How do hospitals define value related to quality improvement? The Electronic Medical Record Adoption ModelSM (EMRAM) is an eight-step process hospitals can use to analyse their organisation’s level of EMR adoption, chart accomplishments, and benchmark against other healthcare organisations across the country. This article will describe the model and include examples of Stage 6 and Stage 7 hospitals in Asia and other parts of the world that have demonstrated quality improvement (not profitability), improved patient outcomes, reduction of errors, and patient safety through the use of information technology.
The vision of improving health with information technology has been the focus of Healthcare Information and Management Systems Society (HIMSS) since its establishment in 1961. Now, as a mission-driven, not-for-profit and global enterprise, HIMSS continues to focus on leveraging healthcare information technology (IT) to improve patient outcomes, reduce costs and expand access to healthcare with offices in the United States, Europe and Asia.
HIMSS leads efforts to improve health with IT solutions through thought leadership, education, events, market research and media services around the world. The organisation includes more than 60,000 individuals, of which more than two-thirds work with healthcare providers, governmental and not-for-profit organisations across the globe, plus over 650 corporations and 350 non-profit partner organisations, that share this cause. Headquartered in Chicago, Illinois, USA, HIMSS has offices and activities in Europe, Asia, Middle East, and Latin America.
Recognised as a global partner and advisor for governments and organisations, HIMSS employs 350 staff members worldwide and hosts more than 100 events across the globe and another 100+ online educational events and webinars. The largest events, from attendance perspective, are the United States (38,000+), Europe (3,000+) and the Middle East (2,000+).
As the market research business unit within the HIMSS organisation, HIMSS Analytics collects data about information systems deployed in healthcare systems in the US and Canada on a census basis, and on a sample basis in Asia, Europe, Latin America and the Middle East.
In 2005, HIMSS Analytics decided to use the collected data to ‘score’ each hospital based on the hospital’s sophistication in using EMR technologies. This data populates the Electronic Medical Record Adoption ModelSM (EMRAM).
The EMRAM is an 8-step process reflecting the typical manner by which hospitals rollout enterprise clinical systems from a largely paper-based environment (Stage 0) through to a highly advanced EMR environment (Stage 7). Using the EMRAM, hospitals and health systems are able to track their health IT implementation progress against healthcare organisations across Asia and other parts of the world and view all scores in the HIMSS Analytics® Database.
Hospitals must follow several steps to earn the Stage 7 designation. Participation in the HIMSS Analytics Asia-Pacific Annual Study allows hospitals to receive their EMRAM score through the collection of specific health IT data. This data tracks implementation and adoption of EMR applications through each stage of the EMRAM. Hospitals receive validation of Stage 6 with phone interview followed by an on-site review by a HIMSS executive or regional designate. The Stage 7 review includes an on-site visit by a HIMSS-lead team, including a physician, to confirm this highest level of health IT adoption.
Share patient data, using electronic health IT systems, with all groups within the health information exchange network
Advance widespread use and sharing of health and wellness information by consumers and providers
Capture and analyse patient care data – with large scale data analytics which show operational, financial, quality and safety improvements throughout the organisation.
In addition, Stage 7 hospitals have a competitive and quality advantage because with sophisticated health IT systems in place, they can access and share patient health data electronically to improve the overall delivery, quality and safety in patient care.
In the last decade, The EMR Adoption Model has become a preferred evaluation tool used by many health systems in Asia-Pacific, Europe, Canada and the United States, as evidenced by the EMRAM models developed for and used by these respective areas .
Several factors account for the acceptance and use of the EMRAM by healthcare and government organisations, since this evaluation tool provides:
• Only recognised evidence-based model of its kind
• Guidance on how a hospital should progress towards a paperless EMR environment
• A roadmap for hospitals, governments and regions
• Information for governments, regions and hospitals of current status quo from a neutral partner; and
• A global benchmarking tool.
The HIMSS Health IT Value Suite is a robust library of value-focused, evidence-based examples of value classified using a common vocabulary namely, the HIMSS Health IT Value STEPS™. The Value Steps identify five types of value, health IT creates for patients, healthcare providers and communities.
S – Satisfaction
T – Treatment/Clinical
E – Electronic information/data
P – Prevention and Patient Education
S – Satisfaction
From these categories, users can further filter the examples based on other selections from location to type of organisation. In this article, examples may reference the ‘HIMSS Value Suite’ as the source.
