EMR Adoption: Benefits Realization

John H. Daniels, CNM, FACHE, FHIMSS, CPHIMS

Global Vice President, HIMSS Analytics

Pre

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Medical Knowledge

Automate to optimize clinical decision making

Ultimate Goal

Ensure the most relevant information

is available to the decision maker at the

right place and at the right time

HOW CAN WE DO THIS?

EMR Adoption Model (EMRAM)

A progressively

sophisticated

roadmap that

enables …

Quality, safety,

and

Operations

efficiencies

Physician Documentation with CDS

• Progress notes

• H&P

• Consult notes

• Problem / Diagnosis list

• Discharge summary

CDS Examples

• VTE risk assessment, “Order this prophylaxis”

• Asthma dx, “Start Asthma Action Plan at discharge”

• Certain antibiotic orders, “Order infectious disease consult”

• CHF diagnosis, “Want to order ACE or ARB?”

• Stroke diagnosis, “Want to order a statin?”

• Diabetes diagnosis, “Follow ADA rule for diabetes orders”

Before the bedside

• Step 1: Physician enters order via CPOE w/CDS

NOTE: At Stage 7, ≥90% of all orders via CPOE for ≥ 4 months

• Step 2: Pharmacist (or other qualified & authorized

professional, e.g., senior physician) verifies the

order in system w/CDS

• Step 3: Pharmacy dispenses barcoded medication

Closed-Loop Medication Administration

At the bedside

NOTE: At Stage 7, ≥ 95% of pts/meds scanned for ≥ 4 months

• Step 4: Nurse scans patient

• Step 5: Nurse scans medication

• Step 6: System verifies ‘5 Rights’ – Patient, Medication,

Route, Dose, Time – with alerts

• Step 7: Nurse administers medication

• Step 8: Nurse verifies / documents administration in EMR

Closed-Loop Medication Administration

0,0%

2,0%

4,0%

6,0%

8,0%

10,0%

12,0%

14,0%

16,0%

18,0%

Timing related errors Non-timing related errors Errors with ADE potential Transcription errors in medadmin documentation

eMAR Manual

Source: Effect of Bar-Code Technology on the Safety of Medication Administration;

Poon, Keohane, Bates, Lipsitz, et al, New England Journal of Medicine, 2010;362:1698-707,

May 6, 2010

Closed-Loop Medication Administration:

A Key Element of Patient Safety

0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

0,45

0,5

Jan 2011 Jan 2013 Jun 2013

710

Pt Scan: 96%

Med Scan 93%

Pt Scan: 79%

Med Scan: 76%

44%

62%

19

Medication Administration Errors per 1000

CMI-Adjusted Patient Days

• Use data to drive improved outcomes related to …

– Process, Financial, Clinical, Quality & Safety

• Are paperless, or near paperless (create no paper)

– All clinically relevant data is in the EMR

• Are fully committed to continuous process improvement

through collaboration

– Strong IT leadership and executive champions

– Clinician / end-user champions

Profile of a Stage 6 & 7 Organization

BENEFITS REALIZATION FROM IT

HIMSS Analytics LOGIC® correlation studies with other

comprehensive data sources.

Top Performing Hospitals By Number of Quality Metrics

Excelling In By EMRAM Stage

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7

4 or more 0,4% 1,8% 6,2% 10,0% 6,4% 6,4% 12,8% 30,1%

3 or less 1,9% 4,8% 10,0% 8,1% 4,2% 6,5% 7,9% 9,7%

0%

10%

20%

30%

40%

50%

All

ho

spit

als

wit

hin

eac

h

EM

RA

M S

tag

e

Source: HIMSS Analytics

2.3%

6.5%

16.3%18.1%

10.6%12.9%

20.7%

39.8%

Hospitals with an "A" Leapfrog Hospital Safety Grade By

EMRAM Stage

0,0% 5,9%12,8% 14,3%

20,1% 21,8%30,8%

62,6%

0%

10%

20%

30%

40%

50%

60%

70%

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7

All

ho

spit

als

wit

hin

eac

h

EM

RA

M S

tag

e

Source: HIMSS Analytics

Tipping Point

38,9

45,5 44,645,9 45,9

42,7

49,0

64,3

30

40

50

60

70

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7

AV

G P

roje

cte

d V

BP

C

lin

ical S

co

re

Tipping Point

Tipping Point

Clinical Performance Scores

Source: HIMSS Analytics

Mortality Rates

0%

10%

20%

30%

Heart Atack RespiratoryTherapy

Actual MortalityLow EMRAM

Actual MortalityHigh EMRAM

Source: HIMSS Analytics

-1,52%

4,91%

-0,43%

6,19%

2,77%

7,95%

-2,0%

0,0%

2,0%

4,0%

6,0%

8,0%

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7

Av

era

ge O

pera

tin

g

Marg

in

In 2011 In 2013 In 2015Source: HIMSS Analytics® Logic™

Financial Performance (Profitability)

