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Data management for hospital administration Soubliere, Jean Pierre 1971

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DATA MANAGEMENT FOR HOSPITAL ADMINISTRATION by Jean-Pierre Soubliere B. Comm., Un i v e r s i t y of Ottawa, 1967 A Thesis submitted i n p a r t i a l f u l f i l l m e n t of the requirements for the degree of Master of Business Administration i n the Faculty of Commerce and Business Administration We accept t h i s thesis a? conforming to the required standard The University of B r i t i s h Columbia, August, 1971 In presenting t h i s thesis i n p a r t i a l f u l f i l l m e n t of the requirements f o r an advanced degree at the Un i v e r s i t y of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission f o r extensive copying of t h i s thesis for scholar l y purposes may be granted by the Head of my Department or by his representative. It i s understood that copying or pu b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. JULY, 1971. ABSTRACT In hospitals, as i n business, the l i t e r a t u r e bears evidence of successful implementation of s p e c i a l i z e d computer systems. Unfortunately, a l l attempts at designing large-scale t o t a l l y integrated h o s p i t a l information systems have so f a r been unsuccessful. It seems apparent that the missing l i n k between the dedicated systems and the " t o t a l " systems i s the non-u t i l i z a t i o n of the systems approach. To demonstrate the importance and the p r a c t i c a l i t y of t h i s approach, i t i s used to outline and evaluate the c r i t e r i a applicable i n choosing a data management system for h o s p i t a l administration. Chapter Page I. - INTRODUCTION 1 A r r i v a l of Computers i n Hospitals 1 Purpose and Scope of the Thesis 8 II. - DEFINITIONS 10 Management Information System............... 10 Data Bank 11 Data Management Systems. 12 HIS C l a s s i f i c a t i o n 15 III. - ILLUSTRATIONS 24 . . Health Information Systems 24 Regional Hospital Information System 25 Total Hospital Information System 27 Dedicated Systems 34 IV. - MIS DESIGN: PROBLEMS AND SOLUTIONS 44 Design Problems 44 Design Approach 49 V. - HOSPITAL ADMINISTRATION INFORMATION REQUIREMENTS AND.THE.CORRESPONDING DATA BANK 63 Plant Expansion 67 Food Services Cost Control 71 VI. - A HIS-DMS 95 HIS-DMS C r i t e r i a 95 Evaluation of Commercial Packages 119 VII. - SUMMARY AND CONCLUSIONS 121 BIBLIOGRAPHY 123 Table oage I. - C l a s s i f i c a t i o n of HIS 23 II. - Long-Range Planning Information 59 I I I . - Cost Control Information 72 IV. - Use of Patient Record Components 80 V. - Adaptation of Table IV to the Systems Approach to Hospital Administration 83 LIST OF FIGURES Figure page I.A - Health Information System 15 I.B - Regional Hospital Information System 17 I I . - Breakdown of Health Related Information Systems 20 I I I . - A Patient Centered Hospital System 55 IV. - Hospital Subsystem Objectives 58 V. - How the Subsystems Work Together 61 VI. - Conceptual Hospital Administration Data Bank. 75 VII. - Hospital Administration Data Bank Structure.. 78 VIII. - I l l u s t r a t i o n of a Food Services Control System 91 INTRODUCTION I. ARRIVAL OF COMPUTERS IN HOSPITALS As i n every other domain, the u t i l i z a t i o n of computers i n hospitals has grea t l y increased i n the past decade. Two main factors have been responsible for t h i s : 1. R i s i n g Costs Canadians becoming acutely aware of t h i s i n the la t e 1950's led to the formation of a Royal Commission on health services. In 1961, 4.137o of our Gross National Product was devoted to health c a r e 1 . By 1970, t h i s figure was 5.2%^. Accordingly, i t i s not even necessary to mention health's s o c i a l consequences to demonstrate i t ' s importance i n Canada. While the above s t a t i s t i c s do not seem to be alarming, symptoms of an incoming health c r i s i s have already appeared i n the United States, thus i n d i c a t i n g that such a s i t u a t i o n might possibly be forthcoming i n 1 Department of National Health and Welfare, Royal  Commission on Health Services, Dominion Bureau of S t a t i s t i c s , Ottawa, 1964. 2 Unless otherwise s p e c i f i e d , s t a t i s t i c s were obtained from D.B.S. catalogues (83-000 series) on Hospital S t a t i s t i c s . Canada. Former U.S. Secretary of Health, Education and Welfare, Robert H. Finch, expressed the following alarming opinion: This nation i s faced with a breakdown i n the del i v e r y of health care unless immediated con-certed action i s taken by government and the private sector^. It i s estimated that 7% of the U.S. Gross National Product i s presently (1971) devoted to health care. In recent years, i t has become apparent that the pouring of large sums of money into the system has not helped. There i s also strong evidence to suggest that one of the main propellers of the cost-push i n f l a t i o n recently experienced i n the health f i e l d has originated from hospital costs. For instance, i n 1970, 387« of the U.S. health b i l l was taken up by h o s p i t a l care'*. This figure rose to 44% in early 1971. In Canada, our h o s p i t a l expenses accounted for 57.3% of our 1961 t o t a l health b i l l , having r i s e n from the 1926 figure of 31.3% at a rate of 8.5% per year. Canadian patient day cost rose by 14.8% between 1967 3 Fortune, " I t ' s Time to Operate", (January, 1970), p. 79. and 1968, In 1970, t h i s figure was $51.15, up by 13.5% since 1968, On the other hand, Americans spent an average of $48.15 per patient day i n 1955, whereas i n 1969, t h i s d a i l y outlay had r i s e n to $67.60, a 39.3% increase^. The present structure of insurance plans and catch-up wage increases have r a p i d l y augmented the cost of hospi-t a l care. Being a labor-intensive industry, hospitals saw 66.9% of t h e i r t o t a l 1958 expenses devoted to wages. In fact, between 1959 and 1969, Canadian h o s p i t a l manpower costs increased by 107%. Contrary to other industries where automation has helped "brake" r i s i n g costs, hospitals have remained labor-intensive. Confronted with these r i s i n g costs, i t i s not s u r p r i s i n g that government and hospitals have stressed cost control, a function which i s greatly f a c i l i t a t e d by the use of computers. 2. Growing Demands on Hospital Administration Hospital Administration i s a mo?t d i f f i c u l t task when compared to other industries. In 1968, there were 1,009 " p r o f e s s i o n a l " hospital administrators i n Canada. Of these, 48.7% had received 5 Fortune, "Hospitals Need Management Even More than Money", (January, 1970), p. 96. no formal h o s p i t a l administration courses, whereas 31% had followed some r e l a t e d part-time courses, and only 20.37% had an o f f i c i a l degree or diploma i n h o s p i t a l administration. When matched with the 1,269 Canadian hospitals, t h i s meant that a maximum of 16% of these hospitals had one i n d i v i d u a l who had received a formal degree or diploma i n h o s p i t a l administration. The p r i n c i p l e of equilibrium between r e s p o n s i b i l i t y and authority has also been neglected i n h o s p i t a l adminis-t r a t i o n . It i s a well known fact that doctors possess most of the influence i n North American hos p i t a l s . The following story, that of a community h o s p i t a l i n Connecticut, gives one of the more blatant examples. A few years ago,the hospital employed a young administrator who, with the apparent backing of his board of trustees, sought to make improvements. He wanted the services of some of the s p e c i a l t y groups which had begun to play an important part i n medi-cine. In t h i s attempt to encourage s p e c i a l i s t s i n his community, the young administrator ran afoul of the county medical society and his own medical s t a f f of general p r a c t i t i o n e r s who resented the idea of s p e c i a l i s t s coming to town, and further resented the idea that the administrator would bring them i n . Gradually, i t became noticeable that t h i s h o s p i t a l , which had been nearly f u l l y occuoied as were most hospitals, was s u f f e r i n g from a decline i n t r a f f i c . Many beds were empty, and i t did not take long for the administrator, his board, and his s t a f f to r e a l i z e that they were facing a doctor's s t r i k e ^ . 6 Hoyt, Edwin P., Condition C r i t i c a l , Our Hospital  C r i s i s , New York, Holt, Rinehart and Winston, 1966. The s i t u a t i o n worsened up to a point where the hospital's patient population was almost n i l , and the young administrator, to save the h o s p i t a l , resigned. The head nurse replaced him as administrator, and gradually, the bed u t i l i z a t i o n increased to i t ' s previous rate. Examples of i n e f f i c i e n c y are not d i f f i c u l t to f i n d . For instance, i n 1970, twenty New York hospitals had open-heart surgery c a p a b i l i t i e s . Five of them were able to perform 2/3 of such operations, thus i n d i c a t i n g a gross m i s - a l l o c a t i o n of resources, and, very probably, some very expensive empire-building*^. Also i n the U.S., even with an improved medical care, the average length of stay i n hospitals increased by almost a f u l l day between 1962 and 1970, up to 8.48. In Canada, our average length of stay i s 10.06 days. Another apparent area of i n e f f i c i e n c y i s capacity u t i l i z a t i o n . In the U.S., the o v e r a l l average i s 80%, whereas i n Canada, the f i g u r e i s 81.2%. When one considers that the estimated c a p i t a l cost of one h o s p i t a l bed i s $35,000, t h i s 18.8% idleness i s rather expensive. 7 Fortune, op. c i t . , p. 99. Further symptoms of i n e f f i c i e n c y i n the U.S. appear in the range of prices for s i m i l a r accommodations, thus r e f l e c t i n g uneven Levels of hospital management The dominance of hospitals by doctors who are not normally (and with reason) economically oriented i s yet another source of mismanagement. The following i s an extraction from a Fortune magazine e d i t o r i a l : The f i n a n c i a l d i s t o r t i o n s , i n e q u i t i e s , and the managerial redundancies i n the system are of the kind that no competent executive could f a i l to see, or would be w i l l i n g to t o l e r a t e for long^. Fortunately, professional hospital administrators are graduating from educational i n s t i t u t i o n s at a steady rate. Also, many hospitals, and this i s true for many countries, are presently i n the process of u t i l i z i n g systems analysis techniques, and, of greater importance, attempting to design t o t a l l y integrated hospital information systems i n search of better patient care, reduced costs, or at least of a better return on investment for hospital care expenditures. The e f f o r t rests on the postulate that a better information system could, for example, op-timize treatment scheduling, thus providing a more e f f i c i e n t and better use of resources, and more importantly, foster and better patient care for the same costs. A medical doctor has even expressed the following opinion: It has been shown that by better adminis-t r a t i o n the same bed might serve twice as many patients-^ The establishment of e f f i c i e n t and uniform account ing and cost accounting methods, the establishment of central purchasing and supply systems, or again the maintenance of personnel information systems, a l l of these among others, have contributed to a more sophisticated management's desire for better information. These more basic systems, coupled with the cost control methods and the growing use of management science tools i n hos p i t a l administration (e.g. c o r r e l a t i o n of types of h o s p i t a l expenses with revenues), have introduced to the h o s p i t a l administration sphere the "information revolution" that encountered the business world i n the early s i x t i e s . Thus was the emergence of the term Hospital Information Systems (HIS), an adaptation of business' Management Information Systems (MIS), and the advent of "true" computer u t i l i z a t i o n i n hospitals. Unfortunately, successful implementation of a large Hospital Information System i s s t i l l a d i f f i c u l t goal to achieve. 10 McGibony, M.D., John R., P r i n c i p l e s of Hospital  Administration, G.P. Putman's Sons, New York, 1959. II. PURPOSE AND SCOPE OF THE THESIS This thesis w i l l explain why a large hospital information system has not yet been implemented, and help solve some of the problems by pre s c r i b i n g the type of data management system necessary for hos p i t a l administration. Vast resources have already been expended i n un-successful attempts at MIS. It would thus be f u t i l e for this thesis to attempt a further design of MIS. On the other hand,.by l i m i t i n g i t s e l f to defining the data manage-ment system necessary to supply hospital administration data, and by doing t h i s while using the general systems approach, i t hopes to contribute i n two ways. F i r s t of a l l , i t ' s main objective i s to determine the various c r i t e r i a of a data management system for hos p i t a l administration. It's second objective i s to i l l u s t r a t e through a p r a c t i c a l a p p l i c a t i o n how the general systems approach may be u t i l i z e d i n defining various parts of the MIS. In effect, i t advocates s t r i c t adherence to the systems approach i n designing information systems. Chapter II w i l l o u t l i n e d e f i n i t i o n s of the main terms to be used i n t h i s essay. It w i l l also contain a c l a s s i f i c a t i o n format which w i l l be observed i n Chapter III to present some of the accomplishments and attempts i n designing and implementing hospital information systems. Chapter IV w i l l then outline some of the information system design problem areas, and present the procedure which w i l l be used to determine the data management system while i l l u s t r a t i n g i t s a o p l i c a b i l i t y to provide solutions to the major problems. Chapter V w i l l continue the implementation of this procedure by defining Hospital Administration information needs i n the areas of food services cost control and of long-range planning. The reports needed to provide t h i s information w i l l be c l a s s i f i e d i n various ways, and t h i s w i l l lead to Chapter VI which i s dedicated to o u t l i n i n g the basic c r i t e r i a which should be used i n s e l e c t i n g a data management system for hos p i t a l administration. CHAPTER II DEFINITIONS In order to provide a d e f i n i t i o n a l basis for Chapter III, which presents i l l u s t r a t i o n s of computer applications to health care, i t i s necessary to specify some of the used terms. The c l a s s i f i c a t i o n u t i l i z e d by Chapter III i n presenting health oriented computer systems i s a l so outlined i n t h i s chapter. I. MANAGEMENT INFORMATION SYSTEMS The expression Management Information Systems has many meanings. A recent survey of d e f i n i t i o n s contained fourteen d i f f e r e n t c l a s s i f i c a t i o n s of MIS interpretations, ranging from a General Systems Perspective to In t e l l i g e n c e Systems, with an aggregation of seventy-one d i f f e r e n t authors-*-. For these reasons, from t h i s thesis w i l l not evolve*, a further i n t e r p r e t a t i o n . On the other hand, one of the more recent conceptualizations w i l l be brought forward. Thus, the following d e f i n i t i o n w i l l serve as a frame of reference for the remainder of thi s study: 1 W i l l , Hartmut J., Management Information Systems  as a S c i e n t i f i c Endeavour: The State of the Art, Working Paper No. 84; Uni v e r s i t y of B r i t i s h Columbia, Vancouver, February, 1971. A Management Information System i s informally defined i n terms of managerial (factual) knowledge (data base) and managerial s k i l l s (model base) and consists of formally organized data and model banks which are managed to provide insiders and/or out-siders of open r e a l socio-economic systems with information about the system's proper goal directed-ness and proper goal achievement ex ante ( i n advance), ex nunc (at the time) and ex post (after the fact) i n the desired display mode, volume, and degree of aggregation r e l i a b l y , with accuracy, and within response time requirements at minimal "cost" to and with maximal "value" f o r the r e a l system.