LESSONS FROM DIGITAL LEADERS

HIMSS WHITE PAPER SPONSORED BY THE HCI GROUP LESSONS FROM DIGITAL LEADERS How to manage a successful EMRAM journey CONTENTS Key summary 02 The digital transformation process and the role of EMRAM 03 Benefits of the EMRAM journey 05 Lessons to learn from digital leaders 08 A journey planner to master a digital transformation 11 Sponsored by:

Key summary The healthcare sector is progressively deploying Information technology (IT) to propel the excellence and efficiency of healthcare delivery. The digital transformation of a healthcare institution is more than a comprehensive IT project as it affects the entire organisation, it is also an undertaking that requires change management. It needs the personal championing of an individual or a team of senior business stakeholders, so-called digital leaders, to integrate technology seamlessly in the organisation. In this way, improved care outcomes, patient safety and organisational efficiencies can be attained. The HIMSS Electronic Medical Record Adoption Model (EMRAM) is regarded by hospitals as a trusted path towards digital maturity and is used in this white paper as a means to identify digital leadership. Analysing dozens of successful digital transformation journeys from hospitals 1, and interviewing two renowned digital leaders in addition to a senior representative of HIMSS Analytics Europe, this white paper identifies benefits associated with a hospital s digital transformation as well as do s and don ts digital leaders recommend avoiding in order to accomplish those rewards. Based on these insights, HIMSS designs a journey planner that aims to support hospitals on their digital transformation. 1 For examples in the US see: Honoring Industry Leaders In Health IT Adoption For Improved Patient Care, HIMSS Analytics, April 2015 02

LESSONS FROM DIGITAL LEADERS The digital transformation process and the role of EMRAM The need for technology With incidences of chronic illnesses on the rise, care delivery faces the challenge of juggling sustainability with quality of care. Against this backdrop, the healthcare industry strives to improve health outcomes and deliver care more efficiently at the same time. This is where IT comes into play it is essential for driving excellence and efficiency. However, introducing IT does not merely mean replacing everything paper-based with digital tools, but it also triggers innovation in preventing, diagnosing and treating sicknesses as well as in the administrative field. Moreover, introducing IT does not only require a tailored implementation of software and hardware in a healthcare organisation, but it also demands change management. The digital transformation of a healthcare organisation is not only an IT project but requires the buy-in of its management. It additionally needs the personal championship of a senior business stakeholder to turn the digital transformation journey into an endeavour that helps to reap benefits such as improved care outcomes and financial efficiencies. It is important that a healthcare institution is aware of the range of potential benefits to be gained before it starts on the EMRAM journey and weigh those against the required resources in order to establish the validity of the business case. This, in turn, will facilitate the buy-in of the management. Introducing IT does not merely mean replacing everything paper-based with digital tools, but it also triggers innovation in preventing, diagnosing and treating sicknesses as well as in the administrative field. EMRAM as a map for the digital transformation For the purpose of this white paper, the essence of digital transformation in the healthcare sector is defined as the journey of becoming a paperless healthcare organisation. At the heart of this change process lies the exchange of patient information in digital format between the various stakeholders involved in the care. The extent to which IT is used to streamline internal processes and workflows not only varies by country, but also from hospital to hospital. A well-established method of measuring the degree to which hospitals have replaced paper-based processes with technology is the EMRAM that was developed by HIMSS Analytics in 2005. Jörg Studzinski, Director Research & Advisory Services at HIMSS Analytics, Europe, explains: EMRAM describes the journey of digital transformation with respect to the introduction of an electronic medical record (EMR) system, which requires changes in the workflow and daily routines. However, it does not reflect the entire journey toward a digitally 03

