[MUSIC] Hi, I'm Nicholas Genes. >> And I'm Matthew Grob. >> And we'll be talking today about the historical development of health IT, health information technology. I read a terrific book last year called The Information by James Gleick, and it really takes a historical perspective on informatics going way back to before the telegram era. And really just what a revolution it was to decouple words from either books or from being in the presence of other people. And it really opened a lot of people's minds about how information can be transmitted. And it made things like weather forecasting and a lot of other technologies that we take for granted today, it really started to become commonplace. But the book was interesting, permit me a little digression for a moment. [LAUGH] There were just these fantastic anecdotes of how difficult it was for people to really wrap their heads around the new realities of life, telegrams. And there are reports of mothers were going to telegram offices because they have been told that they could send messages to the frontline. And so they were coming with gift baskets and baked goods because they thought that, what else would a message be if not an actual bounty? >> Physical manifestation of the message. >> Yes, yes, because why would you just send words? And what would those words possibly convey? It was just a very different time, and a different way of thinking about messages. But modern informatics really began in World War II with Claude Shannon. He was really the first person to kind of promote the idea that all information, messages, words, even complex logic could be represented with numbers, with 1's and 0's. And he also advanced the notion of separating or including messages within noise and separating the signal from the noise. And really laid the basis for modern cryptography, just a pioneer in the field. From Claude Shannon, it was a quick movement from war and cryptography towards more benign, benevolent interpretations of informatics, including health informatics. >> And I thought you were going to make the link between cryptography and physicians' handwriting. >> Very clever, yes. No, but still a lot of physicians had not had their signatures and their words decoded yet. But I hope IT is working on it. But really, we talk about health informatics now, but for decades the terminology was not yet really solidified. And you hear about information science, but that really is about libraries and managing magazines, and journals, and repositories of information. We talk about information theory, but that does go back to cryptography and entropy of the information and so forth. And what we now call healthcare informatics, Ted Shortliffe, who's a giant in the field and wrote the textbook on healthcare informatics, the first edition of his book was just called Computers in IT, or Computers in Healthcare, I think it was called. But anyway, it's a field that's gone through a lot of different phases, and it hasn't set a lot of terminology until really just recently. >> But I think you hit on something that's very important and- >> That's fortunate. >> The whole concept of that it's computers in healthcare, and that's the distinction between computers as a technology, the actual physical manifestation of technology, and the actual science of information and how we use information. Because that has evolved right along with the industry of health IT. >> Well said. All right, let's go decade by decade, starting with the 1960s and the early stirrings of health information technology and MUMPS. MUMPS is kind of a funny name. >> It is, and it was a computer language developed at the Massachusetts General Hospital. Therefore, I think the development of the acronym, it stood for Massachusetts General Hospital Utility Multi-Programming System. So MUMPS coming from healthcare, they were being cute, and it stuck. >> Yeah. >> Because MUMPS became a language that so many of the early system were written in and eventually evolved into the operating system, the programming language that one of today's most popular electronic health record systems still utilizes. >> That's right, and that popular system is Epic, which is being used at Mount Sinai. But also MUMPS and Cache is the underpinning of what's used in Vista, the VA systems, so all the veterans that are getting cared of. And so really many millions of Americans. >> And one of the fellows who helped develop MUMPS went on to found, be one of the founders of the company called Meditech, which is a hospital information system suite of applications for use primarily in smaller hospitals that's still used today. >> Yeah, now MUMPS was ahead of its time in many ways. It was a system where multiple users across a big hospital system could log in and view the same patient information at the same time. Back then, that was kind of revolutionary. You would get locked out from most other systems if someone else was actually using it. So that was hopeful in computer era. And it was a hierarchical database, which was the first way that people really thought about organizing information. If you wanted to get a patient's lab values back from a few weeks ago, you would find that patient's record and then search back in time. Hierarchical databases are kind of intuitive, but they gave way in the 80s to relational databases, which are much faster and support more robust queries. However, we're still stuck with this hierarchical database. The continuing trend, as we look back in the history of health IT, is pioneering initiatives that kind of led the way and then stayed there as the rest of those other industries shot ahead. But yeah, MUMPS was ahead of its time, and in some ways we're