A9133-101479-E1-4A00 Copyright © 2012 Siemens Medical Solutions USA, Inc. All rights reserved. DVHIMSS Summer Education Program Stage 2 and Regulatory.

A9133-101479-E1-4A00 Copyright © 2012 Siemens Medical Solutions USA, Inc. All rights reserved.

DVHIMSS Summer Education ProgramStage 2 and Regulatory Update

Peg MeadowDirector, Government & Industry Affairs, Siemens HealthcareJune 14, 2012


A global company With a local footprint in over 190 countries

1847 Founding of 'Telegraphen-Bauanstalt von Siemens & Halske' in Berlin

1850 First international sales agency in London

1853 Office opens in St. Petersburg, Russia

1904 First permanent office in China

1905 Founding of Siemens do Brasil

1924 Founding of Siemens India Ltd.

1961 Exports exceed 1 billion DM for first time

1968 Siemens passes the 100-country mark

1970 Founding of Siemens Corporation, USA


Energy

Divisions Fossil Power

Generation Wind Power Solar & Hydro Oil & Gas Energy Service Power

Transmission

Healthcare

Divisions Imaging &

Therapy Systems Clinical Products Diagnostics Customer

Solutions (HIT)

Infrastructure & Cities

Divisions Rail Systems Mobility and

Logistics Low and Medium

Voltage Smart Grid Building

Technologies

OSRAM*

Industry

Divisions Industry

Automation Drive

Technologies Customer

Services

Siemens Sectors and Divisions

* In March 2011, Siemens announced its intention to publicly list OSRAM and, as an anchor shareholder, to hold a minority stake in OSRAM AG over the long term


Siemens in the U.S. Is Home to NineWorldwide Businesses/Divisions

HealthcareOncology Care

Concord, CA

HealthcareUltrasound

Mountain View, CA

IndustryPLM (Product Lifecycle Mgt.)

Plano, TX

IndustryVAI MetalsWorcester, MA

IndustryWater Tech.Warrendale, PA

HealthcareHealth ServicesMalvern, PA

EnergyEnergy ServiceOrlando, FL

HealthcareDiagnosticsTarrytown, NY

HealthcareMolecular Imaging

Hoffman Estates, IL

Siemens Employs Over 60,000 People in All 50 States


American Recovery & Reinvestment Act (ARRA)HITECH – February 17, 2009

First Steps

Adoption of certified EHRs

Meaningful use of EHRs

Incentive payments to eligible professionals and hospitals

Investment in nationwide HIT infrastructure

Grant money for demonstration projects

The Intended Destination

High quality, safe, effective, and equitable care for all

Seamless patient-centric care

Realigned incentives and measures that foster prevention, intervention, coordination, effectiveness

Regional clinical information interoperability on a national backbone

“The goals are quality and efficiency…If we encourage better performance, then physicians are going to find ways to improve. And health information technology is one crucial way to do that.”

David Blumenthal MD, MPP National Coordinator for Health Information Technology, ONC


ARRA HITECH Framework for Meaningful Use of Electronic Health Records (EHRs) - $30B/Program

Blumenthal D. N Engl J Med 2009;10.1056/NEJMp0912825


ONC (Office of the National Coordinator) FTEs

020406080

100120140160180200

FY 09 FY 10 FY 11 FY 12est

ONC FTEs

32

84

149

189


HITECH Meaningful Use and the Affordable Care ActThe Market Will Develop in Two Waves

2009 2013 2017

Meaningful Use

Affordable Care Act


ARRA HITECH EHR Incentive $$$$$ - BASICSAn eligible provider using a certified EHR and demonstrating meaningful use qualifies for $$$

Eligible Hospitals / Critical Access Hospitals (EH/CAH) Medicare AND Medicaid Incentive Funds For Medicare,

Four Consecutive Payment Years EH Must start in 2011, 2012, 2013 for Full Payment CAH must start in 2011 or 2012 for Full Payment

Penalties begin in 2015 if not a meaningful user, increase over time, and remain in force

Fiscal Year boundaries

Eligible Professional (EP) Medicare OR Medicaid Incentive Funds For Medicare,

Five Consecutive Payment Years Must start in 2011 or 2012 for Full Payment

Penalties for those who are not meaningful users beginning in 2015 that increase over time

Calendar Year


Achieving Meaningful Use in Stages

SOURCE:

HIT-enabled Health Reform


Health Outcomes Policy Priorities*

Ensure privacy and security protections

Improve

population

health

Engage patients and families

Improve care coordination

Increase quality, safety, efficiency, and reduce health disparities

*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.


