On the path to paperless

Tracking an eventful decade for health IT
By Mike Miliard
12:00 AM
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HIMSS Analytics was founded back in 2004, and has been tracking data relating to IT purchasing, processes and products ever since – most notably with its Electronic Medical Record Adoption Models, which seeks to help hospitals and ambulatory providers track their progression toward a fully-paperless environment.

For the past two years, Healthcare IT News has been producing the "Benchmarks" column with the help of HIMSS Analytics, spotlighting different facets of the industry and taking stock of their growth. This month, we take a look at the past decade, which has been a period of remarkable growth and change – especially in the past five years or so.

The numbers are hard to ignore. Compare 2006 (the first year of EMRAM data) with 2013: Back in 2006, more than 20 percent of hospitals were entirely paper-based – zeros on the scale. By 2013, that number was down to 6.9 percent. Meanwhile, just 0.1 percent ranked Stage 6 and none were Stage 7. By 2013, 13.3 percent had achieved those milestones, combined.

The momentum has really come recently. By way of illustration John Hoyt, executive vice president of HIMSS Analytics, points to two spots on the EMRAM scale – starting with second quarter 2011 and extending to third quarter 2013 (the last period for which there was data at press time).

"That's nine quarters, which may seem like an odd number – why would you want to compare nine quarters?" says Hoyt. "The reason is that Q2 2011 is when meaningful use checks started to go out in the mail."

Since then, "notice that we've had 100 percent growth in Stage 7, about 170 percent growth in Stage 6 and more than 200 percent growth in Stage 5," he says. "The question is, does the stimulus program work? This tells us something's going on."

There are two different ways to look at that shift. The first, says Hoyt, is that "clearly it works – look at that growth!" But the other argument is that the most successful adopters are "the people who were already jogging when the gun went off in the race."

Either way you think about it, "We have stimulated the market."

Hoyt is fond of comparing the U.S., post-HITECH, to our friendly neighbors to the north.

"We have the same chart for Canada," he says. "There are the same vendors in Canada. It's pretty much the same culture, even if there's a different payment mechanism. But the numbers are drastically different. It shows zero percent growth in 7, zero percent growth in 6, and zero percent growth in 5, in the same nine quarters. So I think the stimulus program clearly has helped."

And where would we be had meaningful use never occurred? Nowhere near where we need to be. The adoption we've seen would not have happened without government intervention, billions of dollars, and exactingly prescriptive policies for how that money must be deployed.

And it happened just in time, just as the second decade of the 21st Century got under way. "The fact that we did this helped us get to a tipping point," says Hoyt. "And I think we're at a tipping point. More and more I'm going to hospitals and hearing that the younger doctors are expecting it. It's just a matter of funding it and getting it done."

When the meaningful use program was first announced, "there was excitement" in the industry. But not everywhere.

"I think in the community hospital market – roughly 50 percent of U.S. hospitals are fewer than 150 – I thinks the smaller ones probably were worried."

After all, lest we forget, meaningful use is not just stimulus money to adopt – it's a disincentive if you don't adopt.

"So I think there was some panic on the part of the smaller organizations who did not have the knowledge or the infrastructure in place," says Hoyt.

That said, even if the EMRAM chart doesn't yet show 100 percent Stage 7, "I think the industry has done as well as it could," he says. (Not to mention that there has been a sizable uptick in Stage 7 hospitals and ambulatory clinics, even in the past few months."

The progress made has been impressive, and relatively quick. Even if healthcare still lags other industries, that's something to be proud of, because it's not the only thing going on," says Hoyt. "We also have payment reform and ICD-10. It's just an incredible perfect storm."

Piece by piece

Each month, we speak to Hoyt and HIMSS Analytics Senior Director of Research Jennifer Horowitz about a different species of health information technology. For this issue, we asked Hoyt to take part in a lightning round, offering a quick assessment of where the industry is – and where it should be – with regard to each one.

Ambulatory EHRs. "We still have a long way to go. We are just at the very beginning. And that's where there's some world leadership that the U.S. needs to listen to – especially to the small countries that have wealth, such as Singapore.

"We all know that some 80 percent of the volume of healthcare consumption takes place on the ambulatory side. What they've done – and this is part of their culture; they've got less entrepreneurialism in medical care delivery, and more of a government or corporate influence; frankly we're moving in that direction as hospitals buy practices, and we're positioning ourselves to be more like them and take advantage of economies of scale. But ambulatory EHRs need to get out there more ubiquitously. We're low on that."

Inpatient EHRs. "I think the most prominent change in 10 years is that medical staff has become – or is about to become – highly active users."

HIE. "Continuing struggles. We recognize the importance of it, and frankly I'm very happy that the stimulus program includes HIE. But we continue to struggle and we can not take our foot off the pedal of that."

Interoperability. Same thing. And the federal government's role, I think, has been appropriate: Stimulate the industry to develop and implement standards."

Analytics. "We're at the beginning. We have now gotten to the point where the early adopters and the advanced organizations are collecting huge sums of data, and we're just beginning to become skilled at using the data to improve quality safety and efficiency. And there are some excellent examples of early adopters in Stage 6s and Stage 7s. Generally I would say they're large, and it somewhat correlates – necessity is the mother of invention – the big organizations that have risk contracts clearly have better analytics.

"Jennifer and I were at a community hospital a couple weeks ago on a Stage 7 visit. One or 2 or 3 percent of their contracts were at risk, and their analytics were immature. Two weeks earlier, I was at an organization and 65 percent of its revenue is at risk. And they have MDs and MPHs running their analytics program. Plural. Multiples of them. As opposed to an evening nurse who got tired of running evenings and decided to go into analytics."

Clinical decision support. That subset of the industry has had some interesting changes going on.  I've noticed when I do these Stage 7 visits over the past two years, I ask them, do you use – and I mention a couple brand names – and more than two out of three times, the big places, notably Epic clients, say, 'Nope, we don't use them any more. We used to, but we've got the skills in-house. We don't need to pay $50,000 a year for order sets; we can build them ourselves. We all expect the systems to give us clinical advice. But other than pharmacy, which is a necessity, I'm getting a sense that the bigger organizations, for order sets and protocols are saying, ‘I don't need to pay that kind of money.’ Which was not always the case. When I was a CIO, I remember buying all that stuff and putting it on PCs."

Mobile. "It's exploding. And it's a challenge for the CIOs, on bring your own device and security. But clearly it has a public health benefit, and clearly it has third world implications that we aren't even thinking of; when you hear these people who have been to Africa, which has sort of skipped the landline phenomenon and gone straight to mobile, I think it's very, very helpful for underdeveloped nations.

PACS. "We're at the saturation point, and clearly at the expectation point. Making film is just ludicrous."

Privacy & security. "We're treading water, but mobility is adding a new layer of stress. One new phenomenon that we weren't even talking about 10 years ago is patient involvement in chronic disease management, enabled by technology. Patient portals, etc. That's a whole new subject that wasn't even on the agenda 10 years ago."