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DVHIMSS Summer Education Program
Stage 2 and Regulatory Update
Peg Meadow
Director, Government & Industry Affairs, Siemens Healthcare
June 14, 2012
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A global company
With a local footprint in over 190 countries
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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
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Siemens Sectors and Divisions
Energy
Divisions
 Fossil Power
Generation
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Transmission
Healthcare
Industry
Divisions
 Imaging &
Therapy Systems
 Clinical Products
 Diagnostics
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Solutions (HIT)
Divisions
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Technologies
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Services
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& Cities
Divisions
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Logistics
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Voltage
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Technologies
 OSRAM*
* 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
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Siemens in the U.S. Is Home to Nine
Worldwide Businesses/Divisions
Siemens Employs Over 60,000 People in All 50
States
Healthcare
Molecular Imaging
Hoffman Estates, IL
Healthcare
Diagnostics
Industry
VAI Metals
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Healthcare
Health Services
Healthcare
Oncology Care
Malvern, PA
Concord, CA
Industry
Water Tech.
Healthcare
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Industry
PLM (Product Lifecycle Mgt.)
Plano, TX
Energy
Energy Service
Orlando, FL
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American Recovery & Reinvestment Act (ARRA)
HITECH – February 17, 2009
First Steps
The Intended Destination
 Adoption of certified EHRs
 High quality, safe, effective, and
equitable care for all
 Meaningful use of EHRs
 Seamless patient-centric care
 Incentive payments to eligible
professionals and hospitals
 Realigned incentives and measures
that foster prevention, intervention,
coordination, effectiveness
 Investment in nationwide HIT
infrastructure
 Grant money for demonstration
projects
 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
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ARRA HITECH Framework for Meaningful Use
of Electronic Health Records (EHRs) - $30B/Program
Blumenthal D. N Engl J Med 2009;10.1056/NEJMp0912825
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ONC (Office of the National Coordinator) FTEs
200
180
160
140
120
100
80
60
40
20
0
189
149
84
ONC FTEs
32
FY 09 FY 10 FY 11
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FY 12
est
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HITECH Meaningful Use and the Affordable Care Act
The Market Will Develop in Two Waves
Affordable Care Act
Meaningful Use
2009
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2013
2017
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ARRA HITECH EHR Incentive $$$$$ - BASICS
An eligible provider using a certified EHR and demonstrating
meaningful use qualifies for $$$
 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
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Achieving Meaningful Use in Stages
HIT-enabled Health Reform
Stage 3: Improved outcomes
Stage 2: Advanced clinical processes
Stage 1: Data capture and
sharing
SOURCE:
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Health Outcomes Policy Priorities*
Increase
quality, safety,
efficiency,
and reduce
health
disparities
Engage patients
and families
Improve
population
health
Improve care
coordination
Ensure privacy and security protections
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform
America’s Healthcare. Washington, DC: National Quality Forum; 2008.
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What Defines the ARRA HITECH Process?
“Meaningful Use”* Final Rule
(CMS)
Standard & Criteria Final Rule
(ONC)
Certification Process Final Rule
(ONC)
Test Tools & Procedures
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HIT Policy Committee
Meaningful Use Workgroup
HIT Policy/
Standards
Committees
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, 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
Consumer/Patient Groups, Employers, Government, Multistakeholder Groups, Providers, Vendors
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Trends In Year-To-Date Payments From
May 2011 To April 2012 ($ Millions)
5200
4800
4400
4000
3600
3200
2800
2400
2000
1600
1200
800
400
0
$5,030
$4,484
$3,850
$3,119
$2,533
$1,836
$397 $652
$1,239
$860
$273
$190
Medicare
75
107
149
263
357
528
920 1,384 1,699 2,050 2,392 2,688
Medicaid
115
166
248
389
503
712
916 1,149 1,420 1,800 2,092 2,342
Jun
Jul
Aug
Sep
Oct
Nov
May
Dec
Jan
Feb Mar
Apr
Data from CMS, as of April, 2012
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Actual Year-To-Date Spending vs. Projections
Medicaid and Medicare EHR Incentive Spending In 2011
Actual Year-To-Date Spending versus Projections
$5.03B
$4.7B
$1 to 2.8B
$860.1M
Actual Spending
In FY 2011
Paid Thru 4/12
CMS Projection
for FY 2011
Core HIS Components
CBO Score
For FY 2011
Data from CMS, as of April, 2012
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Actual Providers Paid & Amount Paid
Through April 2012
Providers Paid
Program-to-Date
Amount Paid
Program-to-Date
Medicare Eligible Professionals
56,214
$953,388,119
Medicaid Eligible Professionals
35,040
$735,578,046
Eligible Hospitals
Total
2,843**
94,097
$3,341,140,043
$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%.
Data from CMS, as of April 30, 2012
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Core HIS Components
Copyright © 2012 Siemens Medical Solutions USA, Inc. All rights reserved.
