Maximizing Electronic Medical Records: The Electronic Medical Record Adoption Model and the Health-System Pharmacist

Imagine being able to conduct a medication use evaluation (MUE) in an afternoon. Now envision, after completing the initial MUE, being able to monitor the end points continuously, checking the progress weekly, being able to adjust policy in real time, and proactively improving patient care. For most health-system pharmacists, this is far from the typical experience. Today’s hospital pharmacist, although supported by far better computerization than in the 20th century, is still well short of using technology optimized enough to make the above scenario a reality. However, evidence suggests that this is changing as more health systems turn their attention to electronic medical record (EMR) optimization and demonstrate the capacity for advanced technology.

For example, in a recent survey of national health-system pharmacy leaders, more than half (53%) thought that, by 2018, it would be somewhat likely that hospitals would be capable of continuously monitoring medication use and tracking patient-specific outcomes.¹ This indicates growing confidence that health information technology investments will begin to meet expectations, delivering much-anticipated value. In just a few years, health care technology will empower health-system pharmacists to increase productivity to improve patient outcomes, largely due to advances in EMR.

The Electronic Medical Record Adoption Model

Health-system pharmacists have experienced a flurry of heavy EMR adoption, most notably within the past decade. This trend has been fueled by a combination of federal initiatives, such as the American Recovery and Reinvestment Act, the Health Information Technology for Economic and Clinical Health Act, and the Health Insurance Portability and Accountability Act. Amidst the rapid drive for EMR adoption, the Health Information Management Systems Society (HIMSS) Analytics, a nonprofit subsidiary, has provided the Electronic Medical Record Adoption Model (EMRAM) to monitor and recognize EMR adoption levels for acute and ambulatory health care facilities.² This model is useful for benchmarking a site’s level of achievement and outlines the path toward ultimate EMR optimization.

The EMRAM comprises 8 stages (0-7) designed to allow health care organizations across the country to perform peer comparisons as they track their progress toward paperless EMRs. Starting with the acute-care version at level 0, a baseline with no ancillary department systems (ie, without lab, radiology, and pharmacy installation/integration), the model evaluates the comprehensive merging of technology use, information exchange, analytics, and patient engagement. The model ends with full paperless integration at stage 7.

Hospitals designated to be at stages 1 through 4 will have limited EMR capabilities, capped with computerized physician order entry (CPOE) and clinical decision support (CDS) protocols at stage 4. Stage 5 is achieved with the addition of closed loop medication administration, which requires an active medication order, an electronically identified provider (ie, a nurse), a bar-coded product, and a patient who is electronically identified. A stage 6, designation is awarded with implementation of physician documentation (templates), full CDS, and closed-loop medication administration. Stage 7 is awarded when the hospital no longer uses paper charts and has a variety of distinct data (photos, documentation) digitized within its EMR environment. At this stage, continuous data warehousing is mined in “real time” to analyze clinical data in order to improve patient care, all while clinical information is fluidly and appropriately shared electronically across the spectrum of care.

Based on statistics, most hospitals in the United States have already implemented key components of the EMRAM model. Eighty-eight percent of hospitals have initiated Barcode Medication Administration, with the majority of the remainder planning to install it in the near future. Eighty-two percent of hospitals have already implemented CPOE. Most hospitals in the United States already have bedrock established for advancing stages via EMRAM.³ The emerging focus of HIMSS and health care organizations is the achievement of stage 7 status.

Achieving stage 7 status can help an organization improve patient care, which can in turn improve patient outcomes and experience, leading to a return on investment. Because few health systems have received EMRAM recognition for stage 7, receiving the recognition can provide a “differential value” for organizations in competitive markets that share the same baseline EMR technology. For example, nearly 50% of Americans have an Epic medical record,⁴ with some regions reaching 75% to 90%. How an organization manages and uses its EMR technology can differentiate it from competitors.

Integrating EMRs into a specific disease-care process can change the way diseases are identified and then treated. Headquartered in Phoenix, Arizona, Banner Health is an example of how achieving stage 7 status can optimize patient care. Banner Health patients are monitored 24/7, and their EMRs are set to alert physicians and clinicians (ie, pharmacists) when a patient’s symptoms suggest sepsis. The EMR then presents the provider with an algorithm complete with clinical actions to follow. The suggestions are all rooted in evidence-based medicine shown to improve sepsis mortality. Because this system identifies symptoms early, the mortality rate due to sepsis in the Banner Health intensive care unit is has dropped to 15% to 17%, whereas the nationwide sepsis rate is 25% to 50%.⁵

To achieve outcomes like this, pharmacists need to be involved in the design and implementation of EMRs. For example, if the sepsis early-warning detection system led to a prescription for an antibiotic, the pharmacist must play a role in ensuring timely verification and delivery. Other areas in which pharmacists can contribute significantly to stage 7 include the following:

