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The usual EHR approach won’t suffice in the future. You need to be able to get orders electronically and be more responsible to patients with your reporting.
The Recovery Act (2009) mandates record keeping changes to provide incentive payments for the adoption and use of Electronic Health Records (EHR) provided that such systems support “meaningful use.”
Radiology has not been as included in the meaningful use program for Stage 1 and 2 (2013 deadline) as it should have been. Radiologists need to make sure that they are specifically included in Stage 3 (2016 deadline).
Currently, the only part of meaningful use that has included radiology is the requirement that computerized physician order-entry (CPOE) software include "at least one medication, and one lab or radiology order for 60 percent of unique patients who have at least one such order.”
Get more background on meaningful use
That’s not saying much.
What is clear, though, is that the usual EHR approach won’t suffice in the future.
For example, in Stage 3, 80 percent of all orders from both providers and hospitals will have to come through CPOE. They need a way to transfer order information to radiologists electronically. However, typical CPOE as part of an EHR system doesn’t usually let users send orders from office practices to all the possible hospital EHRs or free-standing facility EHRs for outpatient imaging.
Furthermore, Stage 3 MU requires that radiologists provide patients with an electronic copy of their records in 90 percent of the cases when requested by the patient. This particular requirement gets specific in saying that patient should be able to get their “diagnostic test results” or standard radiology reports. And you have to contact the patient in the manner they prefer.
Finally, the most significant change to radiology reporting will be due to the Stage 3 MU requirement to: “make the information relevant to the patient encounter” available in four days (for follow-up testing) in a summary form. In order to make the testing results relevant, the radiology reporting approach must change-at least to some degree. At present, many reports would not be interpretable by patients as radiology reports provide data and information, but not clinical understanding. Although the referring physician has an important role in assisting the patient with understanding the report, the radiology report itself will seem inadequate without changes to make the findings interpretable.
So what can you do?
Start changing your reporting style now; can you add a summary that makes the findings clear? Start talking to your hospital(s) and key referrers about their plans to get you orders electronically. And start thinking about how you’ll make records available to requesting patients.
V. Katherine Gray, Ph.D., is President, Sage Health Management Solutions, Inc.