As EMRAM is a pragmatic model that can be relatively easily implemented and allows international comparisons, over the last five years, it has become the de-facto reference system for measuring the digital maturity of a hospital. Figure 1: The EMRAM roadmap STAGE EMR Adoption Model Cumulative Capabilities 7 Complete EMR, Data Analytics to improve care 6 Physician Documentation (templates), Full CDSS, Closed Loop Medical Administration 5 Full R-PACS 4 CPOE; Clinical Decision Support (clinical protocols) The EMRAM roadmap 3 Clinical Documentation, CDSS (error checking) 2 CDR, Controlled Medical Vocabulary, CDS, HIE Capable 1 All Three Ancillaries Installed Lab, Rad, Pharmacy 0 All Three Ancillaries Not Installed supported healthcare delivery, but focuses on how comprehensively technology is used to capture electronic information generated in a hospital. The healthcare industry regards EMRAM as an internationally valid standard for measuring the maturity of a hospital s EMR environment. Studzinski explains: There are some other, country-specific models, like those in France and England, that look at specific processes within and outside a hospital. They potentially map some aspects better than EMRAM, but lack the international comparability. As EMRAM is a pragmatic model that can be relatively easily implemented and allows international comparisons, over the last five years, it has become the de-facto reference system for measuring the digital maturity of a hospital. EMRAM permits hospitals to benchmark their digital progress along an eightstage continuum. It maps a progressively sophisticated roadmap for the journey from a paper-based environment, EMRAM Stage 0, to an entirely paperless environment, EMRAM Stage 7 (see Figure 1). Furthermore, EMRAM also offers hospitals a means to compare themselves with its peers. 04

LESSONS FROM DIGITAL LEADERS Benefits of the EMRAM journey The further a hospital advances along the EMRAM journey, the more it will be able to reap the benefits of its investment in terms of an increase in quality, safety, and operational efficiency. It is exactly because of this, that the early stages of the EMRAM journey can also be met with unwillingness. Having assessed many hospitals across all EMRAM stages, Studzinski confirms that EMR adoption often stalls at EMRAM Stage 2, because at that point of the journey, there are costs that are not balanced out by any returns on investment nor realised benefits. In addition, if not managed properly, the changes can impair the relationship between physicians and management. For this reason, it is important to constantly communicate what can be expected of its stage and what has been achieved so far. Although all stages are important, the first four are essential in removing the potential for human error Edward W. Marx, Senior Vice President at Advisory Board/Clinovation and currently acting as an interim CIO to New York City Health & Hospital, knows from his experience in leading several hospitals along that journey at what stage benefits typically materialise: Although all stages are important, the first four are essential in removing the potential for human error. With the introduction of computerised order entry at Stage 4, or the ability to analyse data to create change at Stage 7, the real value of the investment emerges. Then the ability to impact financials, clinical outcomes and quality of care increases exponentially. And Carolyn Byerly, C-Level Advisory Services, HCI Group, and former chief information officer (CIO) at Stanford Hospital & Clinics, Lovelace Health System, Mayo Clinic, amongst others, stresses that the CIO has to communicate at C-level the potential benefits that are associated with the EMRAM journey, ideally at the start of the journey. Nevertheless, there is no formula to determine in advance the exact type and scale of realised benefits along the journey. In addition, it is not always possible to establish a clear connection between an action and its results, especially in complex organisational environments such as hospitals. However, there is a common set of improvements that many hospitals experience that mainly fall in the categories of clinical benefits/increased patient safety, financial benefits/higher efficiencies, and higher satisfaction ratings. 05

