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Benchmarks: Stage 7 success stories

For hospital EMRs, winning strategies require big-picture thinking
By Mike Miliard
09:53 AM
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When looking for advice and best practices for electronic medical record deployments, it's smart to emulate those at the very top of their game.

There are just over 200 U.S. hospitals (and a handful more across Canada, Europe and Asia) that have ascended to the top of the HIMSS Analytics EMR Adoption Model. Stage 7 winners represent elite cohort – just 3.6 percent of the U.S. market – that has achieved remarkable, comprehensive use of healthcare IT.

What's the secret to their success?

"At a very high level, what they are doing right is that they are pretty much enterprise wide with a core clinical system," says HIMSS Analytics Executive Vice President John Hoyt. "In other words – and this may not sound kind – the best-of-breed organizations are not achieving Stage 7. It's the enterprise EHRs that are successful."

It's that sort of end-to-end prowess that explains why, despite its high cost and sometimes challenging rollouts, Epic is the vendor that finds most favor at large health systems looking to drive quality and efficiency from stem to stern.

Of the 200-plus Stage 7 hospitals in this country, 152 of them are Epic customers. In second and third place are Cerner (41 installations) and MEDITECH (19).

[See also: Stage 7 awards are on the upswing]

Epic is dominating the market "for a couple reasons," says Hoyt. "One is that they sell, effectively, as an enterprise solution: Physician's office and acute care. Remember, Epic has been around since the '70s in the physicians offices; they didn't start in hospitals until after 2000. So they are very, very good at getting to physicians. That's number one.

"Number two is that they are intensely – intensely – focused on Stage 7," he says.

Epic CEO Judy Faulkner "will talk about Stage 7 at their annual event," says Hoyt. "I've seen her do it: 'You owe this to the industry to get this. You owe this to your peers.' She talks to them like, 'This is your obligation.' No other organization is that focused. They put peer pressure on the client base to get this."

Increasingly, of course, even longtime holdouts are replacing their homegrown and best-of-breed systems and going with blue-chip enterprise EMRs.

"Look at the big names that have been self-developed for years and years," says Hoyt. "Intermountain: They're ripping it out and going to an enterprise solution from Cerner. Henry Ford: ripped it out and went to Epic. Partners HealthCare: ripped it out and went to Epic. BJC in St. Louis: ripping it out and going to Epic. Mayo Clinic: ripping it out, going to Epic."

On the other hand, Europe – which has just two Stage 7 hospitals, one in Germany and one in Spain – "is very, very much a best-of-breed kind of world – like we were in the '90s."

The challenge in that situation, preventing higher-climbing up the EMRAM ladder, is clinical decision support," says Hoyt: "They buy order entry from one system, they buy ICU from another, they buy physician documentation from another, they buy pharmacy from another. Getting CDS to work in that type of environment is very hard. "

HIMSS Analytics looks for some clinical decision support at Stage 3: "a little bit of duplicate orders," he says. At Stage 4, the goal is physician order entry: "Some of them have order entry without clinical decision support, so there's no artificial intelligence helping them create order sets," he adds.

"And then we expect CDS at Stage 6 because we want it firing off physician documentation – and we expect a full, robust program of it at Stage 7," says Hoyt. "That's where they're having the hardest time in these best-of-breed environments. There are so many parts and pieces to getting an effective clinical decision support program.

Culture is key
But it takes a lot more that technology to get to Stage 7. No matter how comprehensive the EMR system, how flawless the implementation or how strong the support, the key to climbing to the top is ensuring the whole organization is on board: nurses, docs, IT team, C-suite – everyone.

"Without a doubt, it starts at the top," he says. "And it is a cultural transformation."

He says the CEO of Norfolk, Va.-based Stage 7 winner Sentara Healthcare said it best: "Very simply, this is the way we do business."

Same at Phoenix-based Banner Health, says Hoyt. "When I was out there doing their Stage 7 visit several years ago, I heard three or four times that day: 'This is the way we do business.' If you don't like it, thank you, doctor, for your years of service and best of luck with the rest of your career."

Dissent and foot-dragging simply can't be an option. It's critical to embrace these enterprise-wide projects with the attitude that "there is no alternative," he says. "'And we're going to use this as a clinical transformation and not an IT project.'

