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i ti3 iO(, ~ 0~
[COMMITTEE PRINT]
P~UTGERS LAW SCPiUUL LJ~KA~
cAMDEN,~, N. J. 08102
GOVERNMENT ~CUMEN~
COMPUTERS IN HEALTH CARE
REPORT
PREFAFED FOR TEE
SUBCOMMITTEE ON
SCIENCE, RESEARCH, AND TECHNOLOGY
OF THE
COMMITTEE ON
SCIENCE AND TECHNOLOGY
U.S. HOUSE OF REPRESENTATIVES
NINETY-SIXTH CONGRESS
FIRST SESSION
Serial V
AUGUST 1979
Printed for the use of the Committee on Science and Technology
U.S. GOVERNMENT PRINTING OFFICE
48-086 WASHINGTON 1979
S ; 2. : ~ v
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COMMITTEE ON SCIENCE AND TECHNOLOGY
BOBERT A, ROE, New Jersey
~MIKE McCORMACK, Washington
OEORGE B. BROWN, Ja., California
JAMES H. SCHEUER, New York
RICHARD L. OTTINGER, New York
TOM HAREIN, Iowa
JIM LLOYD, California
JEROME A. AMBRO, New York
MARILYN I~LOYD BOUQUARD, Tennessee
JAMES J. BLANCHARD, Michigan
DOUG WAtJGREN, Pennsylvania
RONNIE G. FLIPPO, Alabama
DAN GLICKMAN, Kansas
ALBERT GORE, JR., Tennessee
WES WATKINS, Oklahoma
ROBERT A. YOUNG, Missouri
RICHARD C. WHITE, Texas
HAROLD L. VOLKMER, Missouri
DONALD J. PEASE, Ohio
HOWARD ~WOLPE, Michigan
NICHOLAS MAVROULES, Massachusetts
BILL NELSON, Florida
BERYL, ANTHONY, Jn~, Arkansas
STANLEY N. LUNDINE, New York
ALLEN E. ERTEL, Pennsylvania
XENT HANCE, Texas
JAMES H. $CHEUER, New York
DONALD J. PEASE, Ohio
TOM HARIUN, Iowa
ALLEN E. ERTEL, Pennsylvania
KENT HANCE, Texas
WES WATKINS, Oklahoma
JOHN W. WYDLER, New York
LARRY WINN, JR., Kansas
BARRY M. GOLDWATER, JR~, California
HAMILTON FISH, Ja,, New York
MANUEL LUJAN, JR., New Mexico
HAROLD C. HOLLENBECK, New Jersey
ROBERT K. DORNAN, Cal~fotnia
ROBERT S. WALKER, Pennsylvania
EDWIN B. FORSYTHE, New Jersey
KEN KRAMER, Colorado
WILLIAM CARNEY, New York
ROBERT DAVIS, Michigan
TOBY ROTH, Wisconsin
DONALD LAWRENCE RITTE R, Pennsylvani~
BILL ROYER, California
GEORGE E. BROWN, Chairman
HAROLD C. HOLLENBECK, New Jersey
ROBERT W. DAVIS, Michigan
DONALD LAWRENCE RITTER, Pennsylvania
(H)
DON FUQUA, Florida, Chairman
HARoLD A. GOULD, Executive Director
PISILIP B. YRAGER, General Counsel
REGINA A. DAVIS, Chief Clerk
PAUL A. VANDER MYDE, Minority Staff Director
SUBCOMMITTEE ON SCIENCE, RESEARCH AND TECHNOLOGY
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LETTER OF TRANSMITTAL
HOUSE OF REPRESENTATIVES,
COMMITTEE ON SCIENCE AND TECHNOLOGY,
Washington, D.C., December 19, 1978.
Hon. DON A. FIJQUA,
Chairman, Committee on Science and Technology,
U.S. House of Representatives,
Washington, D.C.
DEAR MR. CHAIRMAN: I Submit herewith the report, Computers
in Health Care. It is based on information collected during the 95th
Congress by the Subcommittee on Domestic and International
Scientific Planning, Analysis and Cooperation, chaired at that time
by James H. Scheuer, of New York.
The report contains an analysis of hearings held in May 1978,
and of information gathered by site visits, interviews and study o'
the available literature.
The report noted that, of the large number of conceivable applica-
tions for computers in health care, a select few show promise of con-
siderable public benefit. These few are ones that process medical,
rather than merely administrative information, and that can assist
in improving the control or prevention of disease. We believe the
Nation could save a great deal of money now wasted in medical prac-
tices of uncertain value and in diseases that we can learn to prevent~
Computers are the natural tools for collecting and processing the data
needed for such purposes.
Regrettably, it appears that we may miss some of the opportunity to
reduce our health problems because society may fail to assure the
development and use of the most promising information processing
tools. We must recognize that if the Government does not systema-
tically encourage computer applications promising the most beneficial
public impact, private incentives may lead this technology in a dif-
ferent direction.
The report discusses the possibility of satisfying both public aspira-
tions and individual hospital technical and financial needs. It concludes
with recommendations for a Government policy toward medical,
rather than purely business administration, applications for com-
puters in health care, and outlines the logic for selecting and implement~
ing a practical development strategy.
I commend these thoughts to your attention, to the attention of
the members of the Committee on Science and Technology, and to the
Members of the House.
Respectfully submitted,
GEORGE E. BROWN, Jr., Chairman,
Subcommittee on Science, Research and Technology.
(111)
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CONTENTS
Page
Letter of transmission - III
Special oversight I
Findings ---- 3
Recommendations 7
Origin and purpose of the investigation 9
The witnesses 11
Summary and analysis of the hearings:
Origin of public interest in the subject. Problems and prospects for
information technology 13
Overview of computer applications in health care - - 14
Hospital information systems 16
PROMIS (problem oriented medical information system) 19
National program and policy considerations 21
HEW plans for technology management~_._ 27
Needs, opportunities, and prospects for management of computer
affairs affecting health care 28
(V)
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SPECIAL OVERSIGHT
Research and development is conducted throughout the Federal
Government. Most agencies and departments support research and
development to further advance those fields of science and tech-
nology which are related to their mission.
In the House of Representatives these research and development
activities are reviewed individually by a number of standing com-
mittees having jurisdiction over the various programs, agencies, and
departments. Beginning with the 94th Congress, the rules of the
House provide that a continuing review of the entire Federal research
~tnd development effort be done. For this purpose the Committee on
Science and Technology is charged with the function of special over-
sight in this area. Rule X, paragraph 3(f) provides that "The Com-
mittee on Science and Technology shall have the function of reviewing
and studying, on a continuing basis, all laws, programs, and Govern-
ment activities dealing with or involving nonmilitary research and
development." This special oversight function is to be performed in
addition to the legislative and direct oversight function of the standing
committees.
The review and the recommendations included in this report are
made pursuant to this special oversight provision of the House rules.
(1)
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FINDINGS
1. Computer applications in health care vary greatly in respects that
should affect Government interest in them. They range over the entire
span of health care, from purely business and administrative functions,
to the direct implementation, management, and recording of patient
care. Over this range, there is much variation in their potential to
improve the cost, quality or accessibility of health care.
2. Findings in regard to computers in health care resemble, in
several important respects, what was earlier observed in regard to
computers in education;' there are general analogies between the two
fields of application:
(a) In both fields, the principal direction of computer applica.
tions has been in administration, rather than in the substance, of
health care or education per se.
(b) The greater impact potential is in applications dealing
directly with the substance of teaching or the substance of health
care. It is substantive, rather than administrative, applications
that are the more likely to cause significant improvement changes
in the field.
(c) Like the rewards to be gained, the difficulties encountered
are also greatest in the substantive applications of computers.
(d) Barriers to substantive applications in health care, just
as in education, include problems of professional acceptance
and economic feasibility. Professional resistance is enhanced by
strangeness and the degree to which computers cause a change in
methods.
Financial feasibility is hampered by "economic externalities".
That is, the principal financial rewards would return to patients
or students and society as a whole, rather than to the institutions
that adopt computerization. A greater barrier is the poor treatment
of capitalization in the hospital industry. Cost reimbursement
does not favor slow pay-off investments. Hence many "invest~~
ments" are made with donations without regard for efficiency.
3. Several characteristics of hospitals provide practical incentives
for computerizing information. It is estimated that 25 to 35 percent of
hospital operating costs are presently attributable to information
processing. However, the present manual methods are primitive,
inefficient and, to an unfortunate degree, faulty. There are many
delays, errors, and omissions, and the information collection, storage
and retrieval methods provide little opportunity to analyze `hospital
operation for more efficient management.
1 "Computers and the Learning Society." Hearings before the Subcommittee on Domestic and Inter-
national Scientific Planning, Analysis and Cooperation of the Committee on Science and Technology. 95th
Cong., 1st sess., Oct. 4, 5, 12, 13, 18 and 27 1977, (No. 47). See also, "Computers and the Learning Society,"
report: Committee Print, Serial 31. U.S. óovernment Printing Office (1978).
