Can Cleveland Clinic Be a Model for Digital Medicine?

CLEVELAND—When Albert Giuliani wakes up each morning, he steps on a scale, takes his blood pressure and pricks his finger to test his sugar levels. Though he’s lived with diabetes and hypertension for decades, he no longer has to bother with pen and paper. The results are automatically uploaded to an electronic record that he and his doctor at the Cleveland Clinic can check anytime.

It’s a far cry from how Giuliani, 55, used to handle his health care. A busy public defender, he rarely made it to a doctor’s appointment without having to reschedule because of a trial or emergency meeting. Now, with regular monitoring, Giuliani has much more energy and saves hundreds of dollars on medicine.

“It's very convenient,” said Giuliani. “It's just saved me a lot of time and effort.”

The way Giuliani manages his disease illustrates the potential for improving patient care in the digital age. Few places can claim to be as far down this road as the Cleveland Clinic, a prestigious medical center that President Obama has praised for having “one of the best health information technology systems in the country.”

Yet an examination of the hospital’s experience yields both a model and a cautionary tale for the administration’s ambitious plan to spend $45 billion to jump-start a national system of electronic medical records. Federal officials want doctors and hospitals to digitize their records within five years, aiming to improve care and reap billions of dollars in savings.

Cleveland Clinic doctors say there is no doubt the switch to digital record-keeping has boosted the quality of care, particularly their management of chronic diseases and routine screening tests. But after nearly a decade and a $100 million investment, cost savings have not materialized and hospital officials are not certain when they will. That is consistent with some recent national studies that question whether electronic records can lead to lower medical spending.

“Buying a computer is not going to suddenly cause your operating cost to drop,” said C. Martin Harris, a physician who has overseen the digital transition at the hospital.

Moreover, some analysts question whether the quality improvements at an elite, well-financed institution like the Cleveland Clinic can be duplicated elsewhere. The hospital was able to go electronic in stages, over nearly a decade, slowly acclimating doctors and staff. That centralized planning was possible, in part, because nearly all of its 1,800 doctors receive salaries rather than being paid as independent contractors under the traditional fee-for-service system.

Proponents of a salaried system say it produces a more cooperative and patient-focused culture that eases systemic change. They say it is no accident that organizations with similar structures—the Mayo Clinic, Kaiser Permanente and Intermountain Health Care, among others—also have had success with digital systems.

“It's not so much about the value of the technology itself but it's rather how you use the technology that produces quality improvements,” Harris said.

Places with a centralized administrative system like the Cleveland Clinic have “a much better chance of being able to implement electronic medical records and to deliver on the potential,” said Howard Forman, a physician who teaches economics and health care policy at Yale University. “I don't think our more fragmented system can do anything near that."

 Trial and Error

From its founding in a small brick building in 1921, the Cleveland Clinic has grown to a sprawling 50-building campus spread across 166 acres. With an annual budget of about $3 billion last year, the Cleveland hospital has 15 family centers throughout the city's suburbs as well as campuses in Florida, Las Vegas, Toronto and Abu Dhabi.

While the majority of the hospital's clients come from close by, its reputation has draw patients from across the globe, including so many from the Persian Gulf region that the hospital built a Muslim prayer room at its Cleveland hub. It built its reputation on a team approach to medical care and individual flair, exemplified by the 4,000-piece collection of paintings and sculptures that give its hallways the feel of a museum.

The technology stands out as well. Wireless laptops attached to moving tables are pushed between doctor’s offices. When doctors meet in the intensive care unit during a shift change, they huddle in the hallways over the computer tables to go over patients’ conditions.

Hospital officials began thinking of adopting an electronic system during the dot-com boom and when they began, in 2001, officials wanted to give doctors and nurses time to adjust. So the changes were introduced slowly and deliberately. Rather than imposing a one-size-fits-all system, the technology was modified through trial and error to meet the specialized needs of each department.

For the first year, the hospital only used the electronic system for scheduling appointments and registering patients.

In 2002 doctors began using it for more clinical purposes. First they would just look at lab results online. Then they started entering patients’ health histories. Finally, they were required to input their impressions of patients’ conditions and how to treat them.

The hospital divided doctors into small groups and gave each one about three months to complete the process. The final group only finished last year.

Harris said that taking it slowly had a significant benefit: It allowed the hospital to slightly increase the average number of patients seen by doctors over the course of each year, even if doctors saw fewer during the first months of using the new system. Many doctors elsewhere have reported that learning to use electronic records initially takes time away from seeing patients.

