Every day at University of Illinois at Chicago Medical Center, more than 1,600 caregivers sign onto a computerized medical record and open electronic charts. No more looking for bulky manila folders. No more calling around for the results of a test. No more elusive clipboards to document medications ordered and given.
That goes for physicians, too. About 85% of the medical center's 715 affiliated doctors use the system. More than half the 15,000 medical orders placed on a given day are entered by physicians themselves. The percentage of medication orders entered by doctors is much higher-95% of the 2,000 drug orders placed daily.
They do it at 3,000 computer stations scattered throughout the medical center's 450-bed hospital, 245,000-square-foot outpatient center and eight satellite clinics, generating 7,000 sign-ons per day. Nearly a half-million charts were opened in a recent month.
That's progress, says John DeNardo, the hospital's executive director, but he's not satisfied yet. Physicians and nurses can't always get on the system whenever and wherever they want, and the institution has to do better at making the information travel with the caregiver, he says. "People should not have to return to the (computer) station to get their job done." The medical center has completed work on a wireless network infrastructure and plans to roll out laptop computers on carts this summer.
The computer system's response time has improved, from as long as 40 seconds for a sign-on in late 1999 to less than 20 seconds now, but it has to get better, DeNardo says. That's a major aim of an $850,000 investment in additional computer hardware and software to go with the $10.3 million already spent on the conversion to electronic records since 1997.
These are the problems of a provider network that already has embraced automation of the clinical information process, says Thomas Handler, M.D., a specialist in issues surrounding successful computerization in care delivery.
"They've gone over that first hurdle and they're working on getting over the next hurdle, which is doing a lot more with the system," says Handler, a research director with the healthcare group of Gartner, an information technology research and advisory organization.
It'll be the fun part, says Joy Keeler, the medical center's chief information officer. Now that the framework is finished and clinicians are using the patient-care system, known as Gemini, UIC Medical Center is positioned to catch adverse events and incrementally supply more and more of the means to prevent medical errors in normal daily operations, she says.
"We're not just giving (information) to the clerk, but to the person who can do something right away," Keeler says. "The hard work is putting that foundation in place, getting it accepted."
Implementing clinical information systems is a complex technological task, but acceptance by physicians is the tougher issue, says Handler, who visited the medical center last February. "It was amazing to watch a second-year resident typing in a discharge summary," he recalls. "That goes against all you hear about doctors."
To get beyond issues of technology, the pluses of using the computer system no doubt were communicated effectively in the rollout strategy employed by Keeler and other planners, Handler says. "She's done the implementation right. Whatever she did, she's gotten most of the doctors on board."
And the implications for medical-error prevention are substantial, he adds. "Clearly by getting access to the data, you've hit a tremendous safety issue."
Safety as part of the routine
DeNardo, a pharmacist by training, has a special appreciation for the dangers lurking on the clinical side of healthcare management. As a hospital pharmacy manager, he remembers handling up to a thousand prescriptions per day manually and trying to stay on top of the interactions involved. Doctors as well as pharmacists needed to know important details about those medications and monitor their effects on patients.
Without the surefire backup of a well-programmed computer, "the degree of monitoring that you got was totally dependent on the knowledge base of the individual practitioner," he says.
Since then the professional responsibilities have grown. "What you need to know today about therapeutics is increasing," DeNardo says.
The clinical information system at UIC Medical Center is organized to present all the data on a patient at once-both in a doctor's office and in the hospital-and it checks for common drug interactions as well as dangers presented by documented allergies of individual patients. The computer won't allow incomplete orders, which, combined with access to previous information, increases the prospects for appropriate medication decisions, Handler says.
"No doubt that what this system has to do for us is the basic safety function," says DeNardo. Whether that means checking for major drug interactions, making lab tests available immediately or using bar codes to match drugs with patients, "every opportunity for error we can eliminate or minimize is incumbent on us to do," he says.
The information access and organizational ability supplied by the clinical system also is transforming the work of nurses, and the hospital already is seeing a difference in the recruitment and retention of caregivers and other clinical professionals.
