Modern Biomedical Communications, 1978
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modern biomedical communications i wish to thank you—the members of the academy of medicine for electing me to honorary membership i am grateful not only for myself but also for the institution i represent the united states national library of medicine your action demonstrates the truly international nature of medical science your president professor amador neghme is a valued friend of long standing under his guidance the pan american health organization's regional library of medicine in brazil bireme has developed into a modern and effective information center providing a high level of service in south america when dr neghme turned over the directorship of bireme to his successor dr. abraam sonis that library was providing about 45000 services each year to health professionals throughout the continent the staff of bireme has been training hundreds of health sciences librarians from many countries in south america and the regional library of medicine now also provides computerized information services from our medlars data base the amount of new knowledge being generated by medical research is staggering if this information is to result in presented at the academy of medicine of chile santiago chile may 18 1978 by martin m cummings m d director national library of medicine

Page  2 2 improved medical care it must be shared promptly with the worldwide community of health professionals and scientists this responsibility has given a great impetus to the field of biomedical communications and to the development of modern information centers the problem faced by health professionals in trying to keep abreast of published new developments has historical roots the english physician john mayow in 1668 wrote disease as it stalks through the land cannot keep pace with the incurable vice of scribbling about it 1 on the other hand the story is told 2 that when boerhaave the most accomplished and celebrated physician of the 18th century died he left behind him an elegant volume the title page of which declared that it contained all the secrets of medicine on opening the volume every page except one was blank on that page was written keep the head cool the feet warm and the bowels open somewhere between these extremes lies the difficult path of today's medical information systems the modern biomedical information center serves three primary audiences scientists and scholars doing research health practitioners seeking to heal patients and students trying to learn for all three groups books and journals are still a main source of knowledge but increasingly we are applying modern technology to facilitate the dissemination of medical

Page  3 3 information computers are playing a most important role in this process the medical literature analysis and retrieval system medlars developed by the u s national library of medicine is one example of such an application medlars is used to produce printed bibliographies such as index medicus and in its online version called medline it can be used to prepare rapidly a list of references and abstracts on any specific biomedical subject the entire computerized data base now contains about three million references from the health-science journal literature the medlars data base is widely used in the united states almost one million searches were done last year for health professionals it is also available in many other places around the world including bireme as i mentioned earlier rapid and comprehensive searches of the biomedical journal literature are of inestimable value to the medical researcher who must be aware both of previous studies related to his own work and the curnent investigations of his peers an article published by a colleague half-way around the world may contain a clue he can apply to his own studies a problem that has puzzled him may have already been solved by another researcher and of course he wishes to avoid unwittingly rediscovering territory already thoroughly explored

Page  4 4 in contrast to the needs of the researcher the information requirements of the health practitioner may frequently be satisfied by providing two or three pertinent recent articles from available journals the practicing health professional is likely to want a rapid review of the literature to help him with a particular problem although the practitioner is less likely than the researcher to require a comprehensive search of the literature he does place a greater premium on quick retrieval and delivery of documents whereas the scientist or scholar tolerates delay in receiving documents the practitioner with a patient to care for wants his information at once and the modern information center must be prepared to serve these requirements expeditiously over the last decade the use of computers for rapid search and retrieval of bibliographic references has been of great benefit to medical research and practice today there are a number of exciting projects that go a step beyond bibliographic retrieval these projects apply computerized techniques to the three basic components of medical practice diagnosis prognosis and therapy the goal of these various systems is to maximize the likelihood of correct decisions about diagnosis prognosis and therapy the decision of a physician in any one of these areas depends on the amount of information he has and his

Page  5 5 ability to apply this information to a particular case no human being can assimilate all available medical knowledge even a team of physicians cannot draw on the total amount of relevant information and knowledge in treating a patient computers however with their virtually infallible memories and their ability to handle and correlate massive amounts of information may be used to expand tremendously the physician's information and knowledge resources in one project at duke university in north carolina a medical information system has been developed for coronary artery disease that provides descriptions of outcomes of patients with various sets of attributes 3 the attributes ekg findings other laboratory findings physical findings history outcomes etc of a large number of patients are entered and stored in a computer the computer classifies these data and assigns them to subgroups when the characteristics of a new patient are entered the computer selects the most closely matched subgroup and displays the courses and outcomes of all patients previously categorized in this subgroup the computer's memory is wholly accurate unbiased by recent or dramatic events and is enhanced by the greater number of entries derived from the entire institution's rather than one physician's experience therefore the physician's management decisions can be based on far more accurate and relevant information than could be possible without the computer

