(WP )HIN/ICP/GPD/002 -E
ENGLISH ONLY
" I
~WORKING
GROUP ON APPLICATION OF INFORMATICS IN HEALTH
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, Philippines 20-24 April 1987
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Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines August 1987
NOTE The views expressed in this report are those of the members of the Working Group and do not necessarily reflect the policies of the Organization.
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This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for those who participated in the Working Group on Application of Informatics in Health, which was held in Manila, Philippines, from 20 to 24 April 1987.
CONTENTS
1. 1. 1 1.2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background.................................................. Objectives of the Working Group.............................
1 1 1
2. 2. 1 2.2 2.3
TECHNICAL PRESENTATIONS..................................... Working doc umen ts ........................ : . . . . • . . . . . . . . . . . . . Background documents........................................ Indications on current health informatics activities in the region...............................................
2 2
3 4 4
3.
RELEVANCE OF INFORMATICS TO HEALTH PROGRAMMES IN THE REGION. 3.1 3.2 Planning and management of informatics in health....... Informatics applications in support of health services management............................. Role of informatics in health workforce education and training •....•.•.•••.••••••••••••..••••• Health services delivery applications in informatics..
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3.3 3.4
6 6 6
4.
PRIORITY HEALTH INFORMATICS PROGRAMME SUPPORT FOR THE REGION 4.1 4.2 4.3 Policy and strategy....... .................... ......... Education and training................................. Informatics applications..............................
7 7 7
5.
RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . ACHIEVEMENTS OF THE WORKING GROUP ...........................
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6.
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ANNEX 1 - PROVISIONAL AGENDA .................................... ANNEX 2 - LIST OF MEMBERS, CONSULTANT AND SECRETARIAT ANNEX 3 - OPENING ADDRESS BY DR H. NAKAJIMA, REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC ............................... ANNEX 4 - CLOSING ADDRESS BY DR S.T. HAN, DIRECTOR, PROGRAMME MANAGEMENT, ON BEHALF OF THE REGIONAL DIRECTOR, WHO REGIONAL OF PICE POR THE WESTERN PACInC ........................
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ANNEX 5 - WORKING DOCUMENTS .................................... 21/22 ANNEX 6 - CONTRIBUTED PAPER: PERSONAL COMPUTERS TOWARDS THE 1990s .•.•...•.•......•.••...•.........•.• 63/64 ANNEX 7 - BIBLIOGRAPHy........................................... 71
1.
INTRODUCTION
1.1
Background
In recent years, the application of information technology to the health and medical sciences has been making a very significant impact on their management and delivery of services. It is envisaged that in the Eighth WHO General Programme of Work (1990-1995), health informatics (HI) will be a pragmatic entity. Recognizing the growing awareness of Member States in the Region concerning the importance of informatics in health and their need for programme support, a meeting of a Working Group on Application of Informatics in Health was convened at the World Health Organization (WHO) Regional Office for the Western Pacific, Manila, from 20 to 24 April 1987. This was the first meeting on the subject in the Region and it was the first time that operational recommendations for the development of health informatics were formulated. The Working Group was opened by the Regional Director, Dr H. Nakajima, who touched on the growing importance of the information age and its attendant implications in his opening address (Annex 3). Dr Nakajima also observed that in the area of health, the significance of health information technology has long been recognized by WHO through its support to Member States in programmes on health system management. The purpose of convening the Working Group was to tap the expertise of its members in recommending to the Regional Office the scope of a programme on health informatics so as to facilitate the formulation of policy and the development of programme guidelines for Member States in the Region. The meeting was attended by five senior health administrators and six health informatics experts from eight different countries, supported by the secretariat, including the Director of ISS/HQ, and Dr Rienhoff (Germany), who served as consultant. Following the opening address, Working Group members and the secretariat introduced themselves and gave brief descriptions of their working backgrounds. After that Dr S. Kaihara (Japan) was appointed as Chairman of the Working Group, with Dr W. Vermeulen (Samoa) as Vice Chairman and Dr K.C. Lun (Singapore) as Rapporteur. See Annex 2 for the full list of members, consultant and secretariat who participated in the WG. 1.2 Objectives of the Working Group
The objectives of the Working Group, formulated by Dr J. Robey, Operational Officer of the meeting, were as follows: (1) to review the state-of-the art of health/medical informatics in the areas of health systems management, facility management and health/medical education;
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(2) (3)
to provide the scope and guiding principles for implementation in these three areas; to make final recommendations on specific regional or national activities to be undertaken by WHO in promoting, developing, utilizing and maintaining health informatics, including procedures and mechanisms; to prepare a discussion document on "Informatics technology and health management" for the meeting of the Regional Committee at Beijing, China, in September 1987.
(4)
Dr Robey envisaged that in the Eighth WHO General Programme of Work (1990-1995), health informatics would be a pragmatic entity. The programme would have two elements: (1) support of informatics activities at WHO headquarters and its regional offices, and (2) outreach programmes to WHO Member States in support of health informatics activities. The focus of the Working Group would be to address the second element, i.e. activities relating to informatics in WHO Member States.
2.
TECHNICAL PRESENTATIONS
2.1
Working documents
Working documents were prepared by six members of the Working Group and were presented and discussed at the meeting in regard to the objectives of the Group: Dr D.M. Bennett (Australia) presented a paper on "Informatics application in hospital management", which introduced a method of classification of computer systems to guide their installation and implementation in hospitals. Dr W. Vermeulen (Samoa), in his paper "Informatics application in perspective health systems management - Samoa", described the experience of his country in the use of microcomputers for health management and suggested proposals on further applications that could be of practical value to the country's health service. He also offered suggestions on how WHO could help countries in the Western Pacific Region to capitdlize on the use of computer and telecommunications technologies in the health sector.
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Dr Young Soo Shin (Korea) gave a review of "Informatics application in hospital management" in which he described the various classifications of hospital information systems and cited justifications for the relevance of the technology to hospital management. Dr S. Kaihara (Japan) described "Contributions of the Hospital Computer Centre, University of Tokyo Hospital as a WHO Collaborating Centre for Medical Information in Health Informatics", reflecting his experiences specifically on the education sector. Dr Fu Lai (China) offered reasons to justify the need for countries to build their own health and biomedical information system. In his paper "Informatics Application in health literature services", he also discussed the principles and organizational requirements involved in the setting up of such systems. Dr B.W. Christmas (New Zealand) submitted a paper entitled "Informatics Application in health systems management - A user's view", which discussed how health information units and systems analysis groups could work with health managers to establish an effective system for the coordination and collation of information within the health system for the planning and management of health programmes. Problems in using this new technology were also discussed in the paper, one of which was the need for health managers to acquire the skills and motivation to use this technology effectively before the next decade. The full texts of the six working documents are given in Annex 5. 2.2 Background documents
Dr S. Mandil (Secretariat), in his capacity as Director of ISS/HQ, briefed members on the document "Present & potential Uses of informatics & Telematics in Health". He explained that the document was produced with the health decision maker in mind, as a manual to which he could refer when relating to informatics issues. The document could provide relevant materials for the preparation of the document to be issued by the Regional Director for the Technical Discussion on "Information technology and health management", which would be held in conjunction with the thirty-eighth session of the Regional Committee in Beijing in September 1987. Dr Mandil also gave favourable comments on another background document "Applications in Health" taken from the book "Microcomputers and their applications for developing countries". Further background information was given to the Working Group through the "draft regional medium-term programme" on informatics of the WHO/Western Pacific Regional Office.
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A resource document on "Personal computers towards the 1990s" was written by Dr Ishida (Japan), and given to the Working Group members (Annex 6). 2.3 Indications on current health informatics activities in the region
The local secretariat prepared presentations on examples of health informatics utilization in the Region. In order to brief the members of the Working Group regarding national experts, additional information was given for the various nations of the Western Pacific, the countries of the Indochina the large developing countries and China. The Working Group did not focus its discussions on the developed nations of the Region other than analyzing their potential contributions (e.g. collaborating centres) to the education and training of users and experts. Furthermore, the Working Group did not include medical informatics applications in tertiary care centres in its discussions and considerations. Dr Vermeulen (Samoa) and Dr Fu Lai (China) complemented this information by briefing the Working Group about various implications of health informatics use in their countries and about the shortcomings of the present support procedures.
3.
RELEVANCE OF INFORMATICS TO HEALTH PROGRAMMES IN THE REGION
The members of the Working Group organized themselves into four sub-work groups to look into recommendations that could be made for the application of informatics in the areas of health systems management, facility management and health/medical education. To facilitate the drawing up of recommendations, members were asked to examine the activity scope, benefits, limiting factors and priorities for the various country groups, bearing in mind that implementation would have to take place in biennial budgeting periods between 1988 and 1995. In addition, the members of the Working Group discussed the table of contents for the Technical Discussion document prepared in conjunction with the Regional Committee, drawn up by members of a task force. The Chairman sought the views of members as to whether the suggested topics were relevant as a framework for the document.
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After several revisions, the structure of the Technical Discussion document was accepted as follows:
INFORMATICS TECHNOLOGY AND HEALTH MANAGEMENT Technical Discussions 1. Introduction 1.1 1.2 1.3 2. History and terminology of health informatics Relevance to WHO programme Objectives and framework of the report
Review of relevant documents 2.1 2.2 Informatics and telematics in health Working Group report
3.
Application of health informatics in Western Pacific Region Member States 3.1 3.2 3.3 Support to management in health development Support to administration Support to patient care Health and biomedical information and documentation services Informatics in education and training Implications of the use of health informatics
3.4 3.5 3.6 4.
Management of health informatics 4.1 4.2 National health informatics policy Informatics personnel development Administrative and financial requisites
4.3
3.1
Planning and management of informatics in health
The sub-working group was asked to analyse the needs for national health informatics policies and the relationship between such a policy, including the design of a national health information system and the national health plan. The question of whether standards are needed at various levels for the guidelines on the application of health informatics also had to be discussed. The group had to consider national absorbability issues in informatics technology transfer regarding economic, human resources, and social implications.
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Last but not least, ideas should be formulated on how an informatics management locus should be institutionalised and how existing institutions could be strengthened, deciding on line or staff clearance, coordination power and budgetary issues. 3.2 Informatics applications in support of health services management
The sub-working group was asked to review how informatics can be used to monitor the performance of health service management and which methods could be introduced to improve the outcome of those services; what role should health informatics play in supporting the formulation of policies and technical programmes, their detailed planning, their budgeting, their evaluation and reprogramming, the considerations to be borne in mind being that management of supply and transport functions can be supported by informatics technology to a high degree. Finally, the importance of health informatics to public health statistics and to national research had to be analysed taking into account that standardized software, e.g. word processing, be introduced and speed up reporting function considerably. 3.3 Role of informatics in health workforce education and training
The sub-working group was asked to examine how informatics can be used to support educational and training activities in the health care system as well as how knowledge and practical experiences in HI can be obtained by health professionals of all levels. In addition the group had to analyze whether new types of professionals should be trained. All recommendations should be oriented towards developing countries, bearing in mind their overall health manpower planning problems with heavy priority on short-term feasibility. 3.4 Health services delivery applications in informatics
The sub-working group was asked to focus on those applications that are of highest relevance to health facility management in primary health care. It was requested to abstract from potentially useful applications in technical programmes of WHO or of specific examples in Member States to formulate in general how health informatics could support specific types of operational functions regardless of their specific implementation.