Congratulations to Siemens Customers Who Have
Achieved Stage 1 MU - 36 enterprises and 62 facilities
June 6, 2012
• Alegent Health
• Main Line Health
• Altoona Regional Health System
• MedCentral Health System
• John D. Archbold Memorial Hospital
• Mercy Health Partners
• Bethesda Memorial Hospital
• Meridian Health System
• Caldwell Memorial Hospital
• Nason Hospital
• Caromont Memorial Health, Inc.
• Nebraska Heart Hospital, Inc.
• Catholic Health System
• Niagara Falls Memorial Medical Center
• CentraState Medical Center
• Nix Health Care System
• Champlain Valley
• Pinnacle Health System
• Clearfield Hospital
• Riverside Health System
• Crozer Keystone Health System
• Saint Joseph Hospital (Boston)
• Danbury Hospital
• St. Joseph’s Hospital and Med Ctr
• Ellis Medicine
• South Jersey Health System
• EMH Healthcare
• Temple University Health (Jeanes)
• Faith Regional Health Services
• Texas Regional Medical Center
• Grenada Lake Medical Center
• Westchester Medical Center
• HealthAlliance Hospital
• Winthrop University Hospital
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Lifespan
• Wyoming Valley Health Care System
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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
Comprehensive
EHR
40%
35%
Basic EHR
With Clinician
Notes
Basic EHR
Without
Clinician Notes
7.2*
30%
25%
20%
13.4%
15%
10%
5%
0%
34.8%*
4.0
7.8
1.6
2008
16.1%*
3.9
19.1%*
9.4*
12.0*
2.8*
3.6
2009
18.8*
3.5
8.8*
2010
2011
*Significantly different from previous year.
Source: ONC/AHA, AHA Annual Survey Information Technology Supplement
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Physician Adoption of EHRs has Increased
Steadily
60%
50%
40%
30%
20%
42.0
Any
EMR/EHR
System
18.2 17.3 17.3 20.8
48.3
56.9
50.7
33.8
34.8
23.9
29.2
10.5
11.8
10%
21.8
16.9
24.9
Basic
EMR/EHR
System
0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Source: CDC/NCHS, National Ambulatory Medical Care Survey
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However, Physician EHR Adoption is Uneven
40
26
35
Fully Functional EHR
30
Basic EHR
25
19
20
15
11
10
5
5
2
0
3
13
6
1-2 Physicians 3-5 Physicians 6-10 Physicians
11+ Physicians
Source: Rao, SR, et al. JAMIA, May 2011.
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Rollout of Meaningful Use Stage 2 Timeline
January 13
HIT Policy Committee
(HIT-PC) – Meaningful
Use (MU) Workgroup
issued a request for
input on Draft
Objectives/ Measures
for Stage 2.
June – September
HIT Standards
Committee identifies
standards and
certification criteria.
March 7, 2012 Federal
Register
CMS Proposed Rule
(EHR Incentive
Program) and ONC
Proposed Rule
(Standards &
Certification Criteria).
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
2011
2Q 2012?
CMS and
ONC publish
Final Rules.
Q1 Q2
2012
March – June
MU Workgroup
prepared
recommendations to
the HIT-PC which
will then modify/
approve and send to
CMS. Approved on
June 8th.
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September – 1Q 2012
CMS and ONC formulate proposed
rules for objectives, measures,
standards, and certification criteria.
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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
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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.
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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
2012
2013
2014
1
1
2
2
3
3
TBD
TBD
TBD
TBD
1
1
2
2
3
3
TBD
TBD
TBD
TBD
1
1
2
2
3
3
TBD
TBD
TBD
1
1
2
2
3
3
TBD
TBD
1
1
2
2
3
3
TBD
1
1
2
2
3
3
1
1
2
2
3
2015
2016
2017
Red line indicates payment adjustments beginning in FY 2015
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Subsection (d) Hospital Payment Adjustments
% DECREASE IN THE PERCENTAGE INCREASE TO THE IPPS PAYMENT
RATE THAT THE HOSPITAL WOULD OTHERWISE RECEIVE FOR THAT YEAR
2015
% Decrease
2016
2017
2018
EHs/CAHs: July 1, 2014 (90-day reporting period must begin by April 3, 2014)
25%
50%
75%
75%
2019
2020+
75%
75%
• 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
To avoid Payment Adjustments EHs/CAHs must first meet MU by
July 1, 2014 (90-day reporting period must begin by April 3, 2014)
Source: CMS at HIMSS12
Table 13: CMS NPRM
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EP Payment Adjustments
% ADJUSTMENT ASSUMING LESS THAN 75 PERCENT OF EPs ARE MEANINGFUL
EHR USERS FOR CY 2018 AND SUBSEQUENT YEARS
EP is not subject to the
payment adjustment for eRx in 2014
EP is subject to the payment
adjustment for e-Rx in
2014
2015
2016
2017
2018
2019
2020+
99%
98%
97%
96%
95%
95%
98%
98%
97%
96%
95%
95%
% ADJUSTMENT ASSUMING MORE THAN 75 PERCENT OF EPs ARE
MEANINGFUL EHR USERS FOR CY 2018 AND SUBSEQUENT YEARS
EP is not subject to the
payment adjustment for e-Rx
in 2014
EP is subject to the payment
adjustment for e-Rx in 2014
2015
2016
2017
2018
2019
2020+
99%
98%
97%
97%
97%
97%
98%
98%
97%
97%
97%
97%
To avoid Payment Adjustments EPs must first meet MU by 10/1, 2014 (90-day reporting must begin by 7/ 3, 2014)
Source: CMS at HIMSS12
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Proposed Meaningful Use Objectives
Stage 1
Proposed Stage 2
Eligible Professionals
15 core objectives
5 of 10 menu objectives
20 total objectives
Eligible Professionals
17 core objectives
3 of 5 menu objectives
20 total objectives
Eligible Hospitals & CAHs
14 core objectives
5 of 10 menu objectives
19 total objectives
Eligible Hospitals & CAHs
16 core objectives
2 of 4 menu objectives
18 total objectives
Source: CMS at HIMSS12
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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.
