online at dartmed.dartmouth.edu—Dartmouth Medicine 45Summer 201144 Dartmouth Medicine—online at dartmed.dartmouth.edu Summer 2011
E
arly in the morning on Saturday, April 2, a
woman arrived at the DHMC Emergency De-
partment suffering from abdominal pain. Her
case marked a turning point for Dartmouth-Hitch-
cock: she was the first patient admitted using a new,
comprehensive electronic health record (EHR).
Many DH staff compared this transition to an
earlier milestone: the 1991 move from Hanover,
N.H., to the then-brand-new campus in Lebanon.
Twenty years ago, however, the primary change was
in where people worked. Once they figured out
where to go, their jobs remained largely the same.
By contrast, says Todd Vogt, senior director of the
conversion to the EHR system, implementing that
transition has required changing how 7,400 people
work—all from one day to the next, and without
disrupting the care of patients.
To those outside the world of medicine, a new
format for health records may not seem of great sig-
nificance. But the change was about much more
than record-keeping. A key goal of the switch to
the new system, dubbed “eD-H,” was to improve
the care patients receive; the process took years of
preparation, thousands of hours of staff time, and an
investment of about $80 million.
Despite the pervasiveness of technology in al-
most every facet of modern life, health care has re-
mained surprisingly reliant on paper to keep track
of patient care. A 2010 survey by the Centers for
Disease Control and Prevention found that 50% of
physicians use some form of EHR, but only about
10% use a system considered comprehensive. And
the most recent rigorous survey of hospitals, pub-
lished in 2009 in the New England Journal of Medi-
cine, found that less than 2% of hospitals use EHRs
in every clinical unit—as DH now does.
There are a number of reasons for this slow pace,
including the complexity of patient care and the
high cost of adopting EHRs. Dr. David Blumenthal,
the national coordinator for health information
technology in the U.S. Department of Health and
Human Services, believes that “the widespread use
of electronic health records in the United States is
inevitable.” But, he admits, “inevitability does not
mean easy transition.”
Federal legislation passed in 2009 allotted up to
$27 billion over 10 years to encourage the switch to
EHRs. Organizations that meet certain standards—
called “meaningful use” requirements—will be eli-
gible for significant payments from Medicare and
Medicaid. In the case of DH, that could mean re-
couping about $30 million over the next few years.
This legislation, explains Dr. Andrew Gettinger, a
leader of DH’s transition, is just one of many rea-
sons that now was a good time for DH to make the
change to a new system.
G
ettinger is an enthusiastic early adopter of per-
sonal technology, and he’s enthusiastic about
the benefits of technology in health care, too.
An anesthesiologist by training, he is also DH’s
medical director of information systems and infor-
matics. Having worked at DHMC since 1983, he
has seen—and helped lead—a number of techno-
logical changes.
In the mid-1980s, DHMC developed its own
software, known as CIS for “clinical information
system,” to handle basic medical record-keeping
functions, such as patient demographics, in some
departments. Other units, including nurses on in-
Esty is the managing editor of Dartmouth Medicine.
On the Record
Dartmouth-Hitchcock is one of a very small number of health systems to have adopted
a comprehensive electronic health record. In every single clinical unit. In a changeover
that happened in just one day. Here’s how that gargantuan task was accomplished.
By Amos Esty
A self-proclaimed technophile, Andy Gettinger was one of the leaders of Dartmouth-Hitchcock’s transition to a comprehensive electronic health record system.
JON GILBERT FOX
Implementing the transition
has required changing how
7,400 people work—all
from one day to the next, and
without disrupting the care of
patients. The most recent
rigorous survey of hospitals,
published in 2009 in the New
England Journal of Medicine,
found that less than 2% of
hospitals use EHRs in every
clinical unit—as DH now does.
online at dartmed.dartmouth.edu—Dartmouth Medicine 47Summer 2011
tively and efficiently. “The reality is, just get it out there and then see
what you need to do to fix it,” Gettinger said before go-live. “It will
be a little bumpy over the next couple of months.”
