Health Insights, London
CHELSEA FOOTBALL CLUB
11 JUNE 2014
Outline
• Introduction to HIMSS Analytics EMR Adoption Model
• What are the benefits of using the acute care EMRAM?
• What is next? The Continuity of Care Maturity Model
History of the Acute Care EMRAM
• The acute care EMRAM was developed in 2005
• Why the structure?
– It is the typical manner by which hospitals rollout enterprise clinical systems
• Are there any usual variations?
– Academic Medical Centers often have CPOE live to enable education for the
medical students and residents
• The first Stage 7 validation occurred in Q4 2008
– Three years after EMRAM introduction
Why Do We Do It?
• Thought leadership
– Quality, Safety, Efficiency improvements
• To inform government policy
– Numerous countries and regions use HIMSS Analytics to gather data
for their policy formulation
• To reflect the market
– Where is the market heading
• To “drive the market”
• Hospital Data sets:
– >5,400 US and >700 Canada
– >8,000 Europe
– >5,000 Asia-Pacific
2011
Q2
2014
Q1
Complete EMR, CCDA transactions; Data
Analytics to Improve Care
1.1%
3.1%
Physician documentation (structured templates),
full CDSS, full R-PACS
4.0%
13.3%
Closed Loop Medication Administration = Bar
Code Enablement
6.1%
24.2%
CPOE, or e-Prescribing, Clinical Decision
Support (clinical protocols)
12.3%
15.7%
Clinical documentation, CDSS (error checking)
46.3%
27.7%
CDR, Controlled Medical Vocabulary, CDS, HIE
capable
13.7%
7.2%
Ancillaries - Lab, Rad, Pharmacy - All Installed
6.6%
3.2%
All Three Ancillaries Not Installed
10.0%
5.6%
N = 5439
N = 5449
Data from HIMSS Analytics® Database © 2012 HIMSS Analytics
What Are the Benefits of Using the
Acute Care EMRAM?
SOME QUALITY, SAFETY & EFFICIENCY
CORRELATIONS OF STAGE 7 HOSPITALS AND HEALTH
SYSTEMS
First, A Look at How US Market Has Changed
Number of Beds in U.S. Hospitals
Number of Hospitals in the U.S.
1,600,000
8,000
1,500,000
7,500
1,400,000
7,000
1,300,000
1,200,000
6,500
1,100,000
6,000
1,000,000
5,500
900,000
800,000
5,000
1970
1975
1980
1990
1995
2000
2005
2010
1970
1975
1980
1990
1995
2000
2005
The shift to outpatient care has dramatically reduced the number of
hospitals and hospital beds – by 2013: <50% of hospitals are >150 beds
Note: Sweden intends to reduce # hospitals by 20% in next decade
Note: Estonia has >50% reduction in # hospitals in five years
2010
EMR Adoption in the U.S. Market Trended
2006 – 2013
Stage
2006
2007
2008
2009
2010
2011
2012 2014 Q1
Stage 7
0.00%
0.00%
0.30%
0.70%
1.00%
1.20%
1.80%
Stage 6
0.10%
0.80%
0.50%
1.60%
3.20%
5.20%
7.30% 13.30%
Stage 5
0.50%
1.40%
2.50%
3.80%
4.50%
8.40% 11.50% 24.20%
Stage 4
3.10%
2.20%
2.50%
7.40% 10.50% 13.20% 14.00% 15.70%
3.10%
Stage 3
18.70% 25.10% 35.70% 50.90% 49.00% 44.90% 41.70% 27.70%
Stage 2
40.00% 37.20% 31.40% 16.90% 14.60% 12.40% 11.40%
7.20%
Stage 1
17.40% 14.00% 11.50%
7.10%
5.70%
4.80%
3.20%
Stage 0
20.40% 19.30% 15.60% 11.50% 10.10%
9.00%
7.50%
5.60%
7.20%
# of
Hospitals n = 4,237 n = 5,073 n = 5,166 n = 5,235 n = 5,281 N=5,337 N=5,310 N= 5,458
This is how long it takes to make “significant” national progress
Data from HIMSS AnalyticsTM Database
Stage 7 Studies on a Macro Scale
Correlations With Stage 7 Status
Representation of TJC Top Performing Hospitals
by # Quality Metrics Excelling In, per EMRAM
Stage
All hospitals within each EMRAM Stage
50.0%
39.8%
45.0%
40.0%
35.0%
30.0%
20.7%
25.0%
16.3%
18.1%
30.1%
20.0%
12.9%
10.6%
15.0%
10.0%
5.0%
0.0%
6.5%
6.2%
2.3%
0.4%
1.9%
0
12.8%
10.0%
6.4%
6.4%
1.7%
4.8%
10.1%
1
2
8.1%
4.2%
3
4
EMRAM Stage
3 or less
4 or more
6.5%
7.9%
9.7%
5
6
7
Source: HIMSS Analytics
Representation of Hospitals with an "A" Leapfrog
Hospital Safety Grade by EMRAM Stage
100.0%
All hospitals within each EMRAM Stage
90.0%
80.0%
70.0%
60.0%
Tipping Point
50.0%
40.0%
62.6%
30.0%
20.0%
30.8%
10.0%
0.0%
0.0%
Stage 0
5.9%
Stage 1
12.8%
14.3%
Stage 2
Stage 3
20.1%
21.8%
Stage 4
Stage 5
Stage 6
Stage 7
Value Based Purchasing (VBP)
Clinical Scores
70.0
64.3
AVG Clinical Score
65.0
Tipping Point
60.0
55.0
Tipping Point
49.0
50.0
45.5
45.0
40.0
44.6
45.9
45.9
42.7
38.9
35.0
30.0
Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7
EMR Adoption Model Stage
What About Cost Efficiency?
