"I would characterize this past year as an accelerating year," says John Hoyt, executive vice president of HIMSS Analytics.
Exactly 12 months ago, Hoyt spoke to Healthcare IT News about HIMSS Analytics' EMR Adoption Model (EMRAM), which was developed in 2005 as a means to track hospitals' implementation and utilization of electronic medical record. At the bottom of that ladder is Stage 0: totally paper-based. At the top is Stage 7: "Complete EMR" - in the full flower of all its functionality.
The sub-headline for that 2012 column was relatively modest: "Step by step, inpatient EMRs are finding their level."
This year? "The number of hospitals that moved to 5, 6 and 7 grew at an astonishing rate. I mean astonishing," says Hoyt.
The number of hospitals attesting for each of those difficult middle-levels have gone up 80 percent for Stage 5, 80 percent for Stage 6 and about 66 or 70 percent for Stage 7, he says. "It's been a good year."
Well, for some hospitals, at least. "I would say it's accelerating in the upper-end adoption, but there is still a stubborn low-end of hospitals still at stage 0 or 1 - or 2, frankly," says Hoyt. "Notably rural and critical access. That's where there market is."
At least the number of Stage 0s has declined markedly in a year: from 9.6 percent in Q3 2011 down to 7.4 percent in Q3 2012. But, of course, that's still not good enough. "We'd like to see 0 disappear, frankly," he says.
And when might it be reasonable to expect that to happened? Hoyt thinks it could be reality within four to six years.
One interesting trend HIMSS Analytics has notice this year is only tangentially related to EMR adoption but important nonetheless: a slow-down in the number of hospitals per integrated delivery system.
"From '09 to '10 it grew from 6.3 to 6.6," on average, says Hoyt. "From '10 to '11 it grew from 6.6 to 6.9. And from '11 to '12 it grew only to 7.0."
The upshot? "Maybe the appetite for acquisition has kind of cooled," he says. "I'm also thinking it's the CFOs leery of taking on big debt for acquisitions, knowing that we've got some Medicare and Medicaid cuts coming.
The catch, when it comes to EMR adoption, is that "M&A of hospitals, I think, that's the salvation of small and rural and critical access hospitals," says Hoyt. "It's those hospitals that are part of an IDN that are clearly moving up the EMR adoption model."
As opposed to their many paper-based peers, "There are Stage 7s who are critical access hospitals; we've got a bunch of 6s that are critical access," he adds "And virtually every one is part of an IDN. The small rurals, 50 beds or less, that are not part of an IDN are not in the upper levels of the EMR adoption model."
For all the forward motion we've seen these past few years, of course, it's hard to argue that one big thing is helping fuel it.
"This is probably a no-brainer, but if we didn't have meaningful use, it's highly questionable how much movement we would have had in the market," says Lorren Pettit, vice president, market research at HIMSS Analytics.
A good way to prove this, says Hoyt, is to look at numbers north of the border. Immediately after incentive checks started hitting the mail, in Q2 of 2011, the U.S. inpatient market started to grow apace. But look at numbers in the same period in Canada, "and it was like a photograph; nothing had changed," says Hoyt.
"The not-so-subtle message was, 'Huh, incentives must work.'"
Not for nothing, this past December was an especially robust one for MU - with a whopping $1.2 billion paid out incentives. There are hospital IT departments across this great land that are working very hard to get that lucre.
"There are CIOs out there, who've got, in their incentive plans, 'You'd better make this money,'" says Hoyt. "I even know a CIO who's got an incentive for Stage 5, and then Stage 6. She earned her stage 5, and she got a big fat check last spring."
And good for her, because getting there isn't easy. In particular, Stage 4 on the EMRAM, with its requirements for computerized physician order entry (CPOE) and clinical decision support, is especially tough.
In fact, some facilities find that Stage 5, which requires closed-loop medication management, to be an easier hurdle.
There are "several hundred" hospitals that don't have CPOE live at Stage 4, but do have closed-loop live at Stage 5, says Hoyt. "They're sitting here at Stage 3, because they're not live at Stage 4. But as soon as they get stage 4, they jump right to 5."
Part of the reason? "They chose to do the nursing stuff before the doc stuff because they're intimidated about messing around with the medical staff. And I understand that. In a very competitive environment, you have do deal with your medical staff gently."
Still, the times they are a-changing. Hoyt recalls a visit to one Stage 7 facility that had seen 11 doctors walk out over its CPOE requirements. "Seven came back," he says with a chuckle. "Because the place they went to said, 'You're gonna have to do that here too.'"
So a lot has changed in a year. What can we expect to see happening with enterprise EMRs at this time in 2014?
"I think we're going to start seeing some growth of integrated information systems to serve accountable care organizations," says Hoyt. And as that happens, "I think we're probably going to see some system replacements, or some major efforts into integration.
"Let's pretend you're the CEO of a hospital, and you've got a bunch of docs out there within 100 miles, and some clinics, and a hospital or two that you've been competing with for years," he says. "But now you decide to contract to be an ACO and you're partners. And they have different brand names. Who in the world is going to keep track of how efficient you are, whether you're making money or not? Somebody's got to be doing that, and it's going to take either major integration efforts, or some system replacement."
In the meantime, on a more basic level, for hospitals that are just beginning to grope their way up the EMRAM ladder, it will be fulfilling just to have further continuation of what we've seen so far, he says: "implementation, implementation, implementation."