Gettinger also realized that not everyone was enthusiastic about
the change. “There are a lot of folks who don’t fully comprehend why
we’re doing this,” Gettinger says. “They’re pretty comfortable with
CIS.” He adds that there are many challenges that face health-care or-
ganizations like DH, including declining resources, the national push
to reduce the cost of health care, and diminishing reimbursements
from payers. “All of those put tremendous pressure on clinicians,” he
says. “So we’re taking a group of folks who are feeling pretty over-
whelmed and saying, ‘Oh, by the way, we’re going to completely re-
tool your workplace.’”
Vogt explains that it is no small thing to ask very accomplished
clinicians, particularly senior physicians who are experts in their fields,
to become beginners all over again. In fact, they might have more
trouble learning to use the complicated new system than younger,
more tech-savvy residents and junior faculty. “That’s extremely hard
for someone with years and years of experience, be it a nurse, a physi-
cian, anybody,” Vogt says.
Dr. James Bernat, a neurologist, said in the days leading up to the
transition that he was a bit apprehensive about how it would go. “I
must say that the complexity of it and the learning curve to become
well-versed in it is greater than I’d anticipated,” he said. “It’s very
complicated.” But, he added, “what’s amazing to me and reassuring is
the number of hours that dedicated people have put into this, plan-
ning it and executing it.”
Bernat, an expert on medical ethics, also expressed concerns that
are relevant to the use of any EHR system. He is very conscious of the
need to make patients feel that they—rather than the computer—
have the attention of doctors and nurses. “I think engaging with the
patient, looking at the patient, making the patient feel that this is
about them is important,” he said. Although he—like every other
doctor and nurse at DHMC—went through hours of training to learn
to use the new system, he acknowledged it would not be until he was
using it with real patients that he would know with any certainty how
it would go. “Until you’re actually doing it, you’re not going to feel
confident about it,” he said.
I
t did not take long on April 2 for the new system—and the doc-
tors and nurses using it—to be put to the test. Soon after the offi-
cial switch, Drs. Edward Merrens and Joseph Perras were paged to
the emergency room. There they admitted the woman suffering from
abdominal pain using eD-H. Merrens says that he and Perras may have
consciously taken a bit more time than usual working with the pa-
tient’s record but that they didn’t have any significant problems. Per-
ras adds that despite some difficulties that slowed them down, “there
were certainly hints to the potential power and utility of Epic.”
At the same time, dozens of Dartmouth-Hitchcock staff sat in a
conference room at the Medical Center and waited for the phones to
start ringing. They were there to ease the transition by answering
questions as clinicians called for help in using the new system. And,
particularly in the first few days, there were many calls to answer. The
“incident command center,” as the conference room was called, was
filled around the clock for two weeks.
Deanna Orfanidis, the nursing director of the intensive care unit
46 Dartmouth Medicine—online at dartmed.dartmouth.edu
patient units, continued to use paper records. Over
the years, DH computer programmers improved
CIS, adding a number of capabilities. Doctors and
nurses could look up patients, see the results of lab
tests, write notes, and perform many other tasks us-
ing the system.
But about four years ago, Gettinger says, it be-
came clear that CIS did not have the power to meet
the institution’s future needs. He says consultants
estimate that developing and maintaining a com-
prehensive EHR system costs between $500 mil-
lion and $1 billion, making a custom system some-
thing few organizations can afford. Using off-the-
shelf software, though still a significant investment,
seemed to be the more cost-efficient option.
Settling on which new software was itself a ma-
jor undertaking. After evaluating the available op-
tions, the DH leadership decided on a system devel-
oped by Epic, a Wisconsin-based company. With
that decision made, the push was on to prepare for
the big change.
In the months and weeks leading up to April 2,
2011, there were plenty of concerns. One was how
well everyone would adapt to the system. Every
clinical staff member spent up to 16 hours in train-
ing classes and had to pass proficiency tests. Even
so, it was impossible to perfectly mimic using the
system in a real-life clinical setting.
As the go-live date approached, Gettinger and
Vogt talked excitedly about the benefits of eD-H.
“It’s not just installing a new information system to
replace those that we already have,” said Vogt. “It’s
changing the way we deliver care.”
