Journal of the American Medical Informatics Association
Volume 13
Number 2 Mar / Apr 2006
127
Historical Perspectives n
Report to the National Institutes of Health Division of Research
Grants Computer Research Study Section on Computer
Applications in Medical Communication and Information
Retrieval Systems as Related to the Improvement of
Patient Care and the Medical Record—September 26, 1966
G. OCTO BARNETT, MD
j
J Am Med Inform Assoc. 2006;13:127–135. DOI 10.1197/jamia.M2009.
(Editor’s note: The full text of the original and previously unpublished 1966 historical document is available via an online
JAMIA supplement at www.jamia.org; excerpts from representative segments follow below. An ellipsis in square
brackets [.] has been inserted at each point where text
from the original document was omitted. Such text appears
in the online ‘‘full’’ version of the document.)
I would like to welcome the Public Health Service visitors to
the Computer Research Study Section Meeting and to express
my personal appreciation for the opportunity to lead this
colloquium. It is both a privilege and a challenge to attempt
to guide a discussion with such a group of participants and
I am certain that it will be an informative experience for
me. In the past few years, my work with the members of
the Computer Study Section has greatly contributed to my
understanding of the problems we are to examine today.
The critical and imaginative ideas and the depth of understanding displayed by these individuals have set a standard
which continues to inspire me.
It is my hope that this colloquium will conclude with an
active discussion. I hope—and expect—to be challenged at
many points and feel that we shall all benefit from such an
approach. It will be interesting to hear from those among us
who may have different philosophies regarding the nature
of the objectives and procedures with which we are
concerned and, above all, from those present who have had
considerable experience in many of the topics we will discuss.
This presentation is divided into four sections.
I. A characterization of the basic needs and problems which
have brought the computer into medical care.
II. A brief review of certain research and development activities currently underway.
Affiliation of the author: Laboratory of Computer Science, Massachusetts General Hospital, Boston, MA.
Correspondence and reprints: G. Octo Barnett, MD, Laboratory of
Computer Science, 50 Staniford Street, Boston, MA 02114; e-mail:
<[email protected]>.
Received for review: 11/03/05; accepted for publication: 11/20/05.
III. A discussion of some of the significant issues encountered
in this type of research and development.
IV. An examination of the possible roles that the computer
industry, the hospital-university community, and the
National Institutes of Health may play in the future of
this research.
I do not plan to review in any detail the research project we
have at the Massachusetts General Hospital, but it will be
obvious that many of my opinions have been strongly
influenced by the experiences we have had there and by the
objectives and procedures we have evolved during the past
several years.
Since it is my intent to be critical and honest in my role as
chairman, and since I still retain the pretensions of being a scientist with some understanding of the scientific disciplines
exemplified in medical and engineering research, I must express my distaste for the superficiality and distortions that
characterize some of the published works and the publicity,
in both the computing industry and in the areas where computers have been applied to medical research. I am concerned
with the scientific integrity of the approach that allows a
broad statement that the computer can do tasks X, Y, and Z
when even a superficial investigation would reveal that X
can be done only on a limited demonstration basis in an artificial environment, Y is being seriously considered as an area
to be programmed three years hence when system ‘‘..’’ is
fully functioning, and task Z looks like a challenging problem
in information processing and wouldn’t it be nice if we could
get a National Institutes of Health grant to carry out a research project. The failure to discriminate between present reality and future speculations has been one of the major causes
of frustration and misunderstanding in the medical applications of computer science.
I. Characterization of Patient Care
[.]
During peak periods of activity [at Massachusetts General
Hospital in 1965–1966], over 500 patients are in transit in
the Hospital. Innumerable telephone calls are made between
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BARNETT, Report to the NIH Division of Research Grants
patient care areas, laboratories and various physicians’
offices. Each time a patient is admitted, pertinent information
is sent to 66 different areas in the hospital. It is estimated that
on an average day over 6,000 doctors’ orders are written and
the Nursing Service administers over 30,000 drugs and treatments. It is also estimated that at least 50,000 separate items of
information are entered into patient records each day, or
almost 20,000,000 items each year. Understandably, the
amount of information processing involved in this magnitude
of activity has almost overwhelmed the established system of
writing requisitions and reports by hand on multiple slips
of paper which are messenger carried from one part of
the hospital to another. The central role of information processing in medical care can also be examined from another
viewpoint—one that emphasizes the fundamental characteristic of patient care. Essentially, the diagnosis and treatment
process can be defined as an iterative sequence of acts of
information processing. Patient care begins when the physician initiates his investigation by gathering selected historical
information from the patient and performing a physical
examination. He then analyzes the data in terms of his medical knowledge and formulates a hypothesis concerning the
nature of the disease process. At this time, the physician
decides whether further historical information is necessary
or a more extensive physical examination required. If the
decision is ‘‘yes,’’ appropriate action is taken; if the decision
is ‘‘no,’’ consideration must be given as to whether any laboratory tests would be useful in accepting or rejecting the
hypothesis, or in refining it. All of this cyclic activity may proceed at a very rapid rate and require only a few seconds in a
patient with a severe laceration or several hours or days in a
patient with an obscure set of ill-defined symptoms. In many
situations, the physician may decide the appropriate course is
to focus only on a certain symptom or particular disease
process, omitting or postponing a complete diagnostic
examination.
