Policy Implications of Medical Information

Systems

December 1977

NTIS order #PB-274857
Library of Congress Catalog Card Number 77-60005 2

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, D.C. 20402 Stock No. 052-003 -00496-8

ii
T ECHNOL O GY ASSESSME NT BOAR D

EDWARD M. KENNEDY, MASS., CHAIRMAN

LARRY WINN, JR., KANS., VICE CHAIRMAN

ERNEST F. HOLLINGS, S.C. OLIN E. TEAGUE, TEX.

HUBERT H. HUMPHREY, MINN. MORRIS K. UDALL, ARIZ.

CLIFFORD P. CASE, N.J. GEORGE E. BROWN, JR., CALIF.

TED STEVENS, ALASKA CLARENCE E. MILLER, OHIO

ORRIN Q. HATCH, UTAH JOHN W. WYDLER, N.Y.

Congress of the United States

OFFICE OF TECHNOLOGY ASSESSMENT

WASHINGTON, D.C. 20510

DANIEL DESIMONE

ACTING DIRECTOR

Committee on Human Resource s

u. s . Senat e

Washington, D. C . 2051 0

Gentlemen :

On behalf of the Board of the Office of Technolog y

Assessment, we are pleased to forward the results o f

the assessment requested by your Committee .

This report provides a balanced and impartial analysi s

of medical information systems . We hope that thi s

analysis will serve as a useful resource for continuin g

evaluation of the issues it discusses .

Sincerely ,

f

Edward M. Kennedy {

Chairma n

Enclosur e

. . .

111
FOREWORD

This report is an assessment of the policy implications of computer-based medical information systems. It was requested by the Senate Committee on Human

Resources because of increased concern over the quality and rising costs of medical

care.

The Committee asked the Office of Technology Assessment to examine:

1. The benefits and limitations of medical information systems;

2. The factors influencing their adoption; and

3. Policy alternatives for the Federal Government with regard to such systems.

The report begins with a summary of the findings and conclusions and the alternative policies that could be pursued. Chapter 2 provides a perspective for the

assessment. Three different kinds of medical information systems that were

examined are described in chapter 3. Chapter 4 discusses the implications of these

systems on such areas of concern as quality of medical care, clinical decisionmaking,

malpractice litigation, and confidentiality of data about patients. Chapters considers

the factors that influence the diffusion and use of information systems in the medical

field. In conclusion, chapter 6 considers a range of policy alternatives for maximizing

the benefits of information systems.

This study was conducted by staff of the OTA Health Program with assistance

from an advisory panel, chaired by Kerr L. White. It was reviewed by the OTA Health

Advisory Committee, chaired by Frederick C. Robbins, and by a wide variety of

individuals in the medical field, industry, universities, consumer organizations, and

Government. The resulting report is a synthesis and does not necessarily represent

the views of any of the individuals who participated in the assessment or the review

process.

DANIEL DeSIMONE

Acting Director

v
OTA HEALTH PROGRAM STAFF

Pony M. Ehrenhaft, Study Director

Susan Corcoran Ellen A. Harwood Howard West

Cheryl L. Sullivan, Administrative Assistant

Carl A. Taylor, Program Manager

OTA PUBLICATIONS STAFF

John C. Holmes, Publications Officer

Kathie S. Boss Joanne Heming Cynthia M. Stern

vii
ADVISORY PANEL

Kerr L. White, Chairman

Director, Institute for Health Care Studies, United

G. Octo Barnett

Director, Laboratory of Computer Science

Massachusetts General Hospital

James P. Cooney, Jr.

Executive Director, Rhode island Health Services

Research, inc.

Gerald A. Giebink

Director, Health Care Management Systems, Inc.

Lillian Guralnick

Statistician, Dade Monroe PSRO, Inc.

Jack H. Hall

Vice President, Department of Medical Education

Methodist Hospital of Indiana

Leonard T. Kurland

Chairperson, Department of Epidemiology and

Medical Statistics

Mayo Clinic

Hospital Fund

Jeanne K. Malchon

Commissioner of Pinellas County

Clearwater, Florida

H. Richard Nesson

Director, Office of Extramural Health Programs

Harvard School of Public Health

Donald C. Riedel

Chairperson, Center for the Study of Health

Services

Institute for Social and Policy Studies

Yale University

Arnold H. Spellman

Director of Project Development

Commission on Professional and Hospital Activities

Mary-j Waterstraat

Executive Director, American Medical Record

Association

. . . Vlll
CONTENTS

Chapter

1.

2.

3.

4.

5.

6.

SUMMARY

Findings and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Policy Alternatives.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Scope of the Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Organization of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BACKGROUND

Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Development and Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DESCRIPTIONS OF THREE SYSTEMS

Technicon Medical Information System (THIS) . . . . . . . . . . . . . . . . . . . . . . . .

Computer Stored Ambulatory Record (COSTAR) System . . . . . . . . . . . . . .

Problem-Oriented Medical Information System (PROMIS) . . . . . . . . . . . . . .

IMPLICATIONS

Institutional Delivery of Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Support of Clinical Decisionmaking and Physician Education . . . . . . . . . . . .

Assessment of the Quality and Utilization of Medical Care . . . . . . . . . . . . . .

Malpractice Litigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Roles of Medical Care Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health Data Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Planning and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Confidentiality of Patient Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FACTORS INFLUENCING ADOPTION AND USE

Acceptability to Medical Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Technical Transferability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POLICY ISSUES AND ALTERNATIVES

Development and Dissemination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Control and Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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LIST OF FIGURES

Figure

Number

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Hospital Departments Where Computer Terminals

are Located . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TMIS Laboratory Test Order Display . . . . . . . .

TMIS Printout of New Orders . . . . . . . . . . . . . .

TMIS Patient Care Plan . . . . . . . . . . . . . . . . . . . .

HCHP Encounter Form for the Internal

Medicine Department . . . . . . . . . . . . . . . . . . . .

COSTAR Patient Status Report. . . . . . . . . . . . .

PROMIS Master Frame . .

PROMIS

Patient

PROMIS

PROMIS

Display

Problem

Frames

. . . . . . .

. . . . . . . . . . . . . . . . . .

for Entering Data

. . . . . . . . . . . . . . . . . .

Narrative on a Patient Problem . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

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. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

About a

. . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .

Display of Outstanding Laboratory Tests . . . . . . . . . . . . . . . . . . . .

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SUMMARY
1 ●

SUMMARY

The complexity of medical care has greatly increased during the past 30 years.

More technology, more professionals, and more support services are involved in the

care of patients than ever before. Today’s medical care institutions encounter problems coordinating and communicating massive quantities of data necessary for cliniical care. Medical professionals must note and remember increasing amounts of data

about each patient from an expanded number of diagnostic tests and therapeutic

procedures. Physicians are also faced with the task of memorizing information about

new diagnostic tests and treatments, knowledge that must be constantly updated.

Outside the clinical context, other changes have increased data that must be retained about each patient. Third-party payment systems, particularity the Federal

programs Medicare and Medicaid, have raised requirements for data to ensure validity of beneficiary claims. Other Federal and State programs for quality review, planning, regulation, and research have brought additional demands for recordkeeping.

And the increase in malpractice litigation has created new pressures for careful documentation of clinical treatment. Traditional handwritten medical records have not

kept pace with the rising demands placed on them.

The application of computer technology offers a possible solution to these problems. Called medical information systems, this new application promises to change

the medical record from a historical document to timely, accurate information that is

instantl y available to all those involved with patients. Medical information systems

can be used to educate and assist medical professionals during clinical care, reducing

the need to rely on memory. Potentially, they can increase efficiency and reduce or

contain institutional costs. They can provide a way to monitor and evaluate the quality of medical services. They can eliminate duplication of data collection and can provide accurate, accessible data for evaluating and planning medical care services. Finally, they can be used to supply data that have previously been unavailable to

researchers and policy makers.

For purposes of this report, a medical information system is defined as a computer-based system that receives data normally recorded about patients, creates and

maintains from these data a computerized medical record for every patient, and

makes the data available for the following uses: patient care, administrative and

business management, monitoring and evaluating medical care services, epidemiological and clinical research, and planning of medical care resources.

No existing medical information system yet provides data for all of these purposes. Those in use were developed through the independent efforts of many investigators and consequently display a diversity of technical approaches and philosophies. For the most part, they are prototypes and vary in goals, costs, and impact.

3
Ch. 1—Summary ● 4

This variation, as well as the developmental status of the technology, makes assessment of benefits and limitations difficult. Few careful evaluative studies have been

conducted to date. However, recent breakthroughs in computer technology can be

expected to increase the availability and reduce the costs of medical information systems. Without a Federal policy toward these systems, their diffusion may well proceed indiscriminately and standardization will not be possible. If so, the full potential

of medical information systems is not likely to be achieved.

FINDINGS AND CONCLUSION S

Benefits and Limitations

Institutional Delivery of Patient Care. Evidence indicates that by facilitating

communication and reducing errors, medical information systems improve the patient care delivered in medical care institutions. Some errors are reduced because the

computer systems help ensure that data about a patient are accurate, available, legible, complete, timely, and organized. Through their mechanisms to check whether

orders have been carried out, medical information systems also monitor performance and prevent some errors of omission.

Support of Clinical Decisionmaking and Physician Education. Some medical

information systems support clinical decision making by supplying physicians with

appropriate medical knowledge and patient data during clinical care, thus reducing

their need to rely on memory. By incorporating valid findings of medical research

into programs, systems can also facilitate the spread of new medical knowledge and

provide continuing medical education. Preliminary studies indicate that errors of

omission by physicians are reduced if timely reminders are provided by the computer systems. Further evaluations are needed, however, to confirm whether physicians’ performance is changed.

Assessment of the Quality and Utilization of Medical Care Services. Medical

information systems can be programed to assess the quality of medical services provided against agreed upon standards for acceptable care. Appropriateness of inpatient facility use can also be monitored. These legally mandated functions could be

accomplished without the expense of any additional data collection. Medical information systems have been used for this purpose in only a few experimental programs,

each of which has been limited to a small number of clinical conditions.

Malpractice Litigation. Whether medical information systems would increase

or decrease malpractice litigation is debatable. Computerized medical records document the conduct of medical therapy. They could eliminate some causes for litigation by reducing errors in patient care. Errors that do occur could be highlighted,

however, and lawsuits increased. No evidence is available to support either hypothesis from institutions using medical information systems.

Roles of Medical Care Professionals. Medical information systems reduce or

eliminate paperwork at the same time that they make available information needed

for optimal job performance. Thus, medical care professionals can make greater use

of their knowledge and skills and assume increased responsibilities. However, there

is insufficient evidence to conclude that personnel actually perform new duties or

that their productivity increases in activities related to patient care.
5 . Ch. 1—Summary

Health Data Systems. Health data systems are collections of data organized

for a variety of purposes including reimbursement of health services, utilization review, assuring quality of care, and planning, monitoring, or evaluating medical care

services. Medical information systems could supply these health data systems with

data more accurate and more accessible than those currently available. If standard

classifications and codes were used and if all data sent to health data systems were

already in computerized form, these organizations would be likely to realize substantial cost savings. At present, no medical information system is coordinated with

health data systems. Further, health data systems aggregate data from more than

one source and could thus take advantage of medical information systems only if

widespread adoption occurs.

Planning and Research. Medical information systems could provide planners

and medical researchers with data that are not readily available from existing health

data systems. The computer systems store a data base that permits detailed analysis.

Such analyses are now attained only with the difficulty and expense of special studies. With this kind of data, managers of institutions could predict needs for new supplies, personnel, and facilities. If medical information systems with compatible data

bases and standard definitions were widely adopted, they could be used to plan medical services resources, to evaluate the cost and efficacy of medical care, and to conduct clinical and epidemiological research on patients’ problems, conditions, and diseases.

Confidentiality of Patient Records. The confidentiality of sensitive medical

data could be violated if computer files were infiltrated by unauthorized persons. In

addition, computerized records facilitate the availability of detailed data to organizations outside of medical care institutions. At present, each facility using a medical information system has developed its own security precautions to maintain confidentiality. Today computer records are more secure than manual records. However,

medical information systems are not in widespread use, and a potential problem does

exist.

Factors Influencing Adoption

Acceptability to Medical Care Providers. Medical information systems require medical professionals to record information in a specified manner, and some

professionals could resist changing established practices. Persuading physicians to

adopt this innovation proved a major hindrance with early systems. More recent experience with the computer systems described in this report indicates that familiarity with a system encourages medical personnel to accept it. Providers who regularly

use a system strongly support it, while those who are only occasional users sometimes find fault with it.

Technical Transferability. Prototype medical information systems have been

proven technically feasible, but most have not yet been made adaptable to the various conditions of different institutions. In order to realize the benefits of a standardized data base and to market systems economically on a large scale, flexible systems

are required. Efforts to make existing medical information systems transferable are

now being initiated.

Cost. Medical information systems are an expensive technology. Operating

costs for a hospital-based system range from $4 to $9 per patient per day. For systems based in ambulatory care sites, costs range from $0.50 to $14 per patient visit.
Ch. 1—Summary ● 6

Costs of implementation are high. Costs are, however, likely to decrease in the future, because of lower prices for computer hardware and higher volume, Moreover,

a majority of both hospitals and ambulatory care facilities now using medical information systems report overall savings in institutional costs due to their computer

systems. At least one study has documented cost savings. In particular, savings are

experienced in labor expenses.

General Factors. Rate of adoption of medical information systems will depend

on multiple factors applicable to any new technology. New developments in computing hardware and software, Federal policies, and economic incentives and constraints could facilitate or impede adoption. The effect of these factors on medical information systems is not now predictable. ,

POLICY ALTERNATIVE S

At present, the National Center for Health Services Research in the Department

of Health, Education, and Welfare supports research on medical information systems

through grants and contracts to independent investigators. The commercial computer industry, the major developer of medical information technology in the past, is

conducting some new research and directing efforts toward limited marketing of

prototype systems.

The Federal Government could continue current policies and allow adoption of

medical information systems to be determined in the open marketplace. However,

this policy could result in medical information systems being marketed and adopted

without additional investment in research to improve certain capabilities. Because

capabilities to improve and monitor the quality of medical care and to facilitate research and planning are the least developed and require standardization, these potential benefits for patients and the medical care system might be lost. Computer

systems limited to administrative and financial functions could continue to dominate

the market. Medical information systems that might be used could also lack high

standards of quality or provide inadequate protection for the confidentiality of patient data.

If Federal action influencing development, standardization, and eventual use of

medical information systems is considered appropriate, a range of policy alternatives

could be pursued. These alternatives are illustrative and not mutually exclusive. Addressing problems through several mechanisms may be most effective.

. Establish a central clearinghouse to coordinate developmental projects and

provide information to the public about medical information systems.

● Provide funding for evaluation of medical information systems in a number

of different medical care facilities and locations to determine their effectiveness in terms of relative benefits and costs.