What Defines the ARRA HITECH Process?

“Meaningful Use”* Final Rule(CMS)

Test Tools & Procedures

Standard & Criteria Final Rule(ONC)

Certification Process Final Rule(ONC)


HIT Policy CommitteeMeaningful Use Workgroup

HIT Policy/ Standards

Committees

Consumer/Patient Groups, Employers, Government, Multi-stakeholder Groups, Providers, Vendors

HITPC MU Work GroupPaul Tang, MD Co-Chair, Palo Alto Medical Foundation

George Hripcsak, MD Co-Chair, Columbia University

Michael Barr, MD American College of Physicians

David Bates, Brigham & Women’s Hospital

Christine Bechtel, National Partnership for Women & Families

Neil Calman, MD The Institute for Family Health

Tim Cromwell Dept of Veterans Affairs

Art Davidson, MD Denver Public Health

Marty Fattig Nemaha County Hospital

Joe Francis Veterans Administration

Leslie Kelly Hall Healthwise

Yael Harris HRSA

David Lansky Pacific Business Group/Health

Deven McGraw Center/Democracy & Technology

Greg Pace Social Security Administration

Latanya Sweeney Carnegie Mellon University

Robert Tagalicod CMS/HHS

Charlene Underwood, Siemens

Amy Zimmerman Rhode Island Office of Health & Human Services


Trends In Year-To-Date Payments From May 2011 To April 2012 ($ Millions)

Data from CMS, as of April, 2012

0400800

12001600200024002800320036004000440048005200

Medicare 75 107 149 263 357 528 920 1,384 1,6992,0502,392 2,688

Medicaid 115 166 248 389 503 712 916 1,149 1,4201,8002,092 2,342

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

$190$273

$397 $652 $860$1,239

$1,836

$2,533

$3,119

$4,484

$3,850

$5,030


Actual Year-To-Date Spending vs. Projections

Core HIS ComponentsData from CMS, as of April, 2012

Actual SpendingIn FY 2011

Paid Thru 4/12 CMS Projection for FY 2011

CBO ScoreFor FY 2011

$860.1M

$1 to 2.8B

$5.03B$4.7B

Medicaid and Medicare EHR Incentive Spending In 2011Actual Year-To-Date Spending versus Projections


Actual Providers Paid & Amount Paid Through April 2012

Core HIS ComponentsData from CMS, as of April 30, 2012

Providers Paid Amount Paid Program-to-Date Program-to-Date

Medicare Eligible Professionals 56,214 $953,388,119

Medicaid Eligible Professionals 35,040 $735,578,046

Eligible Hospitals 2,843** $3,341,140,043 Total 94,097 $5,030,106,208

** 2843 – 566 (Dups paid by both) = 2101/5,011 is 42% of EHs whereas 949/ 5,011 EHs who received Medicare funds only for achieving meaningful use, represents 19%.


Congratulations to Siemens Customers Who Have Achieved Stage 1 MU - 36 enterprises and 62 facilities June 6, 2012 2012

• Alegent HealthAlegent Health

• Altoona Regional Health SystemAltoona Regional Health System

• John D. Archbold Memorial HospitalJohn D. Archbold Memorial Hospital

• Bethesda Memorial HospitalBethesda Memorial Hospital

• Caldwell Memorial HospitalCaldwell Memorial Hospital

• Caromont Memorial Health, Inc.Caromont Memorial Health, Inc.

• Catholic Health SystemCatholic Health System

• CentraState Medical CenterCentraState Medical Center

• Champlain ValleyChamplain Valley

• Clearfield HospitalClearfield Hospital

• Crozer Keystone Health SystemCrozer Keystone Health System

• Danbury HospitalDanbury Hospital

• Ellis MedicineEllis Medicine

• EMH HealthcareEMH Healthcare

• Faith Regional Health ServicesFaith Regional Health Services

• Grenada Lake Medical CenterGrenada Lake Medical Center

• HealthAlliance HospitalHealthAlliance Hospital

• LifespanLifespan

• Main Line HealthMain Line Health

• MedCentral Health SystemMedCentral Health System

• Mercy Health PartnersMercy Health Partners

• Meridian Health SystemMeridian Health System

• Nason HospitalNason Hospital

• Nebraska Heart Hospital, Inc. Nebraska Heart Hospital, Inc.

