Health Insights, London

CHELSEA FOOTBALL CLUB11 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

Data from HIMSS Analytics® Database © 2012 HIMSS Analytics

1.1% 3.1%

13.3%

24.2%

15.7%

27.7%

7.2%

3.2%

5.6%

4.0%

6.1%

12.3%

46.3%

13.7%

6.6%

10.0%

2011 Q2

2014 Q1

N = 5439 N = 5449

Complete EMR, CCDA transactions; Data Analytics to Improve Care

Physician documentation (structured templates), full CDSS, full R-PACS

Closed Loop Medication Administration = Bar Code Enablement

CPOE, or e-Prescribing, Clinical Decision Support (clinical protocols)

Clinical documentation, CDSS (error checking)

CDR, Controlled Medical Vocabulary, CDS, HIE capable

Ancillaries - Lab, Rad, Pharmacy - All Installed

All Three Ancillaries Not Installed

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

The shift to outpatient care has dramatically reduced the number of hospitals and hospital beds – by 2013: <50% of hospitals are >150 bedsNote: Sweden intends to reduce # hospitals by 20% in next decadeNote: Estonia has >50% reduction in # hospitals in five years

1970 1975 1980 1990 1995 2000 2005 20105,000

5,500

6,000

6,500

7,000

7,500

8,000

Number of Hospitals in the U.S.

1970 1975 1980 1990 1995 2000 2005 2010800,000

900,000

1,000,000

1,100,000

1,200,000

1,300,000

1,400,000

1,500,000

1,600,000

Number of Beds in U.S. Hospitals

-25% -41%

EMR Adoption in the U.S. Market Trended 2006 – 2013

Data from HIMSS AnalyticsTM Database This is how long it takes to make “significant” national progress

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% 3.10%

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%

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% 7.20% 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%

# of Hospitals n = 4,237n = 5,073 n = 5,166 n = 5,235n = 5,281N=5,337 N=5,310 N= 5,458

Stage 7 Studies on a Macro Scale

Correlations With Stage 7 Status

Source: HIMSS Analytics

Representation of TJC Top Performing Hospitals by # Quality Metrics Excelling In, per EMRAM Stage

0 1 2 3 4 5 6 70.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

1.9% 4.8%10.1% 8.1%

4.2% 6.5% 7.9% 9.7%0.4%1.7%

6.2% 10.0%

6.4%6.4%

12.8%

30.1%

3 or less 4 or more

EMRAM Stage

All

hosp

itals

with

in e

ach

EMR

AM

Sta

ge

2.3%6.5%

16.3%18.1%

10.6%12.9%

20.7%

39.8%

Representation of Hospitals with an "A" Leapfrog Hospital Safety Grade by EMRAM Stage

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 70.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0.0% 5.9%12.8% 14.3% 20.1% 21.8%

30.8%

62.6%

All

hosp

itals

with

in e

ach

EMR

AM

Sta

ge

Tipping Point

Stage 0

Stage 1

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

Stage 7

30.035.040.045.050.055.060.065.070.0

38.9

45.5 44.6 45.9 45.942.7

49.0

64.3

EMR Adoption Model Stage

AVG

Clin

ical

Sco

re

Tipping Point

Tipping Point

Value Based Purchasing (VBP) Clinical Scores

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

The Trillion Dollar Conundrum: Complementarities and Health Information Technology (NBER Working Paper No. 18281)Used by permission – Avi Goldfarb

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 DRAFTNot 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

1) Only public hospitals, of those 90% with >200 beds2) 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

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)

Source: HIMSS Europe Database (05/2014)

Turkey1 (143)

Europe2 (1,427)

Germany (383)

Netherlands (68)

USA3 (5,449)

EMRAM Score (Means)0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

3.0

2.2

1.8

4.0

4.1

EMR ADOPTION IN TURKEY, EUROPE AND THE US... based on HIMSS Analytics EMR Adoption Model

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

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)

Source: HIMSS Europe Database (05/2014)

Turkey (134)

Europe1 (659)

Germany (193)

Netherlands (63)

USA2 (1,310)

EMRAM Score (Means)0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

3.0

2.6

2.3

4.1

5.0

Only public and non-profit

hospitals with >199 beds

So, What is Expected at Stage 7?

Very Good Analytics

Use Analytics to Find Care Issues to AddressUse 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

• This tells us several things:– A profound finding– Hard to “sell” DNA testing

1 20

200400600800

1000120014001600

Rules Firing vs. DNA Tests

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 CareAnd 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 YOUJohn P Hoyt

jhoyt@himss.org