The Mayo Clinic has undertaken a complex effort over the past decade to transition from paper to digital patient records. While its outpatient clinics were an early adopter of electronic records, digitizing records for its hospital presented greater challenges due to the complex nature of coordinating inpatient care across departments. After many years of implementation, the hospital is set to launch a new computerized physician order entry system in November that will automatically coordinate patient treatments and notifications. The transition has faced resistance from physicians accustomed to paper but is expected to improve patient safety and care coordination through a more seamless digital system.

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T
he Mayo Clinic, known for meti culously
organizing and preserving patient records over
the past century, is remaking itself into a digital
health-care organization.
“Health care, at its root, is an information-intensive business,” says
Dr. Christopher Chute, professor of biomedical information of the
Rochester, Minn.-based organization. “And part of the precepts of infor-
mation is making sure the information is consistent and comparable.”
Mayo’s Jacksonville, Fla., outpatient facility has been at the national
forefront of efforts to digitize patient records. Ten years ago, it required
outpatient physicians at that clinic to trade in their paper folders for an
electronic filing system from software maker Cerner of Kansas City, Mo.
Despite the early success of digitizing records for the outpatient
clinic, Mayo has had a tougher time moving to electronic records and
practices in its St. Luke’s Hospital, also in Jacksonville. In fact, a com-
puterized physician order-entry system, which will enable hospital phy-
sicians to order tests, treatments and medications, is set to go live on
A Complex Operation
After maintaining
paper records for
decades, the Mayo
Clinic has embraced
digitized health
information systems
to better manage
patient care and
trim costs. Adoption
has brought some pain.
By Anna Maria Virzi
case study
6 Health Care

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Nov. 6, according to Dr. Thomas Gonwa, a surgeon leading
the hospital’s effort to roll out the order-entry system.
Mayo is a case study in just how difficult it’s been for
health-care facilities to implement electronic record systems.
Across the United States, adoption has been hampered
by systems incompatibilities and the reluctance of hospital
staff to change the way they work.Another barrier is cost—a
system for a clinic or physician’s office can reach $100,000
per physician, while a hospital-wide system can run millions
of dollars.At Mayo Jacksonville, an estimated $18 million has
been invested in both the inpatient and outpatient systems,
according to Cheryl Croft, chair of information technology at
Mayo Jacksonville and a registered nurse.
As of 2005, only 15% to 20% of physicians’ offices and
20% to 25% of hospitals in the nation had adopted electronic
medical records, says the RAND Corp., a research organiza-
tion. Of those health-care organizations with systems, an
undetermined number cannot share information with other
hospitalsormedicalofficesbecauseofalackofstandards,says
Richard Hillestad, a senior principal researcher at RAND.
But, the rewards can be great from deploying health
information systems. RAND estimates that interoperable
electronic medical systems could save about $77 billion, or
4.5% of the estimated $1.7 trillion spent on health care in
2003 by improving efficiency and increasing patient safety.
Under the current payment setup, however, those savings
largely go to health payors such as insurers and businesses.
As much as $35 billion of the savings stands to come from
reduced hospital lengths-of-stay, because workflow features
found in electronic records systems can better coordinate the
care of patients suffering from chronic diseases.Also, health-
care providers should spend less time waiting or looking for
files once patient records are digitized.
Additionally, electronic prescription systems can cut med-
ication errors by eliminating illegible handwriting and flag-
ging allergies and potential adverse reactions to other drugs.
By one estimate, e-prescriptions can reduce serious medi-
cation errors, defined as those with potential for harm, by
55% and all medication errors by 80%, says Dr. David Bates,
professor of medicine at Harvard Medical School.
But it’s taken Mayo a decade to bring up the inpatient
systems in Jacksonville. One reason why: A hospital’s inpa-
tient system is far more complex than an outpatient one
found in a physician’s office, says Dr. John Mentel, past
chairman of the applied informatics department at Mayo
Clinic, Jacksonville.
