ࡱ> jhabcdk#` Fbjbj\.\.  >D>D&|# 4 kkkh>l"n ou"uuHwHw:|l}y{{{{{{$h HwHwz uZHwߣߣߣ Hw HwyߣyߣߣD ɸHwo %kU4ɷ&E40jLɸɸ ^~rІߣ،^~^~^~^~^~^~ ?RK RK    A History of Computing in Medicine Matthew Case Kevin Clement Genevieve Orchard Rebecca Zou December 2006 Table of Contents  TOC \o "2-7" \h \z \u  HYPERLINK \l "_Toc153190216" Table of Contents  PAGEREF _Toc153190216 \h 2  HYPERLINK \l "_Toc153190217" Introduction  PAGEREF _Toc153190217 \h 3  HYPERLINK \l "_Toc153190218" Applications of Computing in Medicine  PAGEREF _Toc153190218 \h 3  HYPERLINK \l "_Toc153190219" Figure 1 - A Timeline of Computing in Medicine  PAGEREF _Toc153190219 \h 5  HYPERLINK \l "_Toc153190220" Key to Timeline  PAGEREF _Toc153190220 \h 6  HYPERLINK \l "_Toc153190221" Electronic Medical Records  PAGEREF _Toc153190221 \h 8  HYPERLINK \l "_Toc153190222" Benefits  PAGEREF _Toc153190222 \h 8  HYPERLINK \l "_Toc153190223" History of the EMR  PAGEREF _Toc153190223 \h 10  HYPERLINK \l "_Toc153190224" Drawbacks of EMR Systems  PAGEREF _Toc153190224 \h 11  HYPERLINK \l "_Toc153190225" Clinical Decision Support Systems  PAGEREF _Toc153190225 \h 11  HYPERLINK \l "_Toc153190226" A Brief History of Significant Developments in the Field  PAGEREF _Toc153190226 \h 11  HYPERLINK \l "_Toc153190227" Patient-computer interviewing (1960)  PAGEREF _Toc153190227 \h 11  HYPERLINK \l "_Toc153190228" Expert Systems (1970)  PAGEREF _Toc153190228 \h 12  HYPERLINK \l "_Toc153190229" Real-time Clinical Decision Support (CDS) Technology (1980s)  PAGEREF _Toc153190229 \h 12  HYPERLINK \l "_Toc153190230" Widespread Introduction of PCs and Networks into Health Care Infrastructure (~1995)  PAGEREF _Toc153190230 \h 12  HYPERLINK \l "_Toc153190231" Reference Databases and Portable Access (~2000 onwards)  PAGEREF _Toc153190231 \h 13  HYPERLINK \l "_Toc153190232" Current State and Goals of CDSS  PAGEREF _Toc153190232 \h 13  HYPERLINK \l "_Toc153190233" Policy Issues in Computerized Health Care  PAGEREF _Toc153190233 \h 14  HYPERLINK \l "_Toc153190234" Demand for a Health Information Technology (HIT) Policy  PAGEREF _Toc153190234 \h 14  HYPERLINK \l "_Toc153190235" A Broken Record?  PAGEREF _Toc153190235 \h 15  HYPERLINK \l "_Toc153190236" History of Government Involvement in Medical Computing  PAGEREF _Toc153190236 \h 16  HYPERLINK \l "_Toc153190237" Unexpected Consequences of the Computerization of Health Care  PAGEREF _Toc153190237 \h 19  HYPERLINK \l "_Toc153190238" Depersonalization  PAGEREF _Toc153190238 \h 19  HYPERLINK \l "_Toc153190239" Outsourcing  PAGEREF _Toc153190239 \h 20  HYPERLINK \l "_Toc153190240" Medication Errors  PAGEREF _Toc153190240 \h 20  HYPERLINK \l "_Toc153190241" Faulty Information on the World Wide Web  PAGEREF _Toc153190241 \h 21  HYPERLINK \l "_Toc153190242" Unnecessary Procedures  PAGEREF _Toc153190242 \h 21  HYPERLINK \l "_Toc153190243" Care Expectations and Information Overload  PAGEREF _Toc153190243 \h 21  HYPERLINK \l "_Toc153190244" Centralization of Health Care  PAGEREF _Toc153190244 \h 21  HYPERLINK \l "_Toc153190245" Other Consequences  PAGEREF _Toc153190245 \h 21  HYPERLINK \l "_Toc153190246" Summary  PAGEREF _Toc153190246 \h 22  Introduction In his epic 1945 paper As We May Think, Vannevar Bush wrote of his 'Memex' idea: The physician, puzzled by a patient's reactions, strikes the trail established in studying an earlier similar case, and runs rapidly through analogous case histories, with side references to the classics for the pertinent anatomy and histology. Computers appear in todays health care industry in a wide variety of applications, and albeit not in the form of the desk-sized 'Memex', Bush's idea is indeed one of the major ones. Today, electronic medical records and their associated tools enable physicians to assimilate data, both from an individual patient history and from related case histories, and in so doing attempt to provide the best possible treatment and care. Along with this power come difficult issues, though, such as those of privacy and litigation concerns. In this paper we discuss in detail two of the major applications of computers in medicine, namely electronic medical records and clinical decision support systems. We also discuss policy issues and the history of government involvement in working to bring information technology to medicine. We end with a discussion of some unexpected and perhaps interesting consequences of the computerization of medicine. But first, we start with a broad overview of the various ways in which computers have found their way into medicine today. We also mention historical uses as well as possibilities for the future. Applications of Computing in Medicine In addition to the two clinical applications of computers in medicine mentioned in the Introduction, others include computerized physician order entry (CPOE) systems for tasks such as ordering tests and medications; advanced imaging systems; monitoring devices; robotic surgery systems and scrub nurses (a scrub nurses job is to hand instruments to a surgeon); treatment planning such as the computerized Gamma Knife; and in the pathology lab, computerized slide reading. Personal Digital Assistant (PDA) devices are widely used by physicians and nurses for tasks such as looking up drug information, reading health journals and textbooks, viewing practice guidelines, using medical calculators and email. Computer systems are also used for hospital administration, including hospital bed tracking, admissions scheduling, billing and payroll, facility scheduling and inventory control. The Internet has served medicine in a variety of ways: It has enabled the growth of telemedicine including teleradiology (which is discussed in a subsequent section) and remote surgery and patient monitoring. PUBMED is an online database of medical journal citations used extensively by physicians and researchers, but also available to the general public. A wealth of health information is available on the World Wide Web, enabling consumers to research their own symptoms. Google Health ( HYPERLINK "http://www.google.com/Top/Health/" http://www.google.com/Top/Health/), which sorts health information into categories, is one example of such a service. Online comparison-shopping for hospitals and doctors is a growing trend among consumers. The data that feeds such programs comes from medical records provided by doctors and hospitals as well as patient surveys. Online solutions like WebMD are available that allow consumers to enter and track their personal medical histories. Some companies offer websites where critically ill patients and their caregivers can post updates on their status and in so doing avoid having to repeat the same information to concerned friends and relatives. The Internet has also played a role in aiding biomedical research, for example the use of grid computing to help unravel the mysteries of genetic diseases. One of the perhaps lesser known applications of computer technology in medicine is the use of video games to hone laparoscopic surgeons dexterity and to train a new generation of these surgeons. Laparoscopic surgery requires good hand-eye coordination, and video game controllers can serve as low-cost simulators of the surgical controls. A study conducted in 2004 showed that surgeons who played video games for at least three hours per week made 37 percent fewer mistakes than those who did not. NOTEREF _Ref152917087 \f \* MERGEFORMAT 5 Historically, computers have been used for medical applications since about the 1950s. The timeline in Figure 1 and its associated key describe some of the historical uses of computers in medicine. It also includes some general computer history milestones for perspective. What sort of