(3)
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4
4. Business administration and management applications for comrn
puter systems in health care services can contribute to efficiencies
that may or may not be in the public interest. Some applications
can increase the cash flow or the total charges billed by the institu-
tion but these do not necessarily benefit patients or taxpayers. The
benefit value to the public of any changes in cost, or quantity of
service, or volume of patients, is dependent on whether savings are
passed on, the total national health care bill is decreased, more people
who need care receive it, or the efficacy or safety of care is improved.
These public benefits become more probable as computer applications
move more toward clinical care, its management, and the recording
of data on public health and treatment follow-up.
There is, however, a great deal of valuable epidemiological and
treatment information embedded in "administrative" data. Informa-
tion on disease occurrence and care rendered, useful in tracking the
cause and spread of disease, and in evaluating exposure risks and treat-
ment efficacy, can be extracted from administrative data if systems
are designed with this purpose in mind.
5. Better means for collecting and analyzing data on medical
treatments and their outcomes could be a powerful aid toward im-~
proving the cost effectiveness of health care. Billions of health care
dollars are spent on treatments whose effects are poorly known. Some
of this expenditure is wasted on methods whose efficacy or safety is
ultimately repudiated by accumulating evidence. Presently, the col-
lection of evidence is cumbersome, spotty, and characterized by the
inefficiency of manual methods. Present medical information systems
used in day to day hospital care do not help much in the evaluation
of medical practice, but can be improved in that regard. Special
systems for collecting and comparing and evaluating data may be
needed. There is danger we may miss opportunities to improve cost-
effectiveness through neglecting the best applications of computers in
medicine.
6. Only a fraction of the largest and most significant benefits to be
derived from applications affecting cost and quality of patient care
can be captured by hospitals. Cash savings achieved by improving the
cost-effectiveness of health care benefit patients and taxpayers more
than the institutions whose computer investments contribute to the
improvement.
Contributions to epidemiology, environmental health, and disease
prevention would have great public, but no private, financial reward.
Even local improvements in ordering and monitoring of patient care
do not tend to produce cash benefits to the hospital or clinic for use
m financing equipment or systems.
Since investment initiatives depend upon clear opportunities for
gaining a financial return, it is desirable to identify and promote
for computer applications financing options that are satisfactory to
institutions as well as the Nation.
7. There is evidence that computer systems can be designed and used
in such ways that they simultaneously:
(a) Provide an adequate financial return to the investor;
(b) Do not place additional financial burdens on patients or
taxpayers; and
(c) Perform data functions that can improve the cost-effective-
ness of health care.
Such evidence needs vigorous investigation and qualification.
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5
8. Medical information systems capable of saving money in the
operation of a hospital do not do so automatically. Unless a conscious
program is followed to write fewer paychecks or buy fewer supplies
or services, potential cash savings will not be realized by the hospital.
Nonfinancial benefits may also, to some extent, require a "benefit
realization program." Indeed, some observers suggest that more than
a few of the benefits achieved with installation of a computerized
information system are simply the result of management changes
stimulated by the planning for a system.
9. There is apparent need for better, more credible, and more ac-
cessible buyer information on health care computer systems. Managers
of clinics and hospitals find it difficult to determine what technology
and s~tstem design is available, what it can and cannot do, and what the
financial realities are. There is also apparent need for a new kind of
health care professional, able to advise, plan and manage the purchase,
installation, and integration of computer systems in health care
institutions.
10. Government efforts to develop, evaluate, or transfer computer
technology in health care are fragmented and uncoordinated. They
are not integrated or guided by any clear Federal overview, compre-
hensive strategy, or action plan. Many Federal agencies engage in or
support (extramural support is relatively light, and scattered) pro-
grams in this field, but the selection criteria they apply are not readily
apparent. Their programs are independently conceived and executed.
But the limitations or speciality of any one agency's mission requires
coordination with other agencies if plans or programs are to have
balance and wholeness with respect to long term national or societal
priorities.
11. The development and evaluation of computer applications in
health services by the National Center for Health Services Research
has been greatly constrained by austere funding, limitations in
authority, and shifts in that agency's focus of responsibility. The
agency has needed most of its remaining computer budget for main-
taining a selected portion of its established commitments, leaving
little, if any, for new ventures. In addition to budget cuts which have
restrained progress, the removal of explicit authority to support
development activities has left a serious gap in the ]ine of progress.
Current budgeting has been increased, but development authority
has not been specifically restored.
12. The lack of an overall policy on computers in health care, even
within DHEW, is consistent with a general lack of technology over-
sight and coordinating management in that Department. A DHEW
study cited by the Assistant Secretary for Health reported that the
Department had no comprehensive strategy for linking systematically
the life stages of technology development, evaluation, transfer, diffu-
sion, utilization, and phase-out. Agencies of DREW generally decide
independently their technology activities. One step taken to improve
linkage of agency programs was the creation of an Office of Health
Technology, under the Assistant Secretary for Health, to oversee
evaluation of technologies and to stimulate and coordinate appropriate
actions. This office was specifically required by subsequent legislation,
and re-titled as the National Center for Health Care Technology
(Public Law 95-623). Much of its attention will be directed toward
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discouraging; ineffective, unsafe, or unnecessarily costly medical treat~
ment practices. Its future role in stimulating a Department-wide, or
Government-wide, strategy for guiding computer applications in
health care, or in undertaking positive management initiatives, cannot
yet be determined.
13. A major contribution to the utility of computer systems in
processing clinical information could be made by improving the ability
of machines to recognize and logically process natural language words
and phrases. There are serious difficulties in adapting computers to
handle information expressed in the customary structure of medical
language. Often, many more details must be entered into a machine
than would be needed for the information to be "human readable."
Such requirements contribute to dissatisfaction of users, especially
doctors. They also reflect basic shortcomings in both program logic
and machine organization. Advance in either will improve the apparent
"intelligence" of the machine system, and will also improve physician
acceptance.
14. Computers appear to offer the best hope for counteracting the
fragmentation of treatment and records in the care of individual
patients. Medical specialization and the organization of clinics and
hospitals require the participation of different doctors and depart-
ments, in tl~ie treatment ~of a single patient. Episodes may be distrib-.
uted over the lifetime of the patient. The unitary nature of reactions
of the human body to sickness and to treatments, and the importance
and relevance of continuity in medical history records, enhances the
value of unifying and coordinating present and historic information on
each patient. Even small improvements would be desirable.
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RECOMMENDATIONS
1. The Assistant Secretary for Health should assign in hi~ immediate
Office, or within the administrative structure embracing the National
Centers for Health Care Technology and Health Services Research,
responsibility to conduct general oversight, coordination, and p]an-
ning for managing and transferring the successive stages of health
technology being supported by DHEW. There should be one place
within DHEW from which its technology support programs can be
overseen in the broadest context with respect to each other and to
overall national priorities. A secondary center is needed within the rel..
atively isolated National Institutes of Health.
2. The National Center for H~lth Care Technology (formerly
Office of Health Technology) should be given a clear administrative
mandate by the Secretary of Health, Education and Welfare, or by
the Assistant Secretary for Health, to undertake positive manage-
ment initatives for the selective promotion of desirable technologies
or applications. Such initiatives should complement the more negative
watchdog or early warning role that is now clearly expected of this
Center. It is recommended that carefully selected aspects of computing
technology be considered for promotion.
3. The National Center for Health Services Research and the Center
for Health Care Technology should cooperate to initiate development
of a national policy to be perfected and implemented by Federal
agencies, including NIH, active in the development, evaluation, and
use of computer technology in health care.
4. It is recommended that a Gqvernment-wide policy or strategy
should include the following considerations:
(a) Some computer applications have extraordinary potential
for public benefit; others are of little public significance. There-
fore, some are more appropriate than others for Federal attention.
(See findings 4, 5, 6) Government management and oversight
functions should include the identification of criteria for selecting
applications for attention and should apply these criteria to
Federal planning.
(b) Computer applications receiving Federal support must be
compatible with economic realities. Somebody must pay for them.
Who? How? There is evidence that "socially~good" systems can
be made locally self-supporting without adding to anybody's
medical bill. This possibility should be vigorously pursued.
(c) Professional acceptance is a necessary factor for the develop-
ment and spread of "good" systems. How can doctors be induced
to actually use computer terminals? Why have some systems
been successful in that while others have not?
(d) What measures of quality or cost improve when a relatively
"good" system is installed? Preliminary findings indicate that
some expected improvements have derived from unexpected
causes. Systematic efforts should be made to identify the true
cause of reduced patient stays or other benefits that have followed
installation of a computer system.
(7)
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8
(e) Development is a serious gap in what could be an integrated
federal policy toward computers in health care. How can this be
filled?
(f) Late stages of development and evaluation of health care
information systems are very expensive. How can the small
amount of HEW money available for health care computer tech-.
nology be used with the greatest leverage? What strategy will
obtain the most benefit from the limited funds of NCHSR (Na-.
tional Center for Health Services Research)? What roles should
NCHSR, NIH, the Health Care Financing Administration, or the
Center for Health Care Technology play? Can industry or other
private sector elements be enlisted in cooperative strategies or
programs?