Source: HIMSS Analytics

STAGE 7 CASE STUDIES

Actual case studies from validated Stage 7 hospitals

Annual Incident Reports 2009 – 2013*

per 1000 CMI-Adjusted Pt Days

0

0,5

1

1,5

2

2,5

0

5

10

15

20

25

2009 2010 2011 2012 2013*

Med

icati

on

Even

ts

Oth

er

Incid

en

t R

ep

ort

sOther Incident Reports Medication Events

30

20

4 0

5,34

4,47

1,08

0,000

10

20

30

40

50

60

0,00

1,00

2,00

3,00

4,00

5,00

6,00

Jul 10 to Jun 11 Jul 11 to Jun 12 Jul 12 to Jun 13 Jul 13 to Sep 13 (3 months)

# C

AU

TI

Rate

per

1000 c

ath

ete

r-days

Catheter-Associated Urinary Tract Infection (CAUTI)rate per 1000 catheter-days

# CAUTI CAUTI rate per 1000 catheter-days

Central Line-associated bloodstream infection (CLABSI)

Human (breast) milk administration through CLMA process

Attention to detail

Some changes in the pharmacy

Reduction in the number of

unnecessary STAT orders

Great communication by the team

• Grid / Order Set Form Approach for Chemotherapy

• Reduced CPOE from 90 Minutes to 15 Minutes per Patient

Order Sets Process Improvement

50

55

60

65

70

75

80

85

90

95

100

Jan2013

Feb2013

Mar2013

Oct2013

Nov2013

Dec2013

Jan2014

Feb2014

Mar2014

Oct2014

Nov2014

Dec2014

Jan2015

Feb2015

Mar2015

Oct2015

Nov2015

Dec2015

Jan2016

Feb2016

Mar2016

Influenza Immunization Screening/Vaccination Compliance

How did they do this?

Hard Stop at Patient Discharge

• Upon discharge, if the vaccine has

not been addressed the system will

not allow the AVS to be printed

• The nurse will have to click on the

hyperlink → this will take the nurse

to the Core Measures activity →

the nurse will need to answer the

Vaccine Administration question

Breast Milk Process

0

Breast Milk Error Rate

0,00021

0 0 0

0

0,00005

0,0001

0,00015

0,0002

0,00025

2012 2013 2014 2015

Expressed Breast Milk Error Rate per administration

PEDS Go

Live

* Prior to PEDS, all reporting of errors were based on self reporting. After

PEDS, alert reports reviewed. Error rate describes errors that reached the

patient.

Dispensing Errors Types - Prior to

PYXIS Implementation 2015

0 5 10 15 20 25 30 35

Wrong drug dispensed

Wrong dose/strength dispensed

Wrong quantity dispensed

Omission

Wrong drug prepared

Wrong dose/strength prepared

Wrong dosage form prepared

Wrong quantity prepared

Extra drug/s prepared

Wrongdrug

dispensed

Wrongdose/stren

gthdispensed

Wrongquantity

dispensedOmission

Wrongdrug

prepared

Wrongdose/stren

gthprepared

Wrongdosage

formprepared

Wrongquantityprepared

Extradrug/s

prepared

Series3 13 6 7 11 33 7 4 5 7

Workflow Analysis :

Post-Implementation

• Most items will come out of the ADM instead of

having a cart fill.

• No need to physically print the Pick List.

Benefits Analysis: Number of Staff to

Fill and exchange the Cart Fill

(2) Two Pharmacists

(4) Four Pharmacy Technicians

(1) One Pharmacist

(1) One Pharmacy Technician

Before PYXIS After PYXIS

Benefits Analysis: Consumed Time to

Fill and Exchange Cart Fill

Five

Hours

One

Hour

Before PYXIS After PYXIS

Saving Time = 4 hrs

When will your organization reach …

Thank you!

John H. Daniels, CNM, FACHE, FIMSS, CPHIMS

Global Vice President, HIMSS Analytics