computer applications will we see in the future of medicine? The biggest potential role for computers is in the realm of electronic records, which, as is discussed later in this paper, have not yet seen widespread use in the U.S. Other nascent ideas include nanotechnology in medicine, for example tiny chips which can be implanted in the body to continuously measure blood sugar levels and trigger insulin release as necessary. Perhaps we will wear personal monitoring devices that continuously measure blood pressure, pulse, body fat percentage, etc. Perhaps this data will be automatically uploaded wirelessly to a person's electronic medical record, where programs analyze the data at regular intervals and send notification to the individual and their physician if something is amiss. Perhaps people will soon be scheduling doctor appointments via the Internet, much as we can make hotel reservations today. And when we visit the doctor's office, perhaps we will sign in by touching our finger to a pad. We will then sit in a special chair that will measure our vital signs and enter them into our electronic record, doing away with the need for a human technician.  Figure  SEQ Figure \* ARABIC 1 - A Timeline of Computing in Medicine Key to Timeline 1954Computerized cytoanalyzerThis cytoanalyzer was capable of examining mass cells on a slide for signs of cancer.1960The BrainsAn IBM 650 called the Brains was used to scan medical records for subtle abnormalities.1960Patient-Computer InterviewingComputerized questionnaire-based history-taking.1961Administrative and fiscal functionsIn the early 1960s, computers were used for administrative and fiscal functions in hospitals.1962Electrocardiogram analysisElectrical impulses from the heart were relayed by telephone to a central computer which created a curve and analyzed it.1963First decision support systemsA computer approach to rehabilitation is introduced. For example, the computer was used to determine the optimum time a cast should be worn following surgery.1964IBM System/360The IBM System/360 was introduced.1964DEC PDP-8Introduction of the PDP-8 minicomputer.1964MEDLARSMEDLARS was a computerized database system for indexing and retrieving medical citations at the National Library of Medicine (NLM).1965Idea of EMRThe idea of an electronic medical record was already in place in the 1960s.1966MUMPSMassachusetts General Hospital Utility Multi-Programming System (MUMPS) also called M was a programming language for the health care industry.1968IMIAInternational Medical Informatics Association (IMIA) was established in France.1970Computerized lab data processingComputers were used to perform pathology lab calculations such as determining the chemical concentrations in amniotic fluid. This allowed for faster, higher quality results.1971Computerized record processingThe IBM System/3 Model 6 minicomputer was used to process records of patient tests.1971COSTARComputer Stored Ambulatory Record (COSTAR) a successful outpatient electronic medical record system programmed in MUMPS was introduced.1971MEDLINEMEDLARS On-Line (MEDLINE) went online.1972MYCINMYCIN was an interactive expert system for infectious disease diagnosis and therapy. It was developed at the Stanford Medical School and ran on a DEC PDP-10.1972HELPHealth Evaluation through Logical Process (HELP) was developed at the LDS Hospital. NOTEREF _Ref152765552 \f \* MERGEFORMAT 181974First clinical CT scannersThe Computed Tomography (CT) scanner (for the head only) was invented by Hounsfield and Cormack in 1972. A full body scanner became available in 1976.1974Computerized Gamma KnifeIntroduction of the first computer-assisted dose planning program for Gamma Knife, a way to radiosurgically remove brain tumors. The original human-guided Gamma Knife technique was developed in 1967.1974Internist-1This computer-assisted diagnosis system was developed at the University of Pittsburgh for the general internal medicine domain.1977Medical InformaticsThe term medical informatics was defined.1978FilemanUsed at the VA Department of Medicine and Surgery1981IBM PCThe IBM PC was introduced.1983NetworkingIn the 1980s, networking was introduced to the mainstream.1984ACMIThe American College of Medical Informatics (ACMI) was established.1987HL7Health Level Seven, Inc. (HL7) was founded as a standard for clinical data exchange.1988MUMPS becomes IBM-supportedMUMPS became an IBM-supported programming language.1989World Wide WebThe World Wide Web was invented.1992Windows 3.1Windows 3.1 was released.1996Palm PilotThe Palm Pilot was introduced.1996HIPAACongress passed the Health Insurance Portability and Accountability Act.1999da Vinci Surgical SystemThis robotic surgical system was introduced by Intuitive Surgical. A prototype was developed in the late 1980s at Stanford Research Institute under contract to the U.S. Army.2000Image transmissionSome hospitals were electronically transmitting medical images such as X-rays and MRIs.2001Wide adoption of handheldsIn the early 2000s, health care workers started to use handheld devices widely to perform tasks such as accessing medical literature and electronic pharmacopoeias.2003Virtual ColonoscopyThe virtual colonoscopy uses a combination of CT scanning technology and computer graphics.2004World Community GridIBM launched this grid computing project to search for genetic markers of disease.2004Multidetector CT scannerThis new heart scanning technique could largely replace angiograms.2004Executive Order 13335President Bush created this order, titled Incentives for the Use of Health Information Technology2005PenelopeIntroduction of this robotic scrub nurse.2006Microsoft buys AzyxxiMicrosoft bought this clinical health care software that can retrieve and display various kinds of patient data. Electronic Medical Records Back in 1960, an article in the New York Times mentioned a Tulane University Medical School doctor's vision of "medical records stored on tape, or in other ways appropriate to computers, [that] might ultimately replace written records of medical patients altogether" NOTEREF _Ref153166010 \f \h 7. A 1967 article in the same publication mentioned that in the future, "every man, woman and child may have his entire medical dossier electronically recorded in a gigantic memory system in Washington"0. It went on to discuss the benefit of such a system if a person were to have a heart attack while on vacation in another city: "the attending physician could simply telephone to Washington and in seconds have his patient's full medical history before him". Today, 40 years later, we have yet to see widespread adoption of such an electronic medical record (EMR) system. In addition to the remote access benefit mentioned above, EMRs offer numerous other advantages which are discussed in the following section. Based on these benefits and the fact that the idea of electronic records has been around for decades, one would think that EMRs would be widely implemented by now. While some industrialized countries such as Britain and the Netherlands are way ahead in this arena71, the adoption rate in U.S. clinics is only around 17 percent. Benefits The main consumers of an EMR system are doctors and other clinical staff. A basic EMR system allows these professionals digital access to an electronic version of a patients medical records, the same type of data that for years has been stored on paper. So why change something that has been working for so long? Iatrogenic, or physician-induced, complications from errors such as over-prescription or drug-drug interactions are, unfortunately, common, and a big problem in todays medicine. Electronic records combined with clinical decision support