HIMSS WHITE PAPER SPONSORED BY THE HCI GROUP
LESSONS FROM DIGITAL LEADERS
How to manage a successful EMRAM journey
CONTENTS
Key summary
02
The digital transformation process
and the role of EMRAM
03
Benefits of the EMRAM journey
05
Lessons to learn from digital leaders
08
A journey planner to master a digital
transformation
11
Sponsored by:
Key summary
The healthcare sector is progressively deploying Information technology
(IT) to propel the excellence and efficiency of healthcare delivery. The digital transformation of a healthcare institution is more than a comprehensive
IT project as it affects the entire organisation, it is also an undertaking that
requires change management. It needs the personal championing of an individual or a team of senior business stakeholders, so-called digital leaders,
to integrate technology seamlessly in the organisation. In this way, improved
care outcomes, patient safety and organisational efficiencies can be attained.
The HIMSS Electronic Medical Record Adoption Model (EMRAM) is regarded
by hospitals as a trusted path towards digital maturity and is used in this white
paper as a means to identify digital leadership.
Analysing dozens of successful digital transformation journeys from hospitals1, and interviewing two renowned digital leaders in addition to a senior
representative of HIMSS Analytics Europe, this white paper identifies benefits
associated with a hospital’s digital transformation as well as do’s and don’ts
digital leaders recommend avoiding in order to accomplish those rewards.
Based on these insights, HIMSS designs a journey planner that aims to support
hospitals on their digital transformation.
1 For examples in the US see: Honoring Industry Leaders In Health IT Adoption For Improved Patient
Care, HIMSS Analytics, April 2015
02
LESSONS FROM DIGITAL LEADERS
The digital transformation
process and the role of EMRAM
The need for technology
With incidences of chronic illnesses on the rise, care delivery faces the challenge of juggling sustainability with quality of care. Against this backdrop, the
healthcare industry strives to improve health outcomes and deliver care more
efficiently at the same time. This is where IT comes into play − it is essential
for driving excellence and efficiency. However, introducing IT does not merely
mean replacing everything paper-based with digital tools, but it also triggers
innovation in preventing, diagnosing and treating sicknesses as well as in the
administrative field.
Moreover, introducing IT does not only require a tailored implementation
of software and hardware in a healthcare organisation, but it also demands
change management. The digital transformation of a healthcare organisation
is not only an IT project but requires the buy-in of its management. It additionally needs the personal championship of a senior business stakeholder
to turn the digital transformation journey into an endeavour that helps to reap
benefits such as improved care outcomes and financial efficiencies. It is important that a healthcare institution is aware of the range of potential benefits
to be gained before it starts on the EMRAM journey and weigh those against
the required resources in order to establish the validity of the business case.
This, in turn, will facilitate the buy-in of the management.
EMRAM as a map for the digital transformation
For the purpose of this white paper, the essence of digital transformation
in the healthcare sector is defined as the journey of becoming a paperless
healthcare organisation. At the heart of this change process lies the exchange
of patient information in digital format between the various stakeholders
involved in the care.
The extent to which IT is used to streamline internal processes and workflows
not only varies by country, but also from hospital to hospital. A well-established method of measuring the degree to which hospitals have replaced
paper-based processes with technology is the EMRAM that was developed
by HIMSS Analytics in 2005. Jörg Studzinski, Director Research & Advisory
Services at HIMSS Analytics, Europe, explains: “EMRAM describes the journey of digital transformation with respect to the introduction of an electronic
medical record (EMR) system, which requires changes in the workflow and
daily routines. However, it does not reflect the entire journey toward a digitally
03
Introducing IT does not
merely mean replacing
everything paper-based
with digital tools, but it
also triggers innovation
in preventing, diagnosing
and treating sicknesses
as well as in the administrative field.
“As EMRAM is a pragmatic
model that can be relatively easily implemented and
allows international comparisons, over the last five
years, it has become the
de-facto reference system
for measuring the digital
maturity of a hospital.”
