It is most of three years since President George H. W. Bush outlined a plan for electronic health records as a priority in his 2004 State of the Union speech. At the time, the president cited the need for innovation and cost control to begin to offset the estimated $300 billion health dollars spent annually with no impact on patient outcomes, and safeguards to prevent annual accidental deaths of between 44,000 and 98,000 patients due to medical errors.

The president's remarks might have awakened observers with little insight to the cost/opportunity mix of health care and technology, but major medical institutions were already well into programs addressing beneficial patient outcomes, cost and efficiency. Trinity Health, a not-for profit group of 30 owned and 15 managed hospitals across seven states in the Midwest was already close to four years into a project called Genesis, which upon completion would become the third largest initiative in the nation. Trinity arose from the merger of Holy Cross and Mercy Health Services in May, 2001. Prior to that, predecessor organizations had an IS history of hospitals that operated independently and pursued best-of-breed strategies. "At the end of 1999 there were a couple things going on," says Paul Browne, SVP and CIO at Trinity Health. "Y2K readiness was winding down. There were many requests for investment in new systems, so senior management was pondering whether to continue 20 years of everyone doing their own thing, or maybe, find a better way."

As the merger progressed, the governance committee of newly formed Trinity Health established a principle called "Rapid Replication," which aimed to institutionalize proven improvements in medical practice. "The idea was to have management constructs, infrastructure and processes that could replicate successful treatment practices and processes as quickly as possible," Browne says. The strategy was underscored by the cost of medical errors later cited by the president. "All these things coalesced and led to a strategy that said, 'Let's migrate all the hospitals in Trinity Health to a common set of information systems that will provide caregivers with the information they need when they're dealing with patients to help them improve quality and safety.' That's the genesis of Genesis."

An early lesson learned was that paper-based systems provided little in the way of a baseline of performance for processes. As an example, one measure in the hospital environment is the amount of time from when an antibiotic is first ordered by a physician to the time when it is first administered to the patient. "We tried to understand a benchmark by going back to paper-based charts and learned that the information required to put together turnaround time was simply not available," Browne says. As a consequence, the new applications provided the foundation for measurements to come. "As we automate processes we're using transaction systems to capture meaningful baselines, and we're following Genesis with a second push we call 'Care Experience.' This is taking the care delivery processes and redesigning them based on the data we now have to improve quality, safety and customer satisfaction."

The four cornerstones of Genesis - electronic health records (EHR), computerized physician order entry (CPOE), adverse drug event (ADE) alerts and revenue/supply chain - are grounded on partner products: Cerner for clinical systems, McKesson for financial and administrative systems and Lawson for enterprise resource planning and supply chain. Trinity employs a full-time staff of about 1,200 IT professionals, making the project largely self-sustaining outside a handful of consultants. The different platforms also provided some overlap. "We found right away that the clinical processes that surround EHR and CPOE are so integrated with financial processes that we had to address both the clinical and financial systems at the same time," says Browne. Supply chain systems are on a separate but parallel track and, requiring less process change, will be fully deployed sooner and are expected to generate a hard financial return that will help fund the clinical work.

The first piece rolled out across all 30 owned facilities was the ADE alert system, which required a rudimentary electronic health record fed through interfaces for patient demographic information such as name, age and sex. Lab and pharmacy systems also feed the ADE system, which has returned potentially lifesaving results on a large scale. Over the last five years, they system has generated more than 30,000 alerts against doctor prescriptions, more than 80 percent of which have been adjusted as a result. Physician acceptance has been abetted by first routing alerts to pharmacists, who then collaborate on potentially better and safer routes for treatment. "The feedback from physicians reflects that there are literally thousands of new articles every year in medical literature, hundreds of new drugs," says Browne. "By and large they look at the system as an extra level of protection where professionals are working together to understand and act on a particular situation."

With reflective pauses for lessons learned on rollout, about nine of Trinity's P&L groups are now live on CPOE, medical records and financial systems. A similar number are leveraging the updated supply-chain applications, supported by centralized architecture and a single repository for the entire organization. Trinity's "best-of-suite" approach with partners draws on many different modules for pharmacy, surgery, intensive care, nursing et cetera. The Cerner data model for example, contains hundreds of thousands of data elements, an enormous fact set that has been customized for doctors, clinicians, radiologists, nurses and others with specific fields of relevance. "If you can imagine a surgeon, an internist and an OB/GYN all wanting different bits of information about the patient and different combinations of pieces of information, we have tailored the system to provide different groups of physicians different combinations of information," Browne says. "In the paper-based world, a physician has his fingers stuck in different portions of a chart and flips back and forth. We're working hard to make that much more user friendly."

But one advantage of paper is that it is always mobile, just like doctors and nurses, so all of Trinity's facilities are fitted with wireless access. Caregivers on or off duty can use client/server, remote Web access or fixed and mobile devices: laptops on a rolling cart, tablet PCs or mini-laptops that fit in a lab coat pocket. Mobility is one part of the process improvement initiative underway at Trinity. Eighteen months before any go-live date, Trinity kicks off a readiness process, a multi-phase methodology involving a series of activities related to making the case for change, changing job descriptions and medical staff bylaw changes. A separate component compares current process flows with a future state of operations enabled by the platform. "When you have an electronic health record in place, there are aspects of physician/nurse communication that are quite different, opportunities for team review of information that don't exist in a paper-based world." For example, a study across nine of Trinity's hospitals examined joint replacement surgeries, the procedures and drugs utilized and x-rays taken before and after surgery. "We were able to identify specific clinical changes that if applied across the entire organization would improve quality and financial performance," Browne says. "We have started to run a series of reports organized by clinical condition to look at performance and identify specific changes down to drug substitutions which, if implemented, will lead to changes in quality and or financial performance."

Mobilizing the professional workforce to leverage data is one of Browne's lingering concerns, but the installation itself is moving the bar at Trinity with some calculable tradeoffs. "We studied one of our facilities and found that nurses spend more time documenting care on the computer but are able to increase the amount of time actually spent with patients because they spent substantially less time looking for paper-based documents that used to float around the hospital."

Likewise, a paperless environment provides more cohesive documentation but also means no paper trail, so systems must be eminently available at all times. "It requires 24/7 vigilance, says Browne. "We're processing several million transactions per day and the tolerance for error is very small. We have redundancy and our data quality is solid, it's mostly managing availability and response time. But you always remember that the hospital operates nonstop, these aren't financial systems where you have a bunch of online usage during the day and you batch process at night."

Hundreds of millions of dollars into Genesis project, Trinity Health continues to build on care, process and efficiency improvements, managed for long-term continuity as executives come and go. "You go into these things with the idea that if you have the data, you can see the opportunities and make change occur, you buy that intuitively," concludes Browne. "We're at the stage where we have the data in a consistent format and can understand the changes that should be made, now it's about taking it to the next level where change actually occurs." It's an exciting point in time, he says. "The reason it's still a headache is if we're not able to do this successfully, then really we won't get the value out of the investment we've made."

This story originally ran in BI Review in December 2006.

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