When Evanston Northwestern Healthcare committed to electronic medical records back in 2001, its leaders had trouble finding success stories to inspire them. Many of their peers had cobbled together a few of the basics— computerized provider order entry, or a homegrown documentation system, or online results review, or a digital picture archiving and communications system. But none had rolled out a fully integrated, commercially viable EMR across both inpatient and outpatient settings. Even the IT mavens at the time were saying that implementing such a system at most hospitals would take a minimum of three to five years.

Still, the three-hospital system in Illinois forged ahead with an ambitious but risky plan: To roll out a fully integrated EMR in its three hospitals and 68 physician offices within a year from a vendor that hadn’t yet embarked on such a broad project and didn’t even have all the components that ENH needed.

“We wanted to avoid some of the behavioral questioning that comes from such a transformational project—things like, ‘Is this real or is this going away?’ ” says Mark R. Neaman, ENH’s president and CEO. “We wanted to make sure people knew that we were absolutely focused on this and ready for it, because there was no turning back. So we really forced the speedy implementation.”

“Transformation” is a word that Neaman and CIO Thomas W. Smith use frequently when talking about the EMR. “We were trying to transform all of our processes to take out steps and handoffs and errors, improve our care, improve our work environment and improve our overall economics,” Neaman says. “That called for more than just plugging in a new software package; it was more about how we do things at the very core.”

Building the Case

One of Neaman and Smith’s most important early tasks was to convince the ENH board that electronic records were worth the staggering $42 million initial investment.

“It was a big investment, and there certainly was risk involved,” says Harry Kraemer, vice chairman of ENH’s board and former CEO of Baxter International. “But Mark and his team explained how the electronic medical record could have a significant impact not only here in the northern suburbs of Chicago, but also nationwide, by improving quality levels and reducing errors.”

Building the case with physicians—63 percent of whom are independent—would prove more challenging. Fortunately, ENH had taken some important intermediary steps in 1999, when it rolled out both PACS and a chart imaging product.

	Vital Statistics
	Evanston (Ill.) Northwestern Healthcare President and CEO: Mark R. Neaman CIO: Thomas W. Smith Number of Beds: 750 Number of Employees: 7,347 Number of IT Employees: 205 IT Operating Budget as a Percentage of Total Operating Budget: 3.6% IT Capital Budget as a Percentage of Total Capital Budget: 15%

“The physicians had to use that product to discharge the patient and complete their records,” CIO Smith says. “It was very simple—it took about 10 minutes to train them on it—but it was the first time many of them ever had to sign on, get a password, that type of stuff. So that was a good first step, just getting our doctors used to using computers at all.”

PACS may have had a bigger impact in terms of physician acceptance. “It was no longer a huge leap to say, ‘If we’re going to take away all of the films and put them on the computer, then we can remove the physical charts, too,’ ” Smith says. “That helped us build confidence to take on electronic medical records.”

When it was time to select the EMR vendor, physician-friendly functionality was at the top of ENH’s priority list. “The physician had to be front and center and deeply involved in making electronic medical records work,” Neaman says. “We found that Epic was very successful in the physician space. They’d already been quite successful at large physician practices like the Cleveland Clinic and the Palo Alto Clinic. If it worked with physicians, we thought our chance for success over the whole enterprise was greater.”

But there were two big problems: Epic had never done a full-scale rollout in an inpatient setting, and its system was missing some components, including pharmacy and emergency department systems, that ENH needed.

“We took a risk—we liked what Epic could do for physicians, but it was not a proven product in the hospital setting,” Neaman says. “They were missing a couple of key subsystems that would make all of this work, but the basics were there for the rest of it. And they were also looking for someplace to give them a trial.” The vendor quickly finished building those “missing” systems, and the product was ready for the first physician office rollout in January 2003.

In the meantime, ENH focused on process improvement and workflow. “We initially did 500 workflows, with groups of up to 30 people in the room at one time—IT people, physicians, nurses, secretaries, clerks, technicians,” Smith says. “These teams took on things ranging from ‘How do we give medication?’ to ‘How do we take a phone message from a patient and give it to the doctor, since we’re not writing those down on paper anymore?’ ”

Since reengineering those initial 500 workflows, ENH has expanded to about 2,000 workflows. Each one has involved a similarly large and diverse team of clinicians and support staff.

“Those workflows were a very important part of the user input,” Smith says. “I think they made everyone here feel that it was ‘their’ system, not just a system that the administration purchased and installed.”

While physicians’ role in the planning process was necessary for earning their buy-in, it was not totally sufficient. “We could have taken the high road and said, ‘It’s not about you, it’s about the patient,’ but that doesn’t give physicians a reason that involves them,” says Arnold Wagner Jr., M.D., an independently practicing OB/GYN and current medical adviser to ENH’s Medical Informatics Committee who was president of the medical staff during the EMR implementation.

Getting doctors on board required Wagner and his fellow physician champions to talk about not only the EMR’s medical benefits, but also about factors like time saved and duplicate efforts avoided. “Every chance we got, in every platform available, we sang the advantages of how an EMR could help the practice of medicine,” Wagner says. “Doctors want to know, ‘What’s in it for me? This is such a huge behavior change, why should I do anything different?’ Taking the high road and focusing only on the patient wouldn’t have worked too well with the physicians.”

