Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and HIPAA for FREE!!

New INFRAM Model Creates Healthcare Infrastructure Benchmarks

Posted on November 14, 2018 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

During the frenzy that was healthcare organizations rushing to implement EHRs and chase government money, it was amazing to see so many other projects get left behind. One of the biggest areas that got left behind was investments in IT infrastructure. All the budget was going to the EHR and so the infrastructure budgets often got cut. There were some exceptions where upgrades to infrastructure were needed to make the EHR work, but most organizations I know chose to limp along with their current infrastructure and used that money to pay for the EHR.

Given this background, I was quite intrigued by the recent announcement of HIMSS Analytic’s INFRAM (Infrastructure Adoption Model). This new model focuses on a healthcare organization’s infrastructure and whether it’s stable, manageable, and extensible. I like this idea since it’s part of the practical innovation we talk about in our IT Dev Ops category at the Conference. What we’ve found is that many healthcare organizations are looking for infrastructure innovations and the benefits are great.

The INFRAM model has 5 main focus areas:

  • Mobility
  • Security
  • Collaboration
  • Transport
  • Data Center

No doubt these are all areas of concern for any healthcare CIO. Although, I wonder if having all 5 of these in the same model is really the best choice. A healthcare organization might be at a level 6 for secruity, but only at a level 3 for mobility. Maybe that’s just fine for that organization. I guess at the core of this question is whether all of the capabilities of stage 7 are capabilities that are universally needed by all healthcare organizations.

I’m not sure the answer to this, but I think a case can be made that some organizations shouldn’t spend their limited resources to reach stage 7 of the INFRAM benchmark (or even stage 5 for some organizations). If a healthcare organization makes that a priority, it will probably force some purchases that aren’t really needed by the organization. That’s not a great model. If the above 5 focus areas had their own adoption models, then it would avoid some of these issues.

Much like the EMRAM model, the INFRAM model has 7 stages as follows:

Adaptive And Flexible Network Control With Software Defined Networking; Home-Based Tele-Monitoring; Internet/TV On Demand

Software Defined Network Automated Validation Of Experience; On-Premise Enterprise/Hybrid Cloud Application And Infrastructure Automation

Video On Mobile Devices; Location-Based Messaging; Firewall With Advanced Malware Protection; Real-Time Scanning Of Hyperlinks In Email Messages

Multiparty Video Capabilities; Wireless Coverage Throughout Most Premises; Active/Active High Availability; Remote Access VPN

Advanced Intrusion Prevention System; Rack/Tower/Blade Server-Based Compute Architecture; End-To-End QoS; Defined Public And Private Cloud Strategy

Intrusion Detection/Prevention; Informal Security Policy; Disparate Systems Centrally Managed By Multiple Network Management Systems

Static Network Configurations; Fixed Switch Platform; Active/Standby Failover; LWAP-Only Single Wireless Controller; Ad-Hoc Local Storage Networking; No Data Center Automation

No VPN, Intrusion Detection/Prevention, Security Policy, Data Center Or Compute Architecture

As this new model was announced, I had a chance to talk with Marlon Harvey, Industry Solutions Group Healthcare Architect at Cisco, about the INFRAM model. It was interesting to hear the genesis of the model starting first as an infrastructure maturity model at Cisco and then evolving into the INFRAM model described above. Marlon shared that there had been about 21-24 assessments and 35 organizations involved in developing this maturity model. So, the model is still new, but has had some real world testing by organizations.

I do have some concern about the deep involvement from vendor companies in this model. On the one hand, they have a ton of expertise and experience in what’s out there and what’s possible. On the other hand, they’re definitely interested in pushing out more infrastructure sales. No doubt, HIMSS Analytics is in a challenging position to balance all of this.