4.
PRIORITY HEALTH INFORMATICS PROGRAMME SUPPORT FOR THE REGION
The results of the discussions of the four sub-working groups were discussed in the plenum and underwent several interactive circles of further investigation in the sub-groups and additional plenary considerations.
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4.1
Policy and strategy
A national health informatics policy should be in harmony with existing national health policies or plans. It should aim at applying health informatics in an appropriate and cost-effective way so as to enhance the efficiency of information system support. Furthermore, in view of the rapid changes taking place in the health informatics field, the policy should stress the need for a well defined information systems development strategy including adequate resource allocations. To promote and coordinate the implementation of such policy, Member States should set up - preferably at the highest administrative level - a health informatics coordinating group. This committee - where appropriate could be linked with a health informatics technical unit, which in turn would oversee the health informatics applications at the operational level in the various health programmes. 4.2 Education and training
The Working Group clearly recognized that the successful use of informatics in the health sector depends on the availability of appropriately trained personnel at all professional and managerial levels. The health informatics literature published in the last years undoubtedly emphasizes that, independent of the state of development of a country, professional preparation is necessary to achieve a good cost-benefit ratio when introducing informatics technology into the health area. The Working Group related its recommendations to literature published in the last decade in health informatics. It agreed that health manpower development should focus on the establishment of inter-disciplinary groups of competence rather than on the education of individuals, who would work in isolation after promotion.
4.3 Informatics applications To enable certain similar regional level functions to be carried out such as directories, clearing-house activities, the networking of selected health informatics institutions or agencies was suggested. Such a network of national focal points for health informatics could also serve as the regional node in a global network permitting a wider range of data base and other information resource sharing, including informaticians from diverse experience backgrounds. In the event such centres of excellence in informatics were united into a network, they would provide the varied resources and sites for undertaking feasibility and pilot projects in systems design and testing of quality control procedures and standard development and promulgation. It is perceived that these network agents could establish strong coordinating and knowledge transfer linkages with other international
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and bilateral organizations engaged in health informatics activ~ties ~ith Member States of the Region. Some of these network or focal p01nt un1ts could be established WHO collaborating centres while others would be contributing their own expertise and experience on the basis of identification of their role to WHO by the official health organization of the government.
5.
RECOMMENDATIONS
The WHO/Western Pacific Regional Office should give the highest priority to the following:
5.1 (1)
Policy and strategy Member States should be encouraged to formulate a national health informatics policy, including the establishment of a national group charged with the promotion and coordination of the health informatics activities. Focal points or institutions involved in health informatics in both developed as well as developing countries of the Region should be established or formed into a network of collaboration in health informatics activities. Adequate resources should be allocated for health informatics activities. There should be collaboration in relevant activities of national informatics and health informatics association. Education and training Workshops on health informatics in health services development should be sponsored and organized for: high-level health officials mid-level managers health workers and their support staff
(2)
(3) (4) 5.2
(1)
(2)
Support should be promoted for the establishment of a regional network for exchange of information on health informatics and telematics training, application, software and health data bases.
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5.3 Informatics applications (1) A collaborative association should be established with participant Member States to undertake feasibility studies and pilot projects to investigate: (a) the use of informatics in a specific national health programme (such as Expanded Programme on Immunization) which covers all levels of administration from local (district/village) level to central (ministry/national) level; and the use of informatics in the management of several national health programmes at a specific level of administration in a Member State lower than national levels.
(b)
(2)
Support should be provided for the development and use of application software for the management of health facilities. Further, it is recommended as follows:
5.4 Policy and strategy (1) Strong coordinating linkages should be established with other international and bilateral agencies involved in health informatics activities with Member States.
5.5 Education and training (1) (2) Models of training courses in health informatics for various types of health personnel should be established. The development of audio-visual materials and Computer Assisted Instruction (CAl) software relevant to health, including health informatics for training and education should be encouraged, and support provided for the compilation of informatics resource directories, including software and consultants.
5.6 Informatics applications (1) Potential collaborating centres in health informatics in the Region should be identified to provide support for the conduct of research and training. Support should be provided for the strengthening of informatics use in academic and research institutions in terms of hardware, software and personnel.
(2)
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(3)
Transfer of information within and between countries through telematics/informatics applications in health data and literature services should be encouraged and facilitated. The standardization of computer-based registries and the application of data base technology in technical programmes and research projects, particularly in regard to project monitoring and quality control, should be encouraged. Standards on health data coding conventions, terminologies and confidentiality for data collection and processing activities should be reviewed and developed as necessary. The utilization of cheap and simple data entry devices and software should be encouraged and activities promoted to develop and test such technology. The development, acquisition and quality control of computer-aided sytems for prevention, diagnosis and treatment, etc. and risk analysis systems with emphasis on application at the primary health care level should be encouraged and supported.
(4)
(5)
(6)
(7)
6.
ACHIEVEMENTS OF THE WORKING GROUP
The closing remarks were delivered by Dr S.T. Han, Director, Programme Management, on behalf of the Regional Director (Annex 4). He congratulated the Working Group for successfully completing its tasks to identify and formulate operational recommendations on how to further develop health informatics activities in the Western Pacific Region. He also commended the Working Group for providing an outstanding example of how individuals with different areas of interests and specialization were able to come together and, through mutual understanding and dedicated effort, work cohesively as a group. Dr Han assured the members that the Regional Director would consider the recommendations with a high degree of interest. The essence of the work would be reported to the Regional Committee. The report of the Working Group and the Technical Discussion paper in conjunction with the Regional Committee Meeting were finalized the week after the meeting by the operational officer and the consultant, and were approved by the Chairman of the Working Group.
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ANNEX 1
AGENDA
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INTRODUCTION AND ORIENTATION Welcome address Introduction of participants and secretariat History and background of the working group Objectives of the working group Review of the agenda and work plan of the working group
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PRESENTATION OF DISCUSSION PAPERS: Informatics application in hospital management by Dr David Bennett, IMIA, Australia Informatics application in health literature services by Dr Fu Lai, Director, Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing, China Informatics application in hospital management by Dr Young Soo Shin, Deputy Director, Institute of Hospital Services, Seoul National University, Seoul, Republic of Korea Informatics application in health systems management A user's view by Dr B.W. Christmas, Deputy Director-General, Department of Health, Wellington, New Zealand Informatics application in perspective - Health systems management by Dr W. Vermeulen, Director-General of Health, Health Department, Apia, Samoa Contribution of the Hospital Computer Centre as a WHO Collaborating Centre for Medical Information in Health Informatics by Dr S. Kaihara, Professor and Director, University Hospital Computer Centre, University of Tokyo Hospital, Tokyo
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DISCUSSION OF PRESENTATIONS IN RELATION TO WORKING GROUP'S OBJECTIVES
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Annex 1
4
REVIEW AND COMMENT ON BACKGROUND DOCUMENTS IN RELATION TO WORKING GROUP'S OBJECTIVES Draft medium-term programme for informatics Technical Report on Present and Potential Uses of Informatics and Telematics in Health Applications in Health, excerpt from Microcomputers and Their Applications for Developing Countries (Report of an ad hoc panel on the use of microcomputers for developing countries, Westview Press,
1986) 5 6 7 WORK GROUPS I-IV: DISCUSSION AND RECOMMENDATIONS ON PROGRAMME SCOPE AND GUIDING PRINCIPLES PLENARY DISCUSSION OF AND SYNTHESIZATION OF WORK GROUP REPORT INTO A SINGLE DRAFT OF SCOPE AND PRINCIPLES DOCUMENT WORK GROUPS I-IV: DISCUSSION AND RECOMMENDATION ON SPECIFIC REGIONAL AND NATIONAL ACTIVITIES OF WHO IN PROMOTING, DEVELOPING, UTILIZING AND MAINTAINING INFORMATION SYSTEMS, INCORPORATING MODERN INFORMATICS PLENARY DISCUSSION OF AND SYNTHESIZATION OF ALL WORK GROUP DOCUMENTS INTO A SINGLE DRAFT DOCUMENT ON REGIONAL AND NATIONAL ACTIVITIES WORK GROUPS I-IV: DISCUSSION OF AND RECOMMENDATIONS FOR PRIORITY ACTIVITIES, PROCEDURES AND MECHANISMS FOR IMPLEMENTATION OF PROGRAMME AT REGIONAL AND NATIONAL LEVELS PLENARY DISCUSSION OF AND SYNTHESIZATION OF WORK GROUP REPORTS INTO A SINGLE DRAFT DOCUMENT ON PRIORITIES AND MECHANISMS DRAFTING SESSION - PLENARY AND/OR WORK GROUPS CLOSING CEREMONY PLENARY DISCUSSION OF WORK GROUP V'S DRAFT ON RCM TECHNICAL DISCUSSION GUIDE FOR INCORPORATION INTO THE FINAL REPORT ADOPTION OF WORKING GROUP REPORT, INCLUDING RECOMMENDATIONS AND TECHNICAL DISCUSSION GUIDE
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12 13 14
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ANNEX 2
INFORMATION BULLETIN NO. 2 LIST OF MEMBERS, CONSULTANT AND SECRETARIAT 1. AUSTRALIA MEMBERS
Dr David M. Bennett Tourello Avenue East Hawthorn Victoria 3123 Australia 22
CHINA
Dr Fu Lai Honorary Director Institute of Medical Information Chinese Academy of Medical Sciences Beijing Dr Shigekoto Kaihara Professor and Director Hospital Computer Centre University of Tokyo Hospital Tokyo Dr Haruhisa Ishida Professor Computer Centre University of Tokyo Tokyo
JAPAN
NEW ZEALAND
Dr Bryan W. Christmas Acting Chief Health Officer Department of Health Wellington
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Annex 2
PHILIPPINES
Mr Mario Taguiwalo Undersecretary of Health Chief, Secretary's Staff and Chairman, Executive Committee for Field Operation Department of Health San Lazaro Compound Sta. Cruz Manila Dr William Torres Officer-in-charge National Computer Centre Camp Aguinaldo Quezon City
REPUBLIC OF KOREA
Dr Young-Soo Shin Deputy Director and Professor Department of Health Services and Hospital Administration Seoul National University Seoul Dr Walter J. Vermeulen Director-General of Health Health Department Apia Dr K.C. Lun Senior Lecturer Department of Social Medicine and Public Health National University of Singapore Singapore 2. CONSULTANT
SAMOA
SINGAPORE
Dr Otto Rienhoff Professor, Medical Informatics and Head, Department of Medical Informatics University of Marburg Marburg Federal Republic of Germany
- 15/16 Annex 2
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3.