5. The Center for Health Care Technology (NCHCT), or Center
for Health Services Research, working through NCHCT, should speci-
fically undertake to engage the military departments and the Veterans
Administration in devising policy and plans serving broad National
interests. In particular, they should consider the unique opportunities
afforded by the self-contained health care systems operated by military
and veterans agencies. It would be worthwhile, if possible, to de-
velop means for enlisting their cooperation in testing and evaluat-
ing computers in health care, or in providing an initial market for de-
sirable products that industry might be induced to develop.
6. The Department of Health, Education, and Welfare should con-
sider strategies that might enable a large scale demonstration and test
of a medical information system whose general purposes are similar to
the PROMIS system developed at the University of Vermont. Similar-
ities that should be preserved include explicit provisions to reduce:
(a) Problems arising from excessive burdens on a doctor's
memory;
(b) Problems of coordination of patient care and the disunity
of patient records; and
(c) Problems resulting from a lack of score-keeping and feed-
back in the evaluation of patient care procedures.
The test system should be designed to fit within a system concept,
having defined goals, rules for using the information system to reach
those goals, and feedback to correct the logic and procedures in use.
There are several existing systems, including "COSTAR" (Harvard
Community Health Plan) and "HELP" (Latter Day Saints Hospital,
Salt Lake City) in which such an overall design philosophy could be
made manifest.
It is recommended that any planning for such a test consider the
advantages of acquiring a willing partner for the test site, such as the
community of Mobridge, S. Dak. referred to in testimony before the
subcommittee.
7. The committee recommends that HEW, and the Congress, when
devising health system guidelines or when proposing health care cost
containment legislation, take note of the distinction between tech-
nology that is designed to save money and technology that is likely
to increase costs. Certain applications of computer technology are in
the former category. There should be a policy to encourage, not
hamper or penalize, investments in capital equipment capable of re-
ducing overall health expenditures. It would be appropriate to include
requirements that such equipment demonstrate, on a continuing basis
if necessary, that its cost-saving capability is being utilized.
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ORIGIN AND PURPOSE OF THE INVESTIGATION
In the 94th Congress, special oversight responsibility was given to
the Committee providing for a continuing review of "all laws, pro-
grams, and Government activities dealing with or involving nonmili-.
tary research and development" (House Rule X, paragraph 3(f)).
Under this jurisdiction, the subcommittee on Domestic and Inter-
national Scientific Planning, Analysis and Cooperation (DISPAC)
undertook to inquire how computer science might be directed in ways
that would benefit the taxpayer and the Nation, and to review federal
programs and policy in this area. The investigation included appli-
cations in the delivery of educational services, reported separately,
and applications in the delivery of health services, the subject of this
report.
An extraordinary rise in hospital costs, amounting to 1000 percent,
occurred in the past 25 years. In that same period, the health care
industry became much more dependent on, and characterized by, the
devices and procedures of a sophisticated technology. The subcom..
mittee engaged in a broad oversight review of the national health
system, to investigate how technology relates to health care costs, and
to consider how this relationship might be modified or directed to stem
the upward (cost) trend.
Hearings on "Computers in Health Care," held on May 9, 10, and 11,
1978, were a part of that comprehensive study. Related hearings on
"Technology and the Cost of Health Care," held September 26, 27,
and October 6, 1978, explored broader issues, relevant but not peculiar
to computer technology, and are covered in a separate report.
Topics of interest, points of view, and a possible organization of the
subject matter were suggested to the witnesses as follows:
Overview.-Cornputer applications in health care appear to vary
widely in function, sophistication, barriers to adoption, and possible
pay-off to society. An overview of the field, identifying features that
characterize and distinguish the various applications, and that affect
the degree of public significance, would be useful for selecting issues
and devising policy.
Medically-oriented applications.-Appear to deserve special atten-
tion. Important social welfare advantages seem to be derivable from
medical information technology but, like national defense, may lack
desirable guidance or support mechanisms in private enterprise. If so,
an appraisal of benefits, costs, incentives, and Government action
alternatives is in order.
Government policy and implementation.-Is there, or should there be,
a Government policy to guide Federal actions relating to computers
in health care? What are the appropriate policy considerations? What
are the options for implementing policy through Federal actions? Is
interagency coordination necessary, desirable, or feasible?
(9)
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THE WITNESSES
A pu1~Iic hearing~ mi ~QM?U~ERs~ TN ~T~TU CARE was
conducted in three sessi9ns on ~s4ay 9, iç~, 11,1978. TJIis ciivisi9n per-
rnitte4 treatW~~t of i~elated sukje~ts fi~o~n roughly thiee different
approa~h~~: Ove~rview, ~nd organi~~~~on of the ~1eld, emphasis on
medical (as opposed to health business administration) applications,
and consideration of Government policy and programs.
Tuesday, May 9, 1978, Washington, D.C.
OVERVIEW OF THE FIELD AND ASSESSMENT OF ITS PROBLEMS
AND PROSPECTS
Edward N. Brandt, Jr., M.D., Ph.D., Vice President for Health
Affairs, University of Texas System, Austin, Texas. Past Dean, Baylor
College of Medicine and Baylor Graduate School.
Herbert Sherman, D.D.E., Associate Director for Technology,
Center for the Analysis of Health Practices. Harvard School of Public
Health, Boston, Massachusetts.
Melville H. Hodge, President, Suntek Research Associates, Sara-
toga, Calif. Consultant in hospital information systems. Former Chief
Executive Officer for development of the first integrated computerized
hospital information system (Technicon Medical Information Systems
Corp.).
Arnold W. Pratt, M.D., Director, Division of Computer Research
and Technology, National Institutes o Health, Bethesda, Md.
Wednesday, May 10, 1978, New York, N.Y.
PROSPECTIVE IMPACTS ON MEDICAL PRACTICE-
POLICY IMPLICATIONS
Aran Safir, M.D., Director, Institute of Computer Science, Mount
Sinai School of Medicine, New York, N.Y.
Lawrence L. Weed, M.D., Director, PROMIS Laboratory, De-
partment of Medicine, College of Medicine, The University of Ver-
mont, Burlington, Vt.
Henry Cramblett, M.D., dean and vice president for Medical
affairs and Ruann E. Pengov, Ph.D., director, Division of Computing
Services for Medical Education and Research, College of Medicine,
the Ohio State University, Columbus, Ohio.
John C. Beck, M.D., Professor of Medicine, School of Medicine,
University of California, San Francisco, Cal., Past President, Ameri-
can Board of Medical Specialties, Past President, American Board
of Internal Medicine.
Thursday, May 11, 1978, Washington, D.C.
(11)
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12
NATIONAL POLICY AND RESEARCH SUPPORT PROGRAMS
Ruth S. Hanft, Deputy Assistant Secretary for Health Policy,
Research, and Statistics, Department of Health, Education, and
Welfare, Washington, D.C.
H. Phillip Hampton, M.D., Bernard Harrison, Vice President,
American Medical Association and George Polli, M.B.A., Assistant
Director, A.M.A. Departñ~nt~ ~f: cdm~nter Systems in Medicine,
Chicago7 Ill.
Donahi A. B. Lind~rg M.~., 13ire~bbr; Health Ca~ TechT1o~&gy
Oei~ter, Univer~i~y O Mi~SOU~I, oWnbl~4 ~
Gerald A. ~Giebillk,~ ~Dirê~tör~ H~alth Ca~ Ma~agen~fit Systèius~
Inc.; La Jolla, Cal. ~eview~ ~uthof. Consultant ~n clinic~1 data
processing.
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* `SUMMARY ~ND ANALYSIS
ORIGIN OF PtJ~LIC INTEREST~ IN `THE StBJ~C~-~PEOBLE~S AND `Pno-
SI~ECTS FOR INFOEMATION TECHNOLOGY'
*Th~ past 20 years have been marked by much publi~ and private
activity to impro~ve the quality and accessibility of health care. This
actint~ was ~nanifes'ted in heavy investment in all aspectsof the health
care system' and assisted' by landmark legislation' in social welfare re-
forms. Mo~t recently, however, steeply rising expenditures for hospital
care have been a cause for alarm. Concern' has shl'fted' to analyzing
causes, `searehing'for ways t&control costs, while still improving health
resources. `* ` ` `
A plausible' explanation' for the steep~ rise of hospital `costa rests' on
the `subsidy effect of health insurance. Cost-p1u~ reimbursement
through private irisifrance policies, as well as Med'ic;a~e aind Medicaid
encourages both unrestrained `demand and a rapid expansion and in~
tensification of supply. Patients and health care providers have str~rig
and relatively unbalanced. incentives to receive'and render the best or
the most in medical care. Response to unrestrained' demand results in a
steady expansion and upgrading of medical services, marked by
elaborateness and sophistication.