systems (which are discussed in a separate section) are able to provide automatic checks to help prevent these types of mistakes and reduce the number of medical errors. Either a single national medical record database, or a network of private electronic record systems that can interoperate with each other, would offer a distinct advantage to anyone that travels. As mentioned in the opening paragraph, a person's medical records would be instantly available at any place and any time, allowing for a better quality of care. Such a network would also foster better coordination of care among different specialists. If the EMR system can also interoperate with other types of computerized clinician assistance tools, the efficiency of care coordination can be further boosted. EMR systems linked to clinical lab systems can make visits to the doctor go more smoothly when lab work is required. Without such a system in place, the doctor usually fills out a request for the lab work which the patient then carries to the lab. Once the lab work is completed, the results are delivered back to the doctor to be put in the patients paper file. This is a tedious process and can encounter problems such as misread handwriting, paperwork lost in transit, or results not being file correctly. Using an EMR system, physicians can place electronic requests for lab tests. When the results are ready, they can be sent back and stored in the patients electronic file. Some systems can notify the patient that the results are ready and may even provide a means for the patient to check results over the telephone. EMR systems allow for computer-printed prescriptions. Physicians are notorious for their bad handwriting, and their handwritten prescription slips are no exception. Consequently, pharmacists may misread drug names or doses, which in some cases can lead to adverse results. There are numerous accounts of malpractice suits as a result of misread prescriptions. Computerized systems can alleviate this issue. In addition, the paper on which prescriptions are printed can also have security features built in, helping to prevent forgery. An EMR system can be a great resource for patients that want to view their medical histories. Currently one has to request physical copies of their records, rounding them up from every clinic they have ever visited and jumping through administrative hoops. With an electronic system, a patient can have web-based access to all their medical data, allowing them to view trends in weight, condition, blood pressure, etc. This information could be accessed from any place in the world that has a computer and an Internet connection. EMR data can be backed up and stored offsite from the hospital, providing safety in the event of a natural disaster. Hurricane Katrina resulted in the loss of thousands of medical records due to flooding, not to mention the security jeopardization of private patient data. Sites that were using electronic medical records were able to recover their records from an offsite backup location. As more and more facilities begin to implement EMR systems, we will eventually get to a point where hundreds of thousands or even millions of records are stored electronically. If we can strip these records of identifiable markers, to alleviate privacy concerns, and somehow pool these resources, we could have a very large bank of mineable data. Mined data could potentially lead to a better understanding of what causes certain diseases, for example, or which treatment courses work best for a given medical profile. While the up front cost of implementing an EMR system is prohibitive, it is thought that over time that money would be recouped. The increase in efficiency, for example, means that fewer human resources are needed. In addition, the savings from reduced litigation in regard to iatrogenic errors should be substantial. EMRs can offer administrative and management benefits to an institution. For example, they can be used to track the number of procedures performed, complication rates, average time to resolution, and even physician performance. Health insurance companies can gain productivity from an EMR system as well. They can use the system for direct customer billing or to alert doctors of policy changes. Although some might argue that insurance companies should not be driving patient treatment, this is a fact of todays medical system. For example, if a new policy requires that a certain medication be prescribed as a generic, the prescribing doctor can get immediate notification of the fact when entering the prescription into the patients record. Or, perhaps a patients insurance company does not cover certain medications or treatments. This type of information would also be instantly available to the prescribing physician. Clinics can also utilize EMR systems to their advantage to settle insurance company disputes. One group of clinics in New Jersey was able to push back against certain insurance company compliance change requests by mining the data in their own EMR system to prove that they were already in compliance. Without the EMR system, the clinics would have to have done much more work to prove their position, relying primarily on insurance billings and on data from the insurance company. History of the EMR A programming language called the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) was developed in the late 1960s for use in health care systems. It did not become widespread until the 1970s, when it was used to build many clinical applications. Today, some older systems are still running software that was built using MUMPS. While MUMPS was originally used for medical records, it is now widely used (under the names M and Cache) in other places where simultaneous database access is required, for example at banks, stock exchanges and travel agencies. In 1978, Joseph (Ted) O'Neill and Marty Johnson and a host of others began work on what would eventually be called Fileman. It was built using MUMPS and was a set of generalized routines that anyone in the Veterans Affairs (VA) Department of Medicine and Surgery could use. A lot of small tools and systems were built using Fileman in the late 1970s and early 1980s. It was later adopted by the VA as its official medical program. In 1981, Mickey Singer started a software company in Florida called Personalized Programming Inc. This company was one of several companies which ultimately merged to form Medical Manager Inc. They provided proprietary medical practice software to medical practices all across the United States. This software took the market by storm and by 1997 about 24,000 clinics and 110,000 health practitioners were using the system. The Medical Manager system has had its ups and downs and today it has largely been abandoned by most of its users. Stepping in to fill its shoes are open source General Public License (GPL) solutions that allow clients to get away from the proprietary nature of the software. Today there are multiple companies competing for a piece of the EMR pie. Some reports count anywhere from 250 to 500 different companies offering EMR solutions. Some software is focused on a small portion of the EMR system, for example prescriptions or health history, while others focus on packages that cover everything from start to finish. Software giant Microsoft Corporation has also realized the potential for medical software and in July of 2006 purchased Azyxxi, an EMR solutions company whose software is currently in use at seven different hospitals in the Washington D.C. and Baltimore areas. Microsoft has created a health care software division and expects to spread their technology nationwide. It