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The Gemini Project UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER (UICMC)

EXECUTIVE SUMMARY Founded in 1882, the University of Illinois at Chicago Medical Center (UICMC) is today the largest state-funded hospital in Illinois and among the busiest teaching institutions in the nation. UICMC is a comprehensive health sciences center that includes a 450-bed hospital, an outpatient surgery center, an Outpatient Care Center and eight satellite facilities located within a 20-mile radius of the primary campus. The Outpatient Care Center houses 12 primary care and specialist centers. Approximately 715 physicians are affiliated with the medical center, which includes a College of Medicine, College of Nursing, College of Pharmacy, College of Dentistry, College of Health and Human Development Sciences and School of Public Health. The medical center generates revenues of about $316 million annually and employs 2,660 people, including 1,200 nurses. UICMC handles approximately 18,000 inpatient admissions and about 400,000 outpatient visits annually. A recent U.S. News & World Report survey ranked the medical center in the top four percent of America’s hospitals in the specialties of AIDS, cancer, cardiology, endocrinology, gastroenterology, geriatrics, gynecology, neurology, otolaryngology, ophthalmology, rheumatology and urology. As a tertiary site for many complex medical procedures, UICMC supports major programs in neurosurgery, ophthalmology, oncology, cardiology, neonatology and obstetrics. After six years of planning and implementation, UICMC today operate s a computerbased patient record (CPR) that contains medical data on more than two million patients. Demographic and insurance information, inpatient orders, medication charting, nursing documentation, personal and family medical history, lab, radiology and pathology reports, physician notes, test results and outpatient visit records – all are available with the click of a mouse from more than 2,800 personal computers, called “WinStations.” These stations are 73

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located across the institution as well as remotely via the Internet. A network, called the Gemini Project, links the medical center’s hospital, outpatient surgery center, Outpatient Care Center and eight satellite facilities. Currently, an average of 1,600 caregivers access the system daily, and more than 500,000 charts are opened each month. Users include physicians, nurses, licensed physical and occupational therapists, non-licensed clinical support, students from all the health sciences colleges, pharmacists and clerical staff. In addition to providing instant access to a broad array of patient information, Gemini allows caregivers to order a range of clinical and diagnostic tests electronically and then view results as soon as they become available. The system also features a decision support component that alerts clinicians and pharmacists to potential adverse drug events and drug interactions and guides clinicians through the care and documentation process. The Gemini network at UICMC was initially developed to mitigate concerns that the medical center’s legacy patient care information system was not Y2K non-compliant. The project cost was $10.3 million. The system is built on the HNA Millennium® information technology architecture developed by Cerner Corporation, a Kansas City-based health care informatics company. The value of the Gemini Project has been significant. Clinical practice has clearly improved. The system saves the time of the medical center’s nursing staff, freeing nurses to provide more direct patient care. Communication throughout the medical center has improved. Physicians spend less time looking for charts, nurses spend less time on medication administration, and a complete medical record is instantly available when a patient presents for care. In October 2000, UICMC and Cerner jointly conducted an assessment of the value produced to date by Gemini. The study revealed that the total estimated financial value generated by Gemini from project onset to the beginning of 2001 was $3.6 million. Although the network is fully installed and operational, a small number of physicians were initially unwilling to rely on Gemini and routinely documented on paper. Because of this group, as well as Figure 1: Electronic Medical Record Use vs. Paper Records Requests interfaces with external vendors and medical sites, an entirely paperless environment remains some years away. As a result, a document imaging system was incorporated into the conversion strategy to support the transition period. Physicians using paper documentation can send the records (and most other paper inputs) to the Health Information Management department for 74

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scanning into Gemini. Today, all but a handful of physicians have converted to using Gemini exclusively, and the medical center is continually enhancing and expanding Gemini’s functionality, particularly in the area of decision support at the point of care. Requests for medical records have dropped significantly. Figure 1 shows a direct correlation between increased usage of the electronic medical record and reduced requests for paper medical records.

MANAGEMENT CPR System Planning Vision and Strategic Objectives

In the early 1990s, the University of Illinois at Chicago Medical Center began work on a longterm strategic initiative aimed at more fully integrating services between a planned ambulatory clinic and the hospital. Planners understood that the medical center would need to upgrade its information systems infrastructure and replace its legacy patient care system. Underlying the information technology upgrade were a number of objectives, including: Providing caregivers access to a longitudinal electronic health record and improving access to clinical information in the eight ambulatory clinics and satellite facilities. Increasing the efficiency and effectiveness of those who deliver care. Replacing non-Y2K compliant patient care software. Creating a technical infrastructure for modern open systems technologies and flexibility for future growth. The medical center’s Information Technology (IT) Department, working closely with clinical department leaders and physicians, spearheaded the conceptual development of the computerized patient record (CPR), which became known as the Gemini Project. The over arching goals were: 1) to dramatically improve the quality of care by increasing caregivers’ connectivity and access to complete information; and 2) to save money with more efficient operations. Once this group identified a range of strategic and tactical objectives, these goals were refined by medical center leadership. Ultimately, it was determined that the new CPR would: Manage costs, outcomes, quality of care, and the interrelationships between these domains. Emphasize enterprise-wide data integrity. Make the processes at UICMC more efficient. Allow UICMC to monitor its performance both internally and externally. Use modern open systems technologies to provide flexibility for future growth. Combine the inpatient and outpatient medical record. Support education and teaching. Monthly and quarterly updates about the project were provided through committees already in place at the medical center. Information was also imparted at a variety of other events including annual organizational meetings, medical staff meetings, physician-hospital organization gatherings, and events associated with UICMC’s six health sciences colleges. 75

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The planning, selection and acquisition of a CPR system was driven by a central body of executive and clinical leaders called the Executive Management Systems Steering Committee (EMSSC). This committee was responsible for reviewing and prioritizing information technology projects in light of UICMC’s objectives as an organization. Once the system was selected, the Gemini Executive Implementation Committee (EIC) oversaw the planning and decision-making for the implementation of the CPR. The EMSSC reviewed the project quarterly to provide executive support and project oversight, while the implementation group met monthly and was responsible for overseeing all aspects of implementation. UICMC ensured strong physician involvement and ownership of the design and planning process by designating a physician and information technology co-chair for each of the committees reporting to the EIC.

User Needs Assessment and System Selection The patient care system was the intended hub into which various legacy and new applications would be integrated. To incorporate the needs of the clinicians, a list of key users for the new CPR was prepared. Each key user prioritized and weighted a list of system attributes, which included a ubiquitous medical record; increased availability; security; tracked and shared single record; improved physician-to-physician communication; and duplicate checking. The priority requirements were then tallied and ranked to effectively determine and respond to the needs of the user population. Early in the process, UICMC decided that it would not attempt to create its own custom clinical applications. This decision was made for many reasons: the primary one being that UICMC’s core competency is the practice of medicine and the delivery of high quality patient care services, not software development. Although UICMC has a competent information technology group, the organization looked to the vendor community for an application that would allow enterprise-wide connectivity, as well as clinical decision-support capabilities. This approach was less expensive, enabled UICMC to learn from other organizations already using the vendor’s application, and provided an enterprise-wide system that could be recreated at other healthcare organizations. An extensive review of patient care system vendors was conducted. Eventually, potential partners were narrowed to three, who were then evaluated in detail. Ultimately, UICMC chose the HNA Millennium architecture developed by Cerner Corporation. The primary reasons for choosing HNA Millennium included the system’s ability to create a longitudinal record that included both inpatient and outpatient information; the ability to access the information via the desktop in a variety of user-specific configurations; the flexibility of the architecture, which would allow for expansion of both users and functionality in the future; and its powerful expert systems and decision-support applications, which could be deployed to help clinicians improve the care process. Another plus for Cerner was its investment in advanced information technologies. Because Cerner invested nearly $300 million since the mid-1990s, HNA Millennium had a truly enterprise-wide information architecture designed specifically for health care and provided complete clinical connectivity. Moreover, Cerner applications had the highest customer satisfaction ratings of the three finalist vendors.

Business Case Although no specific financial objectives were delineated at the project’s outset, the new system was expected to produce significant dollar benefits in three general areas: 76

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Supply cost reductions. Reimbursement benefits. Revenue enhancements. Early in 1995, University officials sought approval from the Board of Trustees to implement the Cerner HNA Millennium CPR system. They estimated the hardware and software costs at $10.3 million. The medical center added eleven more people to the information technology staff to implement and maintain the system. A specific return-on-investment estimate was not defined. However, with a legacy system that was not Y2K compliant, replacing the existing system was imperative and obtaining funding was not difficult. From the outset, UICMC adopted a strategy of joining the medical center’s new, outpatient center with the CPR. UICMC simultaneously requested Certificates of Need from the Illinois Health Care Facilities Planning Board for both the medical center’s new, $100 million Outpatient Care Center and for the CPR, so both projects would be funded. The strategic plan aimed to create a state-of-the-art medical facility that produced the highest quality care as efficiently as possible, by integrating inpatient and outpatient information. Another important goal was to further strengthen and support academics at UICMC. STRATEGIC OBJECTIVES

IMPORTANT TACTICAL OBJECTIVES

The reasons for upgrading the clinical information system at UICMC extended beyond simply replacing the functionality of the 15-year-old legacy system. Strategically, the organization sought to create a longitudinal, electronic health record that would be available virtually to all clinicians across the organization. Although reducing costs was an objective, it was not the driving force behind developing the CPR. From the outset, the project was envisioned as helping to centralize the ambulatory clinics in the new Outpatient Care Center.

