When Merck Pharmaceuticals pulled anti-arthritis drug Vioxx from the shelves on Sept. 30, 2004, Evanston (Ill.) Northwestern Healthcare determined that it had
about 2,700 patients on the drug and notified their doctors, who then called the patients with a substitute prescription.
The three-hospital system with 65 medical
offices did this “within minutes and hours, as
opposed to days and weeks,” by using its integrated
electronic health-records system, driven
by computerized physician-order entry, says
Tom Smith, chief information officer. “It’s
almost impossible to do that on a manual
basis,” Smith says. “It would have taken many
people in a (conference) room like this, stacking
up charts and going through them.”
“There would have been no way to get to
everybody,” adds Nancy Semerdjian, senior
vice president of medical informatics. “You
would have relied on your patient hearing
that information.”
Approved in 2001 and implemented in
2003, the Epic brand system produces electronic
charts retrievable anywhere, anytime
and is helping ENH build a longitudinal database
of patient information that will be increasingly
useful for both medical and marketing
research. A companion system called ENH
First gives patients access to their information,
enabling doctors to electronically transmit test
results and for especially savvy patients to
schedule appointments.
The Epic system, which cost $25 million for
hardware, software, training, new staff and
other resources, has eliminated both errors
attributable to lost or mislaid charts and delays
while charts were pulled or tracked down elsewhere—
and it has saved more than $12 million
thus far, according to ENH.
The effort stemmed in part from the 1999
Institute of Medicine report, To Err Is Human,
which showed roughly half of medical errors
occurred because of problems on the front end,
says Mark Neaman, president and chief executive
officer of ENH. Neaman’s vision in conceiving
the system and leadership in championing
it have earned him a 2005 CEO IT
Achievement Award, co-sponsored by Modern
Healthcare and the Healthcare Information and
Management Systems Society.
Examples of errors included illegible handwriting,
inability to find information and misunderstood
abbreviations, “all kinds of things
that were pretty solvable with an electronic
record,” Neaman says. Physicians enter orders
electronically, and “Those orders are then
shipped electronically to the places where they
need to go, whether that’s pharmacy, or radiology
or the labs.” Doctors receive information
back electronically, and in “areas like lab or
radiology, even the images are tied,” he says.
Semerdjian, formerly a nurse, remembers
the vagaries of manual procedures. “Before I
could get to the chart, usually, the unit secretary
had picked it up, and he or she would then
interpret the order, and send it down to the
pharmacist or lab, and they would interpret
the order. And again, we’re relying on somebody’s
reading of that handwriting: Was that a
dot on the paper or was that 2.5 or was that
really 25 milligrams?”
Doctors praise the new system. “The biggest
benefit is timely access to complete, accurate
information whenever and wherever you need
it,” says Ned Wagner, chairman of ENH’s medical
informatics committee. “To steal a Bill
Gates phrase, this is medicine ‘at the speed of
thought, not the speed of paper.’ ”
“I live in it,” says David Lerner, an internist.
“I’m in Epic all day—when I’m in an exam
room, when I’m making rounds at the hospital.
Everything’s available immediately. When the
test results come back, it’s immediately in the
chart. I don’t have to go digging for that chart.”
Among the keys to winning physician support
for Epic were providing at least 16 hours of
training and requiring doctors to use Epic if
they wanted to continue to practice with ENH,
and the foresight to involve staff in designing it.
“What we were really looking at was to provide
the leadership to transform the way we
practice medicine, and to change the human
behavior of all 2,000 of our physicians and all
7,000 of our employees,” Neaman says. “This
project is not an IT project. For sure, (the)
information systems (department) is absolutely
essential.”
Neaman shared his vision during twice
yearly addresses, quarterly professional staff
meetings, unit staff meetings and newemployee
orientations. He brought in team
leaders from each of ENH’s seven operational
areas to help design the system. During those
sessions, Semerdjian says Neaman clearly
defined the goals and communicated the
urgency, then gave staff needed latitude.
