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By 2007, the board members who oversaw Dallas-based Parkland Health & Hospital System were becoming impatient. The sprawling taxpayer-supported system had made significant progress in computerizing its functions, but installation had been primarily focused on non-patient care areas, such as billing and patient registration. The IT team, led by Chief Information Officer Jack Kowitt, was working plenty hard, says then-board member Rick Kneipper. Still, board members wanted to get patient treatment tools, such as computerized provider order entry and medication administration, off the planning schedule and into the hospital, he says.

That impatience burst into public view at a board committee meeting in which Kowitt laid out an 18-month time frame for implementing an electronic medical record, as he recalls it. The response from board members, according to Kneipper: Not fast enough. "We said, 'Take that schedule you just delivered to us and speed it up on all the things that would help physicians, nurses, etc., to improve their patient care,' " Kneipper says.

Kowitt's initial reaction? "I grimaced," he says, chuckling. Nancy Folz-Murphy, deputy chief information officer, also remembers the board's pressure. "The first thing you do is you kind of catch your breath. Oh my God, how much more do you want us to do?"

But a new schedule was hammered out, one that pushed the EMR launch date up by three months. It also reflected a more "big bang approach," as Kowitt describes it, enabling the EMR system to be launched throughout the hospital, rather than in phases. Kowitt credits the board with an understanding of the project's demands. "When the board pressed [on the schedule], they also said, 'What kind of resources would it take?' he says. "They didn't withhold the resources that it would take to do it right."

On April 28 of last year, the EMR system was launched at the 685-bed hospital. By then, Parkland officials had installed a wireless system and mobile computer workstations throughout the aging facility, the same hospital where President John F. Kennedy was rushed in 1963. Doctors and nurses today use computers to document and track numerous aspects of a patient's treatment, including laboratory results, physician orders and medications administered.

By the end of this year, Kowitt predicts that the EMR will facilitate 90 to 95 percent of all inpatient and outpatient treatment provided in the system's hospital, specialty and school-based clinics, and community health centers, and through other services. The price tag for the project through fiscal year 2010, according to Kowitt, is roughly $70 million, including a new computer network.

Long-Term Commitment

Parkland's fast-track phase was the final push in a rather serpentine process. While some hospital boards are just now moving forward with EMR implementation, in light of the millions earmarked for incentives and penalties under the American Recovery and Reinvestment Act of 2009, Parkland board members have been striving for roughly a decade to get patient records off paper and into computer systems.

By all accounts, it wasn't always an easy path. During that stretch, there were significant changes in leadership, most notably a board schism. In 2004, four of the seven members of the Parkland Board of Managers, including the chair, quit over differences with the hospital's management and financing. And, as the new board got up to speed, they had a number of pivotal issues to address, including whether to revisit plans—tabled for a stretch—to build a new hospital. A new facility is now in the works, after Dallas residents approved $747 million in bond financing. The 862-bed hospital, projected to cost nearly $1.3 billion, is slated to open in 2014.

Still, even when the new hospital's future was uncertain, board members remained committed to computerizing medical records, says Lauren McDonald, M.D., the board's chair and a trustee since 1999. "We knew whether we had a new hospital or the old hospital, working toward EMR was something we wanted to do," she says.

Achieving that goal has enabled Parkland, as a taxpayer-supported system, to not only improve its own patient care but also remain competitive in Dallas, she says. "I don't think we're smashing the competition, but it's nice to know that we are right alongside everyone else."

Parkland serves as the region's safety net hospital system, as well as the primary teaching hospital for The University of Texas Southwestern Medical Center. The hospital's emergency department, which includes a Level 1 trauma center, handles 130,000 patient visits annually. The clinic system, with 11 community health centers and numerous other school and mobile-based sites, racks up more than 950,000 annual visits. And Parkland's volume of baby deliveries, nearly 16,300 babies in 2007, ranks the system at or near the top of deliveries nationally.

Not surprisingly, that level of patient treatment generates a staggering quantity of paper. A warehouse the size of a football field, with 13.5 miles of shelving, holds the medical records of patients treated within the last three years, says Robin Stults, Parkland's vice president of health information management. Prior to the launch of the EMR system, the quantity of loose paper that needed to be filed in charts at the facility stacked up—literally—into the equivalent of a 15- to 25-foot-tall tower of paper each and every day, she says. "We ran a permanent backlog, truthfully."

But the volume and the complexity of Parkland's patients also make an EMR and related technology tools particularly beneficial, says Ruben Amarasingham, M.D., director of the Center for Knowledge Translation and Clinical Innovation at Parkland. An internal medicine patient hospitalized at Parkland, for example, has eight different diseases on average, he says. "So you have these multiple conditions all requiring multiple treatment plans. And an electronic medical record essentially allows you to manage all of those much more efficiently and carefully."

Amarasingham led an analysis of urban Texas hospitals, published last year in the Archives of Internal Medicine, which found that a 10 percent increase in computerization of patient notes and records resulted in a 15 percent decline in fatalities. Higher scores in specific areas, such as the automation of test results and decision support, also correlated with lower hospital costs, according to the analysis of 41 hospitals.

Picking Up Speed

Parkland's strategic planning and related information technology purchases date back to the start of this decade. But board members revisited their IT goals and timetable regularly, particularly after the four new board members were added. "It was really a re-evaluation of the entire information technology division—all aspects of IT were reviewed," says Louis Beecherl III, a current Parkland board member who was part of the new contingent.

