The EHR

Climbing the Adoption Curve

Ken Ong

Ken Ong

Chief Medical? Informatics Officer New York Hospital Queens New York.

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The electronic health record and its related technologies are new innovations that hold the promise of transforming healthcare. Nonetheless, all innovations encounter an uphill struggle of adoption. Meaningful Use and the HIMSS EMR Adoption Model are two complementary visions of how to make the promise of health IT a reality.

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After receiving more than one thousand public comments to its Notice of Proposed Rule Making, the US Centers for Medicare and Medicaid Services (CMS) is crafting the final rule for Stage 2 of meaningful use of the Electronic Health Record (EHR).

While we wait for CMS’s final rule, it is worth considering EHR adoption in the USA and those forward-looking nations that served as early adopters of this transformative technology.

Diffusion of innovations

Innovation in any field is a challenge. Everett Rogers has studied the diffusion of innovations and explicated its mysteries.

Today it is common knowledge that scurvy is due to vitamin C deficiency and that a diet containing vitamin C will prevent scurvy. How we came to this understanding is a tale exemplary of the many twists and turns an innovation can make before it is finally adopted. The benefit of vitamin C containing foods like citrus in preventing and treating scurvy was discovered and re-discovered multiple times over hundreds of years.

Learning from the knowledge of the native people of the St. Lawrence River, the French explorer Jacques Cartier saved his men from scurvy in 1536. Decades later in 1601, Captain James Lancaster performed a controlled experiment in scurvy prevention. The Captain supplied one of his ships with rations of lemon juice and none to his 3 other ships. One hundred and ten (110) of 278 sailors died of scurvy in the control group.

More than a hundred years later in 1747, James Lind, a physician in the British Royal Navy, repeated the experiment with similar results. Ultimately in 1795 the British Navy did require citrus fruits to prevent scurvy.

Everett Rogers popularized this historical lesson and pioneered diffusion of innovations theory. Mr. Rogers would not be surprised by the history of the EHR, which is no less remarkable.

IBM partnered with Akron Children's Hospital to create the first electronic medical record in 1962.

Demand for this new innovation was nascent until the Institute of Medicine issued a trifecta of revelatory reports that defined the computer-based patient record as an essential technology for healthcare (later known as the EMR and now EHR).

Meaningful use

Prior to the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009, physician and hospital adoption of the EHR in the USA was far behind Denmark, New Zealand, and Sweden. All three countries invested in economic incentives, regulations to foster interoperability, and public-private partnerships to enable standardization.

The HITECH act replicated many of these critical success factors with telling results. The rate of office-based physician adoption of a basic EHR system rose from 10.5 per cent in 2001 to 33.9 per cent in 2011. Hospitals with any EHR system increased from 15.1 per cent in 2010 to 26.6 per cent in 2011.

In the USA, the journey continues. Evidence suggests EHR adoption among physicians over age 55 and those in non-primary care specialties, physician-owned practices, and small practices trail behind that of younger physicians, primary care physicians, and providers in larger practices.

A digital divide has developed among hospitals, as well. Small, non-teaching, and rural hospitals have adopted EHRs more slowly than their larger, teaching, and urban counterparts.

The proposed Stage 2 goals build upon and expand those from Stage 1. Measures optional in Stage 1 will become required in Stage 2 (see Tables A to F). Taking another step towards capturing and reporting quality measures from the EHR, a host of new clinical quality measures will be added to Stage 2.

Citing Professor Rogers, the American Academy of Family Physicians cautions against raising the bar of Stage 2 meaningful use too high: “We encourage HHS not to ignore diffusion of technology theory, which distinguishes the characteristics and capabilities of innovators and early adopters from the larger grouping of early majority, late majority, and laggards. The existing data on Meaningful Use adoption, in our opinion, is limited to innovators and early adopters. Their ability and efficiency in use of electronic health records are not likely predictive of the ability and efficiency of EPs who have yet to embrace meaningful use. We strongly urge HHS to use caution in assuming that outstanding performance on Meaningful Use measures, so far, indicates generalised success and that the bar should be dramatically raised. Successfully on-boarding later adopters is likely to require a gentler approach.”

Indeed, the challenge for policy makers is striking the right balance between the vision of meaningful use with the everyday realities of limited resources.