Hospitals have reported the following benefits, although the scale of each can vary widely between institutions: Clinical benefits / increased patient safety: Reduction in errors decreases mortality rates 2 Reduction of Adverse Drug Events (ADEs) 3 Reduction in medication administration errors 4 Reduction in time spent looking for information 5 Enhanced safety of care 6 Financial benefits / increased efficiency: Reduction of duplicate medical orders 7 Reduction in paper-based costs 8 Reduction in length of hospital stay and preventable hospital readmissions 9 Health plan savings 10 Reduction in errors, reduces potential losses and liability insurance costs, including medical staff s 11 Shift to outpatient and home care 12 Higher satisfaction ratings: Increase in employee staff satisfaction reduces turnover costs 13 Increase in direct patient care time is a staff satisfier 14 Increase in family and patient satisfaction with Closed Loop Medication Administration 15 Reduction in length of stay increases patient satisfaction 2, 3, 7-15: HIMSS Analytics, EMR Adoption and Benefit Realization, Jörg Studzinski CCSS Workshop, Costa Rica October2016 4-6: Hospital IT Benefits Modeling EMRAM Value, May 2013, PricewaterhouseCoopers 06

LESSONS FROM DIGITAL LEADERS Testimonials Clinical benefits We witnessed safety incidences go down, e.g. the fall rate of patients decreased by over 20% and the occurrence of venous thromboembolism (VTE) dropped by 42%. Ed Marx, US We saw hockey stick improvement in terms of quality of care Ed Marx, US Reduction in average time between initial evaluation and biopsy. Onkologikoasan Sebastian Cancer Institute, Spain The introduction of the Clinical Decision Support System reduced the time from the cancer diagnosis to treatment by 57% compared to before. Badalona, Healthcare Services, Spain Financial benefits We saw cost reductions attributable to reaching functional levels of Stage 7. Per year, we save around $20 m ( 19.2m) on printing and millions on transcription services as clinicians document directly into the EHR. Ed Marx, US Fewer inventory items expire before use due to automated tracking. Västerås Central Hospital, Sweden Closed Loop Medication Administration led to a reduction of drugs requiring co-signing from 461 to 390, equating to roughly 15% of nursing time being saved. Galway Clinic, Ireland Physician documentation improved compliance with clinical documentation (entry of clinical notes for discharge summaries from 30% to 95%). Milton Keynes Hospital NHS Foundation Trust, UK A measured reduction of 5-15 minutes per chart reviewed, saving approximately 30 minutes of chart reviewing time per therapist per day increased the number of patients that can be seen each day. Beaumont Health System, US The diagnostic support system has saved us 30,000 per year in diagnostic coding. Badalona, Healthcare Services, Spain Efficient use of staff resources paperless environment reduces physical coding, scanning, integrating documents & facilitates patient requests for copies of documents saving 324,000 annually. Hospital de Dénia Marina Salud S.A., Spain Fifty per cent of the discharge report s content is generated automatically by the EMR, resulting in savings of 5 minutes per report, amounting to 977.33 hours per year of nurses time. Hospital de Dénia Marina Salud S.A., Spain Reduction of hospitalisation in wards from >10 days to <7 days by tracking nurse activities, identifying a gap in training skills, closing the skills gap & continuously monitoring progress IRCCS Candiolo, Italy Availability of all electronic clinical information in EMR for coding results in savings of 5 minutes per major and minor surgery, amounting to savings of 1,249.50 hours per year from either a nurse or a physician. Hospital de Dénia Marina Salud S.A., Spain Satisfaction ratings We saw an increase in patient satisfaction, although the causality cannot be proven scientifically. Still, EHRs and Stage 7 contributed greatly to it. We could indirectly gauge the level of satisfaction as our patients praised how easily they could now access their medical records via the portal that had become available as part of Stage 7 proceedings. For example, at discharge, patients often lost their discharge summary papers, whereas at Stage 7 they can go online and look in their records for aftercare instructions. Ed Marx, US In the year we deployed EHRs and achieved Stage 7, physician satisfaction with IT was rated the highest at 95% very satisfied. We believe it had a lot to do with providing all the attributes that come along with Stage 7. Ed Marx, US The bar code scanning system improved patient satisfaction by providing a real-time breastmilk inventory to help avoid running out of milk or a mother having to make a last minute extra trip home to bring more milk to the hospital. Children s Hospital of Orange County, US 07