Implementation Planning and Change Management The Gemini Executive Implementation Committee met monthly and was responsible for overseeing all aspects of implementation. The project mantra was “Rapid Deployment: Share the Wealth,’’ with the objective of quickly benefiting the widest possible cross-section of the medical center. The committee felt it was important to synchronize Gemini’s deployment with the opening of the medical center’s new Outpatient Care Center. Because the inpatient facilities were computerized with a legacy patient care system but the outpatient setting was solely dependent on paper, the clinical data repository was rolled out first to the ambulatory clinics. The first outpatient clinic was introduced in October, with all of the remaining clinics converted by June 1998. This approach allowed for a progressive or 77

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“waved” introduction and deployment of hardware and software, and also ensured that the necessary resources were available to support the transition. While the outpatient settings were computerized, the order implementation committee defined the functional (or user) requirements for managing orders so the system could be customized to accommodate the physician order entry process for the hospital and clinics. Data feeds were activated in September 1997. Data fed into the repository during the first phase included demographic data, laboratory, anatomic pathology, and radiology interpretation. Transcription, clinical progress notes, blood bank, and microbiology results were scheduled for the second phase. On the inpatient side, phasing in or implementing functionality sequentially was not an option because of the impact on workflow and patient care. The amount of time clinicians would need to enter and retrieve information in two different systems had to be minimized. As a result, a “big bang” approach was taken to deploy the greatest amount of functionality in the shortest amount of time. Prior to hospital deployment, UICMC created a highly detailed functionality requirement from the previous system to ensure that no processes were overlooked during the conversion. The conversion itself took place during the second week of November 1999, with order and documentation functionality converted on all 18 inpatient nursing units over one week. Essentially, this event merged the inpatient and outpatient continuum of care into one clinical data repository. To ensure a smooth transition with minimal disruption, intensive onsite support was provided to each inpatient unit or department and then gradually reduced over a two-week period. Specifically, more than 100 UICMC and Cerner staff were available onsite and around the clock to provide guidance.

Project Governance and Staffing At the tactical level, several committees oversaw the Gemini Project planning and implementation. Each was co-chaired by physicians and an IT representative and included members from relevant ancillary departments. Each group had a specific functional goal. The Implementation Committee, for example, oversaw all aspects of implementation—from hardware placement to training clinicians. Each group provided input relevant to their area of expertise.

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Once the implementation was complete, all committees were merged. The new entity was renamed the Implementation and Operations Committee and includes representatives from laboratory, pharmacy, nursing, physicians, nurse practitioners, as well as numerous other constituencies. From the outset of the Gemini Project, UICMC recognized that the biggest hurdle to clear when installing a CPR was acceptance and utilization by clinicians, particularly physicians and nurses. To address this challenge, the Implementation and Operations Committee met biweekly to focus on issues that might interfere or impede clinician use of the system. This group addressed issues that included: Bringing performance and response time to satisfactory levels. Identifying design issues related to entering and viewing information within the CPR. Prioritizing outstanding software development issues from a patient safety and clinician efficiency perspective. Reviewing user access to ensure the appropriate level of security, confidentiality, and access. Setting standards for nomenclature and data. Figure 2: Original Project Governance

Training and Education Plans for training began well before the first ambulatory clinic rollout. The following training principles were adopted: Lead with Basic Windows 95 training to develop computer competency for a largely noncomputer-using staff population. (This training class was optional based on the user’s self-assessment.) Implement electronic e-mail and scheduling software to reinforce the Windows training and serve as a communications tool. Focus on process improvement and how the application would be used as a tool. 79

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Individualize training as much as possible. Create a group of PowerUsers to support the training effort and provide decentralized, one-on-one, on-the-job support during implementation. Where practicable, utilize computer-based training (CBT) for application training. The overall approach to training was comprehensive and system-wide, with a range of educational options available for end-users. For example, instructor-led classes were available to introduce Windows skills as clinical areas were scheduled for desktop installation. Those requiring this class were identified through a skill self-assessment. The computer-based training program, which ultimately became the mainstay of the Gemini training effort, provided an innovative and unique mechanism for instructing clinicians through role-based and scenario-based learning. The approach proved highly flexible: Users could complete their training in the training lab with an instructor present for guidance, work with the assistance of a PowerUser on their unit, or work independently through any WinStation personal computer. Each of the CBT courses took between one and two hours to complete, depending on the skill or experience of the trainees. The CBT approach ensured that trainees achieved a specific level of competence before being allowed to use the system. A score of 80 percent or better is required before an access code is issued. In all, more than 4,300 users have been trained to date with CBTs. As Gemini has evolved, additional training modules have been developed to train personnel in new areas of functionality. UICMC continues to follow its original and successful approach of developing separate learning paths for both nurses and physicians. Significantly, the computer-based training jointly developed by UICMC and Cerner has become a standard for the majority of other Cerner clients who adopt the Millennium application platform and architecture.

OPERATIONS AND SECURITY Confidentiality and Data Management Before beginning to load data into Cerner’s clinical data repository, UICMC spent considerable time and effort cleaning up its legacy data. Specifically, approximately 28,000 possible duplicates entries were identified and addressed in the master person index. To ensure the integrity of data going forward, a data steward was appointed in the Health Information Management Department. Today, this individual monitors the master person index daily and performs data quality scans and assessments for both new registrations and inputs from automated interfaces. For example, new registrations are scanned for possible duplicates based on a report of “possible combines”. Automated interfaces for results and clinical documents also are included in this review. When a transcribed note is shipped over from UICMC’s transcription vendor, it is evaluated by patient name, patient number, birth date and social security number to ensure that it was matched by the vendor to the correct record. UICMC also developed a gateway through which data from all departments are required to pass before being stored in the Gemini database. This so-called ensure logic is based on a predefined set of parameters established by the organization. Data that does not match these parameters are isolated as unauthenticated and segregated until the data steward reviews and assesses them. 80

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UICMC hired a security administrator to oversee security issues relating to the new information system. The administrator helped medical center management design, implement, and administer data security standards, procedures, and controls well .before implementation of the CPR. Responsibility for achieving compliance, however, ultimately resides at the department level. As a result, each department has a security contact who acts as a liaison between the department and the Information Technology group. All reported or suspected security breeches are investigated jointly by the department liaison and the security administrator. These new security measures were initiated well before the CPR implementation, since they required significant changes in process, heightened employee awareness, and employee training. Although the Health Insurance Privacy and Accountability Act currently is mandating privacy standards for healthcare providers, this process began years ago at UICMC. Some specific components of the medical center’s security program include: Medical center policies and procedures are communicated to new employees at the time of orientation. Security awareness programs are ongoing. Security training information is available on the medical center’s intranet site. Each employee signs a confidentiality agreement, which is reviewed with them annually at the time of their evaluation.

Ongoing Planning Ongoing system direction is overseen and planned by the Group for Advanced System Planning (GASP), which includes physicians, representatives from the medical center administration, and representatives from the medical center’s six health sciences colleges. The group oversees the strategic direction, priorities, and expenditures for information technologies at the medical center. The chief information officer (CIO) implements GASP decisions. The CIO coordinates a variety of resources from across the organization to fulfill the GASP directives. Requests for system changes and enhancements are addressed based on the magnitude or impact of the change. For instance, an enterprise-wide decision – such as changes that would affect patient care – requires the approval of the Implementation and Operations Committee. Alternatively, the creation of templates for a specific department or clinic does not require committee approval, but is reviewed at a staff level. Figure 3: Current Project Governance

Monitoring and Evaluation System usage is monitored through a number of performance indicators (described in this chapter). These include: System availability and downtime Number of log-ins 81

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Average number of daily users Number of charts opened Number of orders entered; percent entered by physicians Duration users stay on the system User types as a percentage of the whole Monthly drug interaction warnings by type and severity Number of hardcopy medical record requests Number of documents (by type and source department) sent for scanning Over time, fewer progress notes are documented on paper and scanned into the system. Instead, they are entered directly into Gemini. The vast majority scanned are records from other health care organizations, or patient consent forms. On average, 1,600 individuals use Gemini each day. Those individuals log onto the system a total of approximately 7,000 times per day. Figure 4: Scanned Documents Per Month

Figure 5: Example of a Monthly Usage Report

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User satisfaction is measured through a variety of means, including regular surveys of the faculty, house staff and nursing staff, as well as periodic one-on-one meetings with key physician leadership. In addition, the effectiveness of Gemini as a recruiting tool for attracting residents to UICMC will be measured in 2001 for the first time. Major sources of analytical input come from two primary user groups, physicians and nurses. An initial faculty survey confirmed much of the anecdotal feedback about the system, namely, that the two areas where improvements would most benefit clinicians were an increased number of WinStations, or system-wide personal computers, and quicker system response time.

Management of the CPR Implementation From the perspective of the chief information officer (CIO) primarily responsible for implementing the new system, the UICMC’s management and implementation approach has succeeded because the electronic medical record has achieved widespread acceptance (Figure 6). Despite initial skepticism by some, CPR usage levels at UICMC are now exceeding expectations, with more than 1,600 caregivers accessing the system daily. Those using the system range from physicians to nurses to clerical staff. In February 2001, 481,617 total charts were opened, with peak usage of 7,203 charts opened in a single day. This success arguably is attributable to several key management strategies, including extensive physician involvement during the planning and implementation process; an incremental, phased implementation approach through the outpatient and inpatient arenas; the “Share the Wealth” mantra, which made available new features quickly before they were perfected, leading to most benefit in the shortest time; and a robust and reliable technical infrastructure purchased from a vendor for less cost than custom development. On the first point, extensive efforts were made from the outset to demonstrate that the CPR was “owned” by clinicians and not the Information Technology Department. The project’s priorities were driven by what clinicians believed would generate the most value, both for themselves and for their patients. Clinicians, operations, and IT staff worked together to meet the project objectives. The waved implementation approach for the outpatient clinics allowed the implementation team to focus on specific clinical areas without their efforts and energy becoming too diffused or fragmented. In each clinical area, the staff was guided through the transition process and received intensive hands-on help until becoming self-supporting. Only after area staff achieved a high threshold of familiarity and competence with the system and the local PowerUsers became proficient did the implementation team move on to the next area. The concept behind “Share the Wealth” was to introduce functionality as soon at it was viable, rather than waiting for the system or application to be perfected in all respects. This incremental introduction provided a steady stream of new value for users, which helped increase end-user support and enthusiasm for the system. It also provided valuable insight for refining the applications going forward. 83