will be interesting to see what happens with a company this large throwing its hat into the arena. Drawbacks of EMR Systems Despite all the benefits of EMRs, there has been low and slow adoption of these systems. We discuss some of the reasons for this. A lot of the current EMR systems on the market do not interoperate. There is little incentive, from a clinics perspective, to interoperate with another clinics computer system. If interoperability and transferability of records makes it easier for patients to switch to another clinic, it creates a conflict of interest. A growing trend in America today is electronic privacy concerns. These concerns are especially prevalent in the realm of electronic medical records. If EMR systems interoperate so that one clinic can share information with another clinic, how do these clinics ensure that private data remains private and can only be accessed by the appropriate people? How easily can these systems be hacked? What other kinds of digital security issues do they present? These are the types of questions that concerned citizens have about EMR storage. These issues could prevent the EMR from ever becoming widely adopted in the health care industry. Computerized systems make it easy to enter new data for patients as they come into the hospital, but a medical history that contains only partial information is not that beneficial. In order to reap the full benefit of an EMR system, it pays to have complete patient histories. Getting old data into the system would require manual insertion, a laborious and costly endeavor. This daunting task could also be a factor in the rejection of an EMR system by adding to the overhead of getting the system up and running. Backing up paper records is as simple as running them through a copy machine. For the most part one is likely to be able to read a piece of paper tomorrow in the same way one reads it today. However, the same is not true for electronic content. The backup system and the format in which the data is stored may change. If the technology changes, will the backed up data still be readable in the future? These are problems that clinics and hospitals are not keen to deal with. Clinical Decision Support Systems In this section we discuss the history of clinical decision support systems (CDSS), current research, commercial focus and potentially interesting domains for future investigation. A Brief History of Significant Developments in the Field Patient-computer interviewing (1960) Perhaps one of the earliest uses of computers to support physicians was the computerized patient interviewing system. The idea stemmed from the recognition of the ad hoc way in which patient history and symptom information was gathered during doctor-patient sessions, and that oftentimes the right questions were not asked. This meant that information important for an accurate diagnosis was not collected, with obvious potential consequences. As early as 1949, the benefits of formalized questionnaire-based history-taking were recognized, and by 1960 the automation of the process using computers was being tried. This approach can yield much better results than less directed questioning for reasons such as the time involved, the volume of information, and in some cases a patients increased comfort in divulging sensitive details to a computer versus a person. However, even today such systems are not widely used in spite of proven benefits. Expert Systems (1970) The expert system is a classic example of a decision support system. In the early 1970s, research on computing in medicine was primarily focused on diagnosis assistance for clinicians. With computers able to store and process vast amounts of knowledge, the hope was that they would become perfect doctors in a box by assisting or even surpassing physicians with tasks like diagnosis. A group of talented scientists and clinical professionals formed a community focused on the application of artificial intelligence to medicine, and they conducted extensive research in this area. One of the first examples of an expert system in a medical context was MYCIN, a system developed at Stanford University. MYCIN was designed to diagnose and propose treatment for blood-borne diseases. MYCIN was implemented as an inference engine a repository of knowledge combined with a set of rules for processing that knowledge in conjunction with data that was inputted by the operator. It worked well and was able to diagnose disorders in its field with a higher degree of accuracy than non-specialized physicians. Nevertheless, MYCIN was never deployed in any working environments due to a combination of practical factors (i.e. the availability and acceptance of computers) and ethical and legal factors (i.e. who takes responsibility for the results?). Other contributors to the lack of adoption of this type of system include that they attempted to replace physicians rather than augment or monitor them, and that it had a steep learning curve. Such expert systems are also hard to develop and maintain. Extracting knowledge from experts in a useful way and then encoding it in these systems is extremely difficult. The adoption of such systems has been very limited over the years and the focus of decision support systems has gradually shifted to include a much broader spectrum of functionality including medication prescribing and clinical surveillance. These systems also found audiences in clinical laboratories, educational settings and data-rich environments like the intensive care ward. There are a significant number of highly specialized systems available,. Real-time Clinical Decision Support (CDS) Technology (1980s) Perhaps the most visible impact of technology in hospitals is hardware such as heart and brain monitoring equipment. By the 1980s these devices were beginning to gain automated features, for example automatic arrhythmia detection in electrocardiogram (ECG) machines. By the 1990s many dedicated machines were being replaced by commodity PCs with some custom hardware and software. Ever more sophisticated computerized diagnostic technology has been developed in years following, especially in the area of medical imaging, giving physicians amazing insight into a patients condition. Widespread Introduction of PCs and Networks into Health Care Infrastructure (~1995) These networked PCs were mostly used for record keeping and administrative functions. Nevertheless, they were a necessary step in the move towards clinical workflow systems and the subsequent integration of CDSS functionality. Reference Databases and Portable Access (~2000 onwards) Computer technology has made reference information easily accessible and searchable in any clinical setting. Examples of such reference information include drug databases, advisory systems, disease databases, and so on. This is perhaps the most widely accepted clinical use of information technology. Today, almost every general practitioner has a desktop and/or handheld computer, facilitating easy access to up-to-date databases of clinical information. In addition to pure reference information, there are also many pieces of utility software (such as dosage calculators) readily available for PCs and portable devices. Current State and Goals of CDSS An ideal clinical decision support system would provide doctors, staff, patients and other individuals with knowledge and person-specific information, all usefully filtered and presented at the right moment in the health care workflow in order to enhance quality, safety and efficiency. Although very successful in limited locales and organizations (for example, adoption of workflow systems incorporating CDS functionality