What can be learnt from digital leaders? The term digital leader, when it comes to Acute Care Hospitals, refers to those who have managed to ensure their organisation has achieved EMRAM Stage 6 or 7 certifications What is a digital leader? The digital transformation of a healthcare organisation demands the personal championing of an individual or a team of senior business stakeholders who can integrate technology seamlessly in the organisation rather than just implement new technologies. This rare breed of IT leader is called a digital leader. Digital leaders use information technology to drive significantly high levels of customer and staff satisfaction, productivity and performance. They are instrumental in shaping and advancing the digital transformation of the organisation they work for. The term digital leader can refer to just a single person but also to a group that chiefly contributed to achieve the digital transformation. Studzinski explains: The term digital leader, when it comes to Acute Care Hospitals, refers to those who have managed to ensure their organisation has achieved EMRAM Stage 6 or 7 certifications as this already represents an important part of the digital transformation pathway. It means that they have already overcome substantial hurdles. This doesn t happen very often, and, consequently, there are few digital leaders. Looking at the distribution of hospitals that have achieved Stage 6 and 7 certifications confirms that there are only few in between (see Figure 2). To fully appreciate how few hospitals there are globally that have achieved EMRAM Stage 6 &7, it is important to consider the overall number of public hospitals in those regions: The US has about 5,400, all of which have an EM- RAM score, Canada has about 640 and Europe, including Turkey, has approximately 9,000 of which more than 2,000 were assessed by HIMSS. For North American hospitals EMRAM Stage 6 & 7 certifications are important brand extensions and can even be relevant for their insurance premiums (i.e. they have to pay lower fees). In Europe this is not as much the case yet, but in some countries similar trends are visible. The absolute number of hospitals in Europe qualifying for EMRAM Stage 6 & 7 could potentially be higher if all hospitals would participate in the assessment. Although EMRAM allows for a comparison of the respective national maturity levels, it is important to consider the push on adoption that national ehealth strategies and incentive schemes such as Meaningful Use in the US and Turkey s Digital Strategy 2018 have on the investment into EMRs. 08

LESSONS FROM DIGITAL LEADERS Figure 2: Distribution of digital leaders (EMRAM Stage 6 &7 hospitals) in North America and Europe Country Total No Stage 6/7 Hospitals No of Stage 7 Hospitals North America 1946 266 1680 Canada 8 1 7 US 1938 265 1673 Europe 61 4 57 Belgium 1 0 1 France 8 0 8 Germany 1 1 0 Ireland 1 0 1 Italy 5 0 5 The Netherlands 9 1 8 Spain 15 1 14 Switzerland 2 0 2 Turkey 16 1 15 UK 3 0 3 TOTAL 2007 270 1737 (Status, Q4 2016) No of Stage 6 Hospitals What does it take to be a digital leader? By examining EMRAM Stage 6 & 7 hospitals, which we refer to as digital leaders, HIMSS Analytics could establish some common characteristics in terms of achievements as well as attitude that they share. Digital leaders use data to drive improved outcomes regarding processes as well as financial and clinical performance; are fully committed to continuous process improvements through collaboration; are supported by champions from different backgrounds such as executive stakeholders, clinicians, or other end users; Be aware that a person s life is at stake and leverage technology to act accordingly. For this, EMRAM offers a beautiful framework with a common language and established best practices for the journey. manage to create a group spirit, a positive emotional attitude towards working on the transformation process; and understand that the EMRAM journey is a change management programme that has to come from the top. Lessons to learn from digital leaders What can those involved in a hospital s digital transformation learn from digital leaders? Marx, well-renowned for his digital leadership for which he received several accolades, has plenty of advice on how to successfully accomplish 09