[.]
The implementation of a particular plan of action may be very
complex and involve a large number of individuals from the
professional and hospital staff, including such diverse groups
as the nursing service, the radiotherapy unit, the operating
room and anesthesiology staff, the pharmacy, the blood
bank, the diet kitchen, the physiotherapy unit, the social service staff, etc. A characteristic feature of the ‘‘doctor’s order’’
is this explosion into a myriad of different orders and communications. Thus, one simple order (such as the request for a
fasting blood test) requires a staggering list of routines: filling
out the laboratory requisition, determining the type and
amount of the sample, informing the team which draws the
blood, notifying the dietary department to delay feeding
and then to reinstate the feeding schedule after the test sample has been taken, checking to prevent conflict of orders and
to ascertain that the patient will be available for the collection
of the sample, collecting the sample, transporting the sample
with the requisition to the appropriate laboratory by the message service, logging-in the sample in the laboratory, scheduling and performing the test analysis by the laboratory
technician, transcribing the test results from the laboratory
work sheet to the original test requisition, filing the information to ensure that the appropriate charges to the patient will
be made, transporting the complete requisition with the test
result to the appropriate patient care unit and, finally, sorting
all the test results for a given care unit, and posting each result
in the appropriate patient’s medical record.
The physician must then collect the information concerning
the patient’s response to therapy. This information has
many different forms and comes from many different sources,
such as the record of vital signs, the nursing notes, and a
variety of laboratory tests as well as from repeated physical
examinations and interviews with the patient. Any treatment
program has some of the characteristics of an experiment and
involves the same iterative process of collecting information,
analyzing data, formulating an hypothesis, choosing a plan of
action and then recycling through the same sequence.
Such a description of the practice of medicine is clearly an
oversimplification, but it emphasizes two important facts:
first, that medical care is a cooperative effort, requiring the
coordinated efforts of a large number of highly trained professionals, and, secondly, that the accuracy, efficiency, and
rapidity of communication and information processing play
a major role in determining the quality of medical care.
Much of this information processing is a component of what
is termed the ‘‘medical record.’’ Far more than a dusty volume filed in the tombs of the Records Room, the medical record is a dynamic record of the total physician-patient-hospital
encounter. It includes not only the narrative account written
by the physician, but also the data on test results from the laboratories, the orders written by the physician, and the record
of the patient’s response to a prescribed course of therapy; in
effect, it is a collection of all the numerous communications
and reports describing the nature and course of the disease
process.
II. Computer Applications in Medical
Communication and Information
Retrieval Systems
A number of investigators have been concerned about the relative inadequacies of the information-processing techniques
currently employed in medical care, and there have been a
number of excellent research projects in relation to these problems. Appendix 1 is a selected annotated bibliography of
some of these efforts. It should be emphasized that this is
only a representative sample and not an exhaustive review;
therefore, there are numerous excellent projects which have
not been included. [.]
In recent years there has been increasing use of remote terminals which allow the user to input and retrieve data directly
from the computer without any intervention on the part of
a computer operator. Increasing attention is also being given
to computer applications in a conversational (or interactive)
mode where the computer can directly monitor input and respond immediately with appropriate data, reports or comments. This type of operation is making available new and
exciting techniques in the application of computers to patient
care.
III. Significant Issues Encountered in
Research and Development
In the time allotted for this discussion, I think it most profitable to concentrate on some of the problems encountered in
the research and development of an automated hospital
Journal of the American Medical Informatics Association
Volume 13
information-communication system. This type of material is
seldom found to any extent in published research, but it
would be shortsighted to fail to recognize the problems and
limitations as essential features in any consideration of the
field. Of prime importance are the following seven areas of
concern:
the
the
the
the
the
the
the
requirement for system analysis
limitations of computer technology
need for specialized personnel
utilization of a hospital as a laboratory
necessity for an evolutionary approach
requirements for terminal development
characteristics of transferability
A. Requirement for System Analysis
It is clear that no automated information-processing system
can be developed or implemented until the existent system
is analyzed and the objectives and procedures are well defined. Since so little attention has been paid through the years
to the modus operandi involved in giving and recording
medical care, the definition of the area marked for analysis
is difficult indeed. Such a definition must include more than
the vague generalizations commonly found in such media
as advertisements and grant applications. The following are
examples of generalizations which have virtually no basis
in demonstrated experience.