● Ensure the availability of medical information systems with specified capabilities and applications by contracting for their design and development.

. Provide incentives for medical care facilities to adopt medical information

systems that improve the quality of patient care and support research and

planning.
—

. Authorize a central organization to develop, validate, and maintain the content of medical knowledge within medical information systems.

● Develop standardized medical data bases, including nomenclature, terms,

definitions, classifications, and codes for use in medical information systems.

. Establish guidelines for precise standards to protect confidentiality of patient data within an institution and release of identified data to third parties.

SCOPE OF THE STUD Y

There are three boundaries on the kinds of computer systems considered in this

report. The first boundary is that this study discusses only those computer systems

that electronically store at least part of the individual patient’s medical record. The

capability to accumulate and retrieve data for each patient is critical for both the process of patient care and research.

A second boundary limits discussion to broad-based systems that could provide

information needed by a medical care institution as a whole. Although computer applications such as automated clinical laboratories, pharmacy systems, intensive care

monitoring systems, and financial systems can benefit particular areas of clinical

care or institutional management, this study excludes computer systems applicable

only to such specialized units or functions.

Third, this report assesses only computer systems that can provide information

about patients during the clinical care process. This boundary limits consideration to

systems meeting two technical requirements. First, the computer itself must be directly linked to both the stored data files and those medical care providers who enter

and use the data; such a system is referred to as “on-line.” Second, the computer system must process and return data quickly enough to be used; such systems are said

to operate in “real -time.” However, systems can combine “on-line” and “off-line”

methods for entering and displaying data.

This report does not attempt to survey the field and categorize systems by design and capacity. Three advanced systems are described to illustrate potential implications of this new technology for patient care in particular and, more generally, for

the whole medical care system. Although an important capability of medical information systems is to provide necessary data for administrative and business needs,

implications of medical information systems for these areas are not examined in this

study because computer applications performing similar functions are already widely in use.

ORGANIZATION OF THE REPOR T

Chapter 2 defines the basic capabilities of medical information systems and

gives a historical overview. Major problems that have hindered development are

reviewed: variations in medical care, inadequate computer hardware and software,

and inadequate commitment of capital for long-term development.

Chapter 3 describes the three medical information systems referred to throughout the report. One system, Technicon’s Medical Information System (TMIS), is de-
Ch. 1—Summary ● 8

signed for acute care hospitals. Its use at El Camino Hospital in Mountain View,

Calif., is reviewed. Another, the Computer Stored Ambulatory Record (COSTAR)

system at the Harvard Community Health Plan in Boston, Mass., is designed for ambulatory care. The third, the Problem-Oriented Medical Information System

(PROMIS), can be used in either setting, although the prototype operates in an inpatient facility at the University of Vermont Medical Center.

Chapter 4 discusses the implications of medical information systems for institutional delivery of patient care, clinical decision making and physician education, assessment of the quality and utilization of medical care, malpractice litigation, the

roles of medical care professionals, health data collection systems, planning and research, and confidentiality of patient records.

Chapter 5 reviews factors that will influence the use of medical information

systems: acceptability to medical care providers, technical transferability, cost, and

general factors that influence the use of any new technology.

Chapter 6 summarizes alternative policies for the Federal Government in relation to medical information systems. Possible actions directing development, standardization, and dissemination of the technology to ensure maximum benefit for the

medical care system are discussed.
2 ●

BACKGROUND
2 ●

BACKGROUND

Medical information systems are being developed on the premise that a medical

care institution gains the greatest efficiency, economy, and benefit if a single computer system meets all its needs for information (37). Although almost 90 percent of

all hospitals in the United States already use electronic data processing in some

form, for the most part, only business and administrative functions are automated

(52). Few medical care facilities use a computer to support activities related to clinical care.

Medical information systems combine both administrative and medical data into

a common set of data files (or data base) for processing by the computer. Once computerized, the data are available for all authorized purposes within the institution.

This chapter describes the basic capabilities of medical information systems and reviews the history of their development and funding support.

CAPABILITIES

Ideally, medical information systems perform four functions (10):

●

●

●

●

Capture data normally recorded about each patient and store the data in a

computer record.

Provide any appropriate part or all of these data, on demand, to medical care

providers for patient care and to administrative and business offices.

Provide administrative and communicative functions, such as sending messages among various departments, scheduling appointments and procedures, and posting charges and preparing bills for the business office.

Provide a data base useful to investigators for quality of care assessment,

clinical decisionmaking, epidemiological and health services research, and

planning and evaluation of medical care.

Meeting all of these needs places extensive technical demands on a medical information system (8). Providers of patient care require data quickly. Medical information systems can meet this requirement only if patient data files are stored within

the system and computer terminals give medical users immediate access to these

files. In such a system, described technically as “on-line,” computer terminals are

connected directly to the computer’s central processing unit, which calls in and processes data stored on computer tape or disks as required. In order for data to be easily available, multiple computer terminals need to be located in all areas where data
— ——

about patients are entered and used (see figure 1). To provide information for physicians and administrators making decisions, the computer system must be able to

quickly manipulate and analyze data in many ways helpful to them. Satisfying this

requirement calls for careful structuring and definition of the data base as well as sophisticated software. Finally, researchers need a medical information system with

capacity to store massive amounts of data on large populations for long periods of

time.

Advances in computer technology have made all these capabilities technically

possible, but no medical information system at present performs all four functions.

Existing systems emphasize different capabilities and vary widely in scope of application. One system, for example, transfers patient data efficiently from one service

unit to another, but has no capability for the long-term storage of patient records.

Another system offers extensive aid to clinicians making decisions about medical

treatments, but does not generate administrative reports or prepare patient bills.

Medical information systems have some common features. All use a computer

for organizing entries of data, patient records, or reports; maintaining data files on

patients; computing; abstracting and summarizing data; generating reports; and

message-switching (2). All systems include some kind of bulk storage and various

types of terminals for entering and retrieving data.

Medical information systems vary, however, in such technical aspects as use of

large or minicomputers, location of the computer onsite or shared computer services

off site, data entry and retrieval devices, storage of data in the system, and programing language. Other variables include who enters and retrieves data about patients, the extent to which the medical record is computerized, whether narrative

information is allowed, which patient data are coded, and in what form data are retrieved.

Because systems differ so much, the term “medical information system” can be

confusing. The label has been applied to computer systems ranging in function from

single purpose subsystems for scheduling patients or for diagnosing single diseases

to complex systems that attempt to provide comprehensive information for an institution. Because medical information systems have been developed through the independent efforts of many investigators, today’s systems reflect a diversity of philosophies and technical approaches.

DEVELOPMENT AND SUPPOR T

Both the computer industry and the Federal Government have recognized the

potential of computers to process the medical data needed for patient care. Computer applications for the clinical management of patients, however, have not been developed as rapidly or accepted as widely as financial and administrative applications.

In the mid-sixties, Federal requirements for accountability in billing spurred the development of a great number of computer applications for hospital business offices.

Computers were also used for such tasks as collecting bills, managing hospital resources, and keeping track of patients within the hospital. These computer systems

succeeded both because there was sufficient demand for them by medical care institutions and because the necessary technology had already been developed and used

in other fields, such as banking and the airline industry.
13 ● Ch. 2—Background

Figure 1-HOSPITAL DEPARTMENTS WHERE COMPUTER

TERMINALS ARE LOCATED

CENTRAL

COMPUTER

\

-

NURSING STATIONS

ANCILLARY SERVICE

DEPARTMENTS

. Laboratory

● Radiology

● Pharmacy

• EKG/EEG

● Other Services

I I 1

I I Administrative/FINANClAL I

DEPARTMENTS

● Admitting

● Medical Records

• Business Office

SUPPORT DEPARTMENTS

● Central Supplies

● Food Services

Ž Housekeeping

I

1 1

●

Outpatient Services

\

Emergency Room
Ch. 2—Background ● 14

Developing computer systems that provided necessary data for patient care as

well as supported management functions posed a different set of problems. A number of early attempts to install integrated information systems in hospitals were

costly failures. These projects, which were launched in the mid-sixties, were typically initiated by private industry with the cooperation of pilot hospitals. At times,

Government research funds gave some support. A review of these unsuccessful

projects cited three primary reasons for their failure: inadequate understanding of

the complexity and variations in medical care; inadequate computer hardware and

software; and inadequate commitment of capital for long-term development (10).

Variable Medical Care. The fundamental requirement of a medical information system is that it store all pertinent data about each individual patient in an integrated computer record. The nature of medical care itself complicates computerizing

the entire medical record. No rules specify what information should be entered into

the medical record in clinical care. Style, format, and language typically differ from

one institution to another and from one clinician to another (12). In addition, because the medical record contains narrative as well as numerical data, a potentially

unlimited amount of information has to be structured and possibly codified for entry

into the computer (22).

This problem has been somewhat resolved by having developers of medical information systems work closely with physicians and other medical care providers to

define data bases in language and formats acceptable to individual institutions. In

most systems, the complete medical record has not been computerized. Sections that

are primarily numerical and defined, such as orders for and reports on laboratory

tests, medications, and routine procedures have long been computerized. Narrative

sections of the medical record that vary in content, such as physicians’ notes on a patient’s progress during therapy, have either been added incrementally to or excluded

from the computer record.

The lack of a precise and complete vocabulary hampers communication between

computer systems and providers. Substantial research is needed to analyze the content of medical data in terms, for example, of the frequency of various items. Such

research would aid in the development of a terminology that is consistent with medical standards and that gives medical care providers flexibility in entering and retrieving data. At present, lack of standardized nomenclature or established protocols

in medical care continues to constrain the development of a generalized data base

(9).

Computer Hardware and Software. Developers of medical information systems have also had to resolve a number of technical problems in order to meet the

requirements of the medical care environment. In order for data to enter and leave

the information system quickly, medical care professionals need to communicate

with the computer directly. Designing a system that permitted direct communication was a major obstacle. Developers eventually designed computer terminals that

were easy for providers of patient care to use. Computer terminals consist of a cathode ray tube ( a television-like screen) and a typewriter keyboard. In some systems,

the medical professional enters or retrieves data by touching, by “pointing” a lightpen, or by pressing a button to the left of the desired item displayed on the video

screens. Typing on a keyboard has become a supplementary, rather than a primary,

means of entering data. High-level computer languages that resemble conversational English have also been developed to facilitate changes in programing.
15 ● Ch. 2- Background

Early systems were slow in responding to inquiries from medical care providers.

Physicians and nurses found that using these systems to enter or obtain data was

more time consuming than traditional methods. As hardware costs gradually decreased, computers that responded almost instantly became feasible. Medical information systems now usually respond in under 2 seconds.

If providers are to rely on medical information systems, the computers also have

to operate 24 hours a day. Systems installed in the late sixties had frequent “downtimes,” but considerable progress has been made. The prototype medical information systems currently in use operate over 99 percent of the time. Backup computers

ensure necessary support for medical care providers.

Today, technical limitations are of a different nature (39). Recent advances in

computer technology are providing smaller and much less expensive hardware, but

are also raising new problems for software and for communication between provider and computer. The use of microprocessors, for example, requires the development of systems software that is more transferable. Software for application programs also continues to need further development. For example, techniques allowing software to be easily modified for different settings are available, but have not

yet been generally applied in medical information systems. Also, low cost, portable

terminals are not yet widely available. Because medical care professionals see patients in a number of locations, the absence of easily portable terminals has hindered

clinical applications.

Funding Support. A third major problem area has been the lack of long-term

commitment of capital. Development of medical information technology has been

characterized by high costs and long lead times. A survey of ambulatory care sites

with automated medical record systems reported developmental costs ranging from

$100,000 to $10 million, with the majority of computer projects costing $100,000 to

$300,000 for development (23). projects required 1 to 7 years of research and development before they became operational. No similar survey of hospital-based medical

information systems is available. Two systems that are currently operational, Technicon’s Medical Information System and National Data Corporation’s VITAL, cost

$25 million and $12 million respectively to develop (2). Development of the former

by the Technicon Corporation and its predecessor, Lockheed, spanned 10 years.

Funding for development of medical information systems has been provided by

private industry, the Federal Government, and, in some cases, medical care institutions themselves. Although commercial groups have emphasized applications for administration, billing, and accounting, private industry has nonetheless been the major source of funding for the research and development of medical information systems (13). Total expenditures are unknown, but far exceed those of the Federal Government.

The principal agency charged with developing medical information systems

technology in the Federal Government is the National Center for Health Services

Research (NCHSR) in the Health Resources Administration of the Department of

Health, Education, and Welfare. Other Federal funds for special projects in this area

have come from the Bureau of Health Manpower and the Indian Health Service in

HEW, as well as the Veterans Administration and the Department of Defense.

NCHSR makes grant funds available to investigators for research and/or demonstration projects in medical information technology. In the 7 years since its estab-
Ch. 2—Background ● 1 6

lishment in 1969, NCHSR has spent a total of $26.6 million for projects relating to

medical information system s.*

According to some investigators, however, project funding is sporadic, subject

to annual approval, and often limited compared to the scope of the project (10, 20).

In addition, in recent years funding support by Government has been decreasing

from the levels of spending in the late sixties and early seventies. Expenditures by

NCHSR for grants relating to medical information systems decreased from a high of

$4.6 million in FY 1974 to $3.3 million in FY 1976. * As a result, competition among

investigators applying for grants has become much stiffer, and some projects have

been discontinued.

Support by private industry for research on medical information technology

has fluctuated. The computer industry developed the basic technologies for medical

information systems in the late sixties and early seventies, but many companies

have not marketed their developmental projects. A 1973 publication listed 15 computer companies actively developing integrated information systems for hospitals (4).

Only five of these companies had operational systems installed in hospitals in 1976.

These five medical information systems, marketed by the Technicon, National Data

Communications, Data Care Systems, McDonnell Douglas, and Medicus Systems

Corporations, are now operational or in the process of being installed in approximately 20 hospitals around the country (2, 15). Two equipment manufacturers, IBM

and the Burroughs Corporation, offer a variety of applications that can be combined

to develop an integrated system, and a few medical care institutions are developing

their own inhouse modular systems from subsystem applications (2). A modular system could permit, for example, an institution to begin with administrative and business systems and later expand to include clinical applications. .

There are no other broad-based systems operational in hospitals. One hypothesis is that the long developmental time lag, frequently 5 to 10 years, and the prospect

of a low volume market discouraged industry in the past (16). However, a number of

companies, building on advances in computer technology, are now developing new

systems using minicomputers (32).

A 1974 survey of ambulatory care identified 175 sites that operated computer

systems with some medical data content (23). These systems were diverse in their

application; most were developed for a specific purpose and collected only minimal

clinical data. Although at least 14 commercial vendors were identified in the survey,

none offered a system that computer processed all the data used in providing patient

care. Only four sites had systems in which all reported data were computerized: the

Harvard Community Health Plan in Boston, Mass., the Cardiovascular Clinic in Oklahoma City, Okla., Brunswick Naval Air Station in Maine (not now operational),

and the Medical University of South Carolina at Charleston, S.C.

