Off the Charts: Electronic Records at Medical Center

Doctors at the University of Illinois Medical Center in Chicago used to hide patients’ medical charts under hospital beds. Better that than let a precious chart descend to the bureaucratic black hole known as the medical records storage department. Let the chart go and a doctor might never see it again. So the doctors would hide it until they were done with it. "We called it hoarding records," says Dr. Bill Galanter, who used to hide his patients’ records in his office rather than under their beds for fear the mattresses would get changed.

Now those records are electronic and accessible from anywhere in the hospital or the Internet. Hard copies don’t exist anymore. When the medical center built its new outpatient center in 1997, it did not include a records storage room. "We burned the bridge. No paper," says Joy Keeler, the IS leader of the medical records conversion, drawing out those last two words while boring a friendly hole in your forehead with her intense brown eyes.

Keeler is a born campaigner, a small, thin wisp who burns very brightly. For five years she has been pounding the halls of the motley scattering of old and new buildings that compose the medical center, trying to convince doctors to change the way they practice medicine. If that sounds like a grandiose goal, it’s because she had no choice. She could not do her job without first changing how doctors did theirs. Change management is important to any system implementation, but it’s everything in a hospital. There is no value to an electronic medical record if doctors don’t use it. It is an all-or-nothing proposition.

The University of Illinois Medical Center won an Enterprise Value Award because of a brilliantly executed change management strategy, through which it managed to get the toughest users on the planet to lift their heads up long enough from the work of saving lives to change the way they deliver care to patients. Most believe they can do their work better and more cost-effectively than they did before the system. Computer system value doesn’t get much better than that.

A Big-Bang Implementation

Change is hard. Despite their complaints about paper medical records, doctors really don’t want to give them up. Only 4 percent to 15 percent of hospitals nationwide have electronic medical records today, according to various industry estimates. It’s still faster to scribble a note than it is to sit at a computer and enter data.

Speed is an obsession with doctors because they see between 16 and 30 patients a day. "I have a maximum of 20 minutes to do everything when I see a patient," says Dr. Patrick Tranmer, head of the Department of Family Medicine at the medical center. "I have to find out what’s wrong, get their history, do a physical exam, make a phone call, write a prescription, instruct the patient, make a follow-up appointment and then educate a student doctor about what I’ve just done."

Seconds matter when you’re in that 20-minute zone, says Tranmer, who stares impatiently at his notebook computer while waiting for Gemini, as the medical center’s assemblage of applications is known, to come up on his screen. Ten seconds pass. He pushes the computer away. "It’s slow today," he says.

Gemini was balky because a chip inside one of the Compaq Alpha computers that runs the system burned up the day before, bringing down the entire system. Ironically, it had been so long since the last outage that the doctors forgot how to access the read-only backup database that Keeler had built for such emergencies. Angry calls streamed into IS. One doctor demanded, "Do you want me to waste time asking my patients about their medical histories?" That’s how valuable the electronic records have become to the doctors?many think they can’t do their job adequately without them.

The doctors’ characteristic impatience explains why Keeler chose a big-bang implementation?the riskiest possible strategy. There would be no pilots. The system went online in two big gulps: the outpatient clinics in early 1999 and the inpatient hospital later that year. Rollouts to selected groups would have collapsed at the intersection of the paper and electronic records, says Tranmer. "Doctors would have said, Now this is twice as hard. Forget it." Worse, he says, they would have rejected the electronic system because the old way was more familiar.

Getting those impatient people to accept a new system required extraordinary patience at the highest administrative levels. When a financial crisis hit the hospital in 1998, outside consultants recommended outsourcing IT and with it the Gemini project, which had begun in 1996. But in 1999, Dr. Charles Rice arrived. Rice, the vice chancellor for health affairs, moved Keeler’s IT group from operations into his administrative department to subsume the IT budget and take outsourcing off the table.

"This is an educational institution," says Rice. "Part of our job is to educate the next generation of medical workers. I don’t know how you do that with an [outsourcer]." During those difficult days, Rice insists that the board never questioned the investment in the electronic medical record project?which is now at $11.2 million and counting, with a $1 million annual maintenance budget.

Keeler is certain the project would have foundered without such support. "First and foremost this has to be the strategy of the organization," she says. "This isn’t a project; this is a culture change. Transformation has to be the goal of the organization?not just of the chief medical officer or the CIO."

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