This complexity includes the ability to coordinate
patient care across departments and specialists. “Pharmacy
systems, lab systems and monitoring systems all need to
function 24/7 without fail, all interconnected to facilitate
the rapid movement of data due to the intensity of service
needed,” Mentel explains in an e-mail.
Over the past 10 years, St. Luke’s has steadily moved from
paper to electronic records on the Cerner software platform.
Croft, the I.T. chair, outlined this schedule for adoption:
Classic PharmNet for pharmacy records in 1997; surgery
scheduling and documentation in 1998; and INet for the crit-
ical care unit, the Open Clinical Foundation data repository,
and FirstNet for emergency-department patient tracking, all
in 1999. Those hospital records, along with the outpatient
physician order-entry system and other electronic documents
and images, are stored in a central repository called Cerner
Millennium and can be accessed by health-care staff working
in Mayo’s inpatient or outpatient facilities in Jacksonville.
a seamless system
When the hospital adopts the physician order-entry system
later this year, a physician will be able to enter an order for
a test, medication or procedure, automatically launching a
series of activities associated with the patient’s care.
Mentel gives this example of how the order-entry system
will work: A person is admitted to the oncology department
for a cancer treatment. A physician will click on an order for
the patient to receive an anti-nausea medicine 30 minutes
before chemotherapy, and then receive three different chem-
ical agents at specific times and in a particular sequence.And
that treatment is to be repeated every 12 hours. The order-
entrysystemwillautomaticallynotifyphysicians,pharmacists
and others in the hospital when a particular treatment needs
to be performed, and monitor dosage amounts and method
of administration (e.g., by mouth or through a vein).
The new system’s seamlessness is in sharp contrast
to the past.
In March 2001, a pilot project to adopt a computerized
inpatient physician order-entry system, using software from
Cerner, hit a roadblock.
At that time, St. Luke’s was using a version of Cerner’s
pharmacy system that was not integrated with the comput-
erized physician order-entry system. So, when a physician
entered an order for a prescription, a pharmacist would have
to print out the prescription and then type the information
into the pharmacy system, according to Croft. Mayo’s med-
ical staff thought this arrangement was time-consuming and
could result in data-entry errors.
Subsequently, St. Luke’s installed a new version of
PharmNet, ensuring that when a physician prescribes medi-
cations, the order automatically goes to the pharmacy—
without requiring someone to re-enter the prescription.
Cerner did not provide a project manager assigned to the
Mayo Clinic to discuss the deployment.
Is the computerized physician order-entry system ready
for the November rollout at St. Luke’s Hospital? “As we have
analyzed, assessed and torn it apart, it looks as if it can handle
[the hospital’s] needs,” Mentel says. In preparation, hospital
staff have performed technical tests to make sure it does not
crash or accidentally modify data, and clinical tests to deter-
At a Glance: Mayo Clinic, Jacksonville
HEADQUARTERS: 4500 San Pablo Rd., Jacksonville, FL 32224
PHONE: (904) 953-2000
URL: www.mayoclinic.org/jacksonville
BUSINESS: Health-care provider owned by Rochester, Minn.-based
Mayo Clinic; the Florida facilities include a clinic with 400 examin-
ing rooms and the 289-bed St. Luke’s Hospital.
Technology chief: Cheryl Croft, chair of I.T.
FINANCIALS IN 2005: Revenue of $5.8 billion, expenses of $5.5
billion for Mayo Clinic; financials for Jacksonville not available.

3. offices required physicians to revise work habits. Doctors,
who previously wrote out notes from a patient exam or con-
sultation on a paper chart, are now expected to dictate this
information.The notes are first transcribed by voice recogni-
tion software, Dolbey’s M2 Transcription, then tweaked by a
transcriber and forwarded to a physician for review—as text
in a document in the Cerner PowerChart Office suite.
Hospital physicians will have to rely more on their
computers. That’s because a patient’s progress notes need
to be reviewed throughout the day, and they cannot wait
to be transcribed.