With Wagner—a self-described techie—and several of the department chairmen on board, ENH’s physician leaders passed a rule that physicians would have to use the EMR to see patients at ENH hospitals. No paper, no exceptions.

“You couldn’t just ask a nurse to do this for you, or write the information down on a piece of paper and deal with it later,” Smith says. “When our physician leadership passed that rule, we took a big step forward.”

To move from file folders to a computer-based system almost overnight required quite a bit of preparation. Each physician had to complete 16 hours of training and pass a proficiency test with a minimum score of 85 percent. Designated super-users walked the floors during each rollout, and heavily staffed “command centers” helped each facility through the transition. The first physician offices started using the EMR in January 2003, and Glenbrook Hospital followed in March.

Later in 2003, ENH realized that it wouldn’t be able to finish its rollout within the planned yearlong time frame, so it adjusted its timetable to 15 months. “But that was not a disappointment in any way, shape or form,” Neaman says. “The original one-year time frame was such a big and aspirational goal that it helped build enthusiasm in the early stages. Even though we had to back off a bit, 15 months compared to a three-year or five-year time frame was a distinct win in an awful lot of ways.”

Proven Value

With the EMR system in place, ENH saw rapid gains in several areas. Through a combination of electronic ordering and bar coding for medication administration, medication errors dropped by 80 percent. MRSA infections were reduced by 70 percent, as the EMR red-flagged at-risk patients and recommended them for a genetic test. For patients who needed antibiotics, the time from their first encounter to drug administration was reduced by 50 percent to 80 minutes.

These gains, and others like them, have led to quality and safety improvements for patients, while providing ease of use and greater efficiency among physicians. Those benefits might have been enough to justify the investment, but financial factors proved the case conclusively.

“Off a $42 million initial investment, we’ve seen $17 million per year in savings,” Neaman says. After factoring in the cost of capital, the system has proven its worth. “We’ve seen a small but positive financial return from the EMR,” Neaman says.

Those returns mainly come from two sources. “We’ve eliminated all of the things such as medication errors that complicate care and cost you money in the long run,” Neaman says. “And we’ve also seen improvement in payment cycles because of the improved quality of documentation.”

A third factor, harder to quantify at this point but just as real, is growth. Neaman and Smith noted that about 2 percent of independent physicians initially stopped referring patients to ENH after electronic records were implemented, but referrals from new physicians who wanted to work with EMRs more than made up the difference.

Physicians aren’t the only ones responsible for growth; patients are demanding electronic services. “Patients already expect seamless and instantaneous information transfer between providers,” Wagner says. “It’s going slowly now, but I think if we were having this discussion 20 years from now, EMRs will be taken for granted.”

That type of demand is already driving service improvements at ENH. Nearly 40 percent of appointments in ENH’s physician practices are made on a same-day basis, a number that was unthinkable in the paper era.

“Doctors and patients don’t want to start fresh with somebody new repeating all their history for a very short visit,” Smith says. “We’re now seeing patients who might not have gone to the doctor at all, or would have gone through an inappropriate and expensive setting in the ED, or gone to a drugstore’s walk-in clinic. This capability is helping our doctors compete.”

Data’s Potential

So ENH, which initially didn’t have many role models to look up to in the EMR world, has become a role model itself. The system has had more than 70 site visits, including 55 from potential Epic customers. Most of the other teaching hospitals in the Chicago area have followed the organization’s lead and started to roll out EMRs of their own.

With four years of hindsight, strong physician acceptance, documented quality improvements and a positive financial return, ENH can call its daring electronic record conversion a success. But Neaman and Smith are quick to shift focus from past accomplishments to their future goals for the EMR.

Two years ago, ENH began building a database, largely supported by the EMR, to measure clinical and financial outcomes in a way that’s much more robust and detailed than current CMS-based reporting requirements.

“We really need to focus on the best practice of evidence-based medicine, and to do that you’ve got to have the data, not just people’s assumptions of what works,” Neaman says. “With that database, I think we’re going to make better decisions both clinically and from a business perspective.”

ENH’s database is already measuring outcomes and documenting care paths for six chronic diseases, including congestive heart failure and diabetes. Smith and Neaman estimate that the database will take another year to be complete and fully functional for clinical and financial measurements across all disease states.

The database will add to the organization’s competitive advantage—but ENH’s plans extend far beyond competition. “There is a unique opportunity, as more and more people get data like we have, to combine it and compare it to make better decisions about the care we give patients,” Smith says.

Such a large-scale comparative outcomes database might be years away, but ENH plans to be ready when medicine finally “catches up” to other industries.

“We’re convinced, from a technological standpoint, that the technological gurus can build this kind of database that goes beyond your four walls of care pretty readily,” Neaman says. “We’re held back a bit right now because only about 5 percent of U.S. hospitals currently have an electronic medical record. But we’re going to keep going forward, because we still think it’s the right dream and the right aspiration.”

Chris Serb is a freelance writer in Chicago.

This article first appeared in the Summer issue of HHN's Most Wired Magazine.

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