HIMSS Analytics' Electronic Medical Record Adoption Model (EMRAM) has been tracking hospitals' slow upward climb towards advanced health IT use  -  an eight step ladder, from paper-based to totally wired  -  since 2005.

This past June, HIMSS released a new version, focused on ambulatory facilities. The Ambulatory EMR Adoption Model (A-EMRAM) tracks IT adoption in nearly 11,000 physician practices and ambulatory clinics that are part of a hospital or hospital system tracked by the HIMSS Analytics database.

"These are tethered practices," says John Hoyt, executive vice-president of HIMSS Analytics, "not the independent docs  -  there are tens of thousands of those, and I can't call em all."

Tracking hospital-affiliated practices is illustrative, however, because that is of course the big trend nowadays.

"I think what's going on is that hospitals are acquiring practices in a strategic competitive mode," says Hoyt. "Once they get the hospitals online in terms of meaningful use, then they spend money on the doctors." 

But while the acquisition of independent practices is undoubtedly a competitive move, he says, "the IT portion of it is initially not the focus at all. It is market share: 'If I can get a couple cardiologists, great. Then I'll figure out their office stuff later.'"

But once they get around to implementing technology, they're doing so in earnest, says Hoyt. And the hospitals best positioned for success with their new satellite practices are those that have made investments in a certain vendor: same for inpatient as for outpatient.

"That's positioning these hospitals to be a step ahead for bundled payments and ACOs," he says. "Those hospitals are proceeding, probably, more aggressively with having EMRs in the doctor's office because they want to be in position to take advantage of having data."

After all, "If you have vendor A in the hospital, and vendor B in all these practices you're buying  -  and sometimes also vendor B, C and D, because in the last few years you've bought a bunch of practices  -  you've got this mess of IT, you're not in a position to manage your continuity of care as well as if it was one database, the same vendor, inpatient and outpatient," says Hoyt.

So acquired doc practices generally won't have much say in the type of technology they end up using. It's generally a "benevolent dictator" model, he says. "If I want to gain economies of scale, I am not going to say to the 20 practices I bought in the past 12 months, 'Use whatever you want.' Just like if the payroll system is centralized and the general ledger is centralized, so is the practice management system and the EHR." 

And rest assured, the vast majority of those EHRs are developed by the brand-name and blue-chip vendors. If hospitals "are striving to have strong position for continuity of care and ACOs, then they really need to be the bigger vendors that have maturity around health information exchange," says Hoyt. 

And what about non-affiliated practices? Those legions of small shops and specialist offices in small communities that haven't been scooped up by hospital systems?

Those are probably still majority paper-based  -  even 55 percent of the tethered practices are, after all  -  but many of the ones that have taken the plunge and embraced IT are making use of the hundreds of small vendors purveying lightweight, software-as-a-service technology designed for cash-strapped practices.

"The small folks, the rural clinics, the adult nurse practitioners, the pediatric nurse practitioners, that's where that market is," says Hoyt. "I don't have any access to data, but their access to capital is probably more limited."

After all, "that's why the docs are selling out to the hospitals, for access to capital."

Of course, there are also significant demographic factors," he adds. "Physicians coming out of residency today, a little more than half are going into integrated delivery systems, saying, 'I wanna be a doctor, I don't want to be an entrepreneur: You run payroll and all that stuff.'"

In developing the A-EMRAM model, Hoyt says HIMSS Analytics wanted to "push the market" toward more robust adoption, just as it had with the inpatient version. They followed the same path, keeping with the concept of a capability maturity model: "As you go up the scale, it gets increasingly more stringent and you are deriving more clinical data value out of the system"  -  from initial billing processes and databases, up through automated patient intake, to e-prescribing, clinical analytics and beyond.

After consulting with physician practice CIOs and technology vendors, the steps up the ladder were carefully laid out. "We followed what we thought was a typical rollout in a multi-physician practice," he says. "We confirmed it with vendor feedback  -  not all of which was homogeneous, believe me."

Above all, the model "has to be attainable," says Hoyt.

"I do not want to bring a model to the market that people just [ignore] and say, 'Forget it, I can't do that for years.' 

"That's why we go to vendors, honestly," he adds. "I've taken questions out of the survey, when the vendor says, 'That's a great idea; we're three years away from that.' So I rip it up, and in three or five years I might put it back in."

In the meantime, ambulatory EHR adoption is seeing an upward steady climb. As of this writing not a single practice has yet to reach the exceedingly difficult to achieve pinnacle of Stage 7  -  but "I suspect I'll be in position to say we'll have some by the end of the calendar year," says Hoyt.