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Man and computer: Computer applications in medicine
Compur. Biol. Med.
Pergamon Press 1973, Vol. 3, pp. 451-454.
Printed in Great Britain.
Man and Computer: Computer Applications in Medicine RALPH S. HORVATH* Department
of
Electrical
Engineering,
Michigan
Michigan
(Received
49931,
Technological
University,
Houghton,
U.S.A.
2 January
1973)
Abstract-The second international conference L’Homme et I’lnformatique (Man and Computer) was held in Bordeaux, France, under the sponsorship of L’lnstitut de la Vie (The Institute of Life) of Paris, during 11-16 September 1972. Of approximately 120 computer scientists and engineers and computer users (educators, physicians, sociologists, economists, urban planners, etc.) from twenty-one countries attending the conference, thirty were in the group on computer applications in medicine. This group presented and discussed fifteen papers on such topics as “Hospital Information and Data Systems”, “Computer Aided Instruction in Medicine”, “Computer Applications in Pharmacokinetics”, “Computer Aided Diagnosis”, “Patient Monitoring”. “Comuuter Aided X-rav Evaluation”. and “Social and Moral Implications of the Use of Computers m Medicine”. Following the presentation of a report on this work to a plenary session of the conference and a subsequent discussion, the group formulated a final report which included conclusions, prognostications, and resolutions in the above areas. THE SECOND international facilities
in Bordeaux,
conference
France,
during
L’Homme
et l’lnformatique
11-16 September
was held
1972. The conference
at the Le Lac was sponsored
by L’ltutitut de la Vie in cooperation with several agencies of the French federal government and several private international organizations. The Institut is a world-wide organization which is dedicated to the improvement of everyday life by the application of the tools of science. The organization was founded in France, and its home office is in Paris. Conference proceedings will be published by L’lnstitut de la Vie. Professor Dr. M. Marois, the conference secretary, divided the conference into five groups: 1. Computers and Education, 2. Computers and Medicine, 3. Impact of Computers on Individual Life, 4. Computers and Human Settlement, 5. Decision making, Planning and Socio-Economic Organization. The opening plenary session was followed by parallel paper sessions held by each of the five groups simultaneously. These latter sessions totalled approximately 16 hr of meeting time during the first 3 days of the conference. On the fourth and fifth days of the conference, an individual member of each group (the general reporter) presented a summary of that group’s work at a plenary session. The group chairman directed a discussion among the entire body immediately following the report. The results of the discussion were then merged with the ideas and opinions of the group members into a final report which each reporter or chairman then presented to another plenary session held on the morning of the sixth day. Each of the final reports included the conclusions and resolutions of the group. In the first session of the computer and medicine group the chairman, Dr. Andre Cournand of Columbia University, presented a brief historical sketch of the medical applications on computers including some of his personal interests and those of many of his associates. *Member of IEEE. 451
452
RALPHS. HORVATH
He emphasized the need to maintain the proper perspective. His own words perhaps best sum up his remarks, “The computer is a tool for technology, but no surrogate for man.” The group then heard and discussed a total of fifteen papers.* The speakers were urged to keep their talks short enough so as to limit the total time devoted to each paper, including discussion, to approximately 45 min. Unfortunately, some had prepared longer papers and were unable to shorten them. As a result the discussions were somewhat limited. In the first presentation Dr. Gronroos described an on-line operating hospital information system in use at Central Hospital, Tampere, Finland. This system is one of the few successful attempts to implement a hospital information system with a small computer (IBM 1130). Even though the particular system was of rather limited scope, the group agreed that its success reflected an efficient utilization of the computer. Dr. Gronroos admitted that the problems of positive specimen identification and the structure of the patient history forms were still not completely solved. However, the administrators and floor nurses who are most intimately involved in its use agreed that the system had resulted in a definite monetary savings. Dr. Varet described a computer-aided-instruction application being used in Paris which is rather unique. The system he described is used to teach hematology to medical students. In this system the student interacts with the computer via an alpha-numeric keyboard, a CRT display, and a computer-controlled slide projector. Another application in medical education was described in a paper written by Dr. Rifkind of the Columbia Medical School which was read by Dr. Cournand. This system was developed to simulate and complement the typical bedside teaching-diagnostic interaction between the physician-teacher and the student. The system includes a free-language approach whereby the student may converse with the computer in a nearly “free-form” fashion. In the absence of the author, it was not certain as to how free the language is or how it is implemented. In the next session Dr. Benet of the University of California presented a tutorial paper on computer applications in pharmacokinetics, the study of the clinical pharmacology of drugs. He described a particular modeling process he has been applying in this area and provided several lucid examples of successful models including clinical results. One successful result which may be of particular interest is the recent development of a digoxin dosage program which has reduced toxicity in the prescribing of digoxin from the normal 20 per cent rate to about 2.5 per cent. This program is now available for use by outside physicians as well. Dr. Dubois then described the DARC system, a pharmacological modeling technique with which he has been working in Paris. The technique employs linear graph theory and similar topological concepts to describe the chemical structure of known compounds in matrix form. A transformation is then assumed to exist which results in a translation of these topological properties into known activity properties. By solving for the inverse transformation in a large number of known cases he attempts to extract the critical transformation information to enable the formulation of other compound matrices having similar activity properties. Preliminary results indicate that the method can provide valid clues to desired compound structure. The next series of papers dealt with diagnostics and diagnostic aids. Dr. Pirtkien described a toxicological diagnostic program in use at Kiel, Germany. It uses a one-time input (no dialogue) combination boolean crossing and statistical decision scheme which provides * The author has the address of each author who presented a paper and will supply same on request.
