From health care fortress to IT showcase

Illinois' Cook County Hospital opened in the 1830s as the Poor House, providing free medical care to poor victims of a cholera epidemic. Now 175 years later, its charter remains the same: to provide quality health care regardless of a patient's ability to pay. The key difference is that the Poor House has become one the most advanced health care centers in the world.

Today, the Cook County Bureau of Health Services is a health care behemoth that includes four main hospitals, 3,582 licensed beds, 35 community health care clinics and more than 40 satellite offices of the county's Department of Public Health.

The centerpiece is the John H. Stroger Jr. Hospital, which stands out like a light box in a neighborhood of limestone hospital buildings on Chicago's West Side. The $623-million acute care facility, which opened in 2002, has helped drive service levels at the bureau to heights worthy of a war effort.

The bureau's facilities account for 1.3 million outpatient surgeries a year, 44,000 inpatient surgeries a year — one every 12 minutes — and 15,000 prescriptions filled daily.

Given such demand and a dependence on public financing, the bureau has a strategy to keep costs under control: wholesale automation of the labyrinthine workflows that have clogged the system with unnecessary expenses and medical errors since it opened its doors.

"We see [information technology] as a key way to enhance quality, improve efficiency and assure safety," said Mike Sommers, the bureau's chief information officer. "Just because a patient cannot pay, that does not mean that they deserve less."

Goodbye, walls

Sommers has led the effort to build a state-of-the-art health care delivery system at Stroger. Once a showcase for medical talent and innovation — it hosted the first blood bank and established the first medical internships in the nation — the old Cook County Hospital had become a fortress of old infrastructures, looping workflows and glacial systems upgrades.

In 1975, conditions were so bad that some doctors were jailed after trying to close the hospital in a revolt against the administration.

Today the hospital boasts a number of technology-based innovations that place it in the exclusive league of 10 percent of U.S. hospitals operating an enterprisewide electronic medical records system, Sommers said.

Now all orders at the hospital are made online. One administrative record follows a patient perpetually, regardless of where or when he or she entered the hospital's clinical network. What's more, the hospital has gone "filmless." Interns no longer have to wait in line at the radiology window to pick up patients' X-rays.

"From an electronic standpoint, our health care system has no walls — it's all one record," said Sommers, a former IBM health solutions executive who has also held IT positions at other hospitals. "If a patient is seen at one of our facilities and two weeks later comes to another facility, it doesn't make a bit of difference to the clinician because the electronic information from ... all previous encounters follows that patient."

The key to "one record" is the bureau's enterprise master person index (EMPI), a metadata system that enables one longitudinal — or continuous — electronic record to be kept for every patient, from the first time he or she enters the system and at every step thereafter.

An EMPI is a software-based registry that uses a patient's demographic information to link their medical records across multiple applications, clinical systems and providers by pointing to data rather than the records themselves.

For example, a physician at Stroger can pull up a record for a patient who has been at Cook County's Oak Forest Hospital, even though facilities maintain unique patient case numbers. The system runs on Cerner's CapStone EMPI software, a component of the company's Millennium solution.

Coffee, tea or lacto-variant kosher?

Record indexing may be invisible to clinicians, but computerized order entry is their power application.

Every time a physician orders a medication, diet, lab test or nursing instruction, it is entered into a computerized physician order entry (CPOE) system, which functions like a master index.

The bureau's Cerner CPOE system is a rare breed — less than 5 percent of U.S. hospitals operate one. The biggest reason is cost. The tab for launching the bureau's CPOE system was $25 million.

A big part of the cost is systems integration. Like all enterprise software, CPOE systems are not plug-and-play. Instead, they are sets of best practices, embedded in software, that must be tweaked to incorporate local care-giving preferences and workflows.

"It's a cookbook," said Ron Hately, a Cerner director who helped the bureau deploy the system. "I can use it to ensure I'm taking into account the experience of others who have gone through this process, and then I can tweak it to fit my own organization."

Sometimes the tweaks can be time-consuming. The original CPOE version included several dietary options, for instance.

"In terms of choices, it was excessive," said Dr. Krishna Das, Cook County Hospital's associate chairwoman for inpatient medicine. "Lacto-variant kosher? Do we need that listed? So we just edited, edited and edited, with physician input, down to about three lines. That satisfied the dietary department and the clinicians."

One of the big challenges in deploying the new system involved configuring workflows for a hospital that had not yet opened.

"While we were bringing up our base applications at the old hospital, we were also building the new facility," Hately said. "Probably the biggest challenge was when we didn't know what the workflow was. Here we were designing a workflow for a department or a nursing station that didn't even exist."