at some institutions has been shown to reduce mortality rates by 6 percent and lower the number of dosage errors by as much as 80 percent), widespread adoption of CDSS has been very slow. As a result, relevant medical knowledge that should be brought to bear in many situations where health care decisions are made is not always available or used. This is an important contributor to the well documented problems and sub-optimal performance of the U.S. health care system. Many medical errors are largely preventable if current mainstream knowledge is fully and consistently applied to each case. In order to achieve the ideal (and realistically achievable) levels of patient safety, quality of care and economy, more consistent, systematic, and comprehensive application of available medical knowledge will be critical; that is, more extensive use of CDS systems. The American Medical Informatics Association (AMIA) cites three necessary prerequisites before the potential benefits of CDSS will be realized for all: Make the best knowledge available where and when it is needed. This consists of: Standardizing knowledge, information and records formats to make it easier for developers to access and use such information. Making this knowledge readily accessible and easy to incorporate into other systems and processes. Widespread adoption and use. Without widespread deployment of compatible systems, systems which are deployed will be somewhat limited in benefit due to their lack of access to complete patient records and limited inter-provider interaction. This requires: Removal of legal, policy and financial barriers (for example concerning access to patient records, liability, and lack of financial incentives to adopt CDSS). Improved ease of deployment and transparent integration of CDSS in clinical workflow systems. Ensuring that CDS logic does not generate false warnings, alerts or directions which can lead to clinicians either ignoring or disabling the features. (In fact, one physician we interviewed commented that he ignores every pop-up warning he receives before he even reads it. He went on to say that in our litigious society, no-one, including the software developers, wants to take responsibility for missed alerts, and in so doing the designers overcompensate by providing an endless list of warnings.) Continuous improvement of knowledge and methods. This includes: Continuously monitoring and learning from the lessons of existing deployments to get feedback about best practices. Advancing medical knowledge by processing and mining the data that becomes available in electronic medical record systems and from the use of CDS systems. Today, CDS systems are being integrated into EMR and workflow systems. Consider the following examples of the benefits of such integration in day-to-day patient care: A triage nurse gathers standard information about an incoming patient, for example blood pressure, heart rate, symptoms, etc. Rather than filling out a paper form, the nurse enters this information into a computerized workflow system. In addition to being stored in the patients records, the system looks at the new information and the patients existing records and suggests additional questions or tests to the nurse. A physician enters his diagnosis into the system and fills out some electronic prescription requests. The system may flag unusual diagnosis-treatment combinations, dosage errors and dangerous drug allergies or drug-drug interactions between proposed and existing medications. Cheaper or more effective alternative treatments may also be recommended. Trends in misdiagnosis, dosage errors, over or under use of particular treatments etc. can easily be monitored by the system, and flagged to the physician and clinic management such that corrective action can be taken (for example, corrective training and review). A patient logs into a personalized health care portal provided by their insurer which allows them to manage prescriptions and appointments and view records. The system may suggest recommended screenings or tests based on age and/or medical history. The more widespread use of CDSS, especially in conjunction with EMR, and the instalment of common standards across vendors has the potential to significantly improve many aspects of patient care: efficiency, cost savings, and of course medical outcomes potentially to a life-saving extent. Policy Issues in Computerized Health Care Demand for a Health Information Technology (HIT) Policy In light of the potential benefits of ubiquitous health information technologies, many have called for a greater role for government and public policy in promoting their development and diffusion. Only within the last several years has the issue gained political traction. In 2004, President Bush called for the development of a national health information infrastructure. This infrastructure would include interoperable EMRs for most Americans by 2014. He established (by Executive Order 13335) a national health information technology coordinator (health-IT czar) position in the Department of Health and Human Services (HHS) to oversee its development and implementation, and appointed Dr. David Brailer to the post. Bush and his former HHS secretary Tommy Thompson have spoken out on the need to computerize health care, characterizing today's system as twenty-first century medicine [held] together with nineteenth-century paperwork. The Bush administration doubled funding for the effort in fiscal year (FY) 2005 and then made further increases in FY 2006, and it enjoys broad bipartisan backing. If health information technologies have been in use for over three decades, why has there only now been a major policy push? Recent high profile reports have exposed the prevalence of preventable fatal medical errors and the potential for HIT, including electronic records, computerized physician order entry and decision support systems, to reduce errors and improve the quality of care. In 2000, the Institute of Medicine (IOM) estimated that between 44,000 to 98,000 people die in the hospital each year as a result of medical errors such as prescribing errors, misinterpretation of orders, and diagnostic errors. Many of these could be prevented through HIT. A 2001 IOM report called for HIT as part of national efforts in quality improvement in patient care and disease management. Studies have shown that efforts like the VA Veterans Health Information Systems and Technology Architecture (VistA) for HIT have resulted in a reduction in prescribing errors. HIT has a potential role in helping to contain escalating health care costs. National health care spending grew to $1.96 trillion in 2004, with government spending accounting for $888 billion (or 45 percent). The estimated cost savings from complete implementation of EMR is in the billions, and the financial costs of preventable errors have been estimated at $17 billion per year NOTEREF _Ref153156854 \h  \* MERGEFORMAT 41. A 2005 RAND Corporation study commissioned by the HIT industry put the figure at $500 billion in savings in direct costs over the next 15 years NOTEREF _Ref153156769 \h  \* MERGEFORMAT 27. Finally, there is empirical evidence of substantial labor productivity gains in other business sectors in the 1990s that have not yet been seen in health care. The convergence of these facts has brought the long ignored issue of a national health information infrastructure to the fore. A Broken Record? Commentators in medicine and computer science have lamented the slow spread of health information systems (HIS) almost since their introduction. Public policy is often cited as a critical factor. In 1974, computer scientist