The source of funding for projects at the 18 sites visited during the survey was

approximately evenly divided between internal funds and external sources, primarily Federal grants. Nearly every site was still developing some aspect of the project

and thus continued to need internal support or direct Federal appropriations.

● Based on expenditures for FY 1971 through FY 1976 supplied by the Department of Health, Education, and Welfare.
17 ● Ch. 2— Background

Thus, although substantial advances, especially technical ones, have been made,

conceptual and funding problems continue to constrain the development of medical

information systems, Because current developmental projects are diverse in capacity

and degree of comprehensiveness, they have different goals, impacts, and costs. No

consensus has been reached on the defining characteristics of medical information

systems.
3 ●

DESCRIPTIONS

OF THREE SYSTEMS
3 ●

DESCRIPTIONS OF THREE SYSTEMS

Because of the different goals, impacts, and costs of existing medical information systems, no single system can be considered representative. In order to illustrate this diversity, three systems are described in detail. One system, the Technicon

Medical Information System (TMIS) at El Camino Hospital, is specifically designed

for the acute care hospital. Another system, the Computer Stored Ambulatory Record (COSTAR) system at the Harvard Community Health Plan, is designed for ambulatory care. The third system, the Problem-Oriented Medical Information System

(PROMIS) at the University of Vermont Medical Center Hospital, is a developmental project that attempts to guide, as well as to support, the provision of medical care.

The prototype operates in an inpatient setting, but the system is designed for use in

any kind of medical care delivery site.

These three systems were chosen for discussion in this report because they represent different technical and conceptual approaches to handling information and

are considered exemplary by professionals knowledgeable in the computer and medical fields. In no way does inclusion in or omission from this report support or criticize any system.

TECHNICON MEDICAL INFORMATION SYSTEM (TMIS )

El Camino Hospital in Mountain View, Calif., was the demonstration site for

the Technicon system. El Camino, a 450-bed community general hospital with a

medical staff of 340 physicians, serves patients under the care of their personal

physicians. The hospital does not have an internship or residency program. It provides no outpatient services except diagnostic procedures for patients referred by

staff physicians. It does have an emergency room.

The Technicon Medical Information System (TMIS) has been in operation at El

Camino Hospital since 1972. Three years of development at the institution preceded

the actual implementation. Implementation of the system throughout the hospital

took 9 months. The Technicon Corporation and its predecessor, the Lockheed Corporation, bore the costs of development (over $25 million). The National Center for

Health Services Research later awarded funds to El Camino Hospital for evaluation

of the project.

System hardware, a large IBM computer, is located at Technicon’s regional computer center, several miles from El Camino Hospital. A second IBM computer is

available at the regional center for backup support. Data are maintained at the central processing facility using disks and tapes for storage. The hospital’s 58 video and
Ch. 3-Descriptions of Three Systems ● 2 2

31 printer terminals are linked to the computer center via high speed telephone

lines. For the most part, software is written in assembly language, and COBOL is

used for financial reports.

The Technicon Medical Information System is a hospital-wide system. It is designed to store patient data and send appropriate data, either upon request or automatically, to personnel who need them. Objectives of the system include more efficient hospital operations, improved patient care, and reduction or containment of

hospital costs. A major goal of the system is to facilitate nursing activities.

Capturing Patient Data. Physicians, as well as nurses, ancillary service personnel, and admitting clerks, enter data through video terminals, which consist of a

television screen, a keyboard, and a light-pen for rapid selection of information presented on the screen. Direct use by physicians distinguishes TMIS from several

other hospital-wide systems. Alternatively, nurses can enter data for physicians.

Terminals are located at each nursing station and in ancillary service departments.

Each authorized person gains selective admission to the system by typing a unique

identification code on the keyboard. This procedure ensures that hospital personnel

can enter and obtain only information appropriate to the performance of their jobs.

The television screen displays a list of items, for example, laboratory tests that

the physician might wish to order (see figure 2). A specific item is selected and entered into the computer system by pointing the light-pen at the desired phrase and

pressing a switch on the barrel of the pen. Using the light-pen, a physician can enter

a full set of medical orders (laboratory work, medications, X-rays, diet, activity, etc. )

for a specific patient. The displays remind physicians to make orders complete; for

example, when a medication is ordered, the display notes the need to specify scheduling and method of administration (oral, intravenous, or intramuscular) in addition

to dosage. The keyboard may be used to enter any information that is not displayed

in the display frames. TMIS prints copies of new orders for verification by the physician or nurse at the nursing station and automatically routes the orders to the appropriate hospital department (see figure 3). Orders to be carried out in the future

are held in the system until the time designated.

Nurses use the system to enter physicians’ verbal or telephoned orders, to report vital signs, and to record medications administered. Nurses must indicate by

light-pen selection whether an ordered medication has been administered and, if it

has not, provide a reason. Several nursing stations are experimenting with a computerized plan for nursing care that enables nurses to enter their patients’ actual and

potential problems and prognoses as well as nursing orders.

Other personnel also use the system. Admitting clerks enter a complete admission record through the video terminals. Clerks or technicians in ancillary services

enter patient data. For example, clerical personnel type in dictated radiologist reports in the X-ray department. Results of high volume laboratory tests are entered

by linking automated laboratory instruments directly to the TMIS computer.

Retrieving Patient Data. Once data are entered into the system, authorized

personnel can review them immediately on the videoscreen terminals. Printer terminals also provide paper copies (printouts) at the nursing stations and in the ancillary service departments. The video terminal can display all data that have been entered from any point in the hospital up to the moment of retrieval.
23 ● Ch. 3—Dwcriptions of Three Systems

Figure 2–TMIS Laboratory Test Order Display

~—- —------ —-----------------------------— pf ~ -1 ~ —

COMMON LAB TESTS

SOURCE Technlcon Corp

Physicians and nurses can retrieve the following information about their patients: admissions data, laboratory test results, X-ray reports, medications given,

current orders, all orders since admissions, nursing notes, diagnoses, and allergies.

Information in any category can be broken down to isolate desired data as, for example, cumulative results of a specific laboratory test. In addition, before each nursing shift, TMIS prints out a Patient Care Plan for each patient that lists all current

orders to be carried out during that shift (see figure 4). “Medications due” lists are

printed automatically throughout the shift.

Physicians can also obtain displays on general medical information compiled by

staff physicians. TMIS currently stores information about subjects of interest in approximately 2,000 display frames. The “medical library” includes such information

as abstracts of current articles from surgical journals, lists of antibiotic sensitivities,

and interpretative aids for laboratory test results.

Communications, Administrative, and Business Functions. TMIS routes orders from nursing stations to the clinical laboratory, pharmacy, radiology, and dietary departments. At the same time that orders are printed in the pharmacy, the sys1 ‘1-71 } I ( ) - 77 -
.—

Ch. .3-Descriptions of Three Systems ● 24

Figure 3–TMIS Printout of New Orders

SOURCE Technicon Corp
25 ● Ch. 3—Descriptions of Three Systems

Figure 4--TMIS Patient Care Plan

● @6-&56- 72 1 2: 53 PtI

●

●

●

●

●

●

●

●

✘

●

●

●

●

●

●

●

D

B

---- ----- ---

---- - ---- -.

● ●

SOURCE Technlcon Corp
Ch. 3—Descriptions of Three Systems ● 2 6

tern automatically produces labels for medications. Worksheets are printed for each

ancillary service department; for example, the laboratory periodically receives lists

of specimens to be picked up from patient care areas. TMIS automates the administrative tasks of admitting, transferring, and discharging patients. The system also

provides reports on current bed status, that is, occupied and unoccupied beds.

A comprehensive business subsystem is part of the total TMIS system. The

computer system automatically generates charges for services and supplies ordered

and bills patients. It also provides for accounts payable, general ledger, budgetary

control, inventory control, employee payroll, labor distribution, and workload statistics.

Patient Record. The individual patient’s medical record is composed of both

computerized and noncomputerized sections. Physician orders, cumulative medications, laboratory and X-ray reports, postoperative summaries, and admitting and

discharge records are computerized. Printouts are produced for the paper medical

record. Physicians’ progress notes, most nursing notes, patient history, physical examination, and other materials are still recorded manually. The paper medical record, including the portions printed by TMIS, is maintained by the medical record department.

Patient data are stored in the active computer data files for 48 hours after a patient’s discharge. These data are then transferred to magnetic tape for permanent

storage. However, at present TMIS has no capability for long-term retrieval of an

individual patient’s record. (The Technicon system has incorporated this capability

at several other hospitals. ) A new computer record is started if the patient returns

for another hospitalization. The paper medical record is used for pertinent information on previous care.

Priorities. Although TMIS has been operational at El Camino Hospital for the

past 5 years, both hospital and Technicon personnel consider the system as, in many

respects, still being developed. Priorities for new applications of TMIS at El Camino

Hospital include:

● medical care and nursing audits;

● management functions, such as patient scheduling for ancillary services

and optimal nurse staffing; and

● information to help physicians reach clinical decisions.

COMPUTER STORED AMBULATORY RECORD (COSTAR) SYSTE M

The Harvard Community Health Plan (HCHP) in Boston, Mass., is a prepaid

group practice of 50,000 members that provides comprehensive medical care, including medical, surgical, and nursing services, laboratory and X-ray facilities, and

emergency care. Since its establishment in 1969, HCHP has collaborated

with the Laboratory of Computer Science (LCS) at the Massachusetts General Hospital to develop and implement COSTAR at its Kenmore Center facility. Costs for

development during the first 5 years of operation were $2.5 million (23). Development of the system was supported by Federal grants. Currently, operational costs

are paid by HCHP. The Laboratory of Computer Science has been responsible for
27 ● Ch. 3—Descriptions of Three Systems

the technical support of COSTAR. However, HCHP has recently decided to assume

complete operation of the system in the near future.

The computers used in the COSTAR system are medium-sized Digital Equipment Corporation computers, located at LCS. Data are stored on moving head disk

storage units. Application programs are written in MUMPS, a high level computer

language designed by LCS. Over 30 video terminals and 3 printer terminals are located in the HCHP facility.

The Harvard Community Health Plan uses COSTAR to provide most of the information it requires for both patient care and program management. The system is

primarily designed to improve the availability of information for patient care with

modest increases in cost. It also is used to assess quality of medical care and to carry

out administrative functions.

Capturing Patient Data. Medical personnel are not themselves required to enter data into the computer. Instead they enter data on a sheet of paper called an encounter form at the time of a patient visit. Clerical staff use video terminals in the

medical record department to enter all data from the encounter forms into the computer, Because items are preceded on the encounter form, these clerks do not need

to extract appropriate data, and problems of transcription are minimized. By checking off items on the encounter form, the provider (either a physician or nurse) records the patient’s problems, medications or other therapies, and disposition. Different encounter forms have been specifically designed for each of the major specialties. Information on the forms is organized according to a carefully defined and limited vocabulary (see figure 5).

The physician or nurse can add a line of text to any of the coded entries. To add

more detailed comments, the provider can dictate findings regarding a problem. All

additions will be associated with that problem and appear with it whenever the record is produced. For an initial health assessment or a routine checkup, the provider

records the patient’s vital signs and completes a checklist of demographic data. Including a brief statement about the patient’s personal and social background is also

an option. X-ray and electrocardiogram reports are recorded on separate encounter

forms. Laboratory test results are entered through a terminal located in the clinical

laboratory.

Retrieving Patient Data. The medical record department enters appointment

lists for each provider into the computer. For each patient, COSTAR automatically

produces a paper printout of summary data that is distributed to the physician prior

to the scheduled appointment. The information included in the summary depends

on the specialty group to which the physician belongs. A limited amount of text

about each diagnosis is always included in the summary. For visits to some kinds of

specialists, extensive text about the patient’s major problems is also included.

The basic printout is a Status Report on the patient and includes (see figure 6):

● identification data;

● up to three lines of background information;

. a problem list with the total number of visits for each problem and the date

of the last visit;

● current and past medication therapy;
Ch. 3—Descriptions of Three Systems ● 28

Figure 5–HCHP Encounter Form for the Internal Medicine Department

4) SITE

6) Hospital or EW Visi t

5) TYPE

A&SC SCHEDULED

B WALK- I N

c TEL E PHONE

D CANCEL LEO

E— DNK

F CALL - I N

G— IN-PATIENT

H— EW

I NON-ENCOUNTER

J GROUP

Approved: — Yes — N o

**.:::* ***** *:. THIS INFORMATION FOR FIRST VI SIT\ PRIMARY PROVIDER ONLY ~~• ;~*::~.:;:’

7) PRIMARY MO PIOfk /“n 8) PRIMARY RN d

9) RACE: A~ CAUCASIAN B BLACK c SPANISH SPKG o OTHER

10) MAR.STATUS: A SINGLE B~MARRIED C WIDOWED D SEPARATED E DIVORCED

11) # OF CHILDRE N d

12) PT. OCCUPATION

PERSONAL BACKGROUND OF PATlENT - Only for primary provider s

(To change , rewrite entire section; max. three lines . Do not repeat above data. )

Consul tat ion w/

(ente r specialty and provider's last name, i f specified)

(IF A CONSULTATION NOTE IS NECESSARY, INCLUDE REASON FOR CONSULT IN ROUTINE DICTATI0N)

43) REFERRAL TO OUTSIDE AGENCY - NON-HOSPITAL

enter fulI name & address o f physician and/or agency)

DOCUMENTS TO BE FORWARDED :

44) HOSPITAL ARRANGEMENTS (make a choice i n each C Olumn )

(continued )
29 ● Ch. 3 —Descriptions of Three Systems

Figure 5 (continued)

INTERNAL MEDICINE DIAGNOSES & PROBLEMS

(M=Major, O=Omit from Status Report, P=Presumptive, S/P=Status Post ,

R/O=Rule Out , I=Place on Inactive List . Simple check=minor )

60, HeightA“~ 61.Weight /,7d Ibs . 62.Pulse/Min ,~~ ~jTenp

64. Blood Pressur e

‘~*et:er ,,ing 3 4 ‘ ) ‘

standinq, sitting, etc .

P H R

Dx deferred (state features )

No demonstrable disease (explain)

Exam for certificate

Rx refill onl y

Immunization onl y

Test results only

Positive family Hx (specify )

Health education

Abnormal t. result (specify )

Lab test not performed (specify )

Pt. left without being seen

Pt. refused Rx (specify )

THYROID

Hypoglycemia

Hypercholesterolemia

Hyperlipoproteinemia

Hyperuricemia

Gout

DIAGNOSTIC

CODE

2 .

FREE TEXT COMMENTS ON DIAGNOSES, PROBLEMS & PROCEDURES

3.