still stuck with it. Let's talk a little bit about the 1970s. >> Yeah. >> An era that is very dear to us. I show this slide of the Incredible Hulk, and it's from the theme at the beginning. because it made an impression on me as a young person in that era. But I always just thought the best technology was at hospitals because that's where the Incredible Hulk went to get gamma-irradiated to become the Hulk and stuff. And I think today the things have changed, and consumer tech is kind of seen as the vanguard of what's possible with technology. >> And I'm lucky enough to have worked at one of the hospitals that implemented one of those early systems that was developed during the 70s. I wasn't in developing, I was implementing it in the 70s. I was really young. I, too, was also always amazed at the technology, not just information technology, but technology in general that hospitals were able to provide for its patients. But it was what Was known by many years, by many names over the years initially Technicon was probably one known by it's best or TDS or Technicon Data Systems. >> Yeah, I know TDS. >> And >> I don't know if that's what we want to talk about. >> Sure, sure. Did you have a lot of friction as you were trying to implement these. >> So let me take a step back, and say that I think the part that we kind of left out, as we moved into the 70s, was that within hospitals, and it's very interesting because We're saying hospitals. And today, we talk about health systems and we talk about ambulatory care as well as in-patient care. But at the time, in the 60s and the 70s and into the 80s is where we really started see the change. Everything was very much focused on the in-patient world. So within hospitals, what we saw first was the automation of using Information technology of financial functions, because that was the types of functions that were automated in other industries. Typically manufacturing and finance. Not a lot of manufacturing in healthcare, so finance was automated, followed by laboratory information. Motion systems for use in clinical laboratories, that's were came in that was the first application of in the hospital setting. And then went off into the realm of order entry and results reporting for physicians and other providers as well as nursing documentation. >> And so it really kind of creeped up on people and maybe the financial aspect were kind of behind the scenes disrupt work or anything like that. >> Yes the finance stuff was pretty cut and dried. You're automating a business process. And here, these systems, systems like Technicon, were trying to automate something that's part science and part art. You know that first hand as a physician. And it's not easy to automate that, yet they did a really good job of it at the time There were challenges with it. It was very, very expensive so only the largest health systems or hospitals at the time could afford it. The technology in that time the 70s and the 80s was not standardized. There was no such thing as an Ethernet cable that you could plug into. Well, we don't see many left today either. >> Yeah. >> With everything wireless. But there was no standard. The jacks and the plugs were actually handmade each one at a time because they had to have specific pinning, and there were 12 individual wires in the cable. And had to go into a particular sequence in the plug, so it was very labour intensive. That being said it was amazing what it could do for physician and for nurses and the way it positively impacted patient care and patient outcome and patient safety. >> When you say patient safety you mean like the tools just bringing. And medical records, did it transform to, inform of critical condition? >> That, and some of the other tools that came along with it. So I eluded earlier to a job about physician health writing, but physician health writing is, was, was with the primary sources of medical records. When you're writing a prescription or you're writing an order for a procedure or a test. And that can be misinterpreted. >> Sorry. >> So, we were -- here we were entering now the information into a technology tool that could display that in a standard format. You're on a display, there were really no mistakes. So, that was one part of it. The other is that, clinical -- nursing documentation systems would produce. A medication do list, that could be dynamically updated. So it produced one every hour. >> Right. >> On every nursing unit, of what each patient was to receive in the coming hour, if they were to receive something. Previously, if a doctor had changed an order, you might have to wait until that got communicated both to the pharmacy And to the nurse. But now it was all done dynamically, in almost real time. So that was both the patient's safety, it contributed to improved outcomes, because you could get the new medication into the Patient's hands or in to the patient sooner. >> Yeah, and it just sounds more efficient and less waste and less throwing away things. It's just easier on everyone. >> It enhanced communication and it enhanced patient care of outcomes. >> Yeah. One notable development in the 70s that I hear about at least in the textbooks is, again, maybe because it's a short lived road in some of the textbooks, but he led an initiative called MYCIN and this was an expert system. The 70s are, I think we're kind of synonymous with these experts in [INAUDIBLE]. A lot of medical knowledge have been collected and organized. The ideal that a clinician would then integrate with that knowledge through a series of questions back and forth, back and forth. Then arrived at a diagnosis and the recommended treatment plan. And this was used for MYCIN was about meningitis