Anthony Wasserman commented, The development of information systems in health care has proceeded more slowly than expected ten years ago. He posed questions about privacy, information security and legal liability arising from the use of decision support systems and patient monitoring technologies. Dr. Donald Lindberg, a pathologist and medical computing expert who became Director of the National Library of Medicine (NLM) of the National Institutes of Health (NIH), remarks in the introduction to his interestingly titled 1977 book The Growth of Medical Information Systems in the United States: The United States health care system has become subject to increasing public criticism. At the same time, computing systems are ever more ubiquitous and successfully used in nonhealth fields to increase management capability and labor productivity. It is natural to wonder why health system management has not also benefited from dosing with the remedy of computer systems. It is this overriding question which makes this case of interest. Why has medicine not been able to use computer systems to solve its information processing problems? Lindbergs question remains today, as do some of the policy questions surrounding the adoption of widespread interoperable HITs that he raised. These include both standards (such as terminology, record format, content, etc.) and the issue of Medicare reimbursement of HIT-related activities NOTEREF _Ref153156914 \h  \* MERGEFORMAT 46. The following sections highlight the governments role in promoting medical computing, beginning with a brief overview of government sponsorship of research that started in the 1950s. The federal government has fed the HIT research pipeline and invested in agency systems, most notably the VAs Veterans Health Information Systems and Technology Architecture, whose recent experience has shown the value of widespread use of EMRs. While extra funding, federal coordination, and goal setting by the current administration is seen as an important policy shift even within the medical computing community, there are enduring factors that may continue to slow the adoption of HITs. At the end of this section we highlight the most important factors, namely 1) problems of collective action, 2) network externalities and standard-setting, 3) economic organization of the health care industry, and 4) concerns about privacy and security. History of Government Involvement in Medical Computing Not surprisingly, government labs were early users and innovators in medical computing. Government purchases of large mainframe computers in the 1950s enabled the development of early applications of medical computing, then called bioengineering. The first use of computers for use in health is credited to Robert Ledley, a dentist at the National Bureau of Standards, who used them in dental projects. He would go on to invent the full-body CT scan in 1974. Ledley and Lee Lusted, a NIH radiologist, published a series of articles, including an influential piece in Science in 1959 about their early work in CDSS using computers and patient information data to conduct Bayesian diagnosis and decision making. As in other areas of science and technology after World War II, the federal government became the primary funder of medical research. Medical informatics gained a foothold in 1960 as a legitimate field for basic research with the establishment of the NIH Advisory Committee on Computers in Research, first headed by Lusted NOTEREF _Ref153156914 \f \h 46. This opened up the field to extramural funding. The first academic treatments of the subject came in the mid-1960s as did the oft-repeated policy recommendations for fostering medical computer use. Several of the early advances in medical information systems were sponsored by government research. Massachusetts General Hospitals MUMPS programming language was supported by a 1966 NIH grant NOTEREF _Ref153157079 \f \h 49. The NLM also became involved as a major supporter of medical informatics. In the early 1960s they digitized the Index Medicus which would eventually become the Medline database. Beginning in the early 1970s and continuing today, the NLM has helped to build capacity in universities by funding extramural grants and training programs in medical informatics NOTEREF _Ref153157103 \f \h 47. In the late 1960s and 70s, the establishment of Medicare and Medicaid and the rising costs of health care led to a new emphasis in medical computing beyond strictly research purposes, that of systems that emphasized the ability to reduce costs and improve communication in the delivery system. In particular, the need to process vast numbers of Medicare claims for reimbursement created incentives for hospitals to develop systems for medical billing, perhaps at the expense of patient care applications NOTEREF _Ref153156914 \f \h 46. Hospital information systems (HIS) developed in this era combined patient records with financial systems for fee-for-service billing. The National Center for Health Services Research (NCHSR), which was the precursor to the Agency for the Healthcare Research and Quality (AHRQ), funded both the Technicon system, developed in 1965 with Lockheed and then commercialized, and the open source MUMPS-based COSTAR (1968). Both of these systems were successfully transferred to hundreds of other sites. In the mid 1960s NOTEREF _Ref153157199 \f \h 51, NCHSR funded systems that combined patient records and decision support, such as the LDS Hospital's HELP system and the University of Vermonts PROMIS. Many of these systems were models for systems that would be developed in the 1970s and 1980s. Early work in decision support and expert systems in medical computing also received government support during this period, notably MYCIN which was funded initially by the NIH and later by the Defense Advanced Research Projects Agency, the US Navy Office of Naval Research, and the National Science Foundation. The failure of Medicare reform and other efforts by the federal government to constrain costs lead to a rationalization of the health care system. This included critiques of the cost effectiveness of computing applications in medicine, such as overspending on CT scanning NOTEREF _Ref153157079 \f \h 49. This period marked a further shift of the use of computers in medicine away from patient care and towards cost reduction, business management, and administration NOTEREF _Ref153157079 \f \h 49. Some experts in this era, such as Kaiser-Permanente founder Sidney Garfield NOTEREF _Ref153157079 \f \h 49, emphasized the ability of computers to make medicine more effective and humane. They could make a whole new kind of medicine possible. These ideas have come full circle in todays policy debate. Rising out of this early work in medical computing, much of which was government sponsored, medical informatics established itself in the 1980s as a discipline concerned with all applications of computing to biomedicine and health. The American Informatics Association, founded in 1990, has served in a leadership role and has been active in U.S. policy NOTEREF _Ref153157103 \f \h 47. Another notable outgrowth is the development of VistA, the VA Medical Systems scalable information system that runs the largest health system in the U.S. It has over 4.2 million patients and over 1000 care sites in its network. VistA is a MUMPS-based system first introduced in 1996, but its origins date back to 1974 with the VAs predecessor, the Decentralized Hospital Computer Program (DHCP). The system is credited with demonstrated productivity and performance increases in the VA system, in addition to reduced errors. Since 1996, while health care costs per