The HIMSS Analytics EMR Adoption Model (EMRAM) was created in 2005 to demonstrate how individual hospitals and integrated delivery systems (IDS) in the United States and Canada – and later in other countries - adopt information technology. It was also seen as a way of encouraging hospitals to progress to higher levels of Information Communications and Technology (ICT) adoption, thereby enabling improved clinical information to assist patient safety and quality of care. The model is built in eight stages, with each stage having a higher level of health ICT “accomplishment”, providing the foundation for improved patient safety, quality of care, health information exchange and resulting in a paperless environment.

EMRAM is the first internationally recognised and specifically designed ICT model that assists organisations in measuring the success of their EMR implementation, thereby providing a level of QA that may often be lacking in ICT implementations. Since 2005, a growing number of countries and hospitals have invited HIMSS Analytics to review the level that they have achieved in the EMRAM model. HIMSS Analytics have made some modifications to the EMRAM model to meet the specific requirements of differing regions including Asia Pacific and Europe.

The EMRAM model approach provides a hospital with a means to benchmark its progress in using ICT and the EMR, against other like hospitals in its own region and country, and in comparison with similar hospitals around the world.

The EMRAM model 

There are eight levels in the EMRAM model. The hospital’s EMRAM score depends on the implementation of the following applications, eg

• Stage 1 Laboratory Information System Radiology Information System Pharmacy Management System
• Stage 2 Clinical Data Repository (CDR)
• Stage 3 Electronic Medication Administration Record (eMAR) Nursing Documentation Order Entry (classic order entry, not Computerised Practitioner Order Entry (CPOE)
• Stage 4 Computerized Practitioner Order Entry (CPOE)
• Stage 5 Pharmacy Barcoding (printing and scanning) supporting Closed Loop Medication Management
• Stage 6 Physician Documentation ®Radiology Picture Archival and Communication Systems (PACS), to include the following: • Radiology – Angiography Radiology – CR (Computed Radiography) • Radiology – CT (Computerized Tomography) • Radiology – DF (Digital Fluoroscopy) • Radiology – Digital Mammography Radiology – DR (Digital Radiography) • Radiology – MRI (Magnetic Resonance Imaging) • Radiology – Nuclear Medicine • Radiology – US (Ultrasound) • Radiology – Orthopaedic Surgical Templating 

Other applications, eg Clinical Decision Support System, Laboratory and Radiology Barcoding, Physician and Patient Ports and Clinical Data Warehouse, will also be considered as part of the EMRAM review process. 

The Calculation of EMRAM Scores

To gather the data to score a hospital’s EMRAM, a hospital either independently or with the support of HIMSS Analytics completes, a comprehensive questionnaire that lists up to 250 potential applications and the hardware supporting the application. Additional data is collected relating to the hospital’s budget and staffing, including the ICT department budget and staffing, so appropriate staffing and investment ratios can be built for benchmarking. HIMSS Analytics software, using a complex algorithm, analyses the hospital’s data and generates a score from zero to 7.0000. Criteria has to be met for each EMRAM stage from zero to seven before the stage level can be awarded to the hospital. Points are awarded for all aspects of adoption, even portions of stages not yet completed. In other words, a Stage 3 hospital might have some aspects of Stage 5 in place, thus their score would measure as greater than 3.0000, but less than 4.0000. All aspects of a stage must be met to complete the stage; thus, a hospital cannot be a Stage 5 if they have not completed all the aspects of Stage 4, even though they may meet all criteria for Stage 5. 

Progress with EMRAM

Within the US, over 50 percent of hospitals have achieved Stage 3, which is the stage that the largest proportion of US hospitals have achieved. Stage 3 is achieved when a hospital has adopted nursing documentation, care plans, flow sheets, vital signs and the Electronic Medication Administration Record. Seven years ago, the proportion of US hospitals at Stage 3 was less than 20 percent, indicating the great progress that the US has made since then with its implementation of an EMR (Appendix A: US Statistics). Other parts of the world have in more recent years been inviting HIMSS Analytics to review their achievements with their EMR implementations, and there are now hospitals in Korea and Singapore that have achieved Stage 6 and Stage 7 of the EMRAM model. 

When hospitals are engaging in the EMRAM model for reviews of their EMR implementations, they are encouraged to use the following advice to ensure that they meet the high EMRAM levels – this list may vary from country to country:

• When a hospital/health organisation is tendering or contracting for an EMR, the organisation should ensure that the EMR vendor can deliver the functions identified within the stages of the EMRAM model, 
• If the hospital is not at a Stage 3 or Stage 4 for EMR functions on the EMRAM Model, a request for information should be made to the EMR vendor(s) to generate written documentation as to their capabilities in meeting the 2011 and 2013 EMRAM measures with their EMR applications and implementations,
• The provider requiring an EMR should create a strategy for meeting 2015 EMRAM measures.