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The waved implementation and the “Share the Wealth” approach collectively brought a large number of users online quickly. This, in turn, helped rapidly populate the system with current clinical information and consequently made Gemini a valuable asset from the clinicians’ perspective sooner than might have been expected. From the standpoint of infrastructure, the chosen configuration proved to be highly effective. The initial concept was for a PC-based system that was easy-to-use, powerful, ubiquitous, omnipresent, and able to interface with non-UICMC PCs. Instrumental to Gemini’s success has been the ability to deliver system updates through the servers without having to reprogram each of the 2,800 WinStations. This approach is quick, easy and transparent to endusers. In contrast, many other hospitals must reprogram each PC to implement updates or modifications. Because UICMC’s users know that Gemini has little or no scheduled downtime, users feel the system is credible and reliable. For all these successes, the management of the Gemini project also had some shortcomings. The timing and leadership of the inpatient implementation was poor. Due to severe financial pressures facing the hospital at the time, the executive team was fragmented and preoccupied. Further complicating matters, an outside consultant was brought in by the hospital to address these financial issues. This consultant’s operations review resulted in key members of the leadership team being replaced by interim consultants six months before conversion. Needless to say, the focus of the temporary leadership group was not on the new patient information system. Hence, the project scope was downgraded at the executive level to the status of a simple replacement effort, and as a result, the project lost a golden opportunity to capitalize on the system for implementing fundamental organizational changes. One effect of the management turmoil and disinterest was that inpatient nurses were not well-prepared for conversion, despite the conversion team’s training efforts. Not until permanent changes were made in Nursing Administration was there a commitment to using Gemini to transform the nursing process. Today, nursing is moving speedily and successfully to a fully electronic support system with automated nurse charting and care plans among other key functions. Nonetheless, the opportunity cost of the leadership vacuum on the inpatient implementation was significant. In a formal survey of faculty physicians conducted after the system went live, the Gemini attributes that were most often identified as needing improvement were system response time and the availability of WinStations. At the same time, physicians found that the new CPR had benefited them in the following ways: Increased ability to communicate with other physicians, improved medical records availability, better access to test results, and a clearly identified attending physician. On the issue of response time, both Cerner and UICMC agreed that the network infrastructure and Gemini platform were fully optimized. As a result, the organizations next scrutinized the design of the software coding and the innate design of the system platform. A performance team headed by a key Cerner 84

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technologist was deployed to identify the top ten pieces of functionality that were slowing the system down. This was accomplished by interviews with clinicians as well as observation. Distinctions were made between usability of the software (i.e., where there were too many clicks) and actual system performance. Once documented and confirmed, Cerner redesigned these components at the programming code level to improve performance. At the same time, a technical team was deployed to evaluate the Gemini hardware, operating system and database platform. Their conclusion was that given the continued growth in system use, operational dependence, and strategic deployment, Gemini would be significantly strengthened by deploying Compaq’s new Wildfire fiber channel technology, which UICMC brought online in 2001. On the issue of the availability of WinStations, a UICMC team determined that the problem was two-fold: First, the increase in clinicians during peak periods of the day at some patient care units hindered workflow and system availability. Second, the absence of wireless devices that could be used at the bedside was contributing to bottlenecks at the wired PCs. The first problem was addressed both by deploying additional PCs and by shifting students who were using the system for training purposes in busy units to other, less concentrated areas of the hospital. Meanwhile, the IT staff accelerated the medical center’s wireless WinStation plan, with the objective of allowing physicians and residents to enter data as they make rounds. Equipment testing was increased, and a network topography developed that would allow clinicians to enter the medical center at any location and walk through the enterprise without losing connection. This infrastructure was installed in test locations on two floors of the hospital. At present, the wireless infrastructure is complete, with tests continuing on more than a dozen wireless devices. System-wide wireless implementation in the summer of 2001. Figure 7: Project Timeline

FUNCTIONALITY Targeted Processes The primary objective of the Gemini Project was to replace both the inpatient and outpatient paper medical record. The overall plan calls for a gradual transformation of the UICMC enterprise to a virtually paperless environment over a period of five years, ultimately developing a CPR “SmartRecord.” Starting with the outpatient record, the medical center has combined a series of applications and technologies to accomplish this goal. Paper records have not been delivered to the Outpatient Care Center since August 1999. Today, the outpatient record largely consists of Gemini, as well as a document imaging system, 85

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which contains all historic outpatient records. Orders are documented electronically, but placed with requisitions. Prescriptions and referrals are electronic, while patient consent forms are on paper. Other clinical systems hold ancillary components of the record and are available from the WinStation desktop. The transformation to paperless began in earnest in early 1999, when WinStations were upgraded across the hospital to allow outpatient physicians access to the earliest longitudinal patient record. Use was voluntary, but users adopted the system rapidly because of its value to clinicians. The hospital’s previous physician order entry system was replaced in late 1999. Physician and nursing staff initially began using Gemini for all inpatient order entry, medication administration records, and laboratory result retrieval. Physicians used the system immediately – doctors quickly became proficient as they were already users on the outpatient side. Nursing staff adopted the system more slowly after they realized the benefits the application could provide. Future enhancements will be delivered simultaneously to the largest number of users possible so the organization moves forward in unison. The executive leadership team communicates implementation goals in a variety of ways. Specifically, the medical director is responsible for the physician components of the record, including Consult Orders, H&Ps, Inpatient Progress Notes and the like. The chief nursing officer oversees the transformation of the nursing organization, while the chief operating officer is responsible for the conversion of supporting departments. Figure 8: Strategy for Future Enhancements

Information Access Comprehensive Data

In addition to electronic interfaces, data reaches the Gemini CPR in several ways: Clinician enters clinical notes either as free-form notes or with templates (templates are designed as reminders for the clinical content required for notes entered by the clinician). Clinicians can either create their own templates or use standard templates available in Gemini. PowerForms (a Cerner product) allows users to define and build forms which capture discrete data elements. Data can be entered in multiple locations, but is stored in a central repository and can be viewed from the Gemini flowsheet. PowerNote (a Cerner product) enables users to select discrete data from mouse-driven menus and then the data composes a text document. The use of discrete data to compose 86

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these text documents supports integration with other facets of the Cerner application, such as order entry (from within the document), result retrieval (into the document) and query capabilities that can drive evidence-based medical decision making. Clinician dictated notes and reports can be transcribed and stored in Gemini. When paper is used for outpatients, it is scanned into the record using imaging technology.

Figure 9: Current Gemini Interfaces

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Data Entry Gemini fully supports electronic ambulatory care documentation. Patient consents, records from outside providers, and many other inpatient and outpatient documents are incorporated into the system through the Health Information Management (HIM) document imaging system. Gemini captures all Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements and clinically necessary data real time during the care process. Clinician-to-clinician electronic communication also is supported and has proven to be a primary benefit from the physicians’ perspective. When a specialist sees a patient, for example, they can easily document the consultation and simply forward the information to the referring physician’s Inbox. The volume of communication between physicians has increased significantly due to the system’s ease of use. Nurse-to-physician communication has also improved through telephone messaging. Messages are easily forwarded to a physician’s Inbox for their review. A simple click allows them to add the message and their response to the patient’s permanent CPR. This mechanism is used extensively for medication refill requests and other, similar requests instead of older paper-based written and phone processes. The HIM Department also uses the Inbox to advise physicians about documentation that requires completion, including delinquencies and incomplete chart components. The inpatient medical record, unlike the outpatient record, currently is in the process of being transformed from paper to electronic form. This effort is being managed in accordance with guidelines established by JCAHO, which stipulate that it is acceptable to maintain a record in both electronic and paper form, provided the source of each piece of information is clearly documented in a centrally available location. Beginning July 1, 2001, the hospital officially embarked on its transformation plan to more expeditiously move toward a fully electronic CPR. Information Availability and Access

The Gemini system is accessible to all authorized and appropriate caregivers throughout all UICMC facilities 24 hours a day, seven days a week. There are 2,800 WinStations within the medical center available in every outpatient exam room, at every nurse station, conference room and physician office. Wireless infrastructure has just been completed in the hospital, clearing the way for increased utilization and mobility. Intranet access simplifies the support of remote users. From college academic offices to home utilization, clinicians regularly use Gemini remotely. Satellite clinics, depending on the size of the facility, are supported through a variety of means. The medical center’s Miles Square primary care facility has 85 WinStations and is connected by a T1 line, whereas smaller sites utilize DSL with comparable performance and reliability. These sites connect securely to 88

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the Gemini system through a secured socket. Gemini also has secure dial-up lines and over 450 clinicians regularly access the system remotely. The system also supports VPN technology and data encryption. Figure 10: Clinic Locations

User Access

Clinical applications are available through the WinStation desktop to all caregivers who have completed training. Access to individual applications is based on need and training. As part of Gemini, the core Cerner applications deployed include the clinical data repository, interactive chart browsing application, interactive order management, clinical documentation, and medical decision support. Applications available from the desktop: Radiology Information System (ADAC) OB/GYN Applications: Radiology Information System Physician Desktop BirthNet CareNotes Cochrane Library Endoscopy (Cmore) Mars Chart Tracking and Deficiency (ProFile) Gestational Age Calculator Anatomic Pathology (CoPath) Maternal Fetal Monitor Network Calculator Gemini Basic Computer-based Training Web Access to Applications: Gemini Orders Training Gemini Patient Care System Gemini Charge Services Radiology Information System (ADAC) Gemini Patient Care System MUSE (EKG) Inpatient Pharmacy (PharmNet) Radiology Information System Physician Desktop Laboratory (Blood Bank) PACS (GE) Laboratory (General) Person Management (Registration) MicroMedex Patient Acuity/Nurse Staffing (ANSOS) Medical Records Imaging (DHT Dynamic Vision) Utilization Management (Midas) Outpatient Pharmacy (Star RX) Enterprise Scheduling Computer-based Training Enterprise Scheduling System and Report Writer (Pathways) 89

