Getting to the Point

As an academic medical center, Rush University Medical Center encompasses a 613-bed hospital, the 61-bed Johnston R. Bowman Health Center and Rush University–home to one of the first medical colleges in the Midwest and one of the nation’s top-ranked nursing colleges.

In 2004, Rush revealed its plan for the most comprehensive construction and facilities renovation program in its history. Known as the “Rush Transformation,” the comprehensive plan has the medical center investing $800 million in new technology and facilities over a 9-year period. “In addition to delivering better care today, this plan raises the issue of how we’re going to deliver patient care going forward,” says Rush University Medical Center CMO David Ansell, M.D. “Facilities and technology are just tools that lead to what occurs at the bedside between a nurse, a doctor and a patient.”

According to Ansell and VP of Information Services Jim Kearns, this complete transformation not only includes technology platforms such as the enterprisewide rollout of a new electronic medical record (EMR) platform, computerized physician order entry (CPOE) and POC solutions, but also the construction of three new facilities which includes a two million square foot hospital addition on the campus.

In order to present a unified leadership model of the project, Ansell and Kearns were tapped as the key leaders for the clinical transformation. “The identification and implementation of mobile devices at Rush is really tied to our Epic Systems EMR implementation, which is more like a 4-year project across three different phases,” says Kearns.

Challenges

Ansell arrived at Rush as the medical center was about to sign a contract with Epic. As he explains, nurses and physicians were used to CPOE, but the early system lacked mobile capabilities as it was done at fixed stations. “Rush was one of the first institutions in the country to develop CPOE, but it was archaic. However, the good news was that we had it in an environment where people were used to ordering via computers,” says Ansell.

According to Kearns, Rush had very little choice in replacing some systems, as some were failing or about to become obsolete. This included the pharmacy system and the billing system, which would end contractually at the conclusion of 2007. Additionally, the ADT (admit/discharge/transfer) system was struggling based on how Rush needed to operate. “These were just a few of the challenges that David and I had in figuring out the timing of go-live for different systems in order to create an effective workflow for the clinicians–both the nurses and the physicians–while solving the technical challenges without really disrupting what happens on the floor,” says Kearns.

Process of Discovery

In order to tackle the plethora of workflow and infrastructure changes, Rush utilized a Failure Modes and Effects Analysis (FMEA) approach. The FMEA approach looks at what could fail in a system and enables you to provide a detailed review of the processes to identify if the risks are workflow or IT oriented, rank them in order of severity and then create a plan for addressing them. “I would say that any place where we did that, we were able to identify human issues, program issues and how best to address them, but wherever we didn’t do that, we found later on that we had some problems,” says Ansell.

As the FMEA approach took hold, the co-chairs became acutely aware that everything boiled down to understanding the enterprise’s workflows for successful system rollout and implementation. In September of 2006, the Epic clinical committee began to sit in large rooms validating workflows. Testing began in late October 2006 with the new CPOE go-live in May of 2007. “Workflows also apply to the mobile devices because understanding workflow is integral to what tools you need, where they are placed and how staff can access them,” says Kearns.

Guiding Principles

Both the clinical and technological members of the committee invested a great deal of time talking to other similar health systems that had instituted the Epic platform in order to identify not only successes to replicate but also mistakes to avoid. This also marked the beginning of discussions around mobile devices for POC such as tablets, wall mounts and carts. “This is a large transformation of our patient care facilities, which were constructed between 1890 and 1980,” says Kearns. “Multiple solutions were required to address disparate needs.”

According to Ansell, one of the guiding principles was to be as close to the bedside with the technology as possible so that computer, caregiver and patient were all together. This led to a democratic process of in-depth discussions regarding types of devices and locations. The devices Rush staff requested included everything from mobile tablets and laptops, to wall-mounted or fixed station computers, to true mobile devices. “We took all of those needs–some of which were constrained by space and electrical requirements–and ultimately came up with a device strategy that was driven by what the users wanted, physical constraints and cost,” says Ansell.

Cart Configuration

The next step was to set up a technology room as close as possible to the hospital and stock it full of various wireless device technologies. This included several types of tablets, laptops, carts with different looks and feels, hand scanners, signature pads and other potential devices. “We created somewhat of a playground where we invited nurses and physicians to come and just experience the Epic EMR on those devices,” explains Kearns. “From there, each unit came up with their proposed device recommendations and quantity as our starting point.”

