To measure electronic medical record development in hospitals and health systems, HIMSS Analytics, a division of the HIMSS organization, created its HIMSS Analytics EMR Adoption Model, an eight-stage schematic (encompassing Stages 0 through 7) that helps healthcare IT leaders assess their progress in EMR implementation. Since HIMSS Analytics created the model in 2005, it has formally recognized 61 hospitals as reaching Stage 7-61 in the U.S. and one in Seoul, South Korea (as of press time).
Becoming a paperless enterprise is a long and winding road, as the latest Healthcare Information and Management Systems Society (HIMSS) Analytics Stage 7 healthcare organizations-Tucson Medical Center; University of California, San Diego Health System; and Nemours Children's Health System-can attest. It is one fraught with hard work and challenges, but ultimately rich in patient care benefits and financial payoffs.
Here's an inside-and detailed-look at how three hospital systems achieved HIMSS Analytics Stage 7, an objective measure of progress toward EMR implementation.
The commonalities among the latest winners, says John Hoyt, executive vice president, organizational services, HIMSS, are medical staff adoption and the energy to accept the organizational change to make the “best of a new world.” He also notes that having an enterprise system for clinical and financial information doesn't hurt, either. “It's not the only way to do it,” he says. “But it seems to be the most effective for enterprise adoption and the fastest route to goal achievement, which is process redesign and quality improvement.”
The Stage 7 criteria are rigorous, with contenders being analyzed against a 12-page checklist that includes such elements as disaster recovery, quality improvement, deployment methodology, training methodology, governance, HIE, and data warehousing. Hoyt conducts a phone interview before the site visit to ensure the organization is ready for Stage 7. During the day-long site visit, the organization gives a 60- to 90-minute presentation on its IT strategy, and then Hoyt walks the floors (medical imaging, pharmacy, ED, the med/surg floors, and the HIM department, among others), accompanied by two CIOs and a CMIO to evaluate the organization's paperless-ness. The team then makes its decision onsite.
As of yet, there is no Stage 8, but additional stages involving HIE and accountable care readiness are likely to be created. There will however be an ambulatory adoption model rolled out in next few months that will assess patient engagement strategies, as well as other meaningful use criteria. What follows are stories from the latest organizations to reach Stage 7.
TUCSON MEDICAL CENTER
On its way to becoming an accountable care organization, Tucson Medical Center (TMC), a 612-bed community hospital, reached HIMSS' highest level of EMR adoption. In late 2008, the organization took a concerted approach to move to an enterprise electronic health record (EHR) its leaders have dubbed OneChart. Starting in 2001, TMC replaced its order entry system and pharmacy module (with software from the Verona, Wis.-based Epic Systems Corp.), and in January 2009, implemented the rest of the Epic modules, including revenue cycle management.
Frank Marini, vice president and CIO, says TMC began to see improvement in cash collections and denials, as well as improvement in turnaround times, from the ED to inpatient admission. Brian Cammarata, M.D., CMIO, an anesthesiologist by trade, says that medication turnaround time dramatically reduced from an average of 166 minutes to under 10 minutes. Further improvements came when TMC went live with its bar code medication administration (BCMA) in a big-bang approach in June 2010; the hospital averted 6,000 medication errors within the first six months.
Hoyt is impressed by the lack of clinically oriented paper at TMC and with the fact that its electronic medication administration record (eMAR) is the one place to look for all patient medications. Clinical information at TMC is reviewed by the medical executive community via dashboards that are customized for cardiac, neurosurgery, nursing, and other areas, in addition to specific reports for the quality care committee of the board of directors.
Even though the hospital is waiting till 2012 to apply for Stage 1 meaningful use, at this point, it is compliant with most, if not all, of the Stage 1 measures. The hospital is currently looking at Stage 2 requirements across the board and performing a readiness assessment to focus on problem list usage.
Beyond meaningful use, TMC is engaged in many ACO preparation activities like information exchange, which happens rather seamlessly, says Marini, in the OneChart program which operates on a common patient database. TMC's employed physician group, Saguaro Physicians, also uses it and is able to see all inpatient information. TMC intends to connect the hospital to a number of practices, specialty and primary care physicians (PCPs), and ancillary services like laboratory and radiology using the Axolotl exchange technology. TMC has also agreed to participate in the recently announced statewide exchange Health Information Network of Arizona (HINAZ) linking all payers and providers.