That said, a healthcare CIO doesn’t have to be beholden to any model. They can use the model where it applies and leave it behind where it doesn’t. Sure, I love having models like INFRAM and EMRAM to create a goal and a framework for a healthcare organization. There’s real value in having goals and associated recognition as a way to bring a healthcare IT organization together. Plus, benchmarks like these are also beneficial to a CIO trying to convince their board to spend more money on needed infrastructure. So, there’s no doubt some value in good benchmarking and recognition for high achievement. I’ll be interested to see as more CIOs dive into the details if they find that INFRAM is focused on the things they really need to move their organization forward from an infrastructure perspective.

Willingness To Invest In Outpatient EHRs and PM Solutions Grows

Posted on September 15, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

While the ambulatory EHR market remains somewhat stable, the number of organizations preparing to get out of their existing system has climbed over previous years, along with an increase in the number of organizations prepared to upgrade their practice management solution, according to new data from HIMSS.

To conduct the 9th Annual Outpatient PM & EHR Study, HIMSS Analytics reached out to physicians, practice managers/administrators, practice CEOs/presidents, PAs, NPs and practice IT directors/staff. A total of 436 professionals responded to its web-based survey.

The survey concluded that 93% of hospital-owned outpatient facilities had a live, in-operation EMR in place. Meanwhile, 70% of respondents representing free-standing outpatient facilities said they had an EHR in place, down from 78% last year.

As part of its survey, HIMSS Analytics asked respondents whether they planned to purchase an entirely new ambulatory EHR system, replace the existing system upgrade the system within the next two years.

The responses suggest that there’s been some new movement in the ambulatory EHR market. Most notably, 10.6% of respondents said they plan to replace their current solution, up from 6.4% in 2014. This is arguably a significant change. Also, 23.8% respondents said they were upgrading their current ambulatory solution, up from 20.8% in 2014.

In addition, the number of respondents with no investment plans fell below 60% for the first time in four years, HIMSS Analytics noted.

Though the practice management system market seems to be a bit more stable, some churn appears to be emerging here as well. Eleven percent of respondents said they plan to upgrade their current PM solution, down from 20.8% in 2014, and 9.3% said they plan to replace their current system, up from 6.4% in 2014.

All in all, there’s not a great deal of replacement activity underway, though the data does suggest a small spike. That being said, I was interested to note that respondents’ willingness to invest in a new system was higher than their willingness to upgrade a system they have.

The question is, why would ambulatory providers be ready to junk their existing EHR and practice management solutions now as opposed to three years ago? Are we reaching the end of a grand health IT replacement cycle or is there more going on here?

One possibility is that with MACRA kicking in, outpatient providers have been forced to reevaluate their existing systems in terms of their ability to support participation in QPP. Another fairly obvious possibility is that ambulatory providers are choosing to systems they feel can support their movement into value-based care.

From what I can tell, providers choosing new systems for these reasons are actually a bit behind the curve, but not terribly so. When their peers attempt to push forward with their three, four or even five-year-old systems, then you may see a replacement frenzy. Sometimes you just can’t afford to stick with Old Faithful.

IT Leaders Question Allscripts Acquisition of McKesson EIS

Posted on August 31, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Not long ago, I shared the results of a poll featured on HISTalk on the potential benefits of the Allscripts acquisition of McKesson EIS. The poll asked readers “Who will benefit most from the proposed acquisition of McKesson EIS by Allscripts?”

Roughly equal numbers of respondents said Allscripts customers would benefit (29%) and McKesson customers (27%). However, a new research report from Reaction Data suggests that many of their peers doubt that things will work out for McKesson customers or even do much to build Allscripts’ market position.

A number of health IT leaders quoted in the report say they’re fearful that McKesson solutions will get short shrift under Allscripts management. Others suggest that both vendors are behind the curve, especially McKesson, and that Allscripts is unlikely to spend enough money on it to catch up to current standards.

