Dr. George A. Saleh is not scared of new technology, new techniques, or the waves of new information that pour daily from the world of medicine. "I have retaught myself five times since I finished school," says the 56-year-old gynecologist in North Kansas City, Missouri. "I now do advanced laparoscopic procedures that didn't even exist 15 years ago."
So Saleh seemed the perfect candidate for a digital, paperless medical office—a system that allows all records and charting to be done on computer. He took out a loan and bought the necessary hardware and software. And last summer, with his staff of three, he switched everything over to the new system. Patient information was entered on a screen instead of on a form attached to a clipboard; Saleh took notes and made orders using a sleek black tablet PC.
Within days, the office was in meltdown. Patients piled up in the waiting room, and Saleh all but lost control of his day-to-day work. Delays grew so bad, Saleh installed a TV to distract patients, and Cerner Corp., the company supplying his software, trundled in refreshments as a goodwill gesture. "I was running an hour-and-a-half or two-hours late," says Saleh. "That's the kiss of death for your practice. It was crazy."
A few months later, Saleh shows off his file rooms, filled floor to ceiling with paper charts. "No paper has been added to these since summer," he says proudly. Not only is his office back on schedule, but his workday is shorter—and he's seeing just as many patients. "When I walk out of the office each day, I'm done," he says. "I don't have to dictate a stack of charts." His bill for dictation services has dropped from $1,200 a month to $60. His staff is thrilled. "It's like a new era," says medical assistant Jamie Clevenger. "It almost feels like a whole new job."
Using digital medical records allows Saleh to file claims electronically, and quickly; he gets paid by insurance companies in 10 to 14 days instead of one to two months. In an emergency, Saleh can access patient charts from home at night; he can view office records from the hospital. The charts themselves cannot be misfiled, misplaced, or left on the wrong counter—they're safe on servers in a Cerner data center designed to survive the most powerful tornado.
Some of the benefits address problems patients would never consider but that doctor's offices have long struggled with. If a birth control pill or cholesterol drug Saleh has prescribed is pulled off the market, for example, "we can push a few buttons and have a list" of who among Saleh's 7,000 patients is taking the medicine, instead of having to go through those charts one at a time by hand.
Saleh doesn't gloss over the tumultuous weeks of transition. He was slowing things down, trying to type into the computer everything a patient told him. He had to reinvent his approach to keeping track of his patients. Working with Cerner, he now has templates with drop-down menus and autofill categories, along with a place for typed comments. "If a woman comes in for an annual exam, I've got a template for the annual exam. I ask her the questions, and boom, boom, boom, I can pick the correct responses. It's done."
Saleh pauses, then brings up a delicate subject. While a bit less personal, the new system "has also made me a better doctor," he says quietly. "There are questions you should ask patients—questions about abuse, about sexual dysfunction. Those are difficult questions. Now I can blame it on the software. It opens up the door to an important conversation." The Cerner software, he says, "has changed the way I work every day, at age 56."
Imagine if stores still put paper price stickers on every item and cashiers still punched in prices on cash registers digit by digit.
Imagine if airlines still used paper tickets—the ones with the red carbon paper on the back of each flimsy flight segment.
Imagine if the banking and financial system still kept most of its records on paper. Not only would there not be anything like debit cards or instant approval of credit-card purchases (remember the booklets of "bad" credit-card numbers that checkout clerks used to consult at the cash register?), there would not be any ATMs. Every time you take money from an ATM, the big banking network consults your account information to make sure you have the money you're requesting.
"It's like a new era," says a doctor's assistant. "It feels like a whole new job."
And yet, in the world of medicine, hurried handwriting remains an essential form of record-keeping. In thousands of hospitals, vital medical records are kept on pieces of paper, snapped into a chart that can be read by only one person at a time, that has to be moved around physically if someone wants to see it, and that is often transported on the lap of the patient, sitting in a wheelchair, on the way to X-ray or the lab or surgery.