One key decision was whether to stop using an outside consultant for information technology, Beecherl says. "We decided that it would be better to oversee it in-house, where we would have more control," he says.

Outsourcing frequently works well, Kneipper is quick to say, not surprisingly given his day job as co-founder of PHNS, a Dallas-based company that provides information technology services to hospitals. But the complexities involved with Parkland's implementation required a more tailored and on-site approach, he says. "You really needed to have something that's staffed by people who understood how Parkland delivers services."

The move also saved money, allowing Parkland to add more staff, Kowitt says. Since IT was brought in-house in 2006, the department has expanded from about 150 staffers to more than 250 full-time employees, he says.

Still, board members remained actively involved, treating the IT staff almost like an outside consultant, with a slate of goals and deadlines that needed to be met, Kneipper says. In short, the board pushed the schedule as much as feasible, Beecherl adds.

"When you hire either an outside or an inside group to do this process, the inclination of the people running the program is to probably go too slow," he says. "From the governance position, if you are going to spend the money, you might as well spend the money and get it done as fast as possible."

The timetable was not the only element in flux. There also were some new faces in the executive suite. Prior to assuming her position in 2007, deputy CIO Folz-Murphy says: "I interviewed with all of the chiefs and executive vice presidents and everybody was new. Everybody had been here less than two years with the exception of Jack Kowitt."

The EMR project, which always had long-time CEO Ron Anderson's backing, really solidified into a systemwide initiative once key expertise, such as Chief Financial Officer John Dragovits (recruited from Cerner Corp.), joined Parkland, Kowitt says. It became easier to get clinicians involved, he says. "This takes staff from all areas—this isn't just an IT project," he says.

As the EMR pace quickened, Kowitt requested that the board's IT committee meet more frequently. There were too many details to discuss than could be fully addressed within the limited IT portion of the full board meeting, he says.

Also, the board helped to streamline the hiring of consultants and other outside expertise needed to meet the compressed schedule. Typically, the board's policy is to approve any contract exceeding $200,000, Kowitt says. But the time lag involved would complicate hiring, he says. Instead, Kowitt developed an IT budget that was approved by the board; he then provided regular updates.

Training and Launch

With roughly 6,000 nurses, doctors and medical residents to train throughout the system, Parkland's personnel challenges were daunting. On the one hand, Parkland's ties to UT Southwestern meant they had a lot of tech-savvy doctors, Beecherl says. There was some grumbling among the older physicians, who preferred to finish out their careers without messing with the new technology, but the board didn't equivocate, Beecherl says. "It was made very well known that once we implemented an electronic medical record that we weren't going back and that all of the paper was going to go away," he says. "So either you adapted to this system or you weren't going to be working at Parkland."

The time that the clinicians spent in training on the technology—Parkland's primary EMR vendor was Epic Systems Corp.—did vary, according to Folz-Murphy. The nursing training ranged from 10 to 16 hours and the physicians anywhere from two to eight, she says.

Parkland's staff had to move quickly to install the necessary cabling and other hardware, including more than 1,200 computers and more than 800 wireless antennae, before the April launch date. Much of that installation didn't get rolling until the prior September, Folz-Murphy says. IT staffers worked floor by floor through the hospital, installing and testing, flexing their hours to minimize disruption to patient care, she says. "For the amount of work that was done, it was very aggressive," she says of the schedule.

In the final weeks leading up to the launch date it wasn't unusual for staffers to be working 24 to 36 hours at a stretch, Kowitt says.

One reason the go-live went as smoothly as it did was the board's willingness to free up funds for technology experts who had weathered launch days at other hospitals, Kowitt says. And they were distributed throughout Parkland Memorial, ready at a moment's notice. "So we could have them right at the elbows of our [clinical] users," he says. "So the users never felt excessively uncomfortable, excessively cast adrift."

Kowitt's staff also provided other safety nets, including a conference room designated as a crying room for those who wanted to decompress. There were only a handful of visitors, he says.

The benefits of a centralized medical record were immediately evident to Parkland clinicians, Stults says. "You basically had access to patient care information instantaneously," she says. "In the traditional paper world, you might have a dozen different people competing for a patient chart."

Thinking Regionally

As Parkland breaks the computerized information barrier, it has plenty of company in Dallas, says Steve Love, chief executive officer of the Dallas-Fort Worth Hospital Council. Other local systems, including Baylor Health Care System and Texas Health Resources, also are implementing the technology, he says.

The hospital council compiled a patient database, with roughly half of the council's 75 hospital members participating, that will help local facilities better track patient trends across the region, Love says. For example, Parkland officials can look at statistical trends regarding what percentage of the hospital system's patients are readmitted, following discharge, at other nearby hospitals.

"And that consolidated data is very important for [hospitals] to understand," Love says. "I just can't give them patient-specific data," he says, citing HIPAA and related confidentiality concerns.

McDonald, Parkland's board chair, believes other elements also play a role. "I think some of it is competition," she says, regarding sharing of patient information between hospitals.

Meanwhile, Parkland continues to wrap up its implementation of EMR and other related clinical tools. Was compressing the schedule risky? Yes, according to Kowitt. "The basic risk would have been just that all of the parts weren't ready," he says.

But Kowitt and his team made it happen, Kneipper says. "You have to just decide what's important," he says. "We decided, as you would if you are in a public, mission-driven hospital, that patient care is everything. So we didn't really care about improving the transactional side as much as we did the patient care side. So speed up those things. And it was a great result."

Charlotte Huff is a writer in Fort Worth, Texas.

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