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Continuity of Care Maturity Model
Going Beyond EMRAM
Model Information
http://himssanalytics.org/CCMM
H. Stephen Lieber
President and CEO
HIMSS
Model supported by…
Presentation version 6-11-2015
THE EUROPEAN EMR ADOPTION MODEL
… in 8 Stages to Highest Quality in Patient Care
Electronic diagnostic and pharmacy
department information
A patient-centered electronic data
repository
Clinical ordering and documentation –
especially nursing care
Electronic order entry with decision
support and result reporting
Completely electronic diagnostic
image management
Full electronic clinical decision support,
and highest medication safety
“Paperless” patient record environment
for highest quality of care,
data continuity & full HIE
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What is “Continuity of Care”?
Citizens’ perspective…
Non-disruption of care provided to a patient throughout his/her care journey, across care settings
and care givers
Industry perspective…
Alignment of healthcare resources across care settings orchestrated in a way that delivers the best healthcare services and value possible for a defined
population under your care
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The Industry Challenge
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Our Solution A multidimensional maturity model promoting the key tenants of continuity of care
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Multiple Model Stakeholders
CIOs
Technology Leaders
CEO/COO/CFO/CSOs
Administrators
CMIO/CNO/CNIOs
Clinical/Medical Leaders
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Continuity of Care Maturity
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Clinical Focus
Comprehensive pop-health. Completely coordinated care across
all care settings. Integrated personalized medicine
CCMM Clinical Focus
Dynamic intelligent patient record tracks closed loop care delivery.
Multiple care pathways/protocols. Patient compliance tracking
Shared care plans track, update, task coordination with alerts and
reminders. ePrescribing. Pandemic tracking and analytics.
Community-wide patient record with integrated care plans,
bio-surveillance. Patient data entry, personal targets, alerts.
Multiple entity clinical data integration. Regional/national PACS.
Electronic referrals, consent. Telemedicine capable.
Patient record available to multi-disciplinary internal and tethered
care teams. EMR exchange. Immunization and disease registries.
Limited shared care plans outside the organization. Leverage 3rd
party reference resources. Basic alerts.
Engaged in EMRAM maturation
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Governance Focus
National and local policies are aligned.
CCMM Governance Focus
Policies address non-compliance.
Policies in place for collaboration, data security, mobile device use,
and interconnectivity between healthcare providers and patients
Best clinical practices are derived from care community healthcare
data and operationalized across the community
Policies drive clinical coordination, semantic interoperability.
Change management is documented and standardized
Policies for CofC strategy, business continuity, disaster recovery,
And security & privacy. Data governance is active
Governance is informal, inconsistent and undocumented
Data governance across organizations
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IT Focus
Near real-time care community based health record and patient
profile
CCMM IT Focus
Organizational, pan-organizational, and community-wide CDS
and population health tracking
All care team members have access to all data. Semantic data
drives actionable CDS and analytics. Comprehensive audit trail
Patient data aggregated into a single cohesive record. Mobile tech
engages patients. Community wide identity management
Aggregated clinical and financial data. Medical classification and
vocabulary tools are pervasive. Mobile tech supports point of care
Patient-centered clinical data presentation. Pervasive electronic
automated ID management for patients, providers, and facilities
Some external data incorporated into patient record.
Data is isolated
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Methodology
• Defining the “Care Community”
– The population who’s continuity of care is being profiled
• Define up to five care settings, such as…
1. Primary Care
2. Acute Care
3. Home based Care
4. Urgent Care
5. Long Term Care
• Completing Survey
– Excel based
– ~250 compliance statements
– 11 categories
– Four pre-defined responses
“Not Applicable”, “Somewhat Applicable”, “Fully Applicable”, “Unknown”
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Example Survey
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Results
Overall
Total 37%
Stage 7 9%
Stage 6 27%
Stage 5 35%
Stage 4 47%
Stage 3 37%
Stage 2 55%
Stage 1 59%
Stage 0 83%
Stage Level
Scoring Sections
Stakeholder Results
Care Setting Results
Overall Results
Compliance
by Stage
Overall Section
Compliance
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Overall Results
Overall Governance Clinical Info Tech
Total 37% Total 33% Total 36% Total 47%
Stage 7 9% Stage 7 12% Stage 7 Stage 7 0%
Stage 6 27% Stage 6 29% Stage 6 13% Stage 6 33%
Stage 5 35% Stage 5 28% Stage 5 18% Stage 5 65%
Stage 4 47% Stage 4 36% Stage 4 82% Stage 4 33%
Stage 3 37% Stage 3 35% Stage 3 27% Stage 3 62%
Stage 2 55% Stage 2 56% Stage 2 52% Stage 2 59%
Stage 1 59% Stage 1 71% Stage 1 43% Stage 1 57%
Stage 0 83% Stage 0 72% Stage 0 100% Stage 0 100%
Example Results
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Overall Results
Overall Recommendations The Client has made significant inroads at coordinating care in the primary care, and to a certain extent the acute care
setting. This is especially exceptional given that many of their patients have a free choice of providers, and physicians can
refer outside of the organization network.
In order to make significant progress to improve continuity of care, it is recommended that the Client pursue tighter
relationships with organizations that control other care settings, and these relationships must foster health information
exchange, shared best practice care plans, as well as care team communication and coordination.