but there were others involving other kinds of clinical diagnoses. But the idea was that a clinician would sit down and relay kind of feed patient data to this knowledge database that had been curated and developed by other experts in the field. And then after 30, 40, 50 questions, something like that. That Myson would say the probability is that it is this form of meningitis. And that you should give that form of bacteria, or that form of antibiotics. And when it was trialed against individuals, it found that it was actually a pretty credible system. But extra systems never really took off. It's kind of a Greek oracle kind of mind set and really, that many big dilemmas in patient care. Aren't that many scratches where you need to sit and interface the system for half an hour or an hour. And often, especially in emergency department, we sometimes shotgun broad spectrum antibiotics when we're not sure what bacteria we're dealing with. And it turns out it's pretty safe and pretty effective. And so expert system that were kind of prophesied in the 1970s to really take off Kind of also was stagnated and never really developed. Plus I think a lot of commissioners just didn't like the idea of feeding data to an oracle and then getting back the results. They want to make something that kind of fit better into their workflows and turn them not into a data regurgitator but actually a partner kind of coming up The plan. >> Well, and I think there was, as we alluded to before, there was an element of a machine taking part of the art away from what they do. >> Yeah. >> And there was, at the time, a bit of a sense from some physicians, not all, that why did I go to medical school if I'm having a machine make these decisions for me? And the machine Can't think of x, y and z and understand the complexities behind it yet what the systems like these have evolved into today are what have given us prescriptive medicine. >> Yes. >> And the ability to take. Mountains of data, to be able to digest it, to be able to use those functions. >> Yeah. And this is where I think the folks at IBM, with Watson, are being smart. If you look at some of their commercials, it does seem like Watson is serving as that Oracle, and just dispensing truth. But when clinicians work with Watson, it is, you know, Watson is Combing the medical literature and coming up with new trials and new nuggets here and there that an individual might have missed. But Watson is presenting that information in a way that is tolerable to both the doctor and the patients. >> Yeah. I do want to mention while we're stuck in 70s, this initiative at El Camino Hospital, kind of in the heart of Silicon Valley. It was called TMIS, and I think was related or one of the precursors to TDS. >> It was, yes. >> Yeah, yeah. >> El Camino was actually the alpha and beta site for what was the TDS system. >> Yeah, and so, this was way ahead of its time. >> This had an interface for doctors on every floor where they could go in and order their meds, their drugs, their labs, their X-rays. And doctors could customize their order sets which is a feature that more doctors wish they had today. And they could do it by specialty, or by their own personal preference. And they interface with a light pen, so more than a stylus, it was actually interacting with monitors. See, my monitor today is kind of a dumb monitor. I can't touch it or do anything with it. >> I know, particularly nurses, but some physicians as well today who will tell you that they would still prefer to go back to one of those light pens than use a mouse or any other type of input device. >> Yeah, and there it was in 1973. It's another example of sometimes healthcare technology is way ahead of the curve. And yet, for some reason it didn't catch on. >> And it was a combination of not just the light pen, but there was sub-second response time. >> Wow, really very fast. >> So you could really go very quickly through your workflow, especially since the screens were, for the most part, static that you were using. So you knew where things were going to be as the screen flipped. You could already have your light pen there. >> Wow. >> So if you could watch some people going through and placing orders or entering documentation it was very, very quick. >> You never had that scrolling beach ball down there? >> No, no beach ball at that. >> [LAUGH] Okay, all right, well, yeah what did proliferate from the 70s into the 80s were these financial systems and then the results reviewed the ancillary systems. >> And as the 70s became the 80s, yes, as we said they have nursing documentation and optimized reimbursement and charge capture and things like that really proliferated. We also started to see clinical decision support tools, not the Oracles that we talked about, but rather just error checking and drug-drug interactions and drug allergy interaction warnings. Which also I think are a boon to patient safety, although they cause a lot of sometimes unnecessary alerts and pop-ups that doctors tend not to like so much. And computers kept getting smaller and faster. We went from mainframes to PCs, it was a mini computer era that- >> I think we started to see the introduction of PCs there in the 80s and as well as the introduction of standardized networking protocols that made it much easier to add devices in an environment, yeah, as the were standardized. >> Yeah and in the 90s, I think that's when the rise of the Internet and expectations that data should be easy to move really helped exchange patient data from one facility to another. Although, that's still an issue today, but at least in the 90s, I think that was when it was first kind of conceptualized. And we saw the