For one thing, the system would be implement-
ed not just at the main DH campus in Lebanon, but
also at all of the sites that are encompassed by DH-
Manchester and DH-Nashua in southern New
Hampshire. Patients who receive care at any of
these locations would have a single medical record,
making it easier to coordinate their care.
G
ettinger also pointed out that the new system
uses a number of evidence-based order sets,
meaning it should be easier for caregivers to
pull up the best available information about how to
treat patients. For example, if a patient is admitted
to DHMC because of a heart attack, eD-H will list
all of the treatments that would typically be pro-
vided to such a patient, according to the very lat-
est evidence. A doctor may decide to change some
of those treatments based on the condition or his-
tory of an individual patient, but the expectation is
that the evidence-based order sets should help stan-
dardize care and cut down on medical errors.
And the fact that the data that’s entered into
the system will be consistent regardless of the pa-
tient, caregiver, or location should make it easier
to track the care provided across DH sites, to bill for
the services provided, and to report on the quality
and outcomes of care.
Vogt says it should also help make handoffs from
one caregiver to another easier, because everything
is documented in the system, so there is only one
place a clinician needs to look to see everything
about a patient.
In addition, the switch to eD-H is intended to
improve patients’ own ability to access information
about their care. Using a website dubbed “myD-H,”
patients will be able to schedule appointments, look
over their medical records from home, and see the
results of various tests, among other functions.
But despite the benefits, it was clear that the
transition was not going to be easy. Gettinger con-
cedes that the strategy for the transition involved
rolling out eD-H before it was perfect. “We’re go-
ing to go forward with a methodology that involves
putting it out there when it’s not quite fully baked,
but it’s good enough for clinicians to use it,” he said
a few weeks before April 2. Vogt added that doctors
and nurses had many good suggestions for improve-
ments to the software, but that at some point it was
essential to move forward, even if the system was
not yet perfect. The plan is to continue to optimize
it, first by fixing any pressing problems and then,
over the long term, by figuring out how the system
needs to be changed to make it work more effec-
Summer 2011
The months leading up to the transition to the new EHR were intense. Every one of DH’s 7,400
clinical employees had to take up to 16 hours of training on the system—requiring over 1,300
hands-on classes, like this one—and then pass a proficiency test before being allowed to use it.
GEOFFREY HOLMAN
ALL: MARK WASHBURN
Many departments conducted dress rehearsals before the April 2 “go-live.”
Vogt explains that it is
no small thing to ask very
accomplished clinicians,
particularly senior physicians
who are experts in their fields,
to become beginners all over
again. In fact, they might have
more trouble learning to use
the complicated new system
than younger, more tech-savvy
residents and junior faculty.
48 Dartmouth Medicine—online at dartmed.dartmouth.edu
and the intermediate surgical care unit, describes
the first week as “pretty hectic.” But, she adds, “I
feel like it’s smoothing out. . . . It has gone better
than I anticipated.” She was impressed by how
quickly the staff have picked up the system. “It’s a
steep learning curve,” she says.
S
andra Dickau, the vice president of patient
care, arrived at DHMC at 5:00 a.m. on April
2. She says the staff she talked to in the days
leading up to the switch were both excited and ap-
prehensive. In the end, she observes, it went well.
“It’s a huge change for us, but in the inpatient side
of the house we’ve done very well,” she says. “It has
gone incredibly smoothly.”
One reason for that success, Dickau says, is that
everyone remained focused on patient care despite
whatever problems arose with the new system. “Our
motto has been the patient first, each other second,
and the chart third,” she says.
Both Orfanidis and Dickau cite a number of
benefits of the new system, particularly the fact that
every piece of information about a patient is now
available within the electronic record, making it
unnecessary to hunt through pages and pages of pa-
per records to find relevant details.
“The information will be so much more readily
available at your fingertips,” Dickau says. And, Or-
fanidis adds, having electronic records gets around
the infamous problem of doctors’ handwriting.
Merrens believes that eD-H also makes it easier
for physicians to discuss a patient with nurses, as all
the necessary information is readily available. But,
he acknowledges, actually finding the information
in eD-H can be frustrating. He compares the tran-
sition to driving a car in England. “You’re still dri-
ving a car, but the rules are totally different,” he
says. Overall, he adds, “it was a little bit bumpy at
the beginning,” but within a few weeks of the tran-
sition he had seen significant progress in doctors’
and nurses’ facility with the system.