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Caregivers can access their personal desktop remotely using any Internet service provider and a terminal server application. This remote access allows the clinician to gain access to information from their home, private offices or out-of-town locations. Over 450 nurses and physicians routinely access Gemini remotely. An increasing number of caregivers are using the Gemini system because of its increased functionality and ability to deliver information electronically. CPR usage levels at UICMC are now exceeding expectations, with more than 1,600 caregivers accessing the system daily. Although usage has increased at a steady pace since Gemini’s inception, the largest surge in usage occurred during the move to the new Outpatient Care Center and the implementation of inpatient orders and documentation. The increased functionality and ease of operation has had significant effects on the numbers of physicians accessing the system. On average, the usage by position is 40 percent nurses, 36 percent physicians, 11 percent non-licensed clinical support, 5 percent students, 4 percent pharmacists and 4 percent clerical staff. Physicians enter about 50 percent of the approximately 20,000 orders entered daily into Gemini. Medication orders represent about 10 percent of all UICMC orders. More than 98 percent of these medication orders are entered by the physician-prescriber, who is consequently able to react more expeditiously to system-generated alerts. Figure 11: Physician Orders

DECISION SUPPORT Information Integration

From the onset, Gemini was designed to be easy to use and learn. The objective was to build in features that would speed entering and retrieving information, and thus help make Gemini an indispensable extension of the clinician’s care process. This process began in 1997 with the design of the Gemini’s clinical viewing screens. A group of physicians representing all types of services and care models were asked to provide input for the screen development. It was this group that determined that results were in blue text until they were reviewed, then shifted to black, while critical results were always displayed in red, whether they have been reviewed or not. Templates help standardize the notes that clinicians enter into the patient record. With the development of templates, the objective was to achieve a consensus among different clinical 90

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groups aimed at not merely automating the paper world, but transforming the patient record. Clinicians worked together to establish a range of standards. PowerNotes definition, for example, began with the prioritization of the more than 300 standards available from Cerner. Working in sets of 10, UICMC clinicians customized these standards to suit the clinical and teaching needs of their specific areas. Some templates, of course, are multidisciplinary in nature and thus are refined among a wider group of users. At the same time, a data dictionary was developed to ensure consistent use and entry of data. This multidisciplinary approach has been fundamental to transformation at UICMC. A similar approach of designing a template is being used to establish standards for capturing patient assessment data in order to streamline the process and improve quality across multiple disciplines. Gemini’s rich functionality has supported enterprise-wide improvements in clinical decision support as well as in the practice and delivery of care. Although it is impractical to provide a complete list of functions and their direct application to improvements, the following list is representative of key features and their positive effect on the quality of patient care: Practice Improvements The forwarding functionality allows better communication between physicians and nurses for abnormal test results and patient phone messages. Patient lists identify new results on patients. Pediatric growth chart enable clinicians to look at growth and development trends. The flowsheet graphs trends in vital signs and lab results in a graphical format. Clinicians have the ability to review clinical documentation for all previous patient visits to ensure continuity of care. The visit list identifies prior encounters and orders placed on those encounters. In addition, IT is an active participant (via the use of CCL reporting) in identifying orders placed on the wrong encounter and targeting those users for any additional training needed. Quality Assurance Measures The patient task list and multi-patient task list identify tasks due, chart medications, and perform quality assurance measures to ensure that all medications are charted for patients in a timely fashion. Allergy rules ensure safe medication ordering and administration. Clinicians utilize the MAR to chart medications, which helps the physicians identify medications that have been administered (i.e. prn insulin or morphine) to assist the MD with appropriate ordering. Results are graphed on the flowsheet for patient education. This is particularly used for the transplant patient to assist them in understanding trends in weight or glucose management. Clinicians have the ability to view previous patient providers to ensure continuity of care. The discharge order details help identify quality of discharge follow-up. The new note type for patient education identifies patient's educational needs as well as response to treatment. 91

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Individuals use system to identify QA indicators such as the skin assessment form (Braden Scale) and pain scale.

Orders and Clinical Practice Standardization One of the design strengths of Gemini is the intuitive nature of the medical record’s layout. Users of the system find that clinical information is easy to locate and consistently available across the system. Whether clinical data is entered directly with templates, transcribed, entered through PowerForms (discrete data) or PowerNotes (combination), the resulting information can quickly be found. Information is available centrally on Gemini’s flowsheet, which is laid out in an easy-to-read, easy-access manner so clinicians can locate information quickly. They also have tools available to compare the information against other data. The templates are effective because they have been created by clinicians to meet the requirements of a particular clinical visit or disease state. Collectively, the templates help ensure consistent care and documentation. In addition, a search function makes it easier to navigate on larger flow sheets by providing the ability to quickly zoom in on any abnormal or critical results. Figure 12: Flow Sheet Screen

Clinical data is organized under the Clinical Notes Tab and hierarchy, which are very intuitive and easily sorted. The Clinical Notes Tab and hierarchy were designed with considerable input from clinicians, along with information technology staff. The tab is a central “index” for all narrative type information, and allows clinicians to quickly locate clinical documents with four sort options: 1) By Type – grouping documents based on the note type hierarchy built by UICMC; 2) By Status – grouping documents by their status, such as authorized, in progress or the like; 3) By Figure 13: Flow Sheet Screen with Seeker

Date – arranging documents by the date they were performed; 4) Performed By – arranging documents by the performing clinician.

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Figure 14: Clinical Notes Screen

Figure 15: Drug/Allergy Interaction

The management of medication orders is one of the salient features of Gemini’s decision support capabilities. Typically, medication is selected and the system performs an automatic search against the Cerner Multum® database for interaction checking and adverse drug interactions. If a conflict is detected, the user is presented with a Drug Allergy/Interaction Summary window that summarizes the ordered medication, the existing allergy, medication previously ordered for which there is a conflict and the severity of the interaction. The caregiver then has the option to discontinue the ordered medication, discontinue the existing medication, or continue with the order. Note that a Discern Rule requires the entry of allergies or specification of No Known Allergies before any medication orders can be entered. In addition to drug-allergy interaction checking, Gemini also supports drug-drug and drug-diet interaction checking as well. Figure 16 shows the typical monthly performance indicator of drug interactions. Figure 17 shows the typical monthly drug/drug interactions-only major interactions are displayed to users. Figure 17: Typical Monthly Drug/Drug Interactions

Figure 16: Typical Monthly Drug Interactions

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A more basic but equally useful form of decision support is the duplicate order checking function available through Gemini. Duplicate order checking can be defined by order and is applied to many lab and radiology orders. When duplicate orders are placed, the clinician entering the order receives a message when the same test is ordered within a predefined time period. Figure 18: Duplicate Order Window

Order entry has been designed with considerable involvement of clinicians as well as the ancillary departments receiving the order. The CPR has several tools to improve the speed, accuracy, and completeness of order entry. Order sets, for example, minimize variability in practice, accelerate order entry and reduce unnecessary testing. Similarly, order sentences allow clinicians to view, at a glance, a summary of order details and thereby safeguard against mistakes or omissions. At the same time, order sentences also make it easy to modify an existing order. Figure 19: Order Set Screen

Figure 20: Order Sentence Screen

All 3 screens show examples of clinical decision support. Gemini’s decision support systems use Cerner’s Discern Expert®, an events-driven, decision support application. Discern Expert employs a graphical user-interface based editor that allows designated clinicians to easily create syntactically correct logic modules. If-then logic can be created that allows users to apply their own criteria to a set of events and then take actions compatible with stated goals. Using this technology, when Orders are placed for medications that have been identified as possibly reacting with diet, notifications are provided to Nutritional Services for appropriate adjustments to be made in a patient’s diet. 94

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Knowledge-Based Prompting

UICMC has embraced the use of expert system functionality to address other patient-safety concerns and facilitate further automation of nursing. From a patient-safety perspective, initial efforts are focused on the Cerner ADE (Adverse Drug Event) rules package and select nursing process rules to prevent erroneous discharges/expirations. The UICMC Medication Use Evaluation (MUE) Committee is leading the clinical side of this ADE effort. This committee is co-chaired by a physician and pharmacist and is comprised of multiple clinical disciplines. The MUE clinicians review the Cerner ADE rules and propose rule logic and rule parameter modifications. The actual ADE rule implementation is performed by the UICMC Information Technology group. The short-term focus of the ADE effort is a suite of three rules designed to prevent Digoxin toxicity. Two of these rules utilize synchronous processing upon the placement of a medication order and the third uses asynchronous processing upon the posting of laboratory results in the CPR. The synchronous rules warn of potential Digoxin toxicity when ordering Digoxin for a patient, or when ordering medications in conjunction with Digoxin. The rules check recent lab results in the CPR to determine if the patient is at risk to develop an ADE. The asynchronous rule warns of lab results posted in the CPR that may predispose the development of an ADE in patients receiving Digoxin. The rules notify multiple clinical disciplines using popup windows. Long-range efforts include implementation of the remaining Cerner ADE rules and a Coumadin ADE rule developed by members of the MUE committee. Another problem the new system addressed was the higher than normal volume of erroneous discharge transactions performed by the admitting department. After some analysis, it was determined that nurses were sending nursing discharge orders on patients who did not have a physician discharge order. In concert with implementation, new nursing process rules prevent nurses from entering a nursing discharge/expiration order on patients who do not have a corresponding physician order. Nursing process rules ensure that multiple inpatient-discharge steps are taken in the appropriate order.

