A E1-4A00 Copyright © 2010 Siemens Medical Solutions USA, Inc. All rights reserved. Page 1 Advancing Adoption of Electronic Health Records and Health Reform Charlene Underwood, MBA, FHIMSS Senior Director, Government & Industry Affairs HIMSS Board Vice-Chair, Chair Elect June 1, 2011

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Agenda  ARRA HITECH Overview  Meaningful Use Definition  CMS EHR Incentive Program  Current Implementation Status  Relationship to Health Reform  A Glimpse to the Future

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. 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

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. ARRA HITECH Stimulus Funds and Meaningful Use 4 An Eligible Provider A Certified EHR Meaningful Use $$$ Using…… …and Demonstrating…… Qualifies for……

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Blumenthal D. N Engl J Med 2009; /NEJMp HITECH Framework for Meaningful Use of Electronic Health Records (EHRs)

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Roll-Out of ARRA HITECH and Meaningful Use Early 2010OctNovDec Jan Mar AprilFebMay June / July ‘10 Final Regulations January ‘ 11 - ongoing States begin making Medicaid incentive payments January ‘11 Eligible hospital & professional begin to register to participate in Medicare Incentive program June July April ‘11 Eligible hospital / professional begin to attest to 90 day meaningful use requirements May ‘11 CMS expects to start making incentive payments Fall ‘10 Certified EHR software available January ‘11 Final Rule on Permanent Certification December ‘10 Self Certification Availability announced

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Meaningful Use Players HIT Policy/ Standards Committees Consumer/Patient Groups, Employers, Government, Multi-stakeholder Groups, Providers, Vendors HITPC MU Work Group Paul 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, The Institute for Family Health Art Davidson, Denver Public Health Department Marty Fattig, CEO, Nemaha County Hospital James Figge, MD New York State Department of Health Joe Francis, Veterans Administration David Lansky, Pacific Business Group on Health Deven McGraw, Center for Democracy & Technology Judy Murphy, RN Aurora Health Care Latanya Sweeney, Carnegie Mellon University Karen Trudel, CMS/HHS Charlene Underwood, Siemens

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved HIT-Enabled Health Reform Meaningful Use Criteria HITECH Policies 2011 Meaningful Use Criteria (Capture/share data) 2013 Meaningful Use Criteria (Advanced care processes with decision support) 2015 Meaningful Use Criteria (Improved Outcomes) Meaningful Use Workgroup Recommendations Achieving Meaningful Use SOURCE:

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Meaningful Use Workgroup Recommendations Health Outcomes Policy Priorities * 5. Ensure privacy and security protections 4. Improve population health 2. Engage patients and families 3. Improve care coordination 1. 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.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. ARRA HITECH Final Regulations Published – June / July 2010  Certification Program for HIT – Office of the National Coordinator (ONC)  Meaningful Use (MU) Rule – Center of Medicare and Medicaid (CMS)  Standards, Specifications, and Certification Criteria – (ONC)

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Medicare & Medicaid EHR Incentive Program Meaningful Use Rule  Defines eligible hospitals ( EHs) and eligible professionals ( EPs)  Creates 3 Stages of implementation;  Establishes payment years & reporting periods;  Provides details on Stage 1 goals and requirements - covering 2011 and 2012.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Meaningful Use Stages Adopted Meaningful Use Workgroup Recommendations StageFocusDate Range Stage 1Episodic care management: data capture, basic medication management function, electronic measure reporting, infrastructure for health information exchange, patient engagement, and population health Starting in 2011 Stage 2Chronic care management: expands on stage 1, advances clinical decision support to manage chronic disease and health information exchange to coordinate care, more support for patient engagement and public health reporting Starting in 2013 Stage 3Patient Engagement and Population Health: promotes more advanced function and health information exchange to help providers do care management across settings and enable patients to do more self care. Adds more support for public health. Starting in 2015

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Medicare Incentives - Eligible Hospitals & CAHs Stage of Meaningful Use by Payment Year First Payment Year Payment Year Stage 1 Stage 2 TBD 2012Stage 1 Stage 2TBD 2013Stage 1 TBD 2014Stage 1TBD 2015TBD Note: For the first payment year only, CMS proposes to define the term EHR reporting period to mean any continuous 90-day period within a payment year in which an EP or eligible hospital successfully demonstrates meaningful use of certified EHR technology. Starting with the second Payment year and any subsequent payment years for a given EP or eligible hospital, CMS would define the term EHR reporting period to mean the entire payment year.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Meaningful Use at a High Level Requirements  Store, display, and report on key patient data  Support provider initiatives for safe medication management  Assist in identification of problems  Promote exchange of clinical information (interoperability) in a standard way that others can use  Provide patients with clinical information electronically  Protect security and privacy using standards  Report on clinical quality measures

