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An unfamiliar buzzword is making its way into healthcare executives' vocabulary, as well as their computer systems. Unix is being touted by many industry observers as the most likely candidate to be a standard operating system for minicomputers, mainframes and computer networks.
As an experiment, a health IC card has been linked into the hospital information system of the National Cheng Kung University (NCKU) Hospital. The NCKU Hospital Information System (NCKU-HIS) services all the procedures for patient registration, billing, prescriptions, and the processing and storing of test results. The health IC card system provides good quality information to the doctors, the hospital, the patients, and the insurance organizations. For a fully comprehensive system, it is essential to integrate the health IC card system into the operational NCKU-HIS, the communication protocols, and the national insurance procedures. The experiment was designed to see if the development of such a system was feasible, and the results have been impressive. It has proved possible to operate the health IC card system, linking into different machines under different computing environments. A single computer system to store all the data of all the patients and to process all the nation's healthcare information would require almost unlimited mainframe processing power and unlimited storage. It would be very difficult to construct such a large computerized information system. All the hospitals would be required to use the same data format to process their information, and a large national healthcare network would have to be built, making the collection and storage of personal medical information very difficult and probably inefficient and unsatisfactory. Even if it was possible, it would be a very costly and time-consuming task. An IC card is cheap and easy to use, and offers an alternative solution to the problem of handling the nation's healthcare information. The original healthcare IC card experiment (started in 1990) was limited to the NCKU Hospital and the Taiwan Government Employees' Clinic. The experimental system was designed to be fully integrated into the NCKU-HIS and has been widely accepted by the users, especially the IC card-holding patients. It is also well-suited to the management of healthcare insurance. An expanded healthcare IC card system was implemented from the end of 1993 and covers six clinics and six hospitals in Penghu County. The operation of the registration and billing subsystems are supported by PC workstations in a client/server network as these subsystems are used very frequently. Some of the other computerized functions in the NCKU-HIS are supported by the mainframe TANDEM computer system. The interfaces with the communication protocols and application software provide for the effective two-way transfer of data and programs. For future use, consideration is being given to the employment of the Health Level Seven (HL/7) protocol for electronic data interchange. National standards such as Chinese information processing, the use of standard codes, the authorization of the content of the IC card, and communication protocols are already incorporated in the system.
We have examined the feasibility of using massively-parallel and vector-processing supercomputers to solve large-scale optimization problems for human movement. Specifically, we compared the computational expense of determining the optimal controls for the single support phase of gait using a conventional serial machine (SGI Iris 4D25), a MIMD parallel machine (Intel iPSC/860), and a parallel-vector-processing machine (Cray Y-MP 8/864). With the human body modeled as a 14 degree-of-freedom linkage actuated by 46 musculotendinous units, computation of the optimal controls for gait could take up to 3 months of CPU time on the Iris. Both the Cray and the Intel are able to reduce this time to practical levels. The optimal solution for gait can be found with about 77 hours of CPU on the Cray and with about 88 hours of CPU on the Intel. Although the overall speeds of the Cray and the Intel were found to be similar, the unique capabilities of each machine are better suited to different portions of the computational algorithm used. The Intel was best suited to computing the derivatives of the performance criterion and the constraints whereas the Cray was best suited to parameter optimization of the controls. These results suggest that the ideal computer architecture for solving very large-scale optimal control problems is a hybrid system in which a vector-processing machine is integrated into the communication network of a MIMD parallel machine.
The health care field is making significant progress in shifting to computer-based patient records. Providers are faced with some difficult decisions about what hardware options are most appropriate. Key issues include the choice of clinical workstations vs. portable computers, the use of new client-server architecture or traditional mainframe-based systems and the role of personal computers. This special report offers an indepth assessment of important hardware trends in the records automation movement. The first story offers an analysis of the hardware implications of client-server architecture and an assessment of the long-term role of mainframe computers. The second story sizes up the potential role for mobile computing, including hand-held devices and wireless technology.