Their comments included the following observations:

  • I don’t see Allscripts as a major player in this space anymore and the acquisition will likely further stress the enterprise. Perhaps in combination they can cobble together a suite of tools, but integration will likely be clunky at best for some time.” – CIO
  • I do not see that McKesson brings anything beneficial to Allscripts, other than more users. McKesson’s products are very different from Allscripts’ current products and so will further dilute their efforts to bring quality product forward.” –CFO
  • McKesson is behind. Does not look like a smart choice moving forward.” –Director of IT
  • Just like Cerner buying Siemens, we were told they would support it and yada yada, here we are on Cerner after having to drop much more cash than we should have been required to.”—CIO

it’s worth noting, for the record, that all the feedback on the acquisition wasn’t negative. Positive comments included the following:

  • Combining Paragon, as the only true integrated, Microsoft SQL-based, hospital and ambulatory HIS on the market, with a solid vendor that focuses exclusively on HIT, is a win-win for the healthcare industry.” – CIO
  • “McKesson was losing and continues to lose ground on EHR systems to Epic and Cerner. They are withering on the vine. This acquisition will help them solidify their position in the market.”– Vice President of Finance

Still, most health IT leaders seemed to think the deal wouldn’t help either party that much. In particular, they were skeptical that McKesson’s high-profile Paragon solution was salvageable. “Paragon…is antiquated,” wrote one manager of information technology. “It will take a big bag of money and a lot of time to fix that.”

To summarize, while HIT execs conceded that the merger might buy Allscripts some customers and time, they felt it wasn’t likely to benefit their organizations. In fact, some argued that the deal could actually undercut the future of their McKesson systems: “Allscripts may focus on their own EMR and how those products I have with McKesson will interact with them rather than on McKesson products as a whole,” worried one director of information technology.

On top of everything else, the previous analysis by HISTalk doesn’t inspire much confidence that the acquisition will work on a corporate level. The analysis asserts that EMR vendors should be judged by the number of 250+ bed hospitals they have as customers, and points out that Allscripts controls only 6% of that market. (Epic, in contrast, has 20%, the article notes, citing HIMSS Analytics data.)

If I’m reading this right, it seems that Allscripts will take two mediocre and/or unfashionable solution sets and try to crossbreed them into a more popular set of tools, in the process scaring whatever loyal customers they have left. All sarcasm aside, I’d like to ask: Has this ever worked before?

HIMSS Analytics Clinical & BI Maturity Model

Posted on March 14, 2013 I Written By

Mandi Bishop is a hardcore health data geek with a Master's in English and a passion for big data analytics, which she brings to her role as Dell Health’s Analytics Solutions Lead. She fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

While the theme of HIMSS 2013 may have been, “How Great Is Interoperability,” the effectiveness of the many facets of interoperability are only as good as the actionable value of the shared data. The clinical insights that should be enabled by Meaningful Use Stage 2+ are expected to drive market trends in myriad areas of the healthcare system: chronic disease management, targeted member interventions, quality measures. In order to assess organizational readiness to capitalize on the promise of Meaningful Use, HIMSS Analytics began measuring the implementation and adoption of EMR and clinical documentation using a maturity model called EMRAM.


But, in analytics terms, EMRAM’s results are simply targeted foundational reporting, answering the question, “WHAT happened with Meaningful Use EMR adoption criteria.” So, you’ve got your clinical data in an EMR. Now what are you able to DO with it?

In 2013, HIMSS Analytics is taking a broader approach with the introduction of a new Clinical Business Intelligence maturity model, creating a framework to benchmark participating providers’ analytics maturity level.

I’ve been fortunate to know James Gaston, Senior Director of HIMSS Analytics Clinical & Business Intelligence, for many years, going back to his days with Arkansas Blue Cross. His appreciation for BI initiatives is matched only by his enthusiasm for the first day of turkey hunting season. When I ran into him at TDWI’s BI World summit in Orlando in November, he acted like a kid on Christmas morning, telling me about the brave new world of clinical data management that he was about to tackle. The excitement continued to build in the months leading up to HIMSS. James was practically glowing when we spoke about the upcoming C&BI Maturity Model release.