‘‘The advantages of the Ô....Õ will affect virtually all people
and functions within the hospital through improved efficiency, cost reduction and better patient care.’’
‘‘Simplicity of order entry and terminal operation provides
greater accuracy and more efficient use of the nurse’s time.’’
‘‘The nursing staff, as a whole, will show a general tendency
to a marked increase in job satisfaction and will be more eager
to work in this newly created atmosphere.’’
Although isolated areas of hospital procedures may have
been analyzed, there has been only minimal examination of
the over-all structure. Such analysis is difficult and timeconsuming. Most hospitals do not have clearly defined procedures and there is marked flexibility and variation even
among those that have been delineated to any extent. At
Massachusetts General Hospital, for example, there are three
different admission offices, each employing different forms
and procedures of discharging a patient. [.] It is important
to remember that the tendency to be overly concerned with
total system description (a tempting mirage at best) must be
tempered by a realistic assessment of the essentials, at the
same time avoiding entanglement with extraneous trivia.
B. Limitations of Computer Technology
It is frequently stated that application of the computer to
medical care involves only simple transfer of well-defined
techniques from the industrial field. This represents a gross
misunderstanding of the difference between the needs of
industry and the needs of hospitals. The great majority
of the techniques used in the business world are those of
straightforward batch-processing, involving simple processing of numerical data. [.] There is little concern with the
type of interaction and communication functions necessary
in the area of hospital information processing.
Because of the dissimilarity between the needs of industry to
which the computer has been applied and those of the
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129
hospital with which we are concerned, computer science research in medicine is in many areas a frontier. The following
are examples of pioneering research efforts in this field:
1. Operation from remote terminals where the interaction
between the user and the system is carried out in a conversational mode using a language similar to English;
2. Establishment of very large files on secondary storage
which are rapidly accessible, allowing many users to enter,
manipulate and retrieve information on the same data base
at the same time;
3. Design of complicated communication functions where an
entry at one terminal causes a variety of messages and reports to be generated at a number of different terminals
and where the content of the messages is a function not
only of the event prompting the entry at the first terminal,
but is also a function of the time and the state of the data
base.
There are two other fundamental ways in which the application of computers in industry differs from that in hospitals.
To begin with, the hospital user, as opposed to his counterpart in industry, is not a computer scientist or even a trained
technician, but is better described as an intelligent individual
whose primary concern is the use of the computer as a tool
to improve patient care. Secondly, it is essential that any system useful for information processing in a hospital must not
be subject to failures or downtime once it has been established and the hospital community assured of its reliability.
[.]
C. Personnel Requirements
Probably the greatest single limiting factor that curtails rapid
development in the application of computers to patient care is
the unavailability of competent and experienced personnel.
This scarcity prevails for both personnel with medical training and those with backgrounds in computer science and engineering. Research projects of this nature require the efforts
of a team of individuals trained in a number of disciplines.
However, it is essential that direction and leadership come
from members of the hospital staff who have the experience
and training to manage such an endeavor. This is due, in large
part, to the existence of an attitude among hospital personnel,
similar to the closed-corporation attitude of the typical trade
union, of very circumscribed allegiances and patterns of communication. It is almost impossible for an individual from
outside the hospital to supervise a cooperative effort involving medical and paramedical staff. In addition, as has already
been pointed out, many hospitals operate on a day-to-day
basis amidst customary but poorly documented procedures,
and only staff members with many years of experience
have an appreciation of which functions are of concern in
the design of a data-processing system and which can be
overlooked or investigated at a later time. Finally, a strong
leadership from individuals on the hospital staff greatly facilitates the acceptance and utilization of any new innovations
associated with the introduction of the computer system.
The planning for the development of the project cannot be
a function of an isolated group, but must involve the participation of individuals representing the wide spectrum of
disciplines found in the hospital: physicians, nurses, administrators, laboratory technicians, pharmacists, etc. I cannot
emphasize strongly enough the importance of commitment
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BARNETT, Report to the NIH Division of Research Grants
on the part of the entire hospital staff, the successful interaction of all departments is a prerequisite to the development
of the system.
