Hospitals seek to improve EMRAM scores with new clinical systems

2015 could be a breakthrough year in Canada as a handful of hospitals prepare to be the first in the country to reach Stage 7 on the Electronic Medical Record Adoption Model (EMRAM), a benchmarking scale developed by HIMSS Analytics, a subsidiary of the U.S.-based Healthcare Information and Management Systems Society (HIMSS).

Others anticipate a quantum leap from Stage 3 to 6 following successful implementation of computerized physician order entry (CPOE), often considered one of the major stumbling blocks to obtaining higher EMRAM scores.

In fact, improving scores is now high on the hospital IT agenda across the country, says Jim Shave, president, Cerner Canada, a supplier of healthcare information technology systems.

“I can think of several instances over the last year where we have been asked to sit down with clients and help them map out what it takes to reach HIMSS 6 or 7, and where they stand today,” says Shave. “There’s a recognition that you’re doing good things as you climb up this adoption scale.”

The EMRAM is an eight-step process designed to help acute-care healthcare organizations track their progress as they move forward with electronic medical record adoption strategies. Each stage depicts a certain level of functionality and deployment, and organizations cannot move up a step until all criteria in the stage are met.

Compare American scores to Canadian scores and one of the first notable findings is that the largest portion of U.S. hospitals are at Stages 3 to 5, whereas most Canadian hospitals fall somewhere between 1 and 3. Canada is also still awaiting its first Stage 7 result, while roughly 3 percent of U.S. hospitals are already there, with another 15 percent close behind. And, the number of U.S. hospitals meeting criteria for Stages 5, 6 and 7 has been steadily rising since 2011 while Canada’s growth remains relatively flat.

At first glance it appears Canada is lagging behind. But what do EMRAM scores actually say about the ongoing journey towards the digital hospital of the future?

John Hoyt, executive vice-president, HIMSS Analytics, would argue there’s room for Canadian governments – provincial or federal – to take a more active role in pushing things along using incentives. He attributes the recent spurt in U.S. achievement to the American Recovery and Reinvestment Act (ARRA) program, which outlines a set of “meaningful use” criteria which organizations must meet in order to receive government funds.

“Our argument is we think the stimulus program has worked,” he says.

But in Canada, the push towards automation has less to do with incentives, competition and scoring and more to do with measuring outcomes and sharing. That often makes it difficult to apply the U.S.-developed EMRAM as a benchmark to gauge overall progress, comments Don Newsham, CEO of COACH, Canada’s Health Informatics Association.

“Here in Canada, we need a broader and more Canadian-focused set of adoption and maturity models to really understand how we’re making progress,” says Newsham. “We’re very supportive of hospitals moving in the direction of higher EMRAM scores … but the importance is the linkage, integration and connectivity to all other components in healthcare.”

In February 2013, COACH published a white paper entitled Canadian EMR Adoption and Maturity Model: A Multi-Jurisdiction Collaborative and Common EMR Adoption & Maturity Model. The report gathered input from B.C., Ontario, Manitoba and Alberta to propose a uniquely Canadian maturity model that divides measurements into three areas: functionality, breadth and outcomes. It also examines integrated care and population impact, two priorities as Canada moves towards “personalized, patient-led, participatory healthcare,” says Newsham.

“It’s not about getting to a certain level, it’s about using technology to the greatest ability and opportunity you have available to you,” says Newsham. “EMRAM simply provides a measuring stick to help demonstrate where you are on that journey, but the importance is the journey. Does a hospital say, ‘I’m Stage 7; I’m done’? Absolutely not. Because the use of digital solutions and the opportunities to use technology to the benefit of patient and provider are ever-changing.”

According to HIMSS Analytics data, the five hospitals in Canada successfully demonstrating Stage 6 functionality are: South Okanagan Hospital in B.C., and North York General Hospital, Markham Stouffville Hospital, St. Michael’s Hospital and Ontario Shores Centre for Mental Health Sciences in Ontario.

When North York General Hospital (NYGH) learned it had achieved Stage 6 back in 2011, the news was “a pleasant surprise,” says Chief Medical Information Officer Dr. Jeremy Theal. “Our focus was never the HIMSS Analytics scale. We embarked on our e-Care project in 2007 to improve the quality and safety of patient care; the EMRAM was not a specific goal.”

Fast forward to today and NYGH now anticipates achieving Stage 7 during its 2014-2018 eHealth strategic planning period. The biggest difference is that Stage 1-6 functionality only needs to be demonstrated in one clinical unit, whereas Stage 7 functionality must be demonstrated hospital-wide, with data exchange taking place outside of the four walls of the hospital, as well.

