The Promise of Communications in Medicine in the Seventies, 1970
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the promise of communications for medicine in the seventies dr ruth m davis and dr martin m cummings the promise of communiations in the 1970's lies primarily in the application of the technologies developed during the previous decade they are big technologies aimed at big problems big in the context of alvin weinberg's reflections on big science the two which figure most prominently are communications technology and computer technology computer technology as an augmentation of man's intellect and communications technology as an extension of man's means for interaction provide new mechanisms for linking man with society and his environment these are the technologies which allow decentralization of controls on education more geographical independence of individuals and institutions more individualization of learning a removal of certain constraints on quality of health care national library of medicine national institutes of health public health service u s department of health education and welfare to be presented at the american thoracic society annual meeting may 26 1970

Page  2 2 and hopefully a lessening of economic burdens on medical institutions underlying the promise of communications and computer technologies is the technology of micro miniaturization microelectronics has made vacuum tubes relics of the past the discrete componentry of transistors resistors and capacitors is being replaced by integrated circuitry and by large scale integration lsi powerful electronic capability is being compressed into extremely small volumes for example in 1960 4000 circuit elements could be contained in an area 120 mils on a side in 1965 50000 active circuit elements were concentrated in the same area just before 1970 over 100000 circuit elements could be packed into this area the first slide illustrates the evolution of microelectronics which began with the introduction of the transistor in 1948 a 1952 transistor is shown at the top all the objects are depicted actual size the next step directly below was to assemble several

Page  3 transistors diodes resistors and capacitors on a circuit board that could be plugged into a computer or other kind of electronic system the example shown here is a circuit board of the type used in the ibm computers in the early 1960's it incorporates 45 electronic devices the ibm 360 series of computers employs a technology called solid state logic bottom left it provides 40 odd devices in six tiny cans the late 1950's saw the development of the first integrated circuits in which transistors diodes and resistors were all formed on a single chip of silicon and linked into a circuit the example in the middle of the bottom row was made in 1965 it contains 91 transistors and resistors the large scale integration lsi example at the bottom right contains 864 devices the second slide shows an enlarged view of the latest example of microelectronics known as large scale integration or lsi the term is usually reserved for integrated circuits whose density is 50000 or more circuit elements per square inch this unit has a density exceeding

Page  4 160000 elements per square inch its actual size is 11 by 14 inch roughly the area occupied by the word the in the typeface of my paper the circuit can store 256 bits of information and with similar units will provide the high speed memory for the advanced illiac 4 computer now under development at the university of illinois the main thrust of microelectronics to members of the medical community is the resultant increase in reliability decrease in size and weight of instruments and increase in quantity of communications and computer power available to them it is these benefits of technology 2 that are making a computer just a plug in the wall rather than a room full of electronic equipment computer terminals which weigh less than thirty pounds and fit under an airplane seat are a product of this technology with such a terminal and a telephone one can be 3 on line to more than 100 commercially available timesharing services from anywhere in the united states

Page  5 5 further as capabilities for communications and computer use increase cost is decreasing in the computer field for example it is estimated that computer power cost improves by a factor of 10 every 2 5 years the computer industry is characterized by a rapid growth of about 50 per year and vigorous competition while the telephone carriers are accustomed to moderate growth of about 8 per year cost is not decreasing so dramatically in the communications field because the communications industry is a regulated industry customers pay tariffs in addition to costs and tariffs are established by the federal communications commission fcc however the advent of communications satellites and the entry of private carriers into the communications arena promise to reduce both cost and tariffs and to increase the variety of services available as an example of federal interest in meeting the communication needs of public services and in particular that of education the fcc recently requested the formation of a committee to study these needs the national library of medicine is represented on this committee and as such is acting

Page  6 6 as a spokesman for the medical community at the initial meeting of the committee in february 1970 it was agreed that the study should not be limited to terrestrial microwave but should look at alternative means of meeting the communications needs of education and other public service users including satellites we believe we can anticipate the application of certain technical developments to assist undergraduate graduate and continuing medical education examples of these will be discussed in the context of program planning which is now underway in our lister hill national center for biomedical communications communications for on line bibliographic access an individual armed with a computer terminal device and a telephone will have the potential to achieve access to information greater than envisioned even by most imaginative of science fiction writers the 1960's saw the generation of the ideas behind this potential and its primitive beginnings the 1970's will see it become a reality

Page  7 the computer terminal coupled with communications is probably the first manifestation of the mechanized augmentation of human knowledge heralded for so long by a small number of visionaries this individualized technical assistant makes it possible to delve into computer information banks and browse through their holdings regardless of geographical location for example there are a number of bibliographic information resources now in computerized form an individual at his office or home can now retrieve bibliographic data covering some 100000 articles in 24 physics journals and the physical review a similar system has been developed which enables one to retrieve bibliographic data from more than 220000 citations to foreign scientific and technical literature the ability to browse through bibliographic information resources has been of especial benefit to researchers engaged in original work or in performing state of the art reviews and surveys selective retrieval based on the bibliographic elements