“Our customers are interested in not just understanding how to deploy IT applications, but how effectively they’re using those applications to support clinical business intelligence, as well as analytical pursuits,” James said. “So, HIMSS Analytics partnered with IIA to create and present a Clinical & BI Maturity Model that helps healthcare organizations measure that level of effectiveness.”

Sarah Gates, the VP of Research for IIA (the International Institute of Analytics), elaborated. “The HIMSS Analytics C&BI Maturity Model leverages the Competing on Analytics DELTA model, developed by Tom Davenport, which measures not only how well you’re using data and technology, but how well you’re building an analytical organization.” There are 5 core competency measurements in the DELTA model that will inform the HIMSS Analytics C&BI analysis: Data, Enterprise, Leadership, Targets, and Analysts. The methodology is holistic, touching on the cultural aspects of the organization as well as the technical, allowing a longitudinal view of the organization’s analytics program. A yardstick value from 1-5 will be assigned to each respondent based on Davenport’s criteria for each core competency.

Although HIMSS Analytics will eventually offer Level 1-5 certification program for those organizations with observed results for analytics, James and Sarah agreed that it is not appropriate for every provider to reach for the Level 5 gold star. Per Sarah, “Healthcare is an industry just starting to discover analytics. We’re expecting to see lots of practitioners that are emerging in use of analytics, so we believe it (survey results) will be heavy on the lower end of the maturity scale. Data warehouse capabilities and staffing career paths for data analysts will be key differentiators for mature programs.” Not all providers have the resources – financial, human, and/or technical – to attain advanced analytics nirvana, and James wants to insure that these providers don’t feel as if they’ve “failed”; the goal is to baseline against the peer group, identify opportunities for improvement, and focus on what is possible for each individual organization, working within their constraints.

What can we expect to see at next year’s C&BI survey results presentation? James said, “We want to be able to talk about benchmarking the industry as a whole, helping healthcare find its way with clinical business intelligence and begin to understand how important it is, and where opportunities lie Everyone’s talking about clinical and BI – it is the opportunity to realize savings in healthcare, to use information to empower people to make better decisions.”

So, it’s up to you, providers and technology partners. You’ve implemented your EMR, achieved a high adoption rate across your organization’s core clinical processes, attested to Meaningful Use Stage 2, achieved Stage 7 on the HIMSS EMRAM scale, perhaps even participated in multi-HIE CCD medical records sharing with other provider networks. You’ve got the data in-house and availabe. It’s time to see how ready you are to rise to the analytics challenge and maximize your return on those EMR and HIE investments.

Attempt to beat your previous Doug Fridsma long jump.

Note: for the complete HIMSS 2013 Leadership Survey Results, please download PDF here.

VA Hospitals Had Big EMR, BCMA Implementation Problems, Study Says

Posted on April 12, 2012 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A new study done at a group of seven VA hospitals has concluded the hospitals rolled out their EMRs with far too little planning, leading to problems that tied staff members and clinicians in knots.

The study, which was published in the American Journal of Managed Care, drew on interviews with doctors, IT staffers, nurses, pharmacists and managers.  The interviews were done several years after the VA had implemented its computerized patient record system (CPRS) and its bar code medication administration system (BCMA).

The respondents told interviewees that for most of them, the new technology created big difficulties. Many of the interviewees didn’t start out familiar with computer use, making the inevitable workflow disruption even worse than in other hospitals.

BCMA was a particualrly sore spot for the VA clinicians and staff, as it was phased in more rapidly and with little training for users.  Staff members at the hospitals essentially had to implement and use the system on their own, according to a story appearing in Information Week.

As if this wasn’t challenging enough, the hospitals ran into major issues in selecting and rolling out hardware to support these new technologies.

For one thing, some of the hospitals had little idea how to  build a wireless network capable of supporting the myriad of computer cards in use at their facility. In some cases, they faced major connectivity problems after failing to test the wireless systems prior to rollout of CPRS and BCMA.  Other hospitals in the seven had great difficulty figuring out how many computer terminal to order.

