Inr J Biomed Cornput, 29 ( 1991) l69- 189 169

Elsevier Scientific Publishers Ireland Ltd.

A BRIEF HISTORICAL OVERVIEW OF HOSPITAL INFORMATION

SYSTEM (HIS) EVOLUTION IN THE [‘NITED STATES

MORRIS F. COLLEN

Division ofReseurch. Kaiser Permunenre Medial Cure Prop-urn. 3451 Piedmont Avenue. Oukbnd, CA
94611 (U.S.A.)

(Received July 9th. 1991)

(Accepted August 23rd. 1991)

This paper describes the evolution of hospital information systems (HIS) in the United States of Ameri-
ca from 1950 to the present and defines HIS within the context of a medical information system. After
a concise review of HIS administrative functions, the paper focuses on HIS clinical functions, including
the following: computer-based patient records: data entry and retrieval; text processing; data and system
protection; networks; clinical subsystems (nursing and medical subspecialties): clinical decision support
and quality assurance; and research databases. The paper surveys early examples of HIS and makes pro-
jections for HIS in the 1990s.

Keywords: Hospital information systems; Clinical information systems; Computer-based patient records;
Decision support; Medical decision making

1. Introduction

The basic kinds of information processed by a hospital information system (HIS)

in the U.S.A. have changed little since the 1950s yet the volume of that information
has increased significantly as a result of innovations in diagnostic and therapeutic
technologies. Information processing has also become more complex due to changes
in medical practice, such as health maintenance organizations (HMOs) and
multifacility organizations, and in financing, such as insurance reimbursement pro-
cedures and Medicare requirements for payments for hospital care by diagnostic
related groups (DRGs). By the 1980s the provision of health care in the United
States had three dimensions of integration of patient care information: local integra-
tion of information within hospitals; vertical integration of information between
hospitals and their affiliated medical offices; and horizontal integration between
associated hospitals. Finally, major changes occurred in computer technology for
collecting, storing, and retrieving medical information.

Correspondence 10: M.F. Collen, Division of Research, Kaiser Permanente Medical Care Program. 3451
Piedmont Avenue, Oakland, CA 9461 I, U.S.A.

0020-7101/91/$03.50 0 1991 Elsevier Scientific Publishers Ireland Ltd

Published and Printed in Ireland
170 M. F. Collen

I. 1. Definitions
As early as 1960, Ledley and Lusted [l] defined an information system as con-
sisting of three essential parts: a system for organizing or documenting the informa-
tion in a file; a method for locating in this file the information on a specific subject;
and a method for keeping the information in the current file. Lindberg [2] defined
a medical information system as a set of formal arrangements by which facts concer-
ning the health and health care of individual patients was stored and processed in
computers.
Clearly, a medical information system (MIS) was a complex integration of multi-
ple subsystems. The MIS could include an administrative information system (AIS),
a clinical information system (CIS), and several clinical support systems (CSS) (Fig.
1). In turn, an administrative information system could include its own subsystems
for accounting and business functions, patient registration, scheduling, admission,
discharge, and other patient processing activities. A clinical information system
could include components of a medical information system which were related to the
direct care of patients [3], such as a hospital information system (HIS), an office in-
formation system (OIS), and an associated computer-based patient record system.
A HIS could contain several modules or subsystem components called clinical
departmental or specialty systems, such as oncology systems, pediatric systems, etc.
Clinical support systems could include laboratory (LAB), radiology (RAD), phar-
macy (PHARM), and other systems.
The various primary users of a HIS - the physicians, nurses, dentists, phar-
macists, administrators, and technologists - first had to define in great detail what
they wanted the system to do, i.e. its functionality. From these administrative and
clinical functional requirements for each hospital, users then had to develop the tech-
nical specifications for the HIS. Through the decades, the functional requirements
of a HIS have changed less than the technical specifications.

2. HIS Administrative Functions

Historically, hospital administrators and health care professionals have had dif-
ferent perspectives on the information processing requirements within a hospital.
Whereas physicians needed information on their individual patients, administrators
needed information on the medical facility as a whole. Administrative needs for a

MIS

HIS 01s css

I I I
AIS CIS AIS CIS LAB RAD PHARM

Fig. 1. Components of a Medical information System (MIS).

