Illinois' Cook County Hospital opened in the 1830s as the Poor House, providing free medical care to poor victims of a cholera epidemic. Now 175 years later, its charter remains the same: to provide quality health care regardless of a patient's ability to pay. The key difference is that the Poor House has become one the most advanced health care centers in the world.

Today, the Cook County Bureau of Health Services is a health care behemoth that includes four main hospitals, 3,582 licensed beds, 35 community health care clinics and more than 40 satellite offices of the county's Department of Public Health.

The centerpiece is the John H. Stroger Jr. Hospital, which stands out like a light box in a neighborhood of limestone hospital buildings on Chicago's West Side. The $623-million acute care facility, which opened in 2002, has helped drive service levels at the bureau to heights worthy of a war effort.

The bureau's facilities account for 1.3 million outpatient surgeries a year, 44,000 inpatient surgeries a year - one every 12 minutes - and 15,000 prescriptions filled daily.

Given such demand and a dependence on public financing, the bureau has a strategy to keep costs under control: wholesale automation of the labyrinthine
workflows that have clogged the system with unnecessary expenses and medical errors since it opened its doors.

"We see [information technology] as a key way to enhance quality, improve efficiency and assure safety," said Mike Sommers, the bureau's chief information officer. "Just because a patient cannot pay, that does not mean that they deserve less."

Goodbye, walls

Sommers has led the effort to build a state-of-the-art health care delivery system at Stroger. Once a showcase for medical talent and innovation - it hosted the first blood bank and established the first medical internships in the nation - the old Cook County Hospital had become a fortress of old infrastructures, looping workflows and glacial systems upgrades.

In 1975, conditions were so bad that some doctors were jailed after trying to close the hospital in a revolt against the administration.

Today the hospital boasts a number of technology-based innovations that place it in the exclusive league of 10 percent of U.S. hospitals operating an enterprisewide electronic medical records system, Sommers said.

Now all orders at the hospital are made online. One administrative record follows a patient perpetually, regardless of where or when he or she entered the hospital's clinical network. What's more, the hospital has gone "filmless." Interns no longer have to wait in line at the radiology window to pick up patients' X-rays.

"From an electronic standpoint, our health care system has no walls - it's all one record," said Sommers, a former IBM health solutions executive who has also held IT positions at other hospitals. "If a patient is seen at one of our facilities and two weeks later comes to another facility, it doesn't make a bit of difference to the clinician because the electronic information from ... all previous encounters follows that patient."

The key to "one record" is the bureau's enterprise master person index (EMPI), a metadata system that enables one longitudinal - or continuous - electronic record to be kept for every patient, from the first time he or she enters the system and at every step thereafter.

An EMPI is a software-based registry that uses a patient's demographic information to link their medical records across multiple applications, clinical systems and providers by pointing to data rather than the records themselves.

For example, a physician at Stroger can pull up a record for a patient who has been at Cook County's Oak Forest Hospital, even though facilities maintain unique patient case numbers. The system runs on Cerner's CapStone EMPI software, a component of the company's Millennium solution.

Coffee, tea or lacto-variant kosher?

Record indexing may be invisible to clinicians, but computerized order entry is their power application.

Every time a physician orders a medication, diet, lab test or nursing instruction, it is entered into a computerized physician order entry (CPOE) system, which functions like a master index.

The bureau's Cerner CPOE system is a rare breed - less than 5 percent of U.S. hospitals operate one. The biggest reason is cost. The tab for launching the bureau's CPOE system was $25 million.

A big part of the cost is systems integration. Like all enterprise software, CPOE systems are not plug-and-play. Instead, they are sets of best practices, embedded in software, that must be tweaked to incorporate local care-giving preferences and workflows.

"It's a cookbook," said Ron Hately, a Cerner director who helped the bureau deploy the system. "I can use
it to ensure I'm taking into account the experience of others who have gone through this process, and then
I can tweak it to fit my own organization."

Sometimes the tweaks can be time-consuming. The original CPOE version included several dietary options, for instance.

"In terms of choices, it was excessive," said Dr.
Krishna Das, Cook County Hospital's associate chairwoman for inpatient medicine. "Lacto-variant kosher? Do we need that listed? So we just edited, edited
and edited, with physician input, down to about three lines. That satisfied the dietary department and the
clinicians."

One of the big challenges in deploying the new system involved configuring workflows for a hospital that had not yet opened.

"While we were bringing up our base applications at the old hospital, we were also building the new facility," Hately said. "Probably the biggest challenge was when we didn't know what the workflow was. Here we were designing a workflow for a department or a nursing station that didn't even exist."

Medications account for the single largest set of orders at any hospital. Cook County's facilities fill a staggering 15,000 prescriptions a day. With that many opportunities for entering a prescription incorrectly or ordering medications that could cause an adverse reaction, the county made computerizing the system a high priority.

Now medication orders at Stroger are sent electronically to the hospital pharmacy, where robots fill the prescriptions and alert the nursing staff. By the end of the year, the bureau plans to install a bar code system capable of tracking an individual pill from the time an order is entered to the time the dose is administered to the patient.

The system will read bar codes on individual pills or small packages of pills. When the dose is administered, a nurse will scan his or her identification badges and the patient's ID bracelet, creating a timeline of the dose. Fewer than 200 hospitals in the United States have such a system, Sommers said.

When an order is entered into the Cerner system, it is also screened for the "five rights": right patient, right medication, right dose, right time and right route. The system checks for potentially adverse drug interactions and allergies. For instance, a prescription for penicillin might not be filled until a patient's allergies have been documented.

Next step: Interoperability

The Holy Grail of electronic medical records is transparency, integrating clinical information from multiple sources and making it instantly available to caregivers. The reality, however, is that specialists - whether in cardiology, obstetrics or intensive care - favor different systems that don't communicate with one