Record Time

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."