Stage 7 functionality also encompasses a longitudinal electronic medication administration record (eMAR), so that all medications are discretely documented in the eMAR, including those given by an anesthesiologist during surgery. In addition, it entails use of business intelligence systems that actively extract and analyze data to inform decisions and improve systems.

Though the spirit of HIMSS 7 is a ‘paperless’ hospital, Dr. Theal prefers to keep the focus on patient outcomes versus degree of automation. He’s also a firm believer that strong system design based on clinician input, workflow analysis, evidence-based principles and well-structured data is the real differentiator, regardless of the EMRAM stage.

“I try to shift the conversation away from words like automation and paperless and switch it more to decisions and outcomes, because I think that’s where the real value is,” he says, noting that the emphasis at NYGH is always placed on quality and safety first. “Although we are happy to be at Stage 6, there are some limitations in the model because it doesn’t really focus on patient outcomes, which is where we prefer to evaluate and improve on our performance.”

University Health Network in Toronto is also building its EMR adoption strategy around patient outcomes. In 2011, senior Vice-President and CIO Lydia Lee outlined the hospital’s goal of achieving Stage 6 on the EMRAM scorecard. After more than two years of planning and due diligence, UHN is ready to move forward with a transformation project to replace a myriad of best of breed systems with one enterprise-wide system. The primary driver behind the hospital’s ambitious plan is better documenting and tracking of outcomes, and that relies on better tools for discrete data capture.

“For us, the Holy Grail is being able to have information captured about our patients and the way we treat our patients, and then tie that to good outcome information so we can always understand what we need to do to continuously improve,” explains Lee.

UHN currently scores near 4.75 on the EMRAM benchmark. Although there are pockets of technology in use throughout the hospital that match the functionality laid out for higher EMRAM stages, it’s not yet pervasive or comprehensive enough to achieve a Stage 6 or 7 score, and won’t be until the transformation project takes places, she adds.

“One of the challenges is that the project to rip out and replace your system is very expensive,” says Lee, noting that it’s much harder for Canadian hospitals to make a financial case. “I don’t have that stimulus funding out there for me to grab. I have to make my case truly on clinical outcomes and what’s in it for the hospital in terms of improving efficiencies.”

There is literature to suggest a correlation between better outcomes and progression up the HIMSS scale. What’s interesting to note, says Hoyt, is that the “big payoff” comes at Stage 7 when all of the criteria are met. There are small, incremental improvements from Stages 1-5, but the more notable improvements start at Stage 6 and increase exponentially at 7.

“So the message is, it takes the whole kit and caboodle to begin to drive quality, safety and efficiency improvements,” he says.

But that doesn’t mean Canada is under-performing or under-achieving simply because the majority of its hospitals are scoring in Stages 1-3. Many Canadian hospitals already have CPOE and Closed Loop Medication Management systems in place; yet, they can’t score higher on the EMRAM scale because they haven’t tackled nursing or clinical documentation. As soon as they do, they will jump from Stage 2 to 6.

“Our advice is this is the typical manner in which a hospital progresses up these stages, but it’s not everybody,” says Hoyt.

Stage 4 in particular stands out as a major stumbling block in Canada. According to Cerner’s Shave, the major hurdle is throughput. Implementing CPOE introduces workflow changes that have a tendency to slow things down and it often takes as long as six months before improvements can be measured.

“Despite better quality, better safety and better outcomes, at the end of the day they’re not getting the throughput they’re accustomed to,” he notes.

When UHN adopted CPOE nearly a decade ago, it changed the entire practice dynamic, says Lee. Prior to CPOE, doctors issued verbal orders, nurses took note, placed the order at pharmacy and then administered it. Now, physicians place electronic orders that go directly to pharmacy for verification.

HIMSS Analytics recently introduced a Continuity of Care Maturity Model, now in pilot stages and slated for launch early next year. Intended as a roadmap to help hospitals reach the goal of a “true interconnected healthcare delivery model,” it’s expected to be the guideline for what comes next, after EMRAM Stage 7.

Beyond EMR adoption, the Continuity of Care model examines interoperability, information exchange, care co-ordination, patient engagement and analytics – all of which are top priorities in Canada – and Canadian hospitals are poised to score better than their U.S. counterparts, says Hoyt. “We’re too competitive (in the U.S.) and we’re paying a price for it,” he says.

Once published, Hoyt expects Canada to score well on the Continuity of Care model, particularly in those provinces that have established regional health authorities and laid the ground work for integrating regional care, primary care, home care and community care.

One example of collaboration is the ConnectingGTA project in Ontario, an effort between the Ministry of Health and Long-Term Care, eHealth Ontario, Canada Health Infoway, UHN and the five Local Health Integration Networks in the Greater Toronto Area. The project will enable 700 service providers to securely share patient health information so that patients receive more co-ordinated care.