While doctors, hospitals, and patients tend to equate technological
sophistication with quality of medical care, some of the practices which
that engenders may' be wasteful'. There is a regrettable lack of syste-
matic information on the effectiveness of many choices and
"standards" in medical practice. And there is often little awareness on
the part of doctors or' the general' public of the detailed costs or the
possible consequences of the expenditures iii~lved.'
Health care information, if `apprppriately collected, analyzed, and
disseminated, would offer a basis for evaluating health care practices,
selecting cost' effective use Of facilities and thanpower, and identifying'
strategies' for preventing disease. `Computerized information systems
offer a promising approach to solving these national information
problems, as well a~s materially improving efficiency and coordination
of services at the local, hospital, level. Witnesses uniformly agreed
that suitable design and applications of computer systems in hospitals,
clinics, and doctors' offices could assist control of cost elements in
several ways. They could provide direct improvements' in the cost
efficiency of information handling and support improvements in the
efficient utilization of facilities (beds, machines, departments, etc.)
They can deteët and prevent errors or unnecessary duplication in tests
or treatment orders. On a somewhat longer range basis, they could
provide feedback data for doctors to evaluate treatments, thus
affecting the appropriateness and effectiveness of medical decisions and
patient management. On a long term basis, cooperative use of ac-
cumulated health data could become invaluable in defining the causes
and distribution (the epidemiology)~ of diseases that might then be
controlled or prevented.
While computers do, at a variety of levels, appear to offer leverage
for the control of costs, the maximum effect on cost would be indirect,
(13)
PAGENO="0020"
14
through the improvement of quality and effectiveness (and thus the
efficiency) of care, ~r~ci through assi~t~nce toward the prevention of
diseases. The potential impact would be expected to increase with the
time, over wliic,h~ cQmputers were employed,' because ot the virtual coIl-
tiuuum of short and long term goals.~ The prospects. of, the longer range
goals depend on the distant possibility of sharing data on a broad
geqgmpl~ie, 4scale. Unfortunately, these grand~ potentiaLs for public
benefit pf~e; small,incentiye for investment by individuaL hospitals.
For hospitals, c1i~ies ,or doctors' offices there has to be a payoff in the
short. terni. and which can ~be captured~by theiinvestor~-or: there, must
be ~i subsidy t~ support. tl~e cost of the necessary technology.
Since, the greatest potential benefits from the use of computer
technology, would take some time to develop and would accrue to the
public in general, rather than to institutions and private investors,
sevej~al questions are raised. What incentives are there for doctors,
hospitals and clinics to install computerized information systems?
Woulcl~privately flnanced systems. b~. the kiucLlihe.ly..to yield ma~çimunì
patio~t~ an4~ taxpayer benefits? What role(s) can or should. Govern-
ment play to recognize and promote development and ~~ise of maximum-
public-benefit systems?. Fortunately,: according to the witnesses and
ether available sources (e.g., PQlicy Implications of Medical Informa-
tion Systems, Office of Technology Assessment, Congress of the
United States, November 1977), there are encouraging answers to
these questions.
OvERVIEw OF COMPUTER APPLICATIONS: IN:HEALTII CARE
1': 1'.
A multit~ide~ of applications exist tor. co utei~e4 information
technology over. .the entire span of: healtI~ caret from the business
office of a clinic or hospital, to more me~jic~1ly-related * functions, in
the care of patients, 4p education for the medical professions, and to
health care research. Di~ , Ruann Pengov, One of th~~vitnesses, offered
a convenient diagram for pictorializing the field of health care in
three ,parts, patient care, medical education, and health research.
PAGENO="0021"
15
The overlap areas of this functional grouping are most strongly
related to health and medicine, per Se, (as opposed e.g. to resource
management or teaching' techniques), and tend to share a common
data base. This is an area where information technology could be
shared. The most medically oriented computer applications reside
in the overlap areas and hence would both serve and benefit from
interchanges made possible by the interdependence of these three
major groups of professionals. In the most extreme case, computer
algorithms, or subprograms for doctor/computer decisionmaking in
diagnosis and treatment, developed by clinical practice or research,
would be readily transferrable in either direction.
It may be anticipated that suitable computer technology might be
developed or initiated in the most receptive or feasible area, like
clinical research, before attempts are made to transfer it to adjacent
areas, like patient care or medical education, where there are tem-
porary barriers to overcome. Thus it appears that a strategy to
promote the dissemination of selected applications would prudently
consider the most hospitable site for introducing them.
In the hearings, many comments suggested that familiarity derived
from contact with computer technology in an academic setting might
reduce or eliminate some of the emotional or intellectual barriers to
use of the technology by doctors in normal practice. It was also
pointed out, however, that getting medical schools or academic medical
centers to introduce any technology or train their students in its use
may be a circular process that is not well understood. New ideas that
are incorporated into training by these centers may spread into general
clinical practice; but acceptance by academics is so dependent upon
clinical validity that there are questions of how, under what condi-
tions, and by what process new technologies gain acceptance into
medical school curricula. Thus, academic centers may prove to be
desirable sites from which to promote the spread of computer appli-
cations in medicine, but it would be unwise to assume that the pro cess
could be easily, or casually, started in academic centers or that other
barriers to dissemination could be ignored.
A second entry for computers into medical education is in the
area of post-graduate education of physicians. The evolution of
specialty training with its attendant process of board certification
and periodic recertification as well as the increasing adoption of state
relicensing requirements, have formalized the need for continuing,
renewing, and periodically assessing the up-to-date knowledge and
competence of practicing physicians. One result has been to stimulate
the exploration and development of computerized methods either for
the training or for the testing burdens created by these growing
requirements.'
According to Dr. Beck,2 one of the hearing witnesses, "There is
little doubt that computer based simulations currently provide the
most promising approach to the measurements of clinical judgement".
1 For detailed information, see Computer Technology in Medical Education and Assessment, Congress
of the United States, Office of Technology Assessment (April, 197~)).
2 Professor of Medicine, School of Medicine, University of California, S~n Francisco, immediate past
president of the American Board of Medical Specialties. Member of Coordinating Council on Medical Educa~
tion and chairman of the Coordinating Council's Committee on Continuing Physician~Competence. Past
chairman of the American Board of Internal Medicine. Testimony before the subcommittee, May 10, 1978.
PAGENO="0022"
16
He notes that "Acceptance by the practicing profession . . . (en-.
counters) a certain amount of resistance . . . which, in a large part,
stems from a lack of understanding and fear of its implications. Newer
generations of physicians will undoubtedly have greater familiarity
with this technology if more substantial training in the information
sciences occurs in the undergraduate phase."
There are three types of barriers to the introduction of computer
systems in hospitals. One includes the problem of how to finance the
technology. The others involve technical feasibility and professional
acceptance. Isolated applications exist, particularly in the business
office and to some extent elsewhere in a hospital, which are technically
feasible and that may be financially appealing to an administrator.
But as with computers in banks or other businesses, there is little
basis for Government interest in them, except insofar as they might
assist or deter development of more socially desirable systems. Several
witnesses expressed concern that investments in some systems have
led to fina~icia1 and technical disappointment, expended funds that
could have been used for "better" systems, or locked hospitals into
technologies incapable of improvement or expansion.
The Office of Technology Assessment has also observed that "eapa-
bilities to improve and monitor the quality of patient care and to
facilitate research and planning are the least developed" (among
medical information systems), and expressed an apprehension that
potential benefits for patients and our health care system might be
lost if medically-oriented systems are supplanted by a less significant
technology.8 There should be public interest, therefore, in how or
whether the most socially desirable information systems can be made
feasible, attractive, and economically sound.
HOSPITAL INFORMATION SYSTEMS
One promising approach to financing computer systems capable of
improving patient care is to include functions that directly save money
in the short run, while still embracing the strictly clinical information
functions of patient care. Several characteristics of hospitals promote
the computerizing of information:
(1) 25-35 percent of hospital costs are traceable to information
processing;4
(2) Present manual methods are inefficient and ineffective, and
(3) They provide little opportunity to analyze hospital opera-
tion for more efficient management.
Since quality of patient care is heavily dependent on the accurate
and timely transmission of orders and findings among several hospital
departments, it is reasonable to expect quality improvements, as well
as cost savings, from methods that improve information handling. The
following examples from the introduction to Melville lodge's recent
book ~ illustrate typical hospital problems and the close coupling
between quality of care, costs, and information processing.
A man who is unconscious is brought to the emergency room by
ambulatice. His wife reports he had just been discharged from the
`Policy Implications of Medical Information Systems. Office of Technology Assessment, Congress of the
United States, November 1977.
(a) Same reference (see also its refs.). (b) Hospital Financial Management Association, private communi-
cation based on 1976 study. (c) The Health Care Financing Administration, DHEW, has consistently
employed the range of 27-32 percent as a rule-of4huenb guide to cost share due to information handling.
5 Information Systems, A Resource for Hospitals, Aspen Systems Corp., Germantown, Md.
(1977). Mr. Hodge was a witness in the hearing, May 9, 1978.
