More than three years ago, while most provider organizations were studying whether to move to computerized clinical information, doctors at Mayo Clinic's Jacksonville, Fla., location were logging in to a paperless system of patient records and test results to the tune of 25,000 sessions in a three-month period.
More than 80% of the time, physicians accessed the clinical system by putting a finger on a special tray instead of typing their user name and password. The fingerprint system, rare elsewhere in the healthcare industry, was installed across the multispecialty clinic in Jacksonville in late 1997, nearly two years after the Mayo division put all clinical data on computers.
The use of fingerprints or other unique body characteristics for identification purposes--a science called biometrics--is emerging as a possible alternative to remembering and constantly keying passwords into computer systems.
A movement toward fully electronic medical information in hospitals and group practices, though still in its infancy, highlights the need to provide workable security while affording quick access to clinical tests, notes and medical histories, experts say.
But like most healthcare technology, the reliance on fingerprint access has proven more complicated in practice than in theory. As the concept of biometrics makes its way into information technology planning nationwide, Mayo's experience offers insight into problems with everything from fingertip scars, body oil and talcum powder residue from latex gloves, to erosion of the biometric option because of mechanical breakdowns and aging hardware.
On a broader level, the emergence of new and more reliable methods of biometric recognition--and other techniques such as sensing a physician's approach to a computer--raises the issue of whether fingerprint recognition is being overtaken by competing solutions before it can even gain a foothold in healthcare.
For Mayo Clinic Jacksonville, the steady buildup of small issues cut into the success of fingerprint biometrics. From the high-water mark of popularity in 1999, the use of biometrics in place of passwords steadily declined at the facility. By the beginning of 2002, the volume of access to the clinical information system had more than doubled--but doctors frustrated with the fingerprint-reading process were opting for the keyboard more than 60% of the time.
Ironically, the biometric option was supposed to relieve doctors of typing tasks. "Having a physician type on a keyboard is just not a good use of a physician's time," says Reginald Smith, vice chairman of Mayo Clinic Jacksonville's department of applied informatics, which tests and deploys technology to improve medical processes.
Mayo's experiment culminated in a major software meltdown last April that put the biometric system out of commission for good. By then, the glitch just sealed a fate that was looming over the access procedure. Officials in Mayo's medical information systems department already were tallying up the problems and seriously considering abandoning fingerprint authorization for other biometric or electronic alternatives, Smith says.
The launch and eventual shutdown of the fingerprint-scanning process should not be viewed as a misstep but rather as a valuable first go-round from which the industry benefits, says Jim Klein, a healthcare analyst with Gartner, a Stamford, Conn.-based IT research and advisory firm.
"That's part of their role in the (healthcare) food chain. Thank goodness they're there," he says of Rochester, Minn.-based Mayo Foundation, which also has clinics in that city and Scottsdale, Ariz. "The Mayos are, and can afford to be, at the absolute cutting edge," Klein says.
The applied informatics department at Mayo Clinic Jacksonville is now testing a technique in which a tiny video camera reads the iris of the eye for unique characteristics. Initial testing shows it's more reliable and less balky to use, but the deployment of that alternative remains "less than decided," says John Mentel, M.D., chairman of the department.
Meanwhile, the sophisticated system, minus the fingerprint-scan biometrics--installed in tandem with biometrics to manage the secure comings and goings of multiple physicians--continues to run on the computers used at the clinic. The only way to get past security these days is through old-fashioned typed identification codes and passwords.
Dependence on computers
The search for acceptable access procedures in patient treatment situations is an outgrowth of efforts to automate the clinical process that began a decade ago at Mayo Clinic Jacksonville. A strategic plan dated Sept. 1, 1992, called for the development of clinical information systems that would improve practice efficiency. Among other things, planners sought to provide simultaneous access to records by multiple physicians and reduce the number of staff members involved in "moving, processing, adding to, sorting and completing the medical record."
Through a developmental partnership with Cerner Corp., a Kansas City, Mo.-based healthcare information systems and services company, Mayo Clinic Jacksonville's three-building medical campus was outfitted with an integrated set of clinical software applications built around a common database--a hefty investment totaling $14.6 million through 1997.
But by the time the system was turned on in January 1996, planning for the wired operation had resulted in a reduction of 165 full-time-equivalent staff, and another 28 positions were cut by 1998. The savings on payroll and benefits have been instrumental in creating a return on investment of more than 30% per year, according to Mayo's calculations.
