Medical Technology and the Health Care System A Study of the Diffusion of Equipment-Embodied Technology (1979) / Chapter Skim
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APPENDIX E: THE DEVELOPMENT AND DIFFUSION OF A MEDICAL TECHNOLOGY: MEDICAL INFORMATION SYSTEMS
APPENDIX E: THE DEVELOPMENT AND DIFFUSION OF A MEDICAL TECHNOLOGY: MEDICAL INFORMATION SYSTEMS
Pages 201-239
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From page 201... ...
To most of us there is a strong implication that whatever information the system contains is organized relative to the person to whom it pertains. That is, there is an integrated patient record.
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developing a modular system is far better for the present, than seeking a so-called 'total medical information system.' Although the long-term objectives of the two strategies are identical, the methods of procedure and the intermediate goals are very different, as is the prognosis for their relative utility and near-term success."7 Collen defined a medical information system in operational terms: "A medical information system ... is one that utilizes electronic data processing and communications equipment to provide on-line processing with real time responses for patient data within one or more general medical centers, including both hospital and out-patient services."12 In his view, subcomponents of MIS's may include a hospital information system, a laboratory data system, a hospital administrative information system, and (presumably)
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That is, there are the minimum essential data elements that would need to be collected, disregarding for the moment all considerations of purpose, usage, and setting. They are: patient identification (number, name, address)
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CURRENT STATE OF THE TECHNOLOGY OF MEDICAL INFORMATION SYSTEMS The data elements collected by a particular medical information system identify it in a kind of common sense way. The various circumstances in which many MIS's have been operated, considered with the purposes for which they were operated, may be taken to characterize the state of the art of such systems.
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From page 205... ...
Example: Feasibility of MIS's With Many Kinds of Medical Service Functions When we examine the current and past MIS's along one sample dimension, i.e., medical service areas, it is clear that a considerable range of application systems have been feasible. The medical service areas have included: Admissions Office;14'16,31 Business Office;5,23 Medical Record Department;2,l4,17 Clinical Laboratory;2'35'38 Radiology;5'40,42 Electrocardiography;10,11,52-54,60 Intensive Care; 30 , 51, 55, 58 Obstetrical Care;46 Mental Health;15,20,24,59 Pharmacy.5,21,29,32,45 Each of these sytems has other dimensions, or secondary characteristics, such as type of patient population, institutional setting, etc.
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Detailed Description: The system provides an integrated patient record that includes essential data elements, plus results of psychological test instruments, nurse's progress notes, general physical, medications, and recordings of diagnoses.21> f2^,^1 Special Features: Experimental programs for prediction of patient behavior, optimum classification for therapeutic purposes, and various customized searches and reports in support of research and management objectives. System costs are entirely recovered from patient fees at $2.60 per day.
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Detailed Description: The medical application areas and functions include: a computerized integrated computer patient record with input from physician's diagnosis; automated multiphasic screening; computerized electrocardiogram interpretation; automated compilation of various laboratory tests, including blood gases; pulmonary functions; clinical chemistry; analysis and interpretation of cardiac catheterization; and physiological monitoring of intensive care units. Output of the subsystems is used primarily by physicians and nurses for direct patient care.
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From page 208... ...
Along with the relative breadth of coverage across the hospital, which is offered by the commercial systems, there is a tendency for a somewhat shallow approach to any individual medical area. Medical information systems are offered commercially by Burroughs Corporation, Data Care, IBM, McDonnell-Douglas, National Data Communications, Inc./Honeywell Corporation, and Technicon Corporation.
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From page 209... ...
The number of computer terminals employed is: Technicon Corporation, Maine Medical Center, Portland, l07 terminals; Technicon Corporation, El Camino Hospital, Mountain View, California, 56 terminals; NDC/ Honeywell, Deaconess Hospital, Evansville, Indiana, 83 terminals; McAuto, Missouri Baptist Hospital, St. Louis, Missouri, 40 terminals.
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At this time, a press release announced that "nationwide availability of the system to the medical community would not come until late l968 or early l969." A major administrative reorganization was announced publicly in December l967. Early in l968 it ceased to make offerings of medical computer services and elected to make offerings of business office and administrative services, aiming at a potential of 600 hospitals.
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From page 211... ...
At its furthest development, this system included extensive general outpatient screening and follow-up data; data for a special, prospective study on benefits of periodic health examination on a population of l0,000; an emergency room patient record and physician's assistance function; prospective records on patient pharmacy records; and a developing system of hospital terminals for orders, record-keeping, and reporting. At a critical juncture, when there were very serious technical problems during expansion, the two major sources of federal funding were precipitously withdrawn.
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Nonetheless, they will be recapitulated briefly, since these are the raw data of our review. After this we will examine the possibility that two categories of obstacles are more or less inherent in the particular medical application area.
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Likewise, all users suffer from the malfunctioning of moving head disk information storage devices. In spite of encouraging increases in disk storage capacity, large medical record files still frequently exceed storage capacity of many systems.
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Medical Barriers to Medical Information Systems Development There is nothing about the computer techniques used in medical information systems that makes them in any way fundamentally different from such systems in nonmedical fields. There are, however, two special nontechnical barriers that have to some extent been inherent to the medical application.