 HIS evolution in the USA 171

HIS included the following: patient demographic and eligibility data; patient iden-
tification, registration, and appointment schedules; hospital admission, discharge
and transfer data; and hospital bed census. Hospital department managers needed
personnel files, schedules and electronic mail services; resources inventory data;
business, accounting, and statistical data; information for resource utilization and
productivity analyses, budgeting, planning, cost accounting, and financial analyses;
and environmental data for forecasting. The HIS had to have the capabilities for
creating selected subsets of data as needed for managerial, operational, and in-
vestigational activities. Such subsets might include inpatient length-of-stay for
utilization review and medical untoward events, or inappropriate procedures for
quality assurance monitoring.
Generally, one of the first computer applications installed in a hospital was for
the automation of its business functions, such as maintaining financial accounts, bill-
ing patients, processing payrolls, maintaining employee records, keeping inventories,
and ordering and paying for supplies and services. In the 1980s national legislation
produced major changes in HIS business subsystems when federal Medicare reim-
bursement policies required that payments for hospital services for Medicare
patients be made on the basis of diagnostic related groups (DRGs) [4,5].
In the early 1950s information such as patient identification data, hospital days,
attending physician, diagnosis, and operations began to be keypunched into cards
for machine tabulating and sorting of hospital statistics by unit record equipment
[6]. As early as 1965, Frederick J. Moore at the Los Angeles County General
Hospital initiated an identification file for 1 000 000 patients by using a punched
card system. His patient identification data included a patient file number, name,
birth date and place, mother’s maiden name, sex, and race [7]. A master patient
record index was usually used by hospital medical record departments to locate
medical records and determine whether a patient being admitted to the system re-
quired a new medical record number or had been assigned one at a prior admission.
With the advent of HISS, the development of patient identification (PID) subsystems
improved the efficiency and accuracy of linking all of a patient’s data to the patient’s
medical record [8].

3. HIS Clinical Functions

The functional requirements to satisfy the patient care needs of all health care pro-
viders were the most difficult to define. Because the practice of medicine is dynamic,
clinical needs are complex and continually change as new treatments and procedures
appear.
Collen [9] defined the clinical functions of a HIS as follows:

?? Provide a computer-based patient record that had a high utility for the individu-
al patient and for all health care professionals. Communicate patient data (1)
to and from all health care professionals in all clinical subsystems and the
computer-based patient record, and (2) to and from clinical support services
(e.g. radiology, laboratory).
 M. F. Collen

Provide to health care professionals clinical decision support, reminders and

warning alerts, and support quality assurance procedures.
Establish a database that can fultil research objectives for clinical and health
services research.
Support education of staff and patients.
Satisfy requirements for data confidentiality, security, integrity, and legality.
Satisfy requirements for system reliability and security.

By the mid-1960s solid state integrated circuits in third generation computers and
improved software began to satisfy some of the technical requirements for HISS. By
1965, Spencer and Vallbona [IO] had optimistically concluded that with the
technology then current and with proper functional requirements and technical
design, medical practice could be improved by using computers for medical diagno-
sis, hospital medical records, laboratory analyses and functional testing, patient
monitoring, hospital communications, and utilization of hospital services and
facilities.

3.1. HIS computer-based patient records

Patient records were usually organized in a time oriented sequence, i.e. the patient
data were chronologically tiled and presented in order of the date and time the data
were collected. A source oriented record was collated by the department of origin
of the data, so that, for example, all ophthalmology notes were grouped together,
and all clinical laboratory tests were filed together. Source oriented data were usually
filed in a time oriented mode within the departmental records, so that all laboratory
results were grouped together and then sequenced by date and time. In the 1960s
although most records contained problem lists, Weed [I 1,121 advanced the concept
of the problem oriented record, which linked collected data to patients’ specific
medical problems.
The earliest computer stored records were fixed field, fixed length files. This inflex-
ible arrangement was grossly inadequate for large patient records [13], so variable
field, variable length records were soon developed. Davis [ 14,15] approached the
problem of integrating long-term records by retrieving the entire patient’s past file
whenever new data had to be entered, transferring the tile into the computer memo-
ry, and opening up the specific fields which were to receive the new data, and, once
the new data had been entered, returning a single integrated record to the medical
record database. As an alternative technology, Barnett [I61 stored separately the
strings of newly entered patient data and linked the time stamped new data by
pointers so that a logically integrated patient record could be presented to the health
professional even though the individual patient’s data might be distributed
throughout various parts of the computer database. The growing volume and variety
of data in patients’ tiles made it increasingly difficult to find and retrieve specific
items or sets of data stored in a large database. Computer scientists in the 1960s
usually designed the database SO as to link the individual patient’s data in a hierar-
chical or tree-structured mode to facilitate the search and retrieval process. In the
late 1970s relational and object oriented databases began to be used. By the 1980s
the increasing volume and complexity of patient data stored in medical records re-
quired a combination of hierarchical, relational, and object oriented designs.
 HIS evolution in the USA 173