PAGENO="0023"
17
hospital seven or eight days before. The patient's record is not in
the medical records department, and two hours after his admission
the chart still cannot be found.
At 8:30 a.m. a patient is escorted to the x-ray department for an
upper GI series. She waits 40 minutes before being taken into an
examining room. The technician asks when she last ate and dis-
covers she had breakfast that morning. Since the x-rays must be
taken on an empty stomach, the procedure must be postponed
until the next day.
A physician writes an order for one of his patients to be given an
electrocardiogram. Since it is late in the morning, he anticipates
the EKG will not be performed until the next day and that the
results will not be available until the day after that. He really ex-
pects the EKG to be normal and will discharge the patient if that
is the case. I-Ic realizes he could save the patient one or two days'
hospitalization if he ordered the EKG STAT (that is,
EXPEDITED) and got the results that afternoon. But there is
no medical justification for the STAT order, so he decides to
follow the hospital's routine procedures.
In a hospital which employs a computerized medical information
system connecting different service departments, there often is no
need for a special "STAT" request to get an immediate service
reaction. Orders entered into the system are immediately transmitted
electronically to the service department. In a well-designed system,
such orders also automatically generate appropriate accounting and
billing information. Without an electronic information system, such
orders are entered on paper, generally at the nurses' station, and may
go through several manual transfers to achieve the same result.
David Rogers, President of the Robert Wood Johnson Foundation,
has written6 that the "task of compiling, storing, and transmitting
patient information-clinical as well as administrative-is a continuing
source of frustration and challenge in a hospital setting, . . . If
anything, the situation is even more difficult. . . in ambulatory care
settings" (hospital outpatient, clinics, group, and solo practice)
"especially those devoted to general, or primary, care." Here "patient
data is rarely gathered and organized in a way permitting analysis
of the types of problems seen, or how they are being dealt with, or at
what cost."
Economic attraction to computer systems is enhanced by the burden
of reporting that Government and "3d party" (insurance) payers have
imposed on health care providers, requiring the gathering and manip-
ulation of patient and administrative data and statistics in numerous
different ways. Indeed, the number of reports required for Govern-
ment financed patients is now so great that the cost of billing for
x-rays and certain other services is said to be greater than the cost of
the service, itsc4f.7 But even without the reporting burdens for in-
surance payments, the task of communicating among the various
services of a hospital is inherently burdensome. If information proc-
essing can be made more efficient, a substantial saving in labor is
achievable. If beds, nursing personnel and other resources can be
utilized more efficiently, further savings can be realized. These savings
6 See "Foreword" to Computer Projects in Health Care, by G. A. Giebink and L. L. Hurst. Health
Administration Press, Ann Arbor (1975).
7 Private communication. Dr. Howard Bleich, Beth Israel Hospital, Boston, Oct. 31, 1977.
PAGENO="0024"
18
may be sufficient to pay for a system which enables more precise and
reliable medication and monitoring of treatment and provides data
for medical auditing. Review of medical data can supply the feedback
that doctors might use in raising the average quality (cost effectiveness,
not intensity) of quality care. Longer term studies of shared data can
reveal regional patterns, identify trends, and assist in the understand-
ing and control of disease occurrence. Thus, short term fiscal savings
may support systems with long term benefits derivable from capturing
and processing medical data.
Surveys of computer system installations in various health care
situations over the past 10 years or so reveal a great variation in
financial success or failure. Witnesses such as Gerald Giebink and
Melville lodge, who have been especially interested in the business
management aspects of computer installations, were particularly
careful to stress what is required for financial success. Both empha..
sized that installing more efficient equipment does not automatically
save money.
Money-saving requires a carefully planned and vigorously executed
"benefit realization program," which will lead to the writing of fewer
pay checks or the purchasing of fewer supplies or services. The early
development of such a plan has been found invaluable for stimulating
a systematic critique of how things are being done, what needs to, or
profitably can be, changed. One result is, even if automation were
not subsequently adopted, some improvement changes are likely to
ensue. Another is that both time and direction are made available for
absorbing constructively-rather than painfully-the shifts in person-
nel and their job functions that should result from a good installation.
A good installation probably would not "automate the status quo."
The immediate financial soundness of a medical information system
depends on the linking of patient medical data, like drug prescription
orders, to business and administration functions, like billing and
reporting. In addition, of course, efficiency would require that such
orders also be linked to the pharmacy, the nurses' station, and the
patient's record. Harmoniously linking all the different hospital
service de$rtments and their many functions is a formidable but
logically desirable task. It is here that one finds the remaining tech-
nical and sok~ial difficulties.
Many of the technical difficulties are problems in business organiza-
tion and management. Some are caused by the more intimate inter-
facing of departments introduced by the mechanization. Others
involve changes in methodology required for the improvement and
benefit realization previously mentioned. A third, and more trouble-
some, source of problems is the interaction between people and the
machine. It is both necessary and difficult to design this interaction
to be facile, so that it is not actually, or perceived as, a handicap. And
there is the additional optional challenge to automate some of the
traditional human functions in medical decision-making. Naturally,
physicians have some reluctance to relinquish any of their authority
or responsibility to a computer. In addition, there are serious diffi-
culties in adapting machines to the customary structure of medical
language. Despite the difficulties, significant progress is being made,
as attested by the number of hospital and ambulatory care services
now routinely incorporating some measure of patient care manage-
ment in their computerized information systems.
PAGENO="0025"
19
To reduce the number of information transfers in the care of patients
and the attendant delay and risk of error, it has been found to be
important to have both doctors and nurses interact directly with the
computer terminals. Existing systems have had varying degrees of
success in enlisting this participation of medical personnel. Apparently,
it is commonly more difficult to gain full personal pai~ticipation among
the attending physicians than among nurses. Since there are notable
exceptions to this experience, where physician acceptance and partic-
ipation is virtually 100 percent, the barrier is evidently surmountable.
This is one of the challenges that could be earmarked for special study
and which would benefit from incentive changes that could affect
a doctor's motivation. The "PROMIS" development program,
discussed in the next section, is one of the several in the nation that
explore the problems and benefits of doctor/machine interaction.
PROMIS (PROBLEM-ORIENTED MEDICAL INr0RMATI0N SYSTEM)
Under the direction of Dr. Lawrence L. Weed, personnel in the
Department of Medicine at the University of Vermont, in Burlington,
have been developing and testing, in a clinical setting, a medical
information system that emphasizes both the benefits and the diffi-
culties of doctor/machine interactions. It is described here not for its
resounding success but for its forthright identification of, and attention
to, key problems in decision-making and patient management.
Because it "takes the bull by the horns," so to speak, it clarifies,
perhaps better than any other known system, principles that are likely
to be important in the evaluation of other medical information systems.
Its head-on approach m~y polarize professional reactions, as indeed
it seems to have done, but it also provides an explicit recognition and
testing of design principles that, if valid, could become accepted as
basic.
The PROMIS system was specifically designed to address four
general problem areas in the doctor-patient relationship: memory
problems, logic problems, coordination problems and audit (feedback
or scorekeeping) problems. The problems derive from the crushing
burden of information that a doctor should but cannot memorize,
from the errors caused by a memory-dependent logic system, from the
fragmented nature of patient care due to specialization and patient
mobility, and from the fact that doctors have no feedback that tells
them the outcome of their decisions.
An overwhelming burden of emerging knowledge forced doctors to
specialize, but knowledge growth continues to saturate the memory of
even the subspecialist. Specialization requires the attention and
coordination of different doctors and departments responsible for the
care of a single patient, yet the human body tends to be unitary;
ailments, medications, and other treatments affect several body
systems at once, all of which may be the provinces of different physi-
cians or hospital departments. Perhaps worst of all-and the objection
most generally affirmed by physicians-doctors have little or no feed-
back from which they can evaluate their effect on patients. As Dr.
Safir pointed out, except for a few outstanding cases marked by
brilliant success or dismal failure-sometimes death-a doctor may
wonder at the end of a year what he has accomplished.
Besides addressing the problems of memory, logic, coordination, and
medical audit, PROMIS was devised to fit within a system concept,
PAGENO="0026"
20
having defined goals, rules for using the system to reach those goals,
and feedback to correct the logic and procedures in use. When criticiz-
ing or evalu~iting PROMIS, it is important to distinguish between the
principles o~i which it was founded, the problems it was intended to
improve, and its actual manifestation in hardware, programs and
operating logic. One could anticipate criticism or objections to the
details of the model; it seems less likely that the premises or the
problem identification could be dismissed. Its developers do not regard
PROMIS as "the solution." The solution (of our medical practice
problems) rests in the principles Dr. Weed invokes and attempts to
implement. PROMIS is regarded as "the tool." It is perhaps still
more proper to regard it as "a tool."