Most studies of the impact of information systems in organizations tend to see the implementation process as a "rollout" of technology, as a technical matter removed from organizational dynamics. There is substantial agreement that the success of implementing information systems is determined by organizational factors. However, it is less clear what these factors are. The authors propose to characterize the introduction of an information system as a process of mutual shaping. As a result, both the technology and the practice supported by the technology are transformed, and specific technical and social outcomes gradually emerge. The authors suggest that insights from social studies of science and technology can help to understand an implementation process. Focusing on three theoretical aspects, the authors argue first that the implementation process should be understood as a thoroughly social process in which both technology and practice are transformed. Second, following Orlikowski's concept of "emergent change," they suggest that implementing a system is, by its very nature, unpredictable. Third, they argue that success and failure are not dichotomous and static categories, but socially negotiated judgments. Using these insights, the authors have analyzed the implementation of a computerized physician order entry (CPOE) system in a large Dutch university medical center. During the course of this study, the full implementation of CPOE was halted, but the aborted implementation exposed issues on which the authors did not initially focus.
Radiosurgical stereotactic thalamotomy was performed in a patient with parkinsonian tremor with a computerized stereotactic brain atlas, which was transformed to fit the patient's thin-sliced magnetic resonance image to select an optimal target in the nucleus ventralis intermedius of the thalamus. The patient's tremor and rigidity disappeared and have not appeared again for more than 1 year since the eighth postoperative month. A method for converting the presurgically planned stereotactic coordinates in the atlas coordinate system to the coordinates in the frame coordinate system is described.
As HMO enrollment climbs, managed care companies like Sacramento-based Foundation Health are turning to easily upgradable systems to give management and customers the information edge they need to thrive in the 1990s.
The evaluation of computer expert systems, a promising diagnostic tool for future application in clinical medicine, is of great importance. We present here the evaluation of our expert system, "RHEUMA". It is stressed, that repeated retrospective testing and updating of an expert system and its subsequent repeated assessment in clinical use and surroundings is mandatory. This increases the diagnostic accuracy of the system. For our system this is demonstrated under three separate conditions. In the first study the information available for the computer system (mainframe) came from medical histories only. Here an error rate of about 25%--similar to that of physicians themselves using the same information--was observed in 358 outpatients, compared to the final diagnoses of physicians also relying solely on information from medical histories. In a second step a completely new system on a personal computer was developed with all relevant diagnostic information. The error rate of this system (0.4%) was much too optimistic because the knowledge base was changed during the study, affecting about 30% of the 282 prospectively recruited outpatients. In a third step the efficacy of the expert system was tested in an additional hospital without the diagnostic involvement of the first testing clinic. The error rate of the system without changing the knowledge base reached 11% in 51 outpatients in this rheumatology clinic. This result reflects the diagnostic accuracy of the system today. Its ability to specify the same diagnoses which clinical experts reached approached 90%. Considerable time is needed for such prospective testing, with repeated updating of the knowledge base--in our case for both the two systems and field studies of 2 years each.(ABSTRACT TRUNCATED AT 250 WORDS)
Computerized provider order entry (CPOE) systems are designed to replace a hospital's paper-based ordering system. They allow users to electronically write the full range of orders, maintain an online medication administration record, and review changes made to an order by successive personnel. They also offer safety alerts that are triggered when an unsafe order (such as for a duplicate drug therapy) is entered, as well as clinical decision support to guide caregivers to less expensive alternatives or to choices that better fit established hospital protocols. CPOE systems can, when correctly configured, markedly increase efficiency and improve patient safety and patient care. However, facilities need to recognize that currently available CPOE systems require a tremendous amount of time and effort to be spent in customization before their safety and clinical support features can be effectively implemented. What's more, even after they've been customized, the systems may still allow certain unsafe orders to be entered. Thus, CPOE systems are not currently a quick or easy remedy for medical errors. ECRI's Evaluation of CPOE systems--conducted in collaboration with the Institute for Safe Medication Practices (ISMP)--discusses these and other related issues. It also examines and compares CPOE systems from three suppliers: Eclipsys Corp., IDX Systems Corp., and Siemens Medical Solutions Health Services Corp. Our testing focuses primarily on the systems' interfacing capabilities, patient safeguards, and ease of use.
