Radiology Providers and The MU Stage 3 Proposed Rule

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By Adrienne Dresevic, Esq., and Leslie A. Rojas, Esq., of The Health Law Partners, P.C. 

On March 30, 2015, the CMS published a proposed rule updating the requirements for stage 3 of its EHR Incentive Program, Meaningful Use (MU).The proposed rule is available here. This article will highlight a few of the proposed provisions applicable to radiology providers.

For All Providers: More Flexibility in the Program’s Requirements

The proposed rule relaxes many of the current MU requirements. For example, providers would have the option to begin stage 3 of MU either in 2017 or 2018, which is a one-year extension from what the regulations currently state. If the proposed rule is adopted, stage 3 MU would be required beginning in 2018, and stages 1 and 2 would no longer be an option for providers.

Additionally, instead of the current 90-day reporting period, a one-year reporting period would be applicable to any first-year program participant, and the first-year program participant would be required to avoid penalties for two years prior to the related penalty year.[1] By way of example, a radiologist who used all five of his or her “significant hardship” exceptions through 2018 must be in compliance with MU in 2018 and for two years thereafter in order to avoid penalties in 2020. Therefore, if the proposed rule is adopted, these providers should start preparing for a 2018 start date well in advance – in 2017 or, preferably, earlier.

The proposed rule also seeks to simplify current MU requirements by reducing the number of objectives to eight, removing redundant measures, and aligning clinical quality measure reporting with other CMS programs.

For Radiology Providers: Applicable Objectives and Possible Exclusions

The eight proposed objectives for stage 3 MU are:

  • Protect Patient Health Information
  • Electronic Prescribing
  • Clinical Decision Support (CDS)
  • Computerized Provider Order Entry
  • Patient Electronic Access to Health Information
  • Coordination of Care through Patient Engagement
  • Health Information Exchange
  • Public Health and Clinical Data Registry Reporting

Diagnostic radiologists would likely meet the proposed exclusions to the following objectives: electronic prescribing, computerized provider order entry, patient electronic access to health information, and coordination of care through patient engagement. For the remaining four objectives, if adopted, radiology providers would need to meet the following measures:

  • Patient Protected Health Information:
    • Conduct (upon installation or upgrade of CEHRT) or review (as necessary, but at least annually) a HIPAA security risk analysis;
    • Address security (including encryption) of data stored in CEHRT;
    • Implement security updates as necessary; and
    • Correct identified security deficiencies as part of a risk management process.
  • Clinical Support Decision:
    • Implement five CDS interventions[2] related to four or more clinical quality measures (CQMs) at the relevant point in patient care (absent four CQMs, the clinical decision support interventions must be related to high-priority health conditions). In the proposed rule, CMS offers appropriate use criteria-based CDS for ordering imaging as an example of an acceptable CDS; and
    • Implement drug-drug and drug-allergy interaction checks. For the drug interaction checks, eligible providers who write fewer than 100 medication orders during the EHR reporting period are excluded from having to meet this measurement. Therefore, some radiologists may meet this exclusion.
  • Health Information Exchange:
    • For more than 50% of transitions of care and referrals, the eligible provider transferring or referring their patients to another provider must create a summary of care record using the certified EHR technology and electronically exchange the summary of care record. Some radiologists may be exempt from meeting this measure if the radiologist did not transfer or refer patients to another provider;
    • For more than 40% of transitions or referrals received and for new patient encounters, the eligible provider must incorporate into the patient’s EHR an electronic summary of care document from a source other than the provider’s EHR system; and
    • For more than 80% of transitions or referrals received and for new patient encounters, the eligible provider must perform a clinical information reconciliation for medication, medication allergies, and current problem/diagnoses list.
  • Public Health and Clinical Data Registry Reporting:
    • Must actively engage[3] with a public health agency or clinical data registry to submit data; and
    • The six data submission options available to providers are: (i) immunization registry reporting[4]; (ii) syndromic surveillance reporting; (iii) case reporting to a public health agency for reportable conditions; (iv) public health registry reporting; (v) clinical data registry reporting; or (vi) submission of electronic reportable laboratory results (for eligible hospitals or critical access hospitals only).


CMS is accepting comments on the proposed rule until 5 pm on May 29, 2015. Until the regulations are finalized, providers should wait to update their compliance programs or to start planning for clinical use.

[1] For Medicaid only, the 90-day reporting period and one year penalty avoidance deadline would still be an option for first-year Program participants.

[2] CDS interventions implemented at the relevant point in patient care can increase quality of care, enhance health outcomes, and help to avoid errors and adverse events, among other benefits. Examples of CDS interventions include: computerized alerts and reminders for providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information. For more information, see CMS’s eHealth University informational tip sheet here.

[3] Active engagement may be demonstrated by registering to submit data; being in the process of testing and validating electronic submission of data; or actually completing the testing and validation of the electronic submission and being in the process of submitting data.

[4] However, certain radiologists may meet the exemption if: (i) the radiologist does not administer immunizations for which data is collected by their jurisdiction’s registry; (ii) the registry is not capable of accepting the specific standards required by the certified EHR technology; or (iii) the jurisdiction’s registry is not ready to receive data.

Adrienne Dresevic, Esq. graduated Magna Cum Laude from Wayne State University Law School. Practicing healthcare law, she concentrates in Stark and fraud/abuse, representing various diagnostic imaging providers, e.g., IDTFs, mobile leasing entities, and radiology and multi-specialty group practices.

Leslie Rojas, Esq. graduated from Wayne State University Law School and is licensed to practice law in Michigan and Illinois. Practicing healthcare law, she concentrates on fraud/abuse issues, compliance with federal and state healthcare regulations, health information privacy and technology issues, and transactional and corporate aspects of healthcare.

The authors are members of The Health Law Partners, P.C. and may be reached at (248) 996-8510 or (212) 734-0128, or at

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