When Medtronic founder Earl Bakken saw the 1931 film Frankenstein, a fascination was born that grew into a conviction that technology could be harnessed to improve life. And so it has. But information technologies dominate some of the newest breakthroughs in healthcare--have you heard of network computers, extranets, thin clients, patient informatics, peopleware, Webtops, or zero administration? If not, you will. Meantime, what do they mean to you? For the most part they promise a return to a simpler, cheaper, easier to run, less scary model for systems development. And also, a returned focus on everyone’s ultimate goal--improving patient care.
The truth about emerging technologies? As our story suggests, it’s as obvious as the scars on Frankenstein’s face: Keep it simple.
--Terry Monahan
Voice, broadcast quality video, 3-D graphics, color photographs and images, animation… it’s not MTV, but it may be the emerging model for the computer-based patient record. The University of Pittsburgh’s Center for Biomedical Informatics’ distributed clinical multimedia environment, called the "Image Engine," is riding the next wave of CPR development (see http://www.cml.upmc.edu). Fueled by National Library of Medicine research grants totaling $2.5 million since 1994, Pittsburgh has integrated clinical text and images--including X-rays, CT scans, EKGs and microscopic pathology--into a single user interface where physicians can point and click from a selection of thumbnail images for micro or macro views, or call up reports on a patient, all from the same screen. Future plans include incorporating digital audio capture and playback. "We want to give clinicians an easy-to-use integrated environment," says Henry Lowe, MD, director of the University’s Clinical Multimedia Lab and principal investigator on the project.
Through the use of internally-developed software agents that aid access to data and images from a number of external and legacy HIS systems, an object-oriented database, low-cost image servers and two sophisticated client applications--one on the Power Macintosh and the other Web-based--the Image Engine compiles information from the enterprise, or off of the public Internet through such services as MEDLINE. A prototype client application for accessing multimedia clinical information over the Internet, WebReport, is also being tested. Image Engine has already generated a great deal of outside interest and will soon be installed in the University’s Cancer Institute. "Everyone who sees it wants to know how they can do it," Lowe notes.
A Simpler World in Store?
When we talk about "emerging technologies," a picture comes to mind of a white-coated technician--even Dr. Frankenstein himself--toiling away for hours, days and years on end, tweaking complex mathematical equations in stuffy supercomputer labs.
Yet emerging tech in healthcare is often as simple as generating widespread clinician use of e-mail--a technology that has been around since the 1970s. And all the fanciful talk of the mind-boggling realm of the World Wide Web is based on the simplest communications standards and protocols known to the computing world to date--technologies that also have been in place for many years. Even the desktop PC--with all its bells and whistles, CD-ROM and floppy drives, modems, sound and video cards--is being whittled back down to a new ’90s version of the dumb terminal, called the "Network Computer." Gone are the days of ponderous, proprietary and costly mainframe environments; hello microworld, ubiquitous GUI WWW interfaces, and anywhere, anytime, anyhow capabilities at rock-bottom prices. Media-hyped myth? The reality, at least for healthcare, lies somewhere in between.
Object Oriented Takes Hold
Object-oriented development, graphical user interfaces, Java, hypertext links, Web-ready applications--these are becoming near requirements for new software products: They promise ease of development, use and maintenance. Object-oriented methodologies are nothing new, but the concept has taken off over the last two years and several categories of the technology exist today. "Object orientation holds real promise to help with the integration problems in healthcare," says Dave Garets of First Consulting, Filer, Idaho, who entered healthcare in 1990 after 13 years with AT&T.
As Garets explains, object brokers or "wrappers" surround legacy applications to make them accessible by newer applications, allowing the integration of legacy technologies into new systems. Object technology is helping to solve the ongoing problem that arises as hardware advancements outpace software technology. "Some of the Java and object tools are allowing software to catch up with hardware," he says.
At the forefront of the object-oriented movement is Sun Microsystems and its heavily-promoted Java development environment. The widespread acceptance of Java, an 18-month old technology, is astounding yet makes perfect sense to many in the software development world; Sun estimates that 450 independent software vendors are developing with Java. According to the "write once run anywhere" mantra, Java applications can run on any computer platform--from Microsoft Windows to UNIX to Macintosh and even to a 3270 terminal. Its cross-industry success has begun to trickle down into the ranks of IT firms targeting healthcare, such as Software Technologies Corporation, HSII, SMS, Alltel, Compucare, Oacis, Lawson, Siemens and Philips--all of which are using Java in application development projects.
