EMRAM Criteria Update Prepared For: Presented by: PHILIP W BRADLEY, FHIMSS REGIONAL DIRECTOR, NORTH AMERICA HIMSS Analytics Prepared For:

Enabling better health through information technology.

EMRAM Criteria Update – Effective 1 January 2018

Topics What is driving the change? Highlights – what is new? Logistics – what has been done & what is left to do?

What’s Driving the Change?

EMR Adoption Model - 2005 Stage 7 Stage 6 Stage 5 Stage 4 Stage 3 CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology CPOE, Clinical Decision Support (clinical protocols) Closed loop medication administration Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP Ancillaries – Lab, Rad, Pharmacy – All Installed All Three Ancillaries Not Installed Understanding the level of electronic medical record (EMR) capabilities in hospitals is a challenge in the US healthcare IT market today. HIMSS AnalyticsTM has created an EMR Adoption Model that identifies the levels of EMR capabilities ranging from limited ancillary department systems through a paperless EMR environment. HIMSS Analytics has developed a methodology and algorithms to automatically score more than 4,000 hospitals in our database relative to their IT-enabled clinical transformation status, to provide peer comparisons for hospital organizations as they strategize their path to a complete EMR and participation in an electronic health record (EHR). The stages of the model are as follows: Stage 1: Major ancillary clinical systems are installed (i.e., pharmacy, laboratory, radiology). Stage 2: Major ancillary clinical systems feed data to a CDR that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary, and the clinical decision support/rules engine. Information from document imaging systems may be linked to the CDR at this stage. Stage 3: Clinical documentation (e.g. vital signs, flow sheets) is required; nursing notes, care plan charting, and/or the electronic medication administration record (eMAR) system are scored with extra points, and are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab conflict checking normally found in the pharmacy). Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians outside the Radiology department via the organization’s intranet. Stage 4: Computerized Practitioner/Physician Order Entry (CPOE) for use by any clinician is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one patient service area has implemented CPOE and completed the previous stages, then this stage has been achieved. Stage 5: The closed loop medication administration environment is fully implemented. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point of care patient safety processes for medication administration. Stage 6: Full physician documentation/charting (structured templates) is implemented for at least one patient care service area. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. A full complement of PACS systems provides medical images to physicians via an intranet and displaces all film-based images. Stage 7: The hospital has a paperless EMR environment. Clinical information can be readily shared via electronic transactions or exchange of electronic records with all entities within a health information exchange (i.e., other hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients) using the CCD transaction standard. This stage allows the healthcare organization to support the true electronic health record as envisioned in the ideal model.

Why Update the Acute Care EMRAM? Minor updates in 2014 & 2015 It is time for more significant changes To reflect the current state of an advanced EMR environment All stages are affected Time to raise the bar globally Focus more on functions accomplished and less on technology itself How technology is used to improve care quality and patient safety?

Highlights of the Changes

Stage 1 – Main Diagnostic Systems Results On-Line Current Requirements Updated Requirements Does have all three: Radiology information system, and Laboratory information system, and Pharmacy information system Note: There has never been a definition of what is in a pharmacy information system … in the US it has included Clinical Decision Support … we do not see that in Europe … Note: We do not define which portions of a Laboratory Information System are present: Chemistry, anatomic pathology, etc. Does have all four: Radiology information system, Laboratory information system, Pharmacy management system, and PACS (radiology & cardiology) for DICOM 100% filmless Patient centric storage of Non-DICOM images New or changed requirements are noted with a

Stage 2 – Core Clinical Data Store Current Requirements Updated Requirements Clinical Data Repository (CDR) is installed and is fed by major ancillary systems CDR contains a controlled medical vocabulary Clinical Decision Support for basic conflict checking is present Internal interoperability exists Clinical Data Repository installed or other multiple data stores installed in such a way that users DO NOT have to sign into different systems Such linkages are context aware (i.e., patient does not need to be re-selected in each disparate data store) Security: Physical access policy in place; security & user security training Appropriate use policy in place with training program Mobile security in place Asset disposal policy in place Device encryption in place Anti-virus, anti-malware tools in place Prevent data storage on local user-owned devices (BYOD) All other requirements remain consistent

Stage 3 – Care Documentation is On-Line Current Requirements Updated Requirements Has “classic” order entry Nursing documentation: vitals, nursing notes, nursing tasks, e-MAR, etc. available for at least one inpatient service eMAR is implemented First level Clinical Decision Support implemented (i.e., drug/drug, drug/food, etc.) Image access from PACS available to physicians outside Radiology department Documentation typically performed by nursing is on-line such as: admission processing, H&P, care documentation, nursing orders & tasks related to Dx & procedure, e-MAR, discharge planning etc. Routine Allied Health documentation completed on-line >50% criteria for all wards/ patient days/ inpatient cases – client chose % method It must also be live in the ED, if any Security: Role-based access control (RBAC) is in place Other criteria is unchanged This is not intended to be an exhaustive list of nursing documentation .. Just a sample list