• Niagara Falls Memorial Medical Center Niagara Falls Memorial Medical Center

• Nix Health Nix Health Care System

• Pinnacle Health SystemPinnacle Health System

• Riverside Health SystemRiverside Health System

• Saint Joseph Hospital (Boston)Saint Joseph Hospital (Boston)

• St. Joseph’s Hospital and Med Ctr St. Joseph’s Hospital and Med Ctr

• South Jersey Health SystemSouth Jersey Health System

• Temple University Health (Jeanes) Temple University Health (Jeanes)

• Texas Regional Medical CenterTexas Regional Medical Center

• Westchester Medical CenterWestchester Medical Center

• Winthrop University HospitalWinthrop University Hospital

• Wyoming Valley Health Care SystemWyoming Valley Health Care System


Trends in Hospital EHR Adoption Show Increasing Adoption but Low Penetration of Full Function

Percent of Non-Federal Acute Care Hospitals With Adoption of EHR Systems By Level of

Functionality: 2008 - 2011

40%

35%

30%

25%

20%

15%

10%

5%

0%2008 2009 2010 2011

13.4%16.1%* 19.1%*

34.8%*Comprehensive EHR

Basic EHR With Clinician Notes

Basic EHR Without Clinician Notes

*Significantly different from previous year.Source: ONC/AHA, AHA Annual Survey Information Technology Supplement

1.67.84.0

9.4*

3.9

2.8* 3.6

12.0*

3.5

8.8*

18.8*

7.2*


Physician Adoption of EHRs has Increased Steadily

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

60%

50%

40%

30%

20%

10%

0%

Any EMR/EHR System

Basic EMR/EHR System

18.2 17.3 17.320.8

23.929.2

34.8

42.048.3

50.756.9

10.511.816.9

21.824.9

33.8

Source: CDC/NCHS, National Ambulatory Medical Care Survey


However, Physician EHR Adoption is Uneven

Source: Rao, SR, et al. JAMIA, May 2011.

1-2 Physicians

40

35

30

25

20

15

10

5

03-5 Physicians 6-10 Physicians 11+ Physicians

25

3

11

6

19

13

26Fully Functional EHR

Basic EHR


Rollout of Meaningful Use Stage 2 Timeline

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Q1 Q2

January 13HIT Policy Committee (HIT-PC) – Meaningful Use (MU) Workgroup issued a request for input on Draft Objectives/ Measures for Stage 2.

2Q 2012?CMS and ONC publish Final Rules.

March – JuneMU Workgroup prepared recommendations to the HIT-PC which will then modify/ approve and send to CMS. Approved on June 8th.

September – 1Q 2012CMS and ONC formulate proposed rules for objectives, measures, standards, and certification criteria.

June – SeptemberHIT Standards Committee identifies standards and certification criteria.

March 7, 2012 Federal RegisterCMS Proposed Rule (EHR Incentive Program) and ONC Proposed Rule (Standards & Certification Criteria).

2011 2012


Meaningful Use Stage 2: Two Proposed Rules

CMS Medicare and Medicaid Programs; Electronic Health Record Incentive Program – Stage 2 Link to Federal Register 3/7/12 Overview

Key Summary Points Timeline Change

Objectives/Measures Clinical Quality Measures Payment Adjustments Appeal Process Medicaid EHR Incentive Program General Information/Stats

ONC Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology Link to Federal Register 3/7/12 Standards & Certification

Interoperability Privacy & Security Usability/Patient Safety


Meaningful Use Stage 2: Two Additional Documents Published

CMS Medicare and Medicaid Programs; Electronic Health Record Incentive Program – Stage 2 CORRECTIONS – 4/18/12

5/2/12 NIST releases EHR Technical Evaluation, Testing, and Validation of the Usability of EHRs (100+ pgs)

Rationale for EHR Usability Protocol (EUP) and outlines procedures for design evaluation and human user performance testing of EHR systems.