PC vs. NC?
The trade press is jumping all over the "Network Computer" (or NC) concept like fleas on a long-haired mutt. Sun is calling it the "fourth big wave in information technology" after the mainframe, mini and PC environments.
The idea behind the NC is to slash PC maintenance costs and speed application development and deployment with a lightweight, scaled down desktop computer that transfers all data administration functions to central network servers--leaving users with little more than a color monitor, a network connection and enough memory to access applications and data from the network as needed. All applications, programs and files reside on the server; the machine has no hard or floppy drives. Launched initially by both Oracle and Sun--Sun’s product JavaStation was unveiled last fall--NC is now being adopted as a strategy by IBM, which recently announced it will run the Java Operating System on its NC. Intel, and yes, even the PC’s biggest long-time rival, Microsoft, are also on board, with Microsoft making plans for a "Zero Administration PC Initiative."
Microsoft’s Worldwide Healthcare Industry Manager John Carpenter explains it as a Windows version of the NC that will minimize overhead administration tasks through capabilities such as automatic configuration and installation, while maintaining the PC/Windows desktop architecture. "While we understand the need to reduce the total cost of ownership for these workstations, we do not feel the best way is to throw out everything you have invested in to introduce a new architecture." While NC backers praise the technology for its potential to drastically decrease hardware, software and maintenance costs, Carpenter demurs: "There really won’t be a big cost difference between the Network Computer and the PC."
It’s not clear that the NC will eventually succeed the PC--even Sun is cautious here. "Replacing legacy terminals is a good fit, but as a word processor it doesn’t make sense," says John Ryan, Sun’s healthcare industry manager. Aside from being a low-cost alternative to replacing dumb terminals (JavaStations start at $742 with 8MB of main memory), they may also be suitable for clinicians who don’t need heavy-duty word processing capabilities but do need to access enterprisewide applications. But will users be willing to abandon their nifty gizmo-packed machines for a plain, pared-down box that is entirely dependent on the network? They may have little choice. As Ryan notes, "The biggest challenge of healthcare is the proprietary nature of the application environment. That’s why we’re so excited about Java and Internet technologies."
As information demands in healthcare increase through easier access to data sources around the world, networking technologies will have to keep pace. The top two considerations of network infrastructure, according to Bob Gaughan, manager of advanced technology for Bay Networks, Billerica, Mass., are scalable bandwidth and quality of service. "The challenge is to address the need for incremental bandwidth to support new applications--like imaging and voice--but also to support legacy LANs." While the typical network today incorporates Ethernet and Internet Protocol, or I/P, technologies, Asynchronous Transfer Mode, or ATM, can handle bigger packets of data at greater speeds--although for a noticeably higher cost.
An even newer technology still being tested is Asymmetric Digital Subscriber Loop, known as ADSL or DSL. ADSL is the fastest modem technology yet for remote access, allowing anywhere from 1.5-to-8MB/sec transmission over existing phone lines, across distances of up to 18,000 feet from the local telecommunications provider. Much faster than a current ISDN line at 128 Kb/sec., ADSL would allow physicians at home to access full motion video, voice and data as if they were sitting right in the hospital. "Accessing an X-ray could take just a few seconds, not minutes or hours," Gaughan observes.
Before healthcare organizations can take advantage of these newer technologies, however, they must get the basic local area network or LAN in place. As Terry Wilk, VP and CIO of Cleveland’s growing Fairview Health System points out: "If you don’t have the fundamental network in place, you’re in trouble." Long term, Fairview is looking at optical storage, CPR and voice recognition technologies. Yet for now, the bulk of investment will go toward upgrading the network infrastructure.
While frustrations abound at the slow rate of implementation in healthcare, there are advantages to being behind the technology curve. The rapid pace of technological advancement may allow healthcare to bypass costly architectures such as ATM until new developments appear. "I probably will not invest in ATM, but in the next generation," Wilk says.
Internet, Intranet, Extranet…
Who would have thought that a $99 navigation tool developed by a Mountain View, Calif., start-up and given out for free on the Internet would have led the computing industry to its current state of Web hyperactivity? Web browsers from the aforementioned Netscape, Mosaic (the browser’s inventor) and Microsoft are ferociously competing to become the standard for not only Net surfing but company-wide surfing--as evidenced by last year’s embrace of the "intranet," the internal LAN architecture based on Internet and Web technologies. Intranets are now being developed to encompass an organization’s customers and business partners--wherever they may be and on whatever platforms they choose. Intranets that run over the public Internet and employ encryption technology are in some circles being called "extranets."