3.2. Data entry and retrieval

It was evident from the first HIS that acceptance by health professionals would
depend upon terminals which permitted them to enter and retrieve data. In the 1950s
and 6Os, punched card readers and typewriters were generally used for data entry.
primarily by clerical personnel. Typewriters were sometimes used as computer
printers, which at first were for the most part restricted to uppercase (capital) letters.
Lengthy printouts were batch processed on higher speed printers. In the 1960s elec-
tronic or optical readers were able to sense marks on paper, making forms and pages
of encoded data readable directly into the computer. By the end of the 1960s great
advances were made in cathode ray tube (CRT) and television-type video display ter-
minals which permitted direct interactive dialogue between the computer and the
human user [17]. With interactive display terminals, physicians and nurses began to
use HISS without clerical intermediaries.
As early as the mid-1960s the Lockheed/Technicon hospital information system
used television-tube terminals which displayed 24 rows of double-sized characters
and provided a pushbutton, lightpen data selector. Many physicians readily accepted
this mode of computer interface for their hospital practice [ 171. Williams and Levy
at the University of Illinois-Urbana developed a clinical record system which used
the terminals of their Programmed Logic for Automated Teaching Operations
(PLATO) system to provide interactive data entry for patient histories and physician
physical examinations. Graphic displays of laboratory results, problem lists, care
plans, and progress notes were available, either encoded or in natural language [ 181.
In the early 1980s Barnett’s group at the Massachusetts General Hospital were using
microprocessors and video display terminals with 24 rows by 132 columns of
characters, with a mouse or touchscreen data selector. Physicians entered into a
codable format natural language text for physical examination findings [ 191. Weed’s
PROMIS terminal displayed 24 rows by 80 columns of characters, every other row
being sensitive to finger touch to select choices from a variety of frames of displayed
functions [20].
The display of graphs generated from the data in a patient’s record was an impor-
tant requirement for clinicians. Early display terminals did not have any special
graphic capabilities, and the cursor could move only from left to right and top to
bottom [21]. This limitation underscored the need to develop terminals with
graphical user interfaces and more flexible cursor control.
During the 1970s and 198Os,most HIS terminals were stationed at the nursing sta-
tions in the hospitals. In the 1980s computer terminals began to be stationed at the
bedside in some hospitals [22]. At first ‘dumb’ terminals, these bedside stations
gradually become ‘intelligent’ microcomputers and, by the mid-1980% were linked
into local area networks. Bedside terminals thus allowed nurses to record the
patient’s vital signs, nursing observations and given medications directly into the
computer. Nurses at the bedside gained access to screen displays or printouts, in-
cluding graphs of the patient’s vital signs and a variety of useful reports. By the end
of the 1980s handheld or semiportable terminals began to be used at the bedside.
Barcodes, which had been used in other industries for some time, began to find
applications in identifying patients’ wristbands, medical records, blood bank
samples, laboratory samples, and x-ray folders [23]. In 1986, Monahan, at the
174 M.F. Collen

University Hospital of Cleveland, hailed the use of handheld barcode readers as a

‘beginning step for automated entry of nurse identification, and nursing diagnoses
of patients’ problems selected from a listing of 61 common conditions’ [24].
With the advent of medical expert systems, data acquisition went from free text,
formatted, and menu based data entry to so-called intelligent data entry. At the Lat-
ter Day Saints Hospital, Warner’s HELP program combined a centralized patient
database and a medical knowledge base to create data entryscreens which fitted the
individual needs of a specific patient and suggested procedures and treatments to be
considered for the patient’s problems [25].
In the 1970s some powerful minicomputers were designed to take advantage of
network filesharing and multitasking capabilities; these were called workstations. By
the late 1980s powerful microcomputers designed to operate as standalone systems
began to have the capabilities of replacing the minicomputers in workstations [26].
Soon clinical workstations with powerful microprocessors were linked together in
local area networks (LANs) in order to better satisfy the online man/machine inter-
face requirements of physicians and nurses. Although the Apple Macintosh comput-
er had provided a graphical user interface since 1985, this technology was not widely
applied to clinical workstations until the end of the 1980s. By this time, workstations
were developed to use multimodal communication interfaces which included the
following: keyboard data entry; high resolution displays; a graphical user interface
with an onscreen pointer controlled by a hand device such as a mouse or trackball;
multiple data and graphics display windows; full image retrieval; and beginning
voice input and output [27].
In 1984, McDonald [28] at the Indiana University School of Medicine reported
a network of workstations connected to a central VAX 117/80 server. Each worksta-
tion ‘. ..carries all its own programs, tables and medical records for a few hundred
patients...provides facilities for entering prescriptions, orders problems, and other
medical information for generating flow sheets, executing reminder rules, providing
ad hoc retrievals and reporting facts about drugs, tests and differential diagnoses.’
In 1986, Tolchin [29] described the installation at the Johns Hopkins Hospital of
several clinical workstations to support their expanding networked clinical informa-
tion system. For some specialized clinical data input functions which required the
use of graphs (such as during the anesthesia of a patient), a digitizing graphics tablet
was developed as the interface for computer record keeping [30]. Although hand
writing was the most natural way for a physician to write notes in the patient’s
record, only hand printed characters could be recognized by optical scanners. Cur-
sive handwriting recognition pads for direct entry of data to the computer were not
invented in the 1980s.
In the 1980s there became available some limited voice recognition input modes
[31]. These were employed by specialists like radiologists and pathologists, who used
a relatively limited and a mostly predelined vocabulary. In the 1980s the systems
would accept up to 10 000 individual words spoken directly into the computer, with
a pause between each word. The computer could be trained to accept a phrase as
a single word, but still lacked the capability to recognize continuous speech [32].
By the end of the 198Os, the available technology had advanced to provide a
hypermedia medical record. Using an Apple Macintosh microcomputer at Dart-
 HIS evolution in the USA 175

mouth-Hitchcock Medical Center, Shultz and Brown developed a prototype HIS

which processed and displayed text, images, animated sequences, linkage to
radiology and pathology images, and permitted hearing digitized heart sounds. The
system drew information from multiple sources other than its own database, such
as a linked laser videodisk and other conventional databases [33].

