Not long ago, medical residents like Peter Joo, M.D., literally had to retrace their patients' steps before commencing a care plan at the University of Illinois at Chicago Medical Center.
The medical record wasn't likely to be current, especially if tests or other clinician encounters took place earlier in the day.
Consequently, Joo often trekked to where a patient had just been to get a handle on what was done and what to do next. Meanwhile patients simply had to wait. It was part of a daily productivity drain caused by elusive paper records and spotty reporting.
Those days are gone, officials of the Chicago medical center assert. A powerful computer engine recently cranked up is making clinical data current and available throughout the 450-bed teaching hospital on the city's near west side.
The electronic record system, dubbed the Gemini Project, also serves the center's extensive outpatient facilities as well as eight primary-care clinics as close as a mile away in the West Loop and as far away as 20 miles northwest in suburban Arlington Heights.
The clinical engine, which started slowly in late 1997 but shifted into overdrive last November, is used daily by 1,500 physicians, nurses and other clinical workers. More than 400,000 electronic charts were opened during March, when the system logged a daily average of 6,200 sign-ins.
UIC Medical Center, which once paid scant attention to information systems potential, has sunk $8 million into the clinical project to reap better coordination of care and economies of scale in so-called integrated delivery systems.
The clinical integration initiative, in conjunction with Cerner Corp. of Kansas City, Mo., now costs about $925,000 a year to operate and maintain, and more capabilities are being added one by one.
Although implementation is still in progress, doctors and nurses already are reporting significantly increased efficiencies in their daily caregiving routines.
Among other things, the little detours to track earlier patient encounters or grab a paper record are no longer necessary, according to physicians and managers. "I save 30 minutes a day not looking for charts," said Joo, a third-year resident in pediatrics.
Everything in its place. For the university healthcare system, which had to hire a turnaround specialist last year to bring expenses under control (See chart, p. 48), computerized recordkeeping is bringing order to what officials concede was once a textbook example of inefficiency.
"We need to eliminate paper as a medium for how we record our information with patients, however and wherever we can," said Charles Rice, M.D., vice chancellor in charge of the medical center's direction.
In incubation more than two years, the medical-record system hasn't yet produced proof of direct savings, such as reductions in payroll. But Rice said that's not the top priority.
"I am less interested in trying to reduce the number of personnel than I am in trying to help the personnel we have work smarter," he said.
For many healthcare organizations, working smarter has translated to working faster--stepping up the pressure to get more done in less time, including increasing the number of patients a physician sees each day.
But experience with a computer record is demonstrating that access to complete diagnostic and medication histories is not always the key to packing extra visits into a workday. In fact, some doctors on staff at UIC Medical Center say the improved information flow is lengthening patient visits instead of shortening them, although for reasons that bode well for quality of care.
"It's more time-consuming to take care of patients, because we have the ability to know all we can about our patients," said Bill Galanter, M.D., an internist at the medical center. "I'm now responsible for things I was never able to find out before."
In an acute-care situation, however, those details have helped speed up care that often was delayed until someone could track down the patient's primary physician and be informed about the case, Joo said.
Nowadays, "When someone gets admitted at 11 at night, you can read what his doctor said about him a week earlier," said Galanter.
Besides enabling "a big jump on care" of an acute condition, Joo said, the comprehensive records also make the hospital aware of co-existing problems that need prompt attention, such as chronic ills requiring medication. "It's made a huge difference in continuity of care," he said.
The paper burden. Two years ago only a few hundred clinicians were testing a handful of features in a medical information system still in the embryonic stage.
Developed by Cerner, a healthcare information services company, the system was organized around tracking patients wherever they get care instead of supporting encounters within the walls of a single location.
In a departure from the usual approach of computerizing inpatient facilities and expanding outward, planners spread the system into outpatient and clinic locations first, gradually laying the groundwork for physician and staff acceptance, said Joy Keeler, the medical center's chief information officer.
In a gamble that the system would eventually demonstrate its worth, and despite a hefty capital investment, medical center officials made participation voluntary. Keeler said the response was likely to be positive if the system could demonstrate value and be "intuitively obvious" to use.
If value meant better than what existed, it was not difficult to demonstrate. In the mid-1990s, clinicians at the medical center coped with paper records that were often unavailable or incomplete.
"The inefficiencies were astounding," said Keeler, who previously was director of patient-care systems.
Inpatient and outpatient records were kept separate and requested individually. The 28 clinics on the medical campus each did things their own way. "There's a lot more autonomy in academia," Keeler said of the difficulty meshing departments.
Only one record was kept on each patient, but an academic facility has "a lot of contention for the chart" from researchers, residents, attending physicians and other caregivers, she said. With 400,000 ambulatory visits and 17,000 inpatient admissions a year, the tracking problem was untenable.
Among physicians, the solution to this mess was a different kind of mess: maintaining their own unofficial files on patients.