1. Continue building relationships with key/critical providers of healthcare that represent other care settings where ACO
patients seek care
2. Extend governance activities and electronic capabilities that support care coordination outside the organization
3. Create documented Information and Communications Tech. (ICT) strategies and operational plans, addressing…
• Internal ICT architecture and infrastructure design
• A strategy and process for internal IT system integration design
• Business continuity and disaster recovery
• For effective integration of data from any data source, including those not anticipated, into the patient's EMR
4. Enable health related data exchange between separate healthcare organizations leveraging secure electronic exchange
5. Extend access so that Citizens / patients have online access to…
• A complete pan-organizational Personal Health Record (PHR) via one viewer or presentation method
• Can update their medical records with personal information and control access
• Allow relatives or social/home care workers to update their patient record
Governance stakeholders pave the way for Information Technology stakeholders and their associated capabilities which are
the foundation for Clinical stakeholders to facilitate coordinated care. It is a positive sign to see Governance at Stage 2
overall, slightly ahead of the other stakeholder groups and making progress to enable their success.
Example Results
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Stakeholder Results - Governance
Governance
Primary Acute Sub-Acute Care Urgent Retail Care Home Care
Total 64% Total 62% Total 9% Total 8% Total 20%
Stage 7 30% Stage 7 30% Stage 7 0% Stage 7 0% Stage 7 0%
Stage 6 61% Stage 6 65% Stage 6 0% Stage 6 7% Stage 6 13%
Stage 5 60% Stage 5 50% Stage 5 5% Stage 5 0% Stage 5 24%
Stage 4 71% Stage 4 71% Stage 4 14% Stage 4 14% Stage 4 7%
Stage 3 68% Stage 3 64% Stage 3 10% Stage 3 8% Stage 3 26%
Stage 2 91% Stage 2 88% Stage 2 34% Stage 2 19% Stage 2 47%
Stage 1 100% Stage 1 97% Stage 1 53% Stage 1 56% Stage 1 50%
Stage 0 100% Stage 0 90% Stage 0 70% Stage 0 50% Stage 0 50%
Governance Recommendations Governance stakeholders are making strides in the Primary and Acute care settings, achieving Stage 3 efforts, but then
progress falls off in other ancillary settings where the client has little to no influence or control. In the home care setting
there is good progress but it is spread thinly across many stages.
To surpass Stage 3 in the Primary and Acute care settings…
1. Work with IT stakeholders and acute care partners to develop an agreed upon set of standards and frameworks for
healthcare and related financial data, interoperability and data exchange
• Technical standards to fully engage and encompass all ICT systems
• Data standards to embrace all types of clinical and related financial data
• Care standards that outline clinical practice guidelines and care protocols Develop a documented strategy
and processes for data center (local and/or third party) disaster recovery and network redundancy, with
routine verification and testing
2. Refine the strategy and process to make tele-health, including telemedicine, available for remote consultations, tele-
monitoring, home care support, and chronic disease management
3. Create collaborative policies with other care settings that outline standards for protecting the security of data (virus
protection, encryption, physical security, etc…)
Example Results
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Primary Care Setting Results
Recommendations Master these activities by building on current progress and momentum to….
1. Create a patient-centered dynamic intelligent record that drives and tracks closed-loop care delivery among the
entire patient care team beyond acute and primary care to include community pharmacies, patient / patient
relatives, rehabilitation, social & home care, elderly homes, etc…
2. Extend shared care plans across providers within, as well as those tethered to the organization
3. Extend coordinated care plans that are managed and include Evidence Based Practices and Programs (EBP)
4. Extend access so that citizens / patients have online access to provide electronic consent and manage access
privileges to their medical record
Advance these activities by starting initiatives that address these capabilities:
1. Extend access so that Citizens / patients have online access to…
• A complete pan-organizational Personal Health Record (PHR) via one viewer or presentation method
• Update their medical records with personal information
• Allow relatives or social/home care workers to update the patient record
2. Capture a significant portion of clinical data in structured format
3. Integrate and use Natural Language Processing (NLP) capabilities where appropriate
Overall Governance Clinical Info Tech
Total 63% Total 64% Total 54% Total 70%
Stage 7 21% Stage 7 30% Stage 7 Stage 7 0%
Stage 6 48% Stage 6 61% Stage 6 13% Stage 6 33%
Stage 5 64% Stage 5 60% Stage 5 38% Stage 5 92%
Stage 4 78% Stage 4 71% Stage 4 100% Stage 4 68%
Stage 3 68% Stage 3 68% Stage 3 50% Stage 3 100%
Stage 2 87% Stage 2 91% Stage 2 83% Stage 2 86%
Stage 1 95% Stage 1 100% Stage 1 85% Stage 1 100%
Stage 0 100% Stage 0 100% Stage 0 100% Stage 0 100%
Example Results
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Scalable from Facilities to Countries
Provider Facility
Provider Network
Accountable Care Org.
Integrated Delivery Network
Province/Cluster/Region
Ministry of Health
State/Country
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James E. Gaston, MBA, FHIMSS
Senior Director, Maturity Models
HIMSS Analytics
Know. Understand. Prepare. Change…with CCMM
John P. Hoyt, FACHE, FHIMSS
Executive Vice President
HIMSS