Man and computer: computer applications to medicine
453
sufficient detail in the print-out to guide the physician to a number of alternatives in the selection of the likely toxicologic agent. The system is operational and is limited only by the size of its data bank. Dr. Pirtkien voiced a plea for more contributions to the data bank, i.e. proven cases of poisonings with symptoms and toxic agent. Dr. Victor then discussed the philosophy of computerized medical diagnostics and several possible approaches, He favored the data bank approach described by Dr. Pirtkien, but also emphasized the desirability of the dialogue interaction approach. He also pointed out the importance of nosology, the clarification of diagnostic terms, and the secondary role of diagnoses behind the primary goal of therapy. Dr. Bonner of IBM (New York) reviewed the status of computerized electrocardiogram analyses. He outlined the original reasons for such analyses, the results and applicability and possible future trends in the area. Mr. Bush then described several cardiological diagnostic aids developed by Dr. Warner’s team at the Latter Day Saint’s Hospital. Included were a computerized catheterization clinic, an electrocardiogram analysis program suitable for use with exercising patients, and an X-ray interpretation program which determines ventricular chamber size semi-automatically directly from standard angiographic X-ray photographs. Dr. Giloi described the pattern recognition work he was involved with at Saarlandes. The system he described has as its goal the presentation of a three-dimensional (perspective) moving picture of the beating heart based on a series of X-ray photographs taken in several planes. He described the display system and some of the processing procedures used in this project. The subject of computer based intensive care and patient monitoring was discussed in two papers. Dr. Beaumont of IBM described the unit at the Pacific Medical Center in San Francisco, and Mr. Morgan described the one at Westminster Hospital in London. Dr. Beaumont expressed concern over the phasing out of research funds for such installations in favor of a fee-for-service structure. He pointed out that there are less than one dozen computer based intensive care units in the United States, and evaluation of such systems is incomplete at this time. He also mentioned several problem areas including the need for improved quality, interaction between the monitoring function and routine bedside nursing procedures, and defective equipment detection. Mr. Morgan described the Westminster system as having been integrated with an existing nursing procedure with emphasis on conversational interaction. This allows the system to be used by nurses without expert help. Dr. Reichertz described a completely integrated hospital information system which has been in use (in varying stages of development) in Hanover since 1969. The system combines the functions of data acquisition, data analysis and reduction, and information communication together with such ancillary functions as billing, inventory control, meal ordering, etc. The system is modularly organized and incorporates software systems developed at the Hanover Medical School and other centers throughout the world. The system will be capable of handling the entire hospital. This will include 2000 beds, about 21 000 admissions per year, and 80-100 EKG’s and 70 pathology reports per day. Dr. Vallbona of Baylor College of Medicine described his experiences in the automation of the Texas Institute of Rehabilitation and Research. This clinic uses a computer to automate the acquisition and reduction of data from physiological testing procedures and to assist in history taking, scheduling, billing, and planning. Dr. Vallbona’s comments on patient files, confidentiality, accessability and security sparked a discussion on the social and moral implications in the use of computers in a clinical environment.