SECRETARIAT
Dr James M. Robey (Operational Officer) Regional Adviser in Health Information WHO Regional Office for the Western Pacific Manila Mr Merlowe An'derson Management and Research Support Officer WHO Regional Office for the Western Pacific Manila Dr V. Ermakov Regional AdViser Health Manpower Development WHO Regional Office tor the Western Pacific Manila Dr T. Imai Systems Analyst WHO Regional Office for the Western Pacific Manila Dr S.H. Mandil Direc1;or Division of Information Systems and Support WHO Headquarters Geneva Mr L. Murdocb Computer Systems Analyst WHO Regional Office for the Western Pacific Manila
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ANNEX 3
OPENING ADDRESS BY DR H. NAKAJIMA, REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC, AT THE WORKING GROUP ON APPLICATION OF INFORMATICS IN HEALTH, MANILA, 20-24 APRIL 1987
Distinguished members of the Working Group, Colleagues and Friends, It is a pleasure for me to welcome you here today to Manila and to this meeting of the Working Group on Application of Informatics in Health. It has been said that the 1980s ushered in a major change in the economic, political and social environment of developed countries. The economies of many large developed countries have shifted from an industrial base to an "information base". This change had been predicted and is well documented, as studies have shown, for example, that in the United States 46% of the gross national product is linked to information-related activities and that nearly half of the labour force works at some type of informationrelated job. Japan, West Germany, the United Kingdom and Sweden follow a similar path in their economic development. These countries are truly entering an age in which technology, especially electronics, is increasingly becoming the principal agent of social change. We have indeed entered the age of information with all of its attendent implications for developing countries. Some experts feel that the principal role of WHO and other international bodies in the near future will revolve around the transfer of knowledge, not only in health and medical affairs, but through the entire spectrum of science and technology. This phenomenon makes the substance of this working group both very timely and extremely important. The significance of informatics or health information technologies has long been recognized by the Organization. The WHO Regional Office for the Western Pacific has been cooperating with its Member States in the promotion and development of computer applications in their health systems management. This activity must be accelerated commensurately with its potential to contribute to the improvement of health care. The purpose of this working group is to review that potential, particularly for the developing countries of the Region and to recommend the scope of our programme of informatics for the future. I see you have a very full agenda and I am pleased that much of your time will be spent on the development of guiding principles for informatics programme development and policy formulation. If I were to make only a single recommendation to guide you in this effort, it would be to encourage you to keep in mind two things: first, that the health informatics programme must be developed in relation to the national health system and health plan; and second, that you arrive at recommendations for specific regional and country activities.
- 18 Annex 3
I should like to take this opportunity to express my appreciation to Dr Salah Mandil, Director of Information Systems and Support in Headquarters, who gives of his valuable time to be with us, and to Dr Otto Rienhoff, who kindly accepted to be the consultant to this Working Group. I would also like to thank those of you who prepared background papers for your valuable contributions to the preparation for this undertaking. Again, let me welcome you to Manila and to the WHO Regional Office for the Western Pacific. I look forward to receiVing your recommendations and I wish you a rewarding meeting and a pleasant stay in our city.
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ANNEX 4
CLOSING ADDRESS BY DR S.T. HAN, DIRECTOR, PROGRAMME MANAGEMENT, ON BEHALF OF DR H. NAKAJIMA, REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC, AT THE WORKING GROUP ON APPLICATION OF INFORMATICS IN HEALTH MANILA. 20-24 APRIL 1987
Distinguished Members of the Working Group. Colleagues and Friends, This Working Group has been meeting to identify and formulate recommendations to the Regional Director on how to encourage the further development of health informatics in the Western PacifiC Region. You have only had five days to analyse the potential benefits of applying a new technology to health care in regard to our global goal of health for all by the year 2000. When this Working Group was conceived and its tasks finally defined in late 1986, some had doubts whether such a difficult assignment could be performed. After reading the first draft of your recommendations. I have to acknowledge that you did your work much more effectively than many would have anticipated. During much of this week, I have been kept informed of the progress you made. Up to Wednesday, the ideas and reflections of health system managers as well as informatics speCialists were refreshing, sometimes confusing, but always on target and meaningful for our Region. Over the last two days, these assorted ideas have been aggregated into a clear and sensible picture of what might be accomplished in the Region in health informatics during the years to come. The collaboration in this Group has proved once again that the most relevant contributions on how to reach our goals usually result from fruitful exchanges between sCientists, administrators and others who work directly in the health field. I understand that at certain points there has been some difficulty in communication brought about perhaps by difference in levels of technical knowledge and background. However, this did not prevent the group from applying themselves to their work with enthusiasm. I congratulate this Working Group on providing us with an outstanding example of mutual understanding and dedicated effort, which is a prerequisite of any important achievement. You may rest assured that the Regional Director will consider your recommendations with the same high degree of interest and commitment that this group has exhibited in their development. The essence of your work will be reported to the Regional Committee meeting in Beijing later this year as part of our Technical Discussion. which should contribute to the success of that undertaking as well.
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Anne"x 4
Now I would like to express in behalf of Dr Nakajima our thanks to all of you and especially Dr Kaihara, your Chairman, Dr Vermeulen, your Vice Chairman and Dr Lun, your Rapporteur for an excellent job. Our thanks are also extended to your consultant, Dr Rienhoff, whose work in drafting the technical document will carryover into next week. I would like to also wish you a safe journey home and hope you have enjoyed your visit to Manila and our Regional Office. This meeting of the Working Group on Application of Informatics in Health is now closed.
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ANNEX 5
INFORMATICS APPLICATION IN HOSPITAL MANAGEMENT by
Dr D.M. Bennett
1
lSenior consultant, CT Bellamy and Associates, Melbourne, Australia
- 23 Annex 5 A. Introduction
Hospitals around the world have been installing computer systems for many years, but although most appeared to have been reasonably successful a small number have been outright failures. When we plan to install systems now we should be aware of the difficulties of the past if we are to avoid the risk of another failure. This paper proposes a method of classification of computer systems which may help to point out which systems carry a high risk of failure while others have almost none, and which systems can be undertaken by those who have limited experience with previous systems while others can be expected to return great benefits to those who can manage the risks. B. Category of system There are many ways to look at computer systems in hospitals. is to group them into business, medical and technical.
One way
Business computer systems handle financial and management information, but not patient information. Payroll, creditors, general ledger, stores, debtors, asset register, word processing, telephone directory and so on, are similar to those used in other commercial or government institutions, although some peculiarities of the funding arrangements often require the programmes to be customized for hospital use. Medical systems handle patient information, and are specific to hospitals and health care organizations. They include such things as patient master index, admission/discharge/transfers, waiting list, diagnosis coding, pathology systems, out-patient booking and order entry. Technical systems include a variety of applications of computers to analytical, monitoring and computational tasks. One or two would be impossible without computation, notably Computed Tomography (eT scan) and Nuclear Magnetic Resonance (NMR), but even the simplest of instruments nowadays will usually contain one or more microcomputers providing local intelligence, storage and perhaps communication with a central system. This classification has its uses but provides little insight into which systems fail and why. Most of the difficult systems appear to be second group (Medical) but we need to look further to find why some are harder than others. C. Class of Processing
There is a general classification of computer systems (used by James Martin in "Application Development without Programmers" and elsewhere) which uses the headings Computation, Data Processing, Information Processing and Knowledge Processing. Computation is the easiest task for a computer to do. It involves large amounts of arithmetic on data with an essentially simple structure, usually leads to a significant reduction in the amount of data, and only incidentally requires facilities for input/output and storage. Benefits arise in the reduction of time spent in manual computation or in enabling t~sks which would be impossible otherwise.
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Annex 5
The CT scanner, NMR and other imaging systems depend heavily on computation, but many of the technical systems and most of the other do not fall into this class. Data processing is the most familiar use of computers today. It involves transforming data from one form into another with little change in quantity. Depending on the time between the creation of the data and its entry into the computer system, they may be further divided into batch or online. The major benefits come from alleviation of clerical tasks (such as filing, cross-indexing and searching) and improvements in accuracy in those tasks compared to manual techniques. Most hospital systems in use today are classical data processing, including all of those listed above. Information processing is defined as the extraction of information from data, and takes over where the simple, pre-defined activities of data processing leave off. At its most basic it includes producing an exception report or a year-to-date summary rather than a listing of the master file. Fully developed, it involves maintenance of large databases including all the data used by the hospital together with powerful tools to manipulate the data and extract from it the information required by decision makers. Effective information processing is not possible until most or all of the hospital's data is being processed by the computer. To support a manager requires access to budget, revenue and payroll data, output statistics and so on. To support a physician requires access to the complete patient history including progress notes, care plan, drug treatment and results of investigations. The benefits come from better management through informed decision-making. A number of hospital computer systems in advanced centres are attempting this approach and a few have made significant progress. They depend upon large amounts of data processing power and storage capacity which have not been widely available. Knowledge processing takes the refinement of data one step further by drawing inferences from information. Policy statements about how the hospital should be run and how patients should be managed is captured into a set of rules called a "knowledge base". The computer examines the data of the institution in the light of these rules, requests additional information if appropriate, and generates inferences such as "based upon the budgetagainst-actual and Rules 43, 56 and 82 the hospital can expect to exceed its budget by $5.3 million this financial year" or "patient Fred Jones in ward 3B is 2 days post-operative and has not been seen by a physiCian for 14 hours which appears to be in contravention of Rule 113". A few hospitals in the United States are using systems of this type in the preparation of patient care plans, monitoring of treatment protocols and "critiquing". They may consume enormous amounts of processing power and are very expensive to run on the current generation of computer eqUipment. When the technical difficulties are eventually overcome there are substantial benefits in supporting and guiding decision makers into better hospital and patient management.