Figure 1: The EMRAM roadmap
The EMRAM roadmap
STAGE
EMR Adoption Model Cumulative Capabilities
7
Complete EMR, Data Analytics to improve care
6
Physician Documentation (templates), Full CDSS,
Closed Loop Medical Administration
5
Full R-PACS
4
CPOE; Clinical Decision Support (clinical protocols)
3
Clinical Documentation, CDSS (error checking)
2
CDR, Controlled Medical Vocabulary, CDS, HIE Capable
1
All Three Ancillaries Installed — Lab, Rad, Pharmacy
0
All Three Ancillaries Not Installed
supported healthcare delivery, but focuses on how comprehensively technology is used to capture electronic information generated in a hospital.”
The healthcare industry regards EMRAM as an internationally valid standard
for measuring the maturity of a hospital’s EMR environment. Studzinski explains: “There are some other, country-specific models, like those in France
and England, that look at specific processes within and outside a hospital.
They potentially map some aspects better than EMRAM, but lack the international comparability. As EMRAM is a pragmatic model that can be relatively
easily implemented and allows international comparisons, over the last five
years, it has become the de-facto reference system for measuring the digital
maturity of a hospital.”
EMRAM permits hospitals to benchmark their digital progress along an eightstage continuum. It maps a progressively sophisticated roadmap for the journey
from a paper-based environment, EMRAM Stage 0, to an entirely paperless
environment, EMRAM Stage 7 (see Figure 1). Furthermore, EMRAM also offers
hospitals a means to compare themselves with its peers.
04
LESSONS FROM DIGITAL LEADERS
Benefits of the EMRAM journey
The further a hospital advances along the EMRAM journey, the more it will be
able to reap the benefits of its investment in terms of an increase in quality,
safety, and operational efficiency. It is exactly because of this, that the early
stages of the EMRAM journey can also be met with unwillingness. Having
assessed many hospitals across all EMRAM stages, Studzinski confirms that
“EMR adoption often stalls at EMRAM Stage 2, because at that point of the
journey, there are costs that are not balanced out by any returns on investment nor realised benefits. In addition, if not managed properly, the changes
can impair the relationship between physicians and management.” For this
reason, it is important to constantly communicate what can be expected of its
stage and what has been achieved so far.
Edward W. Marx, Senior Vice President at Advisory Board/Clinovation and
currently acting as an interim CIO to New York City Health & Hospital, knows
from his experience in leading several hospitals along that journey at what
stage benefits typically materialise: “Although all stages are important, the first
four are essential in removing the potential for human error. With the introduction of computerised order entry at Stage 4, or the ability to analyse data
to create change at Stage 7, the real value of the investment emerges. Then
the ability to impact financials, clinical outcomes and quality of care increases
exponentially.”
And Carolyn Byerly, C-Level Advisory Services, HCI Group, and former chief
information officer (CIO) at Stanford Hospital & Clinics, Lovelace Health System,
Mayo Clinic, amongst others, stresses that the “CIO has to communicate at
C-level the potential benefits that are associated with the EMRAM journey,
ideally at the start of the journey.”
Nevertheless, there is no formula to determine in advance the exact type
and scale of realised benefits along the journey. In addition, it is not always
possible to establish a clear connection between an action and its results,
especially in complex organisational environments such as hospitals. However,
there is a common set of improvements that many hospitals experience that
mainly fall in the categories of clinical benefits/increased patient safety, financial benefits/higher efficiencies, and higher satisfaction ratings.
05
“Although all stages are
important, the first four
are essential in removing
the potential for human
error”
Hospitals have reported the following benefits, although the scale of each
can vary widely between institutions:
Clinical benefits / increased patient safety:
• Reduction in errors decreases mortality rates2
• Reduction of Adverse Drug Events (ADEs)3
• Reduction in medication administration errors4
• Reduction in time spent looking for information5
• Enhanced safety of care6
Financial benefits / increased efficiency:
• Reduction of duplicate medical orders7
• Reduction in paper-based costs8
• Reduction in length of hospital stay and preventable hospital readmissions9
• Health plan savings10
• Reduction in errors, reduces potential losses and liability insurance costs,
including medical staff’s11
• Shift to outpatient and home care12
Higher satisfaction ratings:
• Increase in employee staff satisfaction reduces turnover costs13
• Increase in direct patient care time is a staff “satisfier”14
• Increase in family and patient satisfaction with Closed Loop Medication
Administration15
• Reduction in length of stay increases patient satisfaction
2, 3, 7-15: HIMSS Analytics, EMR Adoption and Benefit Realization, Jörg Studzinski CCSS Workshop,
Costa Rica October2016
4-6: Hospital IT Benefits – Modeling EMRAM Value, May 2013, PricewaterhouseCoopers
06
LESSONS FROM DIGITAL LEADERS
Testimonials
Clinical benefits
“We witnessed safety incidences
go down, e.g. the fall rate of patients decreased by over 20% and
the occurrence of venous thromboembolism (VTE) dropped by 42%.”
