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by John Rayner | Patience Chinwadzimba
Published on 29 November 2019

In this edition of our Cerner blog, John Rayner, regional director of HIMSS Analytics EMEA and Patience Chinwadzimba, healthcare executive at Cerner, walk us through some of the most recent changes made to the HIMSS EMRAM model and the support Cerner can provide as your organisation starts to prepare for its next HIMSS assessment.

Understanding the model

By John Rayner, regional director, HIMSS Analytics EMEA

As you may well know, HIMSS Electronic Medical Record Adoption Model (EMRAM) allows you to track your organisation's progress in adopting electronic patient record technology against your digital plan or against other healthcare providers from around Europe and the world.

While the evaluation involves a thorough preparation and assessment process for organisations that want to assess their electronic health record’s (EHR) maturity, there are a number of myths around what’s involved in achieving the different stages of the model.

Let’s take this opportunity to clear up some of these misconceptions by taking you through the process, and to outline some of the ways in which our requirements for applicant organisations have changed.

1. Getting started

The first point that is important to make is that the EMRAM model is exclusively designed to assess acute hospital settings. It’s used for inpatients only – To assess an outpatient or community scenario refer to the HIMSS Outpatient EMRAM (O-EMRAM) tool.

EMRAM is an eight-stage model, scored from stages zero (least mature) to seven (most mature). At each stage, organisations need to demonstrate a progressive and eventual removal of paper, higher pervasiveness of use and compliance statistics, and an increasing reliance on automation and clinical decision support.

The starting point for any hospital (worldwide) wanting to obtain an EMRAM score and embark on the Stage 6 or 7 journey is to complete an online EMRAM survey.

Stages zero to five can be achieved through a self-assessment process by completing the online survey. All requirements listed on each stage are mandatory, which means only organisations that have met all those requirements will be able to move to the next stage. This sets HIMSS EMRAM apart from the other maturity models where 70% compliance would possibly be enough to reach each stage.

Once the questionnaire has been completed and passed through a quality assurance process, organisations will receive a gap overview report which includes the EMRAM score and some benchmarks.

Many hospitals then opt for an on-site gap assessment after receiving their EMRAM score in order to have further detail of what is preventing them from achieving Stage 6 and what it is that they need to do to close these gaps. If a hospital is identified as a Stage 6 candidate then we would make plans, with their consent, to come onto the hospital site and carry out a Stage 6 validation. It's only at that point that HIMSS acknowledges the fact that there may be a new Stage 6 hospital. Everything else is confidential and done via a self-assessment process, as stated above.

A Stage 6 validation requires an on-site visit that would typically take a whole day, a Stage 7 validation takes two days on average. We are joined by two external assessors who are often drawn from existing Stage 6 and 7 hospitals across Europe. Successful validations last for a three-year period.

2. New and refreshed standards

From 1 January 2018 HIMSS introduced some important changes to the model.

Firstly, the introduction of several new standards. These mainly focus on business continuity plans, security measures, and disaster recovery.

For example, those looking to achieve a Stage 4 EMRAM score need to show how they can cope when their EHR or other relevant clinical system is unavailable – either on a planned or unplanned basis.

The gold standard is for an inpatient facility to have a protected device immune from network outage or power failure. In either of these scenarios, clinical staff should be able to access a summary of a record so patient care is not interrupted. The HIMSS assessors are happy to see paper being used as part of the business continuity process – but they are, of course, also interested in understanding how the paper is managed once system access is restored.

With regards to intrusion detection, Stage 4 looks at how you identify that there has been some kind of intrusion – be it into the network, into the record or indeed into the physical location of the data centre. Occasionally, HIMSS representatives might go and have a look at the data centre. They will certainly want to speak with someone with a responsibility for security to understand how it is being managed on the hospital site.

Taken together, these are all areas that weren’t particularly well covered when the EMRAM requirements were first developed 15 years ago.