THE REAL OBJECTIVE IS TO UTILIZE THIS DATA AND GET IT INTO THE HANDS OF PHYSICIANS IN THE COMMUNITY CARING FOR THESE PATIENTS, SO AS AN ORGANIZATION WE CAN PROVIDE THE MOST COST-EFFECTIVE, HIGH QUALITY CARE TO EVERYONE IN THE COMMUNITY. -BRIAN CAMMARATA, M.D.
The second core element to TMC's ACO foundation is a robust analytics engine (provided by the Eden Prairie, Minn.-based OptumInsight) that will allow clinicians to analyze clinical data, with future advanced capabilities to support clinical activities over the continuum of care and transitional care services. “The real objective is to utilize this data and get it into the hands of physicians in the community caring for these patients, so as an organization we can provide the most cost-effective, high quality care to everyone in the community,” says Cammarata.
Beyond moving forward on its ACO initiative and meaningful use, TMC is focused on its transition to ICD-10. Like its OneChart implementation, it will encompass the whole hospital, but fortunately for this single-platform organization, IT challenges will be mitigated moving forward.
Reaching Stage 7 is not easy, and involves much change management, says Marini. “For something as big, expensive, and risky as an electronic medical record implementation you absolutely need to have your executive team and your CEO on board, fully engaged and committed for the long haul,” he says. “Getting the organization to understand that an initiative like this is not an IT project [is key]. The minute it is looked at as an IT project, you know you're headed in the wrong direction. This is really an organizational initiative; it needs to have leadership from the medical staff, as well as the nursing and operational staff.” Hoyt was impressed by the scope of TMC's IT team, which includes about 100 IT personnel and 20 informatics professionals. “It's clearly a multi-disciplinary effort,” says Hoyt.
WE BELIEVE THAT ALL INFORMATION THAT IS NEEDED FOR PROVISION OF PATIENT CARE IS BEST TO BE IN ONE ENVIRONMENT, SO THAT CARE PROVIDERS DON'T HAVE TO GO TO MULTIPLE DIFFERENT AREAS TO GET THAT INFORMATION. -ED BABAKANIAN
Marini acknowledges the importance of Stage 7 achievement, but says it's really a byproduct of what TMC is trying to pursue. “We didn't think about Stage 6 or Stage 7 when we set out to do this. It was really about the realization that patient care requires better tools; our clinicians require better tools, and that's really what we pursued,” he says. “It was gratifying and validating to use HIMSS Analytics as a benchmark to see that we are on the right track.”
UCSD HEALTH SYSTEM
The story of the University of California, San Diego Health System (UCSD) is one of iterative change, says its CMIO, Josh Lee, M.D. The health system has made many early important decisions that helped it reach Stage 7. The organization, which is comprised of a few specialty centers and two hospitals, UC San Diego Medical Center and Thornton Hospital, operates under one license, with a combined licensed capacity of 552 beds. UCSD has been focused on increasing patient care quality and patient safety through health IT for the last 12 years.
Recently, the system has been transitioning its hybrid systems into a more streamlined, enterprise approach. “We believe that all information that is needed for provision of patient care is best to be in one environment, so that care providers don't have to go to multiple, different areas to get that information,” says Ed Babakanian, who has a team of more than 200 people and has been the system's CIO for 16 years. “That system is supported by these specialized systems like labs, pharmacy, cardiology, imaging, but you have to deploy those in a way like a human body, in that they are integrated and transparent in what they need to do-so a pharmacy system can't be an island of automation all by itself.”
It was UCSD's transition to a unified inpatient EHR that struck Hoyt when he was reviewing the system for Stage 7. In February 2011 the system transitioned its Siemens inpatient system to match its ambulatory system (Epic Systems), so patients could benefit from a centralized registration system and have a record that followed them throughout their care. “I don't think we've ever had a hospital achieve Stage 7 in 12 months of go-live, but that's because they had previous experience, and they were probably at a Stage 5 with their previous system. So they knew what they needed to do, and they put their heads down and did it,” says Hoyt.
