Successfully Achieving HIMSS EMRAM Stage 6 Certification Using a Clinical System Based on an Open Platform – the Journey to Becoming a Paperless Hospital

When we started working with University Children’s Hospital Ljubljana (UCHL) and PICU, Slovenia, they had practically no IT support whatsoever. According to HIMSS EMRAM they were at stage 0.

UCHL’s primary goal was to improve patient safety with streamlined and paperless processes, which would help to prevent dangerous medical errors, but also allow medical teams to spend more time talking and working with patients. They envisioned a modern, mobile solution: fit for purpose-made apps with a high level of security for better collaboration within medical teams, and a system which would not restrict their ability to innovate in the future.

The hospital’s management understood that, like any modern organisation today, they needed to remain agile in a digital, information-driven economy and find an IT solution that would support their ambitions for many years in the future. They were, after all, embarking on the journey to become a paperless hospital.

It took us and the hospital seven years to reach EMRAM stage 6, however, keep in mind that we also had to develop and rollout all the clinical modules they needed and together with the hospital we had to complete a transformation of all their key processes. The changes affected everyone involved in the care process. Both our team and the hospital were constantly learning and adapting. Today, as a result of the knowledge we gained and the development of all the clinical modules, the time it would take to reach the same stage in another hospital, depending on their level of commitment, could take half as long.

When we started working with the hospital we knew that in order to develop a viable healthcare IT solution – one which would support a long-term transformation and continuous improvements in the hospital’s care processes – we would have to:

• introduce a design driven development of all clinical modules to speed up the solution’s adoption;
• introduce a culture of constant improvements through the definition and constant monitoring of KPI’s;
• set up a vendor-neutral, structured clinical data repository to establish a centralised, structured, and lifelong EHR record in order to avoid vendor lock-in and achieve high interoperability of vendors, technologies, and applications;
• rely on standards such as openEHR (for data persistence), IHE, HL7, and more for integration and messaging to simplify integration with ancillary services such as LABS, Radiology, etc.;
• implement a platform approach to enable easy access to all clinical data from different apps and stimulate the development of an ecosystem of apps from different vendors.

So, in our first year at UCHL we deployed a solid, robust, and scalable foundation based on a structured, vendor-neutral clinical data repository that would enable the creation of a life-long EHR. Later this piece of infrastructure became a stand-alone, standards-based health data platform known as Better Platform^TM. And, on top of that foundation we developed a clinical information system with modules supporting:

• the registration of the patients,
• electronic scheduling,
• easy input of patients diagnoses, allergies and SOAP (subjective, objective, assessment, plan) letters,
• the creation, storage and sharing of clinical documents among medical teams,
• nurses to record their most important observations (basic eOBS module).

“With this, the hospital achieved some quick wins – they were now able to easily track patient appointments, store all documents in a single vendor-neutral EHR, and had key patient data at hand any time they needed it – both at the outpatient clinics and at wards.”

At that point, from the perspective of IT, they now had a system in place which guaranteed that all future modules would be built on top of the same clinical data repository, which prevents any fragmentation and duplication of a patient’s clinical data.

The next step, which took a little more than a year, was to transform the processes of ordering laboratories, collecting and tracking lab samples, receiving electronic lab results, as well as the processes of ordering radiology and receiving electronic radiology results, and set up integrated access to radiology images. In parallel, the hospital issued a tender to implement RIS (radiology information system) and PACS (picture archiving and communication system) to fully enable digital radiology diagnostics and reporting. The laboratory and pharmacy already had IT support.

We spent the next three years working with medical teams to develop and implement modules that enabled nursing staff to completely transition to paperless. We worked with acute wards as well as ICU, and that meant we also had to integrate medical devices and offer modules to track the status of lines, tubes, and drains on top of enabling detailed tracking of fluid balances. One of the more successful rollouts was when we introduced our nurse care planning module.

Although at the time we were not following the EMRAM certification requirements, I realised in retrospect that at that moment the hospital was only missing the clinical protocols and clinical decision support to be eligible for EMRAM stage 5.

The third year into the journey, working closely with the medical teams and regularly shadowing them around the hospital, we realised that in order to completely let go of paper documentation and processes we would have to build a comprehensive medication management solution. We also understood that this would be a very challenging task, but at the same time we were in good position because we had no legacy IT support for medication management and we were free to innovate. We set up a dedicated team consisting of a head nurse, a head of pharmacy, a head of paediatric ICU, myself, and a really good UI/UX expert. This team then spent the next three years brainstorming, prototyping, and developing the first version of the medication management module which is known today as Think!Meds^TM. We were quite lucky that we got the chance to include NHS clinical experts into the team, as this in turn sped up the whole development and rollout process. After three years of development and testing on three different wards (including ICU), the medication management product, the rollout methodology, and the medical teams were ready to do a full rollout in all 11 wards, including ICU.

Although the hospital defined, evolved, and tracked actionable KPI’s from the very start of the journey, the gradual rollout and the fact that all the clinical data was stored in a structured form and within centralised clinical data repository meant that the medical teams slowly built better, centralised and comprehensive patient EHRs. Furthermore, they were able to use the now available structured clinical data for research, analysis, and gathering insights into their processes. Having all this clinical data available in real-time, in years six and seven into the journey, made it possible for us to leverage it, and offer medical teams real-time decision support and guidance. Decision support in the hospital today relies on laboratory results, observations, medications, and more to trigger real-time recommendations to clinicians for the next steps in the care process.

Once we were in our sixth year of the journey, we recommended that UCHL apply for HIMSS EMRAM certification in order to get an independent opinion on how extensively their healthcare IT was being used on a day-to-day basis. After the initial interviews and self-completed questioners provided by HIMSS were submitted, the hospital received the news that they were an HIMSS EMRAM stage 6 candidate. The last feature that was missing to be successfully validated as an EMRAM stage 6 hospital was closed-loop medication management. Although the medication management module already supported closed-loop, the more complex part was to actually implement all the improvements into the overall medication management process – from including clinical pharmacists and performing regular reviews of all new or modified prescriptions, to teaching clinicians how to use the system to simply execute medication reconciliation and ensure that the pharmacy was dispensing all medication to the wards with appropriate barcode labels.

Besides the great support we received from management, the gradual rollout, and having appropriate IT support, there is another very important aspect that should not be underestimated in the overall journey to becoming a paperless hospital,  and that is the hardware. It is easy to overlook the fact that different paper forms, in addition to being used to record clinical details, have another very important role: they serve as triggers to move the clinical processes forward. When a doctor fills out a paper order for labs, she places it on a shelf, from which a nurse takes the appropriate form and collects the samples… and so on. The moment you get rid of the paper, you also lose these triggers. So, you need to be sure that you replace these triggers with notifications within the clinical information system. However, since medical teams are constantly on the go, you also need to offer them easy access to the EHR record through mobile devices, bedside PCs, computers on wheels and more – all depending on the requirements and specifics of different care settings.

Transforming a hospital into a paperless one takes time, and it is important that everyone involved understands that this will be a journey. In my future blogs, I will explain each key step of the transformation in more detail, and the lessons learned.