Lower Mortality Rates and Higher EMRAM Scores: HIMSS Analytics conducted two studies in 2014 on lower mortality rates and higher EMRAM scores, one in the United States and the other focused on hospitals in the United Kingdom. In this category of quality, four examples follow:
1. HIMSS Analytics and United Kingdom Trusts
2. HIMSS Analytics/Health grades United States Hospitals
3. Chang'an Hospital (2013) – China
4. The Joint Commission Top Performing Hospitals and Higher EMRAM Scores
This report uses data from the HIMSS Analytics’ EMR Adoption Model and mortality rate measures from 91 National Health System (NHS) trusts in the United Kingdom. The mortality rates are from the Healthcare & Social Care Information Centre (HSCIC), a UK governmental agency that publishes the Summary Hospital-Level Mortality Indicator (SHMI) for all UK hospitals.
Analysis: Providers tending to score higher on the EMRAM have ‘stronger clinical systems in place to support interventions designed to diminish deaths associated with hospitalisation than those with a lower EMRAM score.’ In addition, the EMRAM tracks only IT-related subjects, leading to the conclusion that ‘it is fair to infer that IT progress leads to lower mortality.’
In addition, comments from hospital CEOs or CIOs interviewed by the researchers emphasise their belief that a ‘conditional’ relationship between IT and healthcare quality exists: It’s visible in detail in ways statistics can’t show; get a good useful piece of IT to work, and staff become more effective, less stressed, more attentive, and consequently perform better at their jobs. In a place where it takes everyone to make difference, making anyone’s job easier means making the outcome better.’
HIMSS Analytics and Health grades, an online resource for comprehensive information on US physicians and hospitals, reviewed a total of 4,583 facility records selected from the HIMSS Analytics Database, representing the total number of facilities with complete data from 2010 through 2012. In analysing the hospital mortality metrics amongst 19 different disease cohorts, the report found most cohorts experienced improvement in predicted mortality rates when compared to hospitals with lower EMRAM scores on specific high mortality cardiac and respiratory conditions. The predicted mortality rate is an indicator of the level of documentation and capture of patient risk factors that are correlated to increased risk of mortality.
An increased predicted mortality rate suggests hospitals are more accurately able to identify the per centage of patients at risk of a negative outcome because:
Low EMRAM hospitals are able to accurately estimate that 10.9 per cent of their patients are at risk of experiencing a negative sepsis outcome, while
high EMRAM hospitals are able to accurately estimate that 14.9 per cent of their patients are at risk of experiencing a negative outcome.
In addition, as noted in the report, ‘with the prevalent mortality rates, the analysis found: the more advanced the hospital’s EMR capabilities… the more likely the hospital is to have better risk-adjusted mortality rates when treating conditions, such as heart attack, heart failure, stroke, several types of GI surgeries, pneumonia, sepsis and respiratory failure.’
Chang'an Hospital (2013) – China (Stage 7 hospital): This hospital, as noted in the HIMSS Health IT Value Suite, reduced antibiotic consumption from 727 DDSs (defined daily doses) to 480 DDSs per 1,000 patient days in 7 months. As a result, rational antibiotic use resulted in a 64 per cent decrease in mortality rates.
Quality Measures at US’ Top Performing Hospitals with Higher EMRAM Scores: This example reviews the association between EMRAM and The Joint Commission (TJC) Top Performing US hospitals. The Joint Commission accredits and certifies more than 20,500 healthcare organisations and programs in the United States. In 2013, hospitals could be recognised as a Top Performing Hospital, if they excelled in at least one of the following measures:
• Heart Attack
• Heart Failure
• Surgical Care
• Children’s Asthma
• Hospital-Based Inpatient Psych
Advanced EMRAM stages have a higher proportion of The Joint Commission’s Top Performing Hospitals excelling in multiple quality measures than EMRAM stages with lower EMR capabilities, In other words, the proportion of hospitals excelling in multiple quality measures (4 or more) increases with advancing EMR capabilities.
According to research on medication errors from The Joint Commission in the United States :
• 58 per cent of errors occur in administration
• 36 per cent of errors occur in transcribing from handwriting
• 6 per cent of errors in ordering, transportation, and documenting
• Barcode medication administration (BCMA) has improved patient outcomes and reduced medical errors, as noted in this study on timing errors without & with bar codes.
• 6,723 without bar codes: 11.5 per cent timing errors/3.1 per cent were judged serious ADE
• 7,318 with bar codes: 6.8 per cent timing errors (-40.9 per cent)/1.6
• per cent were judged serious ADE (-50.8 per cent)
• Wrong Medications – 57.4 per cent
• Wrong dose – 41.9 per cent
• Improper documentation – 80.3 per cent
• Transcription errors: - 100 per cent
The five examples included here focus on hospitals that reported these improvements in medication errors using BCMA; these Stage 6 and Stage 7 hospitals must use closed loop medication, as noted on the Asian EMRAM at Stage 6 and on the US EMRAM at Stage 5.