A
few physicians expressed deeper skepticism
about the benefits of eD-H. One described
the system as “clunky,” noting that it is less
intuitive than CIS. The primary problem, he adds,
is that it takes much longer to get anything done
than it did before. He concedes that additional ex-
perience may make using eD-H more efficient, but
he predicts that it will always take longer to get
most things done in eD-H than it did before.
Another physician worried that every task re-
quires so many steps that it will be difficult to con-
duct effective patient meetings, noting that a 15-
minute appointment does not leave a lot of time to
fill out all of the fields required by the system.
One resident was happy about the ability to ac-
cess patient information from anywhere in the
Medical Center but was finding it difficult to ma-
neuver among the program’s many tabs and fields.
Indeed, many doctors appreciated having so much
data at their fingertips, but they seemed over-
whelmed by the process of trying to find the most
relevant information.
Gettinger acknowledges that learning to navi-
gate in the new system is not easy. “It’s very com-
plicated,” he says. “You can get lost very fast.” He
thinks it will just take time for doctors and nurses
to feel comfortable using it. He says he reminds
them that it takes a lot of work to develop the abil-
ity to interact effectively with patients, regardless of
whether a computer is part of the process.
Some of the precepts are pretty simple, he says—
don’t look at the computer during the first few min-
utes of an interaction with a patient, make eye con-
tact, try to establish good rapport early on. “The
computer is an easy fall guy” for bad interactions
with patients, he adds.
Some physicians have also expressed doubts
about the long-term benefits of the system, point-
ing out that there is not a lot of published evidence
showing that EHRs actually improve patient care.
But Gettinger believes that the ability to gather
standardized data will eventually lead to improve-
ments in care. He says that being able to show
Summer 2011
Over 1,500 employees participated to varying degrees in the selection of DH’s new EHR system;
the chosen software was widely preferred by both physicians and nurses. And some 600 employ-
ees got extra training so they could support others in their departments during the transition.
continued on page 61
MARK WASHBURN
Merrens acknowledges that
actually finding information
in eD-H can be frustrating.
He compares the transition
to driving a car in England.
“You’re still driving a car, but
the rules are totally different,”
he says. Overall, he adds, “it
was a little bit bumpy at the
beginning,” but within a few
weeks he had seen significant
progress in his colleagues’
facility with the system.
beginning to hold joint encampments at ma-
jor battle sites where for the first time they
found it possible to salute each other’s valor
and honor.”
Today, 150 years later, the Civil War still
maintains an almost unmatched hold on the
imagination of Americans. Each year, mil-
lions of people visit Civil War battlefields
and museums, research ancestors who fought
in the war, participate in re-enactments,
watch Civil War-related films and television
programs, read a seemingly unending stream
of books and magazine articles (including
this one!), and collect artifacts, photographs,
and ephemera.
The Civil War sesquicentennial, which
runs from 2011 to 2015, will likely spark, re-
new, and intensify interest in the now long-
ago struggle. Thankfully, recent scholarship
has resulted in a shift in attitude among in-
formed Civil War enthusiasts toward the
conflict’s medical casualties and caregivers
and the challenges they faced.
Nevertheless, myths still prevail among
the general public. There is more yet that
can be learned, and shared, about those
“years of change and suffering.”
online at dartmed.dartmouth.edu—Dartmouth Medicine 61Summer 201160 Dartmouth Medicine—online at dartmed.dartmouth.edu Summer 2011
Years of change & suffering
continued from page 43
mater. Like most surgeons of the day, Crosby
almost certainly entered wartime service
holding conventional, even primitive, ideas
about the nature of psychological illness.
Yet by 1864, he was able to recognize
these invisible wounds of war, writing in a
letter to a colonel that one of his patients
had a disease “rather mental and moral than
physical” and that he did not recommend re-
leasing the soldier from the hospital.
And many soldiers continued to bear
emotional scars when they returned to civil-
ian life. Anecdotal evidence of associated
problems abounds: domestic abuse, divorce,
alcohol and drug abuse, and more. It is clear
that Civil War veterans’ combat-related
mental-health tribulations did not stop with
the end of the war.
