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UC San Diego Health System is nationally recognized for its information technology (IT) initiatives, as well as its advanced infrastructure that seamlessly integrates clinical systems — both have improved the quality and efficiency of health care delivery and positively impacted patient safety and outcomes.
Understanding the level of electronic medical record (EMR) capabilities in hospitals is a challenge in the US healthcare IT market today. HIMSS AnalyticsTM has created an EMR Adoption Model that identifies the levels of EMR capabilities ranging from limited ancillary department systems through a paperless EMR environment. HIMSS Analytics has developed a methodology and algorithms to automatically score more than 4,000 hospitals in our database relative to their IT enabled clinical transformation status, to provide peer comparisons for hospital organizations as they strategize their path to a complete EMR and participation in an electronic health record (EHR). The stages of the model are as follows:
Stage 0: The organization has not installed all of the key ancillary department systems (e.g., laboratory, pharmacy, radiology).
Stage 1: Major ancillary clinical systems are installed (i.e., pharmacy, laboratory, radiology).
Stage 2: Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary, and the clinical decision support/rules engine (CDS) for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage. The hospital is health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.
Stage 3: Nursing/clinical documentation (e.g., vital signs, flow sheets) is required; nursing notes, care plan charting, and/or the electronic medication administration record (eMAR) system are scored with extra points, and are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab conflict checking normally found in the pharmacy). Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians outside the Radiology department via the organization’s intranet.
Stage 4: Computerized Practitioner Order Entry (CPOE) for use by any clinician is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one patient service area has implemented CPOE with physicians entering orders and completed the previous stages, then this stage has been achieved.
Stage 5: The closed loop medication administration environment is fully implemented. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point of care patient safety processes for medication administration.
Stage 6: Full physician documentation/charting (structured templates) is implemented for at least one patient care service area. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. A full complement of PACS systems provides medical images to physicians via an intranet and displaces all film-based images.
Stage 7: The hospital no longer uses paper charts to deliver and manage patient care and has a mixture of discrete data, document images, and medical images within its EMR environment. Clinical data warehouses are being used to analyze patterns of clinical data to improve quality of care and patient safety. Clinical information can be readily shared via standardized electronic transactions (i.e., CCD) with all entities who are authorized to treat the patient, or a health information exchange (i.e., other nonassociated hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients in a data sharing environment). The hospital demonstrates summary data continuity for all hospital services (e.g., inpatient, outpatient, ED, and with any owned or managed ambulatory clinics).
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