Figure 21: Nursing Functions Order Details

Discern Expert also serves as the basis for a UICMC federal grant application submitted in January of 2001. This grant is funded by the Agency for Healthcare Research and Quality (AHRQ) to support the development of patient-safety improvements and patient-safety centers of excellence. The UICMC proposal calls for pilot projects centering on the use of Discern Expert. If the grant is awarded, the first pilot study will test the hypothesis that errors in medical diagnosis can be reduced by aggressive use of an electronic problem list integrated with an expert system operating within an electronic health record. In this pilot, Discern Expert will automatically manage the electronic problem list. A second pilot study will test the hypothesis that the use of expert system alerts, combined with an electronic problem list, can reduce unnecessary medication use. Discern Expert will be used to match drugs prescribed through the on-line electronic order system with the electronic problem list. When there is no match between the problem list and the medication prescribed, the prescribing physician will be prompted to delete the medication order or to add a new problem to the problem list. The next phase of decision support implementation will take advantage of the Cerner information technology foundation to increase and expand decision support functionality. 95

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Specifically, the long-term goal is to build the necessary alerts, rules and reminders to enhance quality, cost, and safety at the point-of-care and move toward a disease management model. UICMC clinicians have identified several more rules for improving patient safety and adverse drug events. These rules were developed for implementation in 2001. Coumadin Rules – When the user orders an assessment, the system is triggered to check for specific drugs and/or drugs that affect the rise or fall of INR, and check for drops in Hematocrit results. If one of these conditions exists, the system will alert the user. Potassium Level Rules – These sets of rules will alert clinicians when a patient has an elevated potassium level and are triggered by active orders for medications with potentially exacerbating effects. Conversely, if the user attempts to order a drug for a medication on a patient with high potassium level, the system presents an alert that the drug may have potentially exacerbating effects. Renally excreted drugs with low creatinine clearance results – When ordering a renally excreted drug, this alert suggests a dosage adjustment if the patient has a recent creatinine clearance result that indicates impaired renal function. Conversely, when a creatinine clearance result is posted to the system indicating impaired renal function in a patient with an active order for certain renally excreted drugs, this alert suggests changing the current dose to avoid potential toxicity. Decreasing creatinine clearance with potentially implicated active drug order – This rule alerts the clinician to possible developing renal failure in a patient receiving a nephrotoxic/renally-excreted drug. If a new serum creatinine result indicates a 20 percent or greater than 20 percent decrease in creatinine clearance and the patient is receiving a nephrotoxic drug, the clinician is alerted. Automatic consult orders placed based upon Nursing Admission Assessment – When nurses document specific criteria in a patient’s admission assessment, the system automatically generates “orders for consultation” to various departments. These departments include the Nutrition Department, case managers (when a low Braden score is noted), the Rehabilitation Department (for assessment), and the Risk Management Department (when patients are at risk based upon the Morse Fall score). Knowledge Access

The WinStation supports easy access to online medical center policies and procedures and is equipped with a powerful, easy-to-use search engine. Links to the Internet and short-cuts to frequently used research sites are routinely part of clinical care. Requests for short-cuts to additional sites are common and accommodated to support the care and teaching objectives of the organization. Examples of web sites with commonly used medical information include MDConsult, Harrison’s Textbook of Internal Medicine, OVID, Web of Science, HealthStar (GratefulMed) and Medline. Patient Decision Support

Gemini is used in many ways by clinicians who access the system to support patient education and communication. Some use actual data from the system and show patients their information online to increase patients’ awareness of their condition. Additionally, UICMC has a patient teaching and education tool online (CareNotes), available in both English and Spanish to serve our multi-cultural patient population. CareNotes provides background, information, and instructions to patients on diseases, conditions, medications, diagnostic testing, and procedures. 96

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Other educational benefits include improved communication in a wide range of areas. For example, each patient on the inpatient rehabilitation unit must have a team conference summary (2-3 page report) completed weekly that summarizes diagnoses, risks, goals, outcome, progress, and planned discharge. The team conference is a collaborative meeting between occupational therapy, nursing, physicians, speech pathologists, physical therapists, social workers, and psychologists. Prior to Gemini, each therapist, nurse, doctor and social worker brought a handwritten report to the conference. At conference, these sub-reports were stapled together and then submitted to the typist for typing. The typed report was available in one-to-two weeks for insertion in the chart. With the new system, a PowerForm is created for each patient one day prior to the team conference. From their desktop, each therapist can open the PowerForm, add their input, close and sign. As a result, the Team Conference Summary is nearly complete by the time the team conference is held. From a WinStation in the Conference Room, final touches are applied. The document is then signed and is immediately available in the patient chart, with copies printed for relevant parties. Figure 22: CareNotes Patient Instructions

This approach benefits clinicians by requiring minimal typing due to drop-down lists; enabling simultaneous therapist and clinician collaboration on the document before the conference; providing a discrete, secure and legible document that can be forwarded electronically; eliminating hard-copy typing; and providing timely inclusion in the patient’s chart.

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Figure 23: Team Conference Frames

Aggregated Data Analysis and Reporting The primary toolkits used for extracting data for reporting and analysis, are CCL (Cerner Command Language), PowerVision® and Discern Explorer®. STS Reporting for Cardiology is performed annually with these tools.

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Internal quality and performance assessments are performed in several areas: Transplant Service Patients admitted with elevated creatinine levels by patient gender Nursing Unsigned verbal orders reported for completion to remain within medical center policies and procedures PRN “reason” to identify why medications are ordered PRN Quality of medication delivery and charting Health Information Management Incomplete charts of discharged patients with details of deficiencies by physician In error report of documents included in CPR in error Refuse to sign report of documents returned by physicians Letter for physicians detailing incomplete or delinquent charts

WORKFLOW AND COMMUNICATIONS Functionality within Gemini is designed to enhance communication and teamwork between and among caregivers. On the basic desktop for physicians, called the physician work center, an Inbox supports both workflow and clinician-to-clinician communication. The work center uses a desktop metaphor and enables physicians to view and execute clinical tasks using exceptionbased processing. Physicians particularly like the fact that communication with other caregivers is a by product of their interaction with Gemini and does not require additional steps. For example, the first screen presented when signing on is the Inbox. The Inbox includes folders that contain documents-to-sign, documents-to-review, phone messages and consult orders. Documents arrive in folders through a variety of methods including a Figure 24: Physician’s Inbox transcription interface, from another caregiver, via a phone message recorded about a specific patient, or from new consult orders. Documents sent for signature are generated as a by product of the transcription interface. Gemini supports the documentation workflow associated with educating physicians, nurses, and other clinicians. For example, when a resident documents care associated with a patient (regardless of how it is entered), the resident can use onscreen shortcuts such as mailbox favorites to forward the information to the attending physician. Typically, the action required is a co-signature and brief statement by the attending physician. Prior to Gemini, this process was performed on paper with a slower turnaround time and charts were unavailable to others while awaiting review.

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Figure 25: Forward Document Screen

Figure 26: Phone Message Screen

Gemini greatly streamlines the patient flow process. Typically, when patients present in the exam room, the nurse logs on to record the initial assessment, then uses the Change User function to lock the information for security purposes and to leave it in a ready state for the physician. When the physician arrives in the exam room, they simply log on to immediately view the screen left by the nurse. The physician can then easily document problems, allergies, medication, and procedures. Change User Screen

Figure 27: Problem List Screen

Figure 28: Allergy List Screen

Figure 29: Medical History

Figure 30: Surgery Procedures

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OTHER OPERATIONAL AND STRATEGIC ACTIVITIES Gemini makes high-quality clinical information available in real time across the entire organization. This information is not retrospectively entered or entered by delegates, but rather by the clinician at the point of care. The information can be accessed autonomously by authorized medical center staff without requests to the Health Information Management Department.

Administrative Financial managers in both the medical center and affiliated group practices can access the Gemini system for information required for billing. Also, patient care coordinators review utilization concurrently using Gemini. Forms which support the capture of data discretely allow for updates by other care coordinators as well as future analysis.

Patient Safety Use of Gemini has reduced medical errors and improved the quality of care. Gemini’s adverse drug event expert system helps minimize the risks of negative medication combinations. More broadly, the comprehensive information available through Gemini gives clinicians an up-to-date and complete clinical picture of the patient’s condition. Figure 31: Care Coordination Forms

Research As the medical center continues to accumulate empirical data, it intends to work closely with the Health Sciences Colleges and other health sciences colleges to develop grant-funded research programs and a research database. The Gemini database was designed to fully support a variety of research efforts. Currently, discussions are underway with department heads in the College of Medicine to develop the tools required to support and manage clinical trials.

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Regulatory

Figure 32: MAR Screen

Security policies and procedures mandated by the medical center, JCAHO, and the Health Insurance Portability and Accountability Act are monitored and enforced through Gemini. The Gemini system allows for centralized training, implementation, and management of these requirements. Accommodating audits by regulatory agencies and payers also is much easier than before the implementation of Gemini. Requests for documentation are quickly and comprehensively addressed. Currently, UICMC is routinely achieving 100 percent compliance within one hour for large medical records requests by auditors.