PROMIS is a prototype problem-oriented medical information
system that replaces paper records with a programmed computer
memory, retrieved and up-dated by medical professionals in the
course of their patient care routines. It implements and utilizes a
problem-oriented patient record that aims at improving the logic and
justification for steps to be taken in diagnosis and treatment. `Trob-
lems" range from a patient's stated complaint or symptom to a firm
diagnosis. Diagnostic and treatment guidelines use the problem
orientation as well as do the treatment records, regardless of what
department of medical specialty service executes them. Patient
information can be retrieved by problem, by chronology across all
problems, by source (such as laboratory or radiology) and in several
other modes where appropriate. The organization of data and the
logic by which it is entered or used preserves the rationale by which
it was generated and thereby facilitates audit and review. These pro-
visions are instrumental in providing for accountability for the actions
and decisions of professionals using the system. When, for instance,
medication is ordered, it is recorded in such a way that later review
indicates the problem for which it was prescribed.
Input-output terminals on the ward, in pharmacy, laboratory, and
in radiology and other service departments, make the system a vehicle
for communication among physicians, consultants, nurses, technicans,
social workers, and others. Simplicity of operating features, such as
as finger touches on a TV screen, facilitate using the equipment and
encourages physicians to participate directly. Through choices which
the user can control, he or she may interact easily and quickly with
patient data, with guidance protocols, or with information from the
medical literature contained in the 30,000 or so available reference
dis~lays.
Criticisms of the system which developed during the public hearings,
were primarily apprehensive of the quality or validity of the guidance
protocols. Concern was expressed over who would write, or select,
the protocols for the system, and how accountability or responsibility
for validit~r of the protocols could be established. In the words of Dr.
Safir, "every TV screenfull is an editorial by an unidentified writer...
you will have to pick certain boards of experts. Who are they; what
opinions do they embody; how much room is there in systems like
that for the uncommon person (physician) who deviates from the
norm?" Similarly, Dr. Beck expressed a concern over influencing doctors
to do things the same way. Such a course could perpetuate mono-
lithic errors and penalize creativity if imposed without ingenious
provisions for flexibility and personal freedom.
PAGENO="0027"
21
Defending remarks pointed out that such questions were no more
cogent for the PROMIS system than for medicine as it is now generally
taught and practiced. People with various credentials teach in medical
schools, write textbooks, or journal articles. Medical students and
graduates are trained by people with varying biases and objectivity.
The oral instruction, especially, is virtually unedited. What the
PROMIS method makes available is a broader consensus of experts
that could be reviewed periodically and updated by a formal oversight
process. It also provides for local revision and, at every step, permits
departures from the recommendations at the option of the user. In
the prototype system, such departures require a "type-in" to be
recorded by the user, so that the departures can be evaluated later in
terms of resultant patient outcomes. Thus, depending on outcomes,
medical audits pinpoint both desirable innovations and erroneous
decisions. In Dr. Weed's piquant analogy, if a doctor wishes to ignore
the "road map" provided and "drive in the middle of a field," he has
the freedom to do so. But, if he does the wrong thing it is not out of
ignorance of the best known options; it is because he made a conscious
choice of departure.
Dr. Weed's response to various questions and to criticisms both
explicit and implied, underscored a common misconception, shared
by several questioners. It is not completely logical to judge early
models on the basis of medical outcomes. Outcomes are more a measure
of the quality and adequacy of contemporary medical knowledge
than they are of the guidance system that transmits it. If the system is
to be judged on its performance, which is intuitively desirable, one
must take care to distinguish performance which is system-dependent
from performance that is dependent on outside factors-like knowl-
edge-over which the system initially has little control. Later~
especially if the system were large enough to have widespread use,
the accumulation of outcome data and the critical review which that
enables should lead to modification of medical knowledge and the
resultant diagnostic and treatment guidelines, and thus, finally may
then appreciably promote the improvement of outcomes.
NATIONAL PROGRAM AND POLICY CONSIDERATIONS
The subject of computers in health care covers many different ap-
plications. Accordingly, the technology is being developed and adopted
by many different public and private centers, over a broad spectrum of
conceptions. Some of these developments seem capable of greatly af-
fecting cost and other important qualities of health care, while others
do not. But, while development concepts and goals thus could be se-
lected for their potential impact on national welfare, there is reason
to question whether, how, and where such selection criteria are
operating.
There is at present no evident Federal-or DREW-policy,
planning principle, or strategy guiding the selection, development, or
application of the technology. On the other hand, the subcommittee
perceives a rationale for selecting what computer topics may be of
national significance and what role, if any, the Government should
elect.
The subcommittee recommends the following rationale:
Lack of information underlies much questionable, excessive, or
wasteful health services. Billions of dollars are spent on tests and
PAGENO="0028"
22
procedures whose efficacy, relative to other available choices,
often i~ not known. Development of a suitable information tech*
nology could contribute data for corrective feedback.
In the shorter run, the efficient use of present resources could be
improved. Data are needed to establish PSRO norms for ap~
propriate care, classify institutions for cost containment, and
improve the efficiency of Medicare. Data are also needed to iden-
tify the cost centers in the system so that means can be devii~ed
for controlling them. And data are needed on patient mix, de-
mand, and resource utilization for efficient planning for regional
needs.
At the hospital level, doctors and administrators have an inter-
est in improving how the patient fares and in moderating costs,
but must consider how an investment in technology will clearly
pay for itself, either in cash savings in efficiency, in increased cash
flow, or in increased charges. The latter would need fastidious
justification to establish that it was ultimately in the public
interest. On the other band, systems and uses of technology de-
veloped under private initiative can incorporate features that
help the taxpayer, but private incentives for doing that are not
strong and should not be relied on.
The most important pay-offs for the use of medical information
systems are societal and cannot be returned to the private in-
vestor. Moreover, the local economic feasibility of systems that
would be most beneficial to patient care has not been widely
demonstrated and is still in question. It is in the taxpayers' in-
terest to see whether computer systems can be developed that can
pay for themselves at the local level while, at the same time,
aiming for the most beneficial medical impact.
Abundant evidence indicates that better means for collecting and
analyzing data on medical treatments and their outcomes could be a
powerful aid toward improving the cost effectiveness of health care.
There are frequent claims currently in print-and echoed in the health
technology hearings before this subcommittee-that billions of health
care do11ar~ are expended for results that are poorly known, or are
wasted on treatments that are ineffective or unnecessarily dangerous,
debilitating, or costly. At a news conference 8 publicizing a special
issue of Science magazine devoted to health issues, Howard Hiatt,
Dean of the Harvard School of Public Health, observed that "many
current practices in medicine and surgery have not been evalu-
ated. . . . Tonsillectomies are being done less frequently, but one
can still seriously question the need for close to a million a year." He
urged rigorous evaluation of all medical and surgical procedures on
the basis that the cost of not undertaking it will be greater than
undertaking it. Similarly, the authors of The Costs and Benefits of
Surgery ~ dbserve that many of the 20 million operations performed
each year on Americans are of questionable value. Likewise, Dr.
Kerr White (Milbank Memorial Fund Quarterly 46 (part 2) 117-125,
8 See Victor Cohn, "Health Coats Spur Debate on Who Shall Live, Who Shall Die." The Washington Post,
Friday, May 19, 1978, p. A18.
8 Bunker, John P., Benjamin A. Barnes, Frederick Mosteller, Howard H. Hiatt. Oxford University Press,
New York, 1977.
PAGENO="0029"
23
1968) estimates that only 10 to 20 percent of procedures in current
medical practice have been proved efficacious by controlled clinical
trials. Problems of cost, time delays and the ethical problems of de-
liberately creating a control (untreated) group account for a general
absence of formal trials and enhances the need for alternative means
for systematic evaluations. For the vast majority of diseases, Dr.
Brandt told the Subcommittee, the outcome or value of treatment
remains immersed in ancedotes of limited personal or institutional
experience or in statistical forgis of no practical use. Dr. Sherman
stated his belief that much of the increase in medical cost in the last
two decades is due to application of new medical technologies and
procedures for which effectiveness has not been adequately demon-
strated. He testified that the number of diseases and therapies being
monitored is pitifully small, and many less common ones cannot be
systematically studied at all because data cannot be gathered over
large enough samples.
Lack of information from which to construct appropriate standards
leads to disagreement on appropriate care, and wide variation in
treatment selections. Among the issues currently under widespread
criticism are coronary by-pass surgery, radical mastectomy, tonsil-
lectomy, fetal heart monitoring and various specific applications of
C.T. scanning of the chest or abdomen. Because of inadequacies in-
herent in paper medical records, a national total of 500,000 man-
years of experience with coronary by-pass surgery is presently in-
accessible to data aggregation and analysis. Radical mastectomy re-
mains the most commonly practiced procedure for breast cancer,
although there is no persuasive evidence that it is better than simpler
treatments. The frequency of tonsillectomy, hysterectomy, and
various other surgeries varies enormously from community to com-~
munity according to studies,'° and reflects a lack of definitive data on
when to use the procedures. Monitoring the fetal heartbeat has shown
to result in a doubling of the number of Caesarian birth procedures,
without evidence that this reduces infant mortality or brain damage.
