Enablers of Evanston Northwestern Healthcare

Evanston Northwestern Healthcare's US$30-million IT investment promises to eliminate $10 million annually in expenses at the three-hospital system north of Chicago.

Under the leadership of chief information officer Thomas W. Smith, and with full support of executive management and the medical staff, ENH has achieved virtually 100 percent electronic order entry at Evanston Hospital, Glenbrook Hospital, and Highland Park Hospital and continues to upgrade capabilities.

The health system has nearly complete electronic medical records within the hospitals and is well on the way to being paperless at all of its 65 service locations. Physicians and nurses do rounds with "Jetsons," carts equipped with wireless Wyse thin-client terminals and 12-hour battery packs.

Nobody knows these accomplishments -- or the challenges that lie ahead -- better than the 175-person information services (IS) team that Smith directs. "The IS department really has to be looked upon as an enabler of the rest of the hospital," Smith says. "The IS department really is a service department. It allows people to get their jobs done better, more efficiently, safer."

The department is able to enable because it has the support of executives and clinicians alike, and the dollars to make it all happen.

ENH convened an implementation steering committee in early 2001.This group, comprised of senior hospital management, IS leaders, and two physicians, made the decision to go fully electronic across the entire health system. The committee chose Epic Systems as the primary technology vendor.

"I think it's been a very collaborative process," says Barbara DeMartin, assistant vice president for clinical information services, who reports directly to Smith on issues related to clinical technology. Martin's counterpart for the admin and financial aspects of the system, as well as for network security, is chief technology officer Steven J. Smith.

CIO Thomas Smith says top brass took a deep interest in the effort. "Senior management really set the tone for this," he says. "They made this the No. 1 project. Not the No. 1 IS project, but the No. 1 project for the whole corporation." It remained at the top of the list for more than two years, Smith says.

"To get the mission done, we knew we could always go to administration, (which) would find a way to eliminate obstacles so the IS department could focus on the project," says Dan Exley, a project manager who handles technology in the emergency department and other inpatient areas.

Glenbrook went live with EMRs in March 2003. Evanston has had the full EMR since June 2003. Highland Park came online in January 2004. About 50 sub-acute facilities in the ENH system were fully wired by midsummer, Smith says.

IS still has plenty of work to do. For one thing, nurses still must manually enter data from patient monitors. "It's kind of the bane of the nurses' existence, the data entry," says William MacKendrick, M.D., head of the neonatology division and the infant special care unit at Evanston Hospital.

The IS department also has to integrate the picture archiving and communication system -- a combination of GE Healthcare and Cerner technology -- into the main Epic EMR.

ENH now offers the Epic technology to the offices of 600 affiliated physicians. Independent practices pay for it, but they get the technical expertise that most small practices otherwise could not afford. ENH hooked up the first office in June.

The physician advisory group championed the project, helped design the system, and worked closely as a liaison between the IS department and the medical staff, according to Katherine Reynolds, R.N., senior director of medical informatics at Evanston Hospital.

"We worked with Epic on workflow redesign," says Reynolds, who is not officially part of IS.

IS does listen to what the advisory board says. MacKendrick, a member of the physician panel, worked with the tech group and the hospital pharmacy to implement weight-based dosing and other special requirements for his department. Management and all attending physicians within the health system were required to take 16 hours of training.

"There was a massive amount of training involved," MacKendrick says. "There was a lot of grumbling."

To soften the blow, ENH offered physicians continuing medical education credit for this training and forgave their staff dues for a year. "A few doctors retired," MacKendrick notes.

As the project got under way in early 2002, ENH began a workflow analysis. "We had about 500 different major workflows that we analyzed," Smith says. After breaking the original list into subsets, ENH now recognizes about 2,000 workflows.

"During that time period, when we were doing some building of the system, we spent half of our time doing still some more flowcharts," Smith says. "There were some IS people present, but (the flowcharts) were really done by the users. They told us how we should do things."

Physicians also helped design the templates for documentation because they were the ones who would be using the system, according to Exley.

Senior systems programmer Kris Kuszynski was a key player in the installation of 89 Citrix Systems servers dedicated to Epic, while Michael L. Payne, director of network services, oversaw the upgrade to 1-gigabit-per-second Ethernet and 802.11(b) wireless technology with more than 400 access points. "It really was a massive effort. It took 18 months just to do the hardware upgrades," Payne says.

In the future, DeMartin says, there will be improvements for specialty departments.

"They're using (the system) but certainly their workflows are not ideal. There are things we could do to support workflows," she says. Among the goals over the next five years is to "take clicks out," reducing the number of steps physicians need to make to enter and view data.

Five years from now, Smith expects, the system will be "more robust," with more clinical decision support and integration of other information, from telemetry and billing and possibly wireless infusion pumps. "It's a whole new thing that we'd have to think through," he says.

No problem. His department is well-versed in solutions.

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