“We did it in a very careful way,” Harris said. Doing it otherwise “can be a very dangerous model,” he said, because it could grind an entire hospital to a halt.

Yet others may not have the time the Cleveland Clinic gave itself. Under the administration’s stimulus plan, which envisions creating a digital record for every American in the next five years, hospital and doctors that don’t begin converting by 2015 will face financial penalties.

And still not every part of the Cleveland Clinic is fully electronic. Records dated before 2001 are almost universally in paper form and new patients often come with printed records. In some specialties like ophthalmology, doctors still write notes down on paper because the specialty requires a unique electronic program that the hospital hasn’t implemented.

Even now the system continues to evolve. The hospital is installing voice-recognition software so doctors can dictate their notes directly into the system. That is a “very, very important time saver because in reality the electronic record does require a lot of time,” Cleveland Clinic cardiologist Harry Lever said.

Key Benefits

Once the electronic system was installed, the Cleveland Clinic was able to use the data to track and analyze patient care in new ways. That paid significant benefits.

One key improvement was evidenced by the percentage of patients receiving routine screening tests and vaccines. In 2006, only 73 percent of the elderly and infirm who needed regular pneumonia vaccines were getting their shots. Three years later, the rate was 90 percent, according to the hospital’s figures. Screenings for osteoporosis—critical to keeping the elderly from debilitating bone breaks and fractures—went from 61 percent of patients to 85 percent during the same period. And the hospital has seen similar improvements for mammogram screenings.

Many advocates say that the data-mining made possible by digital systems could transform health care by discouraging unnecessary tests and rewarding doctors for keeping people healthy. The Cleveland Clinic has used its system to create regular report cards that compare physicians to their peers on measures including how well they treat or prevent diseases such as diabetes. Yet doctors distrusted the data at first, and it took months of programming work before they accepted the report cards, said David Bronson, a physician heading the hospital’s Medicine Institute.

The results of the report cards showed hospital executives that they needed to hold doctors more directly accountable for quality measures, said Bronson. Initially, for example, doctors received credit for improving screening if they simply ordered their patients to take a test. That was changed so that the patient actually had to get the test for the doctor to be credited. This translated into extra work for the doctor—or, at least as often, the doctor’s assistant—to follow up with patients.

Elusive Savings

Whether all this effort will save money is unclear. At Cleveland, the jury is still out. The hospital spent roughly $100 million installing the digital record system and still spends 2 to 3 percent of its more than $3 billion annual budget maintaining its entire computer network.

A study of 4,000 hospitals published in November in the American Journal of Medicine—carried out by Harvard researchers who are some of the most prominent advocates of a single-payer healthcare system—found no cost savings or increased efficiencies with digital records. That was consistent with preliminary results from a separate study of 3,000 hospitals by researchers at the Harvard School of Public Health, who found no evidence of cost savings with electronic records.

"I would not say that it’s going to be smooth sailing,” said Catherine DesRoches, a senior research associate at the Harvard School of Public Health and co-author of the forthcoming study. “It’s not going to be easy for hospitals to do this overnight.”

But health policy analysts say that even if the financial benefits of electronic health systems were limited to chronic diseases such as diabetes and hypertension, that could produce enormous cost savings. Chronic diseases affect nearly half of all Americans and comprise more than 75 percent of the country’s $2 trillion in medical spending, according to the Centers for Disease Control and Prevention.

Giuliani, the public defender living with diabetes, is a case in point. In the past, it was up to him to take his blood pressure and record the results several times a day in a little book that he presented to his doctor four times a year—not often enough to recognize deterioration in his health that might require hospital care.

Now he monitors his blood pressure and sugar level as part of a pilot project funded by Microsoft HealthVault in a partnership with the Cleveland Clinic. Microsoft and its chief rival Google, among other companies, hope to see their products widely used in the new digital medical system.

Giuliani can read his own results online, sometimes even before his doctor does. And seeing small improvements helps motivate him to keep going.

“If people have access to their medical records no matter the location, you’re going to definitely give better care and have fewer problems,” said Jennifer Wojtowicz, Giuliani’s endocrinologist.

Recently, Wojtowicz told him that his blood sugars were unusually high in the mornings. So without scheduling an appointment, she directed him to increase his insulin dosage at night. The result? A much more stable blood sugar level that gave Giuliani’s doctor enough confidence to take him off several drugs.

Since then, he’s had more energy and is thankful to be saving hundreds of dollars on medication. His diabetes isn’t gone but his quality of life has improved.

“Getting up in the morning and grabbing a handful of every pill,” he said, “I mean it just gets old after a while.”

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