The workflow at an ordinary McDonald's—orders taken, transmitted to the kitchen, and displayed there all by computer; sales and operational data sent automatically each day to headquarters—is far more digitized, transportable, and useful than in a typical doctor's office or hospital, although the stakes couldn't be more different. The contrast is remarkable even within medicine, where the most advanced digital technology can be used to render a virtual colonoscopy—but the order for the colonoscopy itself, or the report of the results, may be on paper.
"If you flew in from Mars with the assignment to figure out the health-care system in this country," says Clifford Illig, "and all you did was examine the computers we use, you'd conclude that the entire purpose of the system was to prepare a bill." Illig is cofounder and vice chairman of Cerner, a company that has specialized for 25 years in helping hospitals and doctors digitize their day-to-day clinical work. Most of that time, Cerner has focused on hospitals, which have the institutional muscle, the money, and the incentives to tackle major information- technology projects. And even there, the leap from paper and handwritten records to computerized systems is so daunting that only half of 5,759 U.S. hospitals have gone partly or fully electronic.
Cerner, with $1.2 billion in revenue, 7,000 employees, and a steady 20% annual growth rate, competes in a field crowded with large rivals including Siemens and General Electric. But unlike the big conglomerates, Cerner focuses exclusively on software to manage medical care. The company, which is publicly traded, has committed to spending $1 billion in the next five years on research and development. It employs more than a hundred physicians, many just a few years out of clinical practice, and hundreds of nurses, some of whom work both at Cerner and at hospitals to maintain their clinical connection.
Michael Ash, an internist who joined Cerner two years ago from private practice, led a team that analyzed the workflow in an ordinary doctor's office in July 2005. "The printout we came up with was 50 feet long and 4 feet high," says Ash, who is working on an MBA while at Cerner. "The system has to be as complex as the care we're providing. The question is always, How much are we asking doctors to change, versus adapting the system to how they practice?"
Doctors used to wait months for insurers to pay claims. Now it's a matter of 10 to 12 days.
If it is to be truly useful, the software used to manage medical records must be incredibly sophisticated. It must store and reproduce routine information about a person, and it must be able to take in information from medical staff in myriad roles and settings while protecting patient privacy. The software must be able to import, store, and present information in many formats, from ordinary blood-test values to the actual images from X-ray or MRI exams. And it must be able to issue orders for everything from physical therapy to bags of IV fluid. Critically, the software must be able to look at all that data, and the rules a hospital or doctor's practice has set up, and flag problems a patient might experience.
Part of the point of employing hundreds of clinical medical staff at Cerner is to adapt the software to the traditional ways doctors, nurses, pharmacists, and technicians do their work, while also offering them new tools. Many nurses, for instance, carry "cheat sheets" around in a smock pocket, keeping track, patient by patient, of test results they are waiting for or tasks that need to be done. Cerner's software provides a digital version of the cheat sheet—including, for instance, not only a list of test results a nurse might be waiting for, but flagging those results as having arrived when they are loaded into the system by the lab or radiology department. For floor nurses working with handheld computers or wireless laptops, the data is streamed in automatically in real time.
Cerner realizes that one reason paper has persisted in medical settings is that it is fast, and it works. "The reason it seems medicine is so slow to adapt to this technology," says David McCallie Jr., a neurologist and Cerner vice president who runs a software R&D team, "is that with the paper system, a lot of people add value. A doctor writes an order for a test, a nurse flags the order for blood work, the lab clerk looks at how to fit that order into the workflow. If you're going to take people out of the loop, you have to realize all the work that gets done that you're not quite seeing."
But taking the information off paper and putting it into computers changes the way that information can be used—much the way loading a company's financial data into a spreadsheet allows a different level of analysis from simply looking at static numbers on paper. Indeed, it changes health care. Hospitals with digital records can, to use Cerner's phrase, "turn their data on its side and look at it from an analytical point of view—every clinical event is treated as a future learning event." Records can be analyzed to find the sources of postoperative infection, or to see if variations in outcomes are related to the course of treatment, the person providing the treatment, or the characteristics of patients themselves.
Cerner's data center, in fact, is rapidly becoming one of the largest repositories of health information in the country. With federal privacy and anonymity rules in place, that wealth of data about patients and their health care could become a rich source of insight, discovery, and treatment improvement.