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Meaningful Use Objective and Measures Flexible Approach Core Set  Hospitals & Critical Access Hospitals - 14 Objectives/Measures  Eligible Professionals - 15 Objectives/Measures  Must achieve the measure for all Core Set Objectives  Exclusions may apply Menu Set  10 Objectives/Measures  Must meet the measure for all but five of the objectives  EPs and EHs must choose at least one Population Health measure from the Menu Set as part of their Stage1 requirements.  Exclusions may apply and measures that are inapplicable do not penalize the EP or EH (ex: if one does not apply, EH/EP needs to meet 4 of 9 rather than 5 of 10)  Menu objectives not achieved during Stage 1 become required in Stage 2

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. MeasureTitle Emergency Department (ED)-1 NQF 0495Emergency Department Throughput – admitted patients median time from ED arrival to ED departure for admitted patients ED-2 NQF 0497Emergency Department Throughput – admitted patients admission decision time to ED departure time for admitted patients Stroke-2 NQF 0435Ischemic stroke – Discharge on anti-thrombotics Stroke-3 NQF 0436Ischemic stroke – Anticoagulation for A-fib/flutter Stroke-4 NQF 0437Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset Stroke-5 NQF 0438Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 Stroke-6 NQF 0439Ischemic stroke – Discharge on statins Stroke-8 NQF 0440Ischemic or hemorrhagic stroke – Stroke education Stroke-10 NQF 0441Ischemic or hemorrhagic stroke – Rehabilitation assessment Venous Thromboembolism (VTE)-1 NQF 0371 VTE prophylaxis within 24 hours of arrival VTE-2 NQF 0372Intensive Care Unit VTE Prophylaxis VTE-3 NQF 0373Anticoagulation overlap therapy VTE-4 NQF 0374Platelet monitoring on unfractionated heparin VTE-5 NQF 0375VTE discharge instructions VTE-6 NQF 0376Incidence of potentially preventable VTE Clinical Quality Measures - Eligible Hospitals & CAHs Electronically Captured and Generated Measures

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Dr. Blumenthal and the Age of Meaningful Use February 23, 2011  An incentive program, rewarding not only deployment of EHRs but also their effective use for patient benefit;  A new national infrastructure to support deployment and beneficial use of EHRs; and  A vision for an information- powered leap in the quality, safety and effectiveness (including cost effectiveness) of our health care system.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Current Implementation Status Growing Momentum Meaningful Use Certification Regional Extension Centers Workforce Training Planning to achieve MU Hospitals – 81% Physicians – 41% April >30,000 providers registered; >150 – 200 attested to Meaningful Use May Medicaid Incentive Program has paid out $83M from states ($17M EPs and $66M EHs) April 2011  419 Ambulatory EHR Certified Products: 291 Complete EHR Products 128 Modular EHR Products  195 Inpatient EHR Certified Products 53 Complete EHR Products 142 Modular EHR Products ONC supporting 62 RECs nationwide May 2011 – 60,000+ providers have enrolled for REC assistance ONC supports six month training at 84 community colleges 3,400 complete curriculum this spring 10,000 per year is future goal

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. AHA Survey on Stage 1 Readiness – Barriers January 2011

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Rollout of ARRA and Meaningful Use Stage 2  January 13, 2011 – Request for Comment Issued  HIT Policy Committee (HIT-PC) – Meaningful Use (MU) Workgroup issued a request for input on Draft Objectives/Measures for Stage 2  March - April 2011  MU Workgroup will formulate a recommendation to the HIT-PC which will then modify/approve and send to CMS.  April 2011 – 4Q2011  ONC and CMS formulate proposed rules for objectives, measures, standards, and certification criteria  4Q2011  Publish CMS Proposed Rule (Incentive Program with Objectives/Measures) and ONC Interim Final Rule (Standards & Certification Criteria)  2Q2012  Publish Final Rules (per above)