Healthcare could benefit enormously from learning the mistakes others have made with client/server implementations by migrating directly to an intranet environment, according to Garets. "With an intranet, healthcare can go to the ’thin client’ architecture where most of the application control is at a central server."
This is not to say that intranets can replace your current infrastructure entirely. "Because you pursue a Web-based architecture doesn’t mean you don’t have an enterprisewide architecture behind it," says Jim Kazmer, senior consultant with Hewlett Packard who helped the University of Virginia’s Neurological Institute develop a Web-based electronic medical record system that incorporates Web browsers, Web servers, Java and HTML (hypertext markup language), and integrates 11 clinical systems. The middle road, he says, is to combine a Web user interface with an enterprise data repository where analysis and outcomes studies can take place. "Web technologies are trivial," he said. "The real power is that this de facto standard has become the standard. This has happened because of its simplicity."
Even so, the ease of navigation, access and integration achieved with Internet technologies brings with it a new set of challenges. Moving from traditional LANs to intranets where traffic flows are more unpredictable could cause headaches for network managers, warns Bay Network’s Gaughan. "The implication within a business as you implement World Wide Web browsers on client PCs or Macs is that you will be traversing the network rapidly and chaotically." A further complication is the addition of voice and video now running over networks. "Bandwidth can solve a lot of problems, but you still will have some problems with delay."
Many in the healthcare trenches remain skeptical--and rightly so--of the Internet/Web and its many unresolved issues including security, bandwidth and reliability. "The World Wide Web is really the World Wide Weight," quipped Marion J. Ball, professor at the University of Maryland’s School of Medicine and vice president, First Consulting Group, Baltimore. Before it really works, says Ball, "We have to build a whole new infrastructure." Ball’s vision of the future--perhaps 10 or more years away--is one in which cities are reconstructed around a melding of all the major technologies: telecommunications, cable and computers. Despite her wary observations on the state of technology today, the potential Ball sees from the evolving information highway is grand. "There is a whole empowerment going on which is mind-boggling."
Security: The Great Internet Enabler
Healtheon Corp., Netscape Chairman Jim Clark’s latest project and one of the biggest healthcare Internet stories of 1996, is attempting to capitalize on the more risky field of transaction processing over the Internet with its core of Inter/intranet products and services targeting health plan benefits administration. The Palo Alto, Calif., company has already captured the business of insurance powerhouses Blue Shield of Massachusetts, Blue Shield of California, and most recently, the Rocky Mountain Health Care Corporation--a potential market of 4.5 million plan members. Using Healtheon’s service, members can enroll in health plans, choose a primary care physician, communicate with health plans and physicians through e-mail and receive other online health information.
The key to the success of Healtheon and other like Internet ventures lies in the implementation of sophisticated security technology capable of protecting sensitive patient information. Healtheon is using RSA encryption technology with the Secure Socket Layer, or SSL, protocol, with 128-bit length keys. Translation: It’s a military-level security system, says Pavan Nigam, Healtheon’s vice president of engineering. The technology to support and protect healthcare’s large volumes of data over the Internet is already here, Nigam says. The problem is finding people who know how to use it.
Other emerging security technologies are in the area of "biometrics," which uses signature verification or finger image technology to identify users. A newly-formed company developing Internet applications for healthcare, Health+Cast, Philadelphia, is experimenting with an artificial intelligence-based encryption algorithm that constantly mutates, becoming a moving target for potential hackers, according to Mark Hays, senior VP of product development and CTO. "Security technology is the top thing to watch right now. It is becoming a purchasing decision."
Big News on Small Stuff
Apple Computer recently came out with its latest portable platform, the MessagePad 2000, which the company claims is the first in a new generation of hand-held mobile Internet computers. Running on the Newton O/S, the MessagePad 2000 boasts e-mail, a Web browser, word processing, networking capabilities to Windows and Macintosh desktops and a built-in recording system that allows for one hour of voice notes. Weighing in at 1.4 pounds and about the size of a small notepad, MessagePad 2000 is riding with the trend of small and smaller computing.