[.]
The design and implementation of a hospital information
processing system utilize the talents of several groups of individuals who would normally not be a part of the hospital environment. For example, it is very important to have systems
analysts as members of the research team. Most hospital personnel have had little or no training in the critical analysis of a
functioning system; few have had experience in describing all
the information-flow requirements of a complex organization
such as a hospital. The individual who has specialized in this
type of work can make a valuable contribution to a systems
project not only in supplying talent, knowledge, and experience, but also in helping the hospital staff in learning
techniques of analysis.
A successful research and development project also requires
the creative efforts of a large programming staff. One of the
most frustrating features of any project in this field is the
delay involved in developing acceptable computer programs
for the available computer system. The process of preparing
programs for a large time-sharing system is still more of
an art than a science; this characteristic is greatly magnified
in the projects dealing with hospital information systems
where the application programs interact, the data base is
shared by all programs, and a high degree of reliability is
required.
[.]
It is questionable whether any other area of medical research
has a greater need for realistic, experienced, systematic management than exists in the area of designing an automatic
data-processing system in a hospital. In effect, the challenge
is to work rationally in an environment where the atmosphere
is neither that of a scientific enterprise nor a business
endeavor. It is an exceedingly difficult task to plan amidst
such uncertainty and to direct a group of such diverse backgrounds and talents. Compounding the difficulties is the
fact that a system is to be implemented where not only is
the implementation a research effort, but the computer system being used to implement the system is also a research
project. The staff must possess a unique combination of imagination and discipline; they must have a fervor for the
possibilities of the future tempered by a patient concern
with the often mundane aspects of present reality. The
enthusiasm generated by an exciting research effort must
be guided (and sometimes restrained) by the primary
concern—improved patient care.
D. The Utilization of a Hospital as a Laboratory
Large portions of the research necessary for implementing an
information-processing system in the hospital can be carried
out without direct involvement in active patient care. Such
areas would include the development of instrumentation to
facilitate the direct recording of laboratory test data or the development of a retrieval system specifically oriented toward
hospital application. However, it soon becomes necessary to
evolve from the isolated laboratory to the application of these
procedures in the actual hospital environment. Indeed, the
ultimate test of this research activity is the actual usefulness
of the system in day-to-day service operation.
It took us several years to appreciate the futility of setting up
demonstration projects or carrying out the research effort as a
parallel procedure to the normal hospital information processing. Obviously, such methods have value in the initial
stages, but are, hopefully, soon outgrown. Perhaps the principal limitation of such an approach is that parallel operation
does not—and cannot—really simulate the conditions of a
service operation. Secondly, if there exists a routine information system that can be depended upon, it is human nature for
the staff to withhold full support and utilization of the experimental system in favor of the old-fashioned, time-tested one.
Finally, the overall performance of the system and the reaction of the staff can only be adequately evaluated if the system
has been used in actual service operation for a prolonged
period of time.
Most projects—certainly our own—have suffered because of
these limitations, for in very few cases has the computer
system been adequate either in power of reliability or had
appropriate and sufficient funding, to permit service operation on a significant scale for any length of time.
[.]
E. Evolutionary Approach
The innovations introduced by computer technology and the
resultant reorganization and reorientation are not rapidly assimilated; hence, any significant progress in the application of
computers to patient care will occur only through an evolutionary process. There has been little previous experience in
this type of research and there are few laws or precedents
from which to learn. It is probably true that in most research
efforts, progress is realized only through a series of relative
failures; nevertheless, it is frustrating to meet with repeated
disappointments when the objectives are superficially so
simple. Yet one must recognize the necessity of considerable
operational experience before the needs under study can be
adequately defined. Fortunately, in most cases, successful
use of a computer system leads to a better understanding
of the problem and, at the same time, stimulates a more
ambitious and sophisticated approach.
Research workers in computer application areas have
learned to expect that the final program will bear little resemblance to the initial idea and that each program will undergo
innumerable modifications. Evolutionary development is
extremely costly in terms of personnel resources and the
amount of time expended. For example, research on the function we have labeled the Medication Cycle (ordering, listing
and charting of medications) has deeply involved us for over
three years. The programs have been rewritten twice and
patched numerous times, yet the Cycle at present is little
more than a very impressive demonstration and cannot handle many of the procedures or exceptions that actually occur
in the normal course of events. Its limitations reflect the
considerable gap between the capabilities of a demonstration
program and those of an operational system powerful and
reliable enough to cope with the day-to-day functional requirements. Because of this gap, we are starting again from
the beginning to examine the medication problem and to
respecify the flow of information and the needs to be anticipated. After three years, we think we at last understand
the nature of the problem and are able to deal with it
effectively.