- 25 Annex 5
Unfortunately this classification while useful to a degree does not answer the question of why some systems are more difficult, since almost all of the systems in hospitals, successful or otherwise, would be classified as data processing. Another approach is required. D. Level of system
There is one further classification which is much more specific to the problems of putting computer systems in hospitals, and which appears to be the most useful in showing which ones cause problems. It divides such systems into 4 levels of difficulty. Level One - Batch or Cyclical Level One systems generally operate during business hours, and have pronounced cycles of several days or longer. They run in pure batch mode with off-line data entry, or may have on-line data entry from documents but not in real time. On-line access is limited to enquiry and the results are as timely as the last update run. Such systems are highly tolerant of computer failures and the loss of facilities for several hours during the day causes only minor inconvenience, and at night even less. They co-exist with manual methods, which are used to check the computer and are relied upon when the computer is unavailable. Examples include Accounts Payable (as well as most other financial systems) and DiagnosiS Coding. These systems were the best which could be reliably achieved and costjustified with the technology of the 1950s and 1960s, and many organizations have never taken computing beyond this level. There are few difficulties and hospitals should not fear them. Level Two - Departmental Systems Level Two systems show a wide range of sophistication with the most advanced having fully on-line data entry in real time, 24 hours a day operation and highly complex processing. They operate in a single department or organiZational unit, of the hospital with all data entry by personnel under the control of the department head. Communications with the rest of the hospital is by paper, possibly supplemented by enquiry-only terminals in other areas. Examples include Pathology, Pharmacy, Catering and Patient Master Index. These systems were enabled by the minicomputer revolution of the early 1970s. Such computers are relatively reliable and disruption caused by a computer failure is localized to the department effected. Many systems do not have adequate protection against loss of data following equipment or power failure, and survive despite this. The localization of responsibility and the team spirit of the department make these systems unlikely to fail. Level Three - Integrated Systems and Communications Level Three systems have data generated in one part of the hospital and used in another, with the computer providing communications. For example,
- 26 Annex
5
test requests and treatment orders may originate in wards and clinics and be transmitted to the responsible service department, with results and reports being returned to the originator. Stores requisitions, prescriptions, meal orders and theatre bookings are entered into the computer at their point of origin. Discharge summaries and correspondence all pass through the same computer system. The fully developed version is a true Hospital Information System. There are many difficulties to overcome. The computer services must be available 24 hours per day throughout the hospital and must be extremely reliable. There must be little or no possibility of data loss following equipment failure or lost of electrical power. Systems must be well designed if they are to be widely used. Staff must be consulted, educated and motivated if the data entered into the system is to be of high quality. The technology to do these things at reasonable cost has only become available during the 1980s and it is still quite difficult and expensive to do them well. In principle Level Three can be reached by two different paths: either by integration of existing departmental systems through a network or by running all applications on a single machine (or cluster of machines). In practice the only satisfactory approach with current technology is the central machine using a suitable database management system running a single database for the entire hospital. These systems which still cause difficulties are exactly the ones which were tackled naively and disastrously in the 1960s and early 1970s. A hospital which has already gained experience with departmental systems should with adequate planning, commitment and funding be able to make the transition safely into Level Three during the 1980s. Level Four - beyond Level Three Level Four covers the functions which are only possible when most or all of the information flows of the hospital go through the computer. It offers the benefits of Information Processing and Knowledge ProceSSing to the better management of the hospital and better treatment of patients. The technical difficulties are great, and it is likely that Level Four will be enabled by advances in the 1990s. Basic requirements include nonstop operation, a very high degree of resistance to loss of data, resilience of the system as a whole to failure of a part, very large numbers of terminals (at least one per bed), fourth and fifth generation languages, relational database, enormous quantities of processing power and vast quantities of storage (at least 100 megabytes per bed). Few if any hospitals have completed Level Three, but some are experimenting with what lies beyond. Some examples include patient care plans, treatment protocols, automated diagnosis and "critiquing". The proceedings of the MEDINFO 86 conference provide plenty of reading and references. For an illustration of the interrelationships and overlap between the three classifications, see table 1 (Annex 1).
- 27 Annex 5
E.
Summary
This paper presents some possible classifications as an aid in understanding why some computer systems are more difficult to install into hospitals than others. The most useful is the four levels, in which the transition from Level Two (departmental) to Level Three (integrated) cause the greatest problems, but the greatest benefits come from information and knowledge processing in Level Four. Any hospital lacking a reasonable complement of Level One (batch) and Level Two (departmental) computer systems would now be regarded in Australia as behind the times, and probably inadequately managed and unnecessarily expensive to run. Our goal is to fill in the gaps and to press on into the integrated systems of Level Three and beyond. The techniques are well understood and the risks should no longer be feared. The reward is great; the best of health care for everybody at a price we can afford.
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Annex 5
CLASSIFICATION OF HOSPITAL SYSTEMS
Table 1.
11luatratln~
relatlonahlpa between classlticationa
-----claaa-----
--level--
------cateeorv----Med. Bua. Tech. ++++ ++- + +
*-----------------+-----------+-------+-------+-------+
COmputation
I 1 Data I I Proce881ne I 1 1-----------------1 1 I I Intorllation 1 1 I proce .. inlr I I
1-----------------1 1 I I 1
I
I
1 Level 1 Lavel 2 Level 3
I
I
++-++ + + +
I I I I
1
+ + + + + +
Level
,
+ +
,--:::::::::------1 I Proce •• inl I
+-----------------+-----------+-~-----+-------+-------+
1 1
+
I
I I I I I I I I I I. I
1
+++
++-+
The nu.ber ot plua .illla indicates the deeree to which .clasa or level lit procosainr i. of value in category of syatem.
- 29/30 -
Annex 5
INFORMATICS APPLICATION IN HEALTH SYSTEMS MANAGEMENT - A USER'S VIEW by
Dr B.W. Christmas
1
lActing Chief Health Officer, Department of Health, Wellington
- 31 -
Annex
5
INFORMATICS APPLICATION IN HEALTH SYSTEMS MANAGEMENT - A USER'S VIbw In most developed countries the planning of health programmes has been based on information relating to demographic data derived from populations and assessments of health statuS as quantified by indicators based on mortality and morbidity data. The deployment and development of health services, however, has been less influenced by the collection of specific data than by what has been referred to as "impressionistic planning", a process wherein information may be minimal and the basis for decision making is intuitive and political; the end results being determined by past experience, popular pressures and rough estimates and guess work. This historical form of evolution of health services at least provided a workable infrastructure which. in turn, at the local level operated on an ad hoc pragmatic basis responding to local needs and within the resources available developed and replicated services that best seemed to meet those local needs. Health professionals tended to cooperate more readily and communicate more freely working at the local level and this promoted the free exchange of health activities and information. Information and the health services At the central level the need to coordinate and control health service development was governed largely by the constraints of the resources available. The emphasis. until recent years, has been that if there were enough staff. facilities, equipment and finance, the public health and health care services could be expanded and the health status of the population would automatically be improved. Consequently, efforts were directed to increasing the size of the existing services. Data relating to numbers of staff employed, work loads and case loads, number of activities, visits and services provided together with the total cost of operating those services formed the bulk of the health information available for health managers. In the early 1960s it became apparent to most health administrations that health expenditure was not infinite and that the emphasis in planning and development must focus on the more effective and efficient use of the limited resources available. In effect this meant that health planning should be a problem rather than service oriented and result in strategically directed priority programmes. But when the time came to transmit priorities and proposed programmes into actual operation it soon became evident that there was a serious deficit in relevant information. The major areas in which health service data was lacking or not readily available were health workforce development programming, and the evaluation of service effectiveness and efficiency. Health managers found they urgently required this information to enable them to initiate and control the progress and outcomes of the programme operation. To assist in developing appropriate sets of data some health administrations have set up health information units and systems analysis groups that work with health managers to establish what health service data is required, what is essential for the effective control of the operation and how this data can best be used. The establishment of a health information unit enables the health organization to have a single focus for the coordination and collation of any forms and sources of data available within the health system.
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Annex 5
Health information sources Health information generally is derived from three sources. The primary source is the traditional clinical case history that describes a disease process as it affects an individual patient. This data is usually collated as a person-based continuing record for each individual patient, but may also be abstracted into categories for epidemiological or administrative purposes. For epidemiological purposes the data is recorded as disease based and coded in accord with the international classification of diseases. These data are comparable internationally. For health services management the data are utilisation-based and used to measure admission rates, hospital bed occupancy and turnover, etc. Supplementary sources of health information in relation to health status are usually obtained by introducing reporting systems either obligatory or voluntary whereby health personnel working in the periphery are required to report infectious and other diseases of public health importance. This form of reporting has led to the compilation of disease registers, the organisation of minor illness reporting schemes involving family practitioners and health centres and sentinel reporting throughout the country of periodic epidemic diseases such as influenza. The search for more specific health data covering the prevalence of chronic diseases has resulted in the conduct of surveys of sample groups of the population. These surveys either involve the physical examination of the survey group in a cross sectional or prospective cohort study, or the assessment by questionnaire of health behaviour, lifestyle and individual well-being. Only in rare instances, however, are these data linked and related to the base population from which the affected individuals are drawn and there is little or no association with the records of sub-sets of individuals who are under the health care of individual practitioners in the community in health centres. The growth of personal and community health services has also produced at the local level a wealth of socioeconomic as well as health data about individuals and families. In many instances the customary method of recording case notes and family visits is in anecdotal form which is difficult to categorize and often incapable of ready quantification. This practice renders processing difficult and the result has been that much of the information cannot be utilised and serves simply as an aide-memoire for the field worker or accumulates on the files. Health data processing Until recently, the major limiting factor for collating, analysing and tabulating all these separate sets of data has been the massive labour effort that is required to record, check, count and re-arrange manually so many variables from so many separate sources. This inevitably has resulted in considerable delays in the reporting of outcomes which in turn obstructs the efforts of health managers to evaluate the effectiveness of specific disease control and health programmes. Delay in receiving 'information, ~n particular mortality and morbidity indicators, has been a constant €'l"iticism of past health information systems. Mechanisation of data processing using punchcards and later electrical sensing helped to speed up this process, but the methodology still suited only small populations. The advent of the computer and the
- 33 -
Annex 5
microchip has now drastically altered the whole international scene. There is virtually no quantum of data that cannot be processed and stored. Transactions and calculations that took months can now be accomplished in minutes, while the storage capability for detailed information and the access to retrievable information and summaries of scientitic and medical publications obviate the need for vast archives and records centres. Modern technology allows information and data to be transmitted direct from the operator-observer at the local level to the central or regional processing unit where it is immediately collated and tabulated; presenting to the health manager, the health administrator and even the operator-observer in the field an immediate update of the data representation at national, regional and local levels. This process meets one of the essentials of data collection and of surveillance programmes namely information feedback. It will be self evident that most mechanisms for collecting information about sickness and health depend on the conscientious cooperation and meticulous recording and observations of a large number of contributors working at the periphery. These observer groups include not only the employees of the health service but frequently private practitioners and agencies not directly related to the national health service. In order to gain and maintain their cooperation it is essential that the reasons for the data collection is well understood, that the contributors are sufficiently motivated and that they receive some feedback to demonstrate that use has been made of the information. Mere mechanical recording without understanding inevitably results in incomplete or inaccurate reports. When new projects are envisaged and additional health information is required, training programmes involving field starf to explain the reason for the project and upgrade their skills in recording the relevant information have proved a useful means of motivating the group to minimize reporting deficiencies. At the same time it is important that tile collection of other data should be reviewed so that the burden of data compilation does not become excessive. Many field workers complain that so much of their time is taken up in recording and administration that they have little time for actual client care. A too enthusiastic approach to information gathering can lead to a falling off in efficiency and morale. Function of a health information unit The Health Information Unit has a responsibility to bring together all the health data available from within, and if necessary from outside the health sector, to ensure that the data is reliable, as complete as possible and is collected and collated in the minimum time. The unit should also be responsible for ensuring that th~ data when analysed are presented and made available in a form that is readily understood by the user. As user groups will differ and range from top management to the general public such information may need to be presented and edited to meet the differing requirements of these client groups. In preparing health data tailored to meet the needs of individual managers, the Health Information Unit should work as closely as possible with the client and may have to assume a training role to en~ure that managers and admini~trators are fully conversant with the metllodology involved in the health information system. [Jata collection programmes may need to be reviewed regularly to prevent overload of the contributors. Training of all field workers should be incorporated in the health
