The secret to success for electronic health systems is not to do them halfway, says Tom Smith, CIO of Evanston Northwestern Healthcare. When ENH began its three-year, $30 million move to a fully integrated system, he says, the biggest resource was the support of the ENH board, which ensured that all 6,000-plus health care workers participate in the systems development and implementation.
“This was not the No. 1 IT project, it was the No. 1 corporate project,” Smith says. The system effectively shifts “the focus from the institution to the patient. This allows the record to follow the patient—from the physicians office to the laboratory to the hospital—rather than be scattered among various providers. It integrates computerized physician order entry [CPOE] with electronic patient records, so all charting of patients; ordering of tests, procedures and medications; registration; scheduling; and physician billing is done electronically through one system.”
ENHs three hospitals are among 41 throughout the nation that fully comply with the CPOE standards set by the Leapfrog Group, a coalition of large employers that is setting standards for health care.
Installing the System
In August 2001, ENH signed a contract with Epic Systems Corp. of Madison, Wis., for software products and implementation support, and spent the rest of that year training the IS staff and determining appropriate hardware, which currently includes some 6,000 computers, including wireless mobile stations. By January 2002, the real work of integrating began. Teams representing various health care divisions, such as the pharmacy, inpatient and emergency care departments, began meeting to map out workflows, carefully tracking what paper form went where when orders were filled or tests requested.
The teams consisted of doctors, nurses and technicians, who met regularly with IS staff members, sometimes as often as three days a week. “This required a lot of extra work,” Smith acknowledges, “but management really insisted,” and since everyone knew using the system would be required, people were motivated to help set up a system that would work for them.
After about three months of mapping workflows, IS spent another five months going back to the teams to rethink and refine the workflow analysis. In the end, says Smith, “we had about 500 major workflows, each with two or three subsets, such as weekend versus weekday procedures.”
Implementing an EMR System
The Epic system had previously been used in doctors offices, but, explains Smith, “you cant just pick up the code and move it from the office to the hospital.” His team modified features, such as screen flows, to suit doctors making rounds who might see 10 patients in a very short time. The IS team adjusted the interface and screen flows for different specialties, like sending several orders from one page or using smart templates that would be geared for, say, the routine questions that a doctor making rounds in an obstetrics ward might ask.
Before going live in each hospital, ENH spent about a week testing the system at each site. These checks relied on walk-through tests of the system, in which workers would go through routines such as admitting patients, and ordering and receiving lab tests.
The initial intention, says Smith, was to roll out the system all at once at the first hospital, under the assumption that a doctor should never have to look at two places for information. But the documentation part of the system was ready before the pharmacy part, so ENH rolled out those functions first and found that it seemed to help less tech-savvy doctors adjust to the system. So ENH used that sequence when the two other hospitals went live too. The three hospitals, Glenbrook, Evanston and Highland Park, went live in 2003 in March, July and December, respectively.
Once the system was ready, staff training and participation were mandatory. To get an ID and password for the system, staff members had to pass a proficiency test. “The professional staff passed a rule that said, if you dont have an ID, you cant treat patients,” recalls Smith.
The biggest surprise in designing the system, Smith says, was having to make sure there was a way to include every procedure a patient might need. These include services provided by “lots of small, ancillary departments that might only meet as a clinic once a week, or only see three or four patients a month.” Some of these were overlooked in the initial workflow analysis, requiring the IS staff to scurry somewhat to build them in.
Reaping the Benefits
Smith says one of the most dramatic improvements was the reduction in the time it took to get pills to patients. Under the new system, the time it took to get the first antibiotic to a patient dropped from 160 minutes to 80 minutes. Before the system, physicians requesting pills might send requests by messengers or pneumatic tubes. Pharmacy staff would get the request and enter it into a system, and overwork might delay requests. Under the current system, Smith says, requests are submitted automatically. The turnaround time for test results has also dropped from as much as three weeks for a mammogram to one day.
Another difference is the ease in locating patients charts. In a paper-based system, he says, a chart could be in dozens of places. For example, a chart could be with a patient in an X-ray facility, with a nurse in a patients room, or with another doctor in a reading room. Now, Smith says, “the charts are available anywhere, anytime.”
But perhaps the greatest benefit will come from being able to manage what Smith calls “patterns of care.” He described an incident in which the recommended dose of a drug was reduced, and the system was quickly modified so that the prescription template in the system suggested the new dose, along with an alert to the doctors that the system had been changed to reflect the new recommendation. “That kind of thing is real hard to do in a paper world,” Smith says, noting that the usual procedure would be to put up fliers and make announcements at monthly meetings.
Plus, there are cost savings for physician dictation, better co-pay collection, rising reimbursements and falling insurance claim denials. ENH estimates the system will save $10 million a year.
Implementing an EMR System
Looking Back and Forward
Smith says that before implementing the program his team studied systems at other health care facilities, particularly Brigham and Womens Hospital in Boston. Staff also looked at the systems for MetroHealth System in Cleveland and the Geisinger Health System in Danville, Pa.
Though Smith didnt want to mention negative role models by name, he described one expensive system that had been yanked after only five months. The main problem with that, he feels, is that it was implemented as a voluntary pilot program, so too few staff began using it.
Smith says that the biggest reason the system is working is that management made it a priority. For example, management delayed construction projects that might have interfered with the rollout of the system.
While his IS staff is excellent, he says, they could not have installed the system without a clear commitment from management. “Hospitals cant simply look at a project of this scope and magnitude as another software installation.”