SPECIAL REPORT: February 1976 These included computer-assisted methods for acquiring a A Feature of Computer Medicine patient's history, automation of diagnostic and laboratory procedures, and plans for storing relevant diagnostic and THE AUTOMATED PHYSICIAN'S ASSISTANT therapeutic information for rapid retrieval when needed by a physician in the management of his individual patients. By: Arthur E. Rikli, M.D.,, Fred V. Lucas, M.D.; After approximately two years of development, it was and Fred Frazier, M. Ed. decided to attempt the integration of several of the compati- ble projects into a single physician's office. A mock phy- Dr. Arthur D. Rikli is coordinator of the Missouri sician's office was constructed, equipment was installed, and Regional Medical Program (Mo RMP) and professor of what became popularly known as "Dr. Mock's Office" was Community Health and Medical Practice at the School of put into operation. Here it was found that the elements Medicine, University of Missouri-Columbia. In October could be brought together effectively, and the concept of 1975, Dr. Rikli was elected president-elect of the Society exploring the acceptability of the system in the office of a for Computer Medicine. practicing physician was encouraged. Dr. Fred V. Lucas is chairman, Department of Early in 1970, a few of the technologically oriented Pathology, University of Missouri-Columbia. systems were moved to the office of Dr. Billy Jack Bass in Mr. Fred Frazier is assistant director for communi- Salem, Mo., a town located almost 150 miles from a major cations, Missouri Regional Medical Program. medical facility. Dr. Bass remodeled his office so that it would be possible to provide services to his patients using EDITOR'SNOTE: Thefollowingarticleisreprinted either the automated system or his usual model of providing from "Clinical Engineering News" with permission from its services. It was at this point that the program became known editor, Dr. C.A. Caceres. as the Automated Physician's Assistant. After almost two years of operation in Salem, the Some time ago, millions of Americans were transported answers to three of the most common questions were clearly through the medium of the CBS-TV Morning News to the and effectively answered: (1) Technology does work in the office of a private physician in Salem, Mo. (population 4,363), office of an individual physician; (2) There was clear-cut to see the Automated Physician's Assistant (APA) in operation. acceptance of the technology by the patients, office staff, Countless others learned of the program through numerous and physician; and (3) Technology was of value in initial feature articles in newspapers and magazines. Descriptions screening of new patients, periodic health examinations, even appeared in such diverse publications as "Parade" and a and fostering an increased number of measurements and an Japanese "Journal of Medical Engineering." orderly collection of data. All of this public attention was capped off by the The Components following words, which appeared in a White Paper issued by The APA system was synthesized from a number of the Department of Health, Education and Welfare: project activities that had been in various stages of develop- "Technological development also offers opportunities ment in the Missouri Regional Medical Program during what for improving the utilization of scarce manpower skills, while might be called Phase I of APA. also serving other purposes, such as improving the quality of Keeping in mind the concept of APA as shown in Fig- care and the distribution of services. To illustrate: In Salem, ure 1, the following constitutes a brief review of some of the Missouri, under the auspices of a Regional Medical Program major projects, their functioning and present status. grant, a general practitioner's office is linked by computer to 1. Automated Patient History Acquisition System a university. Patients who come in for a physical participate (APHAS) in feeding information into the computer, through a process The APHAS program developed a computer-assiste system similar to self-instruction teaching machines, and nurses add for helping patients record their own medical histories and information from tests they perform. A great deal of infor- providing a preliminary analysis of complaints prior to phy- mation is available to the physician by the time he sees the sician examination. This differed from some of the other patient's computer-recorded file. Technology, the use of the automated approaches in that it made use of both audio to patient as a participant in the process, and the use of nurses assist patients with reading problems and visuals for those substituting for tasks previously performed by the physicians with hearing problems. This program can be said to have each can contribute to improving utilization. The Adminis- advanced the state of the art. tration will continue to support efforts of this nature." II. Automated Diagnostic Procedures The Reason For APA A. Automated Electrocardiogram in a Rural Area- APA was a natural product of its environment. The This project tested and revised the Public Health Service Medical Center at the University of Missouri-Columbia was Program in a rural field network. Computer-assisted diag- established and supported by the state legislature for the nosis of electrocardiograms is now commercially available purpose of helping to bring modern services to the people of and in routine use in approximately 25 hospitals. rural Missouri. B. Mass Screening Radiology-Th is system was de- One of the concerns in Missouri, as well as other areas veloped to provide computer-assisted diagnosis, generation of the country, was the apparent maidistribution of phy- and storage of standardized radiology reports. Now called sicians and