The perception of system and the reduction of uncertainty
Authors: C. D. Flagle
Venue: Proceedings of ACM conference on History of medical informatics (1987)

Until the mid 1960's we had two separate streams of development of medical information systems. One proceeded from efforts under the Hill-Burton Program to develop management systems for hospitals and community health planning, with little stress placed initially on the interactive use of computers. The other, centered within medicine, and medical decision making, was from the outset an effort to exploit the growing potential of computers in clinical matters. Creation of the National Center for Health Services Research in 1968, was a key event in the merging of these two sets of activities, with formation of a program and study section in health systems development and a common source of funding for projects with either administrative or clinical significance, or both. The establishment of the National Center was proceeded by more than a decade of health services research with the objective of improved management systems. The concepts and systems growing out of this research were forerunners of many of the activities in modern medical informatics; they were foundations for the still developing techniques of resource allocation, staffing, scheduling, and for screening and diagnosis. A common theme runs through the early research and development. As a researcher one was faced with perplexing pictures of the behavior of both patients and the people and organizations serving them. Through direct observation of the central actions in patient care and support services, it was possible to perceive some pattern, order, or system in the demands stemming from illness and accident, and these patterns were inherently variable and apparently unpredictable. Whether physician, nurse or administrator, the provider was confronted with the need to make decisions under uncertainty. Having gained insight from research, the task was then one of finding ways to reduce uncertainty: by developing timely predictors of demands, by developing flexible administrative mechanisms to move resources to demands (or vice versa) and by reducing error in the assessment of patient condition. The early work in patient classification by level of dependency led to management systems for nurse staffing and patient placement. Refined by the inclusion of diagnosis as a variable patient classification led to mechanisms of resource allocation and reimbursement. In study of outpatient services, early work drew upon techniques of computer simulation to test alternative approaches to control of congestion and delay in outpatient services through computerized appointment scheduling, and records keeping systems. In applying statistical decision theory to disease screening early work led to awareness of the need to reduce uncertainty of testing, touching off a wave of efforts to base decision rules on multivariate analysis to increase sensitivity and specificity. The path to implementation of all these systems has led appropriately to computer based information systems. In retrospect, one can see in the decades of research and development a process of inexorable growth of intelligence in an evolving health system, growth in precision of sensing, analysis, communication and memory. In this perspective, the disparate research and development efforts begun years ago find meaning in the context of medical informatics, and the role of medical informatics itself can be better understood in the context of the evolving health system.