Sentara Health System – Stage 7: 96 per cent compliance on scanning and 12,459 medication errors avoided per month.
SSM Health System – Stage 7: Journal of Health Care Quality sites 59 per cent reduction in medication
The next three examples -from the HIMSS Health IT Value Suite - cite reduction in medical errors with both qualitative and quantitative data and references to outcome improvements. In this category of health IT value, it is important to recognise this overlap and connection between fewer medical errors and improved patient outcomes.
Prince Court Medical Centre (2014) - Kuala Lampur (Stage 6 hospital): Ensures proper documentation of patient care.
Singapore National Skin Centre (2014) – Singapore (Stage 6 hospital): Reduced probability of medical errors.
Marina Salud (2012) – Spain (First Stage 7 hospital in Europe): 42 per cent reduction over 2 years in the time from suspected breast cancer to initiation of treatment; improved coordination between primary and specialized providers.
The Quality Connection to Advanced EMR Adoption Patient safety efforts address many intersections of patient care – from medication management to accurate medical history and access to that data. With proper IT patient safety systems in place, clinicians and other caregivers can begin improving patient outcomes and reducing medical errors early in the continuum of care.
This component of advanced EMRAM score include:
US Agency for Research, Health and Quality (AHRQ)- Hospital Survey on Patient Safety Culture
Seoul National University Bundang Hospital (2012) – Korea (First Stage 7 hospital in Asia and outside the United States)
Chelsea & Westminster Hospital Trust – UK
Royal Free London NHA Foundation Trust – UK
AHRQ: In general, the more advanced the hospital’s EMR capabilities, the more positive the staff members are about their hospital’s “patient safety culture.” This statement captures a comparison of 2011 EMRAM scores against the most currently available data set (2011) from the US Agency for Research, Health and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture. This review considered two AHRQ variables by EMRAM stage:
System and procedure effectiveness in ensuring patient safety
Overall patient safety culture grade
Both variables showed a strong association with the EMRAM score. The staff’s perception of the effectiveness of their hospital’s systems and processes in ensuring patient safety increased with advanced EMR capabilities. The staff’s self-reported grade of the hospital’s patient safety culture (where A = the best grade;
B = second best grade; etc…) improved with advanced EMR capabilities.
With over 140 clinical pathways built into the system, (up from 32 five years earlier), the hospital has reduced inappropriate administration rate of pre-operative antibiotics to less than 2 per cent of the cases from 10 per cent, while still generating a 15 per cent reduction in length of stay.
Chelsea & Westminster Hospital Trust – UK: 77 per cent decrease in medicines being prescribed despite known allergy.
Royal Free London NHA Foundation Trust – UK: 67 per cent decrease in inappropriate use of proton pump inhibitors.
Summary: The adoption of electronic medical records across the globe offers a universal opportunity that benefits patients in any location: to improve health with information technology. The vision means that hospitals and health systems must evaluate their progress along this path to IT implementation, a task demanding a standardized tools usage with effective and measureable metric milestones. The HIMSS Analytics Electronic Medical Record Adoption Model identifies and reports on hospitals at Stage 6 and Stage 7. With advanced EMR capabilities, these hospitals demonstrate improved quality measurements for improved patient outcomes, reduction of medical errors and improved patient safety.
1. Electronic Medical Record Adoption ModeSM. HIMSS Analytics website. Downloaded on 2-21-2015: http://www.himssanalytics.org/emram/emram.aspx
2. Asia EMRAM. http://www.himssanalyticsasia.org/emram/. Europe EMRAM: http://www.himssanalytics.eu/emram. Canada EMRAM: http://www.himssanalytics.org/emram/scoreTrends.aspx. United States EMRAM: http://www.himssanalytics.org/emram/emram.aspx. All downloaded on 2-21-2015.
3. The 2014 HIMSS Evidence of the Effects of Healthcare IT on Healthcare Outcomes Report. August 2014. Downloaded 2/22/2015: http://www.himssanalytics.org/about/NewsDetail.aspx?nid=82169
4. EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption Has on Mortality Rates. HIMSS Analytics and Healthgrades. August 2014. Downloaded on 2/26/2015 from: http://www.himssanalytics.org/research/AssetDetail.aspx?pubid=82170&tid=122
5. JHCQ, Vol 26, #6, pgs 5-11
6. 2 N Engl J Med 2005; 353:329-331July 28, 2005