3.3. Text processing

Probably the most frustrating problem for a HIS was how to process natural
language in a meaningful way, i.e. narrative text which made up a large part of pa-
tient records. The earliest approach to the computer processing of English words was
to enter, store, and retrieve each word, character by character, without regard to
their structure or meaning. In order to save storage space in the computer, individual
words were usually coded. The processing of encoded English language text imposed
the need to use standard terms and standard rules for aggregating and com-
municating data. In the early 197Os, uniform minimum data sets were published for
hospital patients [34]. Computer-stored data dictionaries were prepared which
provided the code and meaning for each word and began to provide some standards
for the use of medical terms and for their meanings [35]. The nationwide use by
hospitals of one classification system for diseases (ICD-9-CM) and one for pro-
cedures (CPT4), along with the continuing work on standard nomenclature (SNOP
and SNOMED), further improved the efficiency of encoding medical terms and stan-
dardizing usage [36-391. Word phrases and terms used for diagnoses and procedures
were systemized and encoded by ICD and CPT; some meanings and attributes were
added by SNOMED. This led to the development of software to automatically en-
code the relatively standardized ICD and SNOMED terms. Most of the trends in
the 1980s towards standardization of diagnostic coding were driven by the Health
Care Financing Agency (HCFA) through its reimbursement schemes. The beginn-
ings of a Unified Medical Language System (UMLS), under development at the Na-
tional Library of Medicine (NLM), gave some hope of the eventual capability for
automated computer translation between all major nomenclature and classification
systems [40].
Attempts to improve the standards for communicating medical information were
also carried out by the subcommittees of the American Standards for Testing
Materials [41,42]. ASTM’s subcommittee (E 31.12) on Medical Informatics consid-
ered nomenclature and medical records [43], and in 1988 published standards for pa-
tient discharge and transfer data. Also in 1988, ASTM’s subcommittee on Data
Exchange Standards for Clinical Laboratory Results (E 31.1 l), published its
specifications (E 12.38) for clinical data interchange and set standards for the two-
way digital transmission of clinical data between laboratories, office and hospital
systems. In 1987 Health Level Seven (HL7), an organization made up of vendors,
hospitals, and consultants was organized in 1987 [44] to develop interface standards
for transmitting data between applications within hospital information systems [45].
The Medical Data Interchange (MEDIX Pl157) committee of the Institute of Elec-
trical and Electronics Engineers (IEEE), formed in 1987, was also developing a set
of standards for transferring over large networks’ clinical data from mixed sources,
such as from both the clinical laboratory and from the pharmacy systems [46].
176 M. F. Collen

Attempts to automatically encode words required computer languages to identify

both the word structure of sentences and their meanings [47-501. Text processing
programs were developed for automatically translating textual portions of the pa-
tient record, such as discharge summaries, which were used for billing and claims
reporting into codes [51-531. By the late 1970s expert knowledge-based systems were
being developed to improve the interpretation of the meaning of sentences when
translated from English medical text to computer language and then translated back
to English [54-571. Still, the automatic processing of narrative, medical English text
remained a major active research problem even at the end of the 1980s.

3.4. Data and system protection

Data protection meant protecting the privacy, confidentiality, security, and integ-
rity of each patient’s medical data from unauthorized or accidental, intentional or
unintentional access for the purposes of reading, altering, or destroying the data in
addition to ensuring the security of the records from fire and other destructive
forces. Data security was dependent upon adequate system security to protect from
such unauthorized access to the system. Risks to system security included illegal
access to computer rooms, illicit use of data communications by hackers, or illegal
modification of computer programs.
The usual measures developed to ensure confidentiality for patient computer-
based records included some means of controlled access, such as (1) lists of authoriz-
ed users who then obtained access to specified subsets of these data by entering their
assigned unique code or password or using a machine-readable identification card
or (2) user-programmable access in which each user selected an alphanumeric code
which thereafter permitted access to an authorized subset of data. Groups of users,
identified by their user identification codes, would have privileges to access, read,
or enter data into clinical files. For example, physicians and nurses could access all
of their patients’ data after entering their identification codes, whereas laboratory
technologists with their own codes could access only clinical laboratory files. In
many systems, every transaction with a patient’s record was logged with the user’s
identification code. For databases which required a higher level of protection and
needed to conceal information, cryptography could be used which transformed
messages into forms that rendered them unintelligible to unauthorized persons [58].
For the strictest privacy, such as was required for psychiatric records, data isolation
was usually maintained by storing these records in a separate file accessible only to
authorized psychiatrists and psychologists [59,60].
As an example of an early HIS security system, Blum described the security com-
ponent of the Johns Hopkins Oncology Center Clinical Information System [61]:

Through software control, the terminal provides access to all data (and only that data) required to
perform that set of functions.... For example, the terminal in use at an inpatient nursing station allows
access only to information about patients in that unit.... Access to data is controlled by password....
The user identifies the functional terminal desired and a request for his identifier and password is in-
itiated.