Journal of the American Medical Informatics Association
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F. Terminal Development
One of the most critical steps in the establishment of a
hospital (or any other) information-processing system is the
development of a method of entering and retrieving information which is satisfactory from two points of view: providing
communication with the computer in a rapid and acceptable
manner AND providing the user with an instrument which is
relatively simple to operate.
Almost all remote-access computer systems use some form of
slow-speed typewriter device. Yet this is obviously not the
best choice for applications such as entering doctor’s orders
or retrieving lists or long laboratory reports. Other remoteaccess computer systems use a set of control keys that may
be identified with one set of unique overlays. With a given
overlay, each key represents a particular command or unit
of information. This technique is useful when there is a small
set of rigidly defined inputs, but is awkward when the set of
possible inputs is large and not at all usable when the inputs
cannot be defined in advance.
There has been little systematic development of other terminals or of alternative techniques for the entry and retrieval
of information. The research that has been done has been
on an isolated basis, rather than as one aspect of a coordinated program which would consider the terminal problem
within the framework of the overall objectives.
G. Transferability
There is one question that is of paramount concern to any
research program sponsored by the Public Health Service in
the application of computers to patient care: to what degree
can the results of the program be made available for use by
other similar projects and, ultimately, by the hospital community at large? The matter of transferability is assuming increasing importance because of the growth of widespread interest
in the problem and because of the sense of urgency on the
part of a number of hospitals.
[.]
IV. Role of Computer Industry
There are a number of developmental efforts in the field of
hospital information-processing which have been proposed
or undertaken by various computer manufacturers, computer
service organizations, consulting firms, and large aerospace
system organizations. It is my opinion that we cannot expect
a significant contribution from any industrial organization in
the areas of system analysis and specification of needs and
solutions, development of computer programs designed for
specific hospital functions, or implementation of a computer
system as an operational part of a hospital’s activities.
Although there have as yet been no conclusive indications, industrial organizations may prove to be of value in providing
manpower to staff a hospital-guided development, or in providing programming assistance where the specifications have
already been clearly defined. It is too early to determine
whether experience gained by industry in other data-processing activities will be a valuable resource. An appraisal of past
efforts suggests that most industrial organizations have difficulties in appreciating the magnitude and complexity of the
problem and have a very dangerous tendency to oversimplify
and oversell. It is unfortunate that this tendency coincides
with the rather common attitude on the part of medical and
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131
hospital investigators, which is one of naive and uncritical acceptance of the computer technology.
[If the results of any such research efforts] [.] are to achieve
maximal utilization by other hospitals, the most likely channel for such widespread usage is through the adoption of
these ideas and developments by the various computer
manufacturers. This stems from the fact that the great majority of hospitals will have to depend upon computer manufacturers to supply most of the programming resources for
operational service. The need for hospital research programs
to carry out active communication with computer manufacturers cannot be met through the usual channels of
publication, for a number of reasons: the vast amount of information to be communicated; the complexities and ramifications of this information which cannot be communicated
except through hours of discussion and explanation; and
the time lags and limitations imposed by the usual publication routes. In addition, a hospital investigator who has
developed experience in this area has a clear responsibility
for criticizing the developments that the computer manufacturers propose and undertake, since there are very few
individuals in the country who can carry out such constructive criticism of a manufacturer’s activities.
V. Role of Hospitals
One of the major deficiencies in present hospital administration is that there are no traditions or procedures to support
an internal research and development program in improving
the hospital’s raison dÔêtre—the provision of patient care. The
Public Health Service has funds for supporting a limited
amount of research in improving patient care procedures;
however, access to these funds is restricted by the fact that
the recipient hospital must be willing to make long-term commitments of staff and resources to a developmental effort. In
most situations, hospital administration is understaffed and
vastly overcommitted in the decision processes involved in
day-to-day operation and in solving the inevitable crises.
Under present procedures of hospital management, there
seems to be little opportunity to develop explicit objectives
for the various patient care functions and to examine critically
the methods of hospital operation.
[.]
If automatic data processing is to make a significant impact
on patient care, hospital administration and the medical
and nursing professions must assume a major responsibility
in the effort. Commitment to the project will require that
part of the best talent in the hospital be assigned to the program and that staff positions be made available to dataprocessing specialists at salary scales much higher than is
customary in a hospital. It will require the full-time participation of hospital staff who have experience in managing a
research effort and who have the ability to understand and
deal with the Public Health Service funding mechanisms. It
will also require a willingness on the part of the hospital to
gamble on a development where the economic justification
is not defined.