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Annex 5
information system approach and each health manager, when assuming responsibility for developing a specific health programme should ensure that a health information input including the preparation and training of field staff in data collection is an essential component. Evaluation As well as the use of data for planning and for monitoring the operation of a programme, the present day health manager needs to have a special concern for evaluating the outcome of the health programme for which he or she is responsible. This requires assessment specifically of efficiency, or whether the effort expended is the best possible with the resources allocated, the effectiveness, or whether the results obtained are in accordance with the objectives and targets, and the impact which is the overall effect of the programme on health status and socioeconomic deve lopment. Earlier evaluation techniques concentrated on measurement of activities and the number and type of services provided. The use of health status change is now regarded as a more useful and acceptable means of measuring effectiveness and impact. Measurements of efficiency are less widely used and health managers may lack both the basic data and the analytical skills other than the intuitive ability inherent in leadership to assess the possible options available with the available resources. Ideally, the appropriate decision to achieve the most efficient approach should be made prior to the commencement of the programme rather than establishing this retrospectively. The essential tenet is for health management to ensure that the health information expert is involved in the planning of the programme operation at the beginning and not at the end of the operation when the data may not be avai lab Ie 0 r appropr iate. Furthermore, this early consul tat ion allows the health manager to be provided with ongoing data that ensures the progress of the operation to be effectively monitored and adjustments to be made to ensure that activities and resources are being directed in accordance with the overall purpose of the original plan •. Communication of this progress information back to local health administrators will also enable the local services to adjust their own activities to comply with the overall activities and goals. Using the new technology Now that automated data processing is a reality, what are some of the constraints that may limit the effectiveness of this new technology? First and foremost is the factor that the ability to process a vast amount of data very rapidly is only of use if the resulting information is useful or is used. The ability to process substantial quantities of data may lead managers to adopt a "philatelic" approach to data collection. In this approach, the collector's urge takes over a mass of information is gathered indiscriminately and inevitably results in overload of the collecting system. Hard-pressed field workers find themselves committed to an increasing amount of time collecting and recording information. Soon the reliability and the completeness of the data becomes suspect and the health information system falls into disrepute. This is a very real hazard and can lead to the over complex recording system that breaks down under its own weight; but it is not a new phenomenon simply one of degree. The solution is to ensure that all data collected is utilised and accounted for and that data collection services and processes are regularly reviewed and
- 35/36 Annex 5
graded as to their priority of usage. The secund factor is the basic principle that information obtained from a data collection service is put to practical use. Health status data from health surveys and in particular from health surveys involving detailed questionnaires contributing a large nlBDber of variables can now be promptly processed and the results expeditiously tabulated but the action that should follow subsequent to publishing these results is often delayed because the organisation is not geared to react quickly enough. Forecasting health resource needs based on possible population projections and health status assessments can also be readily accomplished using suitable stochastic models and programmes. But the delays in modifying training programmes, stepping up recruitment, building facilities or even deploying staff may nullify any advantage this technique can offer. There is also the risk that forecasted planning may be regarded as a purely theoretical exercise by the more pragmatic managers and administrators unless they themselves are actively involved in the forecast process. Finally, the introduction of computerized data processing highlights the urgent need to develop a systematic approach, including the use of systems analysts, to assist in the selection of suitable and relevant data for use in health management. It is becoming increasingly evident that health managers are to be held more accountable for programme operation, and the necessity for ongoing evaluation to determine the progress and outcomes of their programmes warrants the early training or re-training ot health managers and administrators to develop these new skills. Conclusion The rapid growth in demand for reliable, relevant and timely health information must be met if health management is to cope with the challenge of developing national health systems that fulfill the promise of health for all by the year 2000. The availability of a new technology offering a new automated information system that can provide worldwide access to medical and scientific knowledge, a rapid processing and storage of almost unlimited quantum of health data and a complex record linkage and retrieval system with long distance transmission, represents a major step in this direction. The problem confronting health managers will be to acquire the skills and motivation to use this technology effectively before the next decade.
REFERENCES 1.
2. 3.
4. 5. 6.
Statistics of Health Services and of their Activities, WHO Tech Rep. Series No. 429 (1969) Statistical indicators for the planning and evaluation of Public Health Programmes, WHO Tech Rep. Series ~o. 4il (1~71) Application of Systems Analysis to Health Management, WHO Tech Rep. Series No. 596 (1976) Information Systems for Health Services, Public Health in Europe No. 13 (980) Development of Indicators for Monitoring Progress towards Health for All by the Year 2000, WHO "Health for All" Series No.4 0980 Glossary of Terms WHO "Health for All" Series No.9 (984)
- 37/38 Annex 5
INFORMATIC~
APPLICATION IN HEALTH LITERATURE SERVICES by
Dr Fu Lai l
lHonourary Director, Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing.
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Annex
5
The Necessity of Building a National (Regional) Health Information System. Health literature as distinguised from biomedical (scientific-technical) literature, contains mainly information about the nature and extent of the people's health problems and health management-related questions. A health information service should inform the public the healtll policy makers, administrative staff and otl,er health workers so as to assist them in making correct decisions. Whether providing statistical data or data on qualitative trendS or in presenting data of a quantitative analysis comparing local data with those of other countries or regions, the aim should be an active provision of information. The liteture containing this type of information should be collected, indexed, filed and should be retrievable. However, up to now in many developing countries and regions, there is still a lack of available health literature and the usefulness of health information has not been recognized. Most of it is not properly utilised or even remains as fugitive literature in archives. Improper presentation or presenting materials to the wrong people or at the wrong time, may also lead to the same negative results. The user may find himself surrounded by documents without being able to find the necessary information. In this case, it is clear that there is no national (regional) health information policy. In order to achieve WHO's goal of Health for All by the year 2000, to improve health planning and primary health care, it is necessary for eadl country or region to have its own health and biomedical information policy. Based upon a sound policy, each country should build its own health and biomedical information system. However, to facilitate the processing of documents, whether manual or computerised (totally or partially), will depend on available funding, expertise or sometimes even on language problems and other factors. Principles of Setting up a Computerized National (Regional) Health Information System. The ultimate aim should be the formation of an efficiently working integrated information network. This system structure may eventually take care of both health and biomedical literature and information. Assuming that a national (regional) health and biomedical information policy has already been decided on, it is advisable to carry out the setting up of the system in several steps. The first would be a feasibility study, surveying and reviewing, as well as analysing the status quo of the local health anu biomedical information scene, the in-country resources and constraints (budget, manpower, available literature etc.). By conducting a survey through interviews, one should find out the actual needs and requirements of the different kinds of users. A thorough knowledge of the state ot art of suitable software and hardware in the international field and a survey of available software and hardware within the health community should be developed and the possibility to make use of the international telecommunication links with foreign data bases should be explored. Based upon such a study, a system design and implementation plan could be drawn up for the whole country (region) which then could gradually be implemented.
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Annex 5
The Organizational Structure of a Computerised Health Information System. The structure should include a ~entral coordinating body (center) which, in close cooperation with the network nodes, would decide on policies or give guidelines, plan technical and manpower development and represent the people's interest in the national (regional) and international levels. Its main functions should include tile setting up, maintenance and development of data bases of national (regional) health (and biomedical) literature and knowledge, tacilitating efficient access (electronic or traditional) to documents in-and outside the country (region); it should plan and support promotional activities, training (including the continuing education of the entire staff) participation 1n national and international information programmes. Lts main services should include on- and off-line search of its data bases, current awareness (SDI service) provision, document delivery and necessary publishing activities. According to needs, the network may be subdivided into several sectors, i.e. national (regional) health literature and infor~mation, national (regional) and international biomedical literature and information, administration of medical education and research, etc. Extensive gathering of data or central gathering of certain information should be decided by the consortium. Two types of data bases should eventually be set up. processing and a second one for statistical problems. Governing Principles of Technological Applications According to available funds, the latest technology should be made use of, keeping in mind possible future developments. The system should be open-ended and technologically compatible in spite of different hardware components (which may already have been in use before the system was set up). The technology being applied should be operable by its end users. In order to render good public service, the end user should be able to work 1n a programmer-free environment. If necessary the system should have bilingual capabilities, however one should avoid to have the entire software being translated into the native language. The same operating system should, as much as possible, be used throughout the system. Large hard disk storage should be avoided and CD-ROM readers, connected with micros for data base searches (MEDLARS, CA, etc.) installed instead. Compatible interfaces, search software and query language will be necessary for this purpose. Data bases for national (regional) health and biomedical information may install state of art write-once read many optical disk systems. One for text
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Annex
5
Bilingual full-text inforulation management software, including document formatting, desktop publishing, automatic index generating capabilities, and supporting on-line data base searches should be considered. In case of using non-homogenous computers, terminal to terminal, computer to computer communication should be provided. On-line searching of foreign data bases should be achievable, operating on 300bps-1200bps. The National Data Base (Center) The Center should be equipped with a state of art 32 bits minicomputer with 2MB primary memory (expandable) and 500MB direct accessible mass storage, a magnetic tape drive, and if necessary a laser printer and other bilingual peripherals. Write once read many optical disk system may be an alternative configuration or supplement. In order to work efficiently, a unified terminology, a common bibliographic format, and a common data base management software package are necessary. For training purposes as well as for development and research, the center should at least have some of the most commonly-used microcomputers inside the network. The Network Nodes The network nodes should be equipped with microcomputers, if possible with a CD-ROM system or in case of distributed data catching in the native language, with a write once read many optical disk system and a small laser printer. Technical and Administrative Staff Only dedicated technical and administrative staff should be involved to keep the task force as non-volative as possible. Network nodes should have trained personnel to carry out the service and house keeping functions. Continuous education as well as training tailored to specific tasks should be obligatory and user-oriented marketing consciousness ana activities should be stressed to achieve a favourable cost-efficiency ratio.
REFERENCES 1. The Egyptian STI Network; Five Year Development Plan (1987-1991). v. Slamecka et al. Georgia Institute of Technology, Atlanta, Georgia, USA Private Chinese and Foreign Communications and unpublished Chinese documents.