^ This d e f i n i t i o n implies a general systems framework, which, i n the case of t h i s essay, considers the ho s p i t a l as the organization and the health system i n general as the environment. It also implies that management performs the i n t e l l i g e n c e function of the organization, i . e . goal formu-l a t i o n and goal control. F i n a l l y , information i s regarded as goal related, useful, and timely, thus d i s t i n g u i s h i n g i t from raw data. Accordingly, Hospital Information Systems (HIS) w i l l represent systems which provide goal r e l a t e d information, about the hos p i t a l and i t s environment, to hos p i t a l management. II . DATA BANK The Data Bank i s one or several f i l e s of data supplying the "raw material for a l l management reports 2 W i l l , Hartmut, J., Management Information Systems: A D e f i n i t i o n a l Framework and Short Description, U n i v e r s i t y of B r i t i s h Columbia, July, 1971, p. 5. whether periodic, exception, or as inquiry from a data termma 13." I I I . DATA MANAGEMENT SYSTEM The Data Management System (DMS) manipulates the previously defined data bank, including f i l e creation, updating, deletion, sorting, processing, restructuring, auditing, e d i t i n g , and r e t r i e v a l i n a l l i t s forms. Most of the commercially a v a i l a b l e data management packages f a l l into two broad catagories 4^. The f i r s t and most simple of these i s c a l l e d Host-Language Systems. These systems are no more than basic additions to e x i s t i n g procedural languages, permitting easier and more complex f i l e handling. Thus, the program-mers must be competent i n order to use them. The second category i s referred to as that of the Self-Contained Systems. These are stand-alone systems which permit non-programmer users to access data f i l e s or require professional programmers to use a s p e c i a l language. 3 K e l l y , Joseph F., Computerized Management Infor-mation Systems; London; Collier-MacMillan Limited, 1970, p. 220. 4 O l l e , T. William, "MIS: Data Bases", Datamtion, November, 1970, p.47. In addition to the above d i s t i n c t i o n the Codasyl Programming Language Committee's Data Base Task Group presented, i n 1969, the concepts of a Data Description Language (DDL) and a Data Manipulation Language (DML)5. The "DDL i s the language used to declare a SHEMA"6, which " i s a des c r i p t i o n of a DATA BASE"7, and the DML " i s the language which the programmer uses to cause data to be trans f e r r e d between his program and the data base" 8. For the remainder of t h i s thesis, the expression DMS w i l l stand for the complete data management system. The DMS can now be v i s u a l i z e d as having three basic compon-ents: the DDL, the DML, and the report generating language (RPG). Some of the obvious benefits which have resulted , from the growing use of DMS are a p p l i c a t i o n independency of the data bank f i l e s , defined f i l e and report formats, the saving of programming time, the f a c i l i t a t i n g of data access by both programmers and non-programmers, and, as a consequence of t h i s , greater ease i n data analysis, i . e . the transfor-mation of data into information. 5 It i s assumed that the reader i s f a m i l i a r with the Data Base Task Group CODASYL REPORT, Association for Computing Machinery, New York, October, 1969. 6 Ibid, p. 2-1 7 Ibid, p. 2-1 8 Ibid, p. 2-1 Accordingly, once the organization's objectives have been s e t t l e d , and once the d i f f e r e n t components of th i s organization have been assigned t h e i r respective function, i t i s necessary that the proper information be communicated to each of them so that departmental goals be met, and, ultimately, global goals be attained. While the task of the MIS i s to provide the required information for the attainment of organizational objectives, one of the p r i n c i p l e functions of the DMS i s to store the data and f a c i l i t a t e r e t r i e v a l of necessary information, which i s why some authors prefer to c a l l i t an Information R e t r i e v a l System^. Keeping t h i s objective i n mind, the best DMS would be custom-designed to f i l l the p a r t i c u l a r needs of i n d i v i -dual types of organizations. This design would be strongly influenced by such factors as the volume and types of transactions and f i l e s , t h e i r i n t e r a c t i o n and r e l a t i v e importance, t h e i r usage, necessary outputs, f i n a n c i a l resources a v a i l a b l e , time dimensions, and the users with t h e i r i n d i v i d u a l needs. It follows that a highly dynamic industry would require a f l e x i b l e DMS which would allow f i l e structure 9 Byrnes, Carolyn J., and Steig, Donald B., " F i l e Management Systems: A Current Summary," Datamation, November, 1969, p. 138. a l t e r a t i o n s i n accordance with environmental changes, whereas a more s t a b i l i z e d environment could j u s t i f y a simpler and less expensive system. IV. HIS CLASSIFICATION The ultimate system i n the health sphere i s c a l l e d the Total Health.Information System l u . This system would provide goal r e l a t e d information both from an environmental aspect (health system i n general) and from an organizational aspect ( h o s p i t a l ) . It follows from t h i s that both a Regional Hospital Information System and a Health Information System are necessary for t h i s Total Health Information System to e x i s t . The d i f f e r e n c e between the two rests mainly on t h e i r area of focus. As Figures '."I. A and "I. B help point out, the Health Information System focuses on the environment whereas the Regional Hospital Information System focuses on the h o s p i t a l organization. 10 No Total Health Information System was encountered i n the l i t e r a t u r e . Thus, none w i l l be included i n Chapter I l l ' s i l l u s t r a t i o n s . FIGURE A HEALTH INFORMATION SYSTEM /HOSPlfAL^ ORGANIZATION /HOSP^TAL^ ORGANIZATION \2^y HEALTH SYSTEM ENVIRONMENT DRGANIZATION /HOS'PITALX ORGANIZATION Information Not Provided by System DEFINITIONS FIGURE : i . B REGIONAL HOSPITAL INFORMATION SYSTEMS In e f f e c t , the Health Information System looks at the whole health system i n general (including a l l remedial and preventive components). Its objective i s to f a c i l i t a t e t o t a l health planning for the region. The Regional Hospital Information System, on the other hand, i s t o t a l l y d i r e c t e d towards hospital information requirements. Its basic objective i s to provide a l l goal re l a t e d and operational information for the region's hos p i t a l s . This implies that these hospitals would be sharing a computerized information system and great portions of an a l l - i n c l u s i v e data bank. For this Regional Hospital Information System to exist, each of the region's hospitals must have a Total Hosoital Information System. This system provides a l l required information for a single h o s p i t a l entity. This, t o t a l system would, i n turn, be comprised of several more s p e c i a l i z e d systems. These w i l l be r e f e r r e d to as Dedicated Systems. This f i n a l category includes, for example, a Resource Management System, which might be composed of Personnel, Physical Resources and F i n a n c i a l Systems. On the other hand, the Health Information System would also be broken down into several smaller systems. For instance, one such system could be referred to as a Demograohic System, whereas another one could be an Ambulance Services System. As i s the ca=-e for hospital information systems, the Ambulance Services System would be composed of Dedicated Systems. F i n a l l y , the DMS, as indicated i n Figure II, provides the software l i n k between each of the information systems and t h e i r respective data banks. DEFINITIONS FIGURE I I BREAKDOWN OF HEALTH RELATED INFORMATION SYSTEMS TOTAL HEALTH INFORMATION SYSTEM HEALTH INFORMATION SYSTEM HEALTH SUBSYSTEM #1 e.g. AMBULANCE SERVICES SYSTEM HEALTH SUBSYSTEM #h e.g. DEMOGRAPHIC SYSTEM REGIONAL HOSPITAL INFORMATION SYSTEM HOSPITAL # l k s TOTAL HOSPITAL INFORMATION SYSTEM HOSPITAL #h's TOTAL HOSPITAL INFORMATION SYSTEM DEDICATED SYSTEMS c \ DEDICATED SYSTEMS 1) Patient Care System 2) Resource Management Systems 3) A u x i l i a r y Services Systems 4) Research and Training Systems Data Management Systems DATA BANKS As a further c l a r i f i c a t i o n of F i g u r e l l , i t i s imperative to r e a l i z e that for a system to be c a l l e d "Information System", i t i s not necessary that i t be of the Total Health Information System category. For instance, the simplest Personnel System e x i s t i n g by i t s e l f would be an information system so long as i t provides decision making information. The c l a s s i f i c a t i o n which w i l l be used i n Chapter III i n presenting computer applications i n the health f i e l d i s compised of four major categories. The f i r s t of these w i l l present Health Information Systems. This p a r t i c u l a r grouping i s divided into two classes. The f i r s t class contains a system which i s being designed using a "macro-approach" (systems approach), whereas the l a t t e r contains a system which was o r i g i n a l l y implemented with no plans for expansion, but which i s now being expanded to a Health Information System. It i s thus q u a l i f i e d as a system being designed while u t i l i z i n g a micro-approach. Thus, although both u t i l i z e a piece-meal approach, one i s forward looking whereas the other i s i s o l a t e d and l i m i t e d to a section of the whole. The second category of systems contains Regional Hospital Information Systems. This w i l l be followed by a presentation of those attempts at designing a Total Hospital Information System. I t i s also broken down into two main categories i n order to indicate design a l t e r n a t i v e s for these systems. The f i r s t of these two groupings i s referred to as Custom Designed Systems. This includes a l l those systems designed by and f o r a single h o s p i t a l for i t s own p a r t i c u l a needs. The second group, that of the Commercial Packages, serves to point out that some t o t a l HIS packages are commercially a v a i l a b l e to any ho s p i t a l , and that conse-quently they are of general rather than s p e c i f i c design. F i n a l l y , as indicated i n Table I, the l a s t type of HIS to be presented w i l l be the DEDICATED SYSTEMS. Four sub-groups w i l l be reviewed i n t h i s section. These w i l l include Patient Care Systems, Resource Management Systems, A u x i l i a r y Services Systems, and Research and Training Systems. TABLE I CLASSIFICATION OF HIS I Health Information Systems 1. Macro-approach system 2. Micro-approach system II Regional Hospital Information Systems III Total Hospital Information Systems ' 1. Custom Designed Systems 2. Commercial Packages IV Dedicated Systems 1. Patient Care Systems 2. Resource Management Systems 3. A u x i l i a r y Services Systems 4. Research and Training Systems ILLUSTRATIONS I) HEALTH INFORMATION SYSTEMS 1) MACRO-APPROACH SYSTEM The Daveryd Hospital Computer System^-, presently being designed i n Sweden, has as i t s main objective to continuously monitor the morbidity of the t o t a l regional population, and the usage of a l l health resources, includ-ing h o s p i t a l f a c i l i t i e s . The system i s being designed for one of Sweden's twenty-nine health regions. Sponsored by a Swedish government department devoted to the e f f i c i e n t use of the country's resources, the system i s based on a Central Population Register. This central f i l e was created by merging medical information c o l l e c t e d through hos p i t a l h i s t o r i c a l data, tax information (since the compulsory medical insurance i s paid through taxes), and the census f i l e . Implementation i s scheduled for 1974. 2) MICRO-APPROACH SYSTEM The system which f a l l s i n t h i s category has a micro-approach since, contrary to the Davderyd system, i t 1 Abraham, S., et a l , "Daveryd Hospital Computer System", Computers and Biomedical Research, No. 3, 1970. was o r i g i n a l l y designed to handle a single aspect of the health system, and i s now being modified to handle a t o t a l population. The f i r s t stage of the system, designed i n 1964 at the Hebrew U n i v e r s i t y of Jerusalem, was implemented i n order to f i n d the causes of a pregnancy disease2. Thus, a l l birth? were being put on f i l e i n order to tabulate morbidity rates. From t h i s evolved the concept of a t o t a l health f i l e . The system i s merely i n the planning stages at the moment. II) REGIONAL HOSPITAL INFORMATION SYSTEM Again one must go to Sweden to f i n d the most impressive work i n t h i s approach. In part I of t h i s chapter, i t was shown how a Swedish health system i s presently being developed while using a macro-approach to the problem. P a r a l l e l to t h i s work, the Karolinska I n s t i t u t e of Stockholm^ has, since 1965, undertaken the development of a t o t a l "Patient Information System", 2 Davies, Dr. Michael, "Toward a Medical Data Bank for a Total Population", Datamation, November, 1966. 3 Medical Information Processing: The KS Project, obtained from Dr. Paul H a l l , Karolinska Sjukhuset, Stockholm, A p r i l , 1970. as Dr. Paul H a l l , one of the designers, prefers to c a l l i t . ^ This system i s to be used by several Stockholm hospitals, each one sharing the same computing f a c i l i t i e s . With the environmental information provifed through the Daveryd system, the Patient Information System (Hospital Information System) w i l l provide, once implemented a l l necessary information, be i t for control, planning or operations. The combination of the two Swedish systems, would be a Total Health Information System. In Canada, an i n t e r e s t i n g example of cooperation i n developing information systems i s B r i t i s h Columbia's Hospital Personnel Management System^. It i s being used by 43 hospitals a l l sharing the same data bank (one magnetic tape) and hardware configuration. The system i s b a s i c a l l y nothing more than a p a y r o l l a p p l i c a t i o n at the moment, serving approximately 20,000 employees. But i t does o f f e r many expansion p o s s i b i l i t i e s , such as the sharing of part-time help, regional educational programs, or, even better, a sense of cooperation and of being capable of accomplishing something en masse. 4 Through personal correspondence, A p r i l , 1971. 5 McBride, Laurie, et a l . , A Report on Budgeting  i n B r i t i s h Columbia Hospitals, Presented to Dr. H.J. W i l l as a Term Paper, U n i v e r s i t y of B r i t i s h Columbia, 1971. In the U.S., one of the e a r l i e s t major ho s p i t a l f i n a n c i a l applications began i n 1965^. This p a r t i c u l a r system, as was done with B r i t i s h Columbia's Hospital Personnel Management System, i s the r e s u l t of a cooperative e f f o r t between several hospitals and the main health insur-ance company of the area, i n t h i s case the Minnesota Blue Cross. It covers such basic areas as p a y r o l l , accounts receivable and budgeting. Once again, operational and goal control information are supplied, with planning information being ignored. I l l TOTAL HOSPITAL INFORMATION SYSTEMS 1) CUSTOM DESIGNED SYSTEMS A version of such a system was implemented i n 1956 at the opening of the State U n i v e r s i t y Hospital of the Downstate Medical Centre i n New York*7. Named THOMIS, for Total Hospital Operating and Medical Information System, the system i s operationally oriented. Nevertheless, many probable patient care imporvements are attained, for example, 6 Anderson, John H., "Cooperative EDP for Minnesota Hospitals", U n i v e r s i t y of Michigan Engineering Summer Conferences: Applications of Computers i n Hospitals, 1966. 7 Geisler, Robert, "Thomis Medical Information System", Datamation, June, 1970. through speedier and more accurate drug d i s t r i b u t i o n . Unfortunately, i t i s d i f f i c u l t to measure the d i r e c t benefits of the system since the hospital has never existed without i t 8 . B a s i c a l l y , a patient's record i s entered into the system as soon as admission n o t i f i c a t i o n i s given, at which time a bed i s assigned. After physician v i s i t s , physician orders and patient status data are c o d i f i e d and entered into the patient's record through the use of terminals. Laboratory scheduling and drug ordering are automatic batch outputs of t h i s , as are various administrative reports. No environmental and very l i t t l e planning information are provided. In e f f e c t , the system supplies mainly operational information. The Texas I n s t i t u t e for R e h a b i l i t a t i o n and Research i s i n the process of implementing what i t c a l l s i t ' s Hospital Data Management System^. But i n fact, the system i s much more encompassing than what t h i s thesis has defined a DMS would be. For instance, here are some of i t s objectives: 8 Ibid, p. 135 9 Texas I n s t i t u t e for R e h a b i l i t a t i o n and Research, Demonstration of a Hosnital Data Management System, Progress Report, January-November, 1967. LONG RANGE OBJECTIVES a) To improve patient care by c o n t r o l l i n g information that w i l l reveal deviation from expected performance. b) To evaluate a time-and cost-shared central data processing f a c i l i t y that w i l l accommodate remote input-output devices and a mixture of continual and episodic date processing operations. c) To compare the costs and contrast the r e l a t i v e operational e f f i c i e n c y of a central computer f a c i l i t y shared by s a t e l l i t e s with "small" computers i n each h o s p i t a l . d) To evaluate the eff e c t of the ho s p i t a l data management system on the elements of hos p i t a l per-formance i n order to permit comparative studies and experiment with the systematization of a v a i l -able services. IMMEDIATE OBJECTIVES a) Determine which data management methods are most suitable i n a patient care environment i n order to minimize the c o r r e l a t i o n of erroneous and redundant data, and provide the maximum discrim-i n a t i o n of data. b) Determine most useful formats for computer generalized reports. c) To optimize scheduling of treatment and observations for each patient. d) To provide comprehensive and timely reports on personnel u t i l i z a t i o n , cost-center performance etc. e) To provide a cle a r audit t r a i l and improve cost control. f) To develop means of protecting data from unauthorized a c q u i s i t i o n . g) To develop a standard for optimizing h o s p i t a l services u t i l i z a t i o n ^ 0 . Accordingly, the system does have a strong data management emphasis. But i t i s also evident that patient-care information, both for planning and control, and some goal r e l a t e d f i n a n c i a l information are a v a i l a b l e . Environ mental information i s not provided. Once again, a u x i l i a r y services are not considered. A t h i r d well documented system i s that which i s being developed at the U.C.L.A. Hospital, Los Angeles, C a l i f o r n i a 1 1 . For the past decade, the e f f o r t has been mainly oriented towards data management applications, based on the premises that from medical data c o l l e c t i o n at the point of o r i g i n w i l l evolve the a l l important data base, and from t h i s , the HIS. The following quotation from one of t h e i r progress reports describes the reason for t h i s way of thinking. The task of developing a complete patient information and communication system including both patient and h o s p i t a l management data has proven e x t r a o r d i n a r i l y d i f f i c u l t , both because of the extreme complexity of the communication require-ments of a modern medical care f a c i l i t y and becase much of the data r e l a t e d to the care of patients have ro t previously been expressed i n a form s u i t -able for input into a computing system.12. 