In addition to saving the costs of creating and managing paper records, the computerized system reduced the amount of time and labor needed to work through the clinic's three principal activities in patient diagnosis and treatment: taking a patient's history and conducting physical examinations; scheduling and consulting by multiple specialists; and reviewing results and generating a letter on findings.
The process of taking a medical history and doing physical exams comprised 55 steps when it was done manually, Smith says. The computer conversion reduced it to 25 steps and a consulting process that typically required 40 steps was reduced to 17.
Before computerization, a battalion of workers had to mobilize when test results came back to the floor where the orders originated. About 20 people crowded around a desk thumbing through a 5- to 6-inch stack of paper, prioritizing results according to whether the patients were still at the clinic or had gone home, and marrying all the test documents with the proper patients' charts, Smith says. That process is among many now accomplished automatically.
In the years since the conversion to electronic records, patient visits have doubled to 414,000 in 2001 from 207,000 in 1995. The clinic's physician staff also has swelled in the past five years, to 288 at the end of 2001 from 180 at year-end 1997. Without the computerized clinical record and reporting system, the clinic would have had to add 270 FTEs to the staff of 467 employed in 1995 just to handle the burgeoning growth, Smith says.
The flip side of the successful streamlining is that when it comes to retrieving patient information, physicians basically are on their own--and the computer workstation is the place to get it. "I don't think you'll find a place that's this dependent on computerized records," Smith says.
Besides the clinical ordering and reporting systems for accumulated and new patient data, Mayo operates a 24-hour transcription department that prioritizes and completes dictations in as little as two hours and no more than 48 hours.
An army of 33 transcriptionists at two clinic locations and another 33 working from home have the task of ensuring, for example, that observations from specialists early in a series of tests and physician encounters are available in the computerized record in time to affect decisions and conclusions later in the day, says Jean Adams, Mayo Clinic Jacksonville's transcription manager.
The transcription service, which costs $5 million per year to operate, handles 1,500 to 1,800 documents in an average day from the more than 300 physicians, medical residents, nurse practitioners and physician assistants at the clinic and at Mayo-affiliated St. Luke's Hospital, a 289-bed inpatient facility 10 miles west on J. Turner Butler Boulevard.
With many care providers sharing computers in a fast-paced atmosphere, the challenge for informatics professionals was to find an easy way to give clinicians access to what they need, often while attending to a patient, but also guarantee and protect individual access privileges without subjecting doctors to delays throughout the day, Smith says.
That's a challenge facing any provider organization intent on putting medical information on computers instead of paper, Klein says.
"When it comes to security, convenience is the overriding consideration," he says. It's the "intellectual contribution of the physician" that powers the patient-care process, Klein says, and doctors won't allow technology to hamper their efforts. "If you put anything in the way of that, it will be swept aside," he says.
Mayo's flagship operation in Rochester was using a magnetic swipe card along with a personal identification number, which had the advantage of simplifying the log-on process and avoiding the need to change and remember passwords, Smith says.
But the "smart card," which doubled as the security card to enter buildings, could get separated from its user, and that caused practical problems as well as security concerns. "A physician would leave it in a lab coat and send it to the laundry," he says. A lost card was replaced but the old one would resurface, giving a doctor multiple access tokens that sometimes would get passed to a nurse or physician assistant who would then chart in the doctor's name, Smith says.
Beyond the password problem
Fingerprint biometrics entered the picture as a way to get past the password problem but also provide a reliably available means of authenticating the identity of an approved system user. "You never leave your finger at home, on the dresser or in the car," he says.
A Tampa, Fla.-based firm, National Registry Inc., had developed a low-cost fingerprint image scanner for the financial industry and sought to expand its business into healthcare. Mayo Clinic Jacksonville reached an agreement for NRI to collaborate on the development of a process to manage access to electronic patient records, Smith says. Mayo would own an interest in the new product.
The clinic paid less than $300 per workstation to install special keyboards at computers in 400 exam rooms and at bedside terminals for all beds in St. Luke's, he says. The cost of the startup, including hardware, keyboards, license fee and software, totaled about $800,000.
At Mayo Clinic Jacksonville, by the end of 1997, and at St. Luke's in 1998, clinicians could sign in one of three ways:
* A fingerprint reading only. This option is easiest for clinicians but the biggest challenge for the technology. After scanning 20 to 45 "minutiae points" on a finger, the system has to match it from among all the stored prints kept in digital form in a database.