USER SATISFACTION, PRODUCTIVITY AND EFFECTIVENESS System Use By any measure, Gemini has been an overwhelming success for UICMC ’s hospital and clinics. It is virtually unanimous among physicians and nurses that the system has vastly improved the ability to deliver clinical information and has substantially increased the level of care. Based on the positive experiences and feedback to date, the decision to continue the CPR initiative on the inpatient side and transform the hospital has been embraced across the enterprise. In fact, many clinicians have approached the medical center administration requesting that the implementation be accelerated. System use has increased steadily since the initial go-live date in October 1997. Over time, users have expanded significantly to include physicians, nurses, clinicians, and administrative support personnel. Most agree that, initially, use of the system actually slows down the documentation process until users gain system proficiency. While documenting “first visits” may be slower than previously was the case, users agree that subsequent visits are documented more quickly and resulting benefits outweigh the cost. 102

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Because the response time of key nursing functions have improved, more nurses are using the system and the average time these users spend on the system has decreased. Figure 34: Average Time Spent in Powerchart Per Sign On July/February

The extended use per log-on for faculty members reflects their use of the system to monitor how residents are caring for patients. At any point in time, utilization statistics show that there are rarely fewer than 300 users on Gemini. Figure 35: Gemini Sign-Ons

Multiple audits conducted prior to Gemini implementation demonstrated that the patient record was not available at least 40 percent of the time, leading to the creation of “shadow charts” in the ambulatory clinics. With emergency visits, charts were seldom available. Given that UICMC handles approximately 400,000 ambulatory visits each year, it is safe to say that at least 160,000 patient visits occurred without the availability of a paper record, unless the clinic had a shadow chart. Today, the medical record is available 100 percent of the time. In addition, clinicians are reviewing records in their entirety more frequently due to ease of access to the information. 103

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User Satisfaction and Added Value Surveys of UICMC’s faculty physicians and nurse staff regarding the Gemini system overall, as well as the Matrix Orders (CPOE) system in particular, have revealed a high level of satisfaction. Satisfaction is evaluated in terms of number of users and how the system is actually utilized, as well as analytical feedback from the surveys. A 2000 survey of our faculty physicians revealed a high user acceptance, with 70 percent of physicians categorized as Enthusiastic Adopters and 30 percent as Reluctant Users. The large majority of respondents agreed that the system: Greatly enhanced their ability to communicate with other physicians. Increased the availability of medical records. Provided easier access to ancillary test results. Made it simpler to determine the treating physician (not a trivial challenge in most academic medical centers) Improved the legibility of documentation. Made it easier to locate sought-after clinical information within the chart. Indeed, just six months after conversion and despite the upheaval associated with the consolidation of clinics in the Outpatient Care Center, 65 percent of respondents stated they would choose Gemini over paper records. A recent survey of Housestaff users showed an even higher rate of satisfaction with the CPR. It should be noted that the satisfaction rate was estimated to be much higher among residents, who were not surveyed.

The survey was repeated one year later, in 2001, and this time included house staff. Results were even more encouraging. A full 90 percent of respondents would choose Gemini over paper records. Housestaff were clearly more likely to be enthusiastic adopters than faculty in the 2001 survey. Neither category (enthusiastic vs. reluctant users) could be distinguished by age, specialty, gender, e-mail use, typing skills or years in practice.

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Approximately six months after going live with the new Matrix Orders application, the physician order entry module, Cerner and UICMC surveyed clinician users to better understand acceptance of the system, as well as areas requiring refinement. These one-on-one surveys revealed that clinicians believed the new system was an improvement over the previous system in terms of usability and efficiency and that they would recommend the system to other hospitals.

A large majority of users interviewed about the new Matrix Orders system said the system was the same or better than the previous system and they would recommend the system to others. Figure 36: Personal Efficiency Survey Results

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TECHNOLOGY Overview A major reason for the Gemini system’s success to date has been its ability to deliver, not only the CPR, but a wide range of other stand-alone, non-interfaced clinical and business applications through the WinStation desktop. These heavily used solutions represent fertile ground for future integration into the CPR. In 1996, after approval for the new patient care system, the medical center information technology staff began building a client-server architecture from the ground up. The system was designed to be as efficient and scalable as possible, with relatively static maintenance requirements. This approach has allowed the medical center to minimize total cost of ownership. Although clinical and administrative use of the network has skyrocketed, information technology staffing has not increased significantly. The Microsoft NT network and NT operating system also allows the medical center’s information technology group to respond quickly to change, delivering updates to 2,800 WinStations without touching them individually. Updates to the WinStations are supported by Microsoft Shared Management Software (SMS) delivered in a multicast manner to 100 PCs at a time. Rather than store application software locally, UICMC applications are stored on 15 application servers and a predefined ghost image is all that is distributed to WinStations. This partially homegrown technology performs spectacularly and supports highly efficient maintenance of PCs and servers. Among Cerner HNA Millennium clients, UICMC is ranked in the top five percent of users with respect to speed of response time.

SCOPE AND DESIGN OF CPR SYSTEM System Description

The Gemini (Cerner) applications run on two Compaq 8400 Alpha machines utilizing VMS version 7.1-2 (TCPIP), UCX version 5.0-10 and Oracle 7.3.3.6 as the database. The Alpha’s run in RAID 1 mode with complete drive shadowing, maximizing system availability and complete system redundancy. A tape robot is utilized for backups, performed nightly as exports of the 150 GB database. Each week a full, hot backup of the database is also performed. In addition, transactions which flow through the Cloverleaf interface engine are stored online and are accessible by the Gemini Team for 30 days in case there is a need to replay any transaction. This is facilitated through UICMC-developed Web-based Cloverleaf tools that allow the Gemini Team to access and replay select transactions or select timeframes. Integration

Interfaces between UICMC applications are exclusively managed by an interface engine utilizing HL7 standards. The medical center’s approach since inception has been to keep the interface engine specifications as clean as possible, while shifting any customization requirements to the applications. This follows a clean design methodology and allows for consistent interface definitions and high quality across all interfaces. The interface engine runs on an IBM RS6000 and UNIX operating system. Among the external interfaces is a link to a transcription services vendor. This capability supports dictation into the CPR. An updated copy of the UICMC master patient index (MPI) is provided to the vendor. This allows the transcriptionist to verify correct patient identifier 106

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information as entered or dictated by physicians. After the transcription is completed, the system directs documents into the correct physician Inbox and into the patient’s CPR. Because access to databases outside Gemini are critically important in the clinical environment, there is a connection from the WinStations to the Multum drug database and the CareNotes database, both of which reside on servers in the UICMC Data Center. Access to other external databases is available to support both the teaching and care processes. These databases are reached through high-bandwidth Internet access and embedded routines. For example, shortcuts are created on the WinStation desktop that allow residents and faculty quick access to the MDConsult, Web of Science, OVID, and HealthStar (Grateful Med) knowledge bases. Another knowledge database, Medline, can be accessed through the Cerner Millennium Problems List. Document imaging is an integral part of the electronic health record at UICMC. Images are scanned by Health Information Management and stored on optical platters. Images are then staged to DASD from the optical platters when a patient appears on a UICMC schedule. This process dramatically improves response time when clinicians seek to pull up an image. System Architecture and Data Storage

The UICMC network configuration supports a network of 2,800 WinStations and over 4,500 clients. The network includes 185 Intel servers delivering e-mail, application, database, printing, intranet, and security services. Each individual client is provided personal network storage that is accessible from all network connections. Each department may have common network storage for their employees and shared departmental files. All ancillary systems and most radiology modalities share the same physical network infrastructure with the CPR. For many of those applications not yet fully integrated with the Gemini CPR, access to results can be provided on the “WinStation” via web browsers, Citrix MetaFrame, and other means. Ultrasound clips, low resolution radiology images, EKGs, and endoscopic images also can be provided to authorized clinicians in this fashion. Security for the ancillary systems is integrated into the larger security strategy described later. The network infrastructure varies by building. The newest building, the Outpatient Care Center, has a 10/100 Mbit switched Ethernet available at every data jack. All switches are dual homed to network access points in two buildings. All of the digital radiography equipment is connected to this infrastructure. Image traffic is segregated with the use of a Virtual LAN (VLAN). The buildings have been designed without storage space for charts or films, so the high availability network design is critical. A gigabit Ethernet backbone network connects all switches in the Outpatient Care Center to the hospital. The hospital is also supported by 10/100 Mbit Ethernet switches. Most data connections run at the lower speed. As the wiring plant is improved or when there are special needs, data jacks are set to the 100 Mbit speed. Two physical gigabit paths connect the hospital switches to Outpatient Care Center. Local data centers in each building are maintained for application servers, ancillary data bases, and e-mail servers. Minimal communication services (network access, e-mail, and local data base applications) can be delivered if the building is isolated from the campus network. Separated from the medical center campus, the Information Technology Data Center provides a high security environment with independent power. All of the mission critical clinical databases are housed in this center. Three Compaq Alphas that support the Gemini patient care system reside in this location. Two of the Alphas are configured to fail over to each other. The third Alpha is primarily a testing and certification environment but also maintains another copy 107

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of production data. It is used as another level of production redundancy. Database servers and key computing hardware are connected on a 100 Mbit FDDI network within the data center. External access to the network is strictly limited to data center routers and communications equipment. The use of local modems on individual WinStations is discouraged. In addition to many other performance improvement measures, the medical center is in the final stages of building a data center in the hospital building and will continue to deploy faster, even more scalable servers in anticipation of continued system growth. Figure 37: UICMC Network

Cerner’s Open Clinical Foundation (OCF) Data Repository is the cornerstone of UICMC’s CPR. Cerner’s Microsoft Windows-based viewer, PowerChart, complements OCF. OCF/PowerChart runs on an advanced, three-tiered client/server distributed relational database, which uses a multi-platform, open, Internet enabled approach known as HNA Millennium. HNA Millennium was designed and developed to achieve an advanced, easy-to-use, flexible user interface with shared servers over a single open data model using a standardized language directory. This unified, open information architecture delivers substantial benefits to UICMC, particularly when it comes to integrating existing disparate systems. Transferability

A contributing decision factor in the choice to go with Cerner was the system’s user-level flexibility for supporting specific design requirements at the institution. This flexibility allows UICMC to limit system complexity, control training requirements and produce over-all consistency across the enterprise. As previously stated, one of UICMC’s objectives was to not only create a highly functional CPR for internal use, but to produce a system prototype that could be recreated at other institutions. To that end, UICMC works with Cerner to allow other organizations to adopt the Gemini system’s blueprints, specifications and modifications. Scalability

From the outset of the Gemini Project, scalability was a primary objective for both system performance as well as training and support. As a result, virtually every aspect of the project has been designed, developed and implemented in a manner which facilitates efficient, scalable support. This scalability is reflected in the efficient WinStation desktop model, code distribution approach, and network-driven, computer-based training. Scalability is also aided by closely monitoring and controlling customization by end-users. Templates and forms are evaluated and compared to others to ensure that a standard emerges across similar services. For example, Family Medicine and Internal Medicine share similar template and form requirements for some patient types. 108

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The server architecture and code delivery vehicles were both designed to maximize throughput. Performance tuning is performed regularly at numerous levels throughout the threetiered client server architecture. In fact, the same software robot used to monitor and report system performance around the clock also is used to provide notification when there is a system problem. For example, one factor that generally indicates that a serious problem may be developing is a slowdown of the client software. The monitoring robot provides an early warning to information technology staff when this occurs. Emerging Technologies