Stage 4 – Physician Orders Are On-Line Current Requirements Updated Requirements CPOE used by any clinician with second level clinical decision support capabilities related to evidenced-based pathways & protocols CPOE implemented with physicians entering orders in at least one inpatient service area CPOE usage criteria set at >50% (Use same metric previously used) CPOE live in the ED, if any Documentation by nursing & allied health usage criteria increases to 90% Where publically available, physicians use access to public data bases for medications, images, immunizations & lab results Business continuity services: Access to: Patient allergies, Problem & Dx, medications, recent lab results Intrusion detection system in place Other criteria is unchanged

Stage 5 – Physician Documentation Current Requirements Updated Requirements PACS – Radiology, Cardiology and storage of patient DICOM images Physician Documentation creating discrete data or derived via NLP for alerts, clinical guidance and to serve analytical capabilities Or background processes that are watching multiple variables that fire alerts to physicians >50% criteria for all wards/ patient days / inpatient cases – use same criteria used for nursing documentation Physician Documentation must be live in ED, if any Intrusion prevention system in place Portable device (hospital owned) security Devices recognized & authorized to operate on network Devices can be remotely wiped Is the EMR capable of reporting the timeliness of nurse orders Notewriter – older sites hate it, they think its useless to have rules.. NLP in 2015 find CHF & add to ProbList

Stage 6 – Verification at POC via Technology Current Requirements Updated Requirements Bar code enabled Closed Loop Medication Administration Physician documentation with structured templates creating some discrete data to feed a rules & alerts engine Technology is used to order medications Technology is used to verify medication orders Technology is used to verify medications at the point of administration (medication, strength, route, patient, time) Technology is used to verify blood products administration Technology is used to verify human milk mother-baby match where there is communal storage of milk Technology is used at point of care for specimen collection >50% criteria: Use same metric used previously ED must also meet these criteria but no % required Security: Mobile device security policies applied to BYOD Risk assessments reported to governing authority Physician documentation uses structured templates capturing discrete information for more than 90%

Stage 7 – CPOE & Meds Management Current Requirements Updated Requirements Paper charts no longer used to deliver & manage care Mixture of discrete data, medical images, document images available within the EMR Data analytics leveraged to analyze patterns of clinical data to improve quality of care, patient safety, and care delivery efficiency Clinical data can be readily shared in a standardized, electronic manner as appropriate Summary data continuity for all services is demonstrated Blood products & human milk included in closed- loop med admin process NON-SCORED: Implementation & use of Anesthesia Information System (five years’ notice) NON-SCORED: CPOE-enabled infusion pumps (seven to ten years’ notice) Provide an overview of the Privacy and security program Other criteria unchanged or in earlier stages More vitals integration, and add ventilators … All ICUs have vitals integration … recommended in PACU & ED… give notice on Vitals integration on the wards … back enter the anesthesia meds …. Name, dose, time … as Lorna said

Logistics

Where Did These Ideas Come From? Designed initial “strawman” in July ’15 – several iterations since Focused discussions with international CIOs individually or in groups Sessions in US, Canada, Spain, France, UK, Korea, Singapore, Australia, China, Germany, Brazil, etc. Stage 6 & 7 & Davies Club in Valencia, Spain HIMSS Executive Institute Vendor input sessions to create alignment Input from major local & international vendors

Roll-out Plans First Announced at HIMSS16 – note: announcing ≠ implementing Development of survey questions, definitional text, & scoring mechanisms underway Implementation timeline 1 January 2018 REMINDER: Revalidation Program started in 2015 Validation is good for three years On-site visit required for revalidation

HIMSS Analytics Toolkit Health IT Actionable Insights

We drive the health IT market in the direction it needs to go Improved Patient Care and Health IT Insights EMR Adoption Model Outpatient EMR Adoption Model Analytics Maturity Adoption Model Continuity of Care Maturity Model Digital Imaging Adoption Model

THANK YOU John H. Daniels, CNM, FACHE, FHIMSS, CPHIMS Global Vice President John.daniels@himssanalytics.org WEB: http://www.himssanalytics.org TWITTER: @himssanalytics LINKEDIN: linkedin.com/company/himssanalytics HIMSS ANALYTICS HEALTHCARE ADVISORY SERVICES