Known in medical circles as "shadow charts," the practice takes recordkeeping to a new level of redundancy and inefficiency. Besides duplicating the medical record, the charts were likely to be missing information from outpatient visits.
But "creation of these shadow files was really a necessity," Keeler said. Without them it would be impossible at times to treat a patient, she said.
The practice is common throughout the medical-care business, Rice said. "It's a work-around predicated on the assumption that some information is better than none."
Said Galanter, "We couldn't operate without shadow files before (the new clinical system was installed)."
Gemini's genesis. Compared with the computer norm in the industry even a half dozen years ago, "we weren't even in last place--we weren't in the game," said Keeler.
University leaders "did not have information technology as part of their strategic plan," she said.
About that time, a venerable clinical documentation system "was coming to the end of its useful life," said Rice, who was then the medical center's program director for surgical residencies and sat on a committee to chart a direction for information technology.
Rather than replace the mainframe computer-based system with a newer version similarly limited to inpatient operations, Rice pushed for an approach using personal computers and encompassing all venues.
No single system to do all that was available, so UIC Medical Center latched onto Cerner's plan to set up a medical record that could accept feeds of information from any vendor's system and organize data from many sources into individual patient's records.
"It was a risky decision, because a lot of what Cerner had at that time was vaporware," or software in the idea stage, Rice said.
Planners wanted to make information so available that it could be called up easily and securely by any number of people without going through a formal request for records.
Operational impact. A phase-in period added functions and made sure files were organized correctly by patient. The one-at-a-time addition of outpatient clinics made for a snail's pace in increasing authorized users--several hundred after 18 months.
But with all clinics connected and an average of 650 users per day viewing records online, the system was expanded to the medical center last November. The system consolidated inpatient and outpatient information and gave clinicians the added ability to submit physician orders as well as receive results. The number of daily users doubled in three months.
As of April, about 40% of the users were nurses. Nearly 30% were medical residents and other house staff employed by the medical center.
Keeler said the university is just beginning to study the impact on operational efficiency and clinical effectiveness, but the first reports include:
* Decreased requests for records. The medical center reported nearly 2,000 formal requests for medical records in March 1999. That number dropped to about 800 in October and 600 in December. Four full-time-equivalent medical records workers were reassigned to other duties.
* Reduced potential for medical errors. A drug-interaction computer application was tripped nearly 50,000 times in February alone, mostly to warn against combinations of drugs but also to flag the action of drugs on allergies or food.
Of the drug-to-drug interactions, most were classified as minor or moderate--for example, acetaminophen prescribed concurrently with painkiller Vicodin, which already has acetaminophen in it. But about 8,000 alerts involved major interactions.
* Better information in nursing units. Caregivers closest to seriously ill people rely heavily on information from various places. Obtaining it was once a very time-consuming task, said Amy Looi, for 16 years a registered nurse at UIC Medical Center.
"Having it online . . . gives us instant access so we can communicate with the doctors the right way," she said. "We're less frustrated, obviously, because we don't have to go through the old paper trail like we did before. And the doctors are definitely happier with us because we can give them information a lot quicker."
* Less pressure to repeat tests. In an academic center, a hierarchy of interns, residents and attending physicians can add up to serious money in duplicate testing when the original results are not at hand, said Galanter. "Nothing is more expensive to a medical center than a doctor without a piece of information she needs," he said. "She just orders it over again."
In the hospital, interns are responsible for doing much of the work and writing progress notes, while residents are charged with communicating with attending physicians and making clinical decisions, Joo said.
Those responsibilities are lightened significantly by accessible records and reports of previous tests, he said. A doctor might need to know about a heart-attack patient's cholesterol, for example. If a clinic is closed for the day, the physician is more likely to order a new test so it's there the next morning rather than stop by the clinic in the morning to check whether a test was recently done.
"Ordering (a test) is a trivial act," Galanter said. "Residents don't get in trouble the next morning if they spent $5,000 (on tests). They get in trouble if they don't have the information."
An end to patient `nonvisits.' A lack of information limits what a doctor can do. "Our job is to know everything about our patients," said Galanter. That means having the chart, reaching pharmacy for medication rosters, receiving a clinical note in time for a patient visit.
If the office didn't have the medical record and the patient wasn't forthcoming with medication details, the result was another five-minute visit, or "nonvisit," Galanter said.
Sometimes a doctor had to decide whether to proceed on an assumption or mobilize office staff to nail down a test result
If a mammogram result wasn't delivered, "I might say, `I think it went OK or the doctor would have called me.' That's an assumption--kind of unnerving without having the information in front of me."
But with all the trouble involved in tracking information down, it's easier not to get it, Galanter said.
Full disclosure of pertinent information changes the complexion of patient encounters. It puts an end to the five-minute nonvisit, and it might end up reducing the number of times a patient is seen because more is accomplished in a visit. But "it doesn't save me time per patient," he said.
"There are reasons why having information doesn't make your visit shorter. It means you have to act on it."