At Beth Israel Hospital in Boston, a system was implemented employing passwords

comprised of random combinations of letters and numbers, which were changed
 HIS evolutionin the USA 177

every 6 months. If a user repeatedly entered an incorrect password, the terminal

froze and beeped a loud signal until the situation was corrected [62].
When factors such as filesharing, remote access, or multiprogramming were added
to a HIS, the security of the operating system became increasingly difficult to main-
tain [63]. With the proliferation in the 1980s of personal computers with modems,
the security of computer-stored medical data was especially threatened by external
sources who had access to the HIS through telephone connections [64]. Further-
more, uninvited programs called viruses emerged that copied themselves into other
programs and could destroy data stored in a computer. In November 1988, a news-
paper reported that a virus in the computers of an East Coast hospital caused the
destruction of 40% of its medical records [65].
Preserving data integrity was another important requirement for a HIS computer-
based patient record, i.e. the need to assure its completeness and accuracy, and pro-
tect from any invalidation of the data. There was also the possibility that a software
or hardware malfunction might result in the accidental deletion or modification of
patient data stored in the HIS. This problem usually could be met by maintaining
adequate backup files. HISS with distributed databases had more serious problems
in this regard since the patient data often resided in several computer databases. For
acute patient care with a high transaction rate of data flow, some advocated a
physically integrated patient record database to completely ensure the integrity of
the data, i.e. for the HIS to be capable of reconstructing a valid replicate of a past
medical record which represented the medical record exactly as it was used by the
physician at the time clinical decisions were being made [66].
The use of patient records for administrative reviews of resource utilization and
quality assessment was always a threat to confidentiality. This threat was intensified
by the speed and power of the computer to facilitate such review processes using
computer-based medical records [67].
As an example of the measures taken to assure system reliability, Barnett [68]
described those taken in the early 1970s for the Massachusetts General Hospital’s
computer system:

We believe very strongly that duplicate hardware systems are essential to provide the high degree of
reliability necessary in a medical information system.... We use redundant systems in a hierarchical
fashion, i.e. if one computer system is not available, the various modules can be shifted around so the
highest priority activities will continue to operate while the lower priority activities (e.g. programming
development) will be temporarily halted.

Uninterruptible power supplies to protect against electric power irregularities and

failures were already employed in the late 1960s. By the 198Os, where multiple com-
puters in a local area network were temporarily storing data in various volatile
databases prior to sending the data to a central database, uninterruptible power sup-
plies became essential for the protection of the network [69].

3.5. HIS networks

The majority of early HISS took the modular implementation approach advocated
by Barnett [70]. Hospitals acquired one HIS module at a time as each module
became available. The various modules and departmental subsystems of the HIS had
178 M. F. Collen

to be connected to each other and to all clinical support systems (laboratory, phar-
macy, radiology). In the 196Os, HIS had developed with mainframe computers and
time-shared database systems which required compatible hardware and software; all
peripheral equipment was connected directly to the central computer by wires,
telephone lines, or cables.
Distributed database systems appeared in the 1970s using minicomputers. Com-
puters in various clinical modules required integration of all of the patient data they
generated. An early example of a software solution to this data integration problem
in a modular HIS was the development of the MUMPS language by Barnett’s group
at Massachusetts General Hospital (MGH) (711. Barnett described the MGH system
in 1974 as having four functionally equivalent computer systems on which the
various modules were implemented. Since all of these systems operated under the
MUMPS language, ‘it was invisible to the application programs which particular
system is being used’ [72]. Because Barnett used compatible hardware and software
throughout his HIS, he avoided the problem of interfacing incompatible subsystems.
Hammond, Stead, and their associates [73] at Duke University developed a
generalized, online, DEC PDP minicomputer-supported information system with a
different software approach they called GEMISCH:

GEMISCH is composed of programs which perform specific tasks as defined by tables. User program-
ming consists of the creation of appropriate tables...entered through an interactive editing and tile-
handling system.... The user-oriented source tiles are converted to machine-oriented operating tiles....
These operating files are combined with the system programs to form a GEMISCH operating system.

With the arrival of low cost versatile minicomputers in the early 197Os, followed
by even lower cost microcomputers in the late 1970s patient records began to be
stored in these computers on direct access discs, resulting in various distributed
databases. This developed the need to functionally collate all patient data into a
single medical record usable by clinicians, either through interfaced or integrated
systems. Interfaced computers managed their own files and copies of their data were
exchanged or transmitted between systems, whereas integrated systems shared a
common, central database [74]. However, the fact that these distributed computers
were made by different manufacturers and used different software, introduced the
need for some way of interchanging data between differently designed HIS sub-
system modules. This need stimulated the evolution of communications computers
and networks for processing distributed data, and began to radically change HIS
design [75]. In 1971, at the University of California in San Francisco (UCSF), Blois
described in 1971 a distributed data processing approach which used different com-
puters for the various information subsystems and then integrated these subsystems
by using a separate communications processor to manage the network [76,77].
In the late 1970s the International Standards Organization (ISO) developed a
conceptual model and reference base for network structures comprising seven layers,
which established the rules for exchange of data with the corresponding layer in
another computer. This IS0 model had a great influence on the development of
LANs [78]. It led to the development in the late 1980s of the Health Industry Level
7 (HL7) interface for electronic exchange of data in HISS [79].
In 1979 Zeichner [SO] at Mitre Corporation and Tolchin at the Johns Hopkins
 HIS evolution in the USA 179