Medications account for the single largest set of orders at any hospital. Cook County's facilities fill a staggering 15,000 prescriptions a day. With that many opportunities for entering a prescription incorrectly or ordering medications that could cause an adverse reaction, the county made computerizing the system a high priority.

Now medication orders at Stroger are sent electronically to the hospital pharmacy, where robots fill the prescriptions and alert the nursing staff. By the end of the year, the bureau plans to install a bar code system capable of tracking an individual pill from the time an order is entered to the time the dose is administered to the patient.

The system will read bar codes on individual pills or small packages of pills. When the dose is administered, a nurse will scan his or her identification badges and the patient's ID bracelet, creating a timeline of the dose. Fewer than 200 hospitals in the United States have such a system, Sommers said.

When an order is entered into the Cerner system, it is also screened for the "five rights": right patient, right medication, right dose, right time and right route. The system checks for potentially adverse drug interactions and allergies. For instance, a prescription for penicillin might not be filled until a patient's allergies have been documented.

Next step: Interoperability

The Holy Grail of electronic medical records is transparency, integrating clinical information from multiple sources and making it instantly available to caregivers. The reality, however, is that specialists — whether in cardiology, obstetrics or intensive care — favor different systems that don't communicate with one another.

"To find a system that does everything that needs to be done and then feeds it back to a single computer system — that just doesn't exist," Das said. "Health care is so complex."

Consequently, hospital IT offices often must do their own systems integration. Sommers' team, for example, adapted the bureau's proprietary electrocardiogram system so clinicians could access EKG images for some of the 5,000 patients a year coming to the emergency room with chest pains.

Most of the patients had previous EKGs on file, but without the ability to analyze them and rule out heart attacks, physicians had to admit the patients to the hospital immediately.

Sommers' team built a direct interface to the Cerner system. Today, physicians can visually compare new and old EKGs via the main clinical system. Patients who are at risk for heart attacks or strokes can be admitted at once. Those who have simply a strained pectoral muscle can be sent home with an aspirin.

"That ability is fantastic, and it helps me as an inpatient clinician," Das said. "It really helps the emergency room docs who are seeing these patients when they come in."

While bureau officials look for ways to integrate patient data, they are also exploring the idea of forming a regional health information organization with other hospitals in the Chicago area to share data and thus lower costs and improve patient care.

"Cook County is very progressive in bringing their records under one system," said Johnny Walker, chief executive officer of the Patient Safety Institute, a nonprofit organization that aims to enhance health care by using information-sharing networks. "They're even more progressive in that they are reaching out to form a regional hub in Chicago."

Hospitals often see a competitive advantage in not sharing their health care information. "It takes a much greater vision to reap the economies of scale," Walker said. "Patients no longer stay within one health care organization or hospital system. Not only have they seen the need to lower the cost to taxpayers, but also to be more efficient in working with everybody who funnels them patients and vice versa."

Lessons: Good eyes, hard head

Although its program is still a work in progress, Cook County is one of the few major hospital systems in the country that is breaking ground in health care IT. Sommers attributes this innovation partly to forward-thinking executives.

"Without the executive leadership, it never would have happened," Sommers said. "To do what we did at Cook County really involves a lot of heavy lifting. If you don't have the support from the [chief executive officer] on down, you're going to get about a third of the way into it and say, 'This is too hard to work.' "

"In addition to a strong CEO, you need a stubborn CIO who doesn't know how difficult it is and is willing to take that on," Sommers added. "When we started, the statistics were that one out of three of these implementations failed. No CIO in their right mind would do it unless they had the right factors going in. I think it's getting easier, but it's still a lot of hard work. It's fundamental process improvement and culture change."

IT talent is also paramount. "It has been challenging," Das said. "You need very, very good IT people. This is something I didn't appreciate before. You need people who are very strong at the programming end of it. If we didn't have people with this level of experience, we would not been able to construct the present system we have now."

Finally, clinicians must be consulted at every stage. "This was more than an IT project," Hately said. "It touched everybody. We had to make sure we had representation across the organization. Once the end user gets their hands on the system, they can clearly make the system fail just by using it inappropriately or incorrectly. So it needs to be their system. We're just supporting their efforts."

Soft-selling the system

In bringing users onto the electronic medical records system, the Cook County Bureau of Health Services used a soft-sell approach.

First, staffers made the system view-only, so employees could experiment with it. Then they poured terabytes of live data, including charts, notes and orders, into the system.

"So when we said, 'Great. Start placing orders,' they understood they weren't using the system just so that we could replace a clerk, but so they could benefit from the information," said Mike Sommers, the bureau's chief information officer.