The Technology Solutions Group (TSG) at UICMC is responsible for all platform, network and operations support. To assure maximum sophistication in this group, a back-ground in healthcare technology was not required of recruits. Rather, the group includes individuals who are focused on pure technological improvements, enhancements, and sophistication, which can then be applied to the clinical setting. Two examples of the enhancements developed by the TSG include: 1. Citrix Metaframe was originally developed as a WinStation desktop alternative in 1998 and deployed very early in the CPR development. This technology provided remote access from locations where WinStations were not deployed, such as physician’s homes and academic offices. The Citrix Metaframe allows clinicians to access Gemini through a PC and any Internet Service Provider. 2. ADSM is a hierarchical storage methodology allowing Gemini’s clinical data to be stored in stages, both online, near-line, and offline. The approach makes it much easier to back up and restore data in a crisis situation. New technology utilization at UICMC is driven by both technologists and clinicians. The objective is to deploy functionality that generates the most value for the widest array of users. New technologies are assessed based on their potential impact on a variety of user populations, including nursing, faculty physicians, house staff and pharmacists. Nurses, for example, will benefit from wireless WinStations on medication carts, which allow them to more efficiently chart medication administration. Similarly, wireless WinStations help physicians maintain an upto-date understanding of a patient’s condition. Identifying potentially useful emerging technologies is the joint responsibility of UICMC’s chief information officer and the Group for Advanced Systems Planning Committee. The objective is to continue to take advantage of technology to create a more integrated, information-rich healthcare environment. Although the CPR has been enormously successful, UICMC is constantly looking years into the future to ensure that the organization is wellpositioned to continue delivering the most efficient, highest quality care. Efforts are underway to deliver even more comprehensive clinical information to the WinStation desktop. Currently, the medical center is exploring ways to deliver clinical images through Gemini. The objective is to be able to deliver a wide range of clinical images in an easy-to-use, cost effective manner within the next two or three years.

SECURITY AND DATA INTEGRITY The Gemini system has been designed and developed to support the collection of clinical information during the care process. The objective is for the individual who first learns of the clinical information to be able to easily enter it into the system in real time. The application is structured to either guide or restrict the user in certain choices so the data users enter are more consistent. This consistency enables the database to be manipulated with interactive-type rules as 109

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well as retrospective analysis. Data are carefully backed up and stored in an incremental and redundant manner to protect against an array of potential disasters. Each week, a copy of the Gemini database is stored offsite to protect against massive system failure. With multiple backup methodologies, UICMC has several options for quick recovery under a variety of circumstances. The most likely event would be corruption of data on a specific Oracle table. The system’s nightly database export allows for quick recovery of a particular table, and applies rollback logs to update all transactions. The RAID 1 controller array supports the highest level of system availability possible. With complete system redundancy, the medical center is able to avoid downtime for even a major hardware failure such as the loss on an entire node, as unlikely as that may be. Although archiving the Gemini CPR is not currently performed, the longitudinal record is available in its entirety online. The medical center’s long-term goal is to move to near-line hierarchical model which maintains clinical information at the hands of the users. This approach will be transparent to the end-user.

Security and Confidentiality Cerner’s HNA Millennium architecture is an effective technical foundation of security when used in combination with strong policies, consistently applied procedures, well-trained people, and other technologies. Well-designed information technology provides better tools than were available in a “paper-based” world to protect patients from inappropriate use of their health information. However, they are only as good as the context in which they’re used. UICMC has addressed security from several perspectives: user authentication, access control strategies and accountability strategies. User authentication is the process of positively identifying a user through the use of login names and passwords. Access control strategies restrict the functions and data accessible to a user or group of users according to preset rules. Accountability strategies encourage a user to make appropriate use of health information they are authorized to access. Safeguards against the inappropriate use of health information without compromising timely access to it requires a security model that is flexible and broad. Confidentiality and security issues were addressed early in the planning process. UICMC thoroughly assessed governmental and commercial security standards and subsequently identified key security safeguards aimed at minimizing the risk of loss, damage or misuse of information processed by or stored within the medical center’s computers. UICMC’s security standards and safeguards continue to be reviewed on a periodic basis for improvement and to be sure that the medical center remains compliant with new standards such as the Health Insurance Portability and Accountability Act. Application training is required prior to access being granted and security awareness and confidentiality training are provided annually. The system is built on a multi-tiered architecture so that users do not log into or create transactions directly against the database. In general, security features address the following key areas: User authentication to positively identifies each individual user.

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Access to the electronic medical record is role-based. Access control strategies are provided to restrict functions and data available to a user or group of users according to preset rules. Unique user identification is maintained using network identifications which are password protected and provide an automatic log-off feature. Once a document has been signed, it is protected against deletion or alteration. Accountability strategies encourage a user to appropriately use of health information they are authorized to access. Audit controls are available that log all user events, including the name of the accessing individual, the relationship to the patient, and the access date and time.

User Authentication Anyone who uses UICMC’s software must be positively identified. The authentication process is based on a third-party arbitration scheme and occurs when users log into the system. In this instance, the trusted third party is the system security server, which manages the account database. The login process begins with the user supplying information pertaining to his or her identity, specifically the name of the user and a password. Usernames are comprised of alphabetic or numeric characters and are unique to the individual. The system does not enforce a limitation on maximum password length and the minimum password length is six characters. Initial passwords are pre-expired; users are forced to change passwords upon initial log in. Users may choose passwords that contain combinations of alphabetic, numeric and special characters and are able to select and reset their own passwords at will. User accounts can be disabled in real time by a system administrator, or after an organization-defined period of time of inactivity. At login, a message containing only the username is sent to the security server. The security server locates the corresponding record in the account database, and subsequently extracts the hashed value of the user’s password. Passwords are never stored in the account database in clear-text form. Instead, the password is fed through a hash algorithm, which has the unique property of being non-symmetrical. Given a hash value, it is impossible to compute the original text used in the hash computation. Using the account information, the security server constructs a token and encrypts it with the password hash. The token is then sent back to the user in the form of a message. A hash is then calculated using the password supplied by the user. It is worth noting that the password is never sent over the network, either in clear-text or hash form. The hash calculated by the client program is then used as the key to attempt decryption of the token sent by the security server. If decryption succeeds, the password supplied by the user must be correct. If not, the token is discarded and the login process fails. Inside the decrypted token is a special ticket constructed by the security server that is used in subsequent communications such as connecting to application services. The ticket itself is encrypted by a key known only to the security server, and hence, cannot be modified by the client. Attempts to modify the ticket are ultimately detected by the security server. To ensure security if a user fails to log out of the application, the system ends the session and invokes a screen saver at a preset time-out period. To re-enter the system, the user must be re-authenticated.

Access Control Strategies Access control is based on (1) who the user is, (2) who the patient is, and (3) the desired level of disclosure between the two. Operationally, the system allows for the definition of user 111

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authorizations (position, organization, etc.), patient data characteristics (location, encounter, special status, etc.), and logical relationships between the two to permit sophisticated and flexible access controls. The overall effect is that a user has a specific set of task authorizations, has logical relationships with a given patient at a given time, and each patient has data privileges. UICMC has chosen to limit access to functions for users whose role in care delivery does not require their access to that function. Thus position-level security logic sets permissions to access an application (or a task within an application, or a task group) based on a user’s position. It is defined for every user of the system. Each position is authorized to perform tasks, which equate to functions in the system. Tasks contain a group executable actions that users can or cannot perform and enforce access to data or files. If a user’s position profile prevents access to a task, the application prevents the user from seeing related menu items or other visual displays. Once the user is allowed access into a clinical application, based on his or her position, he/she must have an active relationship with the patient in order to view the chart. Relationships, in practice, are typically used for direct care providers to describe how the provider is associated with a patient. The system respects two types of relationships: A person level and an encounter level relationship. Person level relationships are expected to carry over many encounters, such as Primary Care Physician. Encounter level relationships are associated only with a particular encounter, such as Admitting Physician. Each position is assigned a predetermined set of relationships, which can be associated as the reason for opening a patient’s chart. Additional security can be added for entire records or for selected data within records. Patient charts considered to be at a greater risk for a breach of confidentiality require the use of additional access controls. Situations requiring these controls include prominent individuals such as board members, celebrities, employees; confidentiality protected patients such as victims of child abuse; and organizational/encounter protection such as psychiatric treatment facilities and encounters. Additional security can also be placed on the record when necessary. For example, additional access restrictions are used for mental health notes and consults; this section of the record is restricted to a pool of providers approved for access to this portion of the medical record.

Accountability Strategies All relationships declared by a user as they access a patient’s chart are logged and tracked as they are activated, inactivated, or modified. The list of access is available for review in the patient’s chart. Each time the chart is opened, the system records the user, patient, and the date/time the chart was opened. The data may be extracted into a report to review an individual’s access to a chart(s). There is also a GUI tool to review information on system access. Viewable information includes the user name, the functions accessed, the date and time of the access, the location of the computer, and whether the attempt was successful. A number of auditing reports are available to track system use. These include: Users who have not logged into the Gemini system in a certain period of time. All users by position. All users by application group. All tasks associated to a position. All tasks associated to an application group. 112

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STANDARDS Common User Interface Common user interface standards for UICMC go well beyond Gemini. The medical center has extended the definition of easy user interface all the way to the WinStation desktop. The result is that for end-users, there is little differentiation between applications delivered to their WinStation. Regardless of where a clinician logs onto Gemini, they get the same look, feel and performance. And clinicians enjoy the same performance levels, whether logging on remotely or locally.

Data Exchange and Content HL7 standards are deployed throughout the Gemini architecture, as are discrete definitions of the data fields. The UICMC interfaces between applications was carefully designed to ensure consistency, scalability, and data integrity. Data manipulation on the Cloverleaf interface engine is minimized to ensure consistency-of-use across all applications. The data content and vocabulary standards are maintained by a group within the Gemini Team, and supported by a data dictionary. The data dictionary supports consistent use by limiting a multiplicity of similar terms. Each type of data has a single data field name, allowing for consistent and accurate updating.

