Medical records at Rush University Medical Center in Chicago are now fully electronic, allowing real-time communication and coordination of patient care across departments.
The two-year, multi-phased transition from paper documents to full clinical documentation, using new electronic health records technology from Madison, Wis.-based Epic Systems, was completed in March, according to Rush executives. They said fewer than 2 percent of hospitals nationwide have adopted an EHR system like Rush's that covers all clinical units.
"The new system allows physicians, nurses and other members of the healthcare team to review and document every aspect of patient care online – from medical histories, clinical notes and physician orders to diagnostic tests and prescriptions," said Julio Silva, MD, the hospital's chief medical information officer.
Rush's EHR management system is a key component of the medical center's 10-year transformation project, begun in 2006, which includes new facilities, renovations and technology and is designed to improve clinical outcomes and the patient and family experience.
"We began the transition to electronic health records while simultaneously planning our new facilities so that the benefits of the system could be incorporated into the buildings' design and layout," said Larry Goodman, MD, president and CEO of Rush. "With medical charts online, our building design was able to move away from large central nurses' stations to decentralized work areas and mobile computer platforms at the point of care, dramatically changing how caregivers work with each other and with patients."
The new EHR system also supports Rush's efforts to further improve patient outcomes. The system's clinical decision support features pop-up screens with alerts, reminders and checks for healthcare providers when they log into a patient record.
For example, medication alerts signal if a patient is allergic to a drug that has been newly prescribed, based on the patient's medical history. Medication alerts are also triggered when interactions between drugs could be harmful. Calculations are automatically provided for drugs whose dosage is weight-dependent.
Other electronic reminders prompt caregivers about recommended evidence-based clinical guidelines, such as diagnostic tests and medications to consider for patients with congestive heart failure.
"The records are available in real time and from anywhere both within the hospital and outside through a secure-access online system," Silva said. "Even when physicians are not at the hospital, they can quickly access a patient's records and take any necessary action, such as prescribing a medication or ordering a test."
"Implementation of the electronic medical records system was extremely complex, but highly successful, thanks to the training program we instituted throughout Rush and the full support of everyone involved, from senior administrators to clinicians," said Lac Van Tran, senior vice president and CIO.
According to a study in the New England Journal of Medicine, only 1.5 percent of U.S. hospitals have a comprehensive electronic record system covering all clinical units. An additional 7.6 percent have a basic system serving at least one clinical unit. Only 17 percent of hospitals have implemented a computerized provider-order entry for medications.