"I've been in organizations where the medical docs are just great and the surgeons say, 'I don't have time for this stuff. I'm an expensive, fancy cardiologist and I bring in $40 million a year, and I don't have to use your computers,'" says Hoyt. "You can't have that. I think they key is peer pressure."

As a former hospital CIO, he says he recognized his place on the totem pole – but also the immense importance of getting the medical staff on board with technology.

"I had no business talking to those docs without a physician by my side," says Hoyt. "I'll give you a good story: I was two or three years into an implementation and my chief medical officer came into my office one night and started with the sentence, 'John, you're making a mistake.'

"I said, 'What's that?'

"He said, 'Most of the physicians on your clinical advisory committee are your friends. And they're geeks. And the rest of the medical staff looks at them and says, 'They're not normal. They're not like me.'

"So I asked him: 'If you were in the ICU, or your wife was in labor and delivery of your child was febrile in pediatrics, who would you want attending you?'

"That way, you find the physicians who are revered by their peers," he says. "So that's what I did. I fount those people and put them on my clinical advisory committee. Some of them hated computers. Some of them didn't know what a mouse was.

"But that's one of the tricks: You've got to get the revered physicians as users. And then you go to the other physicians and say, 'Well, he does it. Why can't you?'"


Been there, done that
Lessons from a couple recent Stage 7 winners are illustrative. In January, Tacoma, Wash.-based MultiCare got Stage 7 Awards for its hospitals and ambulatory clinics, having expanded and improved the use of its EHR for 15 years. Among its impressive achievements: comprehensive, cross-disciplinary structured documentation and an "aggressive" analytics program.

Deploying Epic for both ambulatory and acute care, "they see the value of fundamentally positioning themselves like a continuity of care environment where they're capturing one data set for the patient," says Hoyt.

Mobile Ala.-based Springhill Medical Center is another recent winner – the first Allscripts hospital to reach Stage 7.

The 252-bed facility was lauded by HIMSS Analytics for its "extremely paperless environment" – to the point where there aren't even any charts in nursing units, with only monitoring strips in evidence.

Hoyt says the hospital is a ideal example of a deployment that's successful because of cultural acceptance across the organization.

"That place is paperless. They. Are. Paperless," he says. "At times I'm sure they had some wars with the medical staff. There's an Ascension hospital three miles away. But they stood their ground. And they're a very, very solid Stage 7."

The past two years have seen a marked uptick in Stage 7 winners – "a lot more than in years past," says Hoyt. Close to 40 such health systems will be recognized in April at the 2015 Annual HIMSS Conference & Exhibition in Chicago.

That's hugely encouraging, especially since the jump from Stage 6 to Stage 7 is considerably harder than the upswing between other rungs on the EMRAM ladder.

"Stage 6 is a big jump because it requires physician documentation, and that is a big, difficult build," Hoyt explains. "You've gotta make all these templates for physicians and get them to use them."

At Stage 7, "the big jump is analytics," he says. "Now that you've got the technology, use it to show me you're improving patient care."

From the EMR to analytics to medicine reconciliation, HIMSS Analytics wants to see a "pervasiveness of use," at Stage 7, says Hoyt. "We measure by percent of all orders entered by physician and percent of all medications for which we are barcoding.

"Those are big jumps. You can put the medication administration in at Stage 5, but you have to prove you're consistently hitting 95 percent when you're at Stage 7. It may take a year to consistently hit that, well after implementation."

But when it is finally achieved, victory tastes so very sweet. Hoyt remembers one Stage 7 Award ceremony, where staff at a winning hospital were recognized for their hard work.

"They all cheered," he says. "And people started crying. That's a message. It's recognition of people who've worked their buts off for years. And they've put up with a lot of crap from screaming physicians and crying nurses and all this other stuff. They've done it. So Stage 7 is really an award that your team deserves to have for them."

There will be many Stage 7 related activities and education sessions at HIMSS15 in Chicago next week, including a presentation by Cedars-Sinai CIO Darren Dworkin, laying out his Stage 7 organization's strategies for implementing clinical and business intelligence, analytics, and data governance.

* This story has been updated to reflect the fact that there are 19 MEDITECH clients at Stage 7, rather than five, as was first reported. Among them is Ontario Shores Centre for Mental Health Sciences, the first Canadian hospital to reach Stage 7.