SOURCE Laborato~of ComputerSclence, Massachusetts General HospNal
30 ● Ch. 3 —Descriptions of Three Systems

. laboratory test and X-ray results; and

● consultations requested but not yet recorded.

The individual provider can request data in other formats as well, such as the

report of a previous visit, laboratory results not associated with a previous visit, or a

flowchart of a particular problem, laboratory test, or medication.

In addition to the printed record, videoscreen terminals located in every area of

patient care allow the provider to obtain immediate access to any part or all of the

computer record. The video terminal is most often used for reviewing an extensive

record or obtaining information about patients without scheduled appointments.

Entry to terminals does not require a password or other identification. However,

they are located in areas where they can be monitored by professionals.

Administrative and Business Functions. Managerial requirements for data at

HCHP are determined by both its organization as a prepaid plan and its highly mobile population; there is a 20 percent membership turnover each year. COSTAR provides data on current enrollment, certification of claims, and appointments. The

computer produces a variety of administrative reports and statistical analyses for reviewing utilization, budgeting, and manpower and facility planning. Although COSTAR itself produces bills for the few patients who pay fee-for-service, other computer systems perform business services such as cavitation billing, payroll, and financial reports.

Patient Record. The COSTAR system stores all patient data generated at

HCHP. Parallel information is not kept in a paper medical record. The medical record

room maintains files, however, for copies of letters or discharge notices from other

physicians or hospitals, electrocardiogram tracings, and other materials that are not

computerized. Patients’ records are stored on computer disks in the COSTAR system indefinitely for all current members. For permanent storage, former members’

records are put on disks that are not connected to the central processing unit.

Priorities. HCHP’s priority is to expand its use of COSTAR for reviewing the

quality of medical care given to patients. Under a current experimental program,

COSTAR monitors the data files of patients with several specified conditions,

Standards for treatment were developed by a committee at HCHP and programed

into the computer. If the care being given deviates from these standards, reminders

are printed out to physicians. Work is in progress to add computer protocols for additional medical treatments. HCHP also plans to duplicate the COSTAR system at

another HCHP facility in Cambridge, Mass.

PROBLEM-ORIENTED MEDICAL INFORMATION SYSTE M

(PROMIS )

The demonstration site for PROMIS is the Medical Center Hospital, a 450-bed

teaching hospital at the University of Vermont in Burlington. The PROMIS Laboratory, located at the University, designed and implemented the system. Development

began in 1967, and PROMIS was installed and used in a 20-bed gynecology ward in

the hospital from 1971 to 1975. During the 4 years of its operation on the ward,

PROMIS was also implemented in the ancillary service departments most frequently

used: radiology, the clinical laboratory, the pharmacy, and in the doctors’ lounge

where surgeons entered their notes after operations. Secretaries on the ward acted
Figure 6–COSTAR Patient Status Report

MAJOR PROBLEMS

1993 HEMATURIA NO PREVIOUS HX PRIOR 1 WK. IN PROCESS OF EVALUATION

4/1/75-2-4/4/75 (PLOTKIN: M.D.) #D

MINOR PROBLEMS

A150 OBESITY WOULD LIKE TO LOSE AT LEAST 1o POUNDS

P666 TOBACCO ADDICTION 1 PACK PER DAY

4/4/75 (PLOTKIN: M.D.)

 4/4/75 (PLOTKIN: M.D.)

INACTIVE PROBLEMS

S100 S/P APPENDECTOMY 1957

CURRENT THERAPY

RO10 FLUIDS 8 GLASSES PER DAY

4/4/75 (PLOTKIN: M.D.)

4/1/75 (GOLDSMITH: R.N.)

CONSULTATIONS AND REFERRALS

UROLOGY 4/4/75 (PLOTKIN) FOR L993

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~~,

SOURCE Laboratory of Computer Sciences Massachusetts General Hospflal
Ch. 3—Descriptions of Three Systems ● 32

as intermediaries for departments that were not included in the computer system.

Hardware used when the system operated on the gynecology ward included two

large Control Data Corporation computers and 14 touch-sensitive video terminals.

Program languages (MACRO assembly, HIP, and SETRAN) developed by the Control Data Corporation were used. The PROMIS staff itself did the application programing. The entire system was updated by the PROMIS Laboratory in 1975 and

implemented on an internal medicine floor at the end of 1976. The new system uses

Varian minicomputers and high-speed Megadata touch screen terminals. Data are

maintained on disk storage. Application programs are written in PPL, a new language developed by the PROMIS Laboratory.

Support for development of PROMIS has been provided under grants, and currently a contract, from the National Center for Health Services Research. Total

funding through FY 1976 was approximately $4 million. Additional resources have

been provided by the Robert Wood Johnson Foundation and the University of Vermont College of Medicine.

Capturing Patient Data. PROMIS is unique in two respects. It not only radically restructures the medical record, but also directs the process of clinical care. The

PROMIS Laboratory staff developed these capabilities in order to address problems

hindering the provision of medical care: dependence on the physician’s memory, ineffective organization for massive amounts of medical data, and lack of meaningful

feedback about the appropriateness of care.

In PROMIS, data are organized by patient problem. The computer record is

structured around four phases of medical action: an initial data base on each patient,

including medical history and physical examination; a list of the patient’s problems;

diagnostic and treatment plans for each problem; and progress notes on each problem indicating how the patient is progressing during therapy. Except for the initial data

base, every entry into the computer record is associated with a particular problem of

the patient. Thus, when a technician enters the result of a laboratory test, the data

are entered under the problem for which the test was initially ordered. By structuring the record in this way, all information pertinent to a problem is organized logically for review by the physician and other medical care professionals.

Personnel enter data about patients through video terminals. The videoscreen

of the terminal displays an array of choices, and the provider makes a selection by

touching the screen. Data are entered by the medical care professionals who originate them. For example, physicians and nurses enter notes about the patient’s progress, radiologists enter notes as they read films, and technicians in the clinical laboratory enter results of tests. In addition, patients enter their own medical histories.

Each staff member has a unique identification code that allows entry and access only

to those parts of the computer record necessary for the provision of care.

PROMIS guides these medical care professionals in structuring the vocabulary,

content, and organization for the patient computer record. This guidance is accomplished through the display frames viewed on the videoscreen that providers use to

enter data. Sequential frames are displayed according to logic algorithms (decision

trees) programed in PROMIS. The information shown in a particular frame depends

on the choice selected in the previous frame. The answers a provider gives to questions, not the providers themselves, determines what frame appears next. The display frame sequences guide the provider through logical pathways and ensure that

notes and orders are complete.
33 ● Ch. 3 —Descriptions of Three Systems

The videoscreen first shows the provider a master frame (see figure 7). From

this frame, the provider selects a category of information and chooses whether data

are to be added or retrieved from the computer patient record. To enter information

about a new problem, for example, a physician would touch’ ’problem list” from the

“add to” column. A system of the body, cardiovascular for example, is then chosen.

The subsequent frame would show possible diagnoses for the cardiovascular system

(see figure 8A). If “hypertension” were chosen from the list of possible diagnoses,

the frame shown in figure 8B would appear to request more information. This communication between the physician and display frames would continue until a complete narrative description of the problem had been generated. Figure 9 shows such

a narrative that has been retrieved on the problem “cirrhosis. ”

Figure 7– PROM IS Master Frame

SOURCE PROMIS Laboratory
Ch. 3—Descriptions of Three Systems ● 34

Figure 8– PROMIS Display Frames for Entering Data About a Patient Problem

8A

80

SOURCE PROMISLaboratoty
35 ● Ch. 3 —Descriptions of Three Systems

Figure 9–PROMIS Narrative on a Patient Problem

sOURCE FTIOMISLaboratOtl

Along with the sequenced display frames that guide medical care personnel in

entering data about the patient, PROMIS supplies display frames that present medical knowledge. Only medical knowledge appropriate to a specific problem and clinical

action is shown because “medical content” frames are carefully programed and integrated with data entry frames.This integration ensures that physicians receive

medical knowledge automatically.

When the physician orders a drug, for example, the ’’medical content” frames

would indicate such information as side effects, drug and test interactions, cost, and

usual dosage. Display frames on laboratory tests list risks, normal ranges of results,

costs, and contraindications. Medical content frames help to diagnose a particular

problem by suggesting possible diagnoses and tests that would rule out some possibilities. Finally, medical content frames on treatment and follow-up care for particular problems or diagnoses give the physician options for action.

Medical content frames are rigorously researched before they are entered into

the computer system. Recognized experts in the relevant field review the frames for

completeness, accuracy, and currency. The display frames also include numbered

references to medical literature available in the university medical library. Currently, the PROMIS “library” includes over 33,000 frames. Medical literature is constantly reviewed, and if recent articles dictate any changes, the PROMIS staff enters

the new information on display frames.

Retrieving Patient Data. Patient data can be reviewed on the videoscreen terminals or on hard copy printed out by printer terminals. Because all data are linked

to a particular problem of the patient, the information in the computer record is
Ch. 3—Descriptions of Three Systems ● 3 6

well-defined and structured. Data can thus be obtained by almost any parameter required. A physician can review progress notes by problem over time, a pharmacist

can review current medications, and a nurse can obtain all outstanding orders by

problem for each patient. A display frame showing a patient’s current outstanding

laboratory tests is shown in figure 10.

Communication and Administrative Functions. PROMIS routes messages between areas of patient care and ancillary service departments. Currently, PROMIS

does not incorporate administrative functions, such as payroll and accounting. Because entries of procedures, services, drugs, and tests can be associated with

charges, a business subsystem could be integrated into the computer system. The

design of PROMIS could permit the addition of such functions as patient scheduling,

automatic laboratory reporting, and other applications in the future.

Patient Record. All data that are recorded about the patient are stored in the

computer record. In addition, because every entry shows date, time, and staff member who entered it, the process of medical care is clearly documented for future

audit. Computer records are maintained indefinitely on disk storage. Because

PROMIS was installed in only one service, paper medical records were also kept.

Priorities. PROMIS is still in the developmental stage, although it has been

shown

tinued

●

●

●

to be technically feasible. Priorities of the PROMIS Laboratory for the condevelopment of PROMIS include:

implementing the system throughout a hospital;

continued development, validation, and maintenance of the medical content

display frame “library;” and

incorporation of medical audits to ensure quality of care.

Figure 10– PROM IS Display of Outstanding Laboratory Tests

SOURCE PROMIS Laboratory
.

IMPLICATIONS
4 ●

IMPLICATIONS

Medical information systems have important implications for the quality of patient care. Institutional errors can be substantially reduced and coordination improved. Clinicians can obtain guidance on appropriate diagnostic and therapeutic

regimens while patients are still under care. Physicians can be freed from the burden

of relying on fallible memory. Other medical professionals may perform new duties

or acquire added responsibilities because they have been relieved of routine paperwork.

The extensive data base in medical information systems could supply aggregate

health data collection systems with more accurate, easily accessible data than are

now available. In addition, medical information systems could provide a new mechanism for assessing the quality of medical services provided, evaluating and planning

medical care resources, and conducting epidemiological research.

Because medical information systems are designed for different kinds of settings and vary in scope and objectives, not all implications apply to all systems. Examples from the systems described in chapter 3 are given when possible to illustrate

benefits and drawbacks and to differentiate between the proven performance of

medical information systems and benefits that might be expected if the computer

systems are developed further and become widely accepted.

INSTITUTIONAL DELIVERY OF PATIENT CARE

Evidence indicates that by facilitating communication and reducing errors, medical information

systems improve the patient care delivered in medical care institutions. Some errors are reduced because

computer systems help ensure that data about a patient are accurate, available, legible, complete, timely,

and organized. Through their mechanisms to check whether orders have been carried out, medical information systems also monitor performance and prevent some errors of omission.

Avoiding Errors

Accuracy of patient data can be ensured by having the provider or ancillar y

service originating them verify all entries. Errors can thus be detected and corrected

immediately at the source. Detecting an error later is more difficult because the relevant data are not readily available.

In TMIS and PROMIS, patient care providers and technicians enter data

through videoscreen terminals and thus communicate directly with the computer

system. After being typed in or selected by light-pen or touch, data are displayed on
Ch. 4—Implications ● 4 0

the videoscreen a second time for verification before being entered into the computer record. After the implementation of TMIS at El Camino Hospital, accuracy of

medical orders and test results improved (7).

In the COSTAR system, clerks in the medical record department enter data into

the computer from preceded sheets called encounter forms. An inhouse study at the

Harvard Community Health Plan estimated the rate of transcription errors to be

very low, less than 1 percent of the data items (5).

Availability of information can be ensured by giving many providers simultaneous access to the patient record from different locations. A manual medical record

can be in only one place at one time. The three medical information systems described in this report make patient data available on videoscreen terminals located in

various patient care areas. Printer terminals also produce and duplicate paper records.

Lost or mislaid records are a problem in ambulatory care settings. Records are

estimated to be unavailable for as many as 10 to 20 percent of patient visits in some

ambulatory care facilities (5). COSTAR eliminates this problem by providing a summary record in advance of each scheduled patient visit. Videoscreen terminals can

give information to providers when they see patients with unscheduled visits, answer telephone inquiries, or need to review a complete patient record. In some areas

of HCHP, however, a single terminal serves three physicians, three nurses and a receptionist, sometimes resulting in a queuing problem. At El Camino Hospital, one

video terminal and sometimes two are located at every nursing station. Hospital

staff did not indicate any problem regarding access to the terminals.

Legibility is an obvious advantage of medical information systems over manual

medical records. Typed copy available on terminal screens or in computer printouts

is easier to read than the typical handwritten note. Illegible handwritten entries in

the paper medical record can cause delay or, if read inaccurately, may lead to inappropriate action.

Completeness of information can be ensured by entering all data that may be

needed into a central computer patient file. In COSTAR and PROMIS, all data that

are generated during the care of a patient are entered into the computer record. In

addition, PROMIS automatically reminds providers to enter information essential to

diagnosing a problem or carrying out orders. Questions and choices for answers are

displayed in a sequence determined by answers to previous questions.

Computerized information about the patient is more limited in TMIS than in

COSTAR and PROMIS. TMIS does, however, computerize all physician orders and

the resulting reports from ancillary services. The frames used to write orders remind physicians to make their orders complete. After implementation of TMIS at El

Camino Hospital, the number of medication orders that omitted site, scheduling,

and method of administration decreased (7).

Timeliness of information can be ensured by entering patient data into the

computer record as soon as procedures are performed or observations made. As

hospitals have become more complex, the demands placed on ancillary services have

increased, and communicating all the latest information has grown more difficult.