“In other words, ‘Here’s where we’re going to
go: the distance between here and there is yours,’
” she says. “We had nurses involved, physicians
involved, and not just managers. We had people
who take care of patients every day. We had
people that draw blood every day, people that
perform X-rays every day, people that would be
truly using it. … It was a mandate from our
CEO. None of us had any competing priorities.”
Wagner echoes her last comment. “This was
the project of the hospital for the last three
years,” he says. “He took a tremendous risk in
committing the institution to taking this very
large step. He sold it to the board of directors.
He got the participation of the leadership of the
hospital. And he stood up to his word.”
The combination of the system’s benefits
and Neaman’s focus on IT impressed the
judges for this year’s CEO IT Achievement
Award. “It is wonderful to see a visionary
leader such as Mark Neaman walk the talk and
move Evanston Northwestern to a paperless
electronic health-record system,” says Patricia
Skarulis, vice president and CIO of Memorial
Sloan-Kettering Cancer Center, New York.
“He set the vision, created a supportive environment
and then held the entire organization
to firm delivery dates.”
G. Richard Hastings, president and CEO of
St. Luke’s Health System, Kansas City, Mo.,
says other applicants had done some of what
ENH has accomplished but not all. “Most of
the others had done some components of it,
but not as extensively,” he says. “There was a
demonstration he (Neaman) is not only a convert
to the information technology world, but
that he is a communicator of it as well.”
Critical to the system’s success was the recognition
that work-process analysis needed to precede
infrastructure change, Smith says. “We
didn’t just buy a product and turn it over to IS
to build and start installing. We asked the users
to tell us how they wanted to use it,” he says.
“That did a couple of things: One, it gave us
some good ideas about how to install the system,
but it also made the users feel very much
part of it. We could have stopped after the
workflow analysis and made many improvements
just because of that.”
“We didn’t want to pave over the cow path,”
Neaman says. “We want to make sure that our
manual processes were the best they could be.”
Neaman’s leadership in creating the medical
informatics department helped spur the process
that led to workflow improvements, Semerdjian
says. “What I see medical informatics being is
that bridge between the technical side of things
and the clinical side,” she says.
ENH galloped forward with implementation
in about a year’s time, Neaman says. “We
wanted to go quickly in that we didn’t want to
have to run two systems in parallel,” he says.
“And we didn’t want, culturally, people to put
off in their minds that, ‘It’s OK for somebody
else to do it, but I’m not going to have to do it
for three years now. I’ll worry about it then.’ ”
To hard-wire hospital leaders to the implementation,
Neaman tied incentive pay for more
than 30 executives to the system’s success and
made it the top agenda item at every board
meeting. To build physician support, Neaman
tapped a few leaders and spread the word further
through demonstration sessions.
Although he would not describe gaining their
blessing as “easy,” Neaman says most doctors
realized early on that “this is the right thing to
do.” He adds, “Having crossed that hurdle, the
next question that you had to address was, ‘Can
you do it? Is the technology there? And will you
provide the training to make it work?’ ”
All but “a relative handful” of physicians
were sold upon seeing how Epic could improve
their practices, Neaman says. “It dramatically
undermined our ability to negotiate with Epic,
because these people kept coming back and saying,
‘Wow!’ ” he says with a laugh. “I think the
success of it today is, if you went to the physicians
and said, ‘We’re going to take the Epic system
out,’ you would not live to talk about it.”
“The people who made noise about ‘taking
my patients elsewhere because it’s too hard to
do this’ have come back,” Wagner says. Neaman’s
“contribution was standing up and taking
a huge amount of risk and committing the
organization to getting it done.”
Adds Lerner, “We did some salesmanship, a
lot of demonstrations, (and) for the ones that
were just nervous about it, we did a lot of handholding
and showed them it wasn’t going to bite
them. We never forced it down their throats,
but they knew they were going to have to do it.
This was not optional.”