Progress Internationally with the EMRAM Model 

Canada, which was the second of the countries to adopt the HIMSS Analytics EMRAM model as a method of reviewing its quality of their EMR implementation has been making good progress, which is reflected in the table attached (Appendix A). The public health focus and the centralised approach to the implementation of ICT in Health, has no doubt had a positive impact on its implementation of the EMR and on the progress with the EMRAM reviews.

In spring of 2010, HIMSS began surveying hospitals in Europe to produce a European EMRAM. The survey is being translated to enable data collection in 13 countries. The EMRAM model is being used to modify the European Health ICT needs to reflect their market ICT implementation progress while still holding fast for the need to ‘push the market’. 

Singapore and Korea have been leaders in the Asia Pacific region with two hospitals reaching the higher levels of the EMRAM model. They have been seen as a benchmark for the remainder of the Asia Pacific market, and a motivation for other hospitals to progress to high levels of EMRAM scores.

Within Australia, where the hospitals that have participated in EMRAM reviews have been from the public and private health arena, the stages of the EMRAM model achieved, have been between Stage 0-3 (inclusive) (Appendix B), which it is believed derives from the country’s lesser focus on the investment in ICT and the EMR, and particularly with regard to the automation of the Electronic Medication Administration Record (eMAR).  Implementation of the eMAR, which to date has not been widespread in Australia, is required to be used in a closed loop application in order to comply with the higher levels of the EMRAM model. Without greater focus and progress on eMAR in Australia, or a change in the international Asia Pacific EMRAM model to recognise this, Australian hospitals will be slow to progress to the higher stages of the EMRAM model.

Progression of the Development of the EMRAM Model

The HIMSS Analytics EMRAM Model has continued to progress, and HIMSS has been trialling an Ambulatory EMR Adoption Model. HIMSS has been collecting ambulatory ICT information from the hospitals in the US and Canada for over six months. This data is being studied and verified with industry leaders from both vendors and providers. The assessment will determine that HIMSS is meeting a requirement, to reflect how individual hospitals adopt information technology, in systems that support the integrated delivery of care for both inpatients and outpatients.

Benefits from the implementation of the EMR using the EMRAM Model

Key findings of a HIMSS Benefits Study support: 

60% of respondents have a formalized EHR governance structure in place

63% of formalized EHR governance structures involve a cross-functional, multi-discipline participation (April 4, 2013)

Health information technology (HIT) has the ability to provide enhanced access to the clinical information needed to support patient care.  According to the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM)SM, at the end of 2006, less than one-quarter of U.S. hospitals (22 percent) had achieved EMRAM Stage 3 or higher on the EMRAM model; by the end of 2012, more than three-quarters of U.S. hospitals (77 percent) had achieved a minimum of EMRAM Stage 3.  EMRAM Stage 3 represents an important threshold because it represents the minimum level, at which organizations begin to use key nursing applications such as clinical documentation and clinical decision support with error checking. 

The EMRAM model has provided a means to measure improvements to clinician access to information, and an incentive to progress to further levels. Greater levels of implementation of key clinical applications, provide the opportunity for clinicians to have improved access to the information they need at the patient’s bedside in order to provide quality care.  

Research conducted during the 10 year period of 1995-2005 has demonstrated that ineffective team communication is the root cause for nearly 66 percent of all medical errors. When healthcare team members do not communicate effectively, patient care often suffers.

Conclusion

The HIMSS Analytics EMRAM model remains the only internationally recognised analytical model that, provides the ability for health organisations to review their achievements in their implementation of the EMR, and in particular to assess how HIT and the EMR are assisting improvements in patient safety and the quality of care.  The assessed levels of successful progress in EMRAM adoption, following reviews by HIMSS Analytics with health organisations, varies by countries. However there is no doubt that the greater investment in health ICT, if invested appropriately as assessed by the EMRAM model, then the better is the information, assistance and support for the quality of care provided.

The EMRAM evaluation approach provides a methodology for assessing the progress and effectiveness of ICT and EMR implementation in a hospital, which is easily understood by clinicians and management not directly involved with ICT operations and implementations. It also establishes a foundation and framework, upon which senior management executives and clinicians responsible for governance of a hospital, are able to make better informed decisions in respect of the appropriate investments to be made in ICT and EMR. This is particularly important when a hospital is always faced with ever increasing and competing demands for investment in clinical services, and is always faced with scarce resources and funding to meet those demands. 

Jean Evans - eHealth Consultant

Jean has over 25 years’ experience in senior management roles in public and private healthcare organisations including Ministry/Department of Health, hospitals, and for consulting organisations and software developers in Australia, Asia, the Middle East and in Europe.

Jean's previous experience as Chief Information Officer/Director of ICT at the South Eastern Sydney Local Health District (formerly known as South Eastern Sydney & Illawarra Health), and her broad experience across the health information technology and communications for 20 hospitals, has prepared her well, for consulting in many areas of health-related challenges.

During the period from the end of 2012, Jean assisted the NSW Ministry of Health in projects relating to Activity Based Funding. In addition, she participated across Australia in a number of ACHS & National Standards accreditation team’s reviews of both public and private hospitals