11 Lamson, B.G., et a l , "Methods of Information i n Medicine", Journal of Methodology i n Medical Research,  Information and Documentation, A p r i l , 1970. Thus, t h i s p a r t i c u l a r group, recognizing the complete lack of success i n implementing a t o t a l HIS, has spent the l a s t decade on determining the data bank, deciding what data to store and to ret r i e v e , and how to do so. In e f f e c t , a great deal of e f f o r t has been spent on a medical-thesaurus. Stress has also been put on developing patient care and f i n a n c i a l information processing i n p a r a l l e l , to f a c i l i t a t e future integration. Up to now, an accrual revenue and expenditure accounting system (used for p r i c i n g of services and for matching revenues and expenses), a patient i d e n t i f i c a t i o n and census system, and selected patient care data a c q u i s i t i o n and processing systems have been implemented, but only p a r t l y integrated. This p a r t i c u l a r e f f o r t helps to point out how d i f f i c u l t the task of designing a DMS r e a l l y i s . 2) COMMERCIAL PACKAGES Two packages w i l l be described including I B M's Medical Information System Program (MISP)^^ and Honeywell-Data Communication's Real Time E l e c t r o n i c Access Communi-cations, for Hospitals (REACH)14. 13 International Business Machines Corporation, Medical Information Systems Procrram, Catalogue No. H 20-0808, IBM Corporation, New York, 1970. 14 See p. 32 The IBM system was designed with the intent of providing operational information, with the hope that such a major system could be implemented i n many hosp i t a l s . Here are some of the various goals as l i s t e d i n the MISP manual: 1) Reduction of c l e r i c a l work load for profess-i o n a l s t a f f . 2) Improved patient care through rapid and accurate transmission of patient data for instantan-eous access i n a meaningful form for review by physicians or administrators. 3) Capture of charges as they occur. 4) Schedule of service area workloads, appoint-ments, and f a c i l i t i e s to help achieve maximum e f f i c i -ency and cost savings. 5) Timely information to the medical s t a f f e a s i l y r e t r i e v a b l e and cor r e l a t a b l e . 6) Stock usage s t a t i s t i c s through a b i l i t y to monitor supplies disbursement, thereby f a c i l i t a t i n g control of stock l e v e l s . 7) Administrative management control through capturing data for comprehensive and timely reports of operational a c t i v i t i e s ^ . Unfortunately, the MISP requires a 360 model 40 computer, thus eliminating from i t s p o t e n t i a l customers 14 (cont.) Information on t h i s system was a v a i l a b l e from several sources: (1) Vetter, A.O., A Hospital Information System, Paper presented at the National Conference of CIPS and CORS i n Vancouver, June, 1970; (2) Smith, Lorraine, "The REACH System i s Here: Doctors Can Take It or Leave I t " , Modern  Hospital, February, 1970. (3) REACH: A Total Communication Syst em for Hospitals,.National Data Communications, Inc., Texas, 1970. 15 Op C i t , IBM Corporation. most average s i z e hospitals (300-400 beds) 1^. It has also been c r i t i c i z e d for i t s lack of a p p l i c a b i l i t y i n general hospitals, since i t was designed i n a teaching h o s p i t a l environment 1 7. But t h i s p a r t i c u l a r package, i f applicable in general hospitals, can c e r t a i n l y provide valuable functional help through i t ' s data management c a p a b i l i t i e s . The second commercial package, that of Data Communication Corporation, i s mainly an ultra-modern communication system that i s meant to help speed up scheduling and r e l i e v e professional s t a f f from c l e r i c a l work, and, as a consequence, speed up patient care. The package, having taken 200 man years to design, i s based on a series of sound p r i n c i p l e s , such as a modest data base (current information only), t i g h t s e c u r i t y even with the use of numerous C.R.T,S., r e l i a b i l i t y through the use of a back-up C.P.U., and ease of implementation (turn-key operation). The system's basic design philosophy, quite to the contrary of a l l other systems reviewed which claimed that 16 Singer, Peter J., "Computer-Based Hospital Information Systems", Datamation, May, 1969, p. 40. the patient was the central focus of attention (at least i n i n t e n t ) , i s that nothing can take place i n hospitals unless the doctor issues an order. In e f f e c t the whole system centers around the routine that the doctor enters information at a terminal. Certain types of information w i l l cause c e r t a i n things to happen, such as i n d i v i d u a l patient f i l e updating, drug ordering, inventory keeping, and b i l l i n g . Even though a great deal of the planning information which a t o t a l HIS w i l l eventually require i s missing, i t appears that t h i s p a r t i c u l a r package more than f u l f i l l s what i t i s supposed to be, i . e . an ultra-modern communi-cation system that w i l l help speed up scheduling, r e l i e v e prfoessional s t a f f from c l e r i c a l work, and because of these, speed up patient recovery. IV) DEDICATED SYSTEMS A hospital's basic subsystems are Medical Care, Resource Management, A u x i l i a r y Services, and Research and Training. For t h i s reason, the remainder of t h i s chapter w i l l present some of the applications designed or planned i n these various spheres. It i s not s u r p r i s i n g to note that these are the areas where computers have been most succ e s s f u l l y applied i n hospitals, as i s the case with business organizations. 1) PATIENT CARE SYSTEMS The systems reviewed i n t h i s section are of a more s p e c i a l i z e d nature, covering such applications as patient monitoring, medical record management, or automated diag-nosis. A good example of what can be done i n automated medical h i s t o r i e s i s the system being experimented with at the Mayo C l i n i c of Rochester, Minnesota-^. Based on the assumption that a great deal of scarce physician time could be saved i f a patient's h i s t o r y taking could be automated, t h i s p a r t i c u l a r system has the patient answering a series of tree-formated questions on a light-pen terminal. This system also has some value i n preliminary diagnosis. Another approach to improving medical care are the many ambulatory-patient oriented systems. These have both a f i n a n c i a l and patient-care aspect to them. At the Yale-New Haven Hospital i n Connecticut, such a project was undertaken with the following objectives i n mind"^: 18 Mayne, John S., M.D., "Toward Automating the Medical History", Mayo C l i n i c Proceedings, Vol. 43, No. 1, January, 1968. 19 Brenner, Harvey M., et a l , "An Ambulatory-Service Data System", AJPH, July, 1969. 1) To select each item of data to be c o l l e c t e d according to a n t i c i p a t e d research and administrative requirements as based on (1) the a v a i l a b l e medical care and epidemiological l i t e r a t u r e , and (2) current experience; 2) To determine the r e l a t i v e e f f i c i e n c y and effectiveness of various a l t e r n a t i v e methods of i n s t i t u t i o n a l i z i n g the records system-including methods of data c o l l e c t i o n , storage, and processing; 3) To demonstrate some of the major issues and problems involved i n various schemes of implementing such a data system i n a U n i v e r s i t y Medical Centered. More d e t a i l e d goals included the following: 1) Selection of the items of data should enable comparisons with inpatient, emergency service, community-wide, and national s t a t i s t i c s . 2) The basic data systems should be applicable to ambulatory care f a c i l i t i e s of many d i f f e r e n t sizes and types. 3) Both the format of the data c o l l e c t i o n instruments, and the method of storage of the data, should be s u f f i c i e n t l y f l e x i b l e to allow for modifications introduced as a r e s u l t of new l e g i s -l a t i v e and medical care program changes^l.... The concern with environmental information i s one of the more s t r i k i n g elements of t h i s project. The possible benefits of such a system are: 1) Administrative Management - information concerning patients, services, and costs to be used i n program evaluation and planning e.g.; character of population served or patterns of use of medical care. 20 Ibid, p. 1154 - long-term planning to be helped by above trends - resource r e a l l o c a t i o n easier and more e f f i c i e n t - need for expansion or contraction defined more c l e a r l y - c l e a r evaluation of effectiveness and e f f i c i e n c y of the services 2) Monitoring of Patient Care and Research Uses - Monitoring of q u a l i t y of patient care, including u t i l i -zation review and medical audit - Evaluation of new techniques i n medical care - C l i n i c a l Research - Epidemiology (of disease patterns and i n t e r r e l a t i o n s h i p s within populations using i d e n t i f i a b l e ambulatory services) 3) State, Regional and National Data - Continous observation and evaluation of large-scale changes i n patterns of ambulatory care - A l l o c a t i o n of f i n a n c i a l and health manpower resources to d i f f e r e n t types and organizational patterns of medical care. S t i l l i n the f i e l d of improved patient-care, numerous smaller systems are devoted to patient monitoring. A sample of t h i s i s the p o s s i b i l i t y of applying mini-computers such as the Olivetti-Underwood's Programmer 101 to give a running p i c t u r e of a patient's complete cardiac status. As was mentioned e a r l i e r i n analyzing the U.C.L.A. project.22 / medical data recording, expecially i n instances of narrative data, such as physician notes, i s a major problem i n h o s p i t a l computer systems. Thus, a great deal of e f f o r t i s being expended towards f i n d i n g methods on how to record variable length information. U.C.L.A., i n p a r t i c u l a r , claims to have been most successful i n t h i s area23. In the area of multiphasic screening, the Kaiser Foundation Hospital i n Oakland, C a l i f o r n i a , provides a good example of what can be done^. This system consists of having the patient go through a battery of 19 tests, where the data i s recorded automatically and matched against pre-established standards. Immediately following the l a s t test, a report i s p r i n t e d out g i v i n g deviations from the standards, possible explanations, and suggestions for further t e s t s . At the moment, 4,000 people per month submit to the t e s t s . 2) RESOURCE MANAGEMENT SYSTEMS Just as for business organizations, computers were u t i l i z e d mostly i n f i n a n c i a l applications when they were 22 See Section III of t h i s Chapter. 23 Lamson, Baldwin G., M.D., Data Processing i n a Medical Center, Prgoress Report, U n i v e r s i t y of C a l i f o r n i a , Los Angeles, 1966. 24 Op. C i t . , Singer, P.J., p.44. introduced into h o s p i t a l s . On the other hand, several patient care r e l a t e d systems also have a great deal to do with administrative e f f i c i e n c y . For instance, the Massachusets General Hospital, which has also devoted a great deal of e f f o r t towards such projects as a i d i n g i n diagnosis, entering and s t r u c t u r i n g the r e s u l t s of patients' physical exami-nations, or obtaining p a t i e n t s ' medical h i s t o r i e s , imple mented an Automated Patient Census O p e r a t i o n ^ . By simply mechanizing the previous manual system they claim to have gained some insights on introducing computers i n h o s p i t a l s . For instance, t h i s experience permitted them to a r r i v e at the following conclusions: 1) Capable of o r i e n t i n g new personnel to operate computer terminals with a series of demonstrations and p r a c t i c e periods requiring a t o t a l of nine hours (98% accuracy) 2) Involvement and i n t e r e s t of h o s p i t a l s t a f f r e l a t e d to t h e i r understanding of the gains that could resolve from computerization of a system 3) The objective of any h o s p i t a l information system should be to capture information at the point of o r i g i n (e.g. patient-discharge information should be entered at the care unit from which the patient i s being discharged) 4) D i f f i c u l t to evaluate cost/benefit r a t i o . 5) In the h o s p i t a l environment, where the work force i s already committed to the f u l l e s t extent, 25 Hoffman, Paul B., et a l , "Automated Patient Census Operation: Design, Development, Evaluation", Hospital Topics, May, 1969. any new technique which contributes to making working conditions more t o l e r a b l e have a p o s i t i v e e f f e c t on s e r v i c e 2 . These perceptions then l e d them to conclude the following: While i t i s very d i f f i c u l t to define a l l the variables which determine q u a l i t y of care, there i s a high p r o b a b i l i t y that an improved data-communi-cation system w i l l contribute to a higher l e v e l of patient care and conceivably reduce the average length of s t a y 2 7 . On a s t r i c t l y f i n a n c i a l basis, the B r i t i s h Columbia System, as well as the Minnesota Blue Cross a p p l i c a t i o n , are other examples 2 8. The THOMIS, REACH, and MISP systems also provide a great deal of administrative and f i n a n c i a l information 2^, 3) AUXILIARY SERVICES SYSTEMS Some examples of a u x i l i a r y services are laboratory, laundry, food service, or pharmaceutical inventory systems. Laboratories have been a f a v o r i t e experimental ground for t h e i r scheduling, research, and patient care 26 Ibid, p. 40. 27 Ibid, p.40 28 These systems were described i n Section II of t h i s chapter. 29 These systems were described i n Section I I I . 1 and III.2 of t h i s chapter. implications. In Section IV. 1, we have mentioned the Kaiser Foundation Hospital's multiphasic screening system. In Canada, Vancouver's St. Paul's Hospital i s i n the process of implementing such a project. Online recording of data produced by automated t e s t i n g equipment i s being included as part of i t . An example of a food management system i s the one being experimented on at Tulane U n i v e r s i t y ^ . This p a r t i -cular system would use l i n e a r programming techniques to determine optimum n u t r i t i o n , appetizing combinations, and inventory management. 4) RESEARCH AND TRAINING SYSTEMS Several computer systems are being used i n medical research. Again, t h i s p a r t i c u l a r s p e c i a l i t y i s on the fringe of our area of in t e r e s t , and w i l l be reported on for reasons of continuity. One of the physician's main problems i s to keep i n touch with the i n c r e d i b l e amount of l i t e r a t u r e being published. Thus, to help him i n t h i s task, the Cox Coronary Heart I n s t i t u t e of Kettering, Ohio, has designed an i n f o r -mation-retrieval system which i s used to extract from current p e r i o d i c a l s immediate answers to s p e c i f i c questions 30 OP C i t , Singer, P.J.,'p. 44 and bibliographies, abstracts, and/or o r i g i n a l papers on a given subject^ 1. Although the present system i s devoted to coronary heart diseases, i t has useful expansion possi-b i l i t i e s . Diagnosis applications are also popular research studies. Some propose the use of Bayer's theorem to help the physician i n diagnosing a patient's i l l n e s s . At M.I.T., an analog-to d i g i t a l converter helps i n neurosurgical research and diagnosis, on a remote real-time, time-shared computer system32. Again, the approach outlined above when we discussed the Mayo C l i n i c s Automated Patient History system i s another p o s s i b i l i t y . But of great importance to researchers are compre-hensive medical and administrative f i l e s as outline, for example, i n the Yale-New Haven Hospital (THOMIS System) presentation. The integrated f i l e s could provide informa-t i o n to monitor demographic factors, equipment effectiveness, t e c h n i c a l project evaluation, drug e f f i c a c y , or q u a l i t y of patient care. 31 Talbott, G. Douglas, M.D., "Hot Line to the Heart", JAMA, Vol. 196, No. 11, June, 1966. 