Medstreaming/M2S Development Update June 12, 2019 Jack L. Cronenwett, M.D. Chief Medical Officer

Major Technology Releases - Past Year New Architecture implemented for all registries Save incomplete follow-up forms, tabs show completion, download data as text Mandatory fields highlighted on registry follow-up forms Registry-specific rules for “credit” for follow-up, excluding irrelevant cases 30-Day follow-up forms for all relevant registries PVI “Basic” form released, with ability to turn on comprehensive form GUDID integration for PVI balloons, atherectomy devices Quarterly update of new devices Help text revisions, variable option updates, Medicare Beneficiary Number © 2017  M2S, All Rights Reserved Confidential and Proprietary

Major New Technology Releases Scheduled for 2018 Hemodialysis Access registry revision (August 30th) Varicose Vein registry revision (September 10th) New Venous Stent registry (September 20th ) New Vascular Medicine registry (September 30th)

EMR Integration – M2S Abstraction App Location of data highlighted in source document User Report shows data captured and links to source for QA

EMR Integration – M2S Abstraction App Challenges Requires some local IT support and structured note use by providers Progress to Date Epic Pilot Sites: UMASS - extracted JSON file of common data elements, transferred to MS/M2S where Abstraction App was able to auto-populate registry data Cleveland Clinic - configured IT infrastructure to house the Abstraction App on site, expects data transfer to begin this summer Cerner Pilot Sites: Emory - transferred structured procedure note to MS/M2S where Abstraction App was able to auto-populate registry data (now awaiting more local IT support) UAB – created structured notes, will use Cerner Direct Message to transfer clinical notes to MS/M2S Abstraction App, expects data transfer this summer Office-based EMRs: Midwest Institute for Minimally Invasive Therapies has Abstraction App fully deployed and operational, transmitting data to VQI

Vascular Ultrasound Registry Project VQI project with Society for Vascular Ultrasound Auto-populate carotid duplex images and associated velocity data into a new Vascular Ultrasound Registry (VUR) Co-Chairs: David Dawson, MD, Greg Moneta, MD; Steering Committee from pilot sites Method Initial pilot project to show feasibility with centers using Medstreaming vascular laboratory software that has been configured to upload data to the VUR in VQI VUR created in Pathways to receive carotid duplex data Goal Match VUR data with VQI patients in CEA and CAS registries (later Vascular Medicine) Analyze variation across labs, QI reports to labs, machine learning from imaging Progress 11 Centers selected, many required internal software updates, delayed progress 1 Center has now successfully uploaded images, several more expected soon Committee meeting Thursday at VAM to evaluate progress and plan next steps

Medstreaming Image Viewer – Big Data Hadoop Platform Images for First Study Uploaded to VUR

Using VQI to Analyze and Reduce Costs EVAR Cost Project in 18 VQI Centers (2017) Collaboration with Vizient to estimate hospital costs based on charges (with individual cost categories) Used VQI data to define standard EVAR cases without complications Showed 2 fold-variation in cost across 18 centers for similar type cases Largest variation: implant costs Comparison allowed centers to identify opportunities to reduce cost Average EVAR Cost, Categories and Reimbursement $54K $22K Average EVAR Implant + MedSurg Supply Cost n=434 EVAR Cases $31K $7.5K 18 VQI Centers - Lemmon et al J Vasc Surg 2017

Using VQI to Analyze and Reduce Costs VQI@VAM 2018: Ron Dalman, MD Stanford used the EVAR Cost Pilot comparative data to focus cost reduction efforts Analyzed detailed hospital costs, developed care pathways and new device purchasing agreements Reduce costs significantly across multiple dimensions: Devices - 31%; Bed utilization - 50%; Inpatient imaging – 93%; Medications – 38% Reducing costs requires drill down into hospital accounting system Each hospital has its own proprietary system NOT linked to clinical data or VQI Ideal solution: Link VQI clinical data with each hospital’s cost system, provide benchmarking New VQI-Medstreaming Cost Analysis Pilot Project Medstreaming partnership with Biome, for hospital cost analysis linked to VQI clinical data Hospitals transfer detailed cost file to SVS PSO for linkage with clinical data and reporting Similar reports for cardiac surgery have created substantial hospital cost saving -Itoga et al, J Vasc Surg, 22019

PVI Cost Calculator: Average Center Costs per Year Report Filters Based on VQI Clinical Variables Total Mean Cost/ N Procedures Cost Categories Year Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Average Center Costs per Year Select Dimension for Comparison View by Patient Symptom Severity Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Compare Claudication vs. CLI All Treated Patients $13,000 CLI: Much higher cost, due to Med/Surg bed Procedure Med/Surg $29,000 Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Compare by Artery Treated All Treated Patients Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Compare Inpatient vs. Outpatient All Treated Patients Same procedure and stent cost, but Inpatient-related costs much higher Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Compare Claudication vs. CLI Inpatients Only Filters Inpatients Only $17,000 $35,000 Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Compare Claudication vs. CLI Outpatients Only Filters Outpatients Only $11,000 $10,500 Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Average Center Costs per Year Select Dimension for Comparison View by Physician Note: All Data Simulated for Demonstration Mean Cost for each Cost Category

PVI Cost Calculator: Average Costs per Physician All Cases in Selected Time Period Physician with higher costs Mean Cost for each Cost Category Note: All Data Simulated for Demonstration

PVI Cost Calculator: Average Costs per Physician Only Outpatient Treated Claudicants MD with Low Procedure Cost But High Stent Cost Mean Cost for each Cost Category Note: All Data Simulated for Demonstration

PVI Cost Calculator: Drill Down to Individual Items Select “Stents” Shows Summary for this Physician: Drill Down to each stent used Note: All Data Simulated for Demonstration

PVI Cost Calculator: Drill Down to Individual Items Show Pharmacy Charges by Year Select Details to Display Select Highest Cost Item: Alteplase Drill Down to examine procedure details for each case used Case Drilldown Note: All Data Simulated for Demonstration

Using VQI to Analyze and Reduce Costs VQI-Medstreaming Cost Analysis Pilot Project Currently in development for PVI and EVAR in 2 VQI centers Expected general availability in Q1, 2020 (with additional subscription cost) Opportunity for other centers to join pilot project for other registries Provide input for report format and clinical variables to be included Live demonstration available at the M2S/Medstreaming booth, Thursday and Friday in exhibit hall.