PERFORMANCE When Gemini was initially introduced, the system was relatively slow and, from a technical standpoint, was not very reliable and stable. In time, operational procedures and policies were developed and improvements made by Cerner in the middleware and other aspects of the system. Fortunately, we were able to avoid any extended downtime during this early period, and users appreciated the new functionality that Gemini provided. As Gemini became the sole or primary medical record, enormous effort was focused on ensuring system availability and eliminating downtime. While there were a few glitches, overall, the system was rapidly stabilized and monitoring procedures put in place and refined. At the outset of conversion, information technology personnel attempted to anticipate a variety of worst-case scenarios that could impact the system. As a defensive measure, a downtime database was created that included a recent version of the production database. The downtime database was formatted as a read-only system and made available through the medical center’s intranet. During the first week of inpatient orders implementation, Gemini was virtually unusable during peak periods. The downtime data base provided a critically important safety net, and maintained clinician confidence in the Information Technology Department and Gemini during the difficult transition period. Numerous aspects of system availability are monitored regularly, as shown by the following system availability and performance graphs.

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System Availability Two to four hours of monthly downtime is planned for the first Wednesday of every month. All other systems which may impact the availability of information in Gemini follow the same schedule to minimize interruption. Figure 38: Availability Percentage

Figure 39: Response Time

Business Continuation Planning The medical center is well-prepared with both automated and manual systems for planned or unplanned downtime. The organization has manual downtime procedures in place to ensure the continuation of Gemini operations for both the hospital and ambulatory sites. These procedures are practiced in the hospital on a monthly basis. For ambulatory sites, a current copy of the Production database that allows read-only access to patient charts is available over the intranet. IT staff training emphasizes good trouble-shooting and solid decision-making in the event of unplanned downtime, and a series of steps have been developed to ensure that expeditious action is taken. Careful planning and testing of system failover of the totally 114

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redundant system helps guarantee system availability. A wide range of likely scenarios and possible events have been studied and trained for. Upgrades and Enhancements

The medical center has carefully planned how it implements system changes so it has the ability to make extensive updates easily and with minimal interruption to users. IT personnel can deliver client code in a completely hands-off fashion. All changes follow a specific routine that includes extensive testing of back-end and front-end systems. The downtime necessary to make the changes is timed, so that end users will have an idea of when the system will be back up. Also, the upgrade tests are run no fewer than three times to ensure a flawless and expeditious deployment. Communication about system changes occurs through PowerUsers, through the medical center’s intranet training site, and via the Gemini announcement window on each user’s desktop. Gemini response time is monitored 24x7 using automated software drones and displayed on the UICMC intranet.

VALUE Overview Validation of the original business proposition is performed on an ongoing basis. The financial commitment made to the CPR originated not only at the medical center level, but also at the campus, university and Board of Trustee levels. All parties are in agreement that the project’s objectives have been met, and, indeed, believe Gemini’s benefits have substantially exceeded expectations. Qualitative indicators, including feedback from clinicians and patients as well as utilization statistics and fiscal benefits, confirm this success. UICMC’s pioneering role in the area of clinical information systems has been underscored by the numerous health care organizations that have visited the organization to learn more about Gemini. These organizations routinely approach the medical center’s software vendor for assistance in replicating what UICMC has accomplished. Outside organizations that evaluate health care applications and CPR implementations nationwide have been invited to UICMC to assist in validating Gemini’s success. Unanimously and consistently they have reported that UICMC is one to two years ahead of the nearest, similarly sized organization in terms of utilization and depth of implementation of the CPR. As use of Gemini increases, the system is being viewed as both a recruitment and retention tool by all of the Health Sciences Colleges. It also has become part of the curriculum in many of the colleges, including Nursing, Pharmacy, Dentistry and the College of Health and Human Development Sciences.

Measuring Success The previously installed order management system was not Y2K compliant. One of the immediate goals for the inpatient implementation was to replace current state functionality supported by the legacy system, improve upon it wherever possible, and standardize functionality. Intensive system design sessions between UICMC implementation teams and Cerner, resulted in a more functionally rich product that met the basic system requirement to support inpatient needs. 115

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In October 2000, UICMC and Cerner’s Benefits Realization Practice jointly conducted an assessment of the value received to date from Gemini. The study revealed that the total estimated financial value received from the $10.3 million investment in hardware and software has been $3.6 million from the project onset to early 2001. Among the quantitative benefits revealed by the study: Physicians spend 30 percent less time looking for charts. On average, this time savings accounts for 30 minutes saved per day. The outpatient Neurology Clinic reports patients are processed much more efficiently and hence are delivering care to more patients. Number of patients seen without a medical record reduced by 40 percent. Gemini acts as an active agent on behalf of physicians and patients by making a complete medical record available online for every patient visit. More than 5,000 annual radiologist hours redirected to patient care. Thanks to Gemini, each attending radiologist spends, on average, five fewer hours per week reviewing medical records. This time savings is jointly attributable to film access as well as access to a complete medical record through Gemini. Physicians save five hours per week in the review of resident orders. With Gemini, the senior resident staff can manage their patient lists and details of patient care in real time. Previously, this was accomplished through the paper medical record that was often incomplete and unavailable. Approximately $1.2 million of nurse time reallocated away from manual documentation tasks. Gemini’s power and flexibility has enabled nurses to spend less time in the medication administration process. Registered nurses in the charge nurse role report spending 2.75 less hours per shift in the medication administration process, while nurses in the patient caregiver role report spending one less hour in the medication administration process. The nursing staff has reinvested the time savings in the direct delivery of patient care. Seven full-time equivalents, or $172,800, saved in the Health Information Management Dept. Gemini has enabled chart assemblers to improve productivity because orders and results are available online. Prior to Gemini, the assembly rate for each clerk was four charts per hour. With Gemini, that rate has increased to seven charts per hour for a 75 percent increase in chart assembly productivity. Staff in other areas have been reassigned due to the rapidly diminishing need for traditional paper handling. Chart pulls decreased by more than 75 percent (from 2,000 to 500 per month). Requests for charts have significantly decreased due to the availability of electronic outpatient records. It is estimated that chart requests specific to patient care will decrease by at least 90 percent once the inpatient side of UICMC is entirely paperless. The only charts still requested are for audit reviews. Accelerated care review. Physicians, nurses, utilization review and discharge planning staff have found that Gemini allows them to begin the care review process much sooner. Elimination of paper forms. At least 12 paper forms have been eliminated to-date as a result of the automation available with Gemini. These forms are a combination of internally and externally produced forms. Approximately $1.7 million in ambulatory clinic construction costs and $39,000 in annual maintenance costs averted. UICMC was so confident in the Gemini system that 116

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it built the Outpatient Care Center without medical record storage space. This decision resulted in a one-time construction cost savings of $1.7 million, along with an annual maintenance cost avoidance of $39,186.

User Testimonials “I save 30 minutes a day not looking for charts.” – Peter Joo, M.D., pediatric resident. “When someone gets admitted at 11:00 at night, you can read what his doctor said about him a week earlier.” – Bill Galanter, M.D. “When I refer a patient within our network, I know the consultant has all the information I do. I can’t imagine going back to the old system.” – Patrick Tranmer, M.D., Interim Head of the Department of Family Medicine “The key benefit of HNA Millennium architecture has been easy access to information we need to make decisions as physicians. Prior to HNA Millennium, we had difficulty getting the information we needed to manage our patients. Now information access is easy. We don’t have to worry about lost records. Multiple physicians and other health care providers can access the same information simultaneously. The information is legible, it’s well-organized, and it’s in a format that is easy for us to make decisions.” – Daniel Hier, M.D., Professor and Head of the Department of Neurology

Enterprise Success The benefits of the conversion to an electronic medical record are many. Prior to installing the new system, UICMC estimated that a patient’s paper record was not available when the patient arrived for care 40 percent of time. Today, those records are accessible 100 percent of the time for physicians, nurses and other clinicians across the care continuum. Improved access to records has meant dramatically improved efficiencies in a variety of areas. With the paper-based system, the average turn-around time for laboratory and radiology reports was three days. With Gemini, diagnostic test results are available within seconds of being verified and are brought to the physician’s attention through their Gemini Inbox. In addition, redundant orders that were often triggered by result delays have been virtually eliminated with the faster turnaround time, as well as with duplicate order checking on all orders. Communications between clinicians also has improved vastly, particularly between the emergency room and primary care physicians. Nurses also have reported saving time during their discussions with insurance companies. The Gemini system has needed patient information available on one screen. In the previous, legacy system, nurses had to flip back and forth between multiple screens, a tedious task that cost them a considerable amount of time over the course of a day. Patients also have been saved time and aggravation, since the ubiquity of the desktop records means the patient is no longer asked the same questions numerous times by a variety of caregivers throughout the institution. Another important benefit has been the way in which physician co-signatures are obtained and tracked for transcribed inpatient reports, such as operative reports and discharge summaries. In the past, the medical center used three employees to perform this work. Now, the physician signs electronically and the three full time employees have been reassigned. As well, the ancillary charts that previously were kept to safeguard against the possibility of a lost chart have been eliminated, along with the inherent storage and retrieval costs. 117

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In summary, the Gemini Project has been an overwhelming success at the University of Illinois at Chicago Medical Center. All initial strategic and tactical objectives have been attained, and Gemini has exceeded expectations with regard to direct benefits to clinicians, patients, and the enterprise itself. In fact, Gemini is quickly becoming known nationally as an exemplary CPR implementation. More than 50 health care organizations from the United States and abroad have visited the medical center during the past year to witness the transformation in process and learn from UICMC’s experiences. While much has been accomplished, much remains. The opportunities that lie ahead are welcomed by clinicians, administrators and the Cerner Corporation. All are anxious to continue the partnership and complete the transformation.

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