Gonwa expects to hear some teeth gnashing when the
order-entry system goes live on Nov. 6. “The day we turn this
on, some people are going to scream bloody murder [and say],
‘It’s a lot easier for me to write an order than to do it electroni-
cally,’” he writes in an e-mail, acknowledging that physicians
will need to spend more time inputting information, such as
orders for tests and treatments, into the computer.
Under a paper-based system, a physician is able to write
out on paper an order such as “CBC at 8 PM, if Hg < 8 then
transfuse 2 units PRBC.” (Translation: Take a complete blood
count at 8 p.m. Check the results. If the hemoglobin is less
than 8, transfuse 2 units packed red blood cells.) Writing
this order takes five to 10 seconds, but Gonwa estimates it
will take a physician three steps over 60 seconds to input the
instructions into the computerized order-entry system.
“Most [physicians] do not know the steps that go on
after they write a seemingly simple order,” Gonwa says.
mine if order forms meet the needs of the various depart-
ments and specialists.
Benefits and burdens
When Mayo Jacksonville deployed the outpatient system, a
key goal was to save money—an issue that other health-care
organizations contend with as well. “We all know about that
mass of baby boomers marching toward retirement years ...
the different forecasts about when Medicare is going broke,”
saysRegSmith,administratorofMayo’sadvancedtechnology
innovation and planning office. Electronic records, he says,
hold a good promise of reducing the paper shuffle and the
associated administrative costs.
Mayo’s outpatient practice in Jacksonville previously
retained six paramedical employees for every one of its 150
physicians at the time, but that number dropped to about
five paramedics by 1998, according to Mentel. At the time,
that represented an annual savings of $5 million to $7 mil-
lion, taking into account additional expenses for software,
hardware and support.
Proponents of a paper-free hospital say that an automated
clinical practice can make medical staff more effective and
improve patient care. For example, when new test results are
reported in a hospital patient’s file, they will be highlighted
so that a nurse or doctor will be able to see them immedi-
ately—rather than wait for a paper report to arrive.
Still, pain comes with change.
ThemovetoapaperlesssysteminJacksonville’soutpatient

4. “They are used to it just happening.The patient safety ben-
efits outweigh the complaints.”
On the horizon
Physicians at the Mayo Clinic and others are excited about
the promised benefits of electronic medical records beyond
just productivity and day-to-day patient-care issues.
Agoal for Mayo researchers: developing just-in-time out-
comes research that can help a clinician tailor treatment for
someone with a rare disease or condition, says Chute, the
biomedical professor at Mayo.
Under the current setup at the Mayo Clinic in Jacksonville
and elsewhere, Chute recognizes there are limitations. “Our
electronic records are designed primarily for clinicians to
read and understand so they can provide care to the patients
in front of them,” he says. “[Records] are not necessarily
designed to support cross-patient [information] aggregation,
high-level consolidation and cross-patient inquiry.”
To address that, Mayo researchers in Rochester have part-
nered with IBM to harvest information from the health-care
provider’s electronic medical records, put it into a database
and analyze it for patient treatment, according to Chute.
Other challenges include developing standards for health
information, including a consistent vocabulary for complex
clinical descriptions and genomic characterizations; and
making sure that each patient’s privacy is safeguarded.
The challenges notwithstanding, e-health initiatives offer
health-care workers improved ways to treat and prevent ill-
ness. “So much information about the health-care process
is located away in paper,” says Eric Brown, an analyst at
Forrester Research, applauding Mayo’s initiatives. “What
gets my juices going is not shedding paper. It’s all about the
cool stuff we’re going to be able to do once we have clinical
information in some sort of available form.”
Even if it means that some physicians will be gnashing
their teeth as they pound away at a keyboard. 3
Health Care: electronic records
5 Years Ago Today 5 Years from Now
Health-care providers primarily use
paper records for billing and scheduling.
Up to 20% of physicians’ offices and
25% of hospitals use electronic patient
records, but not all records or systems
are able to share information.
Leading medical researchers work with
health-care providers to enhance their
use of computer systems; aim is to col-
lect and analyze patient information to
tailor treatment for individuals.