their tendency to locate in areas adjacent to medi- Missouri Automated Radiology Service (MARS), it has been cal centers. The initial plan theorized that imaginative use adopted for use with a PDP-15 computer, using the MUMPS of technology and communication could result in placing the interpreter, and has received international attention. It is in resources of the medical center as close to the physician as daily use, is fully supported by the University of Missouri his telephone, wherever he might be located. Consequently, Medical Center, and has developed a patient file of more an operational grant provided for development of a number than 30,000. of programs applying technology to medical problems. C. Multiphasic Clinical Laboratory Testing-The SMA- 1 2 autoanalyzer was used to discover indicators of COMPUTER MEDICINE-SPECIAL REPORT: February, 1976 - Page 2 latent disease and to identify the most useful tests for those of data handling systems without incurring the expense of indicators. The project helped to introduce the use of auto- actual construction. It also demonstrated the need for spe- mated blood analysis to essentially all rural areas of Missouri. cific definition of information components. This group is Ill. Computer-Assisted Aids to Differential Diagnosis quite active in the program. A. FACT (Fast Access to Current Text) Bank-This Current Status of APA program was designed to supplement the physician's medical Despite the fact that the Missouri Regional Medical library and give him the opportunity to ask specific questions Program had to terminate its support of the program, the aboutspecificproblemsandgetquickanswers. Morethan Automated Physician's Assistant is still very much alive and one million pages of scholarly and scientific articles from considerable progress has been made in Phase I I I under one 528 medical journals were microfilmed and stored for fast of the authors and Dr. Jay H. Goldman, chairman of the automatic retrieval. This program had to be terminated short Department of Industrial Engineering at the University of of interconnecting the display mechanism with a computerized Missouri-Columbia. Support is being furnished through the depth index. National Center for Health Services Research and Develop- B. Expanded Consider-This computer program ment. Phase III is concerned with basic issues that must be enables the user to key in what symptoms and signs are a- resolved if technological components are indeed to become vailable and immediately access potential diagnosis. Primary effective in real-world health care delivery systems. data base is the AMA's Current Medical Terminology, ampli- The first year of this three-year phase was devoted to fied by a prototype data range of the AMA Drug Evaluation the attainment of three major objectives: (1) Development (1971). The program is in daily use at the University of of a methodology for implementing the design of an ambu- Missouri Medical Center. It is particularly valuable as a latory care system; (2) Development of a technique for pre- teaching aid. and post-evaluation of the effect of introducing a change in the component of a health care delivery system; and (3) The development of an integrated system of software services. Three sites have been selected to participate. Two of these are offices of individual practitioners and, the third, a group of four family practitioners.whose offices are located together. Baseline data have been collected at each of the sites, and hardware is now being installed. :OMPUTIR SYSTEM The participants at each of the sites have indicated the DEV AND SERV.CIS existing programs in which they have an interest, and, initial. AUTOMATED CLINICAL ly, one program will be installed at each of the sites. ro- P.15-C.A@ S TEST MEDICAI SYSTEMS .......... -ITE grams that seem to have the highest priority are patient edu- AN.t'S.S cation, billing, patient scheduling, a doctor's education package, and a patient history. mfo.cat Thus, in Phase III, existing programs will be imple- 11119.TIIE mented in selected demonstration sites, and an assessment .ET.If@Al will be made of the impact of these computer aids on the delivery of primary health care. It has been most satisfying to those at the Missouri Regional Medical Program, who played a prominent role in accelerating its development, to be able to report that the Fig. 1. The APA System Automated Physician's Assistant is indeed functioning well. It is the belief and hope of those in the program that the IV. Operational Programs present phase will lead to a time when the computer will in- Supporting the development of all of these projects were deed live up to its promise as a means of providing substantial three cooperative efforts of the university School of Engi- aid to the physician as he cares for his patients. neering and the medical center. A. Bioengineering- In a broad sense this term corn- bines engineering and medical knowledge to design and test devices that aid physicians in diagnosis and treatment of patients. The success of this program has built a lasting bridge between the two disciplines and has influenced engineers to become involved in problems of medical technology. B. Operations Research and Systems Design (ORSD)- This effort applies industrial engineering principles to solv- ing problems and streamlining various health care patterns. Both bioengineering and ORSD are cooperating in present APA development. This has resulted in the development of a Ph.D. program in health care systems. C. Data Evaluation, Computer Simulation and Sys- tems (DECS)-This is concerned with the systems problems involved in incorporating the components into one program and developing an integrated patient file. It created extensive simulation computer models, thereby permitting evaluation