2.
- 43/44 -
Annex 5
CONTRIBUTION OF THE HOSPITAL COMPUTER CENTRE UNIVERSITY OF TOKYO HOSPITAL AS A WHO COLLABORATING CENTRE FOR MEDICAL INFORMATION IN HEALTH INFORMATICS by Dr Shigekoto Kaihara 1
lDirector, WHO Collaborating Centre for Medical Information, Hospital Computer Centre, University of Tokyo Hospital, Tokyo
-
45 -
Annex 5
1.
His tory
Dr Salah Mandil, Director, Information Systems Support of WIIO Headquarters, and Professor S. Kaihara of University of Tokyo Hospital met at the two meetings concerning health informatics sponsored by WHO. The first one was the Interregional Consultation on National Health Information Systems held in Costa Rica in November 1979, and the second one was the I~terna~ional Consultation on Application of Informatics in Health, held 1n Geneva in November 1981. At both meetings, it was agreed that international collaboration should be strengthened in health informatics field in the future. WHO had already designated two collaborating centres in this field, namely; one 1n Uppsala, Sweden and and the other in Paris, France and it was agreed that another collaborating centre is necessary in the Western Pacific Region. Dr Nakajima, Regional Director of the WHO Western Pacific Regional Office (WHO!WPRO), supported this idea and wrote an official letter to Professor R. Hirano, President of the University of Tokyo, on 2 July 1984 informing that the Hospital Computer Centre of the University of Tokyo Hospital was designated as a WHO Collaborating Centre in Health Informatics. The inauguration ceremony of the Centre was held at Gakushi-kaikan in Tokyo on 28 July 1984. Dr Nakajima attended the ceremony with Dr Mandil and officially declared the opening of the Centre. Professor Hirano, President of the University, Professor S. Mishima, Dean of the Medical Faculty and Professor M. Harasawa, Director of the Hospital, all attended the ceremony and celebrated its inauguration. 2. Terms of Reference
In the letter mentioned above, the terms of reference of the Centre were defined as follows~ (a) to plan and conduct tra1n1ng activ1t1es, particularly in the field of applications of small-scale computers in the health sector; (b) to develop specific computer applications of mutual interest to WHO and the Centre; (c) to link up medical computing centres in developing countries, particularly in universities, with counterpart centres in Japan; (d) to contribute to technical studies on telematics I links to Imo collaborating centres in Japan, and to act as an experimental national mode in such a tele-link; (e) to consolidate and share information on state-of-the-art developments in health informatics technology and its applications; (f) to act as a link between WHO and the Japanese computer industries where new computing equipment is to be researched and developed; and (g) to provide general consultancy services to WHO, particularly 1n the area of networking micro, mini and mainfame computers.
Annex
5
- 46 -
3.
Contribution of the Centre (1) Training Before the Centre was designated as a Collaborating Centre, the hospital computer centre had accepted many foreign students for research or training in the health informatics field. The countries which the students or scholars came from were Bulgaria, People's Republic of China, the Philippines, Republic ot Korea, Singapore and Thailand. Among them, two were fellows sponsorea by WHO. The students for training were mainly given general training of health informatics and on-the-job training of system design or programming according to the ability of the students. The period of the training was usually three to six months. (2) Developmental work The Centre collaborated with Oral Health Division of WHO Headquarters and developed softwares for the community oral health programme at Chiang Mai, Thailand. This is a joint project with ISS/HQ in Geneva. At Chiang Mai, all the inhabitants of some villages are registered and are given a small paper card named as passport, on which the status of oral health is to be recorded. By periodical check-up, the chronological data of oral health are obtained and are recorded on the passport. The data are also entered in a small computer by local people. From the data, epidemiological studies can be conducted. The effect of oral health intervention can also be analysed after accumulating the data for years. The computer programmes for these studies were developed and implemented at Chiang Mai. The training was also given for local people to operate the small computers. This is an on-going project and development of more softwares will be required when the project progresses. (3) Experiment of telematics International computer communication was tested between Tokyo and WHO Headquarters in Geneva. INFONET, International Computer Centre, and BITNET were successfully tested. Computer communication using ICC is now in daily use. (4) Consultancy services The writer attended a couple of health-informatics-related meetings sponsored by ~IO as a Resource Person - the Working Group on International Cooperation in Technology Transfer in the Health Field, held in Tokyo in July 1985, and the International Consultation on Applications of Informatics in He~lth, held in Geneva in 1985.
- 47 -
Annex
5
4.
Some comments on the past activities (1) Training There are different aspects of the training of health informatics. The required area of training depends on the functions of the trainee after he or she goes back to his/her own country. For example: Administrator of health sector and/or health planners: General knowledge of computers especially the knowledge concerning what computers can do in the health field, knowledge about the cost of computers, advantages and disadvantages of the use of informatics, pros and cons of having computer hardware or contracting with outside organizations for information processing, etc. ; Administrator of the computer section and system engineer: Systems design, comparison of ability of small computer and main-frame, characteristics of computer language, method of scheduling, method of traning, etc.; Programmer: Knowledge of programming. In fact, the training in these three areas are completely different. In the first area, the most effective method is the site visit where the health informatics is in effective use. However, in the training of programming, the computer which the trainee is going to use must be available. Preferably, the computer configuration is the same with that in actual use. In the training of system design, the trainee must have the knowledge of the environment in which he/she is going to develop the system. The students who came to the Centre mostly did not know the above-mentioned difference. Some students did not know what functions they will perform in their own respective countries after finishing the training courses. Some students wanted to have the training on programming, but they did not know what computer language they will use in their home countries. If these problems had been known beforehand, probably better training could have been given to them. (2) Developmental Work We enjoyed the developmental work at Thailand. This was because we could have very good counterparts in Thailand who were eager to learn computer technologies. The counterpart team was the product of time-consuming effort of ORH lJivision of WHO headquarters ana we were fortunate that we could utilise them as our counterparts. From this experience, we propose that some collaborating centres of health informatics be designated also in developing countries as counterparts of the centres in developed countries in health informatics. By working together with such centres in developing countries, better ties will be developed in this field between developed and developing countries on health informatics.
- 48 -
Annex 5 (3) Identification of the needs One of the most important roles of WHO in such field as health informatics will be technology transfer. It is obvious that for the effective technology transfer, the technology to be transferred must be well known. However, in the health informatics field, it 1S sometimes very difficult to identify the technologies to be transferred, if we come to the detailed ones, such as systems design, maintenance of hardware, computer programming or operation of computers. For example, it is easy to say or write "training of operation of computer", but there are hundreds of different types of computers in the world and for the technical people who must operate a computer, it is sometimes useless to learn the operation of a different type of computer. The same is true with computer programming. Considering this, one of the important roles of WhO is to identify the area of informatics application in the health field and to give some models for those applications, which WHO-related projects should follow. If this model is shown, technology transfer will be directed along this line and will become far more effective. 5. Conclusion
We described the experiences of our collaborating centres of health informatics. The period of our Centre's existence is still short, but we have enjoyed the collaborative work. I hope that such collaboration will increase in the future in this Region.
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Annex 5
INFORMATICS APPLICATION IN HOSPITAL MANAGEMENT by
Dr Young Soo Shin l
Associate Professor, Department of Health Service and Hospital Administration and Deputy Director, Institute of Hospital Services, Seoul National University, Seoul
1
- 51 -
Annex 5
1.
HOSPITALS AND INFORMATICS
The second half of the twentieth century has witnessed the specialization and differentiation of the industrial structure that has been based on the remarkable development of the various industrial fields. Knowledge and information that is generated by and absorbed into the various industrial fields is differentiating extremely and as well, is increasing exponentially on its volume. It is inevitable that another specialty discipline which deals with various information, and maintains and develops the organic relationships among various information-generating fields should emerge. The emergence and evolution of computer science has given birth to and is continuously fueling the development of Informatics - the study of the scientific handling of information and maximizing its utility. Based on ever-developing hardware as well as software in computer science, Informatics identifies for itself the critical role of a science which seeks to uncover the infinite possibilities in the future development of industry. Hospitals, through medical services, education, research and public health services, perform a central role in the health system in a district. With rapid development in health care technology, the increased hospital services as well as higher quality of care is being emphasized in the advanced as well as developing countries. New and innovative medical technology has resulted in eVer-increasing and sophisticated methods of diagnosis and treatment; personnel in a wide variety of specialties affect hospital organization by increasing the level of differentiation of services. The volume of information which is generated from the separate specialties is increasing at a tremendous rate. As a struggling place for fragile life, hospitals must possess the capacity to integrate, analyze, transfer and exchange information quickly and accurately. Therefore, it is clear that computerization of hospital tools for diagnosis and treatment can greatly enhance the quality of separate clinical information. Based on the functional characteristics of a particular hospital, various information is generated in isolation and dealt with discreetly while other data are accumulated and integrated at a central processing department for the purpose of patient information management and operational hospital administration. Therefore, a hospital has two information systems; separate systems and integrated systems. How to set priorities between the two and/or how to harmonize them, is an important subject in the course of establishing hospital information systems.
- 52 Annex 5
II.
RELEVANCE OF INFORMATICS IN HOSPITAL MANAGEMENT
An ideal hospital information system is one that can provide the right information to the right person at the right time. An effective hospital information system is one that economically provides a comprehensive, detailed, decision-oriented information. Computer requirements for this type of system generally include decision-oriented reporting, a hierarchical information structure and data base management. Information systems are not an end in themselves, but a means of helping managers make better decisions. This is accomplished by providing accessibility to increasingly complex information in convenient ways. For example, physicians may be able to decide more easily on the correct dosage of a particular drug if they are able to see at a glance the comparative laboratory results for the past five days, a list of the patient's allergies, and a list of other prescribed drugs and their potential interaction. By having information available on the timing of ancillary requests, ancillary department managers may be able to improve staffing patterns in the various areas to eliminate excess capabilities while improving service at peak times. Informatics has been applied most extensively at the second and third levels of patient care, namely the hospital level. One reason is that over one third of hospital activities is information handling. Many systems are in operation today. However, these systems vary in their objectives, technologies used, and functions available. Their objectives are multifold, and may be summarized as follows: • to satisfy the data processing requirements of individual departments with stand alone systems, e.g. ward management, laboratory analysis, special monitoring; • To make hospital operation more efficient, by communication of patients' data among hospital departments, processing of patient data, scheduling of patients and resources, etc; To support hospital management by providing administrators with timely data and in an appropriate form for their decision making; To provide physicians and allied health personnel with patient data 1n a timely and appropriate form using an updated patient data base; • To provide physicians and allied health personnel with accurate and updated medical knowledge; • To provide efficient communication with the health related institutions outside the hospital, such as health centres, outpatient clinics, health administration bureaus of the local government; • To provide data for clinical research.