Lee says a novel decision that made its inpatient transition smoother was asking clinicians what they felt was the most important element to preserve; their overwhelming response: transitions of care. About 10 months before the big bang go-live, the IT team brought up the medication reconciliation module, which was a new discharge summary system that forwarded certain communication internally and externally.
On the ambulatory side during medication reconciliation, Lee says his team facilitated workflows for vaccinations at time of discharge, so it could happen at a logical time for clinicians. “We recognize that people need to be introduced to things that clearly meet a demonstrated business need, and we delivered on that early, and they were happy,” says Lee. “Nurses and doctors started to see the inpatient presence of our new EMR, so by the time the change happened, it was already a familiar part of [their work environment].”
UCSD provides its staff with complex dashboarding to give clinicians quality report cards, short-term retrospectives, and over time trending to develop practice-based and evidence-based care approaches. For instance, to improve frail patients' risk of fall, a real-time audit is generated for each patient to see if all the appropriate interventions have been taken.
The health system is currently migrating its entire ambulatory and inpatient revenue cycle/billing and appointment schedule system to its enterprise vendor, as well as other modules like its health information management system, ED, perioperative and anesthesia system, and imaging. UCSD is also refreshing its clinical decision support system, as well as implementing a clinical trials system, research informatics for genome sequencing, and a medical education system to train clinicians. “We have a unique combination of talented IT professionals who move beyond simple IT configuration,” says Lee. “But really do workflow analysis almost to the point of becoming an internal consulting agency for the enterprise.”
UCSD has a robust patient portal, which is used by 30,000 patients to send clinical messages, request refills and appointments, complete health maintenance activities like setting reminders for care activities, and update problem lists. In October, patients will be able to download a free MyChart app to manage their health via mobile device. Soon, Lee says that the portal will be able to capture non-urgent medical images, like a photo of a rash, so patients can provide more information to their providers.
Another way UCSD connects with its patients is through telemedicine. Approximately 10 specialties are doing doing telemedicine amounting to approximately 40 distinct contracts, and 10 to 20 more specialties are in the pipeline to begin telemedicine use soon. UCSD is now preparing to see stroke and psychiatry patients remotely, as well as constructing a new telemedicine building to train future physicians. In September UCSD expanded its outreach to rural communities and launched its eVisits program.
UCSD has been recognized nationally for its outreach efforts by becoming one of the 17 Beacon Communities. A year and half ago UCSD obtained the Beacon grant in large part, Babakanian says, because several clinicians on his team started integrating UCSD with several hospitals across San Diego and linking and interfacing community physician practices through an internal HIE to provide for patient-centered medical homes.
The Beacon project, called the San Diego Safety Net Health Information Exchange (HIE), will allow physicians to electronically make follow-up appointments at participating community clinics for patients being treated in the hospital or emergency department who don't have a PCP. Other Beacon activities include expanding pre-hospital emergency field care and electronic information transmission to improve outcomes for cardiovascular and cerebrovascular disease, patient engagement through web portal and mobile technology, and improving continuity of care for veterans and military personnel through the Veterans Affairs/Department of Defense Virtual Lifetime Electronic Record (VLER) initiative.
“I view Stage 7 as our start,” says Lee. “It's really not a finish; I think you have to achieve this stage to now move into the real exciting part of patient engagement and interoperability, but you have to reach this stage first.”
NEMOURS CHILDREN'S HEALTH SYSTEM
The Jacksonville, Fla.-based Nemours system stretches across four states, and because of its institutional breadth of one hospital, 24 clinics (including primary and specialty care) and on-site care partnership with an additional five health systems in Southeastern Pennsylvania and Southern New Jersey, the use of an integrated platform has made all the difference to link the inpatient and outpatient experience. Gina Altieri, vice president of corporate services, says that in Nemours, information technology is just the enabler; it's really the users, who have embraced IT in their everyday jobs and work alongside the IS/IT team to avoid workarounds.