There is a sense of urgency about digitizing medical record-keeping—one study estimated that 100,000 people in the United States die each year (twice the number killed in car accidents) because of the sort of preventable medical errors that digital medical records help eliminate. A Rand study published last fall (paid for, in part, by Cerner) estimated that at the low end, the United States could save $140 billion a year if digital record-keeping were in place.
The hurdles remain extraordinary. For hospitals, the cost runs to millions of dollars; for a physician practice, the average startup cost is $44,000 per doctor, though the savings that result allow doctors to pay back that investment in about two and a half years. (And Cerner has started offering leasing schemes that require lower up-front investments.) The cultural barriers are equally daunting—for any given hospital or doctor, the easiest thing to do in the short term is to keep using paper. But the benefits of switching are undeniable, tangible, and well worth the cost, say those who have done it. The power of digital records is a reminder that simply changing the medium in which information is stored and shared—without changing the information itself—can radically reshape a profession.
Allen Weiss, an internist and rheumatologist, is president of the two-hospital NCH Healthcare System in Naples, Florida. Back in the early 1990s, the hospitals were using Cerner's software to automate their lab work and results reporting. Over the past five years, they have gradually automated other departments—the emergency room, the pharmacy, the nursing work done on patient floors. Indeed, nurses at NCH hospitals push little laptops on carts from room to room as they make their rounds; the computers use high-speed wireless Internet access that blankets the hospital. The operating room is just about to make the transition to digital record-keeping. Physician charting on patient floors—which is separate from the nursing records and requires separate training—is still done on paper, but will be converted this summer. "Yes, on the patient floors, we have both digital and paper," says Weiss. "It's the worst place to be. But the nurses are now huge advocates of the new system."
Weiss is as unvarnished about the transition as Saleh in North Kansas City. "Nobody had any idea how hard it was going to be," he says. Just recently, the radiology transcriptionists, the people who type reports of exams dictated by radiologists, switched to a new form of digital transcription, and their productivity was cut by 70%—from 2,000 lines of reports a day to 600. "Our transcriptionists, many of them have 30 or 40 years of experience. They were screaming. They get paid by the line. We fell five days behind on radiology reports—and the average length of our hospital stay is four days." Now, though, transcriptionists typically have a doctor's report in the patient's medical record within 10 minutes of the dictation being complete.
Weiss is equally unvarnished about what the Cerner software has done for NCH and its patients: Hundreds of people are not dying because of the hospital's new digital record-keeping system.
Consider one of the chronic problems in treating elderly people in hospitals: bedsores. Elderly people, with less ability to move in a hospital bed, with incontinence problems, with thinning skin, are highly susceptible to bedsores. And the skin infections often prove devastating. "If you are over 75 years old, and you get a pressure ulcer while you're in the hospital," says Weiss, "you have a 50% chance of dying in the next year." Not only that, but treating bedsores costs between $5,000 and $50,000 per patient, depending on the severity.
The national average for hospital-acquired ulcers in patients is 7% to 8%. At NCH, in 2001, 12% of patients were getting the ulcers. "We've got 10,000 people each year in the hospital over age 75," says Weiss. Meaning at least 1,200 of those patients were getting ulcers each year, and maybe 600 of them were soon dead.
Using Cerner's software, every patient is now "scored" on admission for vulnerability to bedsores—based on age, medical problems, test results, and other characteristics. Those at high risk get special attention: different beds, special nursing orders so that patients get turned, heel protectors. "You cannot admit the patient without doing the pressure-ulcer scoring," says Weiss. "The system makes it foolproof."
The rate of ulcers in patients at NCH has fallen to 1.7%. About 170 patients a year over age 75 now get the ulcers, instead of 1,200—perhaps only 85 die within a year from a largely preventable problem, instead of 600. That's 500 lives saved each year, in one pair of hospitals, because of software and because of the new methods it inspires. "That," says Weiss, "is a good use of technology."
Senior writer Charles Fishman (firstname.lastname@example.org) is the author of The Wal-Mart Effect, published by Penguin Press in January.
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