On the basis of presently available evidence, it is very difficult
to defend any large-scale hospital information-processing
system with the statement that the cost of patient care will
be reduced. It is almost impossible to predict the cost of a
computer system since the problems are not yet clearly
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BARNETT, Report to the NIH Division of Research Grants
delineated; even where the problems are defined, there is little
comparable experience in industry that would be useful in
predicting costs. In addition, hospitals have very little documentation that identifies the cost of the present techniques
of information processing. This cost is probably much higher
than most hospital administrators appreciate and may be as
much as one fourth of the total operating budget.
It would be quite erroneous to consider cost alone as the most
important aspect. The decisive factor is the relation between
cost of procedures and value of procedures. For example, an
automatic data-processing system can provide laboratory
test results to the physician faster, in a more readable format,
and probably with less error. In the administration of medications, studies have shown an error rate of over 5% using manual methods of information processing. The value of reducing
this error rate through the use of automated data processing
is very difficult to measure in monetary terms. It is equally
difficult to measure the monetary value of reducing the
need for innumerable telephone calls and interruptions. A
hospital cannot afford every worthy program, no matter
how desirable an individual proposal may seem; in all situations, some type of priority must be established. This type of
cost accounting is, at best, qualitative and it is clear that
the hospitals pioneering in this area will pay a heavier
cost than those which elect to develop an informationprocessing system several years hence. At this time there
probably are not a great number of hospitals which have
the imagination and resources to carry this responsibility,
and it is clear that the Public Health Service will have to
assume a major role in providing inspiration, leadership
and financial support.
VI. The Role of Public Health Service
At the present time, there are two different types of hospital
information-processing projects which are being supported
by the Public Health Service. On the one hand, there are
relatively small projects, concerned with the establishment
of prototype operations in limited areas of the hospital information-flow problem and receiving limited support from
National Institutes of Health. Such efforts are useful as demonstration projects but are usually too restricted in scope of
operation as well as funding to make a significant impact
on the problem. The second type of research project is devoted to more intensive analysis and the development of
new techniques and is not designed to perform in a service capacity for the hospital. These research efforts are of enormous
value in defining specific problems and developing techniques of solution; however, since there is no actual service
implementation, such efforts do not easily lead to a progressive or coordinated solution to the overall need.
Most of the research and demonstration projects come to this
committee for scientific review. Our principal function is to
determine the research merit of a particular proposal. [.]
The relation between the particular research effort under
study and the overall national effort must be taken into consideration: would this particular proposal significantly contribute to the broad development in this field? Indeed, is
this particular area one of national importance in the area of
medical care? How critical is the need for such a project—will
the ultimate benefits justify the support?
[.]
It is becoming increasingly clear that these projects cannot be
evaluated by the same criteria that we would use in considering clearly defined and circumscribed research projects. In
particular, it is almost impossible to apply the usual standards
of scientific merit, for the evaluation of a proposal in the area
of hospital information processing also involves consideration of such aspects as management, hospital staff participation, availability of adequate personnel and potential value of
the results.
[.] The following are, I think, justified if the National
Institutes of Health makes the decision to give strong support
to development in this area:
1. Encouragement of this type of research effort in the
best medical centers throughout the country. Of primary
importance is the quality of leadership, rather than the
name or reputation of the institution. Unfortunately,
many of the more renowned institutions are relatively
deficient in imagination and have little desire to support
developmental efforts in this area. However, it is worthy
of consideration that the larger medical centers are, as a
rule, located in areas where there can be profitable interchange with other computer research projects.
2. Continuous support from the Public Health Service over a
number of years. The myriad problems of building a laboratory with experienced and dedicated personnel require
that the effort be sustained over a considerable period of
time. Without any question, the personnel needed for
this type of research project are much higher salaried
and difficult to find, and the equipment more expensive
than is typical of most National Institutes of Health
projects.
It will take at least three to five years to define a relatively
large-scale hospital information system and a longer period
of time for full utilization. There will be periods of discouragement, and setbacks and reformulations by the score. In
most cases, particular sets of functions will be defined, tested,
modified, and implemented in a stepwise fashion. The additional sophistication gained from the research efforts and the
progress of computer technology itself will inevitably lead
to new areas of development and new problems. In order
to facilitate the evolution of the approach as well as the
computer system, continuity of support is essential.
[.]