We’ve come a long way since then - with healthcare IT becoming a much more critical part of the hospital management processes, it felt like the standards needed a significant facelift and we needed to have them reflect the way hospitals are run today.

Secondly, some of the existing elements that providers are required to demonstrate have also moved from the higher stages into the lower stages.

A great example of that is the pervasive use of picture archiving and communications systems (PACS) for radiology and cardiology. Conscious that most hospitals in Europe now use some kind of image management solution, the imaging standards have been moved from Stage 5 to Stage 1. 

Additionally, non-DICOM (Digital Imaging and Communications in Medicine) images are now a topic of interest in Stage 1. These are the photographs that might be taken by the wound care specialist or by the emergency room doctor. Hospitals also have to ensure that they not only create orders for radiology, but also have to demonstrate electronic systems in place for other imaging specialties too, such as cardiology.

Thirdly, there are increased compliance demands. Systems in place need to be used across more of your organisation’s areas than previous HIMSS standards would have demanded.

Anybody who went through the Stage 6 application process before January 2018 will recall that they were required to show pervasive use of appropriate IT systems in only one area of the inpatient facility.

The recent changes mean that hospitals need to show some of them being used in at least 50% of the inpatient facility, and for higher stages, in 90% of it.

While there is some flexibility around how the 50% figure is calculated, candidates will have to apply it consistently throughout their assessment. So, the criteria the hospital uses to apply the 50% rule at Stage 3, for example, will have to be the same criteria they apply every time a compliance percentage is a requirement for any of the subsequent stages.

3. Closed-loop meds: what and why?

Finally, I’d like to add a word on how closed-loop initiatives covering medication, blood and milk should be integrated into the efforts when seeking Stage 6 and Stage 7 accreditation.

Bad things happen when we get medicines wrong. In the UK, a study published in 2012 found that 40,000 NHS patients die every year due to medical error, with 900 of those deaths being attributed to drug errors.  

This is a problem that transcends geographical borders, with almost every country in the world, if not all, facing similar issues. The only difference is that some countries’ healthcare systems are more transparent about it than others. It’s easy to pick up the wrong bottle of medication, but with the increased use of relatively simple technology like barcodes, these mistakes really should be a story of the past.

That’s why particular value is given within the model to acute providers who can demonstrate that they have strong closed-loop management systems – a fully electronic process ensuring that medication, blood products and milk are prescribed, verified, dispensed and administered in the safest, most efficient way possible.

Many of the requirements around Stage 6 relate to the use of technology to verify various things at the point of care – the bedside.

The requirement is to firstly demonstrate that doctors are creating an electronic prescription. The electronic prescription then needs to be verified by a pharmacist or somebody other than the person who prescribed the medication in the first place.

If you've got a capability to verify medication, that's what HIMSS evaluators will want to see. In an ideal scenario, the pharmacy should be dispensing in unit dose, this often means that the medication is in a little packet with a barcode or a QR code on the back. At the bedside the nurse would electronically identify themselves and then read the barcode on the patient’s wristband in order to correctly identify the patient. The final step would be to read the barcode on the medicine to confirm a match through the five rights of medication administration: right patient, right medicine, right dose, right route, at the right time. If a match is achieved the medicines are administered to the patient and the electronic medicines administration record is updated. A degree of flexibility may be in place around the time that the medicine is received by the patient. However, the system should be able to report on medicines that are given late or missed altogether.

Working together to unlock the next level of digital care

By Patience Chinwadzimba, healthcare executive, Cerner


Now that we've clarified the areas of focus for each HIMSS EMRAM stage and the most recent changes that have been made to the model, I'd like to share some of our learning and experience from helping other organisations receive HIMSS accreditation.

Making the decision to start the HIMSS levels 6 and 7 application and getting key members of your workforce on board is, inarguably, the first crucial step of the process – however, it has also proved to be one of the most challenging, almost dreaded, steps for some of the clients we’ve worked with so far.

