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

2. Enabling better health through information technology.

3. EMRAM Criteria Update – Effective 1 January 2018

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

5. What’s Driving the Change?

6. 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.

7. 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?

8. Highlights of the Changes

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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%

15. 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

16. Logistics

17. 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

18. 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

19. HIMSS Analytics Toolkit
Health IT
Actionable
Insights

20. 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

21. THANK YOU John H. Daniels, CNM, FACHE, FHIMSS, CPHIMS
Global Vice President
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LINKEDIN: linkedin.com/company/himssanalytics
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