Other major IT players are entering the PDA marketplace to compete with Apple. Microsoft’s brand new operating system for pocket-size computers, Windows CE, hit the market at the annual Comdex show last November. Considerably cheaper than the Apple product, a sticker starting at $500 will get you the hardware device, Windows CE, the Internet Explorer browser, e-mail and Microsoft Word. The device is also equipped for a modem and PC card. It weighs one pound and is "the size of a checkbook but thicker," according to Carpenter. He predicts an even smaller future for PDAs--the "wallet PC." "That’s an area we think will take off." Microsoft is working with a slew of hardware manufacturers, including Compaq, HP, Casio, NEC and Hitachi. Carpenter foresees a lot of initial interest in the inpatient physician market, over time moving to outpatient facilities.
A more futuristic vision for PDAs is "channel architecture," according to Tom Munnecke, assistant vice president of Science Applications International Corp., or SAIC, San Diego. This technology would allow PDAs to "tune" into a certain channel prescribed by the user’s "subscription profile." In other words, physicians could control what information will be available to them on the PDA, and when. This "publish/subscribe" concept, as Munnecke explains it, is already being deployed by Marimba, PointCast and others to bring information from the Internet out to users--essentially doing the work for them.
Reality Bytes
Other areas that promise to revolutionize the healthcare industry--on our list of "cool stuff to watch"--include voice and telecommunications technologies, imaging and artificial intelligence-driven systems. Voice recognition systems, in particular, made a splash in late 1996 with key product announcements from IBM, Kurzweil AI, Philips Speech Processing and others. "Voice recognition is really coming to the point that we can use it effectively," says Health+Cast’s Hays. "This will have a big impact."
In the midst of all these exciting developments, a critical factor is sometimes overlooked: technology is just a tool. Real change happens through people, education and changing corporate processes.
"Everyone is interested in all the wonderful new applications, but people need to understand that the new stuff is an interim solution," says Barbara Hoehn, vice president, First Consulting, New York. "The purpose is not to deliver the greatest whiz-bang technology but to improve clinical processes."
Of course, there are plenty who are quick to criticize the healthcare industry of mere technological infatuation with no concrete action. "I’m a little bit of a cynic in the healthcare field," Munnecke admits. "Healthcare as a whole hasn’t done a real good job of looking ahead."
Those who are trying desperately to keep users and senior management happy, like Fairview’s Wilk, are not paranoid about keeping up with the Joneses in the IT race. "My role as a CIO is not to go out and implement the biggest, greatest, leading edge…" His main concern, he says, is supporting the direction of the business. "Somewhere there’s gotta be a balance and reality check. When I feel my organization is ready we’ll go forward."
Making strategic decisions with the latest technologies is a careful game of timing: knowing when to move and when to stay put. Those who are too cautious may wind up losers. With the right tools, says Garets, organizations can save money, simplify workflow and speed up development time. "Healthcare is playing catch up right now and a lot of these new technologies are allowing them to catch up quicker. The smart ones will take advantage of them."
Frankenfacts
The telling and retelling of the horrific and fantastical Frankenstein legend since Mary Shelley’s 1818 novel is the stuff of pure fiction. Yet one of the most celebrated scientists in the medical field, Earl Bakken, was inspired as a kid by the 1931 film Frankenstein, developing a deep-seated fascination with the relationship between electricity and life.
The famous Minnesotan went on to develop the first battery-operated "wearable" cardiac pacemaker in 1957 at Medtronic, Inc., the $2.2 billion developer and manufacturer of implantable and invasive medical devices Bakken co-founded in 1949.
A similar tension between fascination and application--knowing when a new technology is mere hype, and when it truly has profound practical implications--is one that occurs often in the information technology world. In the 1935 follow-up film, The Bride of Frankenstein, a heart was kept beating in a jar by an early version of the pacemaker. One theory has circulated that scientists were originally turned off by the pacemaker concept because of the Frankenstein movies.
Getting over the implicit "Frankenstein fear" of creating a technological monster that gobbles up precious investments, time and resources with disastrous results is one that can only be healed by time, example and perhaps, a little faith. Inventions that seem outlandish at first often lead to breakthroughs that take us into the next century…
In 1975, Bakken established The Bakken Library and Museum in Minneapolis, which documents the 2,000-year history of biomedical engineering. Currently on exhibit at the museum is "It’s Alive! The Science and Myth of Frankenstein"--a collection of scientific contraptions and textbooks from Shelley’s era, film posters and other Frank treasures.
Polly Schneider is News Editor at Healthcare Informatics.
