hospital, doctor, nurse, health care

It was the mid-nineties and the Blue Jays had just won a World Series…twice, Ross loved Rachel, reality television wasn’t yet a reality we had to endure, fears were abound that all computers were going to stop at 11:59PM in the year 1999 because they were only programmed with a two-digit year, and many Ontario hospitals got a brand new Hospital Information System or HIS.

Since then computers survived their two-digit existence, Google has become a word in the dictionary, phones have become smart (and only use a cord to charge), and social media has connected the world in a way that neither Ross, nor Rachel, could ever have anticipated (their relationship status on Facebook would have clarified that whole ‘on a break’ confusion).

The point is there has been a seismic technology shift from that time. It was the pre-information age. Our lives and expectations have changed immeasurably as a result. Now in 2016 many hospitals in Ontario are still clunking along using that same mid-nineties HIS near 20 years later.

When we consider the rate of change in technology it isn’t surprising that Ontario hospitals score very poorly on the Electronic Medical Record Adoption Model (EMRAM) scale. Before we go much further a couple of questions need to be answered: what the heck is EMRAM? But the more importantly, what do EMRAM scores mean to patient care?

First let’s cover EMRAM. EMRAM is a measure established by Health Information and Management Systems Society, HIMSS and tracked by the Ontario Hospital Association, OHA to determine how Ontario hospitals are leveraging technology to deliver patient care. In the United States EMR is synonymous with HIS and doesn’t refer to the primary care EMRs which are found in doctor’s offices across Ontario (I know it’s confusing). So EMRAM measures technology adoption in acute care settings only (hospitals), not primary care settings (family physicians, CCACs, long term care facilities, etc.) or the entire health system (public health, eHealth, etc.).

The EMRAM score is based on seven stages, each representing a different level of technology maturity. The sixth and seventh stages see hospitals move to a near paperless environment, relying on data and systems for many things including decision support.

Below is a chart with a description of each stage with an attempt to put it into context of the patient experience.

EMRAM Definitions

EMRAM Stage Definitions and Criteria


Stages 0-2

A hospital progresses from a speciality centre (where patients can receive certain services but may need to go elsewhere for portions of their care) to a full service hospital (typically characterized by offering Lab, Radiology and Pharmacy services all within the four walls of the hospital). In stages 0-2 hospitals primarily rely on paper to deliver and coordinate care.  Orders are hand written and passed between departments or units. Understandably, there are mistakes and misinterpretation. Patients need to repeat many things that have already been covered because providers may not be able to discern previously recorded observations or have them available at the time of patient interaction.

As hospitals progress towards stage 2 more standards in documentation and language exist, there are computer systems, but many are not integrated, or are poorly integrated. During these stages there is heavy dependence on patients to be knowledgeable about the technical aspects of their care history. Knowing drug names, as well as the medical jargon associated to their condition(s) is important to expedite care.

Stages 3-5

A patient’s health information is more integrated into an electronic record: vital signs, notes, medication administration are stored electronically with the patient record. Greater integration enables electronic charting of trends and diagnoses to enable more proactive care. Pharmacy moves from a fragmented view of patient medication history and consumption to an Electronic Medication Administration Record, EMAR. With an EMAR there is greater electronic error checking to enhance patient safety by confirming that administered drugs aren’t in conflict with each other or with food, labs, or allergies. In later stages Computerized Practitioner Order Entry, CPOE, is available. This capability eliminates errors that occur from written orders and the misinterpretation associated to handwriting. A Clinical Document Repository, CDR, evolves from a repository of information established in earlier stages to provide a second level of clinical decision support capabilities related to evidence based medicine protocols.

During these stages medical images can be accessed electronically and instantly. A patient would notice quicker service between departments, less repetition of their history and less of a dependence on the patient to be knowledgeable about the technical aspects of their care.

Stages 6-7

The hospital becomes near paperless. Physician documentation is data driven and structured. Electronic clinical decision support is proactive and delivers alerts when there is variance from compliance. Medication administration is ‘closed loop’ meaning there is an active medication order by an electronically identified provider (nurse) administering an electronically verified drug to an electronically confirmed patient. This ensures that the “five rights” of medication administration: the right patient, the right drug, the right dose, the right route and the right time are verified at the bedside by scanning a bar code on the medication and the patient. In addition, data warehousing is being used to analyze patterns of clinical data to improve quality of care, patient safety, and care delivery efficiency. Clinical information can be readily shared with all entities that are authorized to treat the patient.

In these stages the patient benefits from a highly integrated approach that shares information with providers both inside the hospital as well as externally in the patient’s circle of care. A patient may have access to a portal to review their own health history as well as access online tutorials and education material about their condition(s) or treatments. Care is coordinated effectively at multiple levels of the health system and transitions are managed effectively and seamlessly.

