Mr. ROGERS. In the long run, we would hope to make a saving in the use of personnel. Is that basically the point?

Dr. MAYNE. Yes, sir.

Mr. ROGERS. What is your estimate for the future that this could bring about as far as the saving dividend? Have you projected this at all?

Mr. LADNER. We have to be honest about this. We would like to say that we have data that indicates or anticipates we could save a certain percentage. However, our feasibility study, that is, our intensified effort in this regard, is not at the stage as yet where we can give any specific figures. But this is actually our intent.

One of the major objectives of the study is to determine if health personnel can be utilized more efficiently in the care of patients. Mr. ROGERS. What jobs do you anticipate can be taken over by an automated system?

Dr. MAYNE. I would say that the automated system can primarily process and store information. It is possible even for the patient himself to interact with a terminal, a bit of hardware, and to give portions of his own history. One can secure physiologic measurements with technicians.

I think at the present time this is a little early to count on saving much time. But it has definte potential. We have some definite experiments just completed within the past week which will be published. I really thought this was not very feasible, but it is.

The machines, as I envision them, would largely be used to process, store, reorganize, present, and retrieve material for the physician or the nurse to use in the care of the patient. But it is possible that we can go further and actually have the patient, himself, interact a portion of the time with the terminal, again further saving time.

Mr. ROGERS. In the overall problems with computers, what are some steps taken by hospitals today to reduce costs of hospitalization? Is it possible, for instance, for a number of hospitals to get together and have a joint effort on, say, their laundering, on bookkeeping, items like that? Is that projected?

Mr. LADNER. Mr. Rogers, I believe considerable work in this area can be done and that savings should result. In our medical center in Rochester, as you probably know, the Mayo Clinic does not own or operate either of the hospitals with which we are associated. St. Mary's has approximately 1,000 beds and the Rochester Methodist Hospital has about 570. Over the years we have worked very closely with these hospitals, and the hospitals have worked very closely with us.

We at this time do have a number of joint efforts in this regard. We are going to have some more in the future.

For example, our hospitals have had mechanical bookkeeping systems for their accounts receivable, their bed counts and this sort of thing. They have come to us recently and have said, "We do not think it is wise for us to continue this way. Wouldn't it be more economical for us if the three of us, the two hospitals plus the Mayo Clinic, embarked upon a joint venture to put all of the accounting, bookkeeping, and so on, into a central computer?"

The three institutions have agreed to do this. We are proceeding to implement this.

In the presentation we are making today, we are not talking about this kind of thing in our statement. We are talking about actually a computer being used in a different sense.

Mr. ROGERS. But you think there is a possibility to help reduce the overall costs?

Mr. LADNER. There is no question about it.

I would like to comment, if I may, a little bit on your earlier inquiry about the use of paramedical personnel. The Mayo brothers, as you know, are now deceased, but were believers in several things that I think we will see more and more of come to pass in this country.

One was that they shared the opinion that paramedical personnel could do many jobs that do not need a physician's training. There has been a ratio in the Mayo Clinic over these 20 years since I have been associated with it of approximately 5.2 paramedical personnel for every physician. This was started, as I said, by the two Mayo brothers. We believe in the specialization of labor, not only physician to physician, in the specialty practice, but a division of labor of such nature whereby the physician's time should be devoted to those elements of patient care that the paramedical person cannot do.

I think we will see an acceleration of that in the future, not only in our institution, but in other medical centers.

Mr. FRIEDEL. The time of the gentleman has expