A History of Computing in Medicine
Matthew Case
Kevin Clement
Genevieve Orchard
Rebecca Zou
December 2006
Table of Contents
Table of Contents
Introduction
Applications of Computing in Medicine
Figure 1 - A Timeline of Computing in Medicine
Key to Timeline
Electronic Medical Records
Benefits
History of the EMR
Drawbacks of EMR Systems
Clinical Decision Support Systems
A Brief History of Significant Developments in the Field
Patient-computer interviewing (1960)
Expert Systems (1970)
Real-time Clinical Decision Support (CDS) Technology (1980s)
Widespread Introduction of PCs and Networks into Health Care Infrastructure (~1995)
Reference Databases and Portable Access (~2000 onwards)
Current State and Goals of CDSS
Policy Issues in Computerized Health Care
Demand for a Health Information Technology (HIT) Policy
A Broken Record?
History of Government Involvement in Medical Computing
Unexpected Consequences of the Computerization of Health Care
Depersonalization
Outsourcing
Medication Errors
Faulty Information on the World Wide Web
Unnecessary Procedures
Care Expectations and Information Overload
Centralization of Health Care
Other Consequences
Summary
Introduction
In his epic 1945 paperAs 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.”[1]Computers appear in today’s 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 overviewof the various ways in which computers have found their way intomedicine 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 nurse’s 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.[2]
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 ( 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[3].
- 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.[4]
- 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.[5] 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.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.
1
Figure 1 - A Timeline of Computing in Medicine
1
Key to Timeline
1954 / Computerized cytoanalyzer / This cytoanalyzer was capable of examining mass cells on a slide for signs of cancer.[6]1960 / The “Brains” / An IBM 650 called the “Brains” was used to scan medical records for subtle abnormalities.[7]
1960 / Patient-Computer Interviewing / Computerized questionnaire-based history-taking.
1961 / Administrative and fiscal functions / In the early 1960s, computers were used for administrative and fiscal functions in hospitals.[8]
1962 / Electrocardiogram analysis / Electrical impulses from the heart were relayed by telephone to a central computer which created a curve and analyzed it.[9]
1963 / First decision support systems / A computer approach to rehabilitation is introduced. For example, the computer was used to determine the optimum time a cast should be worn following surgery.[10]
1964 / IBM System/360 / The IBM System/360 was introduced.
1964 / DEC PDP-8 / Introduction of the PDP-8 minicomputer.
1964 / MEDLARS / MEDLARS was a computerized database system for indexing and retrieving medical citations at the National Library of Medicine (NLM).[11]
1965 / Idea of EMR / The idea of an electronic medical record was already in place in the 1960s.
1966 / MUMPS / Massachusetts GeneralHospitalUtility Multi-Programming System (MUMPS) – also called ‘M’ – was a programming language for the health care industry.
1968 / IMIA / International Medical Informatics Association (IMIA) was established in France.
1970 / Computerized lab data processing / Computers were used to perform pathology lab calculations such as determining the chemical concentrations in amniotic fluid. This allowed for faster, higher quality results.[12]
1971 / Computerized record processing / The IBM System/3 Model 6 minicomputer was used to process records of patient tests.[13]
1971 / COSTAR / Computer Stored Ambulatory Record (COSTAR) – a successful outpatient electronic medical record system programmed in MUMPS – was introduced.
1971 / MEDLINE / MEDLARS On-Line (MEDLINE) went online.
1972 / MYCIN / MYCIN was an interactive expert system for infectious disease diagnosis and therapy. It was developed at the StanfordMedicalSchool and ran on a DEC PDP-10.[14]
1972 / HELP / Health Evaluation through Logical Process (HELP) was developed at the LDSHospital.18
1974 / First clinical CT scanners / The Computed Tomography (CT) scanner (for the head only) was invented by Hounsfield and Cormack in 1972. A full body scanner became available in 1976.[15]
1974 / Computerized Gamma Knife / Introduction 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.[16]
1974 / Internist-1 / This computer-assisted diagnosis system was developed at the University of Pittsburgh for the general internal medicine domain.[17]
1977 / Medical Informatics / The term ‘medical informatics’ was defined.
1978 / Fileman / Used at the VA Department of Medicine and Surgery
1981 / IBM PC / The IBM PC was introduced.
1983 / Networking / In the 1980s, networking was introduced to the mainstream.
1984 / ACMI / The AmericanCollege of Medical Informatics (ACMI) was established.
1987 / HL7 / Health Level Seven, Inc. (HL7) was founded as a standard for clinical data exchange.
1988 / MUMPS becomes IBM-supported / MUMPS became an IBM-supported programming language.[18]
1989 / World Wide Web / The World Wide Web was invented.
1992 / Windows 3.1 / Windows 3.1 was released.
1996 / Palm Pilot / The Palm Pilot was introduced.
1996 / HIPAA / Congress passed the Health Insurance Portability and Accountability Act.
1999 / da Vinci Surgical System / This 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.[19]
2000 / Image transmission / Some hospitals were electronically transmitting medical images such as X-rays and MRIs.[20]
2001 / Wide adoption of handhelds / In the early 2000s, health care workers started to use handheld devices widely to perform tasks such as accessing medical literature and electronic pharmacopoeias.[21]
2003 / Virtual Colonoscopy / The virtual colonoscopy uses a combination of CT scanning technology and computer graphics.[22]
2004 / World Community Grid / IBM launched this grid computing project to search for genetic markers of disease.[23]
2004 / Multidetector CT scanner / This new heart scanning techniquecould largely replace angiograms.[24]
2004 / Executive Order 13335 / President Bush created this order, titled “Incentives for theUse of Health Information Technology”
2005 / Penelope / Introduction of this robotic scrub nurse.[25]
2006 / Microsoft buys Azyxxi / Microsoft bought this clinical health care software that can retrieve and display various kinds of patient data.[26]
Electronic Medical Records
Back in 1960, an article in the New York Times mentioned a TulaneUniversityMedicalSchool 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"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[27] 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[28].
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 patient’s 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 today’s medicine. Electronic recordscombined 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 carecoordination 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 patient’s 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 patient’s 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 resourcefor 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 patientdata. 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 today’s 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 patient’s record. Or, perhaps a patient’s insurance company does not cover certain medications or treatments. This type of information would also be instantly available to the prescribing physician.