University proposed a distributed processing architecture with microprocessor-

based interface units between each network computer or terminal and the com-
munication bus. The Johns Hopkins group reported in 1980 the implementation of
a fiberoptic LAN to integrate three medical ancillary systems and one registra-
tion/identification system, built by three different manufacturers each with different
operating systems. In 1982, Simborg and associates at the University of California,
San Francisco (UCSF), in a joint effort with Tolchin and associates at the Johns
Hopkins University, implemented a fiberoptic network which integrated four dif-
ferent minicomputer systems at the UCSF medical center [81]. A fifth host computer
was interfaced to their network to provide monitoring services for performance an-
alysis and evaluation [82]:
The system is completely heterogeneous with respect to machine vendor models. operating systems,
application software systems, and local data base or tile access systems.

LaSonde [83] reported on Mitre’s work at the Walter Reed Army Medical Center
(WRAMC), which served as an Army test site for the development of a coaxial cable
LAN installed in early 1978. Jackson [84] described the installation by Mitre of a
similar local area network at the U.S.A. Wilford Hall Medical Center (WHMC) in
San Antonio, Texas, for its Tri-Service Medical Information System (TRIMIS).
Gardner and associates [85] at the Latter Day Saints Hospital in Salt Lake City
described their system as:

. ..a network of microcomputers connected to the central HELP system running on a TANDEM com-
puter.... There are I8 microcomputers...and more than 250 terminals and 70 serial printers and plotters
connected to the system.

By the mid-1980s LANs began to interface different software systems such as

MUMPS systems communicating with UNIX systems across ETHERNET at Johns
Hopkins Hospital [86].
By 1987, approximately 20% of hospitals in the United States had computer links
between their HIS and affiliated physician offices. Some had integrated terminals
which enabled data to be exchanged, copied, and modified; some permitted direct
access to laboratory and radiology reports from an office information system [87].
Linkages of an HIS to staff physicians’ offices facilitated the transfer of results of
diagnostic tests to the physicians [88].
Thus, in the 198Os, HISS began using LANs to connect a mix of micro, mini, and
mainframe computers. By the end of the 1980s large HISS with LANs shared
distributed databases, terminals, and printers. Networked HISS integrated auto-
mated machine input and output, barcode readers, word processing, and spread-
sheets. They began to employ workstations, bedside, and portable terminals as well
as to routinely employ electronic mail between the hospital and physician offices,
and retrieve clinical support information from external knowledge databases. By the
end of the 1980s the key to successfully operating an effective HIS was having ade-
quate software, communications technology, computers and associated hardware.

3.6. HIS clinical subsystems

Clinical information systems for separate departments or medical specialties
180 M. F. Collen

within a hospital were basically similar to a HIS except their functional requirements
were limited to the particular specialty [89]. Requirements for the various medical
specialties differed significantly from those for surgical specialties, pediatric services,
obstetric services, and others. Many departmental subsystems were developed in the
1970s to attempt to satisfy the needs of the respective services, but not until the 1980s
did it become possible to interconnect modules with different computers through
communications networks.
3.6.1. Nursing subsystems. Nursing functions were always central to the care of
hospital patients. Nurses had to enter data describing the patient’s status and nurs-
ing diagnostic terms. They needed computer-generated listings of prescribed patient
medications, and they entered into the computer the time, dose, and method of ad-
ministration for each drug. They developed nursing care plans for each patient, car-
ried out these plans and physicians’ orders, and charted all results. Nurses charted
vital signs in graphic format and sometimes prepared flow charts of the patient’s
progress. Nurses wanted to capture source data as close to the patient’s bedside as
feasible. If physicians did not enter their orders directly into the terminals at the nur-
sing stations, then the nurses or clerks entered the written orders, arranged the
schedules for tests and procedures, and called for test results.
By the mid-1980s expert nursing systems, such as the Creighton Online Multiple
Modular Expert System (COMMES), were reported to aid the nurse in developing
patient care plans. The nurse requested a protocol for the care of specific conditions
and then invoked a protocol editor to tailor the set of recommendations into an actu-
al care plan for the specific patient [90,91].
3.6.2. Medical subspecialty systems. Many HIS subsystems were developed for
various clinical specialty services in a hospital. Patient care management plans were
included in some of the earliest HISS. As early as the 1960s Vallbona used the
capabilities of the computer to support calculations of doses of medications, and of
fluid and electrolyte requirements of patients. Tabular printouts of the fluid balance
report provided ‘calculations of water, glucose, sodium, and potassium requirements
and recommended parental fluid therapy for a 24-h period to meet calculated re-
quirements’ [92]. Since 1967, an intensive care monitoring system was operational
at the Latter Day Saints (LDS) Hospital in Salt Lake City, developed by Warner and
associates. In 1975, the LDS system had terminals in each of the four intensive care
units monitoring 15-20 patients, and terminals in each of three surgery suites. In
1969, the pediatrics department of Bellevue Hospital in the New York Medical
Center initiated a pediatric system for the medical records of 60 000 children. The
system provided patient identification data, hospital discharge summaries, problem
lists, progress notes, consultation and follow-up reports, operative reports, clinic ap-
pointment scheduling and chart requisitions, hospital admissions, discharges and
transfers, and laboratory test data and x-ray reports [93].
In the 197Os, Menn [94] described a subsystem for the respiratory care unit at the
Massachusetts General Hospital which gave management guidelines for the care of
patients in acute respiratory failure. Hospital services for patients with cancer
required a wide variety of medical, surgical, and radiation procedures. In 1976 and
 HIS evolution in the USA 181