capita in the U.S. have shot up 60 percent to $6300, the VA has maintained at $5000 over the same period, ostensibly due to the introduction of the system. Under the Freedom of Information Act, the federal government has released the source code for VistA. The several available open source versions of VistA, such as WorldVistA, present low cost options for small practices. At the macro level, most of the prototyping for the National Health Information Network is being conducted in the private sector. Experts doubt whether private practices will be able to utilize the VistA system, however, at a minimum, design decisions that make such systems successful in terms of functionality, workflow support, decision-support protocols, and data definitions would be useful input into the national standard setting process. Perhaps the most fundamental importance of the VistA system is that it makes a strong v-c case for a national HIT network. Through basic research and continued and direct development of systems such as VistA, the federal government and has played an integral role in fostering the development of health informatics tools that can and have been applied in other care settings. While private sector software developers will have a critical role to play in commercializing EMR systems, ongoing barriers to interoperable EMRs remain that may require policy action. Four major sets of issues are summarized below: The Collective Action Problem. The principal strength of the U.S. health care system in promoting competition between providers, which has contributed to innovation in cutting edge treatments and diagnostics and greater consumer choice for patients, has also created a patchwork of public/private care providers, payers, and insurers. Given this competition, individual providers have little incentive to share systems or patient information across providers especially given the high fixed costs of implementing EMR systems NOTEREF _Ref153157335 \f \h  \* MERGEFORMAT 55. However, recent exemptions offered by the Center for Medicare and Medicaid Services (CMS) to the Stark anti-kickback regulation, which prevents cross-subsidization of HIT, have spurred some hospitals to begin purchasing information technology systems for their off-site doctors. The New Economy Problems: Network Externalities and Standards. Just as with the Internet, network externalities are at play in the EMR story. The value of the health information network, where different actors (hospitals, physicians, pharmacists, insurers, government, etc.) in the system can communicate directly, increases as more people join. Similarly, as in the Betamax/VHS case, private markets may not converge on universally accepted standards, terminology, record formats, record interfaces, and network exchanged platforms, which will cause fence sitting on EMRs to continue. The role of the national health information technology coordinator and standards organizations such as Health Level Seven (HL7) will be crucial; however, these issues will take years to unravel. Making Economic Sense. In the fee-for-service system, care that is unnecessary or redundant generates revenue for the provider. Additionally, doctors and hospitals would only receive a small fraction of HITs potential economic benefits. An estimated 90 percent would go to insurers and purchasers of care, including the federal government, in the form of lower premiums and enhanced worker productivity. Security and Privacy Issues and the Health Insurance Portability and Accountability Act (HIPAA). There are widespread concerns about protecting and securing patients protected health information (PHI) in a national health information network, especially one that is based on the Internet. However, the 1996 HIPAA provisions have set into motion the regulatory mechanisms for vendors and providers to supply secure private data exchange within a national EMR system. While HIPAA rules are still in flux with respect to EMR, the framework and many of the safeguards to facilitate such a system are already in place. Given the policy momentum along with the current mood in the administration and Congress, there is an impetus for the government to take action to address many of these issues and to hasten the adoption of EMR systems. If history is any indication, the complex incentives and technology and policy choices involved in creating a robust national health information infrastructure portend a steep uphill battle. Unexpected Consequences of the Computerization of Health Care While it is hard to disagree that computerizing health care is the direction we should be headed in, as we have shown there are obstacles and deterrents to the introduction of computerized health care systems. These include privacy issues, the cost of installing a new system and training the users, altering peoples habits, lack of interoperability and fear of lawsuits against hospitals that share data. There are also some less obvious consequences that bear consideration. Depersonalization The depersonalization of health care was the biggest complaint of Gale Thompson MD, an anesthesiologist at Virginia Mason Medical Center in Seattle who has been practicing since the early 1960s. He believes that computers have only gotten in the way of efficient patient care by diverting the physicians attention away from the patient. Instead of monitoring clinical signs such as pupils and skin color, physicians now concentrate on a computer monitor with blings and bleeps and charts and graphs. He also stated that todays providers have lost the art of clinical assessment due to the advent of computerized monitoring. Steven Angelo, a physician in Connecticut, echoes these sentiments in an editorial he wrote in the Journal of the American Medical Association about the day when his hospitals computer system crashed. At first, the physicians were at a loss as to how to assess a patients condition. Then, they slowly started migrating to their patients bedsides to monitor them directly, evidently a practice that is no longer a natural reflex for some physicians. Angelo states of the period when the computers were down: for a brief moment, I saw what true patient care could be like, without technologys oftentimes distracting presence. That is not the only way in which medical care has been depersonalized by computers. Today it is common for doctors to enter notes into a computer as the patient describes his symptoms. In some examination rooms, the computer is even positioned in such a way that the doctor has his back to the patient as he types. Not only is this type of interaction more impersonal, it has also been reported that some patients are less likely to give a full and accurate description of what they are feeling in such an objectified environment. Electronic communications such as email and instant messaging have reduced face-to-face interactions between people in the world in general. In his blog, author Steven Johnson states: weve embraced technologies that help us block out the people we share physical space with. The hospital setting is no different. Gale Thompson stated that medicine used to be about people working together to take care of patients. Today, instead of impromptu meetings in the hallway to discuss a patients care, for example, doctors and nurses often exchange notes and place orders via email and computerized order entry systems. Perhaps the situation is not as dire as it may at first seem, however. In at least one hospital, the Miami Childrens Hospital, the introduction of an electronic record system and the use of handheld devices has helped to re-personalize the doctor-patient relationship. Doctors and