community health information networks which were a precursor to today's RHIOs. >> Yes. Regional Health Information Organizations. >> And we also saw the same types of standards being applied in greater form and in a more robust way within the walls of the hospital to exchange data between the systems and to manage the flow. So HL7 is a standard for transmission of clinical data, as well as demographic data between systems. So you make sure that every system within the hospital's walls had the same information both to identify the patient as well as clinical information where it was needed. >> That's right, I mean, HL7 was about routing data and using wires and so forth, but the terminologies like SNOMED and LOINC first gained prominence for actually classifying that data. >> Okay. And we can't forget in the Clinton administration in 96, the first HIPAA law passed. And then with that brought a lot of attention and scrutiny towards keeping records private and secure. And that fell largely to IT as we moved from paper to computer-based systems. >> There were number of provisions under the HIPAA law that people, I think, either don't know about or don't realize and it all fell under administrative simplification. And so prior to HIPAA, hospitals would submit claims to payers. And there were up to 400 different formats up then. >> Wow. >> And so one of the things that HIPAA did in addition to privacy and security was to say no, this is the format that you're going to use to submit claims. And everybody is going to use the same format. >> Yeah. >> So the amount of work that was saved was estimated in the billions in terms of gained productivity. >> But do we send all those administrators home? >> [LAUGH] >> [LAUGH] I thought they found a case. >> I think they found a new case to do. >> Okay, well starting in the 21st century, in the last decade, there were a number of advances. And really, we talked about the formation of the Office of the National Coordinator of Health IT in the Bush administration. And then with President Obama's ellection in 2009, the Stimulus bill passed. And with that a lot of provisions for health IT and meaningful use. Incentives to hospitals and clinics for adopting electronic health record and using them in a meaningful way, which included public reporting of throughput metrics and safety metrics. So it really laid the groundwork for today's health care environment. >> So at the same time, we also saw a shift in terms of reimbursement models that have driven how people use IT and health IT. So we've seen a shift of paying from paying for quantity in the fee-for-service model to paying for quality with the advent of accountable care organizations and population health management. And so using technology to drive how patients are cared for and how providers use the technology. >> Yeah, for the first time, systems and individual providers are rewarded for keeping patients out of the hospital and for preventing these expensive procedures from being done. It's a change that really couldn't be imagined, I think a few decades ago. And there was without health IT, there would be no adequate way to track these outcomes and actually reimburse people for doing the right thing. And these are patient-centered goals. I don't think patients want to be hospitalized. They don't want to have these procedures done. So finally, the reimbursement is aligned with what the patient wants. >> And it's a shift that we saw, that I mentioned earlier, where everything used to be hospital-focused. So we saw the start in the 90s and continued through the early 2000s. And in terms of out migration, beyond the walls of the hospital not only of care, but of the tools and the health IT that support it, migrating into the general population of Healthcare providers wherever they may be both within the hospital or within a community. >> And that migration I think a lot has to do with just maybe how the technology has vastly improved and how it shrunk over the years like >> What do you say? >> [LAUGH] Well, we will take some procedures that used to be if you were haven't invent a multi night stay in the hospital and now stand on an out-patient basis. >> Yeah. >> So, enable on that as well. >> Yeah, but I mean when you get started and hospital was like implementing a new system. Is that physically like phasing just a mainframe or a mini computer and a big cloud of somewhere, right? >> Well mainframes needed whole data centers with water based cooling systems to keep the room core, in all this air conditioning and I implemented a lab system. At one point that the power of which is now found in my watch. >> Wow. >> And it's not an iWatch- >> [LAUGH] >> Not Apple watch. The Apple watch does a driven everything in the data center of that point. >> That's. >> Which leads me to this >> Comparison of what IBM's first portable computer looked like in 1984 when it was launched to the Apple iPhone 6 launched 30 years later in the shift. From something that was the size of a large suitcase and weighed 30 pounds to, we all have a pretty good idea of how big an iPhone and how light it is. The IBM computer had two floppy drives, one of which was needed for the operating system. And both and I think about the whole system had 256K RAM and then you look at today is iPhones and the amount of storage that they have here and a gigabyte of Random Access Memory >> More. >> Yeah. >> And so even as we have seen this explosion and the capability of computers, the capability of health IT is also advancing. Maybe not as exponentially, but we're getting there. All right, well this has been Matt Grove, Nick Genes. It's been a pleasure talking with you today about the history of health IT.