Some Ground Breaking Research on the Effect of EMR Deployment
What We Found in Researching
• Hospitals that implemented EMR between 1996 and 2009 did
NOT generally see a reduction in operating expense,
EXCEPT:
– Cost rise immediately during and following implementation and then fall back
to previous levels
• However:
– Hospitals in locations with IT intensive industry found cost reductions after
three years
– Hospitals in other locations found costs increased
– The initial cost increases was smaller for those in IT intensive locations
Used by permission – Avi Goldfarb
The Trillion Dollar Conundrum: Complementarities and Health Information Technology (NBER Working Paper No. 18281)
Used by permission – Avi Goldfarb
Used by permission – Avi Goldfarb
Efficiencies Adjusted for
• Case Mix Index = intensity
• Quality scores, publically available
• Readmission rate, publically available
• Labor input, publically available
– Nursing specifically
• etc. ….
Hospital Cost Efficiencies BY EMRAM Stage
Early DRAFT
Not for
Distribution
Used by permission – Eric Ford
STATUS OF EMR ADOPTION
EMR ADOPTION IN TURKEY, EUROPE AND THE US
... based on HIMSS Analytics EMR Adoption Model
EMR Adoption Model Scores, Means per Country
(data from 4/13 – 5/14 (Turkey), 4/12 – 3/14 (Europe), 4/13 – 3/14 (US), no weighting etc. applied)
Turkey1 (143)
3.0
Europe2 (1,427)
2.2
Germany (383)
1.8
Netherlands (68)
4.0
USA3 (5,449)
0.0
4.1
1.0
2.0
3.0
4.0
5.0
EMRAM Score (Means)
6.0
7.0
1) Only public hospitals, of those 90% with >200 beds
2) Excl. Turkey; incl. Austria (42), Belgium (1), Denmark (16), Finland (3), France (17), Germany (383), Ireland (2), Italy (524), Netherlands (68), Norway (3),
Poland (83), Portugal (29), Slovenia (2), Spain (220), Sweden (1), Switzerland (8), UK (25)
3) The EMRAM algorithm between Europe and the US differs in some degrees in order to reflect HIT implementation of that particular region
Source: HIMSS Europe Database (05/2014)
EMR ADOPTION IN TURKEY, EUROPE AND THE US
... based on HIMSS Analytics EMR Adoption Model
EMR Adoption Model Scores, Means per Country
(data from 4/13 – 5/14 (Turkey), 4/12 – 3/14 (Europe), 4/13 – 3/14 (US), no weighting etc. applied)
Turkey (134)
3.0
Europe1 (659)
2.6
Germany (193)
2.3
Netherlands (63)
4.1
USA2 (1,310)
0.0
Only public and
non-profit hospitals
with >199 beds
5.0
1.0
2.0
3.0
4.0
5.0
EMRAM Score (Means)
6.0
7.0
1) Excl. Turkey; incl. Austria (14), Belgium (1), Denmark (15), Finland (3), France (16), Germany (193), Italy (178), Netherlands (63), Norway (3), Poland (55),
Portugal (13), Slovenia (1), Spain (79), Sweden (1), Switzerland (4), UK (20)
2) The EMRAM algorithm between Europe and the US differs in some degrees in order to reflect HIT implementation of that particular region
Source: HIMSS Europe Database (05/2014)
So, What is Expected at Stage 7?
Very Good Analytics
Use Analytics to Find Care Issues to Address
Use Analytics to Prove that IT Tools are Enabling Improvements
Find Patients Who Could Benefit From
BRCA1 and BRCA2 DNA Testing
• Major University devised rules to search for child bearing
age patients who have relatives with estrogen driven CA’s
• Rule fired 1,355 times in October
– Generated 22 referrals
• Rule fired 1,478 time in November
– Generated ~140 referrals in November
Rules Firing vs. DNA Tests
1600
• This tells us several things:
– A profound finding
1400
1200
1000
800
600
– Hard to “sell” DNA testing 400
200
0
1
2
October & November 2013
Predictive Alerting for Potential Readmissions
• 40 key variable are tracked to generate predictive score
• Alerts to physicians with advice on best practice – updated hourly !
Their Model is at 80% Accuracy
Using I.T. Tools to Improve
Patient Engagement
Target Your Problems and Cohorts
• Rural north central health system attacked CHF readmission rate
– Weight gain due to medication insufficiency or behavior factors, is a
strong predictor of readmission
• Gave away blue-tooth enabled weight scales to targeted CHF patients
– Reduced readmissions by -42% over 12 months
Target Your Problems and Cohorts
• Teenage obesity & Fit Bits.. Create competitive cohorts with PHR
– -11% reduction in obesity in a year
Mature Organizations Have Created
an e-Continuum of Care
And Have Reduced Costs per Person per Year
Introducing The
Continuity of Care Maturity Model
Model Audiences
• Global applicability
• Primary Target Audiences:
– Regional & National Health Authorities/ MoH
– Integrated Delivery Networks (IDN)
– Health Management Organizations (HMOs) /
Accountable Care Organizations (ACOs)
– (Private) care chains
THANK YOU
John P Hoyt
jhoyt@himss.org