TMIS and PROMIS automatically update the patient’s record so that it reflects

the most current status. Reports and results are entered directly into the computer
——

system from ancillary services. With electronic transfer, orders and tests need not

be repeated because of poor communications. In addition, if the time between entering orders and learning results of tests and procedures is reduced, physicians can

proceed quickly with further appropriate diagnostic or therapeutic procedures. The

average length of stay at El Camino Hospital has been shorter since the introduction

of TMIS. Staff have attributed this reduction to improved communications made

possible by TMIS. Other factors, however, may also have contributed.

In COSTAR, new encounter data are usually entered into the system within 2 4

hours of a patient visit. Data are therefore available for the patient’s next visit to the

ambulatory care facility.

Organization of patient data enables providers to find necessary information

more easily. In a manual medical record, information is often scattered among many

pages of a chart that is usually arranged in chronological order and separated by

source. Computerization allows a flexible arrangement of data, permitting the most

effective use of patient data by the provider.

At El Camino Hospital, for example, a physician can retrieve the results of all

laboratory tests on the video terminal. Cumulative results of tests are also available

in paper printout. Because all information in PRO MIS is associated with a patient’s

particular problem, the physician can review progress notes, medications, laboratory

results, and vital signs over time to determine if therapy is effective. At HCHP, a

standard format used to provide a summary is routinely supplemented by flow

charts and extensive visit notes on major problems of patients.

Monitoring for Errors

By monitoring for institutional errors, medical information systems further ensure that orders for the patient’s care will be carried out. Noncompliance with physicians’ orders is a severe problem in U.S. hospitals. An estimated 13 to 15 percent of

all medications are not administered exactly as the physician ordered (so). A study in

one hospital found that 15 percent of ordered laboratory tests were never performed (45).

Each of the computer systems described in this report has mechanisms to monitor whether orders for procedures or medications have been carried out. If they

have not, reminders are displayed or printed. Under TMIS, for example, lists of

“medications due” are printed out hourly, and nurses must record in the system

whether or not the medications are administered. After installation of the computer

system at the hospital, total errors in administering medications were reduced about

so percent from the pre-TMIS period (7). Failures to give medications were almost

completely eliminated. After TM IS, discrepancies between the orders for and actual

scheduling of laboratory and radiological procedures were also reduced. No evaluations of other medical information systems have yet been conducted.

SUPPORT OF CLINICAL DECISIONMAKING AN D

PHYSICIAN EDUCATIO N

Medical information systems can offer support for clinical decision making, provide continuing

medical education, and facilitate the spread of new medical knowledge. Several studies indicate that er-
Ch. 4—Implications ● 4 2

rors of omission by physicians are reduced if timely reminders are provided by the computer systems,

This capability has been more fully developed in one system than in others.

Supporting Clinical Decisionmaking

As students, physicians must memorize enormous numbers of facts. Throughout their careers, they are expected not only to remember this information, but also,

as medical knowledge increases and grows more complex to add new information.

The quality of clinical care often depends on the accuracy and completeness of the

physician’s memory.

Computer systems can assist physicians by reducing the amount of material to

be memorized. During clinical care, computer systems can instantaneously supply

physicians with information about individual patients and medical knowledge from

the literature.

The role of medical information systems in supporting clinical decisionmaking

and continuing medical education may be either passive or interventionist. In a passive

system, information stored in the computer is made available to physicians when

they take the initiative to ask for it. Interventionist systems automatically supply

appropriate information to physicians and other medical professionals.

The “mini-library” of frames displaying medical information incorporated into

TMIS at El Camino Hospital exemplifies a medical information system taking a passive role in continuing education. Medical information frames in TMIS are independent of data entry and retrieval frames. They may be reviewed whenever, but

only when, the physician chooses to do so.

Computer systems have been developed to support some kinds of clinical decisions. Such subsystems could be integrated into medical information systems like

TMIS. For example, a system developed at Beth Israel Hospital in Boston can classify

a patient’s acid-base abnormality and through a series of questions to the physician,

recommend appropriate therapy. Another computer project called HELP (Health

Evaluation through Logical Processing) has been developed by the Biophysics Department at the University of Utah (43). HELP stores data about patients from

terminals in such areas as the coronary care unit, the postoperative intensive care

unit, and the pulmonary function laboratory as well as data from a computerized patient history and laboratory screening. Using these data and algorithms based on

arithmetic and logic statements, HELP can automatically generate a list of options

for treating an individual patient, Other projects include computerized protocols for

managing on an outpatient basis certain diseases, such as hypertension, diabetes, and

kidney stones (49). These systems to support clinical decisionmaking use a computer’s capacity for complex analysis and manipulation of data, but they are nonetheless passive systems because the physician must elect to review the medical information they have stored.

Interventionist systems, in contrast, are programed to provide medical data

automatically when they are needed for patient care. Such systems monitor the acceptability of care while the patient is being treated. They are based on an assumption that physicians are not likely to stop and ask a computer for information, but

would use information automatically supplied.

This capacity exists to some extent in all three of the computer systems described in this report.
●

. In TMIS, computer printouts highlight abnormal laboratory test results in

heavier ink and large characters.

. In COSTAR, computer programs for selected diseases or clinical symptoms

identify followup care that has been omitted. These programs automatically

notify physicians of the recommended procedure for their patients.

. In PROMIS, medical content frames are combined with data entry frames.

Drug sequences provide information on specific drugs. Test or procedures

frames include such information as cost, limits of normal, and producibility.

“Rule-out” frames show why and how certain diagnoses can be ruled out as

causes. Decision trees, which physicians are required to use, incorporate the

entire spectrum of medical knowledge.

This capability of the computer systems to supply appropriate medical information frees the physician from reliance on memory and allows concentration on tasks

that are uniquely human. Although the computer may be better suited to processing

the multitudinous data necessary for diagnosis and treatment, the physician is responsible ultimately for decisions on patients’ care.

Interventionist systems might be expected to improve the quality of patient care

by reminding physicians of relevant data and facts. Results of the experimental program at the’ Harvard Community Health Plan are encouraging (6). After implementation of the program providing automatic feedback, there was a statistically significant improvement in followup treatment of patients with sore throats. Improvement in the followup care of hypertensive patients occurred when repeated reminders were sent.

Several other studies conducted at Indiana University by the Regenstrief Institute indicate that use of computer protocols in ambulatory care reduces errors of

omission by physicians. One study, conducted in an adult diabetes clinic, evaluated

the effect of computer intervention to several medication-related clinical events

(31). It found that physicians responded to 36 percent of the clinical events with

computer reminders and only 11 percent without. A second, more extensive study,

using 390 computer protocols dealing with conditions managed by drugs or induced

by drugs, was conducted in a general-medicine clinic of the same outpatient department (30). This study analyzed physicians’ responses to computer recommendations

for courses of action following certain clinical events. It found that those physicians

given computer recommendations detected and responded to twice as many events

as the control group of physicians. Further, physicians’ response rate fell when they

left the group receiving computer recommendations and joined the control group.

The study thus concluded that the difference in response rate was due not to ignorance of appropriate procedure, but rather to the difficulty of contending with the informational loads of busy practice settings.

These studies give a preliminary indication that computer protocols for the

clinical management of certain problems influence physicians’ behavior. Further

evaluations are needed to confirm these results.

If the role of computer systems in clinical decisionmaking increases in the future, medical education will change. Without the need to accumulate facts, students’

education could emphasize the study of the processes involved in decision making, as

well as the social and psychological aspects of medical care (48). Such an educational

experience would prepare students to take a new role as clinicians.
Ch. 4—Implications ● 44

Dissemination of New Medical Knowledge

Scientific journals report research on new therapies, procedures, and drugs. Incorporate ion of this “new” medical knowledge into the everyday practice of medicine

depends in part upon physicians’ reading journals and remembering results of studies at appropriate moments of medical intervention. As a result, medical practice does

not always reflect current medical knowledge.

Medical information systems can disseminate new medical knowledge by incorporating the most recent medical information into computer programs. The burden

of reading myriad journals shifts from busy practitioners to those responsible for

maintaining and updating a medical information system’s “library” of medical

knowledge. In PROMIS, for example, new medical knowledge is added to the system

as studies appear in the literature and is presented to physicians in the context of related problems, procedures, or drugs. The information is carefully researched before

its entry into the system, and references to the source journal are given on the display frame.

The entry of new medical information that has not been carefully evaluated is a

problem that may arise in the future. At present, developers of systems determine

what information is entered in the prototype systems. As medical information systems are “packaged” for mass marketing, such control will be more difficult. If in

every hospital, for example, unproven or experimental therapies were entered as

options for medical care, regardless of their efficacy, the credibility of the medical information system would be considerably downgraded.

A system such as PROMIS, which attempts to incorporate the whole spectrum

of medical knowledge into its guidance system, particularly runs this risk. To guard

against it, the PROMIS Laboratory has suggested the establishment of “a central organization with the mandate to coordinate, control, and certify developmental and

deployed systems” (54). The central organization, or “national repository of display

frames,” would be charged with developing, validating, and maintaining a library for

medical content display frames. It would also offer technical assistance and supply

updated display frames to user medical care institutions. One example of a public organization that might perform this function is the National Library of Medicine,

ASSESSMENT OF THE QUALITY AND UTILIZATIO N

OF MEDICAL CAR E

Medical information systems can be programed to help assess the quality of medical care in terms

of the care process. Appropriateness of inpatient facility use can also be monitored. These legally manda fed /uric/ions could be accomplished without the expense of an additional data collection system. No

medical information system, however, is programed as yet for these purposes.

Quality of care is usually assessed by judging the process of care, or those diagnostic and therapeutic services ordered for a particular problem, against an agreed

upon minimum standard for acceptable care. Hospital peer review committees have

carried out this retrospective monitoring of care for years.

The 1972 Amendments to the Social Security Act mandated that Professional

Standards Review Organizations (PSROs) be established nationwide to review the

quality and utilization of medical services provided to Medicare, Medicaid, and Maternal and Child Health patients. The PSROs are required to conduct studies of
processes of care. In such a study, called a medical care evaluation, a diagnosis or

procedure is chosen for study, a sample of patients selected, and the patients’ records

examined to determine if the care as recorded meets minimum standards established

by the PSRO. Determining an appropriate patient sample and carefully examining

records in a manual system can be time consuming and costly. A medical information system with patients’ diagnoses and procedures accurately recorded and coded

could facilitate such retrospective review. Data in a computer record are likely to be

more complete and accurate than those in a manual record. Further, a medical information system could select samples of patient records for audit and, if properly programed, examine the records for compliance with standards.

No medical information system is presently used for medical care evaluations in

a PSRO program, but the computer systems described in this report have the potential to fulfill this function. At HCHP, data are collected on structured, preceded

forms. Because almost all data in the computer record are coded, COSTAR can be

programed to monitor the record against predetermined standards of care or to retrieve records for manual audit by a given parameter. At El Camino Hospital, the

major discharge diagnoses and procedures are coded in TMIS. Computer programs

permitting medical audit are in the planning stages. Audit by problem, patient, or

physician could be programed in PROMIS because all activities are linked to specific

problems. In addition, the logic of the patient care process, that is, the reason for a

certain procedure and the relationship of that particular step to preceding and following steps, is explicit in PROMIS. Medical auditors would not need to guess about

the reasons for actions.

Professional Standards Review Organizations also monitor the utilization of

medical care services. If medical information systems were programed to monitor

the “appropriateness” of care in accordance with the requirements of the local

PSRO, physicians could automatically be notified of any failure to meet criteria that

justify keeping the patient in the hospital another day. Because medical information

systems can process and return data as soon as they are entered, such notification

could be given in a more timely fashion than is possible with a manual system. Having medical information systems screen for appropriate utilization could therefore

be more effective than manual systems and could be accomplished without the cost

of an additional system to collect and process data.

MALPRACTICE LITIGATIO N

Whether medical information systems would increase or decrease malpractice litigation is debatable. Computerized medical records document the conduct of medical therapy. They could eliminate

some causes of litigation by reducing errors in patient care. Errors that do occur could be highlighted

however, and lawsuits increased.

A patient’s record is often the most important piece of evidence in any medical

professional liability suit (25). As a deviation from accepted standards for properly

documenting and maintaining records of treatment, a poor record itself constitutes

an act of negligence in the eyes of the court (29).

Computerization of the medical record ensures a legible, orderly, and readily

available record and could, therefore, document proper and careful conduct of medical therapy. Because medical information systems tend to reduce errors in patient

care, litigation may decrease. Errors caused, for example, by poor communications,
———

Ch. 4—Implications ● 4 6

overlooked positive laboratory results, and improper administration of medications

are substantially reduced through use of computer systems. Systems that incorporate medical care audit programs or guidance systems during the care process could

also eliminate some causes for litigation. Adherence to the established guidelines

provided in the systems might be an effective defense for physicians and a possible

deterrent to the filing of suits.

On the other hand, errors that do occur could be highlighted in the computer

record, and the number of malpractice lawsuits increased (34). In addition, legal

problems may arise because the computerized patient record differs from that in the

average medical practice. Until computer records are accepted as consistent with

standards for documentation, they might not constitute legal evidence in malpractice cases. Finally, critics argue that the art of medicine cannot be confined to

standardized therapies incorporated as guidelines into a medical information system.

A physician who deviates from such guidelines might be in jeopardy of a lawsuit and

forced to justify the actions taken.

No data are available from institutions that use medical information systems on

rates of malpractice suits before and after implementation of their computer systems. Contentions that the systems would increase or decrease litigation are, therefore, speculative.

ROLES OF MEDICAL CARE PROFESSIONAL S

Medical information systems allow an upgrading of job responsibilities by permitting medical

care professionals to make full use of skills. However, there is insufficient evidence to conclude that personnel actually perform new duties or that their productivity increases in activities related to patient

care.

Medical information systems reduce or eliminate paperwork at the same time

that they make available information needed for optimal job performance. Pharmacists, for example, can review medication orders for potential drug interactions if

they are freed from typing medication labels, have computer-produced medication

schedules and worksheets, and can obtain patients’ medication profiles. Nurses have

the opportunity to spend more time caring for patients if they no longer must spend

hours performing clerical tasks. The head nurse who has more time for administrative duties and can analyze computer-produced statistics on patient workload has

the opportunity to plan for the most effective use of floor nurses.

In the ambulatory care area, medical information systems allow allied health

personnel to expand upon the kinds of patient care services they provide. For example, in some experimental programs nurse practitioners and physician assistants

provide primary care to patients by referring to computer protocols organized according to specific problems. Studies have indicated that physician assistants using

protocols that explicitly define medical treatments provide care equivalent in quality

to that of physicians in the traditional system (21,28).

A study at El Camino Hospital provides the only available data on how medical

information systems affect the allocation of health professionals’ time (7). An activity analysis of nursing time before and after implementation of TMIS found that:

Ž Time and effort allocated to clerical activities decreased across all units, from

4 percent in the coronary care unit to 47 percent in surgical units;
47 ● Ch. 4—Implications

● The availability of information made reporting easier and less time consuming across all units;

. Time spent in direct patient care activities increased on some services (medical and intensive care) and decreased on others (surgical, orthopedic, pediatric, and coronary care).