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In the use of data base systems for patient and medical records, this difficulty is most apparent. For example, after one knows or guesses that the variables "first trimester pregnancy" and soporific "Thalidomide" are relevant to the diagnosis "phocomelia," it is technically easy to construct the appropriate data base system for patient records.
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Problems with operational medical information systems also attest to the claim that social engineering proceeds less rapidly than hardware engineering. There are repeated mentions of difficulty in getting communication between medical and computing personnel on the same research team, and in establishing communication and cooperation between health care institutions in the same city.
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From page 217... ...
IBM, an early enthusiast for medical information systems, has virtually abandoned medicine as a high-priority marketplace. There are of course still large numbers of computers going into hospital business offices to do accounting jobs.
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In no case do any of the most desirable outcomes -- so long pursued -- present the opportunity to offer the manufacturers the kind of hardware sales "challenge" that compares with either simple automation or new and costly measurement technology, nor even just selling a few more accounting systems. IMPACT OF PUBLIC POLICIES ON THE DEVELOPMENT, ADOPTION, AND DIFFUSION OF MEDICAL INFORMATION SYSTEMS Federal Research Policies Research Support for Computers in Medicine The creation of hospital accounting and business office computer-based information systems has proceeded on the basis of local funding and commercial development and sales.
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Government-Sponsored Computer Centers The initial research grants from NIH in this area took the form of facility support awards. These were made to encourage and subsidize the creation and operation of computing facilities in selected major medical centers.
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Regrettably, this pattern has never been suitable for computer projects. Lusted said that even in l960 it was apparent that computer grant applications differed from all other kinds of grand requests by being for larger sums of money and by including the puchase of computers (certainly a long-term commitment)
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Likewise, a computer system that has.'solved some aspect of medical records processing, for instance how to record automatically a patient interrogation history, cannot save
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In this category, the National Data Communications/Honeywell system cost $l2,000,000 to develop.62 Development costs for the Technicon MIS were reported to be $25,000,000. It is a serious problem that no operational unit of the Department of Health, Education, and Welfare actually has grant budgets of the magnitude required to support the big systems.
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One isolated example may be offered. The University of Missouri Medical Center in Columbia found that, as a direct effect of Medicare, it had to increase its business office claims processing staff from 25 to 32 and increase the record room staff from 22 to 26.
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This is probably not a major disadvantage to the field except in the medical application areas using remote terminals and telecommunication systems. Here it is a definite disadvantage.
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An example of a choice that could reasonably be based upon cost-effectiveness analysis is that between automated clinical chemistry analyzers as compared with manual methods. Briefly,
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The method of cost-effectiveness is unsuitable for evaluation of the entire medical information system because there is no alternative methodology. The raison d'etre for MIS's is to bring together all available parts of the patient record, i.e., to be more than the sum of the parts.
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From page 227... ...
It is especially desirable to estimate health outcomes for such a comparison. One writer warns, however, that: "The growing literature on evaluating medical care and health status clearly indicates that studies rigorously documenting relationships between changes in health delivery process and changes in health status are difficult and costly to undertake."62 In the case of medical information systems the outcomes or benefits to be measured may be specified in terms that are centered upon the patient, the institution, society, or all of these and others.
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The desired benefit is to base the decision for surgical bypass procedures on the computer matching of the outcomes of like patients treated by medical and by surgical regimens. The system does appear to result in measurable improvement in clinical decision making and in improved patient outcomes.
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If the computer hardware were suddenly to become absolutely free, the costs of developing medical information systems would
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The consequence again would probably be a reduction in cost, by eliminating telephone line charges and the associated communication devices. If the computer costs did not change, and based on current cost experiences , the reduction in cost could be as large as 50 percent of the computer hardware budget.
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It would be especially encouraging if these services (e.g., physician assistance functions, quality assurance analyses, screening studies, risk estimates, prognoses, treatment plans, or patient educational services) were made billable as services outside the negotiated per diem.
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Systems of borderline merit, which concentrate primarily upon business office and institutional management functions, will be "permitted." Some systems that are of great merit because of their clinical features (e.g., physician assistance, education, prospective community data base building, etc.) will be immune to evaluation based on dollar accounting,' and will be harmed or destroyed.
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There is no known case in which a business office system has even evolved into a medical information system. The concept of the medical information system under a laissez-faire paradigm will simply not be developed.
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"Draft Summary Report of an Analysis of Automated Ambulatory Medical Record Systems, University of California, June, l975." Rockville, Md.
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Peter, and Stroebel, Charles F "The Use of a Psychiatric Patient Record System." Presented at FASEB Conference on the Computer as a Research Tool in the Life Sciences, Aspen, Colorado, June 27, l974.
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"Information Management in Radiology." Pages 206-40 in Hospital Computer Systems. Morris F
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W "Digital Computer Analysis of the Normal and Abnormal Electrocardiogram." Progress in Cardiovascular Diseases 5(l963)
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"Automated Hospital Information Systems, Case Study Report." Princeton, New Jersey, April 29, l976.
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