1. History of Health Information Technology in the U.S.
Evolution of Health IT: The Early Years
Welcome to History of Health Information Technology in the US, Evolution of Health IT: The Early Years. This is Lecture B, The 1970s. This lecture will discuss some of the major changes that occurred in health IT during the 1970s. Although some developments began in the late 60s they began to have more of a presence in the 70s.
Lecture b – The 1970s
This material (Comp 5 Unit 1) was developed by the University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007.
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2. Evolution of Health IT: The Early Years Learning Objectives
Discuss how the problem-oriented medical record changed the structure of medical records
Discuss the impact that increased access to healthcare had on the use of computers in healthcare in the 1970s
Describe how key informatics innovations such as the problem-oriented medical record, MEDLINE, early EMRs and CDSS relate to the general healthcare environment of the 1970s
Describe some of the early forerunners of today’s EHR including COSTAR, TMR, and the Regenstrief CPRS
Describe early clinical decision support systems including INTERNIST-1, MYCIN and the HELP system
The Objectives for this lecture, The 1970s are to:
Discuss how the problem-oriented medical record changed the structure of medical records.
Discuss the impact that increased access to healthcare had on the use of computers in healthcare in the 1970s.
Describe how key informatics innovations such as the problem-oriented medical record, Medline, early EMRs and CDSS relate to the general healthcare environment of the 1970s.
Describe some of the early forerunners of today’s EHR including COSTAR, TMR, and the Regenstrief CPRS.
Describe early clinical decision support systems including Internist-1, Mycin and the HELP system.

3. General Environment – 1970s
Access to higher education
Increase in science funding
Science applied to education
Mainframe computers
Computer specialists in industry
During the 1970s we saw not only increased access to higher education, but also increases in science and education funding. This was related to the perceived need to improve our science education in order to compete with the Russian space program.
At this time the emphasis was also on science applied to education. That is, not only did we need to improve science education, but we were going to make the entire process of education more systematic and scientific.
In terms of computers, the US had mainly mainframe computers during this time period, and who used them? Computer specialists in industry, research or the business sector were basically the only people who used computers or were comfortable with them. These were the people who were specialists in computer science or information technology or computer programming. Computers were not yet a routine part of the educational process.

4. Mainframe Computers (Courtesy: Lawrence Livermore National Laboratory)
This picture shows how big the old mainframes were.
(Courtesy: Lawrence Livermore National Laboratory)

5. Healthcare Environment – 1970s
Increase in medical students
Increase in NIH funding
Fee-for-service practice model
Few controls on physicians
Escalating healthcare costs
Mainframe computers (fiscal)
Computer specialists
There were parallels in the healthcare environment to what was happening in the general environment.
Remember we said there was a fear of a physician shortage? The response to that fear was to begin admitting more medical students in the ‘70s, and actually increasing the number of medical schools as well. The emphasis on science in the schools and more opportunities for medical education led to more applicants to medical school.
The interest in improving science led to an increase in research funding. The National Institutes of Health, or NIH (Pronounced N-I-H), is the major governmental funding agency for medical research and its support for medical research increased during this decade.
The dominant practice model for physicians was the fee-for-service model, where physicians were able to be reimbursed for each service they provided. There was little control of physicians -- they were pretty much independent; no-one was watching over their shoulder.
It is not surprising, then, that the costs of medical care began to increase. In fact, given the state of clinical documentation, it would have been very difficult to monitor the costs or the quality of care that was being delivered even if anyone wanted to do so. Remember that medical records were mainly handwritten idiosyncratic notes kept in each practitioner’s office.
Computers were beginning to be used more in hospitals, but the focus there was primarily fiscal (billing, tracking charges, data processing, etcetera). Computers were not routinely used in the clinical setting. Most of the people working with computers were computer specialists.
Source: (Kalberer and Newell, 1979)

6. Healthcare Organizations
Increase revenue
Increase number of physicians
Increase in procedures, hospitalizations
Fiscal, data processing automation
Administrative Data Processing
Billing and Collections
Director of Data Processing
Within the healthcare organizations, great increases in revenue became possible. Hospitals could increase the number of physicians because that’s what would lead to an increase in procedures and hospitalizations, which would in turn increase revenues. Remember: physicians and hospitals were being reimbursed by Medicare and Medicaid for whatever they did, so the more they did, the more money they made, and the more money they made for the organization.
Computers in hospital settings were used mainly for fiscal, administrative, and data processing purposes. Automating data processing became important because the focus was on getting paid. Billing and collections were key areas and most hospitals had a Director of Data Processing. Because the information systems personnel were focused on supporting the administrative and fiscal applications, they did not need to know anything about the clinical environment, especially because doctors were not yet using computers at all to care for patients.