Proposed Timeline Change: Stage of MU Criteria by First Payment Year

1st Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

2011 1 1 1 2 2 3 3 TBD TBD TBD TBD

2012 1 1 2 2 3 3 TBD TBD TBD TBD

2013 1 1 2 2 3 3 TBD TBD TBD

2014 1 1 2 2 3 3 TBD TBD

2015 1 1 2 2 3 3 TBD

2016 1 1 2 2 3 3

2017 1 1 2 2 3

Red line indicates payment adjustments beginning in FY 2015


EHs/CAHs: July 1, 2014 (90-day reporting period must begin by April 3, 2014)

Subsection (d) Hospital Payment Adjustments

2015 2016 2017 2018 2019 2020+

% Decrease 25% 50% 75% 75% 75% 75%

% DECREASE IN THE PERCENTAGE INCREASE TO THE IPPS PAYMENTRATE THAT THE HOSPITAL WOULD OTHERWISE RECEIVE FOR THAT YEAR

• For example if the increase to IPPS for 2015 was 2% than a hospital subject to the payment adjustment would only receive a 1.5% increase

Source: CMS at HIMSS12Table 13: CMS NPRM

To avoid Payment Adjustments EHs/CAHs must first meet MU by July 1, 2014 (90-day reporting period must begin by April 3, 2014)


EP Payment Adjustments

2015 2016 2017 2018 2019 2020+EP is not subject to the

payment adjustment for e-Rx in 2014 99% 98% 97% 96% 95% 95%

EP is subject to the payment adjustment for e-Rx in 2014 98% 98% 97% 96% 95% 95%

% ADJUSTMENT ASSUMING LESS THAN 75 PERCENT OF EPs ARE MEANINGFUL EHR USERS FOR CY 2018 AND SUBSEQUENT YEARS

% ADJUSTMENT ASSUMING MORE THAN 75 PERCENT OF EPs ARE MEANINGFUL EHR USERS FOR CY 2018 AND SUBSEQUENT YEARS

2015 2016 2017 2018 2019 2020+EP is not subject to the payment adjustment for e-Rx in 2014 99% 98% 97% 97% 97% 97%EP is subject to the payment adjustment for e-Rx in 2014 98% 98% 97% 97% 97% 97%

Source: CMS at HIMSS12

To avoid Payment Adjustments EPs must first meet MU by 10/1, 2014 (90-day reporting must begin by 7/ 3, 2014)


Proposed Meaningful Use Objectives

Eligible Professionals15 core objectives

5 of 10 menu objectives20 total objectives

Eligible Hospitals & CAHs14 core objectives


Eligible Professionals17 core objectives


Eligible Hospitals & CAHs16 core objectives


Source: CMS at HIMSS12

Stage 1 Proposed Stage 2


Proposed Changes to Stage 1 Effective 2013:Included in Stage 2 Proposed Rules

“Old” 2011 Edition Objective/Measure

“New” 2014 Edition Objective/Measure

Timeframe Required

CPOE Denominator: unique patient with at least one

medication in their med list

Denominator: number of orders during the EHR reporting period

Optional in 2013. Required in 2014+

Vital Signs Age Limits: Age 2 for blood pressure & height/weight

Age Limits: Age 3 for blood pressure. No age limit for

height/weight.


Vital Signs Exclusion: All three elements not relevant to scope of

practice

Exclusion: Allow BP to be separated from height/weight.


Test of Health Information Exchange: One test of electronic

transmission of key clinical information

Requirement removed effective 2013

Effective 2013

E-Copy Objective: Provide patients with e-copy of health

information upon request

Online Access Objective: Provide electronic access to health

information

Replacement objective: Provide patients the ability to view online,

download and transmit their health information

Required in 2014+

Public Health Objectives: Immunizations, Reportable Labs,

Syndromic Surveillance

Addition of ‘’except where prohibited’’ to all three.

Effective 2013


Proposed Clinical Quality Measures

Eligible Professionals3 core OR 3 alt. core CQMs

plus3 menu CQMs6 total CQMs

Eligible Hospitals & CAHs15 total CQMs

Eligible Professionals1a) 12 CQMs (> 1 per domain)1b) 11 core + 1 menu CQMs2) PQRS or Group Reporting

12 total CQMs

Eligible Hospitals & CAHs24 CQMs (> 1 per domain)

24 total CQMs

Align with ONC’s 2011 Edition Certification Align with ONC’s 2014 Edition Certification

Stage 1 Proposed Stage 2


Additional Reference Information - Hidden Slides in Appendix

Additions/Changes/Deletions comparing Stage 2 to Stage 1 per each of the five Health Policy Outcomes (5 Slides)

Stage 2 Objective and Measures Detail with Stage 1 (8 Slides)

