CURRENT

STATUS OF

AMBULATORY HEALTH CARE

COMPUTER APPLJCAllONSGerald A. Giebink, Leonard L. Hurst, Charles L. Foreman, Diana ElserHealth Care Management Systems, Inc.

Introduction

Much of -the present consumer concern with Americanhealth care starts with the discrepancy most peopleexperience between the office visit to a doctor and thefocus of most medical research and its results. Medicalprogress has affected public health and the acutely ill ordisabled, but has had comparatively minor impact on theaverage doctor-patient encounter outside the hospital,university medical center, or other specialized setting. In1970, 72% of the population consulted a physician at leastonce, but only 10.3% reported one or more hospitalepisodes; American Hospital Association statistics showed

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community hospitals averaging 4.6 outpatient visits forevery one inpatient admission.'

Because of the volume of ambulatory care and theincrease of group practices, medical computing systemshold particular promise for improving the efficiency andquality of outpatient care. Administrative and clerical aidsin the form of computerized scheduling systems, financialsystems for routine office work, and automated medicalrecords have already been successful, and clinical systemshave been developed in several fields. Multiphasic testingsystems are of benefit when a high volume of patients isscreened continuously. Computerized interpretation ofelectrocardiograms is now available commercially via

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Project

Ambulatory Care Project,Beth Israel Hospital,Boston, Mass.

Arizona Health Plan DataManagement System,Phoenix, Ariz.

Boston Children's HospitalMedical Center Appoint-ment System, Boston,Mass.

Cardiovascular Clinic Ambula-tory Care Medical RecordSystem, Oklahoma City,Oklahoma

Clinical Computer Applica-tions, University of UtahDepartment of Biophysicsand BioengineeringSalt Lake City, Utah

Community Electrocardio-graphic InterpretativeServices, St. Luke'sHospital, Denver, Colo.

Computer Aids in thePhysician's Office,Bolt, Beranek andNewman, Cambridge,Mass.

A Computerized PatientManagement Systemfor a Community Clinic,Baylor College of Medicine,Houston, Texas

Investigator

Herbert Sherman

Donald Carroll

James Shruhan

Galen Robbins, M.D.

Homer R. Warner, M.D.

Robert V. Elliott, M.D.

Paul Castleman

Carlos Vallbona, M.D.

Demonstration of a HospitalData Management System(Texas Institute for Rehabi-litation and Research),Houston, Texas

Health Information System,Bellevue Hospital,New York, N. Y.

Hospital Computer Project,Massachusetts GeneralHospital, Boston, Mass.

Indian Health Service System,Tucson, Ariz.

Kaiser Permanente MedicalGroup, Med ical MethodsResearch, Oakland, Calif.

Lahey Clinic FoundationAppointment System,Boston, Mass.

Los Angeles CountyPatient Data Bank

Medical Information SystemTechnicon/EI CaminoHospital, Mountain View,Calif.

Missouri Automated Radiol-ogy System, University ofMissouri, Columbia, Mo.

Problem-Oriented MedicalInformation SystemsLaboratory, Universityof Vermont, Burlington, Vt.

Urban Comprehensive HealthCare Information System,Denver, Colo.

William A. Spencer, M.D.

Margaret Lyman, M.D.

G. Octo Barnett, M.D.

Alfred E. Garratt, Ph.D.

Joseph Terdiman, M.D.,Ph.D.

Richard Harrison

Gene E. Thompson

John Gall

James Lvehr, M.D.

Lawrence L. Weed, M.D.

Gerald A. Giebink

telephone lines even to remote practices. For large clinicswith a sufficiently high volume of testing, computerizedlaboratory systems have been'economical and successful.

Recent emphasis on methods for auditing and evaluatingthe quality of health care has led to a search for economicalmethods for acquiring and processing clinical datagenerated in the ambulatory care setting. In many researchand development projects, computers process the clinicaldata used in quality review.

However, the economical application of medicalcomputing systems to ambulatory care depends on

economies of scale unavailable in most ambulatory settingsat present. Difficulties of implementation and costs ofmedical computing systems are often prohibitive, especiallyfor smaller practices, even though the technology isavailable and sometimes operational. Assuming computeri-zation costs continue to decline relative to high labor costsof medical care as they have in recent decades, medicalcomputing systems will be a practical reality in mostambulatory settings in 10-20 years. To assure a rationalapproach to computer applications development inambulatory health care, engineers and medical professionalsmust cooperate in identifying and solving the importantmedical care delivery problems.