7. Physicians Solo, group private practice Artful application of science
Increase in use of technology
Increase in income
Physician dominance
No direct use of computers
The physicians at this time were in solo and group private practice and their focus was on what Marc Berg in his book, Rationalizing Medical Work, called the “artful application of scientific knowledge.” All the new scientific developments were being artfully applied by the physician. Medicine was still considered an art, but now we had more science to back it up. This increased use of technology led to an increase in physician income since at that time, and actually today also, physicians were paid more for doing procedures than for simply talking to patients.
Physicians remained key players in the healthcare environment and had basically nothing to do with computers. Remember, their values were focused on patient care. Computers were still seen as data processing and administrative tools, which in fact they were, and most physicians were not as interested in this aspect of healthcare.
Source: (Berg, 1997)

8. Academic Physicians Scientific practice of medicine Technology
“Objective” data
Emphasis on laboratory medicine
Systematic data collection/recording
Problem-oriented medical record
Now let’s look at the academic physicians. This is one of the key points that we should emphasize. In medical schools at this time there was a paradigm (pronounced para dime) shift in how medicine was viewed. Paradigm shifts mean that, rather suddenly, the entire way we look at the world changes. The term was popularized in a book by Thomas Kuhn (pronounced coon). Kuhn described how entire fields changed their worldview seemingly suddenly, even though in looking back, the evidence had been building for a long time. The shift in medicine was to look at medicine no longer as the artful application of science, but to believe in the value of the scientific practice of medicine.
With the increase in medical technology, came so-called “objective” data. For instance, there was a new emphasis on the use of laboratory data over subjective clinical data. There are both good and bad aspects to this phenomenon, but it clearly represented a change from the previous values of the profession.
We also saw this paradigm shift in terms of an increased emphasis in systematic data collection and recording. Dr. Lawrence Weed’s problem-oriented medical record (which most healthcare providers take for granted today) really began in the late 60s and was flourishing by the early 70s. Now it’s standard in the US and around the world, and provides a model for the structure of most electronic medical records today.
Prior to that time, the medical record was a time-based diary of what happened to the patient. The problem-oriented medical record focused all activities around the Problem List, which allowed better tracking of what happened to each of the patient’s problems over time. The focus on teaching medical students Weed’s approach was a reflection of the desire to be systematic, organized, and “scientific” in the practice of medicine.
Source: (Berg, 1997, p. 22
Weed, 1968)

9. Old-Fashioned Progress Note
Here is an example of the kind of progress note used prior to the 1960s.

10. Problem List
This is an example of the kind of Problem List that Weed advocated.

11. SOAP Note
And here is an example of what is now called a SOAP (pronounced soap) note. SOAP stands for Subjective, Objective, Assessment and Plan. For each problem the physician would record the subjective data, the objective data, his or her assessment of what the data meant, and what the treatment plan was for that problem.

12. Academic Physicians 2 Scientific medical education
Behavioral objectives
Objective evaluation
Multiple choice tests
Problem-based learning
Teach medical problem solving
Not only were the academic physicians emphasizing the scientific practice of medicine, they were also determined to practice scientific medical education. Although there were few offices of medical education in the 1960s, they began to flourish in the 1970s. Educational specialists were brought into medical school to help make medical education more scientific.
We saw the focus in teaching in medical schools shift to behavioral objectives, which provided detailed specifications on what students were expected to learn. Evaluations shifted to objective evaluations, mainly using multiple choice tests. Most of you are very familiar with multiple choice tests and may have assumed that they were always the way testing was done, but in medicine that was not the case. Medical students in the US used to be evaluated by discussing real patient cases with their supervising physicians. There was no uniformity between medical schools or even between their instructors in how students were evaluated. Multiple choice tests carried the aura of educational science and have now become the dominant means of testing for medical licensure and certification.
While having a good bedside manner might still be considered an art, during the 1970s a new focus on teaching medical students to think scientifically began. What has been called problem-based learning and, more importantly, teaching students strategies for medical problem solving became a research and curricular focus.
This is not to say that we shouldn’t be more systematic in our teaching, or that any of these developments are inappropriate, but simply that they reflect a real shift in the thinking of what medicine and medical education should be. It clearly reflected the emphasis of the times that the scientific approach to teaching and learning was important.
Source: (Neufeld and Barrows, 1974)

13. Medical Informaticians
Automated clinical systems
Computers to promote the scientific practice of medicine
Access to knowledge and patient databases
MEDLINE
It was during this time period that some of the early informatics specialists began to apply the concepts of automation to clinical processes. For example, at Kaiser-Permanente (pronounced Kiser Permanentee) in California, one of the early leaders in informatics, Dr. Morris Collen (pronounced col (not coal) len), began work on automating some of the medical screening procedures. Kaiser-Permanente is now a nationwide healthcare system and continues to be a leader in the use of information technology.
Considering that many of the medical informaticians were physicians and medical faculty themselves,  and who were equally enamored with the scientific practice of medicine, it is no surprise they began to see the role of the computer as something that could be used to promote the scientific practice of medicine.
They were developing mechanisms for accessing knowledge and patient data bases. For example, MEDLINE (pronounced med line) (the online resource for accessing the biomedical literature) began at the National Library of Medicine in the 70s. Previously, Index Medicus (Pronounced med ih cuss), the paper index to biomedical literature, was found in the form of huge books in medical libraries. Index Medicus was updated on a regular basis with new volumes. MEDLINE contains the index of literature as far back as 1966, but if you go into medical libraries today, many of them will still have available the old Index Medicus.
Source: (Collen et al., 1971)