The more influence a CIO has on the management team, the higher the likelihood that the organisation will achieve stage 6 and 7 certifications the digital transformation: Be aware that a person s life is at stake and leverage technology to act accordingly. For this, EMRAM offers a beautiful framework with a common language and established best practices for the journey. Have it as part of your planning process otherwise it will not happen. Marx also recommends to develop a common vision in your organisation with the management s buy-in. Focus on key performance indicators and have a future orientation. Have a physician or nurse as a champion to trumpet the benefits of technology as an enabler. Validate externally what you do internally, to get external recognition that what you were doing is working. Don t be afraid to leverage external resources, get outside help to close your gaps. There is no organisation that can do everything well and sometimes you don t even know what you don t know, so it always requires intellectual honesty. Carolyn Byerly advises: The EMRAM journey must start with a leadership team, it needs to be embraced at C-level. It is a change management exercise led from the top that affects the entire organisation. The journey should always start with a gap analysis, it allows us to identify the gaps and to communicate them internally and externally. Studzinski observes: When you get to certify stage 6 and 7 hospitals, you immediately get a sense that there is someone in the management supporting the entire journey. With successful teams, there is a certain positive group dynamic palpable, it s in the way they interact. I witnessed, for example, that a group of people majorly involved in carrying out the EMRAM journey in one hospital started hugging each other and shedding some tears of joy when they became certified. In his view, the digital transformation is an undertaking that requires the backing of the entire management, a crucial success factor is the position of the head of IT within a hospital s organisation chart. The more influence a CIO has on the management team, the higher the likelihood that the organisation will achieve stage 6 and 7 certifications. And here I see many differences: there are CIOs taking part in management meetings or are part of the management. In other cases, the CIO is neither part of the management nor involved in meetings, then it will be relatively difficult to get to stage 6 & 7 as this requires change management from the top. 10

LESSONS FROM DIGITAL LEADERS Journey planner to master a digital transformation Based on our interviewees experience in leading and evaluating an organisation s digital transformation, the following journey planner highlights the essential do s and don ts on the journey. Figure 3: Digital Transformation Journey Planner 1. DEFINING YOUR GOAL: 2. LOOK OUT FOR ROLE MODELS: Start with analysing your current status quo with regards to patient outcomes, your organisation s financial and organisational performance. Determine what your organisation wants to achieve. Assess the digital maturity of your organisation with a gap analysis. Establish priorities with relevant stakeholders in your organisation. Define the transformation path and establish milestones. Focus on the key performance indicators during the digital transformation journey. Specify the timeframe. Which organisations have already achieved EMRAM Stage 6 & 7 certification? What can my organisation learn from those and apply? Potentially involve third parties for advice. 3. ASSESS THE ROLE OF IT IN YOUR ORGANISATION: What is the role of IT and CIO in your organisation? The CIO needs to be aligned with or be part of the management to make the most of the digital transformation. 4. STAKEHOLDER BUY-IN IS ESSENTIAL: The digital transformation is not only an IT project, but one that needs the support of the entire management. Beyond implementing technology, it requires process redesign and change management, physician buyin and satisfaction, as well as patient satisfaction. Communicate the benefits associated with the digital transformation at its various stages. It is important to have a physician and/or a nurse as champion for the digital transformation, it is not sufficient to have a CIO to trumpet the benefits of EMRs. Assess your performance against the defined goals at the agreed milestones. Need to establish and communicate a common vision, especially when heading for Stage 6 & 7 certifications. Have regular stakeholder meetings to discuss the progress of the transformation and to ensure continuous stakeholder support. 7. VALIDATION OF YOUR ACHIEVEMENTS: 5. COMPANY CULTURE: Transformation requires strong leadership and communication with all stakeholders. A well-organised governance structure is critical to physician adoption and ensuring clinical appropriateness of design and build. Training and ongoing support of both staff and senior management are essential. 6. USE OF EXTERNAL HELP: Get outside help to close your gaps. Outside help can be in the form of consulting firms, vendors and/or HIMSS gap assessment services. Validate externally what you do internally. Aim for an external validation to add to your credibility. 11

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