January 1975

The classification and documentation of existingambulatory heafth care computer applications is essential tofurther research and development efforts. This article is asummary of some of the findings of a study conducted byHealth Care Management Systems, Inc. (HCMS) to surveyand document representative projects, and to identify thepatterns of development, technical factors, and operationalconditions which may support or inhibit success in futurehealth care computerization projects. This study wasfunded through a grant from The Robert Wood JohnsonFoundation.

Background

In early 1974, HCMS personnel completed visits to 29projects/subprojects at 19 sites to discuss and observe,first-hand, medical computing facilities. (See Table 1 forproject locations and names.) After the interviews, a draftproject profile' was written for each project using thefollowing outline: 1) project objective, description, and$tatus; 2) location of project and environment; 3) projectfinancing-source and costs; 4) project evaluation; 5)developmental and operational problems; 6) description of

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Table 1. Projects Surveyed and Principal Investigators

computer system; and i) computer system reliability andmajor hardware and software problems. A final report wasprepared consisting of project surveys, and a selectedbibliography with abstracts (containing 4134 citations and1436 abstracts); it will be published as a book in early1975.

The surveyed projects consist of different types ofhealth care organizations which use information processingto provide better patient care. They include eight hospitalswith outpatient clinics, five hospitals, three prepaid healthplans/group practices, three private group practices, onecommunity clinic, and one hospital with an outpatientclinic and a community clinic.

For use in this study, applications were divided intospecific categories. Application distribution among the 29projects (many projects have multiple applications) isshown' in Table 2. Project goals and objectives ranged frombroad statements: "Develop a basis for a community wideambulatory care information system" to more cogentstatements: "Establish standard care plans for specificdisabilities." In most cases projects stated multipleobjectives (see Table 2).

Status of Application Development

In this survey, projects with a clinical servicesorientation outnumbered projects focused on improvedadministrative services. This distribution reflects prioritiesof developmental funding by government and privatesources and is characterized by a 'high percentage ofprojects with applications to medical records, patient care,and diagnostic or consultation assistance. Computerizedadministrative service systems have benefitted most fromcomputer technology and have been offered for manyyears. Because administrative applications are morecommonplace and developmental problems are less severe,such applications were not highlighted in the survey. Thefollowing paragraphs describe some of the major areas ofapplication.

Medical Records In most developmental projects,computerization of the medical record plays a central role.One record acts as a repository for data collected throughcontacts of the patient with practitioners, admissions andregistration clerks, and other' personnel. It then becomesthe information source in diagnosis, treatment selection,consultation, quality review, and practitioner education.Although some computerized systems, such as clinicallaboratory systems or'appointment systems, can operateindependently, their operation is usually integrated throughthe use of data stored in a computerized medical record.Automated records are not in general use, and other than indevelopmental projects,. the record is generally an abstractof a more complete traditional paper-based record.

Diagnosis & Consultation A number of developmentalprojects use computers in differential diagnosis and intreatment selection and care planning. Commercialapplications in computer-aided diagnosis and consultationare almost non-existent. Commercial systems are availablefor use in patient-administered medical history-taking,either as a separate application or as part of a computerizedmulti-test screening system.

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Table 2. Application Distribution

ApplicationsMedical RecordsPatient CareDiagnostic or Consultation AssistanceResearchUtilization and/or Quality AssessmentManagement InformationProvider EducationAdministrative Services

(including business operations)Appointment SchedulingPhysiological Measurement and Analysis

(BCG, EEG, organ scan, etc.)History TakingAncillary Services Support (clinical

laboratory, radiology, pharmacy,physical therapy)

Patient EducationMultiphasic Health Testing

Objectives

Improve quality of patient careImprove utilization of skilled manpowerImprove efficiencyImprove patient servicesImprove management planning capabilityAssist in quality of care assessmentImprove cost controlProvide a research data baseImprove distribution of health servicesDemonstrate capability of health information

system

Vlumber of Projectswith Application

252423201814]12

119

87

522

Vumber of Projects13108775332

2

Physiological Measurement and Analysis Some com-mercial firms now market systems for surgical intensive careunit monitoring which monitor heart and other organfunctions, prepare various bedside reports, and actuatealarms when deviations from preset standards occur.Computer processing and interpretation of ECG data areperformed as a service by both commercial and nonprofitfirms. Other physiological measurement applicationsbecoming more common include pulmonary functiontesting, computer-assisted interpretation of electroen-cephalograms, and interpretation of radioisotope scans.

