Medicalinformationsystems capture thedecisions and actions ofhealth care.providers.Such systems will soonsee widespread use indirect patient care.

IformationSystemsfor Patient CareGuest Editors' Introduction

Thelma EstrinRobert C. UzgalisUniversity of California, Los Angeles

This year we will spend over two billion dol-lars-nine percent of our GNP-on medical care. Sky-rocketing national health costs, increased complexityof medical care, declining productivity in hospitals, re-quirements of third-party payment systems, anddisenchantment with health care providers havecombined to create crisis conditions for our healtlhcare system. Our national commitment of a decadeago, to improve the quality and accessibility of carefor alL has been sidetracked by the overriding need tocontain costs.While computer technology offers a unique

resource for containing. costs and improving thequality and availability of care, many government of-ficials, health research planners, concerned citizens,and even computer professionals claim that medicalcomputing has increased costs while offering insuffi-cient proof of improved health care. They are skep-tical of the positive contributions informationtechnology can make to cost containment and citepoor performances by computer designers over thelast decade, who overestimated the power of thetechnology and underestimated the complexity ofhealth care systems.Many early advocates of health care computing did

not understand that successful technology transferdepends upon social, political, and economic forces aswell as purely technical ones. In this decade ourunderstanding of both the technology transfer pro-cess and of the technology appropriate for medicinehas matured. It is in the spirit of this more matureview that we seek to improve our comprehension ofthe problems posed by the application of computers

to medicine and to become knowledgeable aboutstate-of-the-art medical information systems.The computer plays a significant role in medical

research and supports a growing number of complexbusiness functions, but applications to direct patientcare are rudimentary. Yet clinical medicine is in-herently an information processing activity-theclinician is a decision maker who depends on thequality of the data stored in the medical record. Themedical record maintains the continuity of healthcare for the patient; it acts as a source for guidance.However, the structure of the medical record has notsignificantly changed since the days of the countrydoctor. Frequently the record has the character of a"scrap book," and thus is not well-suited to com-prehensive care. Figure 1, a page from an actualrecord, illustrates this point.As the figure suggests, capture of health care data

is fragmented, incomplete, inaccurate, and poorly or-ganized for long-term care. The communication of in-formation among all providers can therefore beunreliable, disorganized, and inadequate. The recordlacks a structure for benefiting from, or contributingto, the collective experience of large numbers ofhealth care providers. The introduction of theProblem-Oriented Medical Record in the 60's provid-ed a logical organization for the medical record.' Thisformat is now taught in a majority of medical schoolsand as a result fragmented records are becoming lesscommon.Medical information systems organize data nor-

mally recorded in the medical record and make itavailable for

0018-9162/79/1100-0004$00.75 ©D 1979 IEEE COMPUTER4

Fgpatient care,administration and accounting,

t medical service monitoring and evaluation,r epidemiological and clinical research, and* resource allocation.

Figure 2 illustrates a computer-based medical infor-mation system and the relationships among the pa-tient input data on which the medical record is based,the health care output functions which the medicalrecord supports, and the users who enter and retrievedata and medical information. No existing medical in-formation system serves all the functions depicted,but several of the systems described in this issue areamong the most comprehensive.In 1977, the Office of Technology Assessment

issued a report, Policy Implications ofMedical Infor-mation SystemS.2 The report includes a descriptionof three different medical systems, chosen because"they represent different technical and conceptualapproaches to handling information and are con-sidered exemplary by professionals knowledgeable inthe computer and medical fields." These systems areCOSTAR-the Computer Stored AmbulatoryRecord System, PROMIS-the Problem-OrientedMedical Information System, and TMIS-theTechnicon Medical Information System. In opera-tion since the early part of the decade, these systemshave been continually improved; their implementersdiscuss the current status of each in this issue. CO-STAR is designed for ambulatory care; PROMIS is adevelopmental project that guides medical care;TMIS is aimed at the acute-care hospital. Completingthe issue are discussions of two systems used bymedical specialists treating complex diseases-ARAMIS, the American Rheumatism AssociationMedical Information System, and OCIS, the On-cology Information System.The first article, "A Medical Information System

and Data Language for Ambulatory Practices," byBeaman, Justice, and Barnett, discusses COSTAR.Developed by the Massachusetts General Hospital'sLaboratory of Computer Science in collaborationwith the Harvard Community Health Plan, thissystem has been in daily use for a decade. It hasstrong support from the clinical and administrativestaff at the Health Plan, a health maintenanceorganization with 50,000 members. The laboratoryhas developed a significantly revised and expandedversion, COSTAR 5, which is portable to other sites.The medical query language described in this articlewill be of particular interest to computer profes-sionals.PROMIS was developed at the University of Ver-

mont to computerize the problem-oriented medicalrecord. It is more than a medical information system,for it guides the process of clinical care and also at-tacks the problem of provider dependence on humanmemory. Walton, Holland, and Wolf, in "MedicalGuidance and PROMIS," describe the system'smethodology for capturing medical knowledge. Theypresent PROMIS's structured stepwise approach todecision making, also applicable to knowledge-baseddisciplines outside the medical field.

