ABR Foundation Summit 2010 Dr. Keith J. Dreyer

ABR Foundation Summit2010

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

US Healthcare ReformOpportunities for Radiology

•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

Conflict of Interest

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

http://upload.wikimedia.org/wikipedia/commons/4/4c/Barack_Obama_signs_American_Recovery_and_Reinvestment_Act_of_2009_on_February_17.jpg

Meaningful Use of Certified EHR Technology

EHR 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

Transformational Change in Health Care Delivery & Population Health

Technology Adoption

Time

2015

2015 MU Criteria Improved

Outcomes

2013

2013 MU CriteriaClinical Decision

Support

2011

2011 MU Criteria Capture & Share

Data

2009

2009 MU Criteria HITECH

Policies

HIT-Enabled Health Reform

Meaningful Use is Being DefinedTo Follow an “Ascension Path” Over Time*

*Report of Health IT Policy Committee

Meaningful Use Incentives by Adoption Year

Meaningful User

2009 2010 2011 2012 2013 2014 2015 2016Total

Incentive

2011 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000

2012 $ 18,000 $ 12,000 $ 8,000 $ 4,000 $ 2,000 $ 44,000

2013 $ 15,000 $ 12,000 $ 8,000 $ 4,000 $39,000

2014 $ 12,000 $ 8,000 $ 4,000 $ 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 MatrixONC Policy Committee

Radiology MU Submission to ONC

Radiology Meaningful Use MatrixAmerican College of Radiology

• Computerized Physician Order Entry• Clinical Decision Support• Image Management• Interpretation Process• Communication Management• Radiation Safety & Quality

Management

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

II. Ready for Introduction

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

III. Well Developed

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

Clinical Decision Support

Concept Function Priority Care GoalDeployability

Category1. 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


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

III. Well Developed

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.


Apply clinical decision support at the point of care

III. Well Developed

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 GoalDeployability

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.

Care Coordination



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.

Care Coordination



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.




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.

Care Coordination



Interpretation Process


Category

1.

Report Throughput

100% of all reports will be rendered in digital format and made available for distribution within the prescribed timeframe.




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.



III. Well Developed

Communication Management


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



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.

Care Coordination



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.


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.


Generate lists of patients who need care and use them to reach out to patients (e.g., reminders, care instructions, etc.)

III. Well Developed

Radiation Safety & Quality Management


Category

1.Radiation Dose

All patient radiation exposure will be recorded at the examination level in a local database and submitted to national registries.




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.




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

Proposed RulemakingJanuary, 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

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

Combined Key Radiology Society Response

Each measure was reviewed and discussed in the context of a radiology practice

CMS Final RuleJuly, 2010

•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

The definition of EH and EP has been changed

Eligible Hospital Eligible ProfessionalCMS Place of Service Codes84% of all Physicians

Eligibility Determination:If 10% (or more) of your CMS practice is from POS 11, 20, 22, 24, 49

you are considered an eligible professional.

CMS Final RuleJuly, 2010

Relaxed the requirements for 2011-12 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 RuleJuly, 2010

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 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. 2010.

Objectives

Federal Healthcare Reform Preparing for Radiology Meaningful Use

Radiology MU15 Core Objectives

•Required: Technology probably does not exist in your department

1.Implement one clinical decision support rule2.Electronically exchange key clinical information among patient authorized

providers3.Report ambulatory clinical quality measures to CMS/States4.Conduct annual Security Risk Analysis, HIPAA 45 CFR 164.308(a)(1)

•Required: Technology may exist within your department1.Provide patients with an electronic copy of their health information, upon

request2.Provide clinical summaries for patients for each office visit3.Drug-drug and drug-allergy interaction checks4.Record demographics5.Maintain active medication allergy list6.Record smoking status for patients 13 years or older7.Maintain an up-to-date problem list of current and active diagnoses8.Maintain active medication list

•Most radiologists excluded1.Computerized physician order entry (CPOE)2.Record and chart changes in vital signs3.E-Prescribing (eRx)

Radiology MU10 Menu Objectives

•Required: Two of the following seven1.Provide patients access to their health information via an electronic portal2.Generate lists of patients by specific conditions3.Drug-formulary checks4.Incorporate clinical lab test results as structured data5.Send reminders to patients for preventive/follow up care6.Use of certified EHR to identify patient-specific education resources7.Capability to provide electronic syndromic surveillance data

•Most radiologists excluded1.Medication reconciliation2.Summary of care record for each transition of care / referrals3.Capability to submit electronic data to immunization registries/systems

Objectives

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

Radiology MURequired 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 164.308(a)(1)

MGH Radiology Clinical Decision SupportROE-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

Head CT Page1

Selecting a Patient

Doctor or Staff Can Log In

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 choseHead 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

AdjustedAnnual Compound

Growth Rate12%

AdjustedAnnual Compound

Growth Rate1%

MGPO actual imaging tests per 1000 members (MRIs, CT Scans, Nuclear Cardiology)

310.0

315.0

320.0

325.0

330.0

335.0

340.0

345.0

350.0

355.0

360.0

365.0

370.0

375.0

380.0

385.0

390.0

395.0

2004 2005 2006 2007 2008

actu

al t

ests

per

100

0 m

emb

ers

19% Decrease(2005 – 2008)

ROE-DS Results In Minnesota



Radiology MUNew Required Functionality

•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

Wide Area Image Sharing

ROE

Enterprise RIS / PACS /

EMR

5. Gatekeeper reconciles patient and study information, and push to RIS / PACS / EMR

`

1. Physician’s office receive CDs from patients, upload images & reports

4. Physician can nominate to PACS for distribution and/or interpretation by radiology

`

2. Physician review images & reports directly using any PC or Mac on the network

`

3. Physicians can share studies with other physicians with access to the facility’s network

`

CD Import Workflow

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)

Wide Area Image Sharing

* Stage I - Meaningful Use Objective

Secure Internet Distribution

ROE




Render

Lexicon Mediated Entropy Reduction

LEXIMER*Radiology 2005;234:323-329

Noise ReductionNoise Reduction LN

Signal ExtractionSignal Extraction LS

Clinical FindingsClinical Findings

RecommendationsRecommendations

Bilateral subdural hemorrhages with subarachnoid hemorrhage.

A follow up MRI of the brain is recommended within 7 days to assess progression of

hemorrhage.

ClassificationClassification LC

DiscretizationDiscretization LD

Phrase IsolationPhrase Isolation LP

Structured BriefStructured Brief

SNOMED-Terms RadLex-IDFindings: 57003 Hemorrhage 30005 Locations: 18720 Subdural 36230 Subarachnoid 36231 Side: 18235 Bilateral 51444

Etiology: 64573 Unspecified 31564

Recommendation: 39115 Brain MRI 29567 Time: 41066 Days 25870 Quantity: 24620 7 7STRUCTURED OUTCOMES

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 1999. 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.

Render with RadLex via Leximer

Appendicitis

Ectopic Pregnancy

Pancreatitis

Cirrhosis

Abdominal Aortic Aneurism

Osteoblastoma




Objectives

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

Radiology MUSummary

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

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

• 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

• 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

Radiology MUSummary

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

ABR Foundation Summit2010

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

US Healthcare ReformOpportunities for Radiology

Documents

ABR Foundation Summit 2010 Dr. Keith J. Dreyer