Ancillary Services (Laboratories, Radiology, Pharmacy)Computer services in clinical laboratories are nbwcommonly used to acquire signal data and transform it forcomputing test results, prepare various reports of testresults, perform quality control tests, communicate resultsthroughout a hospital, prepare billings, and generally assistin organizing and managing laboratory work (includingradiology). Systems have been developed for pharmacyinventory control, label printing, and other administrativetasks. Under development are a number of systems' whichassist in the communication of orders from hospital floorsto the pharmacy and then perform drug interactionscreening and produce medication warnings.

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Administrative Services and Management InformationHospitals and ambulatory care practices are supported by avariety of computer based and computer assistedadministrative systems. Most such systems are used forbilling, accounts receivable, and accounting functions.Other systems contain features for use in inventory control,payroll, and personnel administration. Many hospitals andambulatory health care systems generate managementreports as part of the accounting process, or separately forservice utilization. Commercial systems providing compu-terized billing and accounting services to ambulatory carepractices produce a variety of management reportsincluding practice analysis by source of income, expendi-ture and revenue reports, and special tabulations onrequest. Commercial groups also operate and developcomputer-based systems for personnel scheduling, patientappointments, patient registration and admission, censusprocessing, and administration of hospital departments suchas dietary, central supply, housekeeping, radiology,laboratories, and medical records.

Problem Areas

Successful application of computers in solving ambula-tory health care delivery problems is hampered by somespecial constraints not readily apparent to someone new inthe health care field. Failure of a terminal at a bank teller'swindow may cause momentary disruption and a longerwaiting time for customers, but failure of a terminal in anintensive care unit could cost a life. A physician is perhapsthe only professional who uses the majority of his workingtime in creating thousands of inter-related data bases (therecords for each patient), using the data to make decisions,recording his decisions, and recording the patient's progressso the data can be used in subsequent decisions. He carriesout his business in his office, in various examining rooms, ina hospital or rest home while making rounds, and in thehospital emergency room nights and week-ends. The doctorplainly needs data processing assistance, but the problem ofentering and retrieving data accurately and efficiently froma variety of locations and sources has not been solved.

Technology Problems Some of the most importanttechnology problems identified during the project surveyprobably require engineering solutions.

All projects surveyed expressed dissatisfaction withmagnetic disk storage reliability. Comments on the types ofdisk failures ranged from "disk controller problems" to"sporadic loss of data." The sources of failures wereexpressed as "inadequate maintenance," "design error,"and "obsolescence." All ambulatory care delivery systemsinterested in computer support for direct patient care mustuse some form of a computerized medical record as thebasic data unit. Even in the practice of a single doctor,more than a thousand active records must be available foruse. Extensive deployment of ambulatory care computerapplications will be dependent on the availability ofreliable, low-cost, direct-access memory.

In most projects, there was little evidence of study ofthe physician and computer interface. Only two projectscited use of response-time studies as part of the design-

January 1975

process. This is peculiar, because most projects expressedconcern with reliable and economic methods for inputtingand retrieving data. Particularly in ambulatory health caredelivery where contacts between patient and professionaloccur in thousands of offices and examining rooms, atechnology supplying a low-cost, reliable data interface isessential. Some projects expressed the need for aneasy-to-use, economical, portable terminal. Other projects,because of the lack of adequate terminals, are resigned tousing an intermediate for input and retrieval of data, acostly step which is sure to decrease record accuracy. Whenterminals have the convenience of a medical record folder,physicians use and acceptance of computer assistance willincrease greatly.

The most frequent complaint about the reliability ofteleprocessing systems was directed at the telephonecircuits used in inter-facility communications. Currentcommunications techniques are still too costly for extensiveuse of processor-sharing capability, especially when apractice is small or remote. Technology improvementsresulting in reduction of communication costs are aprerequisite to regional health care computing networks.

Although a number of programming languages have beendeveloped to facilitate applications system development,few projects have achieved independence from program-mers. Systems such as MUMPS (Massachusetts GeneralHospital Utility Multi-Programming System) combinelanguage interpreters, operating systems, and data manage-ment functions designed initially for use in the medicalcomputing environment. Even with use of systems such asMUMPS, experienced programmers are necessary toproduce efficient applications. More advanced software willbe necessary to achieve closer involvement of physiciansand other health care professionals in the development ofmedic-al computing systems.

Organizational and Social Problems Although equipmentand software improvements will expedite development ofcomputer applications in ambulatory care, social andorganizational problems are equally important.