Beyond regulatory relief, diffusion of innovations theory offers a framework to further the work of adoption. The theory posits four main elements in the diffusion process: (1) characteristics of the innovation itself (2) how the innovation is communicated to its target audience (‘channels’) (3) processes that affect the time to adoption (e.g. innovation-decision and innovativeness and adopter categories) and (4) the social system (e.g. system norms, opinion leaders, change agents).

The EHR itself can and should be made more usable and reliable. In a recent report on health IT the Institute of Medicine viewed this as a patient safety issue. User-centered design and reliable software also positively affect clinician adoption. The proposed new Office of the National Coordinator for Health IT (ONC) EHR certification rule takes a step in that direction by requiring user-centered design and software quality improvement. A better EHR will speed adoption, improve patient safety and clinician satisfaction.

The HITECH-funded Regional Extension Centers (REC) have been charged to provide a variety of adoption services for physician practices including e-newsletters, training, and on-site project planning and implementation. They are well-positioned to optimize services to promote adoption among small physician practices and small, non-teaching, and rural hospitals. Expanding and extending the RECs scope would help deepen adoption.

HIMSS EMRAM

Meaningful use serves as one path for EHR adoption. Another complementary model is the Healthcare Information and Management Systems Electronic Medical Record Adoption Model (HIMSS EMRAM).

HIMSS developed the EMRAM for hospitals in 2004 and for ambulatory care in 2012 (see Tables G and H). The EMRAM serves as a tool for healthcare leaders to align IT initiatives with business strategy, develop a roadmap for future development, or ensure their organisations make the most appropriate use of funding. The HIMSS EMRAM permits healthcare providers and organisations to compare their IT budgets and level of adoption with their peers.

The HIMSS EMRAM has been used by hospitals in North America, Europe, and is expanding to the Asia-Pacific region. Launched June 2011, HIMSS Analytics® has collected data from hospitals from the Asia-Pacific (see Table I).

The Asia-Pacific’s first Level 7 hospital is Seoul National University Bundang Hospital (910 Beds) in South Korea. The area showcases another 13 hospitals that have achieved Stage 6.

It is all about transforming healthcare

Innovation is what drives health IT.

Meaningful use and HIMSS EMRAM are dynamic, not stagnant models for health IT adoption. Both models will evolve as new innovations develop to engage patients, coordinate care, improve individual and community health, and make healthcare more effective and efficient.

Table A

Stage 2 EP Core Objectives

  1. Use CPOE for more than 60 per cent of medication, laboratory and radiology orders
  2. E-Rx for more than 50 per cent
  3. Record demographics for more than 80 per cent
  4. Record vital signs for more than 80 per cent
  5. Record smoking status for more than 80 per cent
  6. Implement 5 clinical decision support interventions + drug / drug and drug / allergy
  7. Incorporate lab results for more than 55 per cent
  8. Generate patient list by specific condition
  9. Use EHR to identify and provide more than 10 per cent with reminders for preventive / follow-up
  10. Provide online access to health information for more than 50 per cent with more than 10 per cent actually accessing
  11. Provide office visit summaries in 24 hours
  12. Use EHR to identify and provide education resources more than 10 per cent
  13. More than 10 per cent of patients send secure messages to their EP
  14. Medication reconciliation at more than 65 per cent of transitions of care
  15. Provide summary of care document for more than 65 per cent of transitions of care and referrals with 10 per cent sent electronically
  16. Successful ongoing transmission of immunization data
  17. Conduct or review security analysis and incorporate in risk management process.

Table B

Stage 2 EP Menu Objectives

  1. More than 40 per cent of imaging results are accessible through Certified EHR Technology
  2. Record family health history for more than 20 per cent
  3. Successful ongoing transmission of syndromic surveillance data
  4. Successful ongoing transmission of cancer case information
  5. Successful ongoing transmission of data to a specialized registry.