- S3 Annex S
Ill.
CLASSIFICATION OF HOSPITAL INFORMATION SYSTEMS
Hospital information systems can be classified based on their functional components, field of application, level of information requirement and type of computer system. 1. Functional components of hospital information systems 1) 2) 3) 4) 5) 6) 7) 3. information processing inside the department communication with other departments patient monitoring systems ward controlling systems patient record management systems operational administration systems management planning and control systems
Level of information requirements 1) transaction systems which handle the day-to-day operational and administrative matters of the hospital. control reporting systems which provide summarized data about the day-to-day operations, giving department managers and health care professionals the necessary information to monitor various activities for which they are responsible. operational planning systems which provide executive management with the information necessary for the proper overall planning and control of the hospital. strategic planning systems which are the provision of a framework for current decisions with long-range implications.
2)
3)
4)
4.
Deployment and structure of information system 1) in-house system - centralized - decentralized - composite centralized 2) shared sytem - centralized - decentralized - composite centralized
- 54 Annex 5
IV.
INFORMATICS FOR HOSPITALS AT THE FIRST REFERRAL LEVEL
The concept of hospital information systems has been developed in rather large hospitals of the tertiary level which give extensive, specialized care to patients. These hospitals have to deal with more complicated, more timely data, with more extensive communication requirements among the hospital departments. The hospital information system for hospitals at the first referral level is quite of a different concept and this has not yet been fully investigated. Hospitals at the first referral level playa critically important role in support of the successful attainment of the PHC goal. The role is condensed into four categories; clinical referral, health programme coordination, education and training, and logistics support. Among the objectives of a hospital information sytem, the patient data base, supply of updated medical knowledge, efficient communication with other institutions, and support of management are all feasible for hospitals at the first referral level. But the configuration of a hospital information system in such hospitals will be different from that in the tertiary level hospitals. Communication among department a may not be so urgent. On the contrary, communications with outside institutions may be more important in performing roles of delivering information such as referral of patients, programme coordination, and administrative and logistic support. The components required for adequate functioning of hospitals at the first referral level are not yet fully developed in the present configuration of hospital information systems. Although such technologies are now being investigated and becoming more popular, the full development of appropriate hospital information systems has yet to be realized. Richard Nolan classifies the development of the application of informatics into 4 stages (stage theory of EDP growth). The first stage is the Initial Stage where an organization starts its computerization in labour intensive job fieldS aiming at cost savings. The second stage is the Expansion Stage where based on the successful experience in the first stage the organization expands its application of computers to every job field possible to increase inputs in equipment, software and computer personnel. The problem at this stage results from the tendency to computerize recklessly, without an adequate assessment of priorities. The top manager of the organization should establish a long-term plan of computerization at this stage. The third stage is the Integration, Formalization & Control Stage. this stage the organization realized that the uncontrollably increasing budget in the computer sector has a deleterious impact on overall operation, and therefore, the organization initiates efforts to develop more effective coordination At the fourth stage or the Maturity Stage, the above-mentioned problems are mostly solved and the application of computers become establised in terms of both finance and management. At
- 55 Annex 5
There is still a considerable disparity of both the number and use of informatics application between developing and developed countries. But as hardware price has decreased dramatically and the software developing capacity has been universally enchanced, even developing countries can afford the new informatics technology. Through appropriate entry followed by an appropriate mix of technology and resources, developing countries can clearly benefit from the current explosion in hospital informatics technology. Actually most tertiary and some secondary hospitals in developing countries are at the first or even at the second stage of EDP growth. As the proportion of hospital services expenditure to total health expenditure is increasing, the need for improving management skills in hospital service standardization and efficiency maximization is also growing. As for this need, the introduction of relevant informatics methodology will make significant conributions to improving management skills and will playa key role in determining the optimal method of utilization of limited health resources in every developing country.
VI.
SOME ISSUES IN APPLICATION OF INFORMATICS TO HOSPITALS
While the scope of informatics application in hospital management is expanding in developing countries, there are some limiting obstacles which could limit the course of this expansion. 1. Technological aspects
Although the price barrier to purchasing computer hardware has been reduced and improvements made in the utility of computer system, the software which could satisfy specific needs of local hospitals has yet to be developed. Furthermore, it is rather difficult to directly apply the software developed in one country to other countries, such as in advanced countries to developing countries. Hence the need for the development of relevant software which is appropriate to the needs of particular countries. Above all, emphasis on integrated efforts to improve community health is crucially important. In this context, the highest priority should be laid upon the development of computer network technology whereby hospitals at the first referral level can comprehensively support the PHC activities of the community. 2. Economic aspects
Al though the price of computer hardware has decreased considerably, the cost burden in system development and operation as well as for the hardware itself is still heavy. Also, unbalanced investments into hardware, characterized by unsystematic and disorderly approaches to
- 56 Annex 5 information system development results in considerable loss. In developing countries, in order to establish the hospital information system in less costly way, the development of standardized hardware and software is necessary. In addition, introduction of computer sharing systems could be helpful. For this purpose, it would be desirable to form a public committtee that assesses the feasibility of various information systems and promotes the introduction of relevant information systems. 3. Operation aspects
The successful operation of a computer system is totally dependent on informed and educated users. If an information system is developed beyond the users' application ability and the maturity of their intrinsic need, the system will be futile. Therefore, it is very important to educate and promote attitude changes among hospital personnel for Infomatics. Among the various departments of a hospital, there will be a wide variety of needs in terms of information technology applications. For its balanced development in proportion to overall demand, the role of the hospital staff is very important. Finally, for the effective integration of the strategy for hospital information system development into the long-term hospital goal, the role of the hospital director is crucially important.
- 57/58 - t
Annex 5
INFORMATICS APPLICATION IN PERSPECTIVE HEALTH SYSTEMS MANAGEMENT - SAMOA by
Dr W. Vermeulen l
lDirector-General of Health, Health Department, Apia
- 59 Annex 5
Samoa, like any other developing country in the region, finds itself at the threshold of a new technological age in which the rapidly expanding knowledge and application of telecommunication gadgetry could soon find its practical expression in every aspect of health care and revolutionise the day to day practice of medicine and health management as well as health/medical education. Communication being the means for transfer of information has become the major force of change in our world today. As one communications expert predicts, it will cause that "any area of the Pacific that cannot keep up with this (information) explosion will not stagnatej it will regress, relative to the rest of the world". Although lacking a comfortable frame of reference and confused by the bewildering array of potential applications of the new communications technology, yet while everyday the limit of its uses are fUrther expanded, the senior health managers in the region have to make choices - and soon - on how best to integrate this new technological alternative with the eXisting health structures and management systems operational in their countries. The bringing together of this Working Group to study in depth all aspects of this exploding technology is a timely initiative by the World Health Organization for which it should be congratulated. This paper will relate the steps Samoa has taken so far to benefit from the applied informatics technology. It will explore further applications which are considered of practical value to the health service way to implement them. It will suggest how WHO could assist the region to maximize the expected benefits of this expanding technology. The present Recently, the Samoan Health Ministry took"possession of five microcomputers, (four IBM XTs and one IBM AT) funded under the WHO country budget. They are being deployed in the following service areas: Health Planning and Information Unitj Medical Records Section of the National Hospital (central), referral hospital of the nationj National Pharmacy and' Laboratory Servicesj Finance Division and Communicable Diseases Control. At present their full utilization is proceeding on an ad hoc baSis, mainly because there is a lack of local expertise on how to use the computers, how to select the most appropriate software for the particular application required and how to design a format of data presentation compatible with computer specifications. At present 3 computers are operational, thanks to the personal commitment of a few individuals who are modestly computer literate. In order to maximize the potential of the now available computers, Samoa has called upon the expertise of a private American health management consultant firm, Mercy International, which, funded by USAID, will come and computerize the Department's financial and stores control functions. It is expected that this aid programme will continue and that gradually all computers will become fully operational when tailor-made programmes are designed which will economize on time and effort, especially if they are simple to operate and junior staff can become readily proficient in their execution. The future 1. As mentioned above, the Health Department hopes to see full utilization of the presently available computers in the very near future, thanks to the American Aid offer. As an immediate benefit, it is expected that the health data which are now being collected will not only be more
- 60Annex 5
safely stored, but the computer will allow a more flexible presentation of data and results which will be more appealing to staff. It is planned for the near future that the regular publication of a Newsletter (itself made possible by the use of the word processor) wherein pertinent data analysis will be reported will counter-balance and make more meaningflul to staff the usual drudgery of data collection and recording. 2. A more rigid financial and stores management control will be installed which will be a considerable planning tool for budgetary control and planning as well as assist in cost control management. Once the senior health staff become computer literate, it is expected that with the word processing facility, the quality of decision-making, health planning and inter-departmental communication will improve as the word processor is a powerful tool for the sorting out of ideas and the orderly presentation of arguments in a form which is easily assimilated. The real technological leap will be achieved by the interaction capability with other computers, especially outside the country. With the use of a modem, the computer can be linked to international data base networks such as the MEDLARS which is now already freely accessible from the Pacific Islands, thanks to a WHO initiative and support from Australia. It is expected that a link up with such networks will significantly assist the health planner, but also the clinician who will have medical library facilities readily available "at the touch of a key" so to speak. To become cheap and practically, faultless, the computer-based communication technology will need to become satellite-linked. Apparently, the amount of satellites orbiting around the globe is such that transponder space can now be rented at a reasonable cost. The recent introduction on the market of small aperture KU-band terminals which cost a fraction of the cost of the larger C-stations, should bring the possibility of satellite communications within the means of even the smallest Pacific nation. The added advantage of such telecommunication facilities is that they can be shared by different departments (e.g. health, agriculture, education, economic development, etc.) which could promote intersectoral cooperation. They will allow an even greater access at an acceptable cost to data bases around the world which will bring critical, current and regularly updated information to decision-makers, educators and technicians improving the services they deliver. Recent applications of this technology now already routinely available in developed countries are "tradefair", a Bulletin Board system allowing 24 hours resource-sharing activities to proceed asynchronously. USAID has stimulated thinking in this direction for a pharmaceuticals bulk purchasing scheme to be set up for the countries of the Pacific if such technology could be made available to them. The purchasing scheme COUld, of course, be extended to other items of importance to the health and other fields, e.g., equipment, spare parts, educational materials, etc. The Omega Rose Foundation, a recently created non-profit organization based in Honolulu, Hawaii, has received backing from USAID to solicit the Pacific countries' support for such an international satellite-linked networking system.
3.
4.
5.
6.
7.
- 61/62 Annex 5
8.