again in 1980, the Johns Hopkins Oncology Center installed computers. The two
computers were linked with distributed database software and had a direct link to
the Department of Laboratory Medicine’s computer system and to an Oncology
Center pharmacy. Daily care plans were designed to assist physicians who treated
patients using complex treatment modalities and protocols [95].

3.7. Clinical decision support and quality assurance

Appropriately designed HISS fostered improved quality of care services by in-
cluding clinical decision support programs, such as the HELP program developed
by Warner at the Latter Day Saints Hospital and the CARE program developed by
McDonald for the Regenstrief Institute. Such programs provided the capability to
monitor patient care online, making it possible to detect inappropriate orders by
physicians and inappropriate administration of medications and procedures by
nurses. Such programs for realtime monitoring of care added a new dimension to
programs for retrospective quality assurance procedures.

3.8. Research databases

HIS support for clinical research generally required a different collection of data
than that needed for patient care. Medical care required selected data on all medical
problems of each patient, whereas clinical research databases collected all data on
selected medical problems. Computer-stored research databases appeared as early as
the 1960s often linked to regional and national databases. By the end of the 1980s
an HIS had to be capable of communicating with outside databases such as with the
National Library of Medicine’s MEDLINE for medical literature retrieval, and with
factual databases such as those for poisons and toxic substances.

4. Some Examples of Early HISS

Most of the medical information systems developed in the 1960s and 1970s focus-
ed on applications of computers to hospital services. Ball [96] classified HISS accor-
ding to their functionality. Class A systems were individual stand-alone systems
which addressed the specific requirements of single departments or specialties. Class
B systems crossed interdepartmental and specialty boundaries by networks. Class B,
Level 1 systems were primarily oriented to administrative functions, whereas Class
B, Level 2 systems were administratively based, but provided some clinical and nurs-
ing services. Class C systems used the patient record as the base, were fully inte-
grated, and supported clinical, nursing, and ancillary systems.
In 1976, Spencer reported the results of a survey of computer applications in
hospitals. Of the approximately 100 hospitals in the United States that responded,
three-fourths indicated they had some computer applications for administrative
functions and only about one-third reported clinical laboratory or other patient care
applications [97].
At the end of the 1970s Young [98] and associates at the University of Southern
California conducted a survey of minicomputer-based HISS in hospitals with from
100-300 beds. They identified 75 different applications which they grouped into five
levels or steps of difficulty in a modular implementation of a HIS. They found that
essentially all hospitals had what Young called step I applications (primarily by
batch processing) which included billing and accounting, payroll, and inpatient
patient census; and also step 2 applications (with limited online data entry) which
included admission-discharge-transfer, patient record data collection, patient iden-
tification number assignment, general ledger interface, and credit and collections.
Only about half of the hospitals had step 3 applications (using online data entry ter-
minals) which included order entry transmission, message communication, patient
number retrieval, discharge abstract preparation, and various inventory applica-
tions. Fewer than one-fourth had step 4 applications (with most functions
automated) including medical record number assignment, discharge analysis and
reports, laboratory worksheets and schedules, budget preparation and expense
reports, and labor time collection. Very few hospitals responding to this survey had
step 5 applications (with two-way data transmission and clinical functions) which in-
cluded test results reporting, medical chart reports, personnel history, and utilization
review.
By the 1980s strategies for designing an HIS were sufficiently advanced that a
hospital administrator could select the HIS functional components desired and refer
to an Automated Hospital Information System Component Catalog developed at
the Health Services Research Center of the University of Columbia-Missouri. This
document [99] described 112 commercially available components that might be used
to design a HIS, and provided standardized descriptions of cost and performance
of each component.
The first HISS in the United States evolved in the 1960s and 70s mostly from aca-
demic medical centers. Some began as prototype HISS, but most expanded into HISS
from computer applications in research programs, laboratory systems, or office
information systems. Among the early HISS developed were the following:

?? William Spencer and Carlos Vallbona at Baylor College of Medicine were

among the first in the United States to develop a fairly comprehensive HIS at
the Texas Institute for Research and Rehabilitation (TIRR). In the late 1950s
they began to use digital computers for research purposes, and in the 1960s ex-
tended the use of computers into patient care functions [lOO,lOl]. Although
TIRR was a highly specialized hospital, the systems development problems they
faced were very similar to those of other HIS developers.
?? In 1962 G. Otto Barnett and associates at the Harvard Medical School began
to employ computers at Massachusetts General Hospital where they developed
the MUMPS language and a comprehensive HIS and extended their activities
to implement COSTAR for the Harvard Community Health Plan [102-1041.
?? Homer Warner and associates at the University of Utah first employed com-
puters in a research laboratory; in the mid- 1960s they expanded their system into
the Latter Day Saints (LDS) Hospital and there developed the HELP clinical
decision support system [ 105- 1091.
?? Donald Lindberg, while at the University of Missouri-Columbia initiated a lab-
oratory system in 1963 which expanded throughout the University Hospital dur-
 HIS evolution in the USA 183

ing the 1970s and evolved into a Missouri statewide medical information system
[llO,lll].
Morris Collen, Edmund Van Brunt, Lou Davis, and associates at the Kaiser Per-
manente (KP) Medical Center in Oakland, California, initiated an automated
multiphasic health testing (AMHT) program for ambulatory patients in 1964
and extended it into a prototype HIS in the San Francisco KP Medical Center.
Although the Oakland AMHT continued to operate through the 1980s the HIS
was discontinued in 1973 due to inadequate long-term funding [ 112- 1171.
Lawrence Weed at the University of Vermont College of Medicine in Burlington
developed the Problem Oriented Medical Information System (PROMIS)
around his concept of a problem oriented medical record. The PROMIS project
was started in 1967, and the system was installed on the 20 bed obstetrics/
gynecology ward in 1971 [118,119].
At the Johns Hopkins Hospital, a group of investigators including Bruce Blum,
Donald Simborg, and Stephen Tolchin came together in the 1970s to develop
one of the most comprehensive networked HISS in the country [120-1251.
Melville Hodge and associates at Lockheed Missiles and Space Company ap-
plied their aerospace expertise in the 1960s to develop a HIS that they called the
Lockheed MIS. In 1971, this became the Technicon Medical Information
System; in the 1980s it was called TDS. In 1971, the El Camino Hospital in
Mountain View, California, a general community hospital, installed the first
Lockheed/Technicon system [126], with the first commercial use of a video
display/lightpen terminal [127,128]. This system was one of the most compre-
hensive HISS developed in the period from 1960 to 1980. By the late 1970s
physicians, nurses, technicians, and clerks communicated with the computer by
means of video terminals; and computer produced printouts fulfilled all hospital
needs [128,129]. The Technicon system was one of the few HISS which under-
went independent thorough evaluation [ 131,132].
In 1972 Clement McDonald and associates at the Indiana University developed
an office information system at the Regenstrief Institute for Health Care and
then extended it in the 1980s into three hospitals in the Indiana University
Medical Center. McDonald’s CARE program provided online reminders to
clinicians [88,133].
Henry Camp and associates at the Georgia Institute of Technology and Emory
University reported in 1979 a prototype HIS called the Medical Aggregate
Record Inquiry (MARI) system [135]. By 1983, they had expanded the system
at Grady Memorial Hospital, named THERESA, into a full HIS linked to their
clinics [ 1361.

5. HIS Projections for the l!BOs

Today as in the 1950s health care professionals and hospital administrators

generally want computers to do much the same things for inpatient care. However,
technological innovations in each decade have modified the desired functionality in
hospitals by improved technology in computer hardware, software, and communica-
tions. The hardware evolved from mainframe computers to minicomputers and
184 M. F. Collen

microcomputers. Software changed from punch card data processing in the 1950s
to administrative management information systems in the 1960s clinical decision
support systems in the 1970s and expert systems in the 1980s. The advent of local
area networks radically changed HIS design and permitted different computers to
be integrated within a HIS.
In the 1960s through the 1980s there were no lags in the implementation of HIS
administrative functions or in the diffusion of clinical support systems (clinical labo-
ratory, radiology, electrocardiography, pharmacy). However, the inability to replace
the paper-based paper record with a computer-based patient record delayed the im-
plementation of HIS clinical functions. This inability could be attributed to the fact
that computers were unable to accept cursive handwriting or continuous voice input;
it was compounded by their limitations in processing text in patient records.
For four decades, it had been hoped that the computer-based patient record would
provide such benefits to patient care as (1) improve efficiency and reduce the costs
of providing patient care, (2) improve the quality of patient care by better clinical
decision support and facilitate the process of monitoring the quality of care and of
services, (3) improve patient care by facilitating health services research through bet-
ter computer-stored databases, and (4) facilitate electronic claims and forms process-
ing. However, even by the end of the 198Os, it was clearly evident that these
important benefits had been only partially achieved.
In 1989, the Institute of Medicine (IOM) of the National Academy of Sciences
recognized this as a high priority need, and established a Patient Record Project with
subcommittees to (1) define the functional requirements for a computer-based pa-
tient record, (2) determine its technical specifications, and (3) develop a national
strategy for its diffusion [137,138].

Acknowledgments

This paper is abstracted from Medical Informatics: A Historical Review of the First
Four Decades in the United States, a book in preparation under contract with the
National Library of Medicine, with the permission of the Director, Donald
A. B. Lindberg, MD. A significantly shorter abstract was also presented at the
September 1991 working group meeting of the International Medical Informatics
Association on hospital information systems, held in Goettingen, Germany.

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