A year ago, the hospital had 70 nurse vacancies. As of last month the vacancy tally was down to 20, and most of them were in the intensive-care unit, one of the toughest positions to fill, DeNardo says. The nurse vacancy rate is now 4%.
The problem of healthcare personnel shortages isn't going to end anytime soon, he says, and institutions must invest in computer systems that lighten the load of workers. "Anything we can have the computer do that the professional or technical person does not have to do is a good thing," DeNardo says.
When charts are always there
On the nursing floors, the conversion to computerized documentation avoids a lot of wasted time, says Roseanne McBride, nurse manager of a "stepdown" unit for inpatients who often need to be monitored for vital signs and heart conditions. Delays and lack of coordination were once unavoidable, she says.
Charting caused miscommunication and confusion: A doctor entered orders and observations on a blue chart, while nurses charted on a separate clipboard. "I don't know what he wrote, he doesn't know what I wrote," McBride says. Nurses sometimes had only half the information and couldn't give family members updates.
If a patient went to radiology or another area of the hospital, the chart often went along but didn't return with the patient to the unit. That required a nurse to backtrack through every department the patient was in, she says.
The unit had to keep alert for test results such as electrocardiograms and echocardiograms, but they often were delayed. "I could wait three days to get an echo report," she says.
Not with computerization. "There's no delay, no lag time anymore," McBride says. Nurses also can routinely use the electronic record to call up previous test results, such as an old EKG, and compare it with the current test.
The availability of charts has ended a money drain once caused by missing charts. The hospital can't bill for services without the clinical documentation for charges, and McBride often was presented with lists of missing charts representing millions of dollars lost each year unless the charts were found.
McBride remembers one patient who stayed in the hospital for eight months, but the chart turned up missing when it came time to tally up the charges. The hospital could not bill for a dime of it.
She also has stories of doctors hiding charts under mattresses because they didn't have time to finish them but did not want to have the chart taken away. Then the doctor just forgot about it, she says.
Pulling the doctors in
The nursing staff initially was not well-prepared for the conversion to electronic charting, mainly because the chief nursing officer was not going along with the change and had not made plans to train a majority of the 1,000 nurses as of 60 days before the inpatient launch, Keeler says.
The administration replaced the nurse executive with an interim chief nurse who "engaged immediately" to train the staff and take the nursing routine paperless, Keeler says.
By that time, physicians already were using electronic records in their outpatient work, and the expansion to inpatient computerization just took it up a notch, she says.
Doctors still write orders on paper in the outpatient setting, but most of them now retrieve test results and post progress notes online in their offices, says Patrick Tranmer, M.D., medical director of a family practice clinic at UIC Medical Center's 3-year-old outpatient facility.
UIC's strategy was not to force doctors but rather to attract them through rapid development of valuable access to information. The decision to start in the outpatient venue, where incomplete paper-based records and unreliable communication with the hospital were the norm, helped Tranmer see the benefit of participating. "It didn't take that much enticing," he says.
For one thing, "it was always a problem getting information back from specialists about what they did with the patient and what their recommendations were," he says. Prior to the move to the new outpatient center, which opened in August 1997, clinics were scattered around the medical center's neighborhood. Hospital charts were often unavailable, and medical assistants had to call for lab and radiology results.
The medical assistants were the first to get the hang of calling results available by computer and printing them if the paper reports did not come back from the lab or radiology departments. When doctors saw that, they wanted to do it too, and they asked for a log-on identification.
"People got used to the idea that there was this computerized patient record, and they could get online and retrieve results," he says.
Tranmer applied his own pressure to the 14 providers and contingent of residents practicing at the family clinic, some of whom were current with training while others were "laggards," he says. As the move-in date approached, he told them that if they wanted a job in the new building, they had better learn the system before then.
Not all clinics are as far along in using the system, and a few specialties still have many physicians who enter their notes on paper instead of online, Tranmer says. But the benefits of communication and patient care are such that when the time comes to refer patients, "I will select a specialist for a referral that uses Gemini," he says.
The family practitioner doesn't come right out and tell specialists that it's a factor in the decision. "I don't think they're aware of that," Tranmer adds.
Well, they are now.