32 Dickson, James F., et a l , "Remote Real-Time Computer System fo r Medical Research and Diagnosis", JAMA, Vol. 196, No. 11, June, 1966. As far as medical t r a i n i n g applications are concerned, a good example i s the U n i v e r s i t y of B r i t i s h Columbia's simulated "heart" which i s used by students to get acquainted with various types of heart beats and t h e i r r e l a t e d causes. This i s done by having a computer hardware configuration produce the various heart beats. This chapter w i l l begin by presenting some of the causes of system design problems. The second part of the chapter w i l l then ou t l i n e an approach t h a t . w i l l help eliminate some of these problems. I. DESIGN PROBLEMS The l i t e r a t u r e bears evidence of success i n applying computers to medicine, but mostly i n l i m i t e d a p p l i c a t i o n s . The Swedish endeavor i s , apparently, the most ambitious attempt to achieve a t o t a l Health Information System. On a smaller scale, the Yale-New Haven Ambulatory System also has a most comprehensive approach. Nevertheless, these systems are not yet f u l l y implemented. Another noteworthy e f f o r t i s that of the U n i v e r s i t y of C a l i f o r n i a at Los Angeles. The s t r i k i n g aspect of t h i s s i t u a t i o n i s the e f f o r t expended (10 years) for the small l i s t of accomplishments. Unfortunately, no one has yet been able to success-f u l l y implement one of the larger and more complex Total Hospital Information Systems. In fact, i t was reported i n a 1959 survey that every single attempt i n implementing such a system had f a i l e d i n more ways than one 1. A year e a r l i e r , i n a 1968 survey a r t i c l e , the following opinion on such a system had been expressed: A "comprehensive" hospital information system should integrate information from both.adminis-t r a t i v e and professional a c t i v i t i e s . It should a s s i s t with inventory control; preparation of d i e t s ; scheduling of procedure; assignment of personnel; analysis and dissemination of laboratory data; administration of drugs; and the recording, analysis, and display of bedside observations. As a whole, current publications indicate a gap between po t e n t i a l and actual a p p l i c a t i o n of comprehensive hospital information systems. S i l v e r and Korn state, "a working information system i s at least a year away"2. This seems to be a gross understatement of the magnitude of the problem^. It i s important to note that industry has also had i t ' s problems i n computer app l i c a t i o n s . For example, in 1964, a computer usage survey concluded that out of 27 major manufacturing companies with more than 300 computer i n s t a l l a t i o n s , 18 were loosing money on t h e i r data process-ing investment^. More recently, the F i n a n c i a l Post reported on a consulting firm's opinions regarding computer u t i l i -zation^. It's conclusion was that only 20% of computer 1 (cont. from P. 44) Op c i t . Singer, P.J., p.38. 2 S i l v e r , William; Korn, Henry, "A Working Total Information System i s at least a Year Away", Hospitals, May, 1967. 3 Levy, Richard P; Cammarn, Maxine R., "Information Systems Applications i n Medicine", Source Unknown. 4 Darrity, John T., Getting the Most Out of Your  Computer, New York: McKinsey, 1964, in Kelly, op. c i t . , p . l . 5 F i n a n c i a l Post, " Emotion continues to Govern Computer Decisions", Toronto, March 20, 1971. i n s t a l l a t i o n s had been successful, while another 40% were just breaking even. The l i t e r a t u r e , i t seems, does present a far more advanced picture than what a c t u a l l y p r e v a i l s . This r e s u l t s from the tendency to write about ambitions and impressive applications, be they only i n the design stage (as are most of those contained i n the l i t e r a t u r e ) . But why i s t h i s so? There are several reasons... For instance, Russel Ackoff has advanced a False Assumption hypothesis^. Here, i t i s stated that systems analysts base t h e i r systems on f a l s e assumptions, such as managers needing more information. Gaylord Freeman J r . , Chairman of the Board of the F i r s t National Bank of Chicago, stated i n 1969: We need more "information" l i k e a drowning man needs another drink of water. We're already up to our c l a v i c l e s i n information, and I don't r e a l l y f e e l that I need any more 7. There are also the hypothesis of Lack of Senior Management Involvement and of the Underqualified Systems 6 Ackoff, Russel L., "Management Misinformation Systems", Management Science, Vol. 14, No. 4, December, 1967. 7 Freeman J r . , Gaylord A., "The Role Top Management Must Play i n MIS Planning and Implementing", Proceedings of Association of Management Information Systems, Founders Conference, 1969. Analysts. Another cause are the pre-computer age manage-ment Techniques u t i l i z e d to manage data processing depart-ments. For example, data processing managers often set target dates for the completion of a system according to the wishes of the user, and not according to the system's requirements. This i n v a r i a b l y brings about less e f f i c i e n t systems than o r i g i n a l l y desired, and as a consequence, high turnover among d i s s a t i s f i e d systems analysts. A further p i t f a l l i s the fact that even though organizations are aware of the t o t a l systems approach and that t h e i r resources do not permit a " t o t a l " design e f f o r t in one instance, they are not sure what part of the t o t a l system should be designed f i r s t , or even why the systems should be integrated. In e f f e c t , knowing of the general systems approach does not insure success, e s p e c i a l l y where p o l i t i c a l factors are present. This i s e s p e c i a l l y true for h o s p i t a l s . F i n a l l y , not to be overlooked i s the discrepancy which currently exists between hardware and software development. In e f f e c t , "the 'state of the a r t ' i n soft-ware development i s sadly lagging behind hardware development" 8. 8 M a d i l l , J.P., and Kuss, J., Study and Recommen-dations for A c q u i s i t i o n of Generalized Data Management Systems, Prepared for Simon Fraser's University Information Systems Committee, February, 1971, p. 2. On a more p o s i t i v e note, a survey conducted by U.C.L.A. indicated that there were some general p r i n c i p l e s associated with successful hospital-computer a p p l i c a t i o n s ^ . 1) In-house E.D.P. competence 2) Attainable goals and timetables 3) Modular approach 4) No complex manual interfaces 5) Think systems wise, rather than l o c a l l y 6) Single d i r e c t o r 7) Involve present s t a f f 8) Report to Top Management This implies that those system design e f f o r t s where these "laws" are not observed w i l l probably cost more than a n t i c i p a t e d while providing less information than had been forecasted. It becomes apparent that one of the main factors which i s often missing i n system design e f f o r t s i s a systems approach. In e f f e c t , various organizations have been successful i n applying computers to the d i f f e r e n t types of smaller and more s p e c i a l i z e d a p p l i c a t i o n s . Keeping t h i s i n mind, and r e c a l l i n g the fact that a Total MIS has not yet been f u l l y implemented, i t follows that one of the missing l i n k s between the dedicated and the " t o t a l " systems 9 Lamson, B.G., Op c i t , p. 73. i s ease of integration, a task g r e a t l y f a c i l i t a t e d by u t i l i z i n g the systems approach. Accordingly, i t i s inadequate to simply purchase a commercial data management package and to attempt to " f i t " i t into a predetermined information system without having done p r i o r d e f i n i t i o n of the tasks demanded of the DMS. Thus, t h i s thesis w i l l o u tline a systems approach which should be used i n determining a DMS for h o s p i t a l administration. This procedure should also be u t i l i z e d i n d e fining and designing the various subsystems of a t o t a l HIS. In e f f e c t , the observance of t h i s approach w i l l g r e a t l y contribute to the successful implementation of a Total HIS, as w i l l be shown below. II. DESIGN APPROACH The approach recommended to determine the DMS which would be capable of providing a l l h o s p i t a l adminis-t r a t i v e information requirements i s a f i v e step procedure. The f i r s t step consists of determining the hospital's global goal. This i s interpreted as to what ho s p i t a l administration must achieve. The i n d e n t i f i c a t i o n of t h i s major h o s p i t a l goal has important implications for hospital administration i n general systems and i n MIS perspective, for determining administrative information requirements, and for designing administrative data banks for hospitals. Secondly, i t i s necessary to e s t a b l i s h what needs to be done to a t t a i n t h i s goal; i . e . what are the required subsystems and how do they i n t e r r e l a t e . This renders possible the determination of the h o s p i t a l administration function. Once t h i s has been done, ho s p i t a l administration information requirements can be determined. This leads to the fourth step which consists i n o u t l i n i n g the data bank structures required to f u l f i l l h o s p i t a l administration information requirements. F i n a l l y , knowledge of the information needs and of the corresponding data bank permits the determination of the DMS. This chapter w i l l implement the f i r s t two steps of the procedure 1 0. In e f f e c t , the next section w i l l determine ho s p i t a l goals, and the following section w i l l determine what h o s p i t a l administration must do to a t t a i n the h o s p i t a l objective. 1. HOSPITAL GOALS It was generally stated in the reviewed l i t e r a t u r e that the purpose of a h o s p i t a l i s "the provision of the 10 Chapter V w i l l implement steps 3 and 4, whereas Chapter VI w i l l be concerned with step 5. best i n health and medical care for the people". This implies that hospital administrators must acquire " a l l " necessary hospital care resources according to environmental demand, and coordinate these resources to provide the best possible patient care, with necessary consideration for manpower, c a p i t a l and technological constraints. From th i s emerges the goal of HIS: to f a c i l i t a t e patient care by providing better information. On the other hand, the following viewpoint on hospital goals was also encountered: A h o s p i t a l does not give or s e l l medical care. It simply makes the f a c i l i t i e s a v a i l a b l e for the s t a f f to give medical c a r e ^ . Although not s t r i k i n g l y d i f f e r e n t at f i r s t glance, the above quotation, written by a medical doctor (author of a book on hos p i t a l administration), provides some insights about administrator-physician r e l a t i o n s h i p s . In e f f e c t , Dr. McGibony states that the hos p i t a l i s not the main provider of medical care, but only a t o o l to be used (and specified) by medical p r a c t i t i o n e r s . If t h i s i s so, i t implies that the hos p i t a l exists merely to answer to the demands of medical doctors who, as a consequence, must have decision making supremacy. Obviously, the hospital s t a f f 11 McGibony, M.D., John R., Op c i t , p. 94 serves more than one doctor and the above statement conveys the impression that goal c o n f l i c t s among doctors are non-existent or non-consequential for ho s p i t a l adminis-t r a t i o n . While i t i s agreed that doctors should have major decision-making authority for some of the hos p i t a l compon-ents (e.g. those purely medical resources), t h i s authority should not necessarily carry-over i n a l l h o s p i t a l areas, such as i n manpower or f i n a n c i a l management. Confronted with these d i s s i m i l a r goals, t h i s thesis w i l l adopt the one which the author believes focuses more d i r e c t l y on the patient, while preserving a necessary sense of cost cont r o l : the r e a l objective of a hos p i t a l i s the provision of patient care. 2. HOSPITAL ADMINISTRATION FUNCTION In a hos p i t a l , there are four major subsystems needed to provide patient care:-^ a) Resource Management Services b) Medical (Patient Care) Services c) Supporting (Auxiliary) Services d) Research and Training Services 12 Bennett, Walter L., "The Systems Approach to Hospital Automation", Source Unkpwn, January, 1969. Each of these u t i l i z e personnel, supplies, f i x e d assets and f i n a n c i a l resources, and h o s p i t a l administration must coordinate these i n d i v i d u a l subsystems tov/ards the attainment of the h o s p i t a l goals. This means that h o s p i t a l administrators have to have information about each of these a c t i v i t i e s which can be c e n t r a l i z e d i n organizational units (subsystems) and evaluated i n terms of personal responsi-b i l i t i e s or systems goal achievement. In e f f e c t , hospital administration circumscribes the i n t e l l i g e n c e functions of goal formulation and of goal achievement control for the h o s p i t a l 1 3 . Goal formulation consits of goal planning and goal s e t t i n g . Goal planning involves an i d e n t i f i c a t i o n of goal a l t e r n a t i v e s such as p r o f i t , job security, wages, employee happiness or i n d i v i d u a l and group s a t i s f a c t i o n . It i s s i m i l a r to some notions of s t r a t e g i c planning and may include goal c o n f l i c t r e s o lution and an evaluation of the degrees to which d i f f e r e n t goals are achievable. Ideally, goal planning r e s u l t s i n an optimum set of goals under d i f f e r e n t or unique c r i t e r i a . The l a s t step of goal planning may include goal s e t t i n g . This involves s e l e c t i n g a set of goals and related subgoals as targets, d i r e c t i o n s , and prescriptions for the organi-zation's a c t i v i t i e s . Thus, goal s e t t i n g represents the actual managerial decision to commit an organization to the achievement of given targets i n the l i g h t of a v a i l a b l e resources and techniques. Goal achievement control requires monitoring of systems performance i n terms of set goals and regulation 13 W i l l , Hartmut J., "Management Information Systems: Int e l l i g e n c e Structures and Intelligence Processes", i n Management Information Systems and the Public Services; New York: Simon and Schuster, 1970. of the system's behaviour i n case of discrepancies between set and a c t u a l l y achieved g o a l s 1 ^ . Figure III i s a diagram of the systems approach to ho s p i t a l administration. This approach i s d i f f e r e n t from the t r a d i t i o n a l mainly i n i t ' s s t r e s s i n g the fact that the subsystems must work together and to do so be properly coordinated. It thus places h o s p i t a l administration i n i t ' s proper perspective, by g i v i n g hospital administrators the authority and r e s p o n s i b i l i t y necessary for global goal achievement, and not only for e f f i c i e n t use of resources. In a data management context, t h i s implies that the DMS must be capable of providing h o s p i t a l administrators with planning and control information on a l l h o s p i t a l subsystems. 