14. Medical Informaticians 2
Computers to systematize practice
Computer-based Patient Record
COSTAR – Mass General Hospital
TMR – Duke University Medical Center
RMRS – Regenstrief Institute
Expert systems research
Clinical decision support, reminders, alerts
MYCIN – Stanford
INTERNIST-1 – Pittsburgh
HELP – LDS Hospital
In addition to the use of computers to promote the scientific practice of medicine, the informaticians (Pronounced inform uh ticians) also focused on computers to systematize medical practice. We saw the development of the beginning of what were called then “computer-based patient records.” This term eventually became today’s “electronic health records.”
Some early examples of these are the COSTAR (Pronounced co-star) system at Massachusetts General Hospital developed by Octo Barnett and his colleagues, and a system called TMR , which stands for “The Medical Record” which was developed at Duke University by Ed Hammond and William Stead (Pronounced Sted like instead) and their colleagues.
As well, there was an outpatient record system that began in the 1970s and was developed at the Regenstrief (Pronounced REE gen streef) Medical Institute in Indianapolis. This record system is still in use and still cited as a “model system” today.
We also saw artificial intelligence methods applied to medicine in the form of expert systems. Expert systems tried to simulate the physicians’ thinking. The expert systems research of the 1970s included the MYCIN (Pronounced MICE-in) program for antibiotic recommendations from Stanford, and the INTERNIST-1 program at Pittsburgh which was a medical diagnostic program. These programs were a logical outgrowth of the idea that if medical problem solving can be taught to medical students, it could also be programmed into computers. Although both of these programs were research prototypes, the HELP (Pronounced help) system at LDS (Pronounced L-D-S) hospital, which also began about the same time in Utah, is still thriving today.
Sources: (Barnett et al., 1979, Hammond, 2001, McDonald et al., 1977,
Shortliffe and Buchanan, 1976, Miller et al., 1982, Warner et al., 1972)

15. Evolution of Health IT: The Early Years Summary — Lecture b
Fee-for-service medicine
Artful application of science
Teaching medical students the “scientific practice of medicine”
Automation of billing processes in hospitals
Research on clinical computer applications to make clinical practice more scientific and to systematize practice.
This concludes Lecture B of Evolution of Health IT: The Early Years.
In summary, the 70s healthcare environment with its emphasis on fee-for-service medicine and the artful application of science as well as the academic emphasis on promoting the scientific practice of medicine, saw supportive computer applications developing that reflected similar emphases. One type of application was automating the billing processes and capturing the revenue that was being generated. Pretty much entirely independently, other computer applications were being developed to make the practice of medicine more scientific. There was a lot of optimism about the potential of computers in medicine at this time. William Schwartz, in a 1970 article in the New England Journal of Medicine, predicted that within twenty years there would be vast changes in the practice of medicine due to the virtually complete incorporation of computers. As we all know, that did not happen quite as predicted.
Source: (Schwartz, 1970)

16. Evolution of Health IT: The Early Years References – Lecture b
Barnett GO, Justice NS, Somand ME et al. COSTAR – A computer-based medical information system for ambulatory care. Proc IEEE. 1979;67:
Berg M. Rationalizing medical work. decision-support techniques and medical practices. Cambridge, MA:MIT Press; 1997.
Collen MF, Davis LS, van Brunt EE. The computer medical record in health screening. Methods Inf Med. 1971;10(3):
Hammond WE. How the past teaches the future: ACMI distinguished lecture. J Am Med Inform Assoc. 2001;8(30):
Kalberer JT Jr, Newell GR Jr. Funding impact of the National Cancer Act and beyond. Cancer Res. 1979;
McDonald CJ, Murray R, Jeris D, Bhargava B, Seeger J, Blevins L. A computer-based record and clinical monitoring system for ambulatory care. Am J Public Health.1977;67(3):240-5.
Miller RA, Pople HE, Myers JD. INTERNIST-1: An experimental computer-based diagnostic consultant for general internal medicine. N Engl J Med.1982;307:
Neufeld VR , Barrows HS. The “McMaster Philosophy”: an approach to medical education. J Med Educ. 1974;49(11):
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17. Evolution of Health IT: The Early Years References 2 – Lecture b
Schwartz WB. Medicine and the computer: the promise and problems of change. N Engl J Med. 1970;283(3):
Shortliffe EH, Buchanan BG. A model of inexact reasoning in medicine. Math Biosci. 1976;23:
Warner HR, Olmsted CM, Rutherford BD. HELP, a program for medical decision-making. Comp Biomed Res. 1972;5:65-74.
Weed LL. Medical records that guide and teach. N Engl J Med Mar 14;278(11):
Weed LL. Medical records that guide and teach. N Engl J Med Mar 21;278(12):652-7 concl.
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18. History of Health Information Technology in the U. S
History of Health Information Technology in the U.S. Evolution of Health IT: The Early Years Lecture b
This material was developed by the University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007.
No Audio.
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