When looking for advice and best practices for electronic medical record deployments, it's smart to emulate those at the very top of their game.

There are just over 200 U.S. hospitals (and a handful more across Canada, Europe and Asia) that have ascended to the top of the HIMSS Analytics EMR Adoption Model. Stage 7 winners represent elite cohort – just 3.6 percent of the U.S. market – that has achieved remarkable, comprehensive use of healthcare IT.

What's the secret to their success?

"At a very high level, what they are doing right is that they are pretty much enterprise wide with a core clinical system," says HIMSS Analytics Executive Vice President John Hoyt. "In other words – and this may not sound kind – the best-of-breed organizations are not achieving Stage 7. It's the enterprise EHRs that are successful."

It's that sort of end-to-end prowess that explains why, despite its high cost and sometimes challenging rollouts, Epic is the vendor that finds most favor at large health systems looking to drive quality and efficiency from stem to stern.

Of the 200-plus Stage 7 hospitals in this country, 152 of them are Epic customers. In second and third place are Cerner (41 installations) and MEDITECH (19).

[See also: Stage 7 awards are on the upswing]

Epic is dominating the market "for a couple reasons," says Hoyt. "One is that they sell, effectively, as an enterprise solution: Physician's office and acute care. Remember, Epic has been around since the '70s in the physicians offices; they didn't start in hospitals until after 2000. So they are very, very good at getting to physicians. That's number one.

"Number two is that they are intensely – intensely – focused on Stage 7," he says.

Epic CEO Judy Faulkner "will talk about Stage 7 at their annual event," says Hoyt. "I've seen her do it: 'You owe this to the industry to get this. You owe this to your peers.' She talks to them like, 'This is your obligation.' No other organization is that focused. They put peer pressure on the client base to get this."

Increasingly, of course, even longtime holdouts are replacing their homegrown and best-of-breed systems and going with blue-chip enterprise EMRs.

"Look at the big names that have been self-developed for years and years," says Hoyt. "Intermountain: They're ripping it out and going to an enterprise solution from Cerner. Henry Ford: ripped it out and went to Epic. Partners HealthCare: ripped it out and went to Epic. BJC in St. Louis: ripping it out and going to Epic. Mayo Clinic: ripping it out, going to Epic."

On the other hand, Europe – which has just two Stage 7 hospitals, one in Germany and one in Spain – "is very, very much a best-of-breed kind of world – like we were in the '90s."

The challenge in that situation, preventing higher-climbing up the EMRAM ladder, is clinical decision support," says Hoyt: "They buy order entry from one system, they buy ICU from another, they buy physician documentation from another, they buy pharmacy from another. Getting CDS to work in that type of environment is very hard. "

HIMSS Analytics looks for some clinical decision support at Stage 3: "a little bit of duplicate orders," he says. At Stage 4, the goal is physician order entry: "Some of them have order entry without clinical decision support, so there's no artificial intelligence helping them create order sets," he adds.

"And then we expect CDS at Stage 6 because we want it firing off physician documentation – and we expect a full, robust program of it at Stage 7," says Hoyt. "That's where they're having the hardest time in these best-of-breed environments. There are so many parts and pieces to getting an effective clinical decision support program.