Page  6 6 the coronary artery disease information system i have just briefly described is an attempt to assist in the management of a specific patient using computerized data relevant to that patient another approach one with which we at the national library of medicine are now experimenting is to develop a computerized method for making readily available the current state of medical knowledge about a particular disease or medical condition to do this we have selected viral hepatitis as a model and constructed a comprehensive bank of computerized information on the subject knowledge pertaining to aspects of viral hepatitis important to the practitioner has been synthesized using the information contained in several outstanding review articles published by hepatitis experts relevant information has been selected placed in a highly organized hierarchical arrangement to permit convenient access and encoded into a mini-computer using online search and retrieval techniques the practitioner will be able to receive a rapid authoritative answer to any question he m y have about an aspect of viral hepatitis the system will also provide on request data supporting the answer as well as citations to primary publications for more detailed study the contents of the hepatitis data base are presently being validated and brought up to date by a group of eleven

Page  7 7 hepatologists these geographically dispersed experts are linked with each other and with the staff of our library by a computer conferencing network once this initial updating is complete the data base will be available on an experimental basis to practitioners useful as it is the computer is only one tool of modern biomedical communications since 1971 we have conducted a series of experiments to demonstrate the potential of communications satellites in improving health care delivery several of the experiments were carried out in alaska a state that like your nation is very mountainous except in alaska's few cities there is no telephone communication shortwave radio communication is very unreliable because of the mountains and also because of atmospheric phenomena peculiar to the northern latitudes the first experiment involved daily two-way communication between community health aides in 26 geographically isolated alaskan communities and a centrally located indian health service physician community health aides are villagers who have 12 weeks of formal training in health care each of the health aides had a satellite radio at home or in the local schoolhouse every day a doctor at the central facility would call each health aide in turn a health aide might ask the doctor for specific instructions after describing a patient's signs and symptoms or might simply verify the health aide's own diagnosis and treatment in a serious case

Page  8 8 the satellite radio was used to arrange for an airplane to evacuate the patient or to bring physicians to the community other uses of the satellite communications that were demonstrated include having hospitalized patients talk to their families in the villages training remotely located students health aides and nurses online computer access to medical data files doctor-to-doctor consultation and ekg and facsimile transmission the second phase of the alaska experiment involved a newer satellite that supplemented the voice channels with two-way color video transmission two remote villages were selected with populations of 400 and 700 using the satellite the health workers in these villages were able to present patients for visual examination by the distant physicians and specialists both phases of the experiment were judged to be highly successful and there were a number of instances when the capability of communicating by satellite made the difference between life and death our most recent experiments with satellite communication involve the powerful new communications technology satellite cts we are currently engaged in a wide variety of inter active television demonstrations that make use of the coast-to coast coverage of the cts one of the most important of these is a series of conferences sponsored by the national institutes

Page  9 9 of health these teleconferences bring specialists located in various parts of the united states into immediate voice and video communication with government researchers at the national institutes of health who discuss their latest findings and how these findings may be applied in medical practice computers and satellites may be the wave of the future but even ordinary communication modalities such as the telephone may be used in innovative ways to improve access to health information for example a system known as mist has been developed by the university of alabama medical center mist stands for medical information service via telephone using mist a physician in alabama any hour of the day may call a specialist on the faculty of the medical center to discuss a problem relating to one of his patients telephone operators at the medical center are specially trained to handle such calls rapidly and to refer the caller to the appropriate faculty expert there is no telephone or other charge to the requesting physician even if he is calling long-distance during the years of its existence there has been a tremendous growth in the use of mist until today it is being used by almost 90 percent of the physicians in private practice in alabama 4 a recent analysis of the cost benefits reveals that

Page  10 10 37000 in travel expenses was saved in s saved in one month s saved in s saved in one month by providing information to primary care physicians and thus reducing the number of patients moved to the university hospital 5 i have placed great emphasis today on the role of modern communications technology in health care delivery and biomedical research it is my firm belief however that the primary vehicle for knowledge transfer in the health sciences will continue to be the published literature this is still the denominator common to health professionals in all nations almost 100 years ago the national library of medicine's first director dr. john shaw billings who attached great importance to the international aspects of medicine said when i say our medical literature it is not with reference to that of any particular country or nation but to that which is the common property of the educated physicians of the world—the literature which forms the intra and international bond of the medical profession of all civilized countries we do not now meet for the first time as strangers but as friends having common interests and whose thoughts are perhaps better known to each other than to some of our nearest neighbors 6

Page  11 11 dr billings' eloquent words were addressed to an international congress of physicians i can do no better than to close by quoting them to my chilean colleagues for his words perfectly express my feelings on this occasion

Page  12 references 1 mayow john on rickets 1668 2 a century of american medicine 1776-1876 by edward h clarke and others philadelphia henry c lea 1876 3 rosati r a wallace a g stead e a the way of the future archives of internal medicine v 131 1973 pp 285-287 4 doermann a et al selected approaches to enhansing the retention of primary care physicians in rural practice mclean virginia the mitre corp mtr-7069 october 1975 p 31 5 dollar m b and klapper m s the economic benefit of mist a preliminary analysis alabama journal of medical science v 14 n 1 1977 pp 103-107 6 billings john shaw delivered in london august 5 1881 before the international medical congress transactions of ihe international medical congress v 1 pp 54-70