14 Ibid, p.3298-9. FIGURE III A PATIENT CENTERED HOSPITAL SYSTEM Resource Management MedicaP Services' 1 Communication Link; Research and Training Services Auxiliary Services From: Bennet, Walter L., The Systems Approach to Hospital Automation", Hospital F i n a n c i a l Management, Journal  of HFMA, January 1969, p. 8. From the above figure emerge several propositions: a) A l l subsytems must d i r e c t t h e i r a c t i v i t i e s toward f a c i l i t a t i n g , improving or providing patient care; thus a l l i n d i v i d u a l subsystem goals must be d i r e c t e d towards the global goal. b) Since a l l subsystems share the same glo b a l goal, a l l must work together and be properly coordinated. c) A l l resources acquired by the i n d i v i d u a l sub-systems must consequently be ultimately d i r e c t e d towards the attainment of the global objective. d) To properly coordinate the subsystems, i n f o r -mation must be provided to h o s p i t a l adminis-tr a t o r s , thus making information one of the important resources. Going one step into further d e t a i l , Figure IV demonstrates a supplementary breakdown of subsystem object-ives, which can be q u a n t i f i e d i n the following manner: a) Resource Management Services objective: - Must insure that Patient Care Resources are e f f i c i e n t l y and economically u t i l i z e d b) Medical Services objective: - Must provide best Patient Care at optimal cost c) A u x i l i a r y Services objective: - Must provide a l l necessary physical resources for the provision of Patient Care at minimal cost d) Training and Research Services objective: - Must improve Medical P r a c t i t i o n e r s ' knowledge of Patient Care and advance Medical Science knowledge FIGURE IV HOSPITAL SUBSYTEM OBJECTIVES MEDICAL SERVICES MUST PROVIDE BEST PATIENT CARE AT OPTIMAL COST TRAINING AND RESEARCH MUST IMPROVE MEDICAL PRACTITIONERS' KNOWLEDGE OF PATIENT CARE AND ADVANCE MEDICAL SCIENCE KNOWLEDGE MUST INSURE THAT PATIENT RESOURCES ARE EFFICIENTLY AND ECONOMICALLY UTILIZED RESOURCE MANAGEMENT MUST PROVIDE ALL NECESSARY PHYSICAL RESOURCES FOR THE PROVISION OF PATIENT CARE AT MINIMAL COST AUXILIARY SERVICES With each subsystem focusing on i t s i n d i v i d u a l goal, cooperation and coordination (thus information) are necessary, which i s the s i g n i f i c a n c e of the broken l i n e between the components i n Figure IV. For instance, medical care cannot be provided i f p r a c t i t i o n e r s are not trained, and neither of these can function unless c e r t a i n services are supplied, and none of these are possible unless f i n a n c i a l resources are a v a i l a b l e . Following t h i s notion of a series of i n t e r r e l a t e d objectives, i t i s necessary to v i s u a l i z e how the a c t i v i t i e s (programs) of the four subsytems intertwine i n order to a t t a i n the hospital's objective of providing patient care. This also provides insights as to the type of data bank necessary to provide h o s p i t a l administrative information on how e f f e c t i v e l y the various a c t i v i t i e s are c a r r i e d out. In e f f e c t , to provide patient care, several a c t i v i t i e s are necessary. For instance, the Medical Care subsystem w i l l insure that proper nursing care w i l l be given, and that physicians orders, such as drug administration w i l l be c a r r i e d out. On the other hand, the A u x i l i a r y Services subsystem w i l l perform such supporting a c t i v i t i e s as providing a proper inventory supply of necessary drugs, and of supplying necessary room services such as food services. The Research and Training subsystem w i l l c o n t r i -bute by providing trained medical p r a c t i t i o n e r s and i n such tasks as suggesting a drug formulary. F i n a l l y , the Resource Management subsystem's r e s p o n s i b i l i t y w i l l rest i n such areas as providing funds for the various subsystems. Figure V gives a graphical presentation of this network of a c t i v i t i e s . FIGURE V HOW THE SUBSYSTEMS WORK TOGETHER* Patient Care Physical Assets" Purchasing \ Funds (RM) Cleaning (RM) Personnel (AS) P a y r o l l Coordinating (RM) (AS) Medical Care Food Administration Resources Personnel Equipment ^Laboratory Personnel l^urchasing (MS) (RM) (RM)(AS) Services (AS) .(ffl) (TE) (MS) K / \ Funds Advice . (RM) (MS) (AS) Equipment Personnel (AS)(RM) Muipmer Funds (RM) Advice (MS) *(RM): Resource Management Res p o n s i b i l i t y (AS): A u x i l i a r y Services Responsibility (MS): Medical Services Responsibility (TE): Training and Education Re s p o n s i b i l i t y It i s evident that the above network i s f a r from complete both i n d e t a i l s and i n length. But clear e r s t i l l i s the fact that the interrelatedness of the a c t i v i t i e s require that a coordinating function be performed i f the h o s p i t a l i s to achieve i t s goal. It thus becomes apparent that the main functions of Hospital Administration consist of formulating the plans and programs of the d i f f e r e n t subsystems and of c o n t r o l l i n g t h e i r achievement. More s p e c i f i c a l l y , t h i s i s the managerial problem of t r a n s l a t i n g objectives into workable a c t i v i t i e s . At t h i s l e v e l , the word goal relates to program objectives and required a c t i v i t i e s i n the planning, programming and budgeting context. In e f f e c t , a planning-programming-budgeting system (PPBS) i s composed of the following steps: 1. The s e t t i n g of s p e c i f i c objectives; 2. The systematic analysis to c l a r i f y objectives and to assess a l t e r n a t i v e ways of meeting them; 3. The framing of budgetary proposals i n terms of programmes erected toward the achievement of the objectives; 4. Projection of the costs of these programmes a number of years i n the future; 5. The formulation of plans of achievement year by year for each program; and 5. An information system for each program to supply data for the monitoring of achievement of program goals and to supply data for the reassessment of the program objectives.and the appropriateness of the program i t s e l f . 15 Planning-Programming-Budgeting Guide, Revised Ed i t i o n , Government of Canada, September, 1969, p. 8; i n W i l l , Hartmut J., op c i t , p. 3301-7 HOSPITAL ADMINISTRATION INFORMATION REQUIREMENTS AND THE CORRESPONDING DATA BANK  The f i r s t stage i n defining administrative i n f o r -mation has already been c a r r i e d out: the establishment of organizational objectives. The essence of the next step was to determine what hos p i t a l administration must do to insure the achievement of the organizational goals. This, i t was found, consisted of guiding the hospital's four subsystems i n a t t a i n i n g t h e i r subgoals so that the global goal could be accomplished. The above steps rendered i m p l i c i t the information needs of h o s p i t a l administration. In e f f e c t , following the d e f i n i t i o n given on PPBS1, i t i s now possible to determine the information required by Hospital Administration to perform i t s task of goal formulation and goal control. This Chapter w i l l use t h i s framework and go into d e t a i l i n two basic areas of r e s p o n s i b i l i t y of Hospital Administration. These are Goal Planning i n the area of Hospital Expansion and Goal Control i n the area of Food Services Cost Control. The h o s p i t a l expansion analysis w i l l provide the information required to perform steps 2, 3 and 4 of the PPBS d e f i n i t i o n , whereas the cost control 1 See Chapter IV, p. 62 analysis supplies some of the information necessary i n step 6. There are three methods by which information requirements can be defined: 1. The t r a d i t i o n a l method has been to ask Top Management. This has always proven useful, but invariably, t h i s method res u l t s i n i n -complete information. 2. A second possible procedure i s to analyse the organization's present uses of information. A frequent r e s u l t of t h i s approach has been systems which simply mechanize e x i s t i n g manual routines without answering to the questions of why the information i s needed and whether i t i s a c t u a l l y u t i l i z e d once a v a i l a b l e . 3. Consequently, i t i s important to amalgamate the previous two methods with a thorough analysis of the organization. In e f f e c t , t h i s i s the most "productive" means of es t a b l i s h i n g the information requirements. In e f f e c t , the author believes that the l a t t e r method, with some help from the previous two, i s the most "productive" mean by which information needs may be established. Even though i t ' s results are based on a more th e o r e t i c a l than r e a l - l i f e foundation, i t does bring about more r a t i o n a l conclusions. Management must without doubt be involved i n the e f f o r t , but the f i n a l outcome must be the r e s u l t of a l o g i c a l e f f o r t i n r e l a t i n g a l l information needs to the functions that must be accomplished, which i n turn must be r e l a t e d to the global goal. Thus, the two areas i n which d e t a i l e d information w i l l be determined w i l l be t h e o r e t i c a l l y analyzed. Once t h i s analysis i s completed, an empirical v e r i f i c a t i o n w i l l be brought forward to compare the r e s u l t s between the t h e o r e t i c a l analysis and the real-world. In analysing the two areas, basic questions w i l l be asked. These, i n turn, w i l l have to be answered v/ith the help of various reports which w i l l be presented as probable h o s p i t a l administration information needs. Each report w i l l then be q u a l i f i e d through a matrix. Each row of the matrix w i l l contain a report, whereas the column headings w i l l be the following: COLUMN NO • EXPLANATION OPTIONS 1 Information Related 1 - Patient Care to or Originates from 2 - F i n a n c i a l A c t i v i t i e s 3 - Fixed Assets 4 - Variable Assets (Supplies) 5 - Personnel THE CORRESPONDING DATA BANK COLUMN NO EXPLANATION OPTIONS 5 - Government Publications 7 - Other Sources (e.g. Regionally-Shared Data Bank) 2 Report Size 1 : Large (50 pages over) 2 : Medium (5-50 pages) 3 : Small (1-5 pages) F i l e Updating Scheduling Requirements Report Scheduling Requirements 1 : On-line 2 : Hourly 3 : Daily 4 : Weekly 5 : Monthly 6 : Yearly 7 : Exception 1 : On demand/ automatic 2 : Hourly 3 : Daily 4 : Weekly 5 : Monthly 6 : Yearly 7 : Exception 5 Updating V o l a t i l i t y 1 : Over 107<» (per month) 2 : Under 10% 6 Reporting V o l a t i l i t y 1 : Over 10% (percentage of input 2 : Under 10% f i l e used) Recommended Access Method 1 2 Direct Sequential COLUMN NO EXPLANATION OPTIONS 8 Program Complexity-Requirements 1 Senior Prog-rammer Only (Very Complex) Junior Prog-rammer (Normal) User (Very Simple) 2 3 9 Estimater Computer Time Needed to process reports 1 2 3 Very l i t t l e 1-10 minutes 11 minutes and up This matrix, having presented some basic t r a i t s of hos p i t a l administration information, w i l l help i n the determination of a DMS c r i t e r i a f or top management i n hospi t a l s . administrators need both i n t e r n a l and environmental i n f o r -mation. In the health context, environmental information i s extremely important for three main reasons, i . e . because of demand (population), because of comparitive f a c i l i t i e s a v a i l a b l e i n other s i m i l a r i n s t i t u t i o n s , and because of the dependency of hospitals on government. Thus, the basic flow to be followed i n determining whether or not a hosp i t a l should expand would consist i n evaluating the I. PLANT EXPANSION To accomplish t h e i r i n t e l l i g e n c e function, h o s p i t a l demand on the h o s p i t a l i n question, of resolving whether t h i s demand could be handled through more e f f i c i e n t u t i l i z a t i o n of e x i s t i n g f a c i l i t i e s or by other hospitals, and i f not, of enumerating the required resources with t h e i r a v a i l a b i l i t y . TABLE II LONG-RANGE PLANNING INFORMATION INFORMATION REQUIREMENTS 1 2 3 4 5 6 7 8 9 Is A) B) there a demand for expansion? ADMISSION INFORMATION 1) Would include such data as 1 3 5 7 1 1 2 1 2 AVG. QUEUE LENGTH, AVG. WAITING PERIOD, with break-down, by types of h o s p i t a l i -zation requirements 2) Should also indicate trends by r e f e r r i n g to H i s t o r i c a l 1 3 5 7 1 1 2 1 2 and Current Information 3) Demographic Information - population trends 6 3 7 7 - Disease rates/trends 7 HOSPITAL CAPACITY UTILIZATION 1) E f f i c i e n c y Ratios (trends) 1 - average stay 2 - bed u t i l i z a t i o n 3 3 5 7 1 1 2 1 2 - employees/patient 4 5 2) Other i n s t i t u t i o n s compari- 5 t i v e information 2 7 REQUIRED RESOURCES 1) Types of patients to plan 1 for 6 2 7 7 - demographic data 7 2) Types of Resources a) Fixed Assets 1 - Room 3 7 7 1 1 2 i 2 2 - Bed 3 - Equipment b) Personnel - Professional 1 3 7 7 1 1 2 12 2 - Non-professional 5 c) Supplies 1 3 7 7 1 1 2 2 S' - Drugs - Food, etc 4 d) Costs 1-2 3 7 7 1 1 1 2 2 2 3-4 5 TABLE II LONG-RANGE PLANNING INFORMATION INFORMATION REQUIREMENTS 1 2 3 4 5 5 7 8 9 D) CAN THESE RESOURCES BE OBTAINED? 1) Internal F i n a n c i a l Condi-tions - Budget Conditions - Other expense programs - Future revenues 1-2 3-4 5 2 4 7 1 1 2 1 3 2) External F i n a n c i a l Conditions - Governmental P o l i c y - Other possible sources - industry - community organizations Other h o s p i t a l plans and demands. 6 7 2 7 II. FOOD SERVICES COST CONTROL Cost control information i s provided by a measure-ment system which derives i t ' s r e s u l t s from what i s expected of the physical system, v/hat i s a c t u a l l y being done, and the differences between the two (variances). Thus, the only type of control information to reach h o s p i t a l adminis-t r a t i o n should be on those events which have deviated beyond acceptable l i m i t s from the pre-established standards. In the case of a hospital's food services, program, very l i t t l e information should reach h o s p i t a l administration. Operating on a cost center basis, the DMS should report any substantial deviations on food supplies (quantity and pr i c e s ) , manpower (quantity and s a l a r i e s ) and/or physical resources (quantity and p r i c e s ) . The expenses should d i r e c t l y a t t r i b u t e to the program i n question, i . e . no uncontrollable costs should be assigned to t h i s program's area of r e s p o n s i b i l i t y . For reasons of s i m p l i c i t y , TABLE III r e s t r i c t s i t s e l f to o u t l i n i n g what information administration would receive i n the case of manpower deviations for food services. TABLE III COST CONTROL INFORMATION INFORMATION REQUIREMENTS 1 2 3 4 5 6 7 8 9 FOOD SERVICES COST CONTROL A) V/hat are the s p e c i f i c deviation; ;? 3 6 7 >— l l 2 2 1 1) Manpower Budget 2) Actual Manpower usage 3) Is deviation i n terms of Average Salary or No. of employees B) Problem Resolution 1) Workload Forecast (e.g. No. of meals) 2) Actual workload with corresponding results 3) Comparative Information from other I n s t i t u t i o n s 4) H i s t o r i c a l Data 5) Trends 5) Transaction highlights (Possible causes of variances) 2 5 2 5 3 4 7 l 1 I 2 2 2 2 „, 5 3 7 1 1 2 2 1 3 6 1 l 1 2 2 2 l _ 4 "3 i l l 1 2 . 5 3 7 7 1-2 3 4 i 11 1 j 2 2 2 1-2 4-5 3 7 l i i i 1 2 l-S 4-5 2 4 l l 2 I 1 1 1 With the above matrix completed, i t i s now possible to enumerate several c h a r a c t e r i s t i c s of ho s p i t a l administration information needs. This w i l l be structured i n such a fashion as to follow the column headings of the matrix. 1. Many of the reports require more than one type of information as input. In ef f e c t , i n t e r n a l information on patients, on f i n a n c i a l r e s u l t s , on f i x e d or va r i a b l e assets and on personnel are required at one time or another. There i s also a very high dependency on environmental information. This can be helped somewhat by government publications or by re g i o n a l l y shared data banks. But one of the important implications of the above i s the ho s p i t a l data bank required for these reports. Patient care r e c e i v i n g a hospital's main focus of attention and each departmental function being oriented i n that same general d i r e c t i o n , i t follows that h o s p i t a l information centers around the patient himself. For example, medical diagnosis i s helped by the patient's h i s t o r i c a l information, research benefits from a grouping of medical records, meals are scheduled according to the patient population, and costs c a l c u l a t e d according to the aggregate of patient care given. Thus, the patient f i l e i s the centre of the hospital data bank, and, as Figure VI indicates, i t must be shared by a l l h o s p i t a l subsystems. As a d i r e c t consequence of the importance of patient information, privacy and c o n f i d e n t i a l i t y of h o s p i t a l information must be observed^. 