454
RALPH SHORVATH
In the final paper Dr. Vienot from the Paris office of IBM described the mandatory medical examination program in France. Since 1946 federal law has required each employer in France to provide for each employee an annual physical examination. Dr. Vienot pointed out the wealth of medical statistics available from a program such as this. He also indicated the need for concrete ready-to-use time-saving systems which are fool-proof, medically sound, simple to use, and require no complex ancillary equipment in the physician’s office. He cited in particular the various automated EKG analyses and the mass screening or automated multiphasic health testing systems. The general reporter for the group, Dr. Horvath of Michigan Technological University, summarized the above papers in a report to the plenary session on the fourth day. This was followed by another plenary session in which members of other groups discussed the subjects described in the summary. The computer and medicine group then met for several informal sessions to prepare a final report which was delivered by Dr. Horvath during the closing plenary session on the sixth day. The final report of the group on computer applications in medicine was divided into three parts : conclusions, prognostications, and resolutions. The conclusion section emphasized the fact that the computer is being used to solve practical problems in the medical field and, as a result, we are starting to see changes in attitudes on the part of hospital personnel, physicians, and medical educators. It also pointed out that the lack of an objective method of cost justification often makes it difficult to initiate certain applications. The prognostications were presented as fairly optimistic but somewhat conservative. The future effect of the computer in the field of medicine was seen to be not that of a revolution, but rather that of a steady evolution along existing lines. In the resolution section the group cited the need for several broad avenues of future development. The major resolution was a call for a world-wide standardization of documentation for signs, symptoms, syndromes, and tests. The increased exchanging and interweaving of programs from many sources in different parts of the world seems to make such standardization mandatory. The group also called for work on extending many of the current systems to applications in the individual physician’s office or clinic. The group urged that in areas where computers are finding clinical application the physician’s education should reflect that fact. Another recommendation was that medical computer systems should be considered as research projects for funding purposes at least until methods for evaluation are developed, and these systems are successfully evaluated. As a final point, the group called for a considerable public relations effort to explain to the public in realistic terms the actual role which computers are playing in medicine today. The group felt that the media have over-emphasized the glamorous aspects of this role and ignored the more long-term, wide-range benefits. The emphasis should be on the use of the computer as a “tool for technology, not a surrogate for man”. The proceedings of the conference are being edited by Professor Dr. Marois of L’lnstituf de la vie and will be published by the Institut as soon as possible. The possibility of a third international conference on Man and Computer was mentioned, but no definite plans have been made at this time.
Pergamon Press 1973, Vol. 3, pp. 451-454.
Printed in Great Britain.
Man and Computer: Computer Applications in Medicine RALPH S. HORVATH* Department
of
Electrical
Engineering,
Michigan
Michigan
(Received
49931,
Technological
University,
Houghton,
U.S.A.
2 January
1973)
Abstract-The second international conference L’Homme et I’lnformatique (Man and Computer) was held in Bordeaux, France, under the sponsorship of L’lnstitut de la Vie (The Institute of Life) of Paris, during 11-16 September 1972. Of approximately 120 computer scientists and engineers and computer users (educators, physicians, sociologists, economists, urban planners, etc.) from twenty-one countries attending the conference, thirty were in the group on computer applications in medicine. This group presented and discussed fifteen papers on such topics as “Hospital Information and Data Systems”, “Computer Aided Instruction in Medicine”, “Computer Applications in Pharmacokinetics”, “Computer Aided Diagnosis”, “Patient Monitoring”. “Comuuter Aided X-rav Evaluation”. and “Social and Moral Implications of the Use of Computers m Medicine”. Following the presentation of a report on this work to a plenary session of the conference and a subsequent discussion, the group formulated a final report which included conclusions, prognostications, and resolutions in the above areas. THE SECOND international facilities
in Bordeaux,
conference
France,
during
L’Homme
et l’lnformatique
11-16 September
was held
1972. The conference
at the Le Lac was sponsored