The data show, as expected, a reduction of clerical activities. They are, however,

inconsistent regarding the productivity of nursing staff in activities related to patient care. * Nurses on surgical units, for example, experienced the greatest reduction in clerical time, but they also spent less time in direct care of patients, The activity analysis at El Camino Hospital resulted in the reallocation and, in many cases,

reduction of nursing staff. However, further evaluations of changes in staff productivity seem warranted.

HEALTH DATA SYSTEM S

Medical information systems could supply health data systems with accurate, easily accessible

data. If standard classifications and codes were used and if all data sent to health data systems were already in computerized form, these organizations would be likely to realize substantial cost savings.

Many health data systems aggregate data on national or regional levels and could thus take advantage only of widespread medical information systems.

Health data systems are collections of data organized for a variety of purposes,

including reimbursement of health services, utilization review, and quality of care

assurance, as well as planning, monitoring, and evaluating medical care services.

Many health data systems obtain needed data from the hospital medical record. After a patient is discharged from an inpatient facility, data are abstracted from the

medical record and placed on multiple forms for different purposes. The same or

similar abstracted data may be used for reports to a Professional Standards Review

Organization (PSRO), third-party payer claims, internal medical care audits, and institutional management reports. In an ambulatory care setting, data abstracted from

the patient record may likewise be duplicated, although fewer health data systems

collect ambulatory data.

The current method of abstracting data involves problems of quality as well as

duplication. Error is possible each time data are transcribed to a different summary

form. In addition, errors in coding can take place during the abstracting process. Patients’ diagnoses and other data entered by medical providers into the medical record

in words are placed by trained clerks into codes based on the international classification of diseases. This process involves interpretation of established rules as well as

skill and care on the part of the clerk.

Medical information systems could provide health data systems with more accurate data in a more accessible form than is presently available. Once data are computerized, they are permanently available. Unnecessary duplication of data collection, with its attendant cost and error, could be avoided.

● In addition to the implementation of TMIS, changes in staffing patterns and other variables may

have contributed to the redistribution of nursing activities.
. —

Ch. 4—implications ● 4 8

Medical information systems could, for example, supply patient discharge

summaries to hospital discharge abstracting services like the Professional Activity

Study (PAS) or for quality assurance programs like Professional Standards Review

Organizations (PSROs). If data are automatically coded as they are entered into the

system by medical care personnel, computer-produced abstracts would reduce both

transcription and coding errors. In addition, medical information systems could

efficiently provide necessary information for payment programs such as Medicare

and Medicaid. With a computer system, these payment programs would be billed

only for services actually rendered.

The usefulness of medical information systems for health data systems largely

depends upon the extent to which patient data are entered into the computer record

and the extent to which the computerized data are structured or coded. A system

such as TMIS does not computerize large parts of the patient record, and some of

the computerized data (for example, dictated radiology reports) are not structured.

This kind of system is less useful for health data systems than a computer system

like COSTAR, in which almost all patient data are entered and coded in the computer record. In PROMIS, all data are entered, structured, and linked to a specific problem of the patient. PROMIS can thus easily retrieve all data. Health data systems,

however, usually aggregate by codes based on diagnosis and procedure rather than

by “problem.” Some information in the PROMIS data base may not be directly

transferable to aggregate data systems. However, the edition of the international

classification of diseases now being developed (lCDA-9CM) includes classifications

for problems, and health data systems will be using the new classification scheme

in the near future.

Computer produced abstracts can be sent to health data systems on paper forms

or on computer tape. Health data systems would likely realize substantial cost savings if the data they receive were already in computerized form. However, these

potential cost savings would occur only if medical information systems were widely

used, standardized, and coordinated with health data systems. For example, only one

of 2,000 hospitals that belong to PAS puts its discharge information on computer

tape. To enter this information into its computer, PAS must process the data just as

if they had been received on the manual forms.

Computer systems that capture some basic patient information for use in internal utilization review are commercially available, but no medical information system

is coordinated with a health data system at this time.

PLANNING AND RESEARC H

Medical information systems could provide planners and medical researchers with data that are

not available from existing health data systems. The computer systems store a data base that permits detailed analysis. If medical information systems with compatible data bases using standard definitions

were widely adopted, they could be used to plan medical services, to evaluate the cost and efficacy of medical care, and to conduct clinical and epidemiological research.

The expense of obtaining data on patients limits the information available in

most health data systems. The specificity necessary for some kinds of research may

be lost when discrete events or diagnoses are grouped into classification codes. Electronic data banks generated by medical information systems such as PROMIS and

COSTAR could make large amounts of disaggregated data available to authorized
49 ● Ch. 4—Implications

planners and researchers. Because the data are structured, patient-oriented, and

accessible, they can be manipulated in an enormous number of ways.

Resource Allocation

Existing data are often inadequate to allow policy makers and planners to reach

informed decisions about resource allocation. For example, little data exist about the

the efficacy of medical treatments or the frequency and costs of complaints or problems that bring people to doctors. Medical information systems have the capacity to

identify costs of medical services as they are provided and to relate these costs to

patients’ diagnoses and problems. In PROMIS, for instance, a charge is associated

with every discrete unit of service, and the costs and effectiveness of medical treatment can be evaluated. Using medical information systems, costs for the treatment

of a particular problem could be compared in various geographic regions, different

kinds of medical care settings, or types of medical providers. Comparing one method

of treatment with other modes can aid in determining efficacy. The availability of

such data would support decisions about the allocation of facilities, manpower, and

other medical care resources.

Institutional Planning

Presently, managers of medical care institutions use statistics based on events

or activities, such as number of days in intensive care or number of electrocardiograms provided, rather than measures of productivity, efficiency, and effectiveness. Medical information systems can help to optimize the allocation of staff

by supplying data on the amount of time spent by staff members on different kinds

of services (41). Medical information systems can help administrators predict needs

for new personnel, facilities, and supplies by providing data about the demographic

and geographic distributions of individual patients being served, the kinds of problems they present, and the types of services utilized, with measures of changes in

these distributions over time. Such information can now be obtained only through

special studies at considerable expense.

Research

Both epidemiological and clinical research could benefit from computerized

medical records that include patients’ demographic characteristics and diagnostic

information. Epidemiological research studies the frequency, distribution, population selectivity, and determinants of all cases of a particular disease or condition in a

defined population. Clinical research experimentally tests hypotheses about diagnosis or treatment in groups of patients.

For studies in which similar groups of patients must be matched, for example,

the computer could identify control groups with appropriate characteristics. Automatic search of the extensive electronic data base would simplify retrieval of outcome data or any other variables, and the computer could test for statisticall y

significant correlations. Followup on patients participating in prospective studies

would be expedited by continually updated information on addresses maintained in

the medical information systems.

Major disease patterns in this country have shifted from infectious toward

chronic conditions. Because chronic diseases have such long duration, gathering

valid data about the histories of patients with such diseases has been virtually im-
-——

Ch. 4—implications ● 5 0

possible. Computer-stored data banks offer the best prospect for learning their

natural histories. The use of a computerized data bank for such research has been

demonstrated in an experimental program at Stanford University (18). A computer

stores data on all visits of patients being treated for arthritis or related chronic diseases. With this extensive data base, researchers have conducted statistical analyses,

developed experienced-based data for clinical teaching, and advised clinicians on the

management of individual patients. Eventually, new interventions could be tested

against accumulated clinical experience to determine the most efficacious modes of

treatment.

The usefulness of medical information systems for research, however, is subject

to several constraints. In most epidemiological studies, valid statistical inferences

can be drawn only if the population base (denominator figure) is known. Thus medical information systems that maintain data about all people in a given locality are

most valuable for epidemiological research. Some studies also require data comparable over long periods of time, that is, trend data. Because only a few medical information systems are now operating, a historical data base will not be attained for

many years. Moreover, the utility of medical information systems will be determined in part by the ability of clinicians to anticipate the “right” information for tomorrow’s research. On the one hand, it is possible that computerizing all recorded

information may not be valuable and economical. On the other, even systems like

PROMIS, in which all recorded information is stored in the computer, may fail to

include data crucial for future research.

CONFIDENTIALITY OF PATIENT RECORDS

The confidentiality of sensitize medical data could be violated if computer files were infiltrated.

Today computer records are more secure than manual records. However, medical information systems

are not widespread, and a potential problem does exist.

Medical information systems make large quantities of personal medical information immediately accessible. The possibility of misusing computerized data has

prompted concern (33). Medical data, especially psychological and social data, can be

damaging to an individual when available outside the clinical context. Computer files

could be infiltrated and lists of people with certain medical and social characteristics

compiled. Such possible abuse presents complex legal problems seldom encountered

with manual records. Unauthorized access to an individual’s manual record is

possible, but sorting records according to diagnostic, social, and other criteria is difficult.

Considerable effort has gone into creating procedures to safeguard the confidentiality of computerized medical records without denying easy access to authorized users. At present, each organization using a computer system has had to develop its own security precautions. These safeguards on computerized records include

such measures as having key-lock terminals, plastic identification cards, passwords,

or other identification codes (38). Codes identify users and permit them access to

only those parts of the medical record necessary for carrying out their duties.

Entries are similarly circumscribed.

No matter how sophisticated or complicated, mechanical security measures cannot ensure the complete confidentiality of medical records. At best, unauthorized

access to computer files can be made time consuming and costly. At the same time,
elaborate security systems may hinder authorized users from obtaining needed information and substantially raise the initial cost of the computer system.

A prime factor in securing the confidentiality of medical records may be adherence to professional codes of ethics by all those who work directly with patient

records, automated or manual (11). Medical professionals are bound by their ethical

codes not to disclose patient information. In some States, breaches of confidentiality

constitute grounds for revocation of license. Similar ethical codes could be extended

to nonmedical professionals, especially data processing personnel, who have access

to computerized patient files (51).

Confidentiality can also be violated after the routine release of patient data to

organizations outside the medical care institution. The Privacy Protection Study

Commission, established by the Privacy Act of 1974, considered possible problems

associated with the release of data about individuals. Its report recognized legitimate

use of these data for research, auditing, and evaluation, but recommended disclosing

only data necessary for a specific purpose and limiting subsequent uses and disclosures (42).

Limited access to the medical record might be more feasible in a medical information system than in a manual system. For example, identification of patients

could automatically be stripped before pertinent data are released. Computerized

records, however, facilitate the availability of detailed data to third parties and thus

could increase the potential for misuse.

In order to control use of information within an organization and release of

identified data to third parties, a report sponsored by the National Bureau of Standards suggests that precise standards be promulgated before computer systems

proliferate (56). The report found that “computerized health records are more

securely kept and processed today than manual records” and that “instances of leakage or misuse almost always take place in manual files” (56). Medical information

systems are not widespread, however, and the report concludes that the main problem is one of potential harm.
5 ●

FACTORS INFLUENCING

ADOPTION AND USE
—

5 ●

FACTORS INFLUENCING ADOPTION

AND USE

Many potential benefits of medical information systems depend on their widespread use. Several factors, such as acceptability, technical transferability, and cost,

can inhibit or encourage their adoption. Acceptability to medical care providers is

crucial. Early systems failed in large measure because medical care providers found

, them hard to use. In order to be feasible economically, medical information systems

must be adaptable to the unique needs of different institutions. Developers are

modifying systems to make them applicable to many sites, but even so, medical information systems are an expensive technology. A number of institutions, however,

have reported overall cost savings. New developments in computer hardware and

software are likely to reduce further the costs of medical information systems.

Other factors, such as economic incentives and constraints, are difficult to predict,

but will also be important.

ACCEPTABILITY TO MEDICAL CARE PROVIDERS

Experience wilh the three computer systems discussed in this report indicates that familiarity with

a system encourages medical personnel to accept it. Providers who regularly use a system support it

more strongly than those who are only occasional users.

Medical information systems require providers to change their patterns of behavior. They must, for example, learn an entirely new set of procedures for keeping

records. Breaking with established, habitual routine is difficult and sometimes frustrating. Providers were alienated at first. Developers point out, however, that most

medical information systems are carefully structured so as not to disrupt traditional

patterns of clinical thinking and patient management. At HCHP, each specialty

group decided the format and content of its department’s encounter form. At El Camino Hospital, physicians worked closely with Technicon’s programmers in designing

both content and organization of display frames.

The developers of PROMIS, in contrast, have not structured the system according to the preferences of the medical professionals who use it. Rather than

adjusting their system to practitioners, the developers of PROMIS insist that personnel adjust themselves to it. PROMIS requires users to follow its decision logic

and accept its guidance. It breaks sharply with traditional practice, in which each

physician adheres only to his own rules and standards. In PROMIS practitioners are

required, for example, to give a reason for any action. Because PROMIS tries to en55
—

Ch. 5—Factors Influencing Adoption and Use ● 56

sure complete and logical care, recordkeeping is structured more rigidly than in

other computer systems. However, in it, like the other two systems, physicians can

add information.

Attitudes of providers toward use varies. At El Camino Hospital, a substantial

majority of the medical staff support TMIS (7). It is used by 78 percent of the physicians at the hospital. Rate of use, however, varies from one service to another.

Eighty-eight percent of all surgeons and internists, but only 32 percent of staff

psychiatrists, use TMIS. Physicians on the attending staff generally accepted

TMIS, and their attitude toward it has grown increasingly positive over time. Physicians are particularly positive about the system’s capabilities for research and education. Nurses at the hospital also express a high degree of satisfaction with the

system. Their evaluations of TMIS are, in fact, usually more favorable than those of

physicians.

A survey at the Harvard Community Health Plan found that 87 percent of

providers, including both physicians and nurses, prefer COSTAR to a manual system (5). Ninety percent of the providers believe that records are more readily available in COSTAR than in a manual system. Eighty percent believe that the automated system is less time-consuming than a manual one.

PROMIS received a mixed reception on the single ward at the University of

Vermont Hospital in which it was implemented from 1971 to 1975. In a 1975 vote on

the gynecology service, all of the nurses and a majority of the house officers, who

were primary users of the system, voted to keep it. However, attending physicians

voted eight to six to discontinue its use.

Acceptability to providers was a major problem in early systems. For example,

early systems often malfunctioned, and physicians were frequently called upon to

help adjust display frames. Resistance on the part of physicians to new innovations

tended to inhibit the use of computer technology for clinical applications. However,

many physicians now graduating from medical schools have been exposed to computer technology. As clinical applications of computers become more available, these

physicians can be expected to use them.

Developers stress that the issue most important for acceptance is whether the

medical information system makes patient care easier to provide. Physicians and

nurses will, in other words, use a medical information system if they believe the

system will aid them in providing care. Conversely, the provider who sees no benefits for personal job performance in the system will not use it regardless of inducements.