2 Curran, William J., et a l , "Privacy, C o n f i d e n t i a l i t y and Other Legal Considerations i n the Establishment of a Centralized Health-Data System", The New England Journal of  Medicine, Vol. 281, No. 5, July, 1969. THE CORRESPONDING DATA BANK FIGURE VI CONCEPTUAL HOSPITAL ADMINISTRATION DATA BANK This conceptualization of a t o t a l HIS data bank demonstrates that patient care information i s and must be a part of a l l or any of the hos p i t a l subsystem f i l e s . Figure VI also helps to point out that some information i s used by only one subsystem, while, at the other extreme, some i s shared by a l l four subsystems. This could indicate either individual-subsystem stand alone f i l e s or larger integrated f i l e s with various parts being r e s t r i c t e d to ce r t a i n users, or again, a combination of the two. In addition to the patient care f i l e , since the subsystems u t i l i z e four basic types of resources, there should also be personnel, f i n a n c i a l , f i x e d and variable assets information. Accordingly, i n a t o t a l Hospital Administration context, the various subsystems should not have redundant f i l e s . For instance, the medical care subsystem would stress patient care treatment and thus have as i t s c e n t r a l f i l e the Patient Care f i l e . A u x i l i a r y Services would derive a large portion of i t s information from inventory f i l e s , but would also need to know a great deal about the patient population. Expanding from t h i s , both these subsystems would need personnel information, which i s also one of the main focusing points of Resource Management. On the other hand,, some medical f i l e s which d i d not involve any other subsystem would also exist, and these could be stand alone f i l e s . The same would be true for a l l other subsystems. For instance, Resource Manage-ment would be concerned with optimal inventory l e v e l s and as long as proper quantities of pencils were kept none of the other subsystems would want to get involved. Thus, ce r t a i n inventory f i l e s (e.g. o f f i c e supplies) would be e n t i r e l y Resource Management's concern, whereas c e r t a i n others would be of i n t e r e s t to and influenced by the other subsystems on a day to day basis. From the above evolves the basic data bank structure outlined i n Figure VII. FIGURE VII HOSPITAL ADMINISTRATION DATA BANK STRUCTURE Medical Care Information Resource Management Information A u x i l i a r y Services Information Research and Training Information Here, i t i s shown that the data bank i s basically-structured according to the o r i g i n a t i o n of the information. On the other hand, i t w i l l be accessed according to sub-system requirements, and according to Hospital Administration information needs, which require integration of the various f i l e s to form c e r t a i n reports. Figure V of Chapter IV indicated how the four subsystems i n t e r r e l a t e i n t h e i r various a c t i v i t i e s . This also c a r r i e s over i n the various f i l e s , as pointed out i n Table IV. This matrix indicates how the various compon-ents of a patient record may be u t i l i z e d i n c e r t a i n h o s p i t a l a c t i v i t i e s . For instance, the patient's i d e n t i f i c a t i o n w i l l be used both for his own treatment and for research purposes (Care of Individuals and Groups). It w i l l also be u t i l i z e d for Quality Control (e.g. to provide such information as to how well his i l l n e s s was cured), for Scheduling and Planning (e.g. bed u t i l i z a t i o n rates), for Economic Matters (e.g. for b i l l i n g the patient or to receive government funds), and for Legal and O f f i c i a l functions (e.g. to observe p r o v i n c i a l laws demanding the s t o r i n g of patient records for d e f i n i t e periods of time). TABLE IV USES OF PATIENT RECORD COMPONENTS Care of Administration Component of Individuals Quality Scheduling Economic Legal and Patient Record and Groups Control and Planning Matters O f f i c i a l Patient iden-t i f i c a t i o n X X X X X Past Medical h i s t o r y X X X 0 X Current h i s t o r y X X X O X Physical exam X X X 0 X Laboratory, X-ray, and other reports X X X 0 X Surgery Record X X X 0 X M.D. orders X X X X X M.D. progress and diagnosis notes X X X X X Nurse's notes X X X X X Nurse's observa-tions. X X X 0 X Serious or c r i t i -c a l l i s t i n g ? ? X O X Consent forms 0 0 0 0 X B i r t h & death forms 0 0 0 0 X Personal Belong-ing l i s t 0 0 0 0 X TABLE IV USES OF PATIENT RECORD COMPONENTS Administration Care of Component of Individuals Quality Scheduling Economic Legal and Patient Record and Groups Control and Planning Matters O f f i c i a l Incident & accident reports • ? X X 0 X Summary Sheet O X X 0 X X = Useful f o r t h i s purpose 0 = Not useful f o r this purpose FROM: Blumberg, Mark S., "Computers for Hospitals, The Uni v e r s i t y of Michigan Engineering Summer Conferences, Applications  of Computers i n Hospitals, 1966. Table V presents an adaptation of Table IV to the systems approach to Hospital Administration. Once again, i t becomes c l e a r l y evident how patient information i s u t i l i z e d by the various subsystems i n a h o s p i t a l . TABLE V ADAPTATION OF TABLE IV TO THE.SYSTEMS APPROACH TO.HOSPITAL ADMINISTRATION Component of Patient Record Resource Management Services Subsystem Patient iden-t i f i c a t i o n X Past Medical h i s t o r y 0 Current h i s t o r y 0 Physical exam 0 Laboratory, X-ray, and other reports 0 Surgery Record X M.D. orders X M.D. progress and diagnosis notes 0 Nurse's notes 0 Nurse's observa-tions 0 Serious or c r i t i -c a l l i s t i n g X Consent Forms 0 Medical Services Subsystem X X X X X X X X X X X X Au x i l i a r y Services Subsystem X X X X X X X X 0 0 X 0 Research and Training Services Subsystem X X X X X X X X X X X THE CORRESPONDING DATA BANK TABLE V Component of Patient Record ADAPTATION OF TABLE IV TO THE SYSTEMS APPROACH TO HOSPITAL ADMINISTRATION Resource Management Services Subsystem B i r t h & death • forms 0 Personal Belong-ing l i s t X Incident & accident reports 0 Summary Sheet X Medical Services Subsystem X 0 X X A u x i l i a r y Services Subsystem 0 0 X X Research and Training Services Subsystem 0 X X X = U t i l i z e d by t h i s subsystem 0 = Not u t i l i z e d by t h i s subsystem ADAPTED FROM: Blumberg, Mark S., "Computers for Hospitals, The Un i v e r s i t y of Michigan Engineering Summer Conferences, Applications  of Computers in Hospitals, 1966. THE CORRESPONDING DATA BANK 2. The reports l i s t e d i n Tables II and III are mostly re s u l t summaries, or exception reports and consequently, are very short. Thus, the b r i e f -ness of the reports i s an important c h a r a c t e r i s t i c of Hospital Administration information. 3. F i l e s must be kept up to date, e s p e c i a l l y i f they are to f u l f i l l cost control requirements. Thus, i t i s i n s u f f i c i e n t to update the data bank with current information only when reports are demanded by Hospital Administration. In eff e c t , i f variances from predetermined goals are to be detected as they occur, f i l e updating must be constant. 4. In the case of long-range planning, the reports would be produced on an "as demanded" basis. This implies unrepetitive and unscheduled reports. On the other hand, to e f f e c t i v e l y control manpower usage i n the area of food services, i t i s necessary that deviations be automatically pointed out by the information system. It follows from t h i s that Hospital Administration should have the c a p a b i l i t y of obtaining answers to the problems very quickly by having easy and THE CORRESPONDING DATA BANK fast access to the data bank f i l e s . 5. It also becomes apparent through the above analysis that f i l e updating v o l a t i l i t y i n hospitals i s very high. This can be seen through such facts as average length of patient stay (10.06 days). This implies that the Patient F i l e w i l l have changed completely three times a month. Current e f f o r t s at implementing drug formularies and at reducing supply inventories to as small a quantity as possible also provide evidence as to the high updating r a t i o s i n the hospital's data bank f i l e s . 6. Hospital Administration information for long-range planning t y p i c a l l y r e s u l t s from a summary of transactions. The same i s true for cost control purposes. Consequently, to produce ce r t a i n types of administrative information, a f i l e must be completely read, whereas exception reports re s u l t from a constant scanning of the involved f i l e s . 7. Because of the high v o l a t i l i t y r a t i o s , sequen-t i a l access i s recommended for the most part. On the other hand, the t r a c i n g of variances would require d i r e c t access to the transaction f i l e s for t h i s function to be performed e f f i c i e n t l y . Thus, d i r e c t access c a p a b i l i t i e s should also be a v a i l a b l e . 8. Another c h a r a c t e r i s t i c of the reports i s the complexity of the programs needed to produce them. In e f f e c t , several of these reports require that data analysis be performed by the programs. This implies that the programs must be written by q u a l i f i e d programmers, and consequently that most of the reports could not be produced by a non-computer trained user " s i t t i n g " at a terminal. 9. The f i n a l category i n the analysis points out that since the reports require as input r e l a t i v e l y large amounts of data so that summary or exception reports may be produced, computer time u t i l i z e d to produce these reports would probably vary between f i v e and ten minutes. This fact could l i m i t the p o s s i b i l i t y of real-time information. On the other hand, the fact that p r i n t i n g length would be almost n i l o f f e r s the possi-b i l i t y of having the reports presented on CRT terminals, thus balancing out part of t h i s time problem. Nevertheless, as stated i n part 4 of t h i s discussion, time remains an important factor i n goal control a c t i v i t i e s . In order to v e r i f y the above statements, a h o s p i t a l administrator was interviewed. He was asked to provide the author with the information which he was already r e c e i v i n g i n terms of cost control f o r food services. Once t h i s was done, he attempted to o u t l i n e what type of information he wished to obtain to supplement the reports which he was already receiving. The r e s u l t s of the interview showed conclusively that the above analysis was correct. In e f f e c t , the administrator d i d not wish to receive lengthy d e t a i l e d reports. Currently, he i s receiving summaries which consist mainly of espense reports. He expressed the opinion that these were not useful to him since he had no basis for comparison. He also stated that as long as food services costs were i n l i n e with expectations, he would rot require further information on the program. On the other hand, as soon as variances appeared he needed to know why the program was not performing according to fore-casts. In these instances, he presently asks the accounting department for further information. These supplementary reports are r a r e l y provided to him as he needs them, sometimes requiring two weeks to be prepared. Combining the above interview with the matrix o u t l i n i n g cost control information for Food Services, Figure VIII outlines a Food Services Cost Control System. The System i s drawn up following several assumptions: 1. Existence of d e t a i l e d budgets and standards, and more s p e c i f i c a l l y of workload forecasts. 2. Existence of General Ledger, Cost Accounting, Inventory Control and Personnel Information System?. 3. Adequate computer hardware f a c i l i t i e s to support d a i l y batch operations. 4. Hardware a v a i l a b i l i t y to produce supplementary reports i n case of variances. 5. Data Management System capable of integrating the various f i l e s and of f a c i l i t a t i n g communi-cation between the f i l e s and administration in the case where information i s needed on an emergency basis. The f i r s t step of the system i s completed by the patient himself: he f i l l s out his menu for two or three days i n advance. This menu i s then key punched i n order to produce (1) a summary computer l i s t i n g of what q u a n t i t i e of food the "kitchen" w i l l have to orepare, (2) a more d e t a i l e d l i s t i n g of how the trays w i l l be d i s t r i b u t e d , for example by f l o o r or ward, and (3) completed stock r e q u i s i t i o n forms with duplicate cards. The Patient F i l e i s used as input to t h i s run i n order to b i l l c e r t a i n patients (e.g. outpatients) and f o r e d i t i n g and auditing purposes. The menu l i s t i n g s are forwarded to the Food Services Department, whereas the stock r e q u i s i t i o n documents are u t i l i z e d to obtain the necessary "raw materials" from the stock room and to update the Inventory Control System. Once the food trays are prepared and d i s t r i b u t e d , p r o d u c t i v i t y data (e.g. cost of personnel and materials) can be entered into the Food Services System, with the P a y r o l l System also being updated concurrently. This data can then be automatically compared to budgetary information, and management control information produced as a r e s u l t of t h i s . THE CORRESPONDING DATA BANK FIGURE VIII ILLUSTRATION OF A FOOD SERVICES CONTROL SYSTEM 1. 2. 3. C.P.U Updated Patient F i l e 1. Patient Menus received by Food Services Dept. on a d a i l y basis. 2. Patient Menus Keypunched 3. Keypunched Menus run on computer to produce Summary and Detailed Menu L i s t i n g s and Raw Material Stock Requisi-t i o n L i s t i n g . Patient F i l e used as input for edi t i n g and b i l l i n g purposes. 4. Menu Summary L i s t i n g : U t i l i z e d for Meal Preparation. Menu Detailed L i s t i n g : U t i l i z e d for Tray Preparation. 5. Stock Requisition L i s t i n g : (Cards)" U t i l i z e d to obtain Raw Materials from Stock Room. 6. Updated Patient F i l e : F i l e d and u t i l i z e d as needed by other Hospital Subsystems. 7. Materials Obtained from Stock Room. Amount taken entered on cards, and these serve as input to Inventory Control System THE CORRESPONDING DATA BANK FIGURE VIII ILLUSTRATION OF A FOOD SERVICES CONTROL SYSTEM 9 10. END Pay r o l l Informatio PeTs^mrei 11 Information System Inventory #. Meals I Prepared 8. Meals Prepared. I. Patient receives Meal. L0. P a y r o l l Informat-ion Supplied. 11. Raw Material Usage information Supplied. Actual Workload information Supplied. 13. Budget Information. A l l f i l e s used as input to detect any variances on personnel and raw materials usage, and to compare actual workload performed with bud-get forecasts and food services standards. Management Control Information. Follow up a c t i v i t i e s . B a s i c a l l y , t h i s i l l u s t r a t i o n of such a Control System serves to point out the numerous f i l e s necessary to complement a h o s p i t a l data bank. For instance, a Patient F i l e , a Personnel F i l e , a Stock Status F i l e , a General Ledger F i l e , and Food Services r e l a t e d information (e.g. standards) are a l l necessary just to operate such a cost control system. More d e t a i l e d information about these f i l e s can also be implied. In the case of the Patient F i l e , variable length records would c e r t a i n l y be an asset since b i l l i n g of food services would only take place under s p e c i a l circumstances for a few patients (e.g. for a patient requesting more expensive food than that outlined on the menu) 3. The auditing function on the various f i l e s i s also extremely important. In e f f e c t , i n addition to the privacy required for the Patient F i l e , a l l hospital systems must be auditable, thus implying cataloging of transactions that a l t e r the various f i l e s . 3 It must be r e a l i z e d that the Patient F i l e could be more than one l o g i c a l and physical f i l e . In e f f e c t , the t o t a l Patient F i l e could be composed of a magnetic tape containing b i l l i n g information (Patient B i l l i n g F i l e ) , of a disk pack containing medical information (Patient Medical F i l e ) , and of manual f i l e s containing h i s t o r i c a l data. A further implication derived from the i l l u s t r a t i o n i s the length of the f i l e s . It becomes apparent that since hospitals operate on a yearly budgetary cycle, a great deal of storage i s necessary to store the transactions. Large storage i s also required i f trends are to be highlighted to f a c i l i t a t e data analysis. A HIS - DMS I. HIS - DMS CRITERIA There are two broad types of requirements that a DMS must f u l f i l l before i t may be acceptable to an organi-zation. The f i r s t type includes c e r t a i n organizational c h a r a c t e r i s t i c s whereas the other refers to the system services that the DMS must provide. The organizational c h a r a c t e r i s t i c s include such items as computer hardware environment ( i . e . the DMS may require a p a r t i c u l a r type of computer), cost (maximum amount allowed to purchase, lease, or design a DMS), or again core requirements. Since these s p e c i f i c a t i o n s must be s e t t l e d by the i n d i v i d u a l h o s p i t a l , t h i s thesis w i l l not attempt to predict, for example, how much a h o s p i t a l sould spend for a DMS since i n d i v i d u a l budgets w i l l determine t h i s . On the other hand, i t must be implied that any purchase (or leasing) of a DMS should be preceded by a f e a s i b i l i t y study, o u t l i n i n g cost-benefit implications as well as the organizational c h a r a c t e r i s t i c s . The other type of DMS c r i t e r i a are the system services that must or could r e s u l t from a c e r t a i n DMS. These services have a more universal a p p l i c a b i l i t y , e s p e c i a l l y i n the realm of one industry. Because of t h i s , t h i s chapter w i l l u t i l i z e a study of DMS that was conducted with the objective of choosing a DMS for Simon Fraser U n i v e r s i t y i n 1970. 