Ed Marx, US
“We saw hockey stick improvement
in terms of quality of care” Ed Marx,
US
“Reduction in average time between initial evaluation and biopsy.”
Onkologikoasan Sebastian Cancer
Institute, Spain
“The introduction of the Clinical
Decision Support System reduced
the time from the cancer diagnosis
to treatment by 57% compared to
before.” Badalona, Healthcare Services, Spain
Financial benefits
“We saw cost reductions attributable to reaching functional levels of
Stage 7. Per year, we save around
$20 m (€19.2m) on printing and
millions on transcription services
as clinicians document directly
into the EHR.” Ed Marx, US
Fewer inventory items expire before
use due to automated tracking.
Västerås Central Hospital, Sweden
Closed Loop Medication Administration led to a reduction of drugs
requiring co-signing from 461 to
390, equating to roughly 15% of
nursing time being saved.
Galway Clinic, Ireland
Physician documentation improved compliance with clinical
documentation (entry of clinical
notes for discharge summaries
from 30% to 95%). Milton Keynes
Hospital NHS Foundation Trust, UK
A measured reduction of 5-15
minutes per chart reviewed, saving
approximately 30 minutes of chart
reviewing time per therapist per day
increased the number of patients
that can be seen each day. Beaumont Health System, US
The diagnostic support system has
saved us €30,000 per year in diagnostic coding. Badalona, Healthcare
Services, Spain
Efficient use of staff resources –
paperless environment reduces
physical coding, scanning, integrating documents & facilitates patient
requests for copies of documents
saving €324,000 annually. Hospital
de Dénia – Marina Salud S.A., Spain
Fifty per cent of the discharge
report’s content is generated automatically by the EMR, resulting
in savings of 5 minutes per report,
amounting to 977.33 hours per
year of nurses’ time. Hospital de
Dénia – Marina Salud S.A., Spain
Reduction of hospitalisation in
wards from >10 days to <7 days by
tracking nurse activities, identifying
a gap in training skills, closing the
skills gap & continuously monitoring
progress IRCCS Candiolo, Italy
Availability of all electronic clinical information in EMR for coding
results in savings of 5 minutes per
07
major and minor surgery, amounting to savings of 1,249.50 hours
per year from either a nurse or a
physician. Hospital de Dénia –
Marina Salud S.A., Spain
Satisfaction ratings
“We saw an increase in patient
satisfaction, although the causality
cannot be proven scientifically.
Still, EHRs and Stage 7 contributed
greatly to it. We could indirectly
gauge the level of satisfaction as
our patients praised how easily they
could now access their medical
records via the portal that had
become available as part of Stage
7 proceedings. For example, at discharge, patients often lost their discharge summary papers, whereas
at Stage 7 they can go online and
look in their records for aftercare
instructions.” Ed Marx, US
“In the year we deployed EHRs
and achieved Stage 7, physician
satisfaction with IT was rated the
highest at 95% – very satisfied. We
believe it had a lot to do with providing all the attributes that come
along with Stage 7”. Ed Marx, US
The bar code scanning system
improved patient satisfaction by
providing a real-time breastmilk inventory to help avoid running out of
milk or a mother having to make a
last minute extra trip home to bring
more milk to the hospital. Children’s
Hospital of Orange County, US
What can be learnt
from digital leaders?
“The term digital leader,
when it comes to Acute
Care Hospitals, refers to
those who have managed
to ensure their organisation has achieved EMRAM
Stage 6 or 7 certifications”
What is a digital leader?