Page  8 8 of title key words author and abstract can greatly reduce non productive reading in search of information the national library of medicine believes that it can make a significant contribution to practicing physicians educators and researchers by providing simple remote online access to medical bibliographic information such access was generally being provided in the 1960's through special computer systems such as our medlars program these systems allow users to adopt a wide range of search strategies and provide a capability for rapidly focusing a search effort many of them however are difficult to learn to use and required a trained intermediary nlm is now planning to provide access to a computerized version of its abridged index medicus through use of part of a large time shared computer system connected to the telegraph twx network this will allow potential access from terminals already existing in some 500 institutions

Page  9 in the medical community more than 100 medical libraries now use the twx network a review of the directory of the twx network indicates that there are 120 hospitals on the network 150 pharmaceutical firms 125 universities including many medical schools and a sprinkling of clinics and private physicians one of the great disadvantages in the first two decades of computer use by large groups of customers was the problem of communicating with the computer computers operate with a forma rigid language having little in common with natural language in the 950's the entire burden of computer communications fell on the customer who had to learn the computer language the 1960's saw this concept modified by attempts to interject between the computer language and our natural language a compromise language known as a high level programming language or a language processor these new compromise languages were designed to possess as many

Page  10 10 of the attributes of natural language as computer technology and cost would permit generally the descriptive documentation was so formidable that customer courses were considered essential before a user could communicate with the computer the beginning of widespread use of remote terminals connected to computers resulted in such an increase in customers that the requirement of documentation or training for each individual customer became impossible we believe that improved communications is the best answer to the problem that communications technology itself has created with proper programming the individual computer terminal can provide instruction on its use for any given information resource the 1970's will see as a common part of any customer service instructions on its use through a dialog between the computer and the user the online bibliographic service to the abridged index medicus to be provided by nlm beginning this year has this self contained instructional feature

Page  11 11 the low bandwidth requirements of such terminals provide inexpensive communications costs for example in the on line bibliographic service planned by nlm the cost of using the abridged index medicus via twx varies from twenty rents a minute to sixty cents a minute depending upon whether a customer is 50 miles or 3000 miles away from the computer there are many estimates as to the numbers of customers who will be augmenting their local resources with such remote computer information banks some predict as many as 300000 terminals online with computers by 1972 others predict a doubling of computers from 50000 to 100000 in the u s in the 1970's with half of the new total providing remote on line services my third slide shows two examples of computer terminals in the offices of practicing physicians these are television like terminals that are cathode ray tubes i e crt terminals today they are generally connected to remote data bases by

Page  12 12 telephone lines the ones shown in the slide are typical of today's terminals they are used in medical schools and hospitals they are integral parts of most computer assisted instruction systewn in the slide are typical of today's terminals they are used in medical schools and hospitals they are integral parts of most computer assisted instruction systems developed or under development for the medical community whichever projection one chooses the outstanding feature of all prophesies is their consistency in predicting rapid growth in individual uwn in the slide are typical of today's terminals they are used in medical schools and hospitals they are integral parts of most computer assisted instruction systems developed or under development for the medical community whichever projection one chooses the outstanding feature of all prophesies is their consistency in predicting rapid growth in individual use of remote information services through a wide variety of communications means communications in tutorial environments programs in the seventies dedicated to the transfer of the technology of the sixties to usable education products services or publications will be marked by a diversity of successful patterns and organizational structures such transfer tends to be unique for each problem area involved and seemingly must be tailored to the specific characteristics of the technology and of the customer group

Page  13 13 this is particularly relevant to educational technology where a democratic heritage implies local control of education ralph gerard dean of graduate studies university of california at irvine points out actually mass development of technologies of communications and so of education have led to the loosening of control of men's minds printing and books are credited with the successful revolt of the people from tight clerical rule the typewriters and telephone possible only with massive conformity have enormously increased the flow of individualized messages with essentially no constraint on their content when the great computer systems and data banks and networks are in operation there should be greater freedom of local content choice and even production than is presently the case with packaged books or tapes or movies teachers

Page  14 14 will continue to prepare the messages however complex or universal the medium for their presentation within the broad outlines of rommunirations and computer technology one can predict particularly desirable immediate objectives for medical education these include a new self paced learning environment which we call the extended textbook or the multimedia text this slide no 4 shows a neurosciences carrel developed by dr robert livingston at the university of california at la jolla with concerted support from a group of associates at many different universities on a project partially sponsored by the national library of medicine the carrel contains a variety of audio visual devices along with the texts and models necessary for teaching the limbic system the equipment cost about 3000 and the educational material sufficient for about five percent of a neuroscience course or eight hours student review time has cost about 8000 the total project including the development of program content cost 156555 this new technology is expensive for use in a single institution only when these information packages are replicated and