* A user ID with fingerprint as a password. The typed identification immediately gives the computer a single set of prints to match against the scanned finger instead of starting from scratch.
* A user ID and typed password. Any problems with reading or matching prints could be circumvented by using the typical security option--which had to be offered and maintained as a fallback option or to suit preferences of physicians.
An equally important part of the access and security routine was a process to hide a physician's onscreen session with one keystroke and make a computer instantly available to a colleague. Then instead of having to start all over again, the physician could return and immediately regain access to the place he or she had left off by signing in again, using one of the three identification methods. Physicians could juggle their frequent sessions all day at a few different computers without losing much time.
"Anything that makes you faster, that's an advantage," says Mark Parkulo, M.D. The internal medicine physician says he goes to the computer screen about 50 times a day, seeing 20 patients daily in three places: his office and two exam rooms. "Fifty times a day is not unusual for a primary-care practice," he says.
The combination of biometrics and lockdowns of individual physician sessions also preserved the integrity of medical records, by providing assurance that orders and observations under the identity of a physician are the work of that physician instead of someone else working on the same computer afterward.
That assurance has consequences for the integrity of electronic signatures, a growing trend as computers replace paper charts, and for compliance with security and privacy regulations of the Health Insurance Portability and Accountability Act of 1996.
To comply with authentication requirements of HIPAA, set to become effective by the end of 2004, Klein says biometrics and other timesaving technologies such as proximity-detection cards will be the only solutions available during the next few years that are unobtrusive enough to get the cooperation of physicians and nurses who use shared workstations to get medical information in busy clinical environments.
From the start, however, the fingerprint method used in the access initiative was "a less than perfect science," Mentel says.
About 10% of the doctors and other clinicians who needed to see information online could not get a usable fingerprint, he says, which complicated the objective of providing easy entree for busy people. "When you're electronic like we are, you have to have access," he says.
The problem of unreadable prints could be caused by scars, other imperfections or a history of working with concrete or mortar, Smith says. Some physicians' fingerprints were readable most of the time but not always.
"I wasn't a fan of the system, only because of the steps it took to keep getting in," says Eugene Page, M.D., a cardiologist on staff. A scar on his index finger and a scanning routine that required crosshair-precise placement on the scanner often made him wait too long for the procedure to properly read his fingerprint.
"If I didn't hit it dead center, that would be bad," Page says. The process routinely took "15 to 25 seconds with me sitting there watching. ... Sometimes I couldn't get in anyway."
Doctors could register any finger as the access match, but orthopedic surgeon Stephen Trigg, M.D., was able to get a readable print from only one finger on one hand. Though he assessed the biometric option as a good system overall, Trigg often found himself playing fingerprint roulette with the reader.
"The problem is, only half the time would it read my print," he says. Visits to the computer often included attempts to reposition his finger in response to messages onscreen saying the system didn't recognize the print. "By then, you might as well type in and use your password," Trigg says.
Other doctors had no problems. "My fingerprint worked well," Parkulo says. "It was always with me, and it was faster than typing it all in. ... I was disappointed that we weren't able to continue with it."
Says Trigg: "Like anything else, the technology is good--but in a high-volume, fast-paced practice, we need performance."
Idiosyncrasies of the scanning method also bedeviled doctors. The miniature camera that takes a picture and converts it to minutiae points depends on a pattern brought out by oil on the finger's surface.
"If your hands were real clean, it was hard to get a reading on a fingerprint," Smith says. "And, of course, we want physicians to wash their hands."
Some physicians just ran their fingers through their hair to get the necessary contrast. Page would rub his nose or behind his ear to pick up the oil that made the scan work. All that posed a problem of contaminating the sensors, Smith says.
In response, managers passed out pads of a sterile, inert moistening fluid to dab on before logging on. But that introduced more time and hassle into the routine. When Page could locate the pad within convenient reach, his first dab usually absorbed too much moisture and he had to wipe off his finger with a tissue and try again. The opposite problem was fingerprint residue from previous users.
Other random obstacles prevented proper contact. The powder inside latex gloves, which doctors go through by the dozen, often obscured the fingerprint patterns, Trigg says. And cold fingers had to be warmed up before the scan would work, Smith says.
Remedies for the mounting problems were sparse, because technical partner NRI sold its interest in the healthcare side of its business in 1998 to another Florida-based company that then went bankrupt and was out of business by mid-2001. The subcontractor that supplied the customized keyboards stopped manufacturing them with the integrated fingerprint device.