In the health/medical education field, besides the ready access to data bases as has been mentioned earlier. educational software could be designed for classroom use in health-related courses. This would also enhance the capability for self-study which, at present. in the smaller countries of the Pacific is rudimentary. Other recently introduced applications in this field ere "problem tank." an asynchronous problem solving tool in which problems are posed by participants for input from other participants; or "Synchrony". a dual or multi-user synchronous conferencing technique for real time inter-actions. The potential of these last two applications is limitless but would once and for all eliminate the professional isolation in which health professionals in the smaller Pacific islands have been practising for ages. From a clinical point of view, it would lift the quality of medical care to levels found in the more developed countries: this would furnish a sensitive measurement of the narrowing of the technological gap between developed and developing world.
WHO role It is our impression that WHO could play a decisive role in bringing the multiple advantages of informatics and especially the comput~r-based (possibly satellite-linked) telecommunication technology to the various countries of the region. especially to the developing countries who lack the technical expertise or the financial resources. Computer hardware and software have already been made available by WHO to the various Pacific countries on a rather ad hoc basis. What is needed now is a concerted effort to standardize equipment and software and to devise programmes which can be readily used by the health professionals. To this effect it is urgently required that training programmes be organized for all levels of national health staff so that the highest possible percent of computer liter~cy is achieved. The admirable initiative of making the MEDLARS networking system available to the region in cooperation with the Australian government, should be further encouraged by WHO and more precise technical guidance should be offered to those countries wishing to benefit from the project (e.g. basic questions like which modem to use should be readily answered). Again, training courses for user staff should be made available at country or regional level. WHO could cooperate with other agencies interested in informatics and promote the development of more recent applications of communications technology such as the satellite linking of computer networks. This could lay the groundwork for still more advanced telecommunication technology such as worldwide educational television coverage and interactive educational networking to become a reality. The developments in this field are so rapid, the changes they bring are so profound and wide-ranging that there is more than hope that they will significantly assist the lesser developed countries in their attempts to achieve the goal of Health for All by the Year 2000.
- 63/64 ANNEX 6
PERSONAL COMPUTERS IN THE 1990s by
Dr Haruhisa Ishida 1
1professor, Computer Centre, University of Tokyo, Tokyo
- 65 Annex 6
In early 1987, IBM and Apple announced new series of personal computers (PCs). Since they are the largest manufacturers of PCs in the world, tile new series are considered to be the trend-setters or the de-facto standards as the next generation of PCs. While the hardware will become available in this region starting 1988, it will be well into the 1990s before applications software for the new 32-bit machines is produced 1n abundance. The following is a conservative observation based on these new advanced PCs (see Table 1), taking other developments into consideration. (1) The central processor is a 32-bit type like 80386/68020 or their advanced versions. The clock rate is 16 MHz or 25MHz or beyond. Speed is expected to be at least 2-4 MIPS (Million Instructions Per Second) initially. (2) The main storage size is 1 MB (Mega Byte = 1,000 KB) to 16 MB, employing 1 M-bit chips. When 4 M-bit chips become in mass production in the 1990s, it will be possible to extend the storage size to 4 to 64 MB at about the same cost. The Macintosh II storage is expandable to 1500 MB even in the present design. (3) The standard floppy disc will be 3.5" (2HD) in size initially with
1.2 MB or 1.4 MB capacity. The micro floppy disc is encased in a dust-free rugged case. Its handling is easier and safer than a 5" floppy disc. Higher density floppies with 5-10 MB capacity are already available but it is not clear which will become the next standard. Standardization in this capacity is urgently needed. (4) The standard diameter of hard discs is becoming j.5" too. The capacity is 40, 70, 80 and 115 MD, even today. A I-GB (Giga Byte = 1,000 MB) disc drive can be expected in the 1990s. (5) A streaming magnetic tape drive is desirable to back up a hard disc. As hard disks expand, it becomes crucial to save the content of a hard disc in some media for later restoration (against possible crush) to avoid the total loss of databases. (6) Power-protection units and the related software are also desirable in places where power failures occur from time to time. Dust-free rooms and dust-covers are essential where dust is a problem. (7) A new type of optical discs called WORM is emerging. Even today's model has an enormous capacity of 200 MB. WORM stands for Write Once Read Many. Users can write data only once in this disc but can read the data many times. Since one cannot alter the data once written, backup is not necessary. (8) The size of the current CD-ROM (another form of read-only optical disc with enormous 540 MB capacity) is 5" and is not size-compatible with 3.5" floppy discs and 3.5" hard discs. Now companies like SONY are developing a more compact and less-costly 3.5" CD-ROM.
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Annex 6
(9) Telephone modems will become increasingly more effective for WAN (wide area network). While 300, 1200 and 240U bps (bits/second) modems are becoming very cheap, high-speed (2-wire) modems (for 4800, 9600 and 19200 bps transmission) are appearing. Protocols like MNP (Mico Networking Protocol) are employed in high-speed modems to enhance the reliability of telephone communication by automatic retransmission of erroneous packets of data. The telephone modems are the basic of BBS (Bulletin Board System) for PCs. (10) As for LANs (local area networks) no single standard is likely to be established. Rather, the co-existence of several different networks will become important by the use of gateway processors. Currently, such network schemes as Ethernet (base-band), token-ring, and broad-band are being used. Now on the other hand, we will have the following problems for the time being. (1) The new PCs are expensive at least initially, although the cost/performance is better. It would take around 2 years for other makers to design clone machines, because of the need for custom-designed LSIs around central processor chip. (2) The only OS (Operating System) available for 80386 is PC-DOS (or MS-DOS) for the time being. This limits the programmable memory to 640 KB even if the physical memory size is more than 640 KB. The storage beyond 640 KB can be used as a memory disc (a faster but volatile floppy disc). (3) Software which can take advantage of the new capabilities of the
new processors will not be available for sometime to come. Users have to use "old" software currently in use. Gain in speed and extended memory disc are immediate advantages. In the area of software, the following observation can be made. First, the new OS/2 (considered to be the next stand for 80286/80386-based PC OS after MS-DOS) has the following features. (1) Available not only from IBM but also from MicroSoft. (2) Upward compatible with the current floppy-based PC-DOS (MS-DOS). MS-DOS itself can be used on the new Macintosh II. (3) Addressing of 16 MB of programmable memory and 1 GB of virtual ~emory. This is for only 80286. To fully utilize the huge addressing capability of 80386, an extension to OS/2 or a still new OS is necessary.
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Annex 6
(4) Multitasking (but not multi-users on multi-terminals). (5) Overlapping multi-windows with graphics. (6) Needs a hard disc (not a floppy-disc OS anymore) ana preferrably a backup device. UNIX - another ana larger OS - will be used for multi-users on multi-terminals. The language C will be used by an increasing number of professional programmers as a aevelopment language on MS-DOS, OS/2, UNIX and MAC-OS. As for applications software, there are several widely used programs. The following "established" programs will be upgraded to take advantage ot new 32-bit processors in the 1990s and continue to be used, although we will see the emergence of new software and the porting of significant software from main frames to new PCs. Lotus 1-2-3 MultiPlan dBase III SAS/PC SPSS/PC+ BMDP/PC
(Spread sheets) (Database system) (Statistical Analysis Package) (Statistical Packages for Social Sciences) (BioMedical Data Processing)
One of the most interesting application area for new PCs is "desk-top publishing", in which one can edit documents with graphics and in character with different sizes and fonts. The desk-top publishing is becoming possible thanks to the availability of low-cost laser-beam printers and LED printers with the resolution of 240 to 300 dots/inch (see attached sample). It is expected in the 1990s that non-impact printers with higher resolution (480, 600 dpi or more) be used with PCs at reisonable cost. Another area of interest is AI (artificial intelligence) systems like expert systems. However, it would be extremely difficult to design expert systems which can be applied "universally" to many countries. This is because, for example, medicines and medical regulations are quite different from country to country. Lastly, for applications requiring more capable computers, workstations (super personal computers) are becoming more powerful each
- 68 -
Annex 6
year. Usually a WS has a higher-resolution display and more hard discs (currently up to 380 MB). The following is a comparison of display resolutions. CRT SIZE 9"
DOTS 512 x 342 640 x 200 640 x 400 1120 x 750 1024 x 816 1024 x 864 1152 x 900 1280 x 1024
RELATIVE 0.04 0.5 1.0 3.3 3.3 3.5 4.0 5.1
EXAMPLE OF PC/WS Macintosh Typical PC Standard PC 1n Japan Advanced PC 1n Japan Sony NEWS Micro VAX II SUN-3 Advanced WS In Japan
12" 12"
IS" 15" 19 " 19" 20"
Note that as resolution becomes high, the display of screenful information requires more speed. For example, filling of a 1280 x 1024 dot screen requires a display speed 5.1 times as fast as 040 x 400 dot screen, if the display has to be completed in the same period.
- 69170 -
Annex 6
Table 1 Examples of 32-bit personal computers expected to be used in the early 1990s IBM PC/2 -80 Processor Clock ROM Main memory 80386 16/20 MHz 128 KB 1-16 ME Apple Macintosh II 611020 16 MHz 256 KB l-ll ME (up to 1,500) (13") 640 x 480 dots 16 (out of 16 x lOb) (3.5") 0.8 ME 40/80 MB to 640 MB 0/4") 38.5 MB
Display Colors Floppy disc Hard disc Stream tape WORM disc
(14" ) 640 x 480 dots (16") 1024 x 768 dots 25b (out of 262,144) (3.5") 1.44 MB 115 ME*2
-
200 MB
-
Printer Network
LED (240 dpi) Token r1ng (4 Mbps) Base-band Broad-band OS/2 PC-DOS (MS-DOS) UNIX
LaserWriter (300 dpi) Apple talk Ethenet (10 Mbps) with UNIX MAC-OS MS-DOS (needs 80286) UNIX
OS
- 71-
ANNEX 7 BIBLIOGRAPHY
Present and Potential Uses of Informatics and Telematics in Health, November 1986, (WHO document no. ISS/86/36) Microcomputers and their Applications for Developing Countries; Report of an Ad Hoc Panel on the use of Microcomputers for Developing Countries, Westview Press 1986, ISBN 0-8133-7252-6 Hospital Information Systems - An Overview, T.K. Shaffert and C.E. McDowell, Aspen Systems Corporation, 1978 Hospital Information Systems - An International Perspective on Problems and Prospects, R.H. Shannon et aI, North-Holland Publishing Company, 1979 The Growth of Medical Information System in the United States, D.A.B. Lindbepg, Lexington Books, 1980 MEDINFO Bo, D.A.B. Lindberg and S. Kaihapa, North-Holland Publishing Company, 19BO Managing the Four Stages of EDP Growth, R. Nolan and C. Gibson, Harvapd Business Review, 1979 The Role of Hospitals in Primary Health Care. Repopt of a Confepence Sponsored by Aga Khan Foundation and the World Health Organization, Karachi, Pakistan, 22-26 November 1981 Hospitals and Health for All. Report of a WHO Expert Committee on the Role of Hospitals at the First Referral Level, Technical Report Series 744, WHO Geneva, 1987