The digital transformation of a healthcare organisation demands the personal
championing of an individual or a team of senior business stakeholders who
can integrate technology seamlessly in the organisation rather than just implement new technologies. This rare breed of IT leader is called a ‘digital
leader’. Digital leaders use information technology to drive significantly high
levels of customer and staff satisfaction, productivity and performance. They
are instrumental in shaping and advancing the digital transformation of the
organisation they work for. The term digital leader can refer to just a single
person but also to a group that chiefly contributed to achieve the digital
transformation.
Studzinski explains: “The term digital leader, when it comes to Acute Care
Hospitals, refers to those who have managed to ensure their organisation
has achieved EMRAM Stage 6 or 7 certifications as this already represents an
important part of the digital transformation pathway. It means that they have
already overcome substantial hurdles. This doesn’t happen very often, and,
consequently, there are few digital leaders”. Looking at the distribution of hospitals that have achieved Stage 6 and 7 certifications confirms that there are
only few in between (see Figure 2).
To fully appreciate how few hospitals there are globally that have achieved
EMRAM Stage 6 &7, it is important to consider the overall number of public
hospitals in those regions: The US has about 5,400, all of which have an EMRAM score, Canada has about 640 and Europe, including Turkey, has approximately 9,000 of which more than 2,000 were assessed by HIMSS. For North
American hospitals EMRAM Stage 6 & 7 certifications are important brand
extensions and can even be relevant for their insurance premiums (i.e. they
have to pay lower fees). In Europe this is not as much the case yet, but in
some countries similar trends are visible. The absolute number of hospitals
in Europe qualifying for EMRAM Stage 6 & 7 could potentially be higher if all
hospitals would participate in the assessment.
Although EMRAM allows for a comparison of the respective national maturity
levels, it is important to consider the push on adoption that national eHealth
strategies and incentive schemes such as ‘Meaningful Use’ in the US and
Turkey’s ‘Digital Strategy 2018’ have on the investment into EMRs.
08
LESSONS FROM DIGITAL LEADERS
Figure 2: Distribution of digital leaders (EMRAM Stage 6 &7 hospitals)
in North America and Europe
(Status, Q4 2016)
Country
North America
Canada
US
Europe
Belgium
France
Germany
Ireland
Italy
The Netherlands
Spain
Switzerland
Turkey
UK
TOTAL
Total No Stage 6/7
Hospitals
1946
8
1938
61
1
8
1
1
5
9
15
2
16
3
2007
No of Stage 7
Hospitals
266
1
265
4
0
0
1
0
0
1
1
0
1
0
270
No of Stage 6
Hospitals
1680
7
1673
57
1
8
0
1
5
8
14
2
15
3
1737
What does it take to be a digital leader?
By examining EMRAM Stage 6 & 7 hospitals, which we refer to as digital leaders, HIMSS Analytics could establish some common characteristics in terms of
achievements as well as attitude that they share.
Digital leaders…
• use data to drive improved outcomes regarding processes as well as
financial and clinical performance;
• are fully committed to continuous process improvements through
­collaboration;
• are supported by champions from different backgrounds such as
­executive stakeholders, clinicians, or other end users;
• manage to create a group spirit, a positive emotional attitude towards
working on the transformation process; and
• understand that the EMRAM journey is a change management
­programme that has to come from the top.
Lessons to learn from digital leaders
What can those involved in a hospital’s digital transformation learn from digital
leaders? Marx, well-renowned for his digital leadership for which he received
several accolades, has plenty of advice on how to successfully accomplish
09
“Be aware that a person’s life is at stake and
leverage technology to
act accordingly. For this,
EMRAM offers a beautiful
framework with a common language and established best practices for
the journey.”
“The more influence a CIO
has on the management
team, the higher the likelihood that the organisation
will achieve stage 6 and 7
certifications”
the digital transformation: “Be aware that a person’s life is at stake and leverage technology to act accordingly. For this, EMRAM offers a beautiful framework with a common language and established best practices for the journey.
Have it as part of your planning process otherwise it will not happen.” Marx
also recommends to “develop a common vision in your organisation with the
management’s buy-in. Focus on key performance indicators and have a future
orientation. Have a physician or nurse as a champion to trumpet the benefits
of technology as an enabler. Validate externally what you do internally, to get
external recognition that what you were doing is working. Don’t be afraid to
leverage external resources, get outside help to close your gaps. There is no
organisation that can do everything well and sometimes you don’t even know
what you don’t know, so it always requires intellectual honesty.”