Optional in 2013. Required in
2014+
Vital Signs Exclusion: All three
Exclusion: Allow BP to be
elements not relevant to scope of
separated from height/weight.
practice
Test of Health Information
Exchange: One test of electronic Requirement removed effective
transmission of key clinical
2013
information
E-Copy Objective: Provide
patients with e-copy of health
Replacement objective: Provide
information upon request
patients the ability to view online,
Online Access Objective: Provide download and transmit their health
information
electronic access to health
information
Public Health Objectives:
Addition of ‘’except where
Immunizations, Reportable Labs,
prohibited’’ to all three.
Syndromic Surveillance
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Optional in 2013. Required in
2014+
Effective 2013
Required in 2014+
Effective 2013
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Proposed Clinical Quality Measures
Proposed Stage 2
Stage 1
Eligible Professionals
3 core OR 3 alt. core CQMs
plus
3 menu CQMs
6 total CQMs
Eligible Professionals
1a) 12 CQMs (> 1 per domain)
1b) 11 core + 1 menu CQMs
2) PQRS or Group Reporting
12 total CQMs
Eligible Hospitals & CAHs
15 total CQMs
Eligible Hospitals & CAHs
24 CQMs (> 1 per domain)
24 total CQMs
Align with ONC’s 2011 Edition Certification
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Align with ONC’s 2014 Edition Certification
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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)
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Increase quality, safety, efficiency, and reduce health
disparities ** (stage 2 compared to Stage 1) - SEE APPENDIX
Additions:
 Medication tracking from order to administration using
assistive technology - EHs
 ePrescribing (for discharge prescriptions) - EH menu set
 Image results and information accessible - EP and EH
menu set
 Record patient family health history as structured data
- EP and EH menu set
Changes:
 Thresholds increases/changes: CPOE, demographics,
ePrescribing for EPs, vital signs, smoking status,
preventative reminders for EPs
 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
**Health Outcomes Policy Priorities
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Stage 2 Objectives and Measures – SEE APPENDIX
HOPP
Stage 2 Objectives
Stage 2 Measures
Eligible Professionals Eligible Hospitals and
CAHs
1
1
Core Set
Use computerized provider
Use computerized provider order More than 60 percent of medication, laboratory, and radiology orders
order entry (CPOE) for
entry (CPOE) for medication,
created by the EP or authorized providers of the eligible hospital's or
medication, laboratory and
laboratory and radiology orders CAH's inpatient or emergency department (POS 21 or 23) during the EHR
radiology orders directly entered directly entered by any licensed reporting period are recorded using CPOE.
by any licensed healthcare
healthcare professional who can
professional who can enter
enter orders into the medical
Stage 1:
orders into the medical record record per state, local and
More than 30% of unique patients with at least one medication in their
per State, local and professional professional guidelines to create medication list seen by the EP or admitted to the eligible hospital’s or
guidelines to create the first
the first record of the order.
CAH’s inpatient or emergency department (POS 21 or 23) have at least
record of the order.
one medication order entered using CPOE.
Generate and transmit
More than 65 percent of all permissible prescriptions written by the EP are
permissible prescriptions
compared to at least one drug formulary and transmitted electronically
electronically (eRx)
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
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Record the following
More than 80 percent of all unique patients seen by the EP or admitted to
demographics
the eligible hospital's or CAH's inpatient or emergency department (POS 21
- Preferred language
or 23) have demographics recorded as structured data
- Gender
- Race
Stage 1:
- Ethnicity
More than 50% of all unique patients seen by the EP or admitted to the
- Date of Birth
eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or
- Date and preliminary cause of 23) have demographics recorded as structured data
death in the event of mortality in
the eligible hospital or CAH
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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)
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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
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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.gov
http://www.healthit.gov/
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Thank You.
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DVHIMSS Summer Education Program
Stage 2 and Regulatory Update APPENDIX
Peg Meadow
Director, Government & Industry Affairs, Siemens Healthcare
June 14, 2012
A9133-101479-E1-4A00
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