by L’ltutitut de la Vie in cooperation with several agencies of the French federal government and several private international organizations. The Institut is a world-wide organization which is dedicated to the improvement of everyday life by the application of the tools of science. The organization was founded in France, and its home office is in Paris. Conference proceedings will be published by L’lnstitut de la Vie. Professor Dr. M. Marois, the conference secretary, divided the conference into five groups: 1. Computers and Education, 2. Computers and Medicine, 3. Impact of Computers on Individual Life, 4. Computers and Human Settlement, 5. Decision making, Planning and Socio-Economic Organization. The opening plenary session was followed by parallel paper sessions held by each of the five groups simultaneously. These latter sessions totalled approximately 16 hr of meeting time during the first 3 days of the conference. On the fourth and fifth days of the conference, an individual member of each group (the general reporter) presented a summary of that group’s work at a plenary session. The group chairman directed a discussion among the entire body immediately following the report. The results of the discussion were then merged with the ideas and opinions of the group members into a final report which each reporter or chairman then presented to another plenary session held on the morning of the sixth day. Each of the final reports included the conclusions and resolutions of the group. In the first session of the computer and medicine group the chairman, Dr. Andre Cournand of Columbia University, presented a brief historical sketch of the medical applications on computers including some of his personal interests and those of many of his associates. *Member of IEEE. 451
452
RALPHS. HORVATH
He emphasized the need to maintain the proper perspective. His own words perhaps best sum up his remarks, “The computer is a tool for technology, but no surrogate for man.” The group then heard and discussed a total of fifteen papers.* The speakers were urged to keep their talks short enough so as to limit the total time devoted to each paper, including discussion, to approximately 45 min. Unfortunately, some had prepared longer papers and were unable to shorten them. As a result the discussions were somewhat limited. In the first presentation Dr. Gronroos described an on-line operating hospital information system in use at Central Hospital, Tampere, Finland. This system is one of the few successful attempts to implement a hospital information system with a small computer (IBM 1130). Even though the particular system was of rather limited scope, the group agreed that its success reflected an efficient utilization of the computer. Dr. Gronroos admitted that the problems of positive specimen identification and the structure of the patient history forms were still not completely solved. However, the administrators and floor nurses who are most intimately involved in its use agreed that the system had resulted in a definite monetary savings. Dr. Varet described a computer-aided-instruction application being used in Paris which is rather unique. The system he described is used to teach hematology to medical students. In this system the student interacts with the computer via an alpha-numeric keyboard, a CRT display, and a computer-controlled slide projector. Another application in medical education was described in a paper written by Dr. Rifkind of the Columbia Medical School which was read by Dr. Cournand. This system was developed to simulate and complement the typical bedside teaching-diagnostic interaction between the physician-teacher and the student. The system includes a free-language approach whereby the student may converse with the computer in a nearly “free-form” fashion. In the absence of the author, it was not certain as to how free the language is or how it is implemented. In the next session Dr. Benet of the University of California presented a tutorial paper on computer applications in pharmacokinetics, the study of the clinical pharmacology of drugs. He described a particular modeling process he has been applying in this area and provided several lucid examples of successful models including clinical results. One successful result which may be of particular interest is the recent development of a digoxin dosage program which has reduced toxicity in the prescribing of digoxin from the normal 20 per cent rate to about 2.5 per cent. This program is now available for use by outside physicians as well. Dr. Dubois then described the DARC system, a pharmacological modeling technique with which he has been working in Paris. The technique employs linear graph theory and similar topological concepts to describe the chemical structure of known compounds in matrix form. A transformation is then assumed to exist which results in a translation of these topological properties into known activity properties. By solving for the inverse transformation in a large number of known cases he attempts to extract the critical transformation information to enable the formulation of other compound matrices having similar activity properties. Preliminary results indicate that the method can provide valid clues to desired compound structure. The next series of papers dealt with diagnostics and diagnostic aids. Dr. Pirtkien described a toxicological diagnostic program in use at Kiel, Germany. It uses a one-time input (no dialogue) combination boolean crossing and statistical decision scheme which provides * The author has the address of each author who presented a paper and will supply same on request.