The foregoing is a small token of the available examples, too numer-
ous to list, to support the general allegation that individual clinicians
lack good information on treatment and outcomes, and seldom have
data on probabilities and costs. David Cullen and co-authors, in a
study of the critically ill 11 observed that doctors expect virtually
unlimited resources to be mobilized for these patients, yet remain
unaware of the statistical results of their efforts. Such considerations
prompted the Office of Technology Assessment to report on the general
need for Assessing the Efficacy and Safety of Medical Technologies,'2
and led the Congress to include provisions for assessment and evalua'
tion in the new Health Services Research, Health Statistics, and
Health Care Technology Act of 1978.
New technologies and their cumulative costs have been expanding
with explosive force in the past 25 years. There have also been some
10 See for instance, Bunker, et al., "Costs and Benefits of Surgery."
11 D. S. Cullen, L. 0. Ferrara, B. A. Briggs, P. F. Walker, and I. Gilbert; New England Fournal of Medi-
cine, April 29, 1976, p. 282. Survival, Hospitalization charges and Follow-up Results in Critically ill Pa-
tients.
12 Assessing the Efficacy and Safety of Medical Technologies, Office of Technology Assessment, Congress
of the United States, September 1978.
PAGENO="0030"
24
dramatic improvements in selected capabilities in medicine, but it is
not evident that the overall effectiveness of medical practice has
changed enough to match the generally increased costs. Lewis Thomas
suggests that, until we can dramatically cure or prevent more dis.
orders, we shall be stuck with what he has termed "half-way tech-S
nologies." These may be helpful, but not decisive, and tend to require
systematic assessment to determine their qualifications and restric-
tions. At present, for lack of adequate information on who did what to
whom, and what the outcomes were, doctors often cannot distinguish
who probably will or will not benefit from a given procedure, cannot
decisively evaluate treatments that may be effective, and cannot
choose reliably among alternative procedures, or decide when to stop.
What can be done in this period, Thomas says, is "identify the areas of
health care in which the spending of money represents outright waste,
and then eliminate them. There are discrete examples all over the
place".
Testimony received in the health technology oversight hearings of
this subcommittee, consistent with the foregoing reference, indicated
a regrettable lack of information to supply dotors' general need for
corrective feedback. In considering what measures could improve the
* situation, it is difficult to escape the conviction that better means for
scorekeeping would rest on a computer technology that deals explicitly
with clinical information. Dean Hiatt, in a medical essay 18 on the
coronary by-pass debate writes "we need improved methods for col-
lecting, aggregating and analyzing clinical data. Computers spew out
minute details concerning the charges incurred by each patient in
*most hospitals, but in most places little or nothing concerning the
medical problems that led to the hospitalization, the details of in-
hospital care, or the long-term outcome of therapy." Dr. Brandt,
expressing a similar view in his testimony, proposed that the great
challenge in medical science is the creation of clinically pertinent data
to define tl~te course of disease and quantify prognosis under chosen
treatments.
Some improvements in the knowledge base or the systems to acquire
it would take a long time to develop; others are much less futuristic.
An intermediate goal could be the collection of information for deter-
mining what health care practices the Nation will pay for, so that
health care might eventually be paid for in terms of output, rather than
input, units. Longer range goals would certainly include efforts to
eliminate or shift costs through prevention or postponement of disease
and disability, and could profitably include explorations into new
ways of making patient care decisions less dependent on human
memory, specialization, and the attendant fragmentation of care.
The existence of exceptionally important applications for computer
technology where there is high societal incentive but low economic
incentives at the local level indicates that a selective federal role is
appropriate. This recognition prompted the Office of Technology
Assessment to observe that needed capabilities to monitor the quality
of medical care and facilitate planning in the health system might be
lost in information systems determined only by the open market
place. In its report on medical information systems,'4 the OTA stated
13 Howard H. hiatt. Lessons of the coronary By-Pass Debate, New England, Journal of Medicine, Dec. 29j
1978, pp. 1462-1464.
14 "Policy Implications for Medical Information Systems," Office of Technology Assessment, Congress
~f the United Statas, November 1977.
PAGENO="0031"
25
that "without a Federal policy toward these systems, their diffusion
may well proceed indiscriminately. If so, the full potential of these
systems is not likely to be achieved."
rfhe inference is reasonable that, if there were a Federal policy, it
would clearly distinguish and emphasize computer applications most
needful and deserving of public support. The pockets of development
or research support that exist in the Federal structure do not appear to
be guided by any such clear criteria. Furthermore, there is no integra..
tion, coordination or even overview awareness of all the parts of what
constitutes the present Federal activity.
Development programs to advance computer Services for patient
care in their own hospitals are under way in the National Institutes
of Health, the Veterans Administration, and the military medical
departments. Extramural grant and contract funding emanates
primarily from the National Center for Health Services Research
(NCHSR) and, to a lesser extent, from the National Library of
Medicine and the Division of Research Resources of NIH. Until
recently, the Bureau of Health Manpower also sponsored independent
investigators. All the Federal programs are independent operations,
generally not concerned with each others' activities. As a result,
there is duplication and overlap, technical gaps, discontinuities in
funding, no progression or handover of projects to other agencies
when that would be advantageous, and little opportunity for ex-
change of knowledge gained from parallel or relevant experience. No
one overseer exists, even within DHEW, or even within NIH, to
ascertain what the total effect is, what its overall progress and
prospects are, or to judge whether, as a balanced whole, it adequately
satisfies long term national or societal priorities.
r~0 the extent possible for a single agency, and under exceedingly
limiting circumstances, NCHSR has been a principal source of Govern-.
ment support for extramural development of medical information
systems and allied projects.15 Its portfolio of contracts and grants
has included a spectrum of research development, demonstration and
evaluation programs of computers in health care delivery, but it has
been grievously constrained by austere funding, limitation of its
authority, and a shifting focus of responsibility. In the period between
1974 and 1979, budget cuts and cost inflation combined to reduce its
contract sponsorship more than 50 percent. Development activities
were officially proscribed and evaluation programs became almost
too expensive to consider. The result is a very small program portfolio
with a serious gap in the area of development.
It may not be surprising that under these discouraging circum~~
stances, NCHSR has not assumed a unifying leadership role. Dr. Safir
remarked in his statement to the subcommittee that NCHSR is the
logical place for such leadership to originate. But he observed that they
have not developed a holistic approach to their computer studies,
insuring continuity, filling gaps in the transfer process, seeking
maximum public payoff, and encouraging an integrated, coordinated
eftort among the several other Federal agencies.
The sharply falling budget for NCHSR virtually cut off considera-.
tion of new programs; because of inherently long development time,
15 The Division of Research Facilities and Resources at NIH was otice an important source of extramural
funding. Its Computer Study Section, recently abolished, served as proposal evaluation center. Now,
proposals are sent to whatever Institute of NIH is responsible for the disease category most relevant to the
proposal. No testimony was offered in the hearing on NIH extramural programs.
PAGENO="0032"
26
the agency has needed all of its shrinking resource base for maintaining
a selected portion of its established commitments. This austerity,
combined with the elimination of a substantial grant program under
the Bureau of Health Manpower 16 not only curtailed much of the
Federal program in extramural computer studies, but also may cause
the loss of a pool of established investigators. The situation leaves new
investigators almost no hope of finding Federal support. Some im-
provement in the situation can be anticipated in a now somewhat
larger NCEISR budget and a. conscious and renewed emphasis on its
commitment to computer technology.
The emphasis was given legislative support in Public Law 95-623
(derived from Senate and House bills S. 2466/H.R. 12584)r changing
the authority to support computer research to a requirement. Recent
reorganization within the Public Health Service, placing the National.
Center for Health Services Rese~rch (NCHSR) and The National
Center for Health Statistics (NCHS) closer to the authority of the
Assistant Secretary for Health, was intended to enhance the im-
portance of how Congress and the Administration perceives the Cen-
ters and thereby to induce more generous appropriation~. The arrange-
ment coulçl also facilitate or promote a greater degree of HEW
oversight and interdivision coordination.
There is a substantial overlap among the technology activities of
the various divisions of DHEW. Differences in mission between
NCHSR and the, parts of NIH supporting computer applications do
not, and should not, guarantee exclusive differences in their computer
research programs. Indeed, many of the projects of the Division of
Computer Research and Technology, the Division of Research
Resources, the National Library of Medicine and The Natioflal Center
for Health Services Research are similar, or of a character not exclusive
to the agency in which they reside. The overlap allows one agency to
fill gaps left by another, and could, but generally, does not, allow for
transfer or progressive handover from one agency to another. The'
National Library of Medicine has initiated a new program in informa-
tion engineering whose ultimate goal is more efficient prevention,
diagnosis, therapy, and care. This is well within the mission of all of
the agencies named, but only NCHSR has a clear jurisdiction over,
and active program for, promoting the last stages of technology trans-
fer to commercial reality. Transfer from NIH to another HEW agency
is possible but not an established process. Without routine interagency
coordination, transfer is less likely, and gaps and duplications are more
likely. Administrative oversight, with authority of, or delegated by,.
the Assistant Secretary for Health could assist in reducing these risks.