Developers of systems also report that the transition to a computer system is

facilitated when (5, 19):

• Providers have time to learn how to use the medical information system on

demonstration models before complete implementation takes place.

● Members of various provider groups are enlisted as spokesmen for the computer system. Providers react more favorably to the advice and example of

their own colleagues than to that of technicians.

. No claims are set forth for the systems that cannot be fulfilled during implemental ion.
57 ● Ch. 5—Factors Influencing Adoption and Use

Undoubtedly, other factors also influence degree of acceptance, and more research

is needed.

TECHNICAL TRANSFERABILITY

Medical information systems will have a major impact on the provision of medical care only if

they can be successfully transferred to many medical care institutions. Prototype systems have been

proven technically feasible, but most have not yet been made adaptable to the various conditions of different institutions.

Institutions differ on such fundamental characteristics as size and complexity,

types of services provided, kinds of data collected, how data are used, and populations served. Institutions may perform similar procedures differently. Requirements

for reporting laboratory tests may vary by institution. Medical care providers may

use different formats and nomenclature for reporting the same therapy or procedure and do not agree about the definitions of many medical terms (12). As a result

of these differences in institutions’ needs, medical information systems transferred

to new institutions have had to be modified during implementation.

Only if medical information systems are generalizable to various settings can

the benefits of a standardized data base be realized and systems be marketed economically (3). If each institution modifies nomenclature and codes for patient data to

accommodate individual needs, data cannot be used for planning and research. Modifying a medical information system for each institution is more costly than initially

designing a system that many institutions can use. One study, based on statistical

projections, concluded that if a system is to be used in 10 or more institutions, a

“flexible” system, although initially expensive, is less costly than repeatedly modifying a more rigid prototype (57). Developers of COSTAR, TM IS, and PROMIS are

working to make these systems more easily adaptable to various kinds of institutions.

The Laboratory of Computer Science at Massachusetts General Hospital and a

group at George Washington University have worked together to develop a model

ambulatory care system, based on COSTAR, that can be applied to many different

practices. The new system is modular; it allows the basic capabilities of medical records, billing, registration, scheduling, and generating reports to be combined in various ways for different ambulatory care sites with minimal programing. Each practice will choose which modules to include in its system. For example, a practice could

initially choose not to include the report scheduling module, but could add it to the

system later.

The medical records module is the key component of the system. Each practice

may design its own encounter forms, define much of the format, and choose the

coded options it wants to include. Any additional coding schemes chosen by the practice will be introduced into the uniform COSTAR coding scheme to provide a standardized medical data base. If special programs, for example, for audit and peer review, were added to the system in the future, t hey could be easily transferred

because all users will have the same file structure and programing language.

TMIS is already installed in six hospitals, including research and teaching institutions. In addition, activity is underway to make TMIS available to hospitals i n

modular form. The business office subsystem of TMIS can already be purchased
Ch. 5—Factors Influencing Adoption and Use ● 58

separately. Although the basic system would still include computerized patient records, such capabilities as reporting results from the laboratory and radiology departments and plans for nursing care, could be excluded. These functions would be available as options that could be added to the core system at any time elected by user

institutions.

The PROMIS Laboratory is redesigning hardware and software to make

PROMIS transferable to locations of various sizes and financial resources. The system will be available in multiples of a small-scale unit called a “node. ” Each node

consists of a minicomputer that supports from two terminals to between 30 and 6 0

terminals. A group practice may require only one or two nodes. In a hospital, many

nodes can be joined to support hundreds of terminals. The PROMIS Laboratory has

also developed a high-level computer language, PROMIS Programing Language

(PPL), for any reprogramming that institutions might require and for keeping content

of the system current (47).

In all of these approaches, developers are working to develop a system with a

core that is applicable to many sites. Such a design would also allow purchasing institutions to make changes in display formats in order to meet special needs.

COST

Medical information systems are an expensive technology. However, a majority of institutions

using medical information systems have reported considerable cost savings, particularly in labor expenses. Moreover, costs of computing hardware and thus the costs of medical information systems are

expected to decrease.

Medical Information Systems in Hospitals

Operating costs for a hospital-based medical information system range from $4

to $9 per patient day or from 4 percent to 7 percent of the total hospital operating

budget (2, 14). Technicon is marketing their system for $4 to $8 per patient day.

PROMIS is still being developed. However, the PROMIS Laboratory estimates its

costs will be in line with those of other medical information systems (35).

Cost depends upon the system, capabilities utilized, service arrangement with

the vendor, and size of the institution. A 200-bed hospital, for example, may have

expenses of $10 per patient day, while a 1,200-bed hospital, only $6 per patient day.

Factors unique to the institution, such as patient mix (more intense care generates

more activity to record and process), number of terminals desired, and degree of

customization, further determine operating costs.

Operating costs for a medical information system are included with other operating expenses of an institution for the purpose of third-party reimbursement. No

hospital reported any difficulty in obtaining third-party reimbursement for its medical information system (2).

Startup costs vary widely because many financial arrangements between hospitals and vendors are possible (2). Hospitals can lease or lease-purchase equipment

and pay for an agreed upon list of services on a monthly basis. Computer hardware

can be installed onsite, or the hospital can share the services of a central computer

facility. Hardware and software can also be purchased under long-term financial
59 ● Ch. 5- Factors Influencing Adoption and Use

arrangements. Either the institution or the vendor can employ technical support

staff for the computer. One large hospital (over 500 beds), which purchased hardware and software, had initial costs of $2.5 million (2). Implementation costs in a

medium-sized hospital, including physical installation and site development, for the

Technicon system were reported to be about half-a-million dollars (24).

Installation of a medical information system may or may not be subject to Federal and State approval. Under Section 1122 of the 1972 Amendments to the Social

Security Act, capital expenditures over $100,000 must be reviewed and approved by

the Secretary of the Department of Health, Education, and Welfare. Thirty-five

States have passed certificate-of-need laws that regulate expenditures by medical

care facilities for new construction, equipment, and services. These laws require

State review and approval for large capital expenditures, but the size of expenditure

needing review varies from State to State.

In 1976, only three medical information systems had been reviewed by comprehensive health planning agencies, the precursors to health systems agencies (2). Not

all systems require capital expenditures large enough for review, and relatively few

medical information systems have been installed in hospitals. Two of these reviews

were conducted under the authority of Section 1122, and one, in New Jersey, under

certificate-of-need authority. The applications of all three hospitals were approved.

Savings in the costs of handling information is the primary justification for

medical information systems. Baseline data on the costs of handling information in

hospitals are sparse. Findings from two studies estimate that hospitals spend from

24 percent to 39 percent of their total operating budget on information processing

(26, 44). About one-half of this cost is attributable to payroll expenses for personnel.

Hospitals presently spend, on average, from 2 to 3 percent of their total operating

budget for electronic data processing for accounting and management purposes (14).

Medical information systems cost about double the current average expenditure

for the financial and management computer applications that they replace. Hospitals

attribute savings in other areas to medical information systems: the elimination of

printed forms, reductions in clerical, admissions, and nursing staff, and reduction in

“lost charges”* (2). Because medical information systems could make possible improved cost accounting, reductions in length of patient stay, and increased productivity of medical care professionals, other savings may accrue.

Only one study has been reported that compares costs of an operating medical

information system with costs that would have occurred if the hospital had used a

manual medical record system during the same period (19). El Camino Hospital

conducted this study. Under the terms of its initial contract, cost savings determined

the hospital’s payments to Technicon.

A large base of management data enabled El Camino Hospital to identify

changes in costs, particularly costs of labor, throughout all departments of the hospital. Cost savings in labor were evaluated by three methods. First, potential savings

in manpower time were measured by comparing time required for clerical tasks in a

manual system and in TMIS. Next, actual nursing hours per patient day after implementation of TMIS were compared to nursing hours expected for the same time

● Because supplies and services are entered from areas of patient care into the medical information

system at the time they are offered or provided and transferred electronically to the business office,

chargeable items are not lost.
Ch. 5—Factors Influencing Adoption and Use ● 60

period with a manual system. Finally, trend analysis was used to compare El Camino’s costs for nursing labor to those of other area hospitals providing similar services.

El Camino Hospital concluded that substantial cost savings in labor were realized from TMIS. Estimated savings attributed to the computer system ranged from

$72,000 to $189,000 per month, and fixed operational cost of the system, as negotiated with the vendor, was $89,800 per month. Original projections anticipated that

cost savings would not be shown before 4 years of operation, but were in fact demonstrated within 18 months of operation. Net benefits, after paying for the costs of

the system, were estimated to range between $30,000 and $50,000 per month or between $3 and $5 per patient day. Labor savings, particularly in nursing, accounted

for about 95 percent of the TMIS total cost savings. Certain revenue benefits, savings in materials, and avoidance of minor costs made up the other 5 percent.

As part of an evaluation contract with the National Center for Health Services

Research, the Battelle Laboratory is conducting an independent evaluation of the

economic impact of TMIS on El Camino Hospital. No data are presently available to

verify the results of the El Camino Hospital Study.

Medical Information Systems for Ambulatory Care

A survey in 1974 of 18 ambulatory care sites operating medical information systems reported that costs ranged from $1 to $50 per patient year and from $0.50 to

$14 per patient visit (23). If continuing development costs and depreciation on

equipment are calculated with operating costs, total expenses range from $1 to $101

per patient year and $0.50 to $22 per patient visit. The total costs for operating

COSTAR at HCHP, as reported in the survey, were $15 per patient year and $3 per

patient visit.

In ambulatory care facilities as well as hospitals, installation costs for medical

information systems depend on the kind of services to be acquired. Because most

of the systems surveyed in 1974 were prototypes, costs of installation could not be

separated from costs of development.

Twelve of the 18 surveyed sites credited their medical information systems with

containing or reducing costs. Ten facilities cited savings in expenses for medical personnel. Eight sites estimated savings from more efficient financial and administrative management. However, the authors of the survey concluded that, while aggregate facility costs were reduced, there was no indication that medical information

systems would have a direct effect on the cost of individual medical services. Further, no true cost savings in the ambulatory care facilities as a result of better utilization of personnel were identified.

Only one study in the literature reports costs of handling information in ambulatory care settings (40). The National Center for Health Services Research under

contract to Bolt, Beranek, and Newman calculated costs according to time expended

by personnel in data handling. The study suggested that a medical information system would lead to substantial savings if it stored all medical records and information

for billing and also made data instantly available in many places. This study, which

analyzed the clinic operated by an 11 physician group practice in Nashua, N. H., concluded that a minimum of $87,000 and a maximum of $142,000 in data processing

and personnel salaries could be offset by an automated ambulatory medical record
61 ● Ch. 5--Factors Influencing Adoption and Use

system. The study suggested that such a medium-sized group practice could support a capital investment for physical equipment in the range of $275,000 to

$460,000 .

Few medical information systems are located in such practices. Most operate in

health maintenance organizations, outpatient departments of hospitals, large group

practices, and federally subsidized clinics. The operating expenses of these large

organizations for medical information systems are not representative of the costs

that a smaller group practice might experience. The research group that has modified COSTAR estimates that the capital costs of their system will be about $85,000

at current prices for group practices of five to eight practitioners and about

$125,000 to $200,000 for larger multispecialty group practices (6). Average monthly costs are projected within the range of current expenditures by group practices

for billing activities alone, from $1,200 per month for small groups to $4,000 p e r

month for larger group practices. If these cost projections hold up in the marketplace, such an automated record system would result in substantial cost savings by

virtue of offsetting costs for information processing as reported in the Bolt, Beranek, and Newman study.

Cost Effectiveness

Although considerable cost savings due to medical information systems have

been demonstrated at some institutions, no rigorous analysis of cost effectiveness

has been conducted to date. A given technology is considered cost effective if it

yields the desired outcome at the lowest cost unit (27). Analysis of cost effectiveness

assumes that the desired outcome is known and can be measured. If a new technology is replacing a system already in existence, for example, a clinical laboratory system or a billing and accounting system, the desired outcome is well established. The

new technology is accepted as cost effective if its costs are equal to or less than those

of the system already installed.

Because medical information systems incorporate functions that did not exist in

the manual medical record system, their cost effectiveness is more difficult to determine. The objectives of the old and the new systems are different. The timeliness

of information transfer, the simultaneous availability of information at multiple locations, and the formation of an electronic medical data base are among benefits that

were not possible with a manual system. Because medical information systems computerize necessary data, administrative costs of other organizations, such as abstracting services, PSROs, Medicare, and Medicaid may also be lowered. These possible savings are not typically considered when evaluating the potential of this technology.

Medical information systems have multiple objectives, then, and many of the

new benefits cannot at present be directly measured. Current expenses for medical

information systems may not represent true costs because most systems are still in a

developmental stage. Developmental costs always are greater than subsequent routine operational costs (10). Also, methods for evaluating cost effectiveness have not

been well developed. The National Center for Health Services Research, for example, has a contract with the University of Vermont to compare the effectiveness of

PROMIS to a manual problem-oriented medical record used in the same clinical

setting. The study group found that in order to conduct a valid comparison, the data

entered in the manual records would have to be run through a computer.
Ch. 5—Factors Influencing Adoption and Use ● 62

In summary, although cost effectiveness has not been demonstrated, several

studies have found that the introduction of medical information systems leads to

considerable savings in labor expenses. In the past, wages of personnel have continually risen while the cost of computing hardware has decreased. Cost savings for

institutions from the use of medical information systems can thus be expected to

grow.

GENERAL FACTORS

Rate of use of medical information systems will depend on multiple factors applicable to any new

technology. New developments in computing hardware and software, Federal policies, and economic

incentives and constraints could facilitate or impede adoption. The effect of these factors on medical information systems is not now predicable.

Moving from development to availability of a new technology is a gradual process that proceeds through five phases: research, development, demonstration, industrial development, and finally, marketing (53). The general acceptance and use of

a new technology usually lags considerably behind its availability. Estimates for the

average time lag are from 10 to 15 years, but wide variation occurs (53). For example, the stethoscope was developed 113 years before its general use; defibrillators, 25

years; and electrocardiogram analysis by computer, 10 years (17).

The three medical information systems described in this report are at different

stages in the transfer process. TMIS is being marketed and has already been installed in six hospitals. The research group developing an exportable COSTAR system estimates that several prototype systems will be operating by the end of 1977

(55). Staff at the PROMIS Laboratory estimate another 2 to 5 years of developmental activity before PROMIS will be available for marketing (35).

Medical information systems, in general, are still in the early stage of acceptance

as an innovation in medical care. Factors applicable to any new technology may facilitate or impede the diffusion of medical information systems, but they have not yet

come into force.

.

For a rapidly changing technology such as computers, advances in hardware

could considerably speed the acceptance of medical information systems (l). Recently, microprocessors with the power and capacity of large computers at a fraction of

the cost have become available. Further development could make low-cost computing feasible even for individual use. New memory technology has been developed

that could remove all limitations on the volume of data stored. Small battery operated clipboard terminals, which are currently being designed, could allow providers

to enter or obtain data from virtually any location.