“[We have] achieved a seamless, integrated platform where the inpatient and outpatient experience, as well as the patient and physician portals are all together, and the interfaces essentially being transferred to the vendor through the upgrade process, where they're actually responsible for actually speaking together,” says David Milov, M.D., CMIO, who is an attending in the division of pediatric gastroenterology. He mentions that another early milestone that was crucial to the system's success was its insightful board in 1984 who advocated implementing computerized physician order entry (CPOE).
“We had a lot of information over a wide geography, and an enterprise system is the best way to deliver that same level of care to every doctor in the hospital or in the clinic,” says Bernie Rice, chief of information technology. “Leveraging that enterprise system anywhere, anytime, on any device, has brought the true power of that system to every clinician throughout our enterprise.”
WE CHOOSE TO LOOK AT METRICS WHETHER FROM A CUSTOMER PERSPECTIVE, OR FINANCIAL PERSPECTIVE, OR OUR OWN ASSOCIATES' PERSPECTIVE. WE LOOK AT METRICS FROM AN ENTERPRISE LEVEL, AND WE CASCADE THAT DOWN TO OPERATING DIVISIONS. -GINA ALTIERI
Altieri says the main transition from Stage 6 to 7 involved transforming data from its data warehouse, which it has had for more than 14 years, into information. “We use information in a very organized way through our strategy management system,” she says. “We choose to look at metrics whether from a customer perspective, or financial perspective, or our own associates' perspective. We look at metrics from an enterprise level, and we cascade that down to operating divisions.”
HIMSS' Hoyt adds Nemours strengths are in their quality performance improvement programs that are owed to its effective deployment of its enterprise system, along with clear goals achieved. “Nemours is clearly a data-driven organization,” says Hoyt. “They showed us lots and lots of graphs of data they track and several of those graphs showed a notable improvement starting in May of 2009-that is when they went live.”
Currently, clinicians can use a reporting workbench tool to do simple queries on their patients. For instance, a clinician can see how many of their diabetic patients have been seen in the last six months and have their hemoglobin A1C measures documented or have an action plan that is current. Physicians are highly motivated toward quality improvement, as they have a portion of their salary at risk to achieve agreed upon performance metrics. Milov adds that there are several internal improvement collaboratives, like an obesity initiative that charts doctors by division, shows adherence to the use of available clinical decision support (CDS) tools, and tracks outcomes. The organization knows what percentage of all PCPs who have provided optimal patient information to the families of obese children. Rice says that Nemours is working on a new enterprise intelligence initiative to channel all data into digital dashboards containing real-time information for organizational leadership and clinicians to check their progress, their department's progress, and compare it with their peers.
Nemours is in the midst of working out the thorny issue of information exchange, as it is somewhat dependant on state activities. Within the Nemours enterprise, continuity of care documents (CCDs) have been exchanged since August. In Delaware, Nemours hospitals have agreed to participate in the Delaware Health Information Network (DHIN). But in Florida, on the other hand, there are hospitals in three different districts, all using three different HIEs. An HIE committee has been meeting regularly to figure out which HIE will be worth investing in.
Patient engagement is another strong suit of Nemours. For two years the institution has been deploying kiosks in clinics to ease registration burden, and now has 10 in five sites. Nemours is now working on training patients to trust the kiosks, which is no simple task, Milov says. He notes one kiosk had 16,000 encounters in September, which attests to the growing utility of this initiative. Also, there has been an intense marketing and resource push from the whole organization to achieve informed and activated patients through the organization's MyNemours patient portal. The portal has gone from a few thousand users to now more than 40,000 participating. An ambitious enterprise goal has been set at 100,000 users.
Nemours is now working out the IT components of its cutting edge logistics center at its new Nemours Children's Hospital to open next fall in Orlando. Nemours leadership has borrowed and built upon concepts from airports command centers to local 911 call centers. This children's hospital command central will be staffed by clinicians, who will be able to monitor patients in any room via video and medical monitoring equipment. Also building management systems like elevator operation for trauma cases or helipad operation will be tied in. Nemours has been working with Epic on coding specifics to make sure clinicians are kept in one single application that is integrated with all systems in the hospital.
Healthcare Informatics 2011 December;28(12):25-30