Advocates work to build radiology's place in healthcare reform infrastructure

On Jan. 24, 2009, newly sworn in President Obama uttered a bold promise: “To lower healthcare costs, cut medical errors, and improve care, we'll computerize the nation's health records in five years, saving billions of dollars in healthcare costs and countless lives.” It's those words that marked the beginning of healthcare reform. In the 18 months since that first weekly address, a number of significant events have unfolded. This article will take a look at how we got to where we are today, the challenges along the way, and measures taken to ensure alignment with radiology's scope of practice. It will also review solutions that will be at the forefront in this new era of healthcare.

WHERE WE ARE TODAY

On Feb. 13, 2009, less than four weeks after Obama's inauguration, Congress passed the American Recovery and Reinvestment Act of 2009 in direct response to the economic crisis. Four days later, the president signed the $787 billion dollar act into law. Out of this act, the Health Information Technology for Economic and Clinical Health (HITECH) Act was born. This subset of ARRA provides more than $20 billion in funding to improve healthcare IT in the U.S.

At the forefront of these health IT efforts is the Office of the National Coordinator for Health Information Technology (ONC). This organization, located within the Office of the Secretary of Health and Human Services, acts as a resource to support the adoption of health information technology and improve patient care through implementation of a nationwide health information exchange (HIE).

On March 20, 2009, the Obama administration appointed a Massachusetts General Hospital colleague, David Blumenthal, M.D., M.P.P. (master of public policy), as national coordinator of health information technology for the ONC with his primary objective being to lead the implementation of a nationwide interoperable and protected health information technology infrastructure as called for by ARRA. Subsequently, Dr. Blumenthal recruited Partners Healthcare System's chief information officer, John Glaser, Ph.D., as a special advisor to the ONC.

At the same time, and under the auspices of the Federal Advisory Committee Act, the Health IT Policy Committee and Health IT Standards Committee were formed. Both are charged with making recommendations to Dr. Blumenthal. The policy committee focuses primarily on the national health information infrastructure and helps establish medical information exchange standards, while the standards committee is responsible for implementation specifications and electronic exchange certification criteria and focuses on policies developed by the policy committee. These groups, under the ONC, became responsible for providing recommendations to the Centers for Medicare and Medicaid Services, the group responsible for defining meaningful use criteria.

On Dec. 30, 2009, after months of deliberation, the ONC issued its Interim Final Rule, a summary of recommendations on meaningful use. The interim rule proposed the initial set of standards and certification criteria as well as implementation specifications. That same day, CMS issued a Notice of Proposed Rulemaking, which outlined three incentive programs and the provisions governing each program, including the communication of results to patients, communication with electronic medical records (EMRs) outside the enterprise, and the use of five decision support rules.

Following the release of the interim rule and the proposed final rulemaking, a public comment period was initiated with a deadline of March 15, 2010. During this comment period, numerous radiological societies joined forces to ensure meaningful use descriptions were defined in such a way that they are reasonably achievable for all radiologists.

ENSURING RADIOLOGY GETS COVERED

Like most medical specialties, diagnostic imaging–specific measures were not sufficiently addressed by providers in variant meaningful use definitions. On Oct. 29, 2009, working on behalf of the radiology community, the American College of Radiology proposed topics to the HIT Policy Committee that it viewed as relevant to the discussion of meaningful use of radiology. Radiology meaningful use can be thought of as the use of IT in the practice of radiology to enhance quality, improve patient safety, decrease costs, and demonstrate improved outcomes. Areas of focus include order entry, decision support, image sharing, interpretation, communication management, and quality and safety.

Five months later, in March 2010, the ACR, joined by the RSNA, the American Board of Radiology, and the Society for Imaging Informatics in Medicine, issued a collective set of comments on all 25 reporting measures of the proposed EMR incentive program as they apply to radiology. This letter, the drafting of which I coordinated, urged CMS to define meaningful use criteria in such a way that it would be achievable by all eligible radiologists. It also offered specific ways in which CMS could improve the final rule to ensure this relevancy. Ongoing work is being done to ensure that radiology's role in patient care coordination is appropriately addressed by the final meaningful use criteria.

SOLUTIONS FOR THE NEW ERA

We have already discussed radiology meaningful use topics of interest, but now let's examine those areas emphasized as priorities for improving the quality of patient care and accessibility to radiology information: order entry, decision support, and image sharing. Order entry and decision support will proliferate with widespread EMR adoption and use, while image sharing will expand as new and viable solutions enter the marketplace.

In November 2009, as other health initiatives were under way, the RSNA was awarded a grant from the National Institute of Biomedical Imaging and Bioengineering to develop an Internet-based medical image sharing network for patients. The goal of the RSNA Radiology Informatics Committee, which oversees this activity and of which I am a member, is to create a reference model based on Cross-enterprise Document Sharing for Imaging (XDS-I), an IHE profile designed to enable sharing of medical documents and data.

Technology does exist today to take advantage of these standard IHE protocols to create an immediate and plausible exchange platform. We have recently deployed a technology at MGH to eliminate physical media for image sharing. This cloud-based image sharing platform (lifeIMAGE, Newton, MA) is now an integral part of our strategy to meet care coordination goals. The universal imaging inbox makes it possible to securely collect, view, and share diagnostic imaging cases among physicians and patients. Currently, the lifeIMAGE Local Appliance lets our physicians view, store, and share the contents of incoming patient CDs/DVDs throughout the enterprise. The next release of this product will allow us to communicate across institutions and share results with outside physicians and patients, regardless of location.

With nearly half a billion federal dollars being distributed to HIEs, cloud-based technologies will facilitate clinical care coordination. Improved access to patient health data offers numerous benefits, such as eliminating an estimated 12% of redundant exams and reducing exposure to unnecessary radiation. This is just one example of how innovative technology is being used to support this new era of healthcare reform.

Where we stand now

Healthcare reform began with a bold promise from our 44th president to computerize the nation's health records. Since that statement was made 18 months ago, a great deal of effort has been put forth to turn that promise into a reality. While current meaningful use definitions have failed to address specific needs of most non-primary care specialists, including radiologists, groups like the ACR, ABR, RSNA, and SIIM are working aggressively to define radiology meaningful use and ensure final measures are reasonably achievable by all eligible radiologists. Whatever the final outcome, radiology practices should look to new technologies that help address the impending requirements in this new era of healthcare in the U.S.