A layered system is under development to enhance our legacy system as a backend in a WEB-enabled system. Each layer of the system has defined functionality, leverages the investment in the layer below, and follows the strategy of reducing support requirements for workstations. The mainframe system provides administrative integration of sub-systems, security, and the central data repository for most information. The second layer is a graphical user interface (GUI) to the system for Windows platforms. Support needs are limited by relying chiefly on X-terminals and application servers. The "Intranet" layer is a WEB Server building upon the second layer gateways to provide platform-independent access to selected information and images. The fourth layer, under evaluation, will extend access to the central data repository for Internet users of web browsers that support private-key/public-key encryption.
We were given the opportunity to design and implement a general data processing system to accommodate several different epidemiologic studies to be conducted by a new research group. A survey of 15 operating data centers was conducted in preparation for undertaking the design and development of our system. The results of the survey indicated that data processing activities can be classified, both conceptually and operationally, into three modules: data recording and data entry, data management, and data analysis, and that the data management functions were those amenable to generalization. Based on our survey and the varying needs of our studies, we selected a "mixed" hardware environment, using both a computer center mainframe and microcomputers. We created the systems using commercially available software, including a mainframe database manager and mainframe statistics packages, microcomputer data entry software, and a communications package to link the two environments. Our strategy was to buy software, when possible, rather than to build custom programs, and to let software tools govern hardware needs. Hardware independence, price, and functional capability directed our software choices, while hardware selection was constrained most importantly by available software, then by budget, by available computing resources, and finally by the marketplace. The system has been used successfully in three studies differing in design, size, data collection locale, and rate of data accrual.
The Columbia Clinical Repository is the foundation of the Clinical Information System at the Columbia Presbyterian Medical Center (CPMC). The Repository is implemented as a relational database on an IBM mainframe, using a generic design that employs a small number of tables. Client applications on remote platforms send and receive data through Database Access Modules (DAMs), which support the HL7 protocol, while applications on the mainframe manipulate data through DAMs supporting a locally defined "query template". Implementation using static (compiled) SQL is compared to dynamic (ad hoc) SQL in terms of efficiency and flexibility.
In conclusion, the successful implementation of a medical record abstracting system was realized due to the following factors: extensive planning, thorough organization of tasks, controlled implementation, and ongoing controls. While thorough planning and organization will result in an efficient implementation, ongoing controls will ensure continued success and produce high quality results for any medical record system.
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A microcomputer mainframe linked system is described which allows video camera data capture and storage of one-dimensional whole-cell protein electrophoresis gel images, processing of normalized traces to produce a similarity matrix, and analysis of the matrix using the commercial cluster analysis program CLUSTAN. A new similarity coefficient is introduced which takes into account both band position and intensity. Forty-five strains of Haemophilus influenzae, including the eight biotypes and six serotypes, were analyzed using this system. Results demonstrated groupings which are consistent with known genetic relationships.
A prospective audit of the frequency of infective complications after all abdominal operations was carried out between January 1977 and December 1986. A total of 3100 abdominal procedures (2041 elective; 1059 emergency) were performed in 3056 patients. There were 50 (1.6 per cent) in-hospital and 66 (2.1 per cent) late wound infections (overall 3.7 per cent). Fifty-four (1.8 per cent) patients developed postoperative intraperitoneal sepsis. Ninety-eight patients died (overall mortality 3.2 per cent) and intraperitoneal sepsis was a related factor in twelve (0.4 per cent). Wound infection, peritoneal sepsis and mortality were related to the degree of operative contamination and to reoperation. The results support the traditional, although sometimes inadequately stressed, teaching that technique is an important factor in preventing infection. Infection is also reduced by peroperative antibiotic lavage. The limited value and the potential difficulties of the unstructured introduction of computerized audit should be recognized.
The current status of mathematical models of biological systems is reviewed. Advances in supercomputer hardware allows more complex models to be constructed. The new generation of microcomputers are quite adequate for many computer simulations of biological systems. A theory of modeling is being developed to improve the relationship between the real biological system and the model. Deterministic models, stochastic models and applications of control theory and optimization methods are discussed. Examples given include models of molecular structure, of experimental techniques, and of biochemical reactions. It is recommended that experimental biologists consider the use of microcomputers to model the system under study as a part of their research program.
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