Man and computer: computer applications to medicine
453
sufficient detail in the print-out to guide the physician to a number of alternatives in the selection of the likely toxicologic agent. The system is operational and is limited only by the size of its data bank. Dr. Pirtkien voiced a plea for more contributions to the data bank, i.e. proven cases of poisonings with symptoms and toxic agent. Dr. Victor then discussed the philosophy of computerized medical diagnostics and several possible approaches, He favored the data bank approach described by Dr. Pirtkien, but also emphasized the desirability of the dialogue interaction approach. He also pointed out the importance of nosology, the clarification of diagnostic terms, and the secondary role of diagnoses behind the primary goal of therapy. Dr. Bonner of IBM (New York) reviewed the status of computerized electrocardiogram analyses. He outlined the original reasons for such analyses, the results and applicability and possible future trends in the area. Mr. Bush then described several cardiological diagnostic aids developed by Dr. Warner’s team at the Latter Day Saint’s Hospital. Included were a computerized catheterization clinic, an electrocardiogram analysis program suitable for use with exercising patients, and an X-ray interpretation program which determines ventricular chamber size semi-automatically directly from standard angiographic X-ray photographs. Dr. Giloi described the pattern recognition work he was involved with at Saarlandes. The system he described has as its goal the presentation of a three-dimensional (perspective) moving picture of the beating heart based on a series of X-ray photographs taken in several planes. He described the display system and some of the processing procedures used in this project. The subject of computer based intensive care and patient monitoring was discussed in two papers. Dr. Beaumont of IBM described the unit at the Pacific Medical Center in San Francisco, and Mr. Morgan described the one at Westminster Hospital in London. Dr. Beaumont expressed concern over the phasing out of research funds for such installations in favor of a fee-for-service structure. He pointed out that there are less than one dozen computer based intensive care units in the United States, and evaluation of such systems is incomplete at this time. He also mentioned several problem areas including the need for improved quality, interaction between the monitoring function and routine bedside nursing procedures, and defective equipment detection. Mr. Morgan described the Westminster system as having been integrated with an existing nursing procedure with emphasis on conversational interaction. This allows the system to be used by nurses without expert help. Dr. Reichertz described a completely integrated hospital information system which has been in use (in varying stages of development) in Hanover since 1969. The system combines the functions of data acquisition, data analysis and reduction, and information communication together with such ancillary functions as billing, inventory control, meal ordering, etc. The system is modularly organized and incorporates software systems developed at the Hanover Medical School and other centers throughout the world. The system will be capable of handling the entire hospital. This will include 2000 beds, about 21 000 admissions per year, and 80-100 EKG’s and 70 pathology reports per day. Dr. Vallbona of Baylor College of Medicine described his experiences in the automation of the Texas Institute of Rehabilitation and Research. This clinic uses a computer to automate the acquisition and reduction of data from physiological testing procedures and to assist in history taking, scheduling, billing, and planning. Dr. Vallbona’s comments on patient files, confidentiality, accessability and security sparked a discussion on the social and moral implications in the use of computers in a clinical environment.
454
RALPH SHORVATH
In the final paper Dr. Vienot from the Paris office of IBM described the mandatory medical examination program in France. Since 1946 federal law has required each employer in France to provide for each employee an annual physical examination. Dr. Vienot pointed out the wealth of medical statistics available from a program such as this. He also indicated the need for concrete ready-to-use time-saving systems which are fool-proof, medically sound, simple to use, and require no complex ancillary equipment in the physician’s office. He cited in particular the various automated EKG analyses and the mass screening or automated multiphasic health testing systems. The general reporter for the group, Dr. Horvath of Michigan Technological University, summarized the above papers in a report to the plenary session on the fourth day. This was followed by another plenary session in which members of other groups discussed the subjects described in the summary. The computer and medicine group then met for several informal sessions to prepare a final report which was delivered by Dr. Horvath during the closing plenary session on the sixth day. The final report of the group on computer applications in medicine was divided into three parts : conclusions, prognostications, and resolutions. The conclusion section emphasized the fact that the computer is being used to solve practical problems in the medical field and, as a result, we are starting to see changes in attitudes on the part of hospital personnel, physicians, and medical educators. It also pointed out that the lack of an objective method of cost justification often makes it difficult to initiate certain applications. The prognostications were presented as fairly optimistic but somewhat conservative. The future effect of the computer in the field of medicine was seen to be not that of a revolution, but rather that of a steady evolution along existing lines. In the resolution section the group cited the need for several broad avenues of future development. The major resolution was a call for a world-wide standardization of documentation for signs, symptoms, syndromes, and tests. The increased exchanging and interweaving of programs from many sources in different parts of the world seems to make such standardization mandatory. The group also called for work on extending many of the current systems to applications in the individual physician’s office or clinic. The group urged that in areas where computers are finding clinical application the physician’s education should reflect that fact. Another recommendation was that medical computer systems should be considered as research projects for funding purposes at least until methods for evaluation are developed, and these systems are successfully evaluated. As a final point, the group called for a considerable public relations effort to explain to the public in realistic terms the actual role which computers are playing in medicine today. The group felt that the media have over-emphasized the glamorous aspects of this role and ignored the more long-term, wide-range benefits. The emphasis should be on the use of the computer as a “tool for technology, not a surrogate for man”. The proceedings of the conference are being edited by Professor Dr. Marois of L’lnstituf de la vie and will be published by the Institut as soon as possible. The possibility of a third international conference on Man and Computer was mentioned, but no definite plans have been made at this time.