Conclusion
As we approach the end of this decade and the threshold of
the next, there is abundant evidence that we are in the midst
of a revolution as powerful in its ultimate impact on civilization as was the industrial revolution of a century ago. Just as
the development of gasoline engines and electrical power
extended and magnified the physical powers of man, so the
application of computers to science, education, and industry
extends the intellectual abilities of man. The use of the computer is bringing about significant changes in the fundamental nature of many diverse fields—commerce, transportation,
space exploration, education, finance, manufacturing, scientific research, and government.
[ . ] In our concern for the quality of present-day medical
care, we must do more than carry out research in the etiology
and treatment of disease; we must do more than build new
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Volume 13
nursing homes, clinics and hospitals; we must do more than
train the highest quality of medical and paramedical personnel. These are worthy efforts, but we must also concern ourselves with the quality, efficiency, and effectiveness of the
practice of medicine and the provision of medical care. This
is an area which has been too long neglected by medical
schools and by the National Institutes of Health.
The practice of medicine is many things. Essentially, it is an
encounter on a one-to-one basis between the physician and
the patient. It is an exercise in management and administration, complex enough to challenge the highest intellectual
and creative abilities. But it is also, inherently, a process of
information handling and a natural challenge for today’s
computer technology.
[.] Results from projects dealing with isolated areas of a
computer information system are very encouraging. There
seems to be a real potential for facilitation of routine procedures and easing the burden of paperwork currently required
of staff members, particularly in the areas of laboratory test
reporting and communicating bed occupancy information.
From a long-range point of view, the application of computer
technology to medical care offers hope for the development of
new and different concepts and radically different methods of
procedure that will not only contribute to the improvement
of hospital administration but will facilitate medical research
and greatly improve the giving of patient care.
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Appendix 1
(Editor’s Note: The original appendix, available as an online
JAMIA data supplement, contained the following sections
[but references from all the sections appear above in this
abridged document].
A. General (definition of problem area, system analysis, etc.)
B. Punched-card systems applied to clinical laboratory test
ordering and reporting procedures
C. Checklist procedure for collecting clinical information
D. Time-sharing computer systems
E. Procedures for retrieving free-text information
F. Applications in diagnosis and treatment
Two representative [of the six original] sections of the appendix each containing selected annotated bibliographies on the
application of computers to patient care follow below).
Overview of Appendix 1
A comprehensive bibliography on the use of computer in
hospital administration, patient care procedures, and medical
record automation would include at lease 2,000 references
depending on the limits used in defining the field. A much
smaller number was selected on the basis of choosing a representative sample of the topics and projects which seem most
significant. The annotations are an attempt to place the articles in perspective and represent the author’s predilections.
More extensive bibliographies are contained in the notes
(prepared by Karl Bartscht and Richard Jelinek) of the
University of Michigan Engineering Summer Conference on
the ‘‘Application of Computers in Hospitals, 1966,’’ and also
in a System Development Corporation technical report by
Anne Summerfield and Sally Empey entitled ‘‘ComputerBased Information System for Medicine.’’ A bibliography on
the larger topic ‘‘Computers in Medicine’’ has recently been
prepared from Index Medicus by Arch Turner of the
University of Missouri School of Medicine.
One of the difficulties in reviewing the current state of work
in this field is that much of the information is contained in unpublished progress reports, proceedings of conferences that
have not yet or will not be published, and internal technical
reports of IBM. In addition, there is considerable work in
progress, the description of which is available only through
personal communication. The various individual investigators, Dr. Helen Gee, and the staff of the National Institutes
of Health Computer Study Section, and IBM have been
most cooperative in supplying many of the references.
E. Procedures for Retrieving Free-text Information
In any procedure which requires coding or transformation of
data at the time of input, there is likely to be distortion of data
or loss of information. The act of establishing a dictionary for
the purpose of retrieval and processing information assumes
a hypothesis about the underlying structure of that information. Most clinical research on medical record information has
been done on data which are very rigidly coded, using
retrieval and analysis techniques that [.] are quite limited.
However, there are several projects which have developed
techniques involving fewer restrictions on input and greater
sophistication on retrieval.
Korein et al.45,46 have utilized the approach of fixed first, second and third-order paragraph headings which are coded
for computer processing and retrieval. The content of the paragraphs is of variable length and may consist of sentences or
entire paragraphs. Retrieval is accomplished through selection
of specific coded [sections with free text content, or else by
exact work match in a specific free text section]. Pratt and
Thomas47 have described a computer-based information
processing system for pathology data, using organization and
classification of diagnostic data according to the ‘‘Systematized
Nomenclature of Pathology’’ (SNOP). SNOP is a special-purpose
language which, by its vocabulary, identifies all admissible
primary data terms. Its organization specifies the syntactical form of any diagnostic message, first by restricting a
term to a single information field and second by fixing
the order in which the form information fields must be
read. This system carries out a search and identification
of a subset of patient records based on any logical combination of [subject matter data within a record]. Smith and
Melton48 have developed a system for coding of autopsy
records wherein the coding process of the diagnostic text
is performed automatically by the computer. The coding
uses a classification scheme to separate words into classes
such as pathological processes, anatomic sites, modifiers,
etiologic agents, and operations. The coding process also
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Volume 13
includes a hierarchical structure which allows retrieval at both
generic and specific levels. Because there is no syntactical
checking on input, errors on retrieval are possible because of
grammatical complexities such as negative statements.
