Medical Mouse Practice

By Kathleen Kingsbury/Cleveland

He's not a doctor, but Bob Lemon has been saving lives for nearly 30 years. As lead computer-systems analyst at Cleveland Clinic, Lemon has had a hand in every facet of the hospital's electronic infrastructure since 1980. He has digitized Cleveland Clinic's charts, given patients online access and found ways to allow doctors to perform exams over the Internet. What Lemon does every day on the job "ensures my heart patients receive the best care on the planet," says Dr. James Young, a cardiologist at Cleveland Clinic.

Lemon is part of a team of 700 technologists at Cleveland Clinic who are reinventing the hospital experience for health-care providers and patients alike. Renowned for its cardiovascular care, the medical center has also positioned itself as a leader in health-information technology at every level of patient care. The medical charts of nearly 5 million patients have been digitized, more than 3 million electronic prescriptions have been filled, and more than 120,000 patients regularly access their full health records online. And along the way, the team of doctors, nurses, Web developers and software engineers has improved safety, cut costs and given patients more control over their care. The transition away from paper, says chief information officer Dr. C. Martin Harris, "has allowed us to use technology to transform the practice of medicine."

Walk into any exam room in the medical center's 140-acre (57 hectare) campus east of downtown Cleveland, and you'll find a computer terminal on a small rolling cart that physicians and nurses use to document every step of patient care in an electronic chart. Instead of scribbling notes by hand on a metal-clad clipboard, doctors and nurses use the fill-in forms on the monitor to type in each patient's symptoms and vital signs, progress and prognosis, and medications prescribed and taken.

With the rest of the world living and working on e-mail and the Web, an electronic health record (EHR) might seem like an obvious step. But it is, in fact, a revolution. American physicians have been notoriously slow to adopt digital record-keeping--only 14% of U.S. medical practices keep electronic records, according to the Department of Health and Human Services. When Harris began Cleveland Clinic's technology push in 1999, the hospital's 1,800 M.D.s were equally resistant to change, he says. "We had to prove that this effort was going to make their job easier, not harder."

Luckily, Harris' IT team was able to solve one problem for doctors and nurses right away with the digital chart. Hospital policy mandates that every time a Cleveland Clinic patient sees a doctor in any of 37 buildings on the main campus or dozens of satellite locations in Florida, Abu Dhabi and southeastern Ohio, that doctor will be holding his or her medical chart. With paper records, physicians didn't have those records 20% of the time. As soon as charts were digitized, EHRs were at their fingertips. "No more repeat tests, no more taking extensive histories," says Gene Lazuta, marketing manager of e-Cleveland Clinic, the hospital's electronic initiative. "It instantly saved time, money and energy."

As doctors' resistance broke down, the technologists turned to patients, who also needed a little convincing. Placing exam-room computers on moving carts was an important early step, so that physicians didn't have to turn away from the patient to enter data into the terminal. This helped resolve a common patient complaint, that electronic records seem impersonal.

Harris, a practicing general internist and a Wharton M.B.A., has used his clinical experience to foster innovation that directly benefits patients. The hospital's 3 million--plus patients can schedule appointments online, for example, and fill out paperwork on the Web before they get to the waiting room. Cleveland Clinic's specialists supply second opinions to patients worldwide who enter symptoms into an Internet form and then send test results to doctors via FedEx. Cardiologists silently, invisibly monitor patients' pacemakers and other implanted devices remotely to make sure they're functioning correctly. Soon robotic carts will transport supplies and sanitary waste from the buildings on its main campus.

Harris put together a diverse collection of health-care providers and computer scientists to create Cleveland Clinic's flagship online product, MyChart. Launched in 2005 on the clinic's website, MyChart allows patients to access their EHRs and find up-to-date medical research on their ailments. Doctors must log all examinations, lab results, prescriptions and diagnoses for patients to review. Mary Adams, who lives in a western suburb of Cleveland, is one patient who has come to rely on MyChart. "I can log on, it reminds me I need a tetanus booster, and I schedule it," she says.

That kind of connection is a reflection of the intense collaboration that went into developing MyChart. Gisela Nehring, who heads the project, says her job as a respiratory therapist working in hospital intensive-care units means she can interact directly with hospital staff for input. "I can walk up and down the halls and hear from the nurses what's working and what's not," Nehring says. "I relate to what they're saying because I've been there myself." Web developers like Lemon show their medical colleagues what's possible. "We'll ask aloud if we can do this or that cool thing," Nehring says. "Bob figures out how to make it real in two minutes." The interaction works because the whole team has one thing in common, Lemon says: "We're all tech-geeky types."

The success of MyChart, which is used regularly by more than 120,000 Cleveland Clinic patients, inspired Dr. Toby Cosgrove, the hospital's CEO, to make an even bolder move. Doing away with decades of hospital tradition, Cosgrove declared last year that patients should have access to their EHRs at all times. Only a handful of hospitals worldwide have adopted this level of transparency. "The charts really aren't the hospital's--they belong to the patients," says Cosgrove, a heart surgeon. "We think it's their right to have that information."

Cosgrove believes giving patients access to their EHRs will improve care. For one, errors are more easily avoided. The electronic chart automatically alerts doctors when the drugs they prescribe are inappropriate or could cause harmful interactions with medicine a patient is already taking. Young's patients even note typos in their charts, corrections that could avert disaster. "They'll point out things like, 'Hey, doc, I had my left coronary artery operated on, but you've got right written down here,'" Young says. "It's an important distinction."

The IT team has addressed the thorniest issues in EHRs--patient privacy--with an abundance of caution. In addition to standard confidentiality safeguards, the hospital opens an ongoing e-mail dialogue with patients to give them full disclosure about exactly who has accessed their data. "Some people complain we communicate too often," Lemon says.

Their work has won the Cleveland Clinic team a feather that any techie would covet in his cap--the attention of Internet giant Google. Cleveland Clinic was one of the search engine's early partners in Google Health, an online EHR service that was launched on May 19. For the hospital, it's an opportunity to expand patients' access to records. "We could only get so big on our own," says Joe Turk, a Web developer and the director of new products on the Cleveland Clinic technology team. "Google Health lets us go national."

Google Health is a universal version of Cleveland Clinic's MyChart. Instead of collecting the information from just one hospital, Google Health serves as an online clearinghouse for patient information. Once you've signed up for an account, which closely resembles Google's Gmail, you can grant permission for doctors, pharmacies or insurers to upload any pertinent data, thus creating a single destination for your whole health history that you can access from anywhere in the world. "Because a lot of medical information is not digital, it's not being put to good use," says Marissa Mayer, Google's senior VP for search and user products. "We want to define a standard that makes it more portable and available to people."

In February, Cleveland Clinic and Google began a six-week pilot project of Google Health. Of the 15,000 Cleveland Clinic patients asked to participate, about 1,500 MyChart users signed up. Mayer described the test cases as "beautiful." They helped Google identify early adopters for Google Health--snowbird seniors who spend their time in different homes during the year, for instance.

But if the U.S. is serious about improving health care and reining in costs, the rest of the industry is going to have to get on board too. There are a number of Internet powers trying to stake out the EHR space, among them Microsoft and Revolution Health Group, led by AOL co-founder Steve Case. In Cleveland, Google has a partner that is already ahead of the curve.