Page  15 15 shared by all medical srhools will they be cost effective the next two slides slide no 5 and no 6 show what the lister hill center calls an individualized education or information module the first slide no 5 simply illustrates that the equipment ran be rarried in an ordinary briefcase or attache case which weighs only twelve pounds fully packed the equipment shown in use in the next slide no 6 contains a microprojector shown on the left of the desk it is projecting a microfiche on a small piece of cardboard on the right of the desk the projector will also project slides film strips aperture cards microfilms and microjackets it weighs three pounds in the center of the desk is a compact cassette tape recorder capable of providing two hours of listening material on a cartridge 4 by 2 1/2 by 3/8 the american college of cardiology now is providing a monthly talking journal called access using these cartridges in less than a year this new service has 2400 subscribers

Page  16 16 the rapid pare of application of these technologies to education has precipitated certain problems which must be resolved in the 1970's the significant phrase here is the rapid pace of technology for certainly technology is no stranger to education the introduction of the blackboard in the 1840's probably heralded the only important technical adaptation within the educational system in the 50 year period subsequent to that event when the motion picture was introduced to the education coinmunity as a new medium in the 1920's it had no competition for attention there was ample time for adaptation to it by the teacher and student alike actually the adaptation to films had taken place outside the classroom in the local movie theater the teacher had to adapt to it in the classroom rather than to under stand how to make effective use of it

Page  17 17 in the 1960's and certainly still in the 1970's the stresses felt by the education community from the pressures of technology and the demand for its utilization are due to the great amount of available relevant technology all of it is expensive all of it is sophisticated in the sense of requiring forma training of the teacher in its use and most of it is foreign in the sense of not having been developed under the aegis of the education community the stresses and the inability to adapt rapidly enough has created a schism between technology and many educators we all know that students are more receptive to new technology than are their teachers television as a communications medium television is undoubtedly the single most important communications medium now available to education its applications are already numerous and increasing most students entering medical schools have grown up on television having been exposed to it on an average

Page  18 18 of 20 hours per week from its initial uses in the early 1950's instructional or educational television has carried with it the realization that simple transmission of a grey picture of a grey haired scholar in a grey suit dispensing grey ideas is a gross misuse of an extremely valuable medium of communication and education in spite of the fact that much progress has been made over the last two decades in the utilization of television the principal aim of the 1970's is the same as it was in the early 1950's the development of messages that are really worth televising teacher performance however is still lacking although there is a seemingly infinite number of specific applications for educational television there are three basic methods of use first it can be used as a substitute for live presentations in a large auditorium second to broadcast such processes as clinical or laboratory demonstrations so that large numbers of students may view a single visual production and

Page  19 19 thirdly to provide instruction via microwave to receivers in locations where it is not feasible to staff a given course or where the specific contribution of some noted but distant lecturer is desired some of the most interesting uses of television are those that allow the student to see events that would otherwise be inaccessible or unobservable or where the presence of observers would introduce distracting or contaminating elements into the event under study there are many examples of television technology that could be cited one on which the national library of medicine will be expending its efforts in the 1970's is that of interactive television involving two way audio and video transmission the next slide no 7 shows the simple equipment that can be used for interactive tv the camera is at the right rear of the desk and is projecting to the remote participant the image and conversation of the physician at the desk the tv monitor is in turn showing the image of the remote participant and transmitting his conversation

Page  20 20 a specific illustration of such an existing application with a dual purpose of education and health care is that of psychiatric treatment here there is a two way link up between a hospital which has limited psychiatric facilities and a medical srhool or psychiatric clinic psychiatrists in the medical school or clinic are able to remotely view the patient and the attending physician or student in the hospital on a split screen the attending physician or student can view his patient and the psychiatrist the patient sees only the psychiatrist in the several locations where such links now exist they appear to be in heavy use such specialist services provided remotely will be particularly important for patient therapy involving real time medical education in the seventies an audio acress information service audio services are showing themselves to be useful to both medical education and health care needs the national library

Page  21 21 of medicine is advocating their use because their cost is much less than that of television recently a medical education jukebox developed at albany medical school was installed for demonstration purposes at the national library of medicine it is pictured in the next slide slide no 8 operating just like a jukebox the listener selects one of the available audio messages by title then using earphones he listens to it and views selected slides which may accompany the education message this device is designed for use in the community hospital where physicians congregate for practice and for meetings presently rapidly advancing scientific knowledge and increasing burdens of health care place a number of obstacles before both the medical student who must learn new facts and the busy medical practitioner in his efforts to apply new information in the delivery of good health care frequently he is faced with a problem and has to make a decision when he does not have access to his usual sources of information or he may have concern that his own reference material is outdated a second obstacle is the shortage of time available for his continued education in any form