Biometric popularity fades
The plain fact, Smith says in summation, is "anybody can get a rejection at any time." And over time, the supposed solution to the issue of creating easy clinical system access had the opposite effect. "Every time the biometrics doesn't recognize you, frustration sets in," he says.
The frustration was felt by a majority of the physician staff by mid-2000, when a survey found that 51% of the 119 doctors responding to the inquiry preferred to use an ID and typed password--38% "strongly" preferred typing, 13% "moderately" so. Only one-third preferred the fingerprint option. The rest had no preference.
Asked which was faster, only 9% thought fingerprint access was "much faster" and another 15% considered it "moderately faster." But 37% said the traditional user-password access was much faster; 18% judged it moderately faster.
In practice, however, research showed that biometric access was more popular than it seemed from the survey results. The computer system's ability to record user activity allowed Mayo to analyze all 48,600 log-ons during the same three-month period of 2000 in which the survey was conducted. That enabled a tally of which access methods were used, Smith says. Despite the polled preferences, 53% of log-ons were biometric only, and another 10% used the typed ID with a fingerprint as password. The rest typed in their access codes.
Nevertheless, the results confirmed a significant shift away from biometrics compared with the first few years of operation (See chart, p. 26).
The analysis of computer activity isolated a few other reasons for the decline in preference besides the inherent quirks of using the scanners.
For one thing, the special keyboards started failing, reducing the biometric access option. Of 310 workstations operating from April 2000 to June 2000, the scanners on 19 stations were not working. By the same period of 2001, 33 of 355 workstations had no biometric access, and by January 2002 the number of failed keyboards nearly doubled to 60.
Another change affecting access was a move to lock access to computers automatically after they sit idle for a short period--defaulting to a screen saver and requiring another log-on to lift the aptly named Privacy Curtain. Instead of offering open access for an hour, the computers were reprogrammed to cut access after 10 minutes of inactivity in physician practice areas and three minutes in the hospital, Smith says.
The shorter time limit followed HIPAA-era security practices but increased the number of times physicians had to log on. From June 1999 to June 2000, the number of authorized users increased 45%, but the number of accesses doubled. Delays and other problems using fingerprints were magnified, and the percentage of biometric access plummeted during that period to 53% in 2000 from 82% in 1999.
By June 2001, fingerprint-only access had declined to 39%, and it fell further to 33% by January 2002.
The timed lockout "is a bit of a nuisance, because it requires two or three things to be entered to make the Privacy Curtain go away," Trigg says.
Page says the computer might cut to the screen saver several times during an encounter with a patient, making him sign in again and again.
A fizzle and a pop
To address the problems of breakdowns and obsolescence, Mayo Clinic Jacksonville would have to find another vendor to supply upgraded software and hardware to replace what it had, a significant investment to be weighed against the benefit of continuing a process that had lost credibility, Smith says.
Executive discussions about either updating the technology or seeking alternatives became academic in April, however, when a software "time bomb" went off in the section of code that operated the fingerprint-reading mechanism.
Ostensibly slipped in long ago by a programmer, the willful glitch made it impossible for the Privacy Curtain software to read a fingerprint. A subcontractor had supplied the reader mechanism to NRI. No one had the critical source code to diagnose and fix the problem, and "the trail was too long" to right the wrong, Smith says.
With the falloff in popularity and other issues related to incorrect identification, the prudent solution was to abandon the biometric option for now, says Smith, who called the cyber-ambush "fortunate and unfortunate at the same time."
While emerging technology gets a hearing, Mayo Clinic Jacksonville plans to expand the Privacy Curtain protection to computers in all business and patient-care areas across the organization next year, with or without biometrics, he says.
The clinic's fallback to typed access runs counter to the Gartner pronouncement about providing more unobtrusive options. "Mayo's result is disturbing--but it's also enlightening," Klein says.
If the value of what's in the computer is worth the extra effort to get at it, he says, it's an encouraging sign that comprehensive clinical information systems can win over the physician community and render access issues less important.
Most healthcare organizations still use clinical systems to supplement the paper record, either by making bits of it accessible online or by supplying printouts of computerized information for the paper chart. The paperless clinical practice is a long way off for the industry at large, Klein says, and alternatives to typing "will track and follow the adoption of paperless medical records."
He predicts that by the time healthcare moves into the paperless era, "biometrics probably will be up to the task."