On the other hand, institutions may defer investing in a system until the technology is more stable. Existing medical information systems are not expected to become obsolete in the near future, however, provided that current maintenance and

development efforts continue (2).

Federal policy and economic factors will also impinge on the adoption of medical

information systems. Managers of medical care institutions will consider general

economic constraints and incentives in determining their need for a computer system. Government could encourage or discourage use through reimbursement policies and Federal and State regulations concerning capital expenditures. Direct Gov-
63 ● Ch. 5—Factors Influencing Adoption and Use

ernment intervention, as well, can be an effective tool influencing the diffusion process (36). Finally, market forces such as competition, profitability, and consumer

demand will be important determinants of the time lag between the introduction

and final adoption of a new technology (46).
POLICY ISSUES

AND ALTERNATIVES
—

6 ●

POLICY ISSUES AND ALTERNATIVES

A broad range of impacts accompanies the introduction of medical information

systems into medical care institutions. Improved quality, coordination, and timeliness of data about patients have been documented. Some institutions have experienced cost savings, particularly in labor expenses. Other anticipated benefits, as well

as possible disadvantages, of medical information systems have not yet been carefully studied. Two reasons are primarily responsible for this lack of evaluation. First,

those medical information systems in use are, for the most part, prototypes. Second,

those applications of medical information systems that may have the broadest impact on the medical care system are least developed. For example, few systems incorporate applications that support clinical decisionmaking and are capable of influencing the quality of medical care. None have been used to produce data on the

cost and efficacy of medical care.

Careful consideration of Federal policy on medical information systems is nonetheless worthwhile at this stage of their development. The Federal Government

supports basic research on such systems, but has few policy mechanisms to promote

or guide the demonstration and diffusion of the technology. The issue of when and

how the Federal Government should become involved in the development and use of

medical information systems is important for several reasons.

●

●

●

●

Existing systems vary in scope, cost, and impact on the medical care system.

Consensus has not been reached about the defining characteristics of a

medical information system.

It is unlikely that a strong constituency will form in medical care institutions

either supporting or opposing medical information systems. Unlike new diagnostic or therapeutic technologies that impact on special groups, medical

information systems improve the use of medical services and affect all providers and patients in a medical care institution.

Medical information systems are a costly technology. Initial costs for implementation ma y amount to millions of dollars; and operating expenses in a

medium-sized hospital may exceed a million dollars annually.

Medical information systems are currently installed in few institutions. Recent advances in computer technology, which will lower costs, could lead to

rapid acquisition of a variety of systems. Unless the Federal Government

formulates a policy toward medical information systems now, development

and diffusion could proceed indiscriminately, making standardization impossible.

.
— — —

Ch. 6—Policy Issues and Alternatives ● 68

The range of policy alternatives that follows addresses how development of

medical information systems can be directed for maximum benefit to the medical

care system. The alternatives discussed are neither exhaustive nor mutually exclusive.

DEVELOPMENT AND DISSEMINATION

Presently, development of medical information systems is conducted by many

investigators pursuing different approaches. The commercial computer industry is

conducting limited marketing of medical information systems and continuing some

research, Grants and contracts from the National Center for Health Services Research support research for some projects. Other Federal agencies (Veterans Administration, Indian Health Service of HEW, Department of Defense) are funding

projects for Government-supported medical care facilities. A number of medical care

facilities are using internal funding or funds from local government or foundations

to develop systems for inhouse needs.

Alternative 1: Continue current research and development policies and

allow dissemination of medical information systems to be determined by

the open marketplace.

The first alternative available to the Federal Government is to allow the evolution of systems without direct intervention. The Federal Government could continue current levels of funding for research without attempting to influence the

kinds of computer systems used in various medical care settings. This policy continues the pluralistic approach that now characterizes the delivery of medical care in

the United States. Further, one school of economic thought presumes that in the

open marketplace those computer systems benefiting the medical care institution

will be adopted, while those that do not will compete unsuccessfully.

Continuation of present policy, however, could have several disadvantages.

Because medical information systems support the organization of medical services,

administrators of medical care facilities have been their primary consumers. The

capabilities of medical information systems for improving institutional efficiency

and supporting administrative functions are thus most marketable, as well as best

developed, and systems limited to these functions could predominate.

A further risk is that industry will elect to market the technology without additional investments in research and development (R&D). Capabilities of medical information systems to improve and monitor the quality of medical care and to facilitate research and planning primarily benefit the patient and the medical care system

as a whole, rather than the institution. Without further development, these potential benefits to the medical care system may be lost, although taxpayers would continue to support a large portion of institutional costs for computer systems through

Medicare and Medicaid payments.

Continuation of present policy could also maintain a slow rate of dissemination

for medical information systems. Except for the few institutions with the technical

personnel, financial resources, and motivation to develop their own computer systems, medical care facilities would have the option of choosing only from among

those systems available commercially. Because industry must recover R&D costs
69 ● Ch. 6--Policy Issues and Alternatives

through market prices, institutions without large capital resources (primarily

smaller facilities) might be unable to acquire a medical information system.

tion

If Federal action influencing development and eventual use of medical informasystems were considered desirable, several strategies could be pursued.

Alternative 2: Establish a central clearinghouse to coordinate develop-

 mental projects and provide information to the public about medical information systems.

Conferences, or other forums, could ensure that technical innovations are

shared and ideas exchanged. Various medical information systems could be classified and ranked by their capabilities. Guidelines could be developed for use by hospitals and other medical care facilities in selecting, implementing, and evaluating medical information systems.

Because diverse groups are developing medical information systems, representation by all sectors, including public, private nonprofit, and commercial, would be

appropriate at these forums. Although the coordinating group need not be a governmental agency, several Federal agencies could perform this function. Since its establishment in 1969, the National Center for Health Services Research has had primary

responsibility for medical information systems technology. It has convened a conference for investigators working on automated ambulatory medical records. The

Bureau of Health Planning and Resource Development (BHPRD) provides technical

assistance to areawide health systems agencies (HSAs), which have regulatory

authority over capital investments by medical care facilities. BHPRD currently is

funding a study comparing automated hospital information systems that are available commercially. Other offices in the Department of Health, Education, and Welfare might also perform the clearinghouse function. For example in the National Institutes of Health, the Lister Hill National Center for Biomedical Communications

has a mandate to develop networks and information systems for improving health

education, medical research, and the delivery of medical services.

Having a central organization coordinate information about medical information systems would demonstrate the Federal Government’s interest in these computer systems. By increasing public awareness, it might promote adoption of medical

information systems. If systems were carefully classified by capability and relative

value, administrators would be more able to act as prudent buyers. Furthermore, an

approach based on public information would not violate current policy of removing

the Federal Government from the direct dissemination of new technologies. This

approach, however, holds no incentives for developers to expand the capabilities of

systems or for medical care facilities to purchase such systems.

Alternative 3: Provide funding for evaluation of medical information

systems in a number of different medical care facilities and locations to determine their effectiveness in terms of relative benefits and costs.

A number of questions regarding medical information systems remain unanswered. Because a medical information system in a medium-sized community hospital is the only one that has been evaluated in depth, * studies of costs and impacts in

● The Technicon Medical Information System at El Camino Hospital was evaluated in an in-house

study and by an independent contractor, the Battelle Laboratories.
————-

Ch. 6—Policy Issues and Alternatives ● 70

other kinds of medical care delivery settings are needed. For example, smaller institutions would not necessarily realize the same economies from medical information

systems as large facilities. Existing systems have differing capabilities, but it is not

known which systems would have the greatest impact in different kinds of settings.

The cost effectiveness of systems designed for use in small groups or even solo practices has not been carefully studied.

Priorities on the kinds of medical care facilities that might use medical information systems have not been established. On one hand, priority might be given to

teaching hospitals so that detailed data about less common conditions can be made

available for research. If, on the other hand, priority went to small hospitals, community physicians could benefit from the capabilities of medical information systems for continuing education and quality assurance.

Funding the evaluation of a sufficient number of medical information systems

would provide the necessary information on which policy makers could base decisions. In addition, placement of medical information systems in various kinds of

facilities and in different parts of the country would enhance their visibility. Having

a number of systems operational could itself spur further adoption.

The National Center for Health Services Research has authority to fund such

evaluation projects through grants and contracts to investigators in the field. Medical information systems in institutions operated by the Government could be funded

directly by the responsible Federal agencies. No new legislation would be required to

implement this approach, although additional funding may be needed.

Alternative 4: Ensure the availability of medical information systems

with specified capabilities and applications by contracting for their development.

Additional development of medical information systems is necessary to achieve

the full range of anticipated benefits described in this report. To speed development

of systems with desired characteristics, the Federal Government could conduct a

targeted research and development program. Government could contract directly

for the development of medical information systems with specified capabilities and

applications.

Under this approach, Government would absorb the larger portion of R&D

costs, while private industry would be encouraged to invest its money in marketing

the systems and reducing their costs. Targeted development would eliminate duplication of efforts and would ensure the availability of broad-based systems with full

capabilities. Without more extensive information than is presently available, however, specifications for such development would be difficult to formulate. Supporting research by grant funds tends to encourage new ideas and approaches. Grants

may still be the most appropriate mechanism for developing medical information

systems.

Contracting with industry for the development of needed technologies is a common procedure for Federal agencies such as the Department of Defense and the

National Aeronautics and Space Administration. The National Center for Health

Services Research, however, does not currently have the authority to contract for

the development of new medical technologies. Contracts can be used only to obtain

specifications for the operation of an existing technology. Enabling legislation limited NCHSR to support of research, evaluation, and demonstration projects. Modifi-
cation of NCHSR Legislation would therefore be required to implement this alternative. *

Alternative 5: Provide incentives for medical care facilities to adopt medical information systems that improve the quality of patient care and

support research and planning.

Even after medical information systems with full capabilities have been developed and tested in the field, several factors could discourage their purchase. Medical

information systems must compete with other technologies for the financial resources of medical care facilities. They compete directly with computer systems

designed solely for administrative and billing purposes. The functions of these subsystems would be subsumed by medical information systems, but management and

financial systems are well established, have proven capabilities, and can usually be

purchased at lower cost than medical information systems.

Current payment methods encourage the adoption of technologies that produce

revenues for the institution. Thus, facilities might invest in new diagnostic and therapeutic technologies instead of medical information systems. Hospitals can itemize

patients’ bills for tests and procedures, but not for the services of medical information systems, which are included as a part of a daily inpatient rate. Furthermore, the

practice of public programs paying on the basis of “reasonable costs” does not create

a strong incentive for institutions to adopt cost-saving technologies, although medical information systems can reduce some institutional expenses.

The Federal Government could promote the dissemination of medical information systems through appropriate incentives and sanctions for medical care institutions. Two possible mechanisms could be employed: regulatory authority over capital expenditures and direct subsidy.

Under section 1122 authority of the 1972 Amendments of the Social Security

Act and, in many States, under certificate-of-need legislative authority, local health

systems agencies (HSAs) review and either approve or deny hospital applications for

capital expenditures over $100,000. Under Federal guidelines, these HSAs could

deny applications for computer systems that do not meet specified capabilities. The

Bureau of Health Planning and Resource Development (BHPRD), which supplies

HSAs with technical advice, could issue guidelines to define acceptable computer

applications.

The Federal Government could also directly subsidize the purchase of medical

information systems. Grants, loans, loan guarantees, or interest subsidies could be

given to institutions purchasing approved computer systems. Such financial assistance could be a strong incentive for implementation of computer systems by medical care facilities otherwise lacking sufficient capital.

Existing legislative authority allows NCHSR to make grants available to nonprofit institutions for the demonstration of medical care technologies. Health sys -

tems agencies could also give grants from their area health services development

funds. State health planning and development agencies could make loans, loan guarantees, and interest subsidies available from health resources development funds.

This latter alternative would require amending legislation by Congress. Health resources development funds are now restricted to modernization projects of facilities

and exclude the purchase of new equipment such as medical information systems.
Ch. 6—Policy Issues and Alternatives . 72

CONTROL AND STANDARDIZATION

Beyond the development and dissemination of medical information systems,

initiatives by the Federal Government could ensure uniform impact of the computer

systems. Controls on medical knowledge incorporated into medical information s ystems would maintain the quality and credibility of the computer systems. Standardized patient data bases would permit PSROs, planners, and researchers to use medical information systems. Issuance of standards could protect the confidentiality of

computerized patient records. In each case, the professional groups affected should

be consulted. The following alternatives address these issues of standardization.

Alternative 6: Charge a central organization with authority for developing, validating, and maintaining the content of medical knowledge within

medical information systems.

Without controls on the entry of medical knowledge into medical information

systems, therapies, drugs, or tests of unproven efficacy could be incorporated a s

guidelines for physicians in computer programs. A central organization could control and accredit the content and distribution of medical knowledge frames, All

systems would thus contain carefully researched medical information of uniform

quality. Having a central organization distribute medical content frames would also

ensure the dissemination of new medical knowledge as it becomes available.

The National Library of Medicine in the National Institutes of Health has recognized expertise in the area of medical information. It, or a newly established organization, could be funded and staffed to perform this function.

Alternative 7: Develop standardized medical data bases, including nomenclature, terms, definitions, classifications, and codes, for use in medical

information systems.

A standardized data base would permit the coordination of medical information systems with health data systems. If standardized, data from different medical

care settings and geographic areas would be comparable and could be used for research and planning. More uniform specifications of data base content would expedite the transfer of the technology by enabling the production of multiple copies of

systems and fewer “custom-built” applications, Similar research and development in

the standardization of programing languages also would be required so that software could readily be exchanged among systems.

The National Center for Health Statistics (NCHS) is the Federal agency charged

with providing general-purpose health statistics on the Nation’s population. Many

activities of NCHS bear upon comparability and definitions of medical data. The U.S.

National Committee on Vital and Health Statistics is an independent panel of experts who serve in an advisory capacity to the Secretary of DHEW. The National

Committee has recommended minimum uniform data sets for different medical care

settings and is now conducting a review of the classification of diseases. These

groups, or others, could direct development of standardized medical data bases.

Alternative 8: Establish guidelines for precise standards to protect confidentiality of patient data within an institution and release of identified

data to third parties.
Unauthorized access to patient data within an institution is a potential danger of

medical information systems. Standardized security precautions and careful delineation of staff responsibilities would minimize this risk. Computerized patient files

also make detailed data available to outside organizations. Laws and policies that

define limits on data sharing could be developed as well as mechanisms to police

these boundaries. The National Bureau of Standards in the Department of Commerce, which has recently supported a detailed study on computers and health records, is one agency that could develop standards and recommendations to protect

the confidentiality of patient data.
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U. S. GOV EN NM ENT PR INl [NC; OF FIC- E : 1C177 0 - 95-70 1