● Improving barcode scanning rates

● Reducing transcription-related adverse drug events

● Reducing overall average cost of care

● Preventing readmissions

● Preventing falls

● Improving transitions of care

● Preparing immunization documentation and management

● Empowering rural hospitals and clinics

● Improving pharmacy generic dispensing rates

● Improving monitoring of drugs with narrow therapeutic indices (eg, heparin, warfarin, digoxin)

● Implementing an acetaminophen safety net

● Improving vaccination rates

Staying Up-to-Date

Health-system pharmacists need to stay up-to-date with existing and emerging EMR capabilities. An initial step is to use himssanalytics.org/stage7 to identify your organization’s currently recognized EMRAM stage.² If your site is not listed, your stage can be estimated using the stage descriptions. It is interesting to note that more than 50% of sites surveyed are at least stage 5. However, there is always room for improvement. If your organization is not at stage 7, consider how you can contribute to achieving it. If your organization has already demonstrated it is at stage 7, remember that this achievement only demonstrates that your organization has the ability to use your EMRs to drive higher quality and greater outcomes. It is up to you, your colleagues, and your leadership to realize the outcomes.

Most EMR vendors have user-group websites where individuals can create an account and connect with the user base across the country and around the world. Joining your EMRs’ user group is a great way to stay in tune with your EMRs’ community and up-to-date on its functionality, which you can compare with other EMR sites. Additionally, setting up subscriptions to topics relevant to your practice will bring fresh information to your inbox. EMR vendors usually coordinate user-group gatherings. Larger sites often send some attendees to participate. Attending one of these conferences, perhaps in lieu of another annual conference, can further your competency regarding EMRs and help ensure that pharmacy practice at your site is fully engaged in bringing advanced pharmacy-centric EMR capabilities to your site. Some programs at EMR conferences provide continuing education hours. If attending a conference is not feasible, signing up for webinars or conference calls may be an alternative.

Health-system pharmacists who work alongside other health care practitioners (eg, physicians, nurses) are in a strategic position to discuss opportunities for, and collaborate on, implementing new EMR capabilities. By following your organization’s process for submitting EMR requests, you can add traction to ideas discussed in your clinic or on your floor. Individuals interested in becoming more involved can offer to serve as “super users” or subject matter experts during EMR upgrades. Discussing with your supervisor the addition of EMR-oriented goals to your performance evaluations is a great way to add accountability to your EMR competency. Individuals who are interested in health care informatics can seek advanced training through residencies, master’s degree programs, and EMR certification programs, or can request additional pharmacy informatics responsibilities in their current role.

Conclusion

Author William Gibson once said, “The future is already here—it’s just not very evenly distributed.” This could be said about the advanced capabilities of EMRs, such as continuous MUEs. Today’s health-system pharmacist can help evenly distribute EMR technology by measuring EMR adoption using the HIMSS EMRAM, staying up-to-date on EMR functionalities, and optimizing EMR in his or her organization. With a bit of extra effort and participation, the future health-system pharmacy practice is just around the corner.

Adam S. Wolfe, PharmD, MS, BCPS, practices clinical and analytic management as the pharmacy services manager at CHESS, a health enablement company located in High Point, North Carolina. His professional interests include advancing pharmacy practice through the intersections of clinical, administrative, and data management.Ryan M. Farrington, PharmD, BCPS, is a clinical pharmacist and member of the institutional review board at Saint Alphonsus Regional Medical Center in Boise, Idaho. His professional interests include pharmacy informatics and medication safety.

References

• Pharmacy Forecast: Strategic Planning Advice for Pharmacy Departments in Hospitals and Health Systems 2014-2018. Chapter 5. ASHP Foundation website. ashpfoundation.org/MainMenuCategories/CenterforPharmacyLeadership/Pharmacy-Forecast. Accessed November 9, 2015.
• HIMSS analytics. Health Information Management Systems Society website. himssanalytics.org/stage7. Accessed November 9, 2015.
• State of pharmacy automation 2015. Pharmacy Purchasing & Products Magazine. pppmag.com/article/pppv12n8s0/State_of_Pharmacy_Automation_2015. Accessed November 9, 2015.
• 50 things to know about Epic, Cerner, MEDITECH, McKesson, athenahealth and other major EHR vendors. Becker's Healthcare website. beckershospitalreview.com/healthcare-information-technology/50-things-to-know-about-epic-cerner-meditech-mckesson-athenahealth-and-other-major-ehr-vendors.html. Accessed November 9, 2015.
• Banner Health. EMR and sepsis. Banner Health website. bannerhealth.com/About+Us/Innovations/Electronic+Medical+Record/EMR+and+Sepsis.htm. Accessed November 9, 2015.