Lampson49 has developed a similar approach in filing and
retrieving surgical pathology data in unedited, uncoded, unrestricted prose form. This technique uses a thesaurus which
relates all the words having identifiable relations (either
‘‘synonym’’ or ‘‘inclusion’’) in the vocabulary of surgical
pathology data. Searches are performed by simple serial
matching of the data, without regard for word order, and
therefore are highly dependent on the completeness of the
thesaurus. In addition, false retrieval is occasionally caused
by compound queries, compound diagnoses, syntax, and
semantics.
At the Massachusetts General Hospital, on the Hospital
Computer Project,50,51 there is a system to permit hospital
personnel to define and establish private data files, to enter
or change moderately large volumes of English text or coded
data, and to retrieve and mathematically manipulate selected
output information without the need for special assistance or
any direct intervention by trained computer programmers.
The design objective in constructing the information storage
and retrieval programs was to facilitate Teletype console
interrogation of both special research files and standard automated hospital care files (for both active and discharge patients). The data retrieval is controlled by complex logical
descriptors defined at each retrieval session.
F. Application in Diagnosis and Treatment
The application of computers in medical diagnosis is the one
that has received the greatest attention by both the lay public
and by computer scientists. Nevertheless, there has been little
operational success in the area and most of the work has been
either theoretical, developmental, or sharply limited. In 1959,
Ledley and Lusted52 published an examination of the problem of diagnosis from the probability approach; this discussion has significantly influenced the application of
computers to medical diagnosis. Warner et al.53 have quite
successfully used the probability approach (Bayes theorem)
in the diagnosis of congenital heart disease; Overall and
Williams54 have applied it to the diagnosis of thyroid disease;
Lodwick55 has used it in the diagnosis of bone tumors.
Brodman and Van Woerkom56 have applied another type of
probability model to the diagnostic screening of outpatients
for common disease processes and Collen57 has used a third
variation in the multiphasic screening process. A number of
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135
other models of the diagnostic process have been reported
but few have been tested on clinical material.
A much more successful application of computers to medical
diagnosis is the automatic classification of electrocardiographic abnormalities. There have been a number of different
approaches to the classification scheme; the two investigators
who have most thoroughly investigated the problem are
Pipberger et al. and Caceres. Pipberger et al.58 use orthogonal
leads and a form of multivariant analysis. Caceres59 uses the
standard 12-lead electrocardiogram and attempts to duplicate
the diagnostic procedures used in clinical electrocardiography.
All applications of computers for diagnosis have been based
on correlating output of the model with known clinical conditions determined by independent methods. The inherent
difficulty of collecting sufficient documental and accurate
clinical material has been a major limiting factor in the development of this area.
Computers have been used for treatment planning in several
applications. Two of the most successful have been menu
planning for patients’ meals60 and the planning and execution
of radiotherapy. In planning menus, the mathematical model
(using techniques of linear programming) contains the dietary requirements and preferences of the patients. It has
been claimed that use of the computer to plan the menus
reduces the raw food costs by up to 24% with simultaneous
improvement in the quality of food service and patient care.
In treatment of a tumor with radiation, the therapist must deliver an adequate dose to the tumor without destroying vital
tissues that either surround the tumor or lie along the paths
that the rays must travel. Because of the complexity of dose
distributions when multiple sources are used, it was impossible to do more than proceed on the basis of rough estimates
prior to the application of computers. At the present time,
computers are used both in the computation of dosage in interstitial radiation therapy61 and in external beam therapy.62
There have been several prototype applications of computers
in the management of life-threatening situations. In certain
critically ill patients, it is very important to monitor a variety
of physiological variables constantly, in order to establish
the current status and to aid in the selection of treatments.
Weil et al.63 are primarily concerned with the development
of transducers and the on-line monitoring of patients critically
ill with shock. Vallbona et al64 have a research effort utilizing
considerable analog pre-programming that is concerned with
the preparation of chronological listings and summary reports
of all entries made over a prespecified period of time.