ABR Foundation Summit 2010 Dr. Keith J. Dreyer

1. 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 US Healthcare Reform Opportunities for Radiology

2. Conflict of Interest • 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

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

4. 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.”

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

6. 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

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

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

9. Meaningful Use Incentives by Adoption Year $1.5B incentive opportunity for US radiologists $10B annual penalty impact for US radiologists

10. 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

11. Meaningful Use MatrixONC Policy Committee

12. Radiology MU Submission to ONC

13. Radiology Meaningful Use MatrixAmerican College of Radiology • Computerized Physician Order Entry • Clinical Decision Support • Image Management • Interpretation Process • Communication Management • Radiation Safety & Quality Management

14. 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

15. 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

16. CMS Final RuleJuly, 2010 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.

17. 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

18. 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.

19. Objectives Federal Healthcare Reform Preparing for Radiology Meaningful Use

20. Radiology MU15 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 164.308(a)(1) • Required: Technology may exist within your department • Provide patients with an electronic copy of their health information, uponrequest • 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)

21. Radiology MU10 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 forpreventive/follow up care • Use of certified EHR to identify patient-specificeducation 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

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

23. 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)

24. 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

25. ROE-DS Secure Web Site

26. Selecting a Patient Doctor or Staff Can Log In Head CT Page1

27. Selecting A Study To Order

28. Considerations / Protocols (here for Head CT)

29. Indications Specific To Study Type (here for Head CT)

30. Duplicate Exam / Radiation Warning

31. Decision Support Feedback Screen Here user chose Head CT with indication of dementia only

32. Screen To Proceed On Red

33. Exam Ordered But Not Yet Scheduled

34. Office staff can schedule the exam

35. Automatically select the first available time slot

36. Or, pursue web scheduling calendar

37. View, Cancel, Reschedule, Print Instructions

38. Patient Instructions Directions To Imaging Center

39. ROE DS Effect On Imaging Volumes

40. OP Visit Volumes

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

42. ROE-DS Results In Minnesota

43. Radiology MUNew 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

44. 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

45. CD Import Workflow 2. Physician review images & reports directly using any PC or Mac on the network 1.Physician’s office receive CDs from patients, upload images & reports 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

46. Main Login

47. Initiate Study Upload

48. Locate Image Files

49. Confirm Upload

50. Upload in process