Concern with protecting the privacy of patients andprofessional records will influence decisions about compu-ter sharing, regional health delivery networks, recordidentification, and communication and processor security.As increased amounts of personal medical data are stored incomputer records, there is a corresponding increase in theneed for data security measures.

Engineering solutions to hardware, software, andcommunications protection may partially resolve theprivacy problem, but considerable effort must be made toidentify and describe social and legal safeguards forprotection against breaches in privacy.

The fragmented nature of the medical care deliverysystem resists organized, systematic attempts to developgeneralizable computer applications. Gaining agreementamong practitioners about the content and format of acomputerized record is difficult in an organized deliverysystem; it is impossible in our highly individualistic nationaldelivery system. Much must be learned about medical caredecision-making and the usefulness of patient health databefore a significant degree of commonality can beexpected.

Most successful projects possess a highly qualifiedinterdisciplinary staff with strong medical and engineering

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skills. An increase in developrment projects with anappropriate blend of skills will be necessary to acceleratethe pace of computer applications development inambulatory health care.

Recommendations

Technology Low-cost, easy-to-use portable terminals,more reliable and less costly communications technology,and low-cost reliable mass memories must be developed.Computer-based systems used by smaller practices andhospitals must be more reliable and require lessmaintenance since qualified operation and maintenancepersonnel are too costly for such installations. Untilreliability improves, most smaller ambulatory care practicesand hospitals must continue to use time-shared services.This is a problem for practices remote from such services,due to the high cost of communications.

Economic Evaluation Economic evaluation of newmedical computing applications is often overlooked orincomplete. The transition of applications from develop-mental projects to operational use could be expedited bycareful economic evaluations of the new application,particularly in analysis of costs compared to high-qualitymanual system alternatives. The development communityin general has not been concerned with economic issues andis therefore often frustrated by questions of economicfeasibility. Not only must there be an improved emphasison economic justification, but there must be a corres-

Gerald A. Giebink is president of Health CareManagement Systems, Inc., a nonprofit cor-poration engaged in research and educationprojects in health care information systemtechnology since 1968. His firm is currentlyoccupied with evaluation of computer-assistedsystems for quality assurance and utilizationreview in health care. Giebink's backgroundincludes management of computer-based sys-tems development projects in the aerospace and

defense industries, and he is author and co-author of numerouspapers, monographs, and journal articles in the field of health careinformation systems.

Leonard L. Hurst is assistant director of HealthCare Management Systems, Inc. His backgroundin the aerospace and defense industries includessystems analysis and technical and administra-tive supervision. Hurst is currently participatingin a national effort to develop standards for amedical computing programming language, andis author and co-author of various papers andarticles in the field of health care informationsystems.

ponding increase in research and development of newways to measure cost and benefit. Methods must bedeveloped for applying values to intangibles encompassedby the statement "improved patient care." Some specificstandardization of terms and measures would help potentialusers make decisions about which equipment and whatsystem to choose.

Conimunication/Dissemnination of Information The lackof communication among developmental projects issurprising. Several actions might help reduce the communi-cation gap: a continuing program for review anddocumentation of current rpedical computing developmen-tal projects, an increase in symposia targeted at developersworking in similar areas of computer application,maintenance of an up-to-date compendium of government-sponsored medical computing research and development inmedical computing.

Many medical computing projects appeared to besomewhat isolated from computer system research anddevelopment currently underway in aerospace, defense,commercial processes, and social programs other thanhealth care. Although a project cannot be expected totnaintain total cognizance, translation of research findingsin studies of man/machine interfaces, computer languages,and operating systems and communications from otherareas of application to the health care field would result indirect benefits. Transfer of such knowledge can be achievedby a flow of personnel between application areas and by aconcerted effort to organize knowledge available fromother fields of application for use in medical computingresearch and development.

Charles L. Foreman, assistant director of HealthCare Management Systems, Inc., is a seniorsystems analyst and research designer. Hereceived his BS in Mathematics and MS inStatistics from the University of Arizona,Tucson. His background includes teaching atthe secondary and college levels and Director ofData Processing at the University of Denver.Foreman is also author and co-author of articlesand monographs in the health care informationsystem field.

Diana Elser is a technical assistant/writer forHealth Care Management Systems, Inc. Herbackground includes newspaper feature writing,proofreading and copy editing, and generalsecretarial experience. She received a BA inEnglish from Utah State University, Logan,Utah.

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