The HIMSS Analytics EMR Adoption Model (EMRAM) was developed in 2005 in order to track the implementation and usage of electronic medical records at hospitals and health systems across the United States.

The EMRAM scores hospitals in the HIMSS Analytics Database on their progress as they make their way through the model’s eight stages – levels 0 through 7 – toward an entirely paperless patient record environment.

The measurements for stages 0 through 6 are based on mathematical derivatives of data supplied by hospitals to HIMSS Analytics. Stage 7 is attained only after a site visit from HIMSS Analytics officials, including two CIOs and a CMIO.

The model is "the one and only benchmark used for acute care," said John Hoyt, executive vice president of HIMSS Analytics.

Its standards are exacting. Of the 5,299 hospitals surveyed as of Q3 2011, just 1.1 percent have attained Stage 7. Nearly 10 percent, meanwhile, have yet to get off the ground at all, and are currently stuck at Stage 0.

The largest group of hospitals – more than 46 percent – is hovering at Stage 3, which requires nursing/clinical documentation (flow sheets), a clinical decision support system (CDSS) and PACS available outside the radiology department.

"It is clear, from looking at the model, that Stages 4, 5, 6 and 7 are the more difficult ones," said Hoyt. "The numbers drop off drastically from Stage 3, which is 46 percent of the hospitals, to Stage 4, which is just 13 percent."

Something must be a sticking point at Stage 4? Precisely, said Hoyt: "physician order entry."

Stage 5 is no picnic either. It calls for closed-loop medication administration: every bit of medication in the hospital barcorded and verified at the bedside before being administered to the patient.

Still, said Hoyt, "We are seeing an uptick in the number of hospitals that say they are implementing barcoding in pharmacy and nursing. In fact, they might implement Stage 5 before they implement Stage 4. We have some data that shows that's going on."

Still, "you can't be a Stage 5 if you're not a Stage 4," Hoyt clarified. "If you have all the nursing documentation in the world, you're still a Stage 3. And then, if you implement closed-loop, you're still a stage 3."

That said, "Once they get CPOE – boom! – they jump from 3 to 5. We're seeing data saying hospitals are barcoding. So as soon as they get that done and get a handful of physicians – say, hospitalists – on board with CPOE, I predict we'll see a growth out of 3 and into 4 and 5 pretty quickly."

Stage 6, with its requirement of physician documentation, is yet another stretch – just 4.4 percent of hospitals have gotten that high up the ladder. The level's dependence on docs making notes at computer terminals is problematic for many.

Indeed, "there's one subtle thing that wouldn't ever be talked about in the statistics,” said Hoyt. “Stages 4 and 6 have a lot to do with physicians."

His advice? "It is politically – and strategically – astute to make sure the nurses in the hospital are on board and are good users of the system before you start going to the medical staff, in general."

All that said, Hoyt has noticed that "the number of hospitals that have been coming into stages 5 and 6 the past few years has been accelerating, so the stimulus program is clearly having some effect, we believe."

In fact, looking at last year's data, "we actually had a decrease in stage 3," said Hoyt. "Why's that? Because they're moving out of Stage 3 and into Stages 4, 5 and 6. So that's a good thing."

In the coming year, Hoyt said, "we do believe that we will see a continued growth into Stages 4 and 5." Sure, it's "capital intensive" and recalcitrant docs can sometimes slow upward movement. But "I think there's momentum picking up."

Of course, "We have a long way to go," said Hoyt. "We know that."