Page  22 22 in recognition of these limitations a pilot project was initiated at the university of wisconsin in 1966 to provide prompt convenient access to authoritative medical information by telephone initially tape recordings of four seven minutes duration presenting core information on a variety of medical subjects were made the tapes were placed in self rewinding cartridges which could be played in an inexpensive tape recorder coupled to a telephone line a brochure was distributed to physicians in the state and a user had only to dial the number indicated ask for a tape by subject and it would be played for him the service proved sufficiently popular that it has been expanded to almost 300 tapes a postcard suvery of physicians utilizing the wisconsin service between october 1 1968 and june 30 1969 provided that such a service has value in both immediate health care delivery and postgraduate medical education and may have changed the practicing behavior in nearly one third of the physicians who used it

Page  23 23 on the basis of such studies of audio access information services a concept for a national service has been developed using a special dial access system of the at&t which allows calls to the audio access center from anywhere in the nation this new service has begun satellite communications communications satellites are essentially an extension of line of sight microwave transmission on the ground the normal distance between microwave repeaters is between 30 and 50 miles depending on the terrain a sateliite used as a microwave repeater can be seen simultaneously from the east coast and the west coast of the united states or it can be seen simultaneously from different continents at synchronous altitude the satellite can be simultaneously seen by stations on 42 percent of the earth's surface this means that the cost for transmission between two points that can simultaneously see the satellite is essentially independent of distance this is

Page  24 24 in contrast to normal telephone or tv where the cost for transmission between two lorations inrreases with the distance between them the reliability of satellite communications has improved considerably over the years it is now competitive with if not 8 better than terrestrial microwave systems within the present state-of-the-art one can confidently design satellites with an expected lifetime of at least five years this is achieved through a high degree of redundancy rigorous test programs and conservative design elements of the medira community were early proponents of the use of satellites to handle certain kinds of biomedical communications the university of wisconsin has obtained an fcc license to broadcast on nasa's ats-i satellite wisconsin is currently conducting preliminary test transmissions with stanford university stanford university has been keenly interested in satellite communi cations for some time and is now in the process of initiating

Page  25 25 comprehensive biomedical communications experiments using ats and small inexpensive transmitter receiver terminals stanford is currently working with the university of hawaii college of health sciences to develop a capability to extend medical consultation services to selected pacific islands e g guam samoa marianas on an experimental basis using ats facilities of nasa the program calls for the installation of small inexpensive terminals on each of the selected islands where the local physician or health aide will use the terminal to obtain consultative services from the university of hawaii college of health sciences alaska has no formal telephone system until recently all communications in this state were developed and managed by the military alaskan medical authorities have indicated that satellite communications could serve four principal health care needs provide 24 hour telephone service throughout alaska so that emergencies could be answered illnesses diagnosed or trans portation arranged provide health education for the public

Page  26 26 provide continuing education for health personnel and provide for the utilization of a health care data bank the lister hill center in anticipation of assisting in the alaska project and in preparation for satellite communications experiments as a part of the biomedical communications network has arranged with nasa's goddard space flight center for the use of an ats vhf transportable satellite receive transmit terminal and antenna the terminal and antenna are now ready for operation and are mounted on the roof of the clinical center of the national institutes of health slide no the antenna is about the size of a rooftop tv antenna and cost only 78 00 the transceiver used costs around 700 with this small investment group conversations were initiated in april between the lister hill center the university of wisconsin stanford university the university of washington at seattle and the university of alaska at fairbanks alaska

Page  27 27 even though satellite communications for medical applications are only in the embryonic stage it is already abundantly clear that there are at least two basic guidelines that overshadow all other considerations the first guideline is that without planning and some degree of coordination there will foe a proliferation of disparate projects and efforts which collectively or individually will fail to product the experience and data needed for crucial decisions regarding the proper use of satellite communications the second guideline is that a demonstration or pilot project is required to collect the cost data for decision making and the detailed design of effective communications within the medical community concluding comments in summary we can perhaps make one solid prediction the future of communications holds great promise for service to medicine in the seventies because it involves the extension of man s senses its

Page  28 28 applications will affect in one way or another the life of earn of us the printing press the telegraph the telephone the radio and recently television have changed man s way of life in great leaps h g wells pointed out that civilization is a race between education and catastrophe today we are attempting to systematically plan for the application of the new communications technology to help win the race for education time alone wiil tell whether or not this approach is successful in any case as we prepare for these applications in the medical community we should bear in mind that we may be affecting the behavior of men of the future since we are not certain whether the changes will be timely or desirable it behooves us to tread gently