This part of the process revealed the challenges associated with possible solutions in workflows that had yet to be implemented. Additionally, staff was asking for more devices than the committee anticipated, but the FMEA process in conjunction with the guiding principles resolved the issue. “The first 50 carts were really about checking the concept, so all of them had to be completely overhauled as we ultimately selected a very different cart with different capabilities, technology and accessories than the one for the pilot,” says Kearns.

POC Partners

A long-term relationship with technology reseller CDW Healthcare was an integral part of the POC mobile cart solution for Rush. The reseller has a strong presence in the Chicago market as well as a large warehouse and technology configuration center. The huge undertaking of the Rush Transformation presented so many different areas of concern that defining, assembling and testing what would eventually be more than 400 carts would have required Rush to become experts overnight.

With space at a premium, Rush and CDW held a number of planning sessions geared towards a first-quarter 2007 rollout. Time constraints also became an issue as Rush began meetings with CDW in December of 2006 with implementation of carts happening just two months later. “They thought we were kidding, but once we got them past that, they quickly put together a program for us where we could literally purchase all of the components, put them together in their Vernon Hills warehouse facility, test them for QA to very tight specifications, store them and, as needed, have them delivered in groups of 20,” says Kearns.

The final custom-configured Ergotron carts included height-adjustable LCD monitors, Wyse thin client terminals with wireless PCMCIA cards, optical mouse and keyboard trays, power and Ethernet cable management systems, rechargeable batteries with status panels, storage baskets and the imaging software to deliver the EMR applications and evidence-based order sets for CPOE.

While configuring, testing and storing the carts for rollout was a challenge, facilities management at Rush identified a potential problem with plugging in some 400 units. Internal discussions with clinicians revolved around getting units in all patient rooms in order to achieve the guiding principles of POC in every room. Rush learned late in the game that each one of these devices draws five amperes, and electrical capacity challenges within parts of the infrastructure limited the number of possible devices at any given time. “You have to assume that battery recharging will happen concurrently, and the total amperage drawn would create problems,” says Ansell.

Deployment

Ultimately, POC at Rush was a carefully orchestrated assemblage of more than 1,000 units with mobile carts, fixed units, wall-mount units and some laptops in order to address both human and space concerns. “For example, there are some places that were so tight–such as where our Pyxsis machines were located (where medications were distributed)–that the nurses couldn’t get the carts up to them, so we mounted laptops on top of them,” says Ansell. “We’re also experimenting with having mobile carts for every room on some floors and evaluating the effectiveness.”

The normal process of shifting things around, and the age span between buildings, generated some of the key issues, one of which was the IS team deciding on thin clients as well as a resultant expenditure of roughly $1.8 million to dramatically update Rush’s wireless infrastructure across all patient care areas. “The carts have thin clients utilizing Citrix application delivery, which obviously supplies huge support benefits because we don’t have to worry about viruses, or doing individual application upgrades,” says Kearns.

To date, the only additional challenge with the POC surrounded the need to log in multiple times based on the applications used. “Our recent implementation of single sign-on functionality has resolved that issue,” says Kearns. “Further optimization is being tested in the form of proximity devices and fingerprint readers.”

Training

Training on the Epic systems and carts began in December of 2006 for an April 2007 go-live and was composed of several key elements including classroom, online, video and written training reinforcement. Video modules were created as a post go-live refresher. In addition, some of the carts from CDW were set up in what Rush called a “playground” mode, where staff was allowed to practice with fake orders and patients.

In order to deal with the various learning curves of nurses, the committee created a mandatory nurses assessment test of their PC skills. This was because none of Rush’s older previous technology was mouse-driven. “We put hundreds of nurses, patient care attendants, those without post-secondary degrees and those without computer experience through a test and they had to get a certain score,” says Kearns. “Ideally, you want to train everyone the day before go-live so everything is fresh in their minds, but we had to train almost 7,000 people, so it was physically impossible.”

Moving POC Forward

Qualitative results from such a massive undertaking that is still in its early stages are still being identified, gathered and interpreted. However, significant early indicators show documented results for specific areas such as Pharmacy, where the number of non-formulary drugs utilized within the institution have significantly decreased on average from 250 per month to less than 40 per month. Additionally, the first day of go-live revealed that at least one medication error had been avoided.

As positive gains continue to reveal themselves, both men see the project’s success thus far being chiefly about not repeating the mistakes of others. “When I started out, I didn’t see a single organizational approach that I thought would work at Rush, so we invented a new model,” says Kearns. “A lot of that model was driven by our culture. We have a saying here that ‘culture eats strategy for lunch.’ A lot of hospitals struggle with this because you have to do this within the confines of the culture.”