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Stage 2 / 3 MU Request for Comment “Signal to the industry”  43 objectives (33% increase).  Thresholds are increased and objectives have more requirements.  10 menu objectives moved to core.  6 new Stage 2 objectives.  6 new Stage 3 objectives.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Stage Two and Three meaningful use objectives are getting some pushback  Syndromic surveillance. Agencies don’t have infrastructure in place for analysis or technical/policy. Also would take extra resources.  Drug formulary checks. Large percentage of patients may not have formularies in systems. Matching issues with PBM databases.  Medication reconciliation. OK as core in Stage Two, but don’t set the bar at 80% until Stage Three.  Patient access in 4 days. View on demand requirement may be difficult. Standards undefined and requirements unclear. Stay at Stage One levels.  Immunization data. Premature given lack of transmission mechanisms in state systems. Stay at Stage One.  Clinical information exchange. As above. Requires more technical and policy work. Stay at Stage One.  Clinical decision support. Lack of infrastructure beyond a few simple rules. Need more evidence-based rules.  Reportable lab data. Not appropriate until there is more standardized lab coding beyond numerical values.  Drug allergy and other interaction checks. Minimal concern about Stage Two. Stage Three calls for more complex interaction checking which may not have broad systems support. This is in response to the release of ONC’s policy committee current ideas about Stage Two and Three MU rules. They will make recommendations over the summer. * CCHIT survey of 468 providers and vendors. These areas are considered too aggressive by over 1/3 of respondents.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Stage 2 / 3 MU Request for Comment Industry Response  422 comments submitted which contained thousands of individual comments.  Providers and software developers stressed need for adequate lead time, flexibility, focus, clarity, and standards. Suggested building on the momentum of stage 1 by increasing thresholds and minimize net new function.  Consumer advocates, payers, and other non-provider stakeholders want stiffer requirements.  Many unknowns being proposed. Anticipate impact in clinical quality measures, where a significant increase is expected.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. CMS Views – MU is not the center of the Universe! HIT Policy Committee - April 13, 2011  Tony Trenkle, director of the CMS Office of e-Health Standards and Services, and member of the HIT Policy Committee:  "Meaningful Use is not the center of universe. We can write rules for ACOs and test things at the CMS Center for Innovation.” CMS Center for Innovation  "We have to adopt a more global mindset besides Meaningful Use."  Do you think Trenkle wants the Meaningful Use bar to go higher? No, he wants the committee to stop piling on and go for simplicity over complexity.  From Healthcare CIO

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. New Head of ONC - Farzad Mostashari, MD April 8, 2011  Succeeds Dr. David Blumenthal  Previously Deputy National Coordinator for Programs and Policy at ONC  Joined ONC in July 2009  Before ONC, NYC Health and Mental Hygiene Dept. as Asst. Commissioner for Primary-care information project  ONC grew from 38 FTEs to 138 (2/10 to 2/11)  Will focus on “alignment with health reform” and improving communications

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. ARRA and Health Reform ARRA (HITECH) February 19, 2009  Meaningful Use  Certified EHRs  Incentives  Quality reporting Affordable Care Act (PPACA) March 23, 2010  Expanding coverage  Reforming the delivery system  Financing reform  Medicare and Medicaid payment  Building more primary care  Wellness and prevention  Quality and safety  Regulatory oversight

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Medicare Shared Savings Program Proposed rules for accountable care organizations  Goals are better care, better health and lower cost growth.  Promote evidence-based medicine and patient engagement  Coordinate care via telehealth, remote patient monitoring or other enabling technology.  HIT that can aggregate and analyze data, provide patient- level feedback and provide alerts at the point of care. Stress HIT as a core competency – well beyond meaningful use …  Attend to care transitions using EMRs and HIEs.  Support patient-centered medical homes and health homes. Don Berwick, CMS Administrator “Information management — making sure patients and all health care providers have the right information at the point of care — will be a core competency of ACOs.” Intent is to use the best, most advanced models of care, using modern technologies, including telehealth and electronic health records.

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Achieving Meaningful Use provides the foundation for Accountable Care … Importance for Accountable Care 2011 IT Investment Priorities Importance for Meaningful Use Population Health Surveillance Immunization Registries Patient Data Privacy and Security Performance Monitoring Tools Personal Health Record ICD-10 Closed-Loop Medication Administration Data Analytics Infrastructure Cost Analytics Tools Ambulatory EMR CPOE / CDSS Interoperability Health Information Exchange (HIE) Clinical Documentation Reporting Capabilities Continuity of Care Document Ancillary Systems Source: 2011 The Advisory Board Company

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. What they asked for?

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. The Role of the CIO …  ICD-10 CM  Meaningful Use  Hospital Value-based Purchasing Program  Accountable Care Organizations  Hospital Readmissions  Hospital-acquired Conditions  Payment Bundling

A E1-4A00 Copyright © 2011Siemens Medical Solutions USA, Inc. All rights reserved. Thank you