As I read the situation, the hospitals’ BCMA rollout led to the biggest problems and greatest possibility for harm.  All seven of the hospitals reported having major BCMA issues, including miscoded medications, empty unit-dose packages being delivered items not scanning.

Perhaps even worse, nurses sometimes had to cut the ID bands off of patient wrists just to scan them, or scan from extra wristbands in patient charts. “At some VA hospitals, staff were implicitly or explicitly permitted to use various workarounds with BCMA, such as…doing all scanning after medication administration,” the magazine reports, quoting the research report.

Not only that, many workarounds remained in place years after the BCMA rollout — a testimony, if there ever was one, to getting things right the first time.

Apparently, according to IW, BCMA is at stage 5 in the maturity scale HIMSS Analytics has established for measuring the maturity of a hospital EMR rollout. HIMSS says that 8.4 percent of hospitals are at this stage.

The thing is, a maturity scale shows its own weakness when you can laud a hospital for getting there even if their implementation has disrupted workflow greatly and even put patients at risk.  And I’m not aware of any ratings scale from HIMSS (or a similar entity) that grades quality of execution.

Do you know of other ratings systems for hospital EMR rollouts that do more to adjust for poor planning or implementation problems?  If you do, I’d love to hear about them.  This story is pretty scary.

Highly Functional EMRs Aren’t Necessarily High-Functioning

Posted on July 28, 2011 I Written By

I’ve just turned in a story for InformationWeek Healthcare about the new “Essentials of the U.S. Hospital IT Market, 6th Edition” report from HIMSS Analytics. That report details the progress hospitals and integrated delivery networks have made in IT over the past year and gives an update on how far along providers are according to the HIMSS Analytics EMR Adoption Model. That’s the seven-level scale (eight if you count Stage Zero) that measures adoption of various EMR components.

At the top of the scale, 1 percent of nonfederal hospitals in the U.S. attained Stage 7 in 2010, meaning that the EMR served as the legal medical record for all departments, was capable of exporting patient records as Continuity of Care Documents and had data warehousing and mining in place. That was up from 0.7 percent in 2009. The number of Stage 6 hospitals—with electronic clinician documentation, full clinical decision support and full PACS for radiology—doubled in the same time frame, from 1.8 percent in 2009 to 3.2 percent in 2010.

Here’s how the entire scale breaks down:


Actually, the EMRAM Web page shows newer numbers, through the 2011 second quarter. We’re up to 1.1 percent for Stage 7, 4 percent for Stage 6, 6.1 percent for Stage 5 and 12.3 percent for Stage 4. HIMSS considers Stage 4 to be the closest to the current requirements for “meaningful use” of EMRs.

It’s nice to see progress in installing technology and it’s nice to see hospitals using EMRs in a “meaningful” way, but that doesn’t mean there won’t be problems. As everyone in health IT knows, EMR certification, a prerequisite for meaningful use, does not measure usability, and this still is the first of three stages for meaningful use. That means we’re a long way from perfect, or even ideal. How do I know this?

The mother of a good friend of mine is now on dialysis and eventually will need a kidney transplant because she was given a medication that is contraindicated for Type 2 diabetes, which she suffers from. The harmful interaction resulted in her losing about 80 percent of normal kidney function. This happened at a HIMSS Analytics EMRAM Stage 7 hospital. Apparently, either the patient record didn’t show she was diabetic, the medication order didn’t get flagged, or the ordering physician, pharmacy and administering nurse all missed or ignored an alert. As the chart above illustrates, the medication loop should have been closed by Stage 5.

I’m not going to name the hospital or give any more details because there’s a good chance a malpractice suit is coming. I’m also aware of a medical informaticist with a long history of implementing and working with EMRs losing his mother due to a medical error that an EMR exacerbated. Again, I’ve been asked not to say more because of the legal ramifications.

It’s no secret that healthcare is in trouble. In this push to install technology and earn Medicare and Medicaid bonuses for meaningful use, we can’t take our eyes off the ultimate goal, creating a safer health system.