Carolyn Byerly advises: ”The EMRAM journey must start with a leadership
team, it needs to be embraced at C-level. It is a change management exercise
led from the top that affects the entire organisation. The journey should always
start with a gap analysis, it allows us to identify the gaps and to communicate
them internally and externally”.
Studzinski observes: ”When you get to certify stage 6 and 7 hospitals, you
immediately get a sense that there is someone in the management supporting the entire journey. With successful teams, there is a certain positive group
dynamic palpable, it’s in the way they interact. I witnessed, for example, that
a group of people majorly involved in carrying out the EMRAM journey in one
hospital started hugging each other and shedding some tears of joy when
they became certified”. In his view, the digital transformation is an undertaking
that requires the backing of the entire management, “a crucial success factor
is the position of the head of IT within a hospital’s organisation chart. The more
influence a CIO has on the management team, the higher the likelihood that
the organisation will achieve stage 6 and 7 certifications. And here I see many
differences: there are CIOs taking part in management meetings or are part of
the management. In other cases, the CIO is neither part of the management
nor involved in meetings, then it will be relatively difficult to get to stage 6 & 7
as this requires change management from the top”.
10
LESSONS FROM DIGITAL LEADERS
Journey planner to master
a digital transformation
Based on our interviewees’ experience in leading and evaluating an organisation’s digital transformation, the following journey planner highlights the essential do’s and don’ts on the journey.
Figure 3: Digital Transformation Journey Planner
1. DEFINING YOUR GOAL:
• Start with analysing your
current status quo with
regards to patient outcomes, your organisation’s
financial and organisational
performance.
• Determine what your
organisation wants to
achieve.
• Assess the digital maturity
of your organisation with a
gap analysis.
2.LOOK OUT FOR ROLE MODELS:
• Which organisations have already achieved
EMRAM Stage 6 & 7 certification?
• Establish priorities with
relevant stakeholders in
your organisation.
• What can my organisation learn from those and apply?
• Define the transformation
path and establish milestones.
• Potentially involve third parties for advice.
• Focus on the key performance indicators during
the digital transformation
journey.
3.ASSESS THE ROLE OF IT
IN YOUR ORGANISATION:
• Specify the timeframe.
• What is the role of IT and CIO in your organisation?
• The CIO needs to be aligned with or be part of
the management to make the most of the digital
transformation.
4.STAKEHOLDER BUY-IN IS ESSENTIAL:
• The digital transformation is not only
an IT project, but one that needs the
support of the entire management.
Beyond implementing technology,
it requires process redesign and
change management, physician buyin and satisfaction, as well as patient
satisfaction.
• Communicate the benefits associated
with the digital transformation at its
various stages.
• It is important to have a physician
and/or a nurse as champion for the
digital transformation, it is not sufficient to have a CIO to trumpet the
benefits of EMRs.
• A well-organised
governance structure
is critical to physician
• Have regular stakeholder meetings
to discuss the progress of the transformation and to ensure continuous
stakeholder support.
• Assess your performance against the
defined goals at the agreed milestones.
5.COMPANY
CULTURE:
• Transformation requires
strong leadership and
communication with all
stakeholders.
• Need to establish and communicate
a common vision, especially when
heading for Stage 6 & 7 certifications.
adoption and ensuring
clinical appropriateness
of design and build.
• Training and ongoing
support of both staff
and senior management are essential.
11
6.USE OF
EXTERNAL HELP:
7. VALIDATION OF YOUR
ACHIEVEMENTS:
• Get outside help
to close your gaps.
Outside help can be in
the form of consulting
firms, vendors and/or
HIMSS gap assessment services.
• Validate externally what
you do internally. Aim for
an external validation to
add to your credibility.
HIMSS Europe GmbH
Bertha-Benz-Straße 5
10557 Berlin
Germany
+ 49 (0) 30 346 55 42 13
[email protected]
HIMSS Analytics
Schwaegrichenstraße 9
04107 Leipzig
Germany
+ 49 (0) 341 333 953 00
[email protected]