1 The approach u t i l i z e d by the u n i v e r s i t y was to outli n e a series of c r i t e r i a and to evaluate a v a i l a b l e DMS according to them. The c r i t e r i a were divided into four groups and weighting factors assigned according to whether the c r i t e r i a n was a "MUST" or a "WANT". This thesis w i l l enumerate the c r i t e r i a and outline t h e i r r e l a t i v e importance i n determining a HIS - DMS. These c r i t e r i a , therefore, would permit the assess-ment of the a v a i l a b l e DMS i n terms of the features required to supply the inte r f a c e between ho s p i t a l administration information and the hos p i t a l data bank. The four groups i n which they are divided are the following: A) Processing C r i t e r i a B) Input/Output C r i t e r i a C) Control C r i t e r i a D) Environmental C r i t e r i a The Processing section w i l l include any c r i t e r i o n r e l a t e d to data manipulation. The Control section w i l l dations Systems, 1 M a d i l l , J.P., and Kuss, J., Study and Recommen-for A c q u i s i t i o n of Generalized Data Management Simon Fraser University, Vancouver, 1971. present those features d i r e c t l y r elated to physical hardware Input/Output c a p a b i l i t i e s such as remote terminals, and related to actual report presentation features. In turn, the Control section w i l l o u t l i n e features which w i l l permit the user to better u t i l i z e the DMS, such as adequate documentation and diagnostics, whereas the Environmental section contains some c h a r a c t e r i s t i c s which have a strong dependency on the organization obtaining the DMS. A) PROCESSING 1. Data e d i t i n g c a p a b i l i t i e s - describes the f a c i l i t i e s provided by the system to edit innut data. Consideration i s given to features allowing t e s t i n g for range of values, performing numeric or alphabetic tests on data, and specifying v a l i d code conditions.^ This would c e r t a i n l y be one of the important a t t r i b u t e s of any DMS which had to - f u l f i l l administrative requirements. In the case of a hospital, the large volume of transactions on the various f i l e s would almost make t h i s indispensible. This feature could also be u t i l i z e d in an extension of basic data editing. For instance, i t could be u t i l i z e d to " f l a g " c e r t a i n variances, thus f a c i l i t a t i n g the provision of cost control information as outlined i n Chapter V. 2. F i l e d e f i n i t i o n and creation c a p a b i l i t i e s - this feature i s concerned with the ease with which new f i l e s can be designed and the a b i l i t y of the system to create new data f i l e s . 3 3 Ibid, p. 23 This feature i s e s p e c i a l l y helpful i n an environment where (a) the computer systems must constantly evolve to su i t environmental changes, and (b) i n organizations where the various information systems are presently under development. Since i n the case of hospitals, as was indicated i n Chapters III ( I l l u s t r a t i o n s ) and IV (Design Problems), information systems have not yet been comprehensively defined, and much less implemented, a DMS which f a c i l i t a t e d f l e x i b l e f i l e d e f i n i t i o n and creation would c e r t a i n l y be an important asset. 3. Updating c a p a b i l i t i e s - indicates whether the system has the f a c i l i t y for adding, deleting, i n s e r t i n g new f i e l d s or records within the f i l e or changing data contained therein.4 As was the case for SFU, t h i s i s a must for any DMS which would answer to h o s p i t a l administration information needs. In e f f e c t the analysis i n the previous chapter concluded that HIS f i l e s had high v o l a t i l i t y r a t i o s . This implies constant updating ( i n a l l i t s forms) of the records. Since Hospital Administrations require up to date information, the DMS would c e r t a i n l y have to be e f f i c i e n t i n i t s updating function. 4. Enquiry c a p a b i l i t i e s - describes the a b i l i t y of the user to r e t r i e v e from one or more f i l e s . i . e . How much time and e f f o r t i s required to specify requests, can data be extracted from multiple cross-reference 4 Ibid, p.23 f i l e s , can i n d i v i d u a l f i e l d s of data be r e t r i e v e d without reading and processing the entire record.^ In a HIS context, the most important feature of the enquiry c a p a b i l i t i e s l i s t e d above rests i n whether or not data can be extracted from multiple cross-reference f i l e s . This need was i l l u s t r a t e d i n the example of a Cost Control Food Services System (Chapter V) where variance analysis must permit the tr a c i n g of i n d i v i d u a l transactions from the General Ledger F i l e . Thus, th i s feature i s also a "must" for a HIS - DMS. 5. Batch processing c a p a b i l i t y - t h i s feature i s concerned with the ease and e f f i c i e n c y with which the system handles normal batch processing jobs.6 A t o t a l HIS would require enormous amounts of data processing computer time. In e f f e c t , a hospital's data bank, i f i t i s to remain useful, must be constantly up-dated. With a large quantity of updating runs, and each run having a large quantity of transactions, batch process-ing e f f i c i e n c y would indeed be necessary to (a) speed up updating and a v a i l a b i l i t y of information (b) and to avoid f o r c i n g hospitals already having tight budgetary constraint into having to purchase more computer hardware than i s necessary i f sequential batch processing i s adequate. 5 Ibid, p. 23 6. Audit t r a i l and transaction s t a t i s t i c s - the c a p a b i l i t y of the system to automatically produce a f i l e of a l l transactions which a f f e c t the data stored in master f i l e s including the f a c i l i t y to provide s t a t i s t i c s on the number of records added, inserted, changed or deleted from these f i l e s . 7 An audit t r a i l i s mainly necessary to f u l f i l l governmental auditing requirements. It i s also needed i f the DMS i s to help i n tracing the f i n a n c i a l transactions in response to health care requirements. 7. Arithmetic c a p a b i l i t i e s - does the system provide a l l of the normal arithmetic operations, i . e . addition, subtraction, m u l t i p l i c a t i o n and d i v i s i o n . 8 Once again, t h i s feature i s a "must" for a HIS -DMS. But i n addition to basic arithmetic operations, a t o t a l HIS would also require c e r t a i n a n a l y t i c a l t o o l s . In e f f e c t , s t a t i s t i c a l programs and mathematical program-ming packages or simulation languages would be useful for such tasks as long-range planning, q u a l i t y control, scheduling, and forecasting. 8. Logic c a p a b i l i t y - describes the l o g i c a l operators which the user can employ in using the system. e.g. Greater than, less than, equal, etc.9 This feature i s e s s e n t i a l for exception reporting, 7 Ibid, P. 23 8 Ibid, P. 23 9 Ibid, P. 23 thus e s s e n t i a l for a HIS - DMS. For instance, the food services cost control a p p l i c a t i o n of Chapter V assumed the existence of an Inventory Control System. In such a system, the l o g i c c a p a b i l i t y could be u t i l i z e d to permit the updating programs to automatically produce a report of those items which were req u i s i t i o n e d from the stock room i n greater than accep-table q u a n t i t i e s . This feature also allows h o s p i t a l administrators to obtain a l i s t i n g of transactions which varied outside of acceptable ranges, thus f a c i l i t a t i n g variance analysis. 9. Random processing - t h i s feature i s concerned with the a b i l i t y of the system to handle d i r e c t access f i l e s and with the techniques employed for accessing and organizing the f i l e s . 1 0 The matrices of Chapter V on long-range planning and on cost control irformation showed that d i r e c t access processing c a p a b i l i t i e s were not necessary because of the high v o l a t i l i t y of the f i l e s (over 107<>). Nevertheless, the i l l u s t r a t i o n of a food services cost control system i n that same chapter led to believe that this might not be so i n a l l instances. For example, an administrator might be interested in f i n d i n g out what cost centers used a p a r t i c u l a r type of supply on a c e r t a i n day i n order to discover the cause of an unusually high variance i n supply costs. Direct access would permit the r e t r i e v a l of only a few transactions, while not having to read the complete Stock Requisition Transactions f i l e . * Thus, as hospitals get larger and as control gets consequently more d i f f i c u l t , d i r e c t access processing c a p a b i l i t i e s would become a very important asset i n variance an a l y s i s . Other applications which would also benefit from d i r e c t access would be patient b i l l i n g , entering physician orders i n a patient record, or seeking information on a p a r t i c u l a r patient or employee. Accordingly, i t i s recommended that d i r e c t access processing c a p a b i l i t i e s be a part of any DMS obtained by a h o s p i t a l . 10. Sequential processing - describes the ease and e f f i c i e n c y with which the system processes sequential data f i l e s . 1 1 In terms of hardware usage e f f i c i e n c y and response time requirements, t h i s i s one of the important features needed by the DMS, since most of the hospital administrative information requirements can be provided through sequential processing as shown i n the analysis of Chapter V. 11. Fixed length records - the a b i l i t y of the system to handle f i x e d length data records of various types.!2 Even through v a r i a b l e length records are a very useful feature for any DMS, t h i s type of record format i s also, at times, wasteful i n terms of storage space since each record needs a control key which contains information as to how many characters are contained i n the p a r t i c u l a r record. For instance, i f only variable length records were permitted, a Stock Status f i l e , which does not need variable length records, would nevertheless require the control key. This would mean that with a control key of ten characters for example, a f i l e containing ten thousand records would see 100,000 characters wasted. Accordingly, i n a hospital administration context, since many f i l e s (e.g. Stock Status, General Ledger) would u t i l i z e f i x e d length records, f i x e d length records c a p a b i l i t i e s are needed. 12, Variable length records - f a c i l i t i e s contained i n the system to handle records consisting of a variable number of fi x e d length data segments.13 12 Ibid, p. 24 This i s also a necessary asset of any HIS - DMS. The Patient F i l e , i n p a r t i c u l a r , makes thi s so because of the large variance i n length among i t ' s records. For instance, an infant's record would hardly contain any h i s t o r i c a l data, whereas an e l d e r l y person's record would require a much larger number of secondary storage locations. 13. Demand reporting f a c i l i t i e s - assesses the ease, c a p a b i l i t i e s and techniques for designing and obtaining unanticipated reports.14 As a re s u l t of the time dimensions a r r i v e d at through the analysis of Hospital Administration information needs, i t became apparent that, for the most part, on-demand reporting f a c i l i t i e s were not c r i t i c a l . On the other hand, because of the control function of a HIS, c e r t a i n demand reporting f a c i l i t i e s should be a v a i l a b l e . Thus, a happy medium must be found between fast response for demand reporting and the technical requirements of RPG's i n host language systems or s p e c i a l language features. Because of t h i s , t h i s f a c i l i t y , although not c r i t i c a l , must be c a r e f u l l y assessed. 14. M u l t i p l e f i l e cross-referencing - the f a c i l i t i e s contained within the system for using f i e l d s of data i n one f i l e to locate records i n other associated f i l e s for subsequent processing.15 14 Ibid, p. 24 that multiple f i l e cross-referencing f a c i l i t i e s would play an important role i n a t o t a l HIS. For instance, the a l l o c a t i o n of a ce r t a i n type of drug to a patient must access a drug inventory f i l e and the patient f i l e , and possibly a b i l l i n g f i l e . In turn the inventory f i l e would also be re l a t e d to a purchasing or accounts payable f i l e . The t r a c i n g of transactions i n variance analysis would also u t i l i z e t h i s f a c i l i t y , which, therefore, i s very important to a HIS - DMS. 15. Interface to other high l e v e l languages -the a b i l i t y to process f i l e s which are created i n the system language using other high l e v e l languages.15 In a t o t a l system environment, t h i s f a c i l i t y becomes a requirement since the m u l t i p l i c i t y of applications, ranging from purely s c i e n t i f i c medical applications to the more routine business procedures would require programming in c e r t a i n high-level languages such as FORTRAN, COBOL or PL/1, and as a consequence free and easy access to and processing of DMS created f i l e s would be necessary. 15. Independent of f i l e changes - describes the degree to which the system i s independent of changes in the structure, content or format of data f i l e s . Also describes exit c a p a b i l i t y provided and the ease with which the system interfaces with user written sub-routines.I 7 16 Ibid, p. 24 The above feature i s e s p e c i a l l y useful i n an environment where system development i s i n i t s infancy or, as stated for c r i t e r i o n #2, i n a constantly changing environment requiring changes in f i l e structures. Since the h o s p i t a l information systems are i n the process of being developed, t h i s feature i s therefore a very important asset, regardless of the programming language applicable. 17. Ease of use - describes the ease with which the user can communicate with data f i l e s through the f a c i l i t i e s provided by the system.IS As was stated e a r l i e r i n Chapter IV, design and implementation of large computerized HIS has proven d i f f i -c u l t . Thus, t h i s feature, by providing easier communication between user and data f i l e s , could contribute to f a s t e r implementation of information systems.. It i s also a d e f i n i t e asset i n a l l phases of patient care, such as obtaining i n d i v i d u a l patient information as needed, or i n preparing budgets and i n performing control a c t i v i t i e s . This feature could also provide s i g n i f i c a n t cost-benefit advantages. An "easy to use" system implies fa s t e r implementation of programs or less q u a l i f i e d (and less salaried) employees. 18. Data base e x p a n d i b i l i t y - assesses the capabi-l i t i e s of the system for adding new data f i l e s to the data base and e s t a b l i s h i n g or r e v i s i n g linkages between f i l e s . 1 9 The DMS must have th i s c a p a b i l i t y . The main reason for t h i s i s , once again, that hospitals are in the develop-ment stages of information systems. If the DMS permits the addition of new data f i l e s and the r e v i s i o n of linkages between f i l e s , t h i s takes some of the d i f f i c u l t i e s away from system design. A systems analyst, for example, can now design a p a y r o l l system with the intention of i n t e g r a t i n g his P a y r o l l F i l e with the General Ledger F i l e s , but without having to know a great deal of d e a t i l s as to "how" the two f i l e s w i l l be cross-referenced. He need only define his index structures, and not have to write the software routines that v/ould l i n k the two f i l e s . This feature could also permit a system, such as the food services cost control system of Chapter V, to create temporary f i l e s containing c e r t a i n types of trans-actions (e.g. those which contain data which vary outside predetermined ranges). For example, i f 100 transactions updated on a d a i l y basis a Stock Status f i l e , and 5% of these were for unusually high amounts, the system could be programmed to create a temporary f i l e and to store these transactions. At the end of a week, i f no important variances v/ere reported for the t o t a l week's transactions, the f i l e could be destroyed. Otherwise, i t would be a v a i l -able for quick reference. 19. Type of f i l e structure - describes and assesses the permissible data base structures. Example: sequential records, inverted structure, r i n g structure, etc. Also indicates whether h i e r a r c h i c a l record structures are p e r m i t t e d . 2 0 Because of the great v a r i e t y of a hospital's information needs, many d i f f e r e n t f i l e structures could be required at one time or another. The exact types are d i f f i c u l t to predict u n t i l the actual design stage of the system i s reached. Therefore, i t i s recommended that the more types of f i l e structures offered the better as far as keeping the design options open. 20. Cataloging of requests - describes c a p a b i l i t i e s for s toring a p p l i c a t i o n programs i n a data set and a c t i v a t i n g them by means of control cards o n l y . 2 ! Although not c r i t i c a l , t h i s feature o f f e r s the c a p a b i l i t y of s i m p l i f i n g the operating procedures for c a l l i n g i n the desired programs. In c r i t e r i a #17 were outlined a few advantages of an easy to use system. These apply to t h i s c r i t e r i o n also, rendering i t one of the recommended features of a HIS - DMS. 20 Ibid, p. 25 21. Allows f i l e r e structuring - describes the f a c i l i t i e s of the system to change the f i l e structure, i . e . sequential to indexed sequential, etc. and also to change the record structure, e.g. Fixed to variable, etc.22 This i s a valuable system development t o o l . Accordingly, since Chapters III and IV indicated that hospitals provide an environment where large scale system development i s i n i t ' s infancy, t h i s feature i s recommended. 