Table C

EP CQM Measures: 125 Potential Measures covering the categories of conditions / disease management, drug management, preventive care and medical practice:

  • ADHD
  • Adverse Event Reporting
  • Alcohol / Drug Dependence
  • Antibiotic Use: Pharyngitis, Bronchitis, Upper Respiratory Infection, Perioperative Care
  • Asthma
  • Blood Pressure
  • Cardiology: Heart Failure, Atrial Fibrillation, Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), Myocardial Infarction (MI), Chronic Obstructive
  • Chlamydia Screening
  • Cholesterol
  • Colon, Breast, Prostate, Prostate
  • Complex Chronic Condition Assessment
  • Dementia
  • Dental Decay
  • Depression
  • Diabetes
  • Diagnostic Imaging Reports
  • Eyes: Cataracts, Glaucoma
  • Falls Risk
  • Hepatitis C
  • HIV / AIDS
  • Hypertension
  • Immunizations: Flu, childhood, pneumonia, HCV, HBV
  • Infection
  • Joints / Bones: Rheumatoid Arthritis, Osteoarthritis, Osteoporosis, Lower Back Pain, Knee / Hip Replacement
  • Kidney Disease
  • Maternal / Prenatal Care
  • Medication Reconciliation
  • Melanoma Diabetes
  • Oncology: Chemotherapy / Radiation / Pain, General Oncology, Breast, Cervical, Colorectal, Colon, Prostate,
  • Osteoarthritis (OTC Assessments)
  • Otitis Externa
  • Perioperative VTE Prophylaxis and Antibiotic Timing
  • Psychiatric: Major Depressive Disorder, ADHD, Bipolar Disorder
  • Pulmonary Disease (COPD)
  • Specialist Referral Loop Closure
  • Tobacco Screening
  • Urinary Incontinence
  • Use of High Risk Medications in Elderly
  • Weight Screening
  • Wound Care.

Table D

Stage 2 Hospital Core Objectives

  1. Use CPOE for more than 60 per cent of medication, laboratory and radiology orders
  2. Record demographics for more than 80 per cent
  3. Record vital signs for more than 80 per cent
  4. Record smoking status for more than 80 per cent
  5. Implement 5 clinical decision support interventions + drug / drug and drug / allergy
  6. Incorporate lab results for more than 55 per cent
  7. Generate patient list by specific condition
  8. EMAR is implemented and used for more than 10 per cent of medication orders
  9. Provide online access to health information for more than 50 per cent with more than 10 per cent actually accessing
  10. Use EHR to identify and provide education resources more than 10 per cent
  11. Medication reconciliation at more than 65 per cent of transitions of care
  12. Provide summary of care document for more than 65 per cent of transitions of care and referrals with 10 per cent sent electronically
  13. Successful ongoing transmission of immunization data
  14. Successful ongoing submission of reportable laboratory results
  15. Successful ongoing submission of electronic syndromic surveillance data
  16. Conduct or review security analysis and incorporate in risk management process.

Table E

Stage 2 Hospital Menu Objectives

  1. Record indication of advanced directive for more than 50 per cent
  2. More than 40 per cent of imaging results are accessible through Certified EHR Technology
  3. Record family health history for more than 20 per cent
  4. E-Rx for more than 10 per cent of discharge prescriptions.

Table F

EH / CAH CQM Measures: 49 possible measures covering the categories of conditions / disease management, drug management and medical practice

  1. Antibiotics: Pneumonia, Perioperative
  2. Asthma
  3. Cardiology: AMI, HF
  4. Emergency Department Throughput
  5. Home Management Plan of Care
  6. Immunizations: Pneumococcal, Flu
  7. Ischemic Stroke
  8. Labor / Delivery: hearing, elective births, surfactant, complications
  9. NICU temperatures
  10. PICU Pain Assessments
  11. Pneumonia (antibiotics)
  12. Surgical: VTE Prevention, Antibiotics, Catheter, Hair Removal
  13. VTE Prophylaxis.

Table G

Table H

Table I

Table J

The HIMSS Analytics® Asia Pac EMR Adoption Model (EMRAM) was launched in June of 2011. HIMSS Analytics Asia Pac is focused on collecting EMR adoption data in the following countries

  • Singapore
  • Malaysia
  • South Korea
  • China
  • Thailand
  • Taiwan
  • Hong Kong
  • India
  • Australia
  • New Zealand
  • Saudi Arabia
  • UAE

References are available at www.asianhhm.com

Author BIO
Ken is Chief Medical Informatics Officer of New York Hospital Queens, a member of the New York-Presbyterian Healthcare System. The second edition of Ken's award winning 'Medical Informatics: an Executive Primer' was published 2011. He is Chair of the Informatics Council of NYPHS and a Member, Board Directors of HIMSS.

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