Recent research has made us even more
aware of just how debilitating such injuries
can be. (And it bears mentioning that much
of the research about what we now call
PTSD has come from the Veterans Affairs
National Center for PTSD, which is housed
continued from page 48
doctors how their patients fare compared to
patients cared for by other doctors is a pow-
erful way to inspire changes that can lead to
better care. “The value of an electronic
health record is that you are able to acquire
that actionable data and then feed it back to
the clinical community for them to make
changes,” Gettinger says. He notes that CIS
was able to track some basic measures, such
as a list of medications and a patient’s height,
weight, and other similar information, but it
could not be used for more sophisticated
data-gathering.
The ability to collect and analyze data is
also integral to DH’s involvement in a new
national group—the High Value Healthcare
Collaborative, a collective effort by 14 lead-
ing health systems to compare the quality,
outcomes, and costs of care for a number of
common conditions, such as knee replace-
ments. (For more about this initiative, see
dartmed.dartmouth.edu/sp11/v02.)
Following go-live for eD-H, Bernat said
that the transition had gone about as he had
Dartmouth
CENTER FOR CONTINUING EDUCATION IN THE HEALTH SCIENCES Educational Opportunities: Fall 2011
The Dartmouth-Hitchcock Medical Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
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On the Record
at the Dartmouth-affiliated White River
Junction, Vt., VA Medical Center.)
Remembrance
The nation was not long in waiting to com-
memorate the Civil War after the cessation
of hostilities. Memorials were built and en-
comiums were offered to the living and the
dead of both the North and South.
In 1913, the Dartmouth Class of 1863
raised funds for a large bronze plaque listing
the name, rank, and unit of all 56 classmates
who had served in the Civil War—including
three who had fought for the Confederacy.
The College then had a similar plaque made,
as a companion piece, listing by class the 73
alumni who had died in the war—63 for the
Union cause and 10 for the Confederacy. In-
cluding the names of troops from both sides
is “very rare on war memorials,” according to
the late Charles Wood, Dartmouth’s Daniel
Webster Professor of History, in A Guide to
Dartmouth’s War Memorials. “It must be re-
membered, though,” Wood explained, “that
this memorial was created only in 1913, a
half-century after the event and at a time
when the elderly veterans of both sides were
expected. It was taking time to master all of
the features available in eD-H and to figure
out how to use the system efficiently. But, he
added, “once we all learn how to use it well,
I’m sure it will go smoothly.”
A
n early test of eD-H will come when
the organization attempts to qualify for
federal “meaningful use” payments lat-
er this year. The initial standards that must
be met in 2011 and 2012 include keeping
track of patients’ demographic information,
as well as safety features such as checking for
potentially dangerous interactions among
the medications a patient is taking.
Starting in 2013, there will be still more
requirements, which could earn DH and oth-
er institutions additional payments. And, by
2015, the Centers for Medicare and Medic-
aid will likely penalize organizations that
remain unable to meet the meaningful use
requirements.
Vogt says eD-H has everything needed to
earn meaningful use payments—it’s up to
staff to be sure the system is used effectively.
“It’s not a technical issue, it’s getting folks to
change the way they deliver care,” he says.
“And I think we’re going to be successful.”
Gettinger admits, as he shows off his iPad
and smartphone, that he’s a technophile. He
believes technology can be used to even
greater effect in health care in the future.
“Technology is going to become much more
user-friendly,” he says. “It’s going to be much
easier to bring it in to clinical care.”
“This is a golden opportunity,” agrees
Vogt. “You don’t often get the funding and
the staff for two years to think about how
you want to improve what you’re doing. . ..
I think we’ve done a good job of really
leveraging all of the resources that Dart-
mouth has committed to making this a suc-
cessful project.”
Despite the difficulty of the transition,
Bernat points out that the limitations of CIS
made it essential to change. “There are many
really valuable features in eD-H,” Bernat
adds, mentioning the evidence-based order
sets as but one example.
And Merrens believes that merely mak-
ing the transition was beneficial. “You look
for challenging experiences to test your
group,” he says. And this one, he maintains,
“has strengthened our culture.”
