), although not put in such blunt terms:
- Expand your vision. Recognize that a "cookie-cutter" approach defining "meaningful use" for general practitioners is not applicable to medical specialists, and it can waste money and hinder adoption efforts.
- Make financial incentive program requirements more flexible.
- Get real about technological realities and the actual costs of implementation that physicians will bear.
- Electronic health record (EHR) access to diagnostic images and radiology-related data is of critical importance to reduce costs and improve healthcare.
In other words, meaningful use committee, go back to the drawing board.
These sentiments were issued in a February 22 letter from the ACR, representing more than 34,000 radiologists, radiation oncologists, interventional radiologists, nuclear medicine physicians, and medical physicists, and in a February 25 letter jointly signed by 39 professional medical organizations. The letters were sent to the ONC at its own request for comments regarding the draft proposal recommendations, which were published on January 14, 2011.
ACR comments
The ACR comments to the workgroup focused on several concerns:
- Diagnostic images and related information, such as radiation dose data, imaging history, and radiology reports, should be accessible via certified EHR technology.
- Specialty-specific requirements for stage 2 would be more appropriate than the final stage 1 requirements' one-size-fits-all paradigm. If specialty-specific requirements are not adopted, then exclusions from individual objectives or measures need to be more flexible.
- Providers should only be required to implement EHR modules they actively use.
- The bar should be raised in terms of computerized physician order entry (CPOE) with integrated clinical decision support tied to appropriateness guidelines.
In its letter, the ACR reminded the ONC of the takeaway messages of a two-day workshop it cosponsored with the National Institutes of Health (NIH) on January 10 and 11, entitled "Images, Electronic Health Records, and Meaningful Use: A Vision for the Future."
Attendees at the workshop concluded that diagnostic images and other radiology tools are essential to patients' health records, and that this information must be accessible using EHR technology. Also, CPOE with integrated clinical decision-support software would increase efficiency of diagnosis and appropriateness with respect to both the necessity of exams and radiation dose exposure.
Finally, the requirements of the Medicare and Medicaid EHR Incentive Programs were not "meaningful" for radiologists, despite the specialty's continued leadership in HIT standards, interoperability, and implementation, and the fact that most radiologists have already converted to digital from x-ray film and paper-based recordkeeping.
Clinical studies have shown that radiology orders can be reduced by up to 12% when prior exams can be accessed digitally, the ACR noted. The organization also stressed that EHR technology should incorporate radiation dose exposure in a patient's medical record, and that this needs to be tied into the CPOE process. Physicians need to be cognizant of the cumulative radiation dose exposure of their patients, the ACR explained, and weigh the probable benefits of a diagnostic imaging exam against its potential risks.
The organization recommended that radiology exam order-entry systems should become a separate meaningful use objective and be certified independently from the current integrated prescription/laboratory/radiology systems that ONC has defined. By having a separate certification criterion, the Centers for Medicare and Medicaid Services (CMS) and the ONC would promote innovation and more rapid adoption, the ACR contends.
In the ACR's opinion, having 43 preliminary draft objectives/measures that need to be met will be extremely daunting to most participants. It suggested that items not under the direct control of a physician or not applicable to a physician's specialty be excluded.
The ACR letter, which was jointly signed by ACR chair Dr. John Patti and Dr. Keith Dreyer, PhD, chair of the ACR's government relations subcommittee of the IT and informatics committee, includes detailed responses to specific items; it can be accessed here.
The AMA weighs in
The 46-page letter sent by the AMA and 38 other medical societies represented both general practice physicians and numerous specialties, including but not limited to anesthesiologists, psychiatrists, pathologists, emergency physicians, dermatologists, cardiologists, endocrinologists, allergists, gynecologists and obstetricians, surgeons, and ophthalmologists. Radiation oncologists were represented by the American Society for Radiation Oncology (ASTRO) and interventional radiologists were represented by the Society of Interventional Radiology (SIR).
The societies' stated that their members support the objective to convert from paper-based records to EHRs in a timely manner to transform healthcare as it is currently practiced in the U.S. However, it warned that the ONC and CMS must be realistic.
"Asking physicians to do more within an environment that is still not largely interconnected, and in which commercially available products cannot perform the required functions reliably, will simply result in additional financial and administrative burdens," they warned. "Inflexible, overly ambitious incentive program requirements will only hinder health IT transitions under way today."
The societies recommended the following:
- CMS and ONC should survey physicians who did and did not register to receive stage 1 financial incentives to identify barriers to and solutions for physician participation prior to moving to stage 2.
- "Meaningful use" should be applicable and appropriate to a physician's routine practice. The rules should fit the needs of medical specialists.
- The value achieved from implementing stage 1 requirements should be thoroughly assessed and publicly vetted. Moving on to stage 2 should be postponed until this analysis has been completed.
- High thresholds should be avoided for objectives that cannot be met due to the lack of available, well-tested tools or bidirectional health information exchanges.
- Measures that require adherence from anyone other than a physician should be removed from the requirements. This includes laboratories reporting test results and patients being able to access their records.
The letter specifically addressed specialists who "do not come into direct contact with patients, like pathologists and radiologists." The societies emphasized that "these specialists' use of health IT is critical, as is their ability to begin exchanging health information with other healthcare providers."
CPOE integrated with clinical decision support was also addressed. The societies pointed out that standalone CPOE systems are more robust, especially radiology systems which "are far more robust than certified modules that handle all three order types." They noted that "most of the cost savings that are generally attributable to the use of CPOE involve systems that are integrated with clinical decision support."
Expressing concern "about the current ability of many hospitals to meet CPOE requirements given the complexity associated with its implementation, including the length of time it takes to train physicians," the societies recommended "either removing the lab and radiology requirements for stage 2, or decreasing the proposed threshold requirement substantially."
This is where the ACR and the 39 societies have polarized opinions about the proposed requirements for CPOE. Otherwise, they are in lockstep in their recommendations that major revisions are needed for the proposed stage 2 requirements.