Whether it’s the fact that staff are too busy caring for patients, or the stress of spending months preparing for the assessment – or a combination of both – I’d like to use this space to try and alleviate some of these pressures.

The first thing that I’d like to reiterate is something that I’ve heard John say repeatedly in various HIMSS education sessions, and it’s the fact that HIMSS assessments are designed to help organisations reach their full digital potential and understand why it is that they are not there yet, if that is the case – as such, the process is not, as some may wrongly think, designed to make organisations fail in their applications.

“Rest assured that the onsite visits we make as part of the Stage 6 and 7 validation processes are not designed to catch you out”

John Rayner speaking at the 2019 European Collaboration Forum

4. We're here to help

Once the decision has been made to pursue HIMSS stage 6 or 7 certification, Cerner associates like myself will be there to support your organisation all the way through, and ensure we provide you with the guidance and advice that we’ve learned from going through the same process with other organisations here in the UK and indeed around the world.

Trusts who have achieved HIMSS stage 5 accreditation would have received a gap analysis identifying the areas where they need to focus on when pursuing certification for a higher stage – the initial step of our support begins with a detailed review of this report to help you identify different ways of closing down those existing clinical and process gaps.

This step would then be followed by a ‘mock visit’ from our team. The date for such visit is agreed between both teams, Cerner and client team, and is designed to mimic the HIMSS visit that will determine whether your organisation receives HIMSS stage 6 / 7 validation or not.

During this mock visit, your team would take us to the wards and departments that you will be using for the purposes of your application, and we will talk to your clinicians to understand their level of understanding of the solutions available to them and the clinical decision support provided by each.

This, alongside our familiarity with the solutions your organisation has in place and the way they are being used, will enable us to better guide you as to the critical areas that need to be looked at and improved before the HIMSS visit takes place, and give you our key recommendations on how to make these improvements happen.

From having gone through this process many times, we know HIMSS representatives always have particular areas of interest they want to assess as part of the tour - such as drug rounds - and particular information they expect to see in the presentation you will deliver the day of the final visit.

Using this knowledge, our team will also provide support in the creation a robust presentation that shines light on the main areas where technology is being used to positively impact patient care and care processes. We can additionally help in putting together the final agenda so you can ensure the right resources and members of staff are available at the right time throughout the HIMSS visit.  

“Just like when you’re trying to join a club, it would be wise to take guidance from a friend, one who has seen the inside and can tell you before you leave the house if you’re wearing the wrong shoes.

“For us, this friend came in the guise of our colleagues at Cerner. They understood the criteria from the beginning of the process and were invaluable in helping us eliminate any potential pitfalls.”

Matt Parkinson, IM&T project manager, Royal Free London NHS Foundation Trust

5. Beyond HIMSS recognition

On top of validating your organisation’s digital maturity and use of technology to deliver high-quality care, obtaining HIMSS recognition will bring a raft of additional benefits.

As part of the preparation process, your clinical staff will become more aware of the digital tools available within the organisation and the different ways these can be used to make a difference for their patients, by delivering safer and more efficient care. This will automatically raise the level of technology adoption among both clinical and non-clinical staff, taking your organisation one step closer to delivering the goals and desired outcomes behind your different digital programmes.

As a result of this increased awareness, your Trust will then be better placed to implement different strategies to improve adoption of digital tools across other hospital sites and wards. It equally allows us to provide you with further and better support to help you reach the full potential of your digital tools, scaling the technology the organisation has in place now to reach the next level of your digital journey.

Another added benefit comes with the industry recognition your organisation receives from reaching a high level of digital maturity – this recognition can then play a big and positive role in your workforce retention programmes, recruiting strategies, and creates invaluable opportunities to spread and share your knowledge beyond your Trust’s walls, including the opportunity to speak at high-profile industry events.

Having shared this information, we now want to know: how can we help you? Whether you’re ready to embark on your HIMSS journey or you are just starting to consider it, get in touch with us or reach out to your Cerner relationship owner and let us know what we can do to support you.

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