Clinical Quality Measures: Eligible Hospitals and CAHs (1 Slide) 49 Proposed Measures which includes 15 from Stage 1 (24 Required)

Reporting and Reporting Methods

Clinical Quality Measures: EP Reporting Options (1 Slide) 125 Proposed Measures includes 41 from Stage 1 (12 Required)

Reporting Options, Reporting Methods and Group Reporting

Vocabulary Standards (1 Slide)

Consolidated CDA Sample with new data sections (1 Slide)


Additions: Medication tracking from order to administration using

assistive technology - EHsEHs ePrescribing (for discharge prescriptions) - EH menuEH menu set Image results and information accessible - EP and EH EP and EH

menu setmenu set Record patient family health history as structured data

- EP and EH menu setEP and EH menu setChanges: Thresholds increases/changes: CPOE, demographics,

ePrescribing for EPsEPs, vital signs, smoking status, preventative reminders for EPsEPs

Lab and Radiology ordering required for CPOE Age requirements changed: Blood pressure, growth

charts Clinical Decision support rules increased from 1 to 5 and

expected to support CQMs Consolidated Objectives: Drug-drug and drug-allergy

checks, problem list, medication list, medication allergy list, drug formulary check

Reporting Clinical Quality Measures separated from MU objectives

Increase quality, safety, efficiency, and reduce health disparities ** (stage 2 compared to Stage 1) - SEE APPENDIX

**Health Outcomes Policy Priorities


Stage 2 Objectives and Measures – SEE APPENDIX

HOPP Stage 2 Objectives Stage 2 Measures

Eligible Professionals Eligible Hospitals and CAHs

Core Set1 Use computerized provider

order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local and professional guidelines to create the first record of the order.

Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines to create the first record of the order.

More than 60 percent of medication, laboratory, and radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.

Stage 1: More than 30% of unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) have at least one medication order entered using CPOE.

1 Generate and transmit permissible prescriptions electronically (eRx)

More than 65 percent of all permissible prescriptions written by the EP are compared to at least one drug formulary and transmitted electronically using Certified EHR Technology.

Stage 1:More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

1 Record the following demographics- Preferred language- Gender- Race- Ethnicity- Date of Birth

Record the following demographics- Preferred language- Gender- Race- Ethnicity- Date of Birth- Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH

More than 80 percent of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) have demographics recorded as structured data

Stage 1:More than 50% of all unique patients seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) have demographics recorded as structured data


Industry Calls for Stage 2 Changes…..

> 400 comments for each NPRM. Many requests for clarifications. Timeframe impact on Final Rules and confusion over “single source of truth.”

Make the transition period from Stage 1 to 2 realistic Requests for 90 Day Reporting for Stage 2 Delay Payment Adjustment reporting period to be in line with FY15

Reduce volume of Objectives/Measures and Quality Measures Actually 17 new to core or new to MU Objectives in Stage 2, some with multiple

measures 174 Quality Measures (49 EH/CAH, 125 EP)

Reduce complexity of 2011/2014 Edition CEHRTs and Stage 1 and 2 Allow use of 2011 Edition until CY 2015 so all will have same opportunity to spend two

years on the same technology. Maintain link between Stage 1 and 2011 CEHRT Edition

Eliminate holding providers responsible for patient’s actions Delete inclusion of ICD-10 and usability metrics Delete or delay to Stage 3 those standards and quality measures that are not

vetted in the industry (i.e. Implementation experience of smoking status and NQF endorsement of measures)


Executive’s Role in Orchestrating Health Reform …

ICD-10 CM

Meaningful Use

Hospital Value-based Purchasing Program

Accountable Care Organizations

Hospital Readmissions

Hospital-acquired Conditions

Payment Bundling


Links & References

Office of the National Coordinator of Health Information Technology: www.hhs.gov/healthit/

CMS Electronic Health Record Incentive Programs: https://www.cms.gov/EHRIncentivePrograms/

HIMSS Meaningful Use OneSource http://www.himss.org/ASP/topics_meaningfuluse.asp

HealthIT.govhttp://www.healthit.gov/


Thank You.


DVHIMSS Summer Education ProgramStage 2 and Regulatory Update APPENDIX

Peg MeadowDirector, Government & Industry Affairs, Siemens HealthcareJune 14, 2012

A9133-101479-E1-4A00 Copyright © 2012 Siemens Medical Solutions USA, Inc. All rights reserved. DVHIMSS Summer Education Program Stage 2 and Regulatory.

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