"The MATRIX Data Base Management System,"by Sneider, Boyce, and Tapella, discusses the latestimplementation of Technicon Corporation's medicalinformation system. MATRIX represents an evolu-tion of that firm's TMIS system, and is the only sys-tem in this issue for which the private sector hasborne the cost of development. El Camino Hospital ofMountain View, California, was the development andimplementation site for this system, which is com-mercially available and used in other hospitals.ARAMIS, developed at Stanford University, in-

troduces the time-oriented patient record. ARAMISis not used for daily patient care, but makes availablea data bank of collected clinical experience to aid deci-sion making in the management of chronic disease.The article by McShane, Harlow, Kraines, and Fries,"TOD: A Software System for the ARAMIS DataBank," includes a discussion of multiple logisticregression, a methodology used to identify key prog-nostic and diagnostic variables.Blum and Lenhard, in "An Oncology Clinical Infor-

mation System," deal with Johns Hopkins OncologyCenter's OCIS. Though simplest from a computerscience perspective, this system is an important toolfor physicians treating a most complex medical prob-

From Your Health Care and How to Manage It, by L. L. Weed, courtesy ofEssex Publishing Co.

Figure 1. The paper-medical record.

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lem, cancer. OCIS helps the oncology health careteam cope with masses of clinical data by producingdaily care plans for each patient as well as plots andtabulations to assist in monitoring the effects ofdrugtherapies.

Health care computing is still in its infancy andthe medical information systems described here areamong the few successfully implemented compre-hensive systems. As more systems are designed itwill become increasingly important to develop stan-dards and measures by which to assess their perform-ance. The design-of new systems would benefit frombasic research in the structure of medical informa-tion, the behavior of users and decision makers, andthe development and use of simulation models to

Figure 2. The computerized medical information system,illustrating the relationship between the patient data onwhich the medical record is based (left side of figure), thehealth care functions the medical record supports (rightside), and the users who enter patient data and retrievemedical information (top). The data entered in the medicalrecord includes medical history (i.e., the patient's symp-toms and signs as determined in the physical examina-tion), x-ray and laboratory reports, and physiological

understand the flow of medical information. In addi-tion, we must train a cadre of health care computerprofessionals to provide leadership for the field andto develop computer literacy among health care pro-viders.

Critics of medical information systems point toproblems of confidentiality and depersonalization.They ignore the ease with which the security of thetraditional paper medical record can be compro-mised. They also ignore the tremendous burden thatthe medical information explosion places on thehuman memory. Medical information systems pro-vide logical organization of the medical record,reduce dependence on human memory, improve coor-dination among users of medical information, andmake patient information available for clinical

measurements, particularly important in critical caresituations. The physician's orders set in motion proced-ures, therapies, and medications, which are recorded. Atpresent it is not common for the patient to have access tohis medical record, although several automated self-administered medical history systems have been verysuccessful.3 Future medical practice will undoubtedly in-clude the patient as an active participant in the healthcare process.

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research, epidemiological studies, medical audit, andresource planning. With this better management ofthe medical effort, the patient will see improved careand cost containment. U

References

1. L. L. Weed, Your Health Care and How to Manage It,Essex Publishing Co., 1978. (Distributed by PROMISLaboratory, MCHV-MFU, Adams Residence, Bur-lington, VT 05401.)

Thelma Estrin is an adjunct professorof computer science and anatomy at theUniversity of California, Los Angeles,where for the past ten years she hasbeen director of the Data ProcessingLaboratory for the UCLA Brain Re-search Institute. In 1977 she waselected to Fellow Grade of the IEEE for

_wi=contributions to the design and applica-tion of computer systems for neuro-

physiological and brain research. A past president of theIEEE Engineering in Medicine and Biology Society, shecurrently serves on the Board of Directors of the IEEE andof the Association for the Advancement of Medical In-strumentation, and is a member of the Board of Trustees ofthe Aerospace Corporation. She is vice-chairman of theIEEE Publications Board and is a member of the IEEEComputer Society Publications Committee.Estrin received her PhD in electrical engineering from

the University of Wisconsin.

2. Congress of the United States, Office of TechnologyAssessment, Policy Implications ofMedical Informa-tion Systems. (Available from Government PrintingOffice, Washington, DC 20401; Stock No. 052-003-00496-8.)

3. J. H. Greist, et al., "Computer Interviewing: BeyondData Collection," Proc. SecondAnnualSymposium onComputer Application in Medical Care, Washington,DC, Nov. 5-9,1978, pp. 227-230. (Available from IEEEComputer Society, 5855 Naples Plaza, Suite 301, LongBeach, CA 90803; Catalog No. 198.)

Robert C. Uzgalis is an assistant pro-fessor of computer science at the Uni-versity of California, Los Angeles, andwas formerly on the staff of the UCLABrain Research Institute and theUCLA Health Sciences ComputingFacility. His interests include graphics,operating systems, computer lan-,guages, and computer language design.VHe has served as a consultant to numer-

ous firms including Macro Data, Inc., the Los AngelesUnified School District, Environment Dynamics, Inc., D.A. Wismer and Associates, Zenith, Information Systems,Systems Development Corporation, and Bell Laboratories.Uzgalis is a member of the IFIP Working Group 2.1, and

a past-chairman of the WG2.1 standing committee on Algol68 support.

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