REMINISCENCE - HOSPITALS - PART 2

by BERNARD A HODSON

In Part 1 the feasibility and outline of an on line integrated hospital information system was described, along with the tremendous interest it generated around the world. This follow on article briefly describes the system approach that was used. In some ways the project brought the mystiques of medicine and computer science together - like attracting poles.

The system was designed to use a large scale omputer on a real time basis. This in fact means that the computer can be used for hospital's functions twenty-four hours a day, seven days a week. It did not mean, however, that the computer would be in actual use for the hospital functions every minute of the twenty-four hours, no 200 bed hospital (the size of the hospital being piloted) could have afforded the system. It was estimated that less than one hour per day of actual computer time was needed when the system was fully operational. Had a small computer been used, it would have had to be used by the hospital alone or in conjunction with one or two other hospitals, but the unit cost of operation would have been considerably higher.

The objective of the system was to capture all data once only, as follows:
  1. Patient admitting data.
  2. The recording of Doctor's Orders and the inclusion of these in the patient's record, together with the necessary operations to transfer these Doctor's Orders into action.
  3. The capture of the results of laboratory tests, of X-rays and of other services, placing them in the patient record.
  4. Monitoring drug activity ordered for, and given to, the patient.
  5. The ancillary capture of data needed to run the hospital but which generally is not captured in the patient's record. This included such data as personnel data, the receipt of goods from Purchase Orders, Pharmacy inventory, etc.

At each Nursing Station and throughout the hospital there were to be computer video terminals. These monitors were to be used by Ward Clerks, Nurses and Doctors, after suitable identification, for communicating with the hospital departments and, in particular, to have access to the patients' medical records.

A typical sequence of activity is now presented. It should be emphasised that this approach is now quite common in business but had not been tried heretofore, and it was before the era of mouse availability, selection being by key depression. The screen presentations are also shown linearly to save presentation space although in fact they were vertical displays.

After suitable identification of the user, a base screen would be presented on the monitor such as:
  1. DOCTORS ORDERS
  2. OBSERVATIONS
  3. PATIENT HISTORY
  4. PHYSICAL EXAM
  5. LAB REPORT
  6. ADMIT PATIENT
  7. EXAMINATION OF PATIENT RECORD

If a 1 was selected the system would check that a nurse was at the terminal (wishing to report on a patient) and present a screen showing categories of doctors' order, such as:
  1. ALIMENTARY SYSTEM
  2. CARDIOVASCULAR SYSTEM
  3. EMOTIONAL STATUS
  4. GENERAL SIGNS AND SYMPTOMS
  5. GENITO-URINARY SYSTEM
  6. INTRA VENOUS THERAPY
  7. LOCOMOTOR SYSTEM
  8. NERVOUS SYSTEM
  9. PAIN
  10. PATIENT HAVING SURGERY
  11. RESPIRATORY SYSTEM

If the nurse now selected 2 it would indicate a report on the cardiovascular system was needed, giving:
CARDIOVASCULAR SYSTEM
  1. PULSE AND HEART RATE
  2. EDEMA
  3. BLEEDING
  4. LYMPH NODES
  5. OBSERVATIONS

Selection of 3 by the nurse might then lead to presentation of a display on bleeding, and a selection from that screen would complete the nurses input. At some point, usually at the beginning of the sequence, the patient would have been identified.

If a nurse indicated a wish to make several observations, the computer software would keep track of the sequence of selections, and a summary of the selections made presented on the screen for verification. If accepted the transaction would be processed. In the above 'nurses note' sequence the nurses' observation would be placed on the patient record. Other types of sequence entered by authorised personnel might involve preparation of a prescription, a request for an X-ray or physiotherapy.

The hospital activity was broken down to a sequence of screens similar to those just described, and allowed any type of transaction for the patient to be handled quite quickly, once the staff had become familiar with the process.

It soon became evident that the structure developed for use by doctors and nurses, and the technique for handling the structure, were useful in other non hospital environments, the project having shown its usefulness in handling supply orders, doctors' orders, nurses' notes on patient progress, medication orders, admitting and discharge functions.

It meant that the systems methodology and generalised software could now be considered for a variety of other application outside the hospital, and was further proof that the concept of a single piece of software to handle all applications was quite practical. This was done for a business credit system with Creditel, demonstrated effectively in Vancouver, and for on line accounting. It was also a useful instructional tool.

As the displays are being presented and choices being made, checks were being carried out by the software. For instance certain responses must be followed by certain other responses (e.g. a drug order must have a route (oral, intravenous), treatments must have an associated time. Any contravention of these rules caused a warning message to be presented. Any data manually entered would have validity checks before acceptance. This was accomplished by associating with each display an internally stored edit table. Also internally stored was a destination table which was used when the transaction was accepted as correct. This would result in a transaction message going to another screen (e.g. a supply order to Central Supply, a drug order to the Pharmacy) and to transfer a copy as appropriate to the patient file.

While this and other projects showed the potential for integrated hospital information systems there was a great reluctance by hospital administrators and Health Authorities to go this route until many years later due, in part, to the cost of systems development and the horrendous cost of software where a generalised approach was not being used.