EMRAM scores and the benefit to the patient

So what does this technology really mean in terms of patient benefits? Based on the HIMSS white paper I’ll highlight some key areas:

Elapsed time from medication orders to medication dispensingStage 6 benchmarks in this area appear to be 15 to 20 minutes for routine orders, and less than 10 minutes for STATS.
Diagnostic report turn-aroundStage 6 hospitals are reporting turnaround times in minutes instead of hours.
Reduction in medication errorsStage 6 hospitals are finding more medication errors, but are also able to show significant reductions in medication errors. Improvements in hospitals report that 42 percent of errors attributed to handwriting have been eliminated, and omitted drugs have been reduced by 70 percent.
Reduction in agency nursesTwo facilities reported a reduction in the use of agency nurses. This saves cost of service delivery, but also by leveraging staff, familiarity of systems and the hospital improve timely patient interaction
Length of Stay (LOS).Stage 6 hospitals sharing metrics in this area had either reduced their LOS metrics or maintained the same LOS metrics with increasing census and acuity. HIMSS Analytics has found that there is a reverse correlation – higher EMRAM stages/scores have a reverse correlation to LOS (the higher the score the lower the LOS).

HIMSS White Paper

The Adoption Challenge

When moving from a largely paper based environment to a technology driven one, organizations often face challenges with change management. This isn’t specific to Healthcare. However, when I meet with physicians I’m often struck with how much of health care is still based on verbal inquiry and physical touch. Technology and EMRAM scores will not change that. As a result technology changes have additional challenges in healthcare settings that are unique. This isn’t because of obstinance. It is largely a result of technology not being a core competency associated to the delivery of care.

However, things are changing. We are moving from an era where physicians didn’t know who Ross and Rachel are because they are too old to an era where physicians don’t know who Ross and Rachel are because they are too young. Technology is becoming interwoven into our lives and as a result expectations are moving towards having technology tools that enhance patient interactions.

Still an HIS is a very different technology experience than the technology we use in our everyday lives. The education curve is steep and often counter intuitive. Physicians can often be frustrated with how many steps are required to use modern HIS solutions when Siri knows exactly what they want when they ask for something. That said vendors are making efforts to make interfaces more familiar and use of smart phones to perform many of these tasks is becoming more prevalent. Regardless most hospitals, and physicians, recognize that the enhancements to patient care associated to modern HIS solutions are worthwhile for the patient even if the path is cluttered with confusing turns and detours.

Where We are Today in Ontario and the eHealth Impact

Looking at the Ontario EMRAM chart below, almost 50 per cent of Ontario scores less than 3 on the EMRAM scale and 80 per cent of Ontario is at three or less. This places pressure on the overall eHealth experience. If the majority of our healthcare institutions are leveraging paper to deliver care can Ontarians truly claim that they have an electronic health record? Many Ontarians experience poor coordination of their care as a result of these known technical deficiencies. Although there are some eHealth related repositories in place to aide the consolidation of a patient’s health record, the majority of services delivered at the point of care are still paper based. In addition, because eHealth repositories are primarily dependent on acute institution’s data contribution, these eHealth solutions often suffer from the lag time associated to waiting for institutions to finalize paper diagnoses and convert them into an electronic format before they are contributed. This is where the breakdown often occurs and creates challenges in the timely coordination of care across the continuum.

EMRAM Trend in Ontario

Ontario EMRAM Scores

Y2K and Next Steps (Don’t Worry it’s Good News)

How is this all related to Y2K? Well much like the concerns over electronic systems’ preparedness to move from a 2 digit year to a 4 digit year and the perceived risk of a global reset, hospitals have had their own expectations reset. With health funding reform the whole funding model has changed for hospitals. The hospital funding model has recently changed to HBAM, Health Based Allocation Method. We’ll review this at greater length in a future post, but in summary hospital funding is more dependent on the ability to identify the true costs associated to a patient encounter. This is a reset for the entire health sector. The 20 year old HIS systems were not designed to capture all these variables easily and efficiently. If hospitals are unable to capture the true cost of delivering care throughout the patient journey, linking workload, materials and ancillary services to the cost per case then hospital’s will find themselves running deficits without data to justify greater funding. Like Y2K, this is the external threat that has created greater urgency for hospitals to move towards HIS change and has become an agenda item for eHealth 2.0. This change, like Y2K, is not a trivial exercise. PWC commissioned a report to the Central West LHIN outlining that hospitals can expect about three years to complete this activity, near 120 resources and over 100 million dollars per hospital.

The good news? HIS replacement, update, and the resulting climb up the EMRAM scale to stages 5-7 will largely happen over the next 10 years. Patients will benefit from a much better health system. In addition, like Y2K, which fuelled an industry of consultants that both trained and employed numerous members of the workforce, this change will have the same effect and generate numerous opportunities that will train and employ the next generation of healthcare workers in Ontario. Coincidentally, the Blue Jays are once again competitive and challenging for a World Series title. Maybe there’s something correlated to the Jays’ success and healthcare technology advancement. At least it gives us another reason to cheer for them along with the health system modernization we need in Ontario.

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