nurses there are using camera attachments on their handheld devices to take digital photographs of their young patients, which then get sent up to the patients chart; now there is a face to associate with each record. According to the article, The images have restored a little of the humanity that the factory-inspired paper records diminished. Outsourcing The growth of the Internet and the availability of high speed network access have enabled medical images to be sent halfway around the world in a matter of seconds. This means that radiology work such as the analysis of X-rays, M.R.I.s and CT scans can be sent to places like India, where radiologists make far less money and thus cost less. This trend of teleradiology, which started in about 2003, is appealing not only for the cost reduction, but also because when an emergency case arises at midnight in America, it is daytime in India. The interpreted results can be received back by the originating hospital in less than 30 minutes in some cases. Before computer networks made this possible, a groggy radiologist might have been woken from her sleep to analyze the image, or else the scan and its interpretation would have had to wait until morning. Other forms of telemedicine are appearing as well, such as surgeons operating robotic surgery machines from a remote location. While in some cases such a choice might be made in order to have the expertise of a specialist operate without the patient having to travel a great distance, in other cases it might just be a matter of cost savings. The outsourcing of medicine has caused some radiologists to worry about job security, and an adviser to President Bush suggested that fewer medical students would specialize in radiology. NOTEREF _Ref152831535 \f \* MERGEFORMAT 63 There has also been concern about the quality of patient care given that the overseas radiologists may not have the same qualifications as those in the U.S. Medication Errors While electronic medical records and computerized order entry systems are touted for their ability to reduce the occurrence of medical errors, they are not foolproof. Daniel Warren MD, an anesthesiologist at Virginia Mason Medical Center in Seattle, commented that "there is a problem with relying on computers to reduce errors in the sense that computers still rely on human input. And the human input is the continued source of error, even in a "perfect" computer system". In addition, computerized systems may also introduce new opportunities for doctors and nurses to make errors. One study showed that a computer system could actually increase the risk of medication errors due to factors such as having to scroll through 20 screens of information to find all of a patients medications. Another study showed that a computer for physicians failed to warn of many adverse drug effects, an advertised feature of information technology pharmacy systems that some doctors and nurses may be depending on. In addition, computerized systems can make it easy to drag and drop a medication onto the wrong chart, or to confuse the charts of two people with very similar names. In the end, it has not been shown that these risk factors outweigh the benefits of the electronic systems, and it is only through iterative development that these systems can improve. As Dr. Herbert Pardes put it in a letter to the editor of the New York Times, [medicine] also unfortunately experiences mistakes on the way to innovation. When we identify the mistakes and push to correct them, then advances occur. Faulty Information on the World Wide Web A 2002 article stated that more than 50 million adults in the U.S. use the World Wide Web as a source of medical information. A well-informed patient is better equipped to maintain good health and to recognize serious problems when they occur. However, much of the health-related content available on the Internet is inaccurate and even potentially life-threatening. This can mean, for example, that a person could make a self-diagnosis based on faulty information and decide not to visit the doctor. In some cases, misleading numbers inaccurately communicate the risk of a disease. NOTEREF _Ref152839015 \f \* MERGEFORMAT 68 The solution to this problem is to implement quality standards for publicized health information. Unnecessary Procedures Its very, very, very hard to control a technology. These are the words of Dr. Hlatky of Stanford University, referring to the overuse of multidetector CT scans of the heart. While this scanning technique, developed in 2004, takes only seconds, produces detailed images of the heart and arteries, and can be used in place of painful angiograms, its very ease of application has led to much debate in the medical community. It is technologies like this that can cause doctors to apply them to people who do not need them, for example scanning people who do not need to be scanned. Sometimes these unnecessary scans uncover "problems" that do not need to be fixed, leading to undue worry for the patient, or worse yet, unnecessary procedures. Every medical procedure carries risk and if there is no demonstrated benefit, that risk cannot be justified. Care Expectations and Information Overload Electronic access to years of case histories and patient data can put everything a physician needs to know at his fingertips as he works through a case. One of our interviewees, Dr. Daniel Warren, reported that while it is beneficial to have all that data, patients expect their care to be based on all of it. In reality that can be an insurmountable task given that the physician would need to weed through all the information and pull out only that which is applicable to his specific case. Centralization of Health Care The development of technically advanced medical instruments for diagnosis and treatment has centralized health care by creating a wider gap between wealthy urban medical centers that can afford the machines and less wealthy rural clinics that cannot. This means that some patients may now have to travel greater distances for a procedure than they did in the past. Other Consequences There are various other less serious but nevertheless interesting consequences of the continuing computerization of medicine. In the emergency department of a New York hospital, doctors pointed out that the arrival of their computer system had brought some peace and quiet to the place. Whereas before the department was positively cacophonous with announcements, now they hardly use the intercom. In the same department, a system called LastWord that tracks patients in emergency care makes it easy to see how many patients each nurse is caring for. This feature has led to some disgruntlement and complaints from nurses who believe that the workload distribution is unfair.70 Summary Computers have been used in medicine since about the 1950s. We showed a timeline of historical events in computerized medicine as well as the broad spectrum of medical applications where computers are used today. We discussed two of these applications, electronic records and decision support systems, in detail, listing their advantages and disadvantages. There are many incentives for clinics and hospitals to computerize various processes and techniques: to increase quality, reduce errors, reduce costs, provide greater accountability, and increase efficiency. However, the associated policy issues are enormous and government will have to step in with funding and other measures if medicine is to move convincingly into the computer age. We ended with a discussion of some of the hidden consequences of computerized health care systems.     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