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EMRAM 2.0: HIMSS Analytics Raises the Bar in its Push for Hospitals to Reach Stage 7

May 19, 2016
by Rajiv Leventhal
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In 2005, HIMSS Analytics, the research arm of the Chicago-based Healthcare Information and Management Systems Society, created the Electronic Medical Record Adoption Model (EMRAM) as a methodology for evaluating the progress and impact of EMR systems for hospitals in HIMSS Analytics Logic.

There are eight stages (0-7) that measure a hospital’s implementation and utilization of information technology applications. The final stage, Stage 7, represents an advanced patient record environment. The validation process to confirm a hospital has reached Stage 7 includes a site visit by an executive from HIMSS Analytics and former or current chief information officers to ensure an unbiased evaluation of the Stage 7 environments. The model was extended to ambulatory facilities in 2012; the idea is the same as for acute care facilities, which is working toward creating a paperless patient record environment.

After EMRAM was introduced in 2005, healthcare organizations made slow EMR adoption gains. However, after the meaningful use program was signed into law in 2009, EMR adoption accelerated significantly. Indeed, the number of acute-care organizations reaching at least Stage 5 on the scale grew from 3 percent in 2009, to 6 percent in 2013, to 37 percent in 2014, to 67 percent in 2015. As such with so many hospitals reaching these advanced levels of EMR maturity, the need to make more significant changes to the EMRAM model became apparent.

Nonetheless, Stage 7 organizations are still somewhat of a rare breed. According to recent HIMSS Analytics data, during the fourth quarter of 2015, only 4.2 percent of the more than 5,400 U.S. hospitals in the HIMSS Analytics Logic received the Stage 7 Award, and fewer than 8 percent of the more than 34,000 ambulatory clinics in HIMSS Analytics Logic received the Stage 7 Ambulatory Award.

Recently, HIMSS announced that it would make upgrades to its EMRAM model as priorities and goals have certainly changed for providers since the original model debuted 11 years ago. Previously, incremental tweaks have been made, but future upgrades will be much more substantial, says John P. Hoyt, executive vice president, organizational services at HIMSS Analytics. Hoyt recently spoke with Healthcare Informatics about what patient cares organizations should be expecting and why widespread changes are now needed. Below are excerpts of that interview.

John P. Hoyt

Give me some insight into “EMRAM 2.0,” and the need to expand beyond the original model.

Well, the original model was made in 2005, this is its 11th year, so it’s time to adjust it to reflect how the market has changed in a decade. Originally, the model never had anything in there about security, and that has now taken on front and center. We have periodically made changes to Stage 7; we did so in 2014, but we never made changes to other stages because it requires a software change. The score a hospital gets is a derivative of how they answer our survey. If I am going to change Stages 0 to 6, I have to change the survey and change the algorithms. We all know about software change, especially when you know internally that it’s a product that will sunset. Why spend the effort when you are going to kill the thing?

We have known for a few years that the existing older version of the HIMSS Analytics database and application code is going to be rewritten. Making changes to Stage 7 is easy—you make an update to the reviewer’s guide and tell everyone. But we are moving some of those changes from Stage 7 into some of the lower stages where they belong.

As far as what we’re changing, we have also added security, and we have additionally made updates to reflect the current market. What we are moving from Stage 7 to lower stages does require software changes. This summer, I will be working on designing the new questions that go into the questionnaire, designing acceptable answers, then scoring algorithms, and testing that in Germany, Singapore, Sal Paolo, as well as other places.  

When will the new model be deployed?

It will be sometime in 2017. It will not be Jan. 1 or Dec. 31, but sometime in between. It will be up to my successor, John Daniels. We still have to build the questions and test them.

What are the security aspects in the 2.0 model?

In Stage 3 of the model, we will be asking about role-based security, which is sort of like meaningful use Stage 2, as in, do you have it? I will come up with attributes so the respondent can check yes or no. Here’s an example: I was recently in a hospital in China, and they were confused about what [role-based security] meant. In China, IT has too much authority. The [hospital I was at] changed the EMR; it was an old structure, so they ripped out nursing and physician documentation, and physician order entry. They were so proud since they did it with only a month of testing. We are talking about a 1,250-bed hospital with a 64-bed neonatal unit with no weight-based dosing. So the physicians are hand calculating the dosing, and they have pharmacists verifying orders, but the patients’ weight isn’t on the screen so there is no way to verify dosing. I asked them, where is your clinical leadership? It’s a different culture—in the Western culture you get input from clinicians and pharmacists, but they have an authoritarian culture.