22. Table lookup - describes the c a p a b i l i t y of the system to design tables and to reference these tables using d i f f e r e n t methods of access. Example -binary search, sequential, displacement.23 Table lookup i s necessary to avoid having to read a complete f i l e i n instances where very few records are to be retrieved. This applies for such applications as mechanizing patient h i s t o r y taking, where only one record out of a whole patient f i l e has to be accessed. In the evaluation of criterium #9 (Random Processing), i t was stated that d i r e c t access was not needed to provide most ho s p i t a l administration information needs. Nevertheless, the requirements of other computerized hospital systems meant that d i r e c t access was a d e f i n i t e asset. The same can be s a i d about table lookup. 22 Ibid, p.. 26 23. User Coding Required - Assesses the amount and complexity of user coding required to perform functions r e l a t i n g to f i l e maintenance, transaction editing, program l o g i c control, etc.24 Once again, the easier the coding the more econom-i c a l the system, since programming d o l l a r s may be saved with easier coding requirements. Consequently, t h i s i s a very important c r i t e r i o n . 24. Interpretative or compiled - t h i s section assesses the e f f i c i e n c y and speed with which an executable module i s produced. These packages are generally driven by input parameters prepared by the user. The parameters are used by the package either to compile programs which process the user's data or to interpret the statements and configure core with the s p e c i f i c package modules necessary to process the user's data.25 This feature i s r e l a t i v e to the amount of processing done on a computer system (hardware environment) p r i o r to execution. In e f f e c t , the greater the volume of processing, the more important i t becomes that the executable module be produced with e f f i c i e n c y and speed. On the other hand, even i f a h o s p i t a l represents a large volume of data process-ing, the production of an executable module i s not an important time factor. Thus, t h i s feature, although useful, i s not c r i t i c a l . 24 Ibid, p. 25 25. Back-up f i l e c a p a b i l i t y - describes the f a c i l i t i e s provided by the system for creating back-up f i l e s i n case of loss of data through system f a i l u r e or f i l e destruction. 27 This i s most important i n a mass storage f i l e environment. On the other hand, simple hourly or d a i l y f i l e dumps may be s u f f i c i e n t for those c r i t i c a l f i l e s where "re-updating" would be very time-consuming as long as information can be r e l i a b l y provided t h i s way. Thus, this may be an important HIS - DMS feature for case h i s t o r i e s and other data that have to be of extreme r e l i a b i l i t y . 26. Interactive c a p a b i l i t i e s - describes the f a c i l i t i e s for user enquiry/response i n t e r a c t i o n at the terminal.27 In Chapter III, several applications, such as the Kaiser Foundation's Multiphasic Screening System (p. 38), Downstate's THOMIS System (p. 27), or Data Communication's REACH system, a l l u t i l i z e d i n t e r a c t i v e terminals. While reviewing the cost control information matrix of Chapter V, i t also became evident that t h i s f a c i l i t y would be necessary i f a l l h o s p i t a l administrative information was to be supplied. Interactive c a p a b i l i t i e s are also extremely h e l p f u l i n program development. Thus, i t i s recommended that the DMS have i n t e r a c t i v e c a p a b i l i t i e s . On the other hand, the audit t r a i l f a c i l i t y and the security of data f i l e s must be emphasized even more with 26 Ibid, p. 27 the a v a i l a b i l i t y of terminals so that unwarranted changes to or interrogation of the data bank not be possible, or at least be traceable. B) INPUT/OUTPUT 1. Handle large f i l e s on tane or disk - assesses the a b i l i t y of the system to e a s i l y and e f f i c i e n t l y handle numerous f i l e s containing a large number of long records. e.g. 20,000 records of 10,000 bytes per record.28 Chapter V's analysis indicated that some reports would require several input f i l e s . It also became evident that some of the f i l e s would eventually contain a large number of records (e.g. Stock Requisition F i l e ) while others would have records with a large number of charac-ters (e.g. Patient F i l e ) . On the other hand, i t i s important to r e a l i z e that memory requirements would also be a l i m i t i n g factor on size of f i l e and record handling c a p a b i l i t i e s . Because of t h i s , t h i s c r i t e r i o n should be evaluated i n terms of av a i l a b l e memory siz e i n addition to the f i l e handling requirements. 2. Report c a p a b i l i t y -a) E d i t i n g - assesses the c a p a b i l i t i e s for ed i t i n g output data f i e l d s including leading zero suppression, f l o a t i n g d o l l a r signs, etc. b) Headings - assesses the c a p a b i l i t i e s provided by the system for specifying t i t l e s , s u b - t i t l e s and column headings. Also indicates whether the user can default to automatic column heading, page numbering and date s p e c i f i c a t i o n s . c) Formating - indicates the degree of control permitted the user regarding maximum f i e l d sizes permitted and date placement on output reports. d) Summary l i n e s and control breaks - s p e c i f i e s whether control breaks are allowed and the number and l e v e l of breaks permitted. Also describes the type of information that can be contained i n summary l i n e s such as counts, t o t a l s , averages, etc.29 Such report c a p a b i l i t i e s , are mostly important for the programming time saved. A further advantage of such f a c i l i t i e s i s also found i n the " a r t " of presenting reports to potential users. In eff e c t , i n a hospital as in every other industry, the format i n which the report i s f i r s t presented has a great deal to do on the po t e n t i a l user's acceptance or r e j e c t i o n of the report. Thus, the "ni c e r " the report, the better the user's " f i r s t impress-ion" w i l l be. Another factor which i s influenced by the a v a i l a -b i l i t y of report c a p a b i l i t i e s i s the speed with which information can be provided to administration. Accordingly, i n the cost control matrix of Chapter V, i t was pointed out that variance analysis information should be av a i l a b l e on demand. Therefore, report c a p a b i l i t i e s form a very important c r i t e r i o n i n choosing a HIS - DMS. 3. Capable of so r t i n g report f i l e s - describes the maximum number of sort f i e l d s allowed and indicates the number of characters that can be s p e c i f i e d for sorting.30 A DMS' sortin g routines are, without any doubt, a necessary a t t r i b u t e . The author's own experience has led him to conclude that once a user discovers the possible benefits that may be derived from various formated reports, he w i l l not hesitate to ask for the new reports. This has often e n t a i l e d a d i f f e r e n t or supplementary sort of an old report, a function which i s greatly f a c i l i t a t e d by av a i l a b l e s o r t i n g routines. As far as the number of characters or sort f i e l d s allowed i n the sort, routine t h i s has not presented s i g n i f i c a n t problems. On the other hand, the t o t a l number of records that the sortin g routine can handle should not be overlooked. 4. Multiple Input/Output f i l e c a p a b i l i t i e s -indicates the number of input and output f i l e s the user can process with the system.31 Chapter V's analysis of Hospital Administration Information and the r e s u l t i n g data bank c l e a r l y indicated that a t o t a l HIS would require a large number of f i l e s . It was also indicated that to produce c e r t a i n reports, the programs would have to access sometimes as many as 30 Ibid, p. 25 four f i l e s . Thus, a HIS - DMS having multiple f i l e capa-b i l i t i e s may be more v e r s a t i l e and may f a c i l i t a t e a better integration of single f i l e s . 5. Remote Terminal job entry - describes the f a c i l i t i e s contained within the system to allov; sub-mission of processing requests v i a remote terminals.32 In evaluating c r i t e r i a n #26 i n Section (A) of this chapter, i t was stated that i n t e r a c t i v e c a p a b i l i t i e s would be required i n a hospital environment. The same reasons stand for remote job entry f a c i l i t i e s . This c a p a b i l i t y i s also recommended for a further reason. In B r i t i s h Columbia, i t appears that regional hospital information systems w i l l become the trend because of lower i n d i v i d u a l expenses through shared hardware and software development costs. For t h i s reason, remote terminal job entry f a c i l i t i e s must be a v a i l a b l e through the DMS. 6. Error recovery and r e s t a r t procedures -describes the f a c i l i t i e s provided by the system for saving processing data i n case of system f a i l u r e , i n order that the system can be restarted from some check point without having to resubmit the entire data.33 Since batch processing would be s u i t a b l e for most administrative information needs, an u l t r a - s o p h i s t i c a t e d 32 Ibid, p. 26 error recovery and restart procedure i s not c r i t i c a l , provided the f i l e s can be regenerated within reasonable time requirements. 7. Security - t h i s feature describes the provisions to ensure that only authorized users are permitted access to the system. Also assesses f a c i l i t i e s to l i m i t access to only those records or f i e l d s which the user i s authorized to query or update.34 Security i s imperative i n a hospital environment. In e f f e c t , patient information i s both priva t e ( i . e . patient does not want anyone to know about c e r t a i n information^) and c o n f i d e n t i a l ( i . e . information i s given to ce r t a i n i n d i v i d u a l s wi th the understanding that they w i l l not release i t to other indi v i d u a l s 3 6 ) t and only very l i m i t e d access should be permitted. For thi s reason, the chosen DMS must provide a thoroughly secure data bank. C) CONTROL 1. Adequate documentation - describes the type and q u a l i t y of documentation provided with the systems for users, programmers and operators. The number of sets of documentation provided and the a v a i l a b i l i t y and cost of add i t i o n a l sets are also considered.37 34 Ibid, p. 25 35 Curran, William J., et a l , "Privacy, C o n f i d e n t i a l i t y and other Legal Considerations in the Establishment of a Centralized Health-Data System", The New England Journal of  Medicine, Vol. 281, No. 5, July, 1959, p. 241. 36 Ibid, p. 241 37 M a d i l l , Op C i t , p. 25 glance. Once again, the authors own experience dictates that lack of adequate documentation (either i n q u a l i t y or quantity) has been the source of many f r u s t r a t i o n s due to unforseen problems i n programming with the DMS or i n not u t i l i z i n g a DMS to i t s f u l l capacity. It i s also imperi-t a t i v e to prevent major problems due to personnel changes or system modifications. 2. Comprehensive diagnostics - describes the type and q u a l i t y of messages provided when errors occur i n compiling, loading, or running the system and i t s DMS asset. But of more importance are debugging routines presently a v a i l a b l e i n c e r t a i n high-level languages such as COBOL's TRACE statement. Thus, this feature, although not a "must", would c e r t a i n l y be of f i n a n c i a l value i n terms of saved debugging time. D) ENVIRONMENTAL 1. OS release independent - the system must be independent of changes i n operating system releases.39 This feature i s e s p e c i a l l y important i n t h i s instance since the chosen DMS would be i n s t a l l e d with the hope of Comprehensive diagnostics i s also a very important 38 Ibid, p. 25 designing a t o t a l HIS around i t , thus having long-range implications. Therefore, i n addition to chosing a DMS which i s sutiable for a c e r t a i n type of computer configur-ation, a h o s p i t a l should also be c e r t a i n that any future operating system changes w i l l not make the DMS obsolete. 2. Eas^e of implementation - assesses the ease with which the system can be implemented on the operating system and the amount of t r a i n i n g and technical know-ledge required of the systems, programming and operating staff.40 A "turn-key" operation i s , of course, desirable since no lengthy and expensive (at least i n s a l a r i e s ) t r a i n i n g time i s required and since results can be obtained almost immediately. Nevertheless, since the computers s t a f f should be competent, th i s f a c i l i t y should not be one of the deciding factors since the chosen DMS w i l l be kept for a long period of time i n order to help i n the design and implemen-t a t i o n of HIS and to become an i n t e g r a l part of the HIS once these are implemented. 3. Upward compatible - describes the degree to which the system i s compatible with larger systems and with changes i n peripheral devices and other hardware.41 Once again, the f i n a l objective being the implemen-ta t i o n of a t o t a l HIS, the DMS must be adaptable to larger 40 Ibid, p. 25 and more complex hardware configurations that could be needed once a hospital's t o t a l information system i s designed. II EVALUATION OF COMMERCIAL PACKAGES With the above c r i t e r i a , i t now becomes possible to choose a DMS that w i l l provide the necessary services required to i n t e r f a c e a h o s p i t a l data bank with HIS. It i s recommended that for t h i s evaluation to be done e f f e c t i v e l y , the various vendors be asked to submit information as to how t h e i r respective systems would compare to the c r i t e r i a . This information, validated with independent DMS evaluations such as the Codasyl Systems Committee - or the Mitre Corporation reports on DMS and with s u i t a b l e benchmarks, should permit a h o s p i t a l to choose the DMS that would be most suitable for i t s i n f o r -mation needs.42 43 But i t must be r e a l i z e d that the conclusions of the above study must be adjusted to the needs of the other components of the h o s p i t a l . 42 Codasyl Systems Committee, A Survey of Generalized  Data Base Management Systems, Association for Computing Machinery, New York, 1969. 43 Fry, J., et a l , "Data Management Systems Survey", Mitre Corporation Report, AD684707, January, 1959. For example, i t i s a l l very well to state that the accounting department needs business oriented hardware, (e.g. d i g i t a l computer), and to conduct a s i m i l a r study on the research department where one would conclude that an analog computer i s needed. In ef f e c t , the two "con-clusio n s " must be amalgamated into one "best" s o l u t i o n for the organization. In t h i s instance, the problem could be solved by acquiring a d i g i t a l computer with an analog/ d i g i t a l converter. In e f f e c t , t h i s thesis has outlined the requirements for a Hospital Administration DMS, and not what the t o t a l HIS - DMS should be. The basic objective of t h i s thesis was to outline the c r i t e r i a for choosing a DMS for hospital administration. E x i s t i n g computer applications i n hospitals were reviewed i n Chapter II I , and i t was found that no totally-integrated HIS has yet been implemented. Several causes for t h i s were brought forward i n Chapter IV. This chapter also recommended the systems approach i n order to solve some of these problems. To give a p r a c t i c a l meaning to t h i s , the remainder of the thesis used i t to help define the c r i t e r i a necessary for a DMS to provide h o s p i t a l administrators with desired information. This procedure consisted of (1) o u t l i n i n g the organizational objectives, of (2) determining what had to be done to meet these objectives, of (3) determining the information required to accomplish t h i s , and (4) the data bank necessary to provide t h i s information. Once these steps had been c a r r i e d out, the DMS c r i t e r i a could accordingly be determined and evaluated. The contributions of t h i s thesis are consequently both of a d i r e c t and i n d i r e c t nature. F i r s t of a l l , i t outlined hospital administration data management implications. In doing so, i t applied PPB3 and systems analysis to hospital administration, provided a l i t e r a t u r e survey of computer applications i n hospitals, and outlined the major problems i n systems design. Several questions have yet to be resolved. For instance, even with the a v a i l a b i l i t y of the proper DMS, i t i s s t i l l necessary to design HIS properly for hos p i t a l administration. This would require i d e n t i f i c a t i o n of the various modules necessary to a r r i v e at a t o t a l HIS. The procedure outlined i n t h i s thesis would be useful for t h i s purpose. Further research would also be necessary to define the implications of having i n d i v i d u a l stand-alone t o t a l HIS instead of a large regional HIS. Nevertheless, i t seems apparent that a successfully integrated t o t a l HIS i s a long way o f f . 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