The Electronic Medical Record: What? Why? When? and What Next?• Basis for Research:• Our experience of visiting 120 hospitals in Ireland, UK, Australia, UAE and the US in 2011 and

how approaches to striving to achieve a fully Electronic Medical Record (EMR) differ across the world.

• Finding 1: The EMR is not just built, it has to be constantly proven…• There is the growing realisation that “One Version of the Truth” otherwise known as an

Electronic Medical Record, needs to be adjudicated and validated, and not just systematically integrated. Just because it’s all joined up, doesn’t mean it’s correct.

• Finding 2: Because it can’t be shared, it has to be constantly mined and analysed…• Above all, beyond the Electronic Medical Record lies the need for hospital and healthcare

systems to mine and analyse the data to ensure more accurate business planning in the light of increasing global healthcare costs and reducing healthcare revenue.

• Conclusion: • Without adjudication and validation, mining and analysis, patient outcomes will not benefit

from an EMR and neither will improved business planning.

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EMR: The levels:EMR Adoption Model – EMRAM

Stage Cumulative Capabilities

7Complete EMR; Continuity of Care Document (CCD) transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP

6Physician documentation (structured templates), full CDSS (Clinical Decision Support Systems) with variance & compliance, full R-PACS (Radiology Picture Archiving and Communication System)

5 Closed loop medication administration

4CPOE (Computerized Provider Order Entry), Clinical Decision Support (clinical protocols)

3Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

2CDR (Clinical Data Repository), Controlled Medical Vocabulary, CDS (Clinical Decision Support), may have Document Imaging; HIE (Health Information Exchange) capable

1 Ancillaries - Lab, Rad, Pharmacy - All Installed

0The hospital has not yet installed all of the three key ancillary department systems (Laboratory, Pharmacy, and Radiology).

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INTEGRATED DATA VIEW OF MULTIPLE HOSPITAL SYSTEMSINTEGRATED DATA VIEW OF MULTIPLE HOSPITAL SYSTEMS

MULTI DATA INPUT METHODS

FLEXIBLE TO CREATE, EASY TO USEFLEXIBLE TO CREATE, EASY TO USE

SECURE AND ACCESSIBLE, ANYWHERE

EMR: How has the US faired?

EMR Adoption Model – EMRAMStage Cumulative Capabilities 2011

7Complete EMR; Continuity of Care Document (CCD) transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP

1.1%

6Physician documentation (structured templates), full CDSS (Clinical Decision Support Systems) with variance & compliance, full R-PACS (Radiology Picture Archiving and Communication System)

4%

5 Closed loop medication administration 6.1%

4CPOE (Computerized Provider Order Entry), Clinical Decision Support (clinical protocols)

12.3%

3Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

46.6%

2CDR (Clinical Data Repository), Controlled Medical Vocabulary, CDS (Clinical Decision Support), may have Document Imaging; HIE (Health Information Exchange) capable

13.7%

1 Ancillaries - Lab, Rad, Pharmacy - All Installed 6.6%

0The hospital has not yet installed all of the three key ancillary department systems (Laboratory, Pharmacy, and Radiology).

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Only 1.1% of 5,000+ hospitals surveyed in the US have achieved level 7 “Complete EMR”.

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EMR: Is there a divide?

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Table 2: EMR scores by Hospital TypeHospital Type Segment Mean Min Max Median NumberRural 2.24 0.00 7 2.16 1246Critical Access 2.25 0.00 6 2.23 1304Others 2.61 0.00 7 3.10 2115Independent Hospital 2.75 0.00 7 3.15 2014NonAcademic 3.01 0.00 7 3.23 5088IDS 3.24 0.00 7 3.29 3296Urban 3.30 0.00 7 3.30 4064General Medical/Surgical 3.34 0.00 7 3.32 3193Academic/Teaching 4.12 0.48 7 4.24 220

Segmenting by hospital type (Table 2) shows that Rural, Critical Access, Independents, and Non-Academic hospitals have most catching up to do in Health IT (EMR scores of 3 or less), whereas Acadamic/Teaching hospitals are most advanced, scoring 4 or higher. The divide widens based on how funding is allocated. Leading to a future issue regarding inability to achieving an EMR based on the type of hospital you operate…

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EMR: Is big better?

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Table 1: EMR Scores by Bed SizeBed Segment Mean Min Max Median Number

0-100 Beds 2.53 0.00 7.06 3.08 2,769101-200 Beds 3.33 0.00 7.07 3.30 973201-300 Beds 3.70 0.01 7.07 3.40 608301-400 Beds 3.74 0.19 7.07 3.40 407401-500 Beds 3.72 2.02 7.04 3.42 213501-600 Beds 4.03 2.17 7.07 3.45 150

600+ Beds 4.16 2.07 7.07 4.18 190

While no hospital with more than 400 beds has scored less than 2, at least some hospitals in all segments with 400 or fewer beds have no EMR at all (i.e. Min = 0). On that basis smaller hospitals have more catching up to do in terms of Health IT adoption. These figures are based on a survey of 5,300 hospitals, so it gives quite a complete picture given that total number of US hospitals is around 6,000. In a situation where data can’t be shared, what is the impact on decision making and planning in smaller hospitals?

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The Electronic Medical Record: What next?• Hospitals often forget the basics. Integration is the key to an EMR, not a “one

system does all” approach. – Yes, integration is difficult but without building on the basis of integration

you’ll never move beyond level 2 and buying a “one system does all” rarely gets Hospitals past level 3 (without significant spend) due to the complexity of implementation.

• Hospitals seeking to compensate for the lack of an EMR by the introduction of more mobile and consumer electronic devices into Hospitals.– Only makes it more obvious that there isn’t an EMR and confusion about IT

ownership and control over data and infrastructure when Clinician’s own devices are used.

• Hospitals struggle to plan for their business, yes, that’s the nature of healthcare but hospitals are based on population areas and trending of the data over time can be a very powerful business planning tool.– How many organisations in Healthcare mine their data?

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The Electronic Medical Record: What next?• Hospitals need to realise that the adjudication of the data, when integrated, is vital in

order for it to be valuable in the data mining phase. – Bear in mind that not all of this occurs visibly within the EMR, frequently peer

review over email takes place.– Hospital’s can’t share data (like Dell can share with Intel) hence they need to plan

using their own data. If it is unadjudicated then it can’t be used for business planning. This is Cleveland Clinics Number 1 focus: correct data adjudication.

• Challenge: A significant question is, why are hospitals striving for the EMR when so few are getting there, whether through lack of Capital, local skills or priority.– High ranking Quality hospitals in the US don’t have an EMR, and they are small

rural hospitals in some cases.– There is no statistical link between improved Patient Outcomes and an EMR.

However, there are links between improved outcomes and the introduction of better care pathways and access to evidence based research at point of care.

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