Oversight, from a level near the top in HEW, could also inject a.
management component derived from a less parochial mission orienta-
tion. It should be possible, without being heavy handed, to link agency
perceptions and decisions with considerations that are more National.
or more health-care-systemwide.
~ Authorized by the comprehensive Health Manpower Training Act, this program has bad only slight
relationship to "health manpower" but has supported a substantial reservoir of ~kil1 in the medical appli
cation of comp1~ter technology. No appropriations are anticipated after 1978.
/
PAGENO="0033"
27
HEW PLANS FOR TECHNOLOGY MANAGEMENT
In testimony before the Senate Subcommittee on Human Re..
sources, on the o'~casion of hearings on renewal authorizations for
NCHSR and NCHS, Dr. Julius Richmond, the Assistant Secretary
for Health, observed that HEW had no comprehensive strategy for
linking systematically the life stages of technology development,
evaluation, transfer, diffusion, utilization, and phase-out. Agencies of
HEW generally decide independently their technology activities and
engage themselves on selected segments or stages of technology de-
velopment or transfer. Action agencies, like the Health Services
Administration, or the Health Care Financing Administration, need
technical information for guiding their actions, and would benefit
from links to agencies like NCHSR and NIH that produce knowledge.
In 1977, the Office of the Assistant Secretary for Planning and
Evaluation, in collaboration with the Office of the Assistant Secretary
for Health, conducted a preliminary study of management needs and
opportunities at DHEW. With authorization from the Secretary,
changes were initiated to provide managerial leadership and coordina-
tion from a high level in the Department. Shifting the organizational
position of NCHSR and NCHS, alluded to earlier, was one of the
changes in what was intended to become a continuing study and modi-
fication of how technology is managed at DHEW. A parallel step was
the creation of an Office of Health Technology also within the Office
of the Assistant Secretary for Health. This new office was to catalyze
formation of Department policies on technology management, monitor
DHEW agencies' management of technologies to identify gaps and
opportunities, and serve as a focal point for liaison with other Federal
agencies and outside parties.
In her statement to the Subcommittee, Ms. Ruth Hanft, Deputy
Assistant Secretary for Health Policy, Research and Statistics,
indicated the Department's intention to have the new Office "direct,
systematize, and coordinate Departmental health technology manage-
ment." She indicated that it was expected to function as the Depart-
ment's lead agency for health technology management. To carry
out this function it would:
(a) Identify deficiencies in the Department's health technology
policy and propose improvements;
(b) Coordinate and facilitate collaboration with Federal
agencies and;
(c) Supply a managerial approach to priority selection, tech-
nology assessment, and information exchange.
These functions would include overseeing the development of the
Secretary's decision documents relating technology findings to reim-
bursement, regulation and Department initiatives.
The statement submitted for a subsequent hearing on health tech-
nology17 by Dr. Richmond, who headed a delegation of HEW ad-
ministrators, addressed new functions of the Office of Health Care
Technology ~ mandated by law. His testimony indicates
17 See the testimony of iulius 13. Richmond, Assistant Secretary for Health, DREW in the hearing record
of October 6 1978, "Technology and the Cost of Health Care." Subcomnilttee on Domestic and international
Scientific Planning Analysis, and Cooperation. Committee on Science and Technology.
18 Under The Health Services Research, Health Statistics and Health Care Technology Act of 1978 (Public
Law 95-623) derived from bills S. 2466 and H.R. 12584, the Office of Health Technology became the National
Center for Health Care Technology, with functions including demonstrations, evaluations, and epidemi-
ology.
PAGENO="0034"
28
no conflict between the functions described by Ms. Hanft and those
presented by the new legislation. The new Office would promote
technology assessment and assist in the formulation of utilization and
reimbursement policy, as well as stimulate the internal coordination
and steering of technology development. In his words, "The Office
(of Health Care Technology) will act as a catalyst for policy develop-
ment related to technology management, as well as functioning as a
liaison to outside organizations, collaborating with other Federal
agencies, and monitoring activities in the business and academic
areas." For all health oriented agencies, "The Office of Health (Care)
Technology should provide a forum for mutual information exchange
on health technology activities, for airing individual agency perspec-
tives on particular issues, for identifying critical needs and important
opportunities in this area, and for seeking agreement on useful com-
mon approaches to problems and appropriate priorities."
NEEDS, OPPORTUNITIES AND PROSPECTS FOR MANAGEMENT OP COMPUTER
AFFAIRS AFFECTING HEALTH CARE
From the testimony received, it appears that DHEW intended for
the Office of Health Care Technology to embrace technology policy
development and broad management oversight, as well as the evalu~
ation and assessment obligations now specified by law. Since assess-
ment of the manifold impacts of computers on health care is a natural
prerequisite for policy development and implementation, there is no
logical incompatibility in these functions. There are grounds for con-
cern, however, over the balance between them that might be stcuck
within a realistically' modest budget (assessments are very expensive)
and over the particular nature, scope, and `variety of the management
activities that might be elected.
Much support for legislating technology assessment derives from
the fact that technology is `a major contributor to the cost of health
care. Most of the incentives for customers of health care technology
favor improving quality of care with little regard `for cost. Assessments
and evaluations to be performed under the new law will be directed
toward curbing excessive and inappropriate practices and toward
throttling the development and spread of technologies that are of
questionable efficacy or are unreasonably costly for the benefits they
can produce. Thus the Center for Health Care Technology has been
promoted as a pivotal component and source of initiative for an early
warning system. One should hope, however, that affirmative oppor-
tunities will not be overlooked. Computer applications seem to be
particularly deserving of careful discrimination to identify those whose
promotion and positive guidance would be clearly in the Nation's
interest. To insure such promotion and provide such guidance is a
complex and delicate management task. rfhere are many barriers to
overcome and many opportunities that would be missed if nobody
undertook the responsibility to devise and implement a comprehensive
strategy to get the "best" computer systems developed and applied
to the most socially needful problems. Consequently, it is the subeorn-
mittee's hope that the Center for Health Care Technology will rec-
PAGENO="0035"
29
ognize and implement what appears to be a unique opportunity to
support, cajole, stimulate and assist appropriate HEW actions in the
orchestration of a comprehensive management policy and action pro-.
gram.
Illustrative material for deriving health care computer policy, re-
ducing problems, or selecting opportunities for technology manage-
ment or oversight, is offered in the following list of topics:
Some computer applications have extraordinary potential for
public benefit; others are of little or no public significance. There-
fore, some are more appropriate than others for Federal attention.
Important management and oversight functions include the iden-
tification of selection criteria and their application to Federal
planning.
Applications having national social value must meet economic
realities. Somebody must pay for them. Who? How? There is evi-
dence "socially good" systems can be made locally self-supportive
without adding to anybody's medical bill. This possibility should
be pursued.
There are numerous special questions to be addressed to facili-
tate development and spread of "good" systems. One is profes-
sional acceptance. How can doctors be induced to actually use
computer terminals? Why have some systems been successsful in
that? Also, what measures of quality or cost improve when a
relatively "good" system is installed? Preliminary findings have
often been surprising; some expected improvements have derived
from unexpected causes. After installation of a computer system,
what has been the true cause of reduced patient stays or other
observed benefits?
The National Center for Health Services Research (NCHSR)
and other HEW supporters of health care computer technology
have miniscule budgets. Evaluation of information systems is
very expensive. So are the later stages of development. What
strategy will harvest the most benefit from NCHSR's limited
funds? What roles should NCHSR, NIH, the Health Care Financ-
ing Administration, or the Center for Health Care Technology
play? Can industry and other private sector elements be enlisted to
cooperate to the advantage of all?
Development is a serious gap in what could be an integrated
federal policy toward computers in health care. How can this be
filled?
The National Center for Health Care Technology (NCHCT),
NIH, and NCHSIR are all in the Public Health Service (PHS)
under the Assistant Secretary for Health. Health Planning and
Evaluation (P. & E.) is under another Assistant Secretary. Even
more importantly, reimbursement for Medicare and Medicaid is
under control of the Health Care Financing Administration
(HCFA), independent of and of equal rank with PHS. How can
NCHCT or NCHSR engage the cooperation of HCFA to en-
courage acceptance of systems and applications identified as cost-
saving? Will NCHCT mediate cooperation between P. & E. or
PAGENO="0036"
30
HCFA and NCHSR? Will NCHSR ask for NCHCT help in this
task? Will NCHCT perceive the need or opportunity without
prodding from NCIISR and, in effect, itself be the prodder?
It is particularly difficult to engage agencies like the military
departments or Veterans Administration in a national strategy
that is not obviously in their mission. In addition to poverty of
available mechanisms, these agencies have relatively limited inS.
terests, tailored by their specialized missions. They do, however,
have control of self-contained health care delivery systems. It
would be difficult, but probably worthwhile, to develop means for
enlisting their cooperation in the testing and evaluation of certain
aspects of computers in medicine, or in the provision of a guar-
anteed initial market for products which industry might then be
induced to develop.
0