HIMSS Analytics, devised the EMR Adoption Model to track EMR progress at hospitals and health systems called the EMRAM. The EMRAM scores hospitals in the HIMSS Analytics Database on their progress in completing the 8 stages to creating a paperless patient record environment as shown in the figure below:
HIMSS EMR Adoption Model
EMR Adoption Model Structure Ensures Objectivity :
- All application capabilities within each stage must be operational before that stage can be achieved.
- All lower stages must have been achieved before a higher level will be considered as achieved.
- A hospital can achieve Stages 3-6 if it has met all of the application requirements for a single patient care service (e.g. single nursing floor, cardiology service).
- Using the rules above, additional points are given for the implementation of applications in stages higher than the one fully achieved by the healthcare organization. In this fashion, other implementation paths than those prescribed by the stages can be taken into consideration for correlation with quality and financial research.
The detailed stages of the model are as follows:
Stage 0: The organization has not installed all of the key ancillary department systems (e.g. laboratory, pharmacy, radiology).
Stage 1: Major ancillary clinical systems are installed (i.e., pharmacy, laboratory, radiology).
Stage 2: Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary, and the clinical decision support/rules engine (CDS) for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage. The hospital is health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.
Stage 3: Nursing/clinical documentation (e.g. vital signs, flow sheets) is required; nursing notes, care plan charting, and/or the electronic medication administration record (eMAR) system are scored with extra points, and are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab conflict checking normally found in the pharmacy). Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians outside the Radiology department via the organization’s intranet.
Stage 4: Computerized Practitioner Order Entry (CPOE) for use by any clinician is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one patient service area has implemented CPOE with physicians entering orders and completed the previous stages, then this stage has been achieved.
Stage 5: The closed loop medication administration environment is fully implemented. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point of care patient safety processes for medication administration.
Stage 6: Full physician documentation/charting (structured templates) is implemented for at least one patient care service area. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. A full complement of PACS systems provides medical images to physicians via an intranet and displaces all film-based images.
Stage 7: The hospital no longer uses paper charts to deliver and manage patient care and has a mixture of discrete data, document images, and medical images within its EMR environment. Clinical data warehouses are being used to analyze patterns of clinical data to improve quality of care and patient safety. Clinical information can be readily shared via standardized electronic transactions (i.e. CCD) with all entities who are authorized to treat the patient, or a health information exchange (i.e., other non-associated hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients in a data sharing environment). The hospital demonstrates summary data continuity for all hospital services (e.g. inpatient, outpatient, ED, and with any owned or managed ambulatory clinics).