Most clinicians flew though training. "The previous system was not intuitive at all, and that kind of system requires a lot more training," said Dr. Krishna Das, associate chairwoman for inpatient medicine at Cook County Hospital. For the past three years she has been the department's liaison to informatics, helping refine the system by expressing clinical users' needs to the technology staff.

But training is just the first step in getting staff to adopt the system. "It has to become part of the culture so that you don't even think about seeing a patient without seeing the electronic chart," Das said.

— Paul McCloskey

What's inside

Cook County, Ill., electronic medical records system

Hardware/software:

  • IBM AIX.
  • Citrix Systems client server.
  • Oracle database.
  • Cerner electronic medical records (EMR) software.

EMR data loads:

  • 10 terabytes of data.
  • 3.5 million patients.
  • 8 million encounters.
  • About 200 million pieces of patient data.
  • About 30 million pages of scanned paper documentation.
Building 'two hospitals'

Moving several decades' worth of medical records — including paper documents, film and irregularly formatted electronic files — to John H. Stroger Jr. Hospital in Cook County, Ill., while the old Cook County Hospital was still open required some sleight of hand.

"In essence, we built two hospitals," said Mike Sommers, chief information officer of Cook County's Bureau of Health Services. "We built the old Cook County [Hospital] and we built Stroger." That meant developing workflows in an older environment for a new hospital where only diagrams existed.

Yet the switch "was really a seamless operation," Sommers said. "By the time we moved patients into Stroger, fundamentally what we did was just change each patient's record from Hospital A to Hospital B and Bed X to Bed Y."

They also added a flood of older data: five years' worth of lab results, seven years of radiology reports, two years of electrocardiogram and nearly 25 years of inpatient discharge summaries. Although most of the conversions involved decoding and converting file formats electronically, they also scanned several million documents from the emergency room, where doctors have relied on the grease pencil for generations.

Today, the electronic medical records system contains 35 million to 40 million scanned documents. The system awakened the staff to the value of newer, computerized methods. That realization has been especially notable in the emergency room, where most patients must be treated immediately without referencing medical records, even though about four out of five ER patients had been previously admitted.

"You would come in, and the clinician was flying blind," Sommers said. "Today, 85 percent of people seen in a clinic have a previous electronic record accessible in under 10 seconds, which is phenomenal in terms of enhancing patient care."

— Paul McCloskey

Decision support systems

Cook County's computerized physician order entry system has some intelligence built in. The system will even screen against a patient's metabolic factors. In the case of a physician prescribing an antibiotic that must be used only in limited doses for patients with kidney disease, the system will flag the order for any patient whose kidney function is abnormal.

Dr. Krishna Das, associate chairwoman for inpatient medicine at Illinois' Cook County Hospital, calls such clinical missteps "errors of commission." Yet officials at the county's Bureau of Health Services envision an even smarter system that will note when clinicians fail to place an order or when they might be confused about the right order to make.

"Our vision is a very smart system that will interact with clinicians, feeding them clinical data and recommendations, taking new input, revising the recommendations, and feeding them back," she said.

With a more proactive system, electronic medical records could be used to scan for members of the community who are most vulnerable to seasonal allergies or viruses, for example. Last year the bureau studied who was getting flu shots. They found that even though most of their patients were candidates for a shot, a large percentage were not receiving them. So Mike Sommers, the bureau's chief information officer, and his team wrote a computer program that flags a doctor attempting to discharge a candidate who has not received a flu shot.

The bureau also wanted the system to remind doctors to prescribe blood thinners for patients at risk for blood clots.

"That isn't just doing background checking," Das said. "Instead, it's the database work that computers can do that really interacts with the clinical status of the patient and the clinician."

Ultimately, Das foresees a system that does not rely on physician input but automatically searches clinical records for instances where preventive measures should be taken or where trouble might be brewing.

— Paul McCloskey

EMR: Remote control

When officials at the Cook County, Ill., Bureau of Health Services chose hardware for health care providers, they decided not to place computers in patients' rooms because they could not be supervised around the clock. Instead, they opted to place the computers near the nurses' station.

The hospital campus has an 802.11b wireless network that supports physicians with personal digital assistants or tablet PCs in addition to Computers on Wheels at the nurse's stations. The Wi-Fi network is also equipped to support physicians who want to access the system from home. Another project links glucometers for diabetics to the system.

Bureau officials are testing a small group of residents are using mobile PDAs in hospitals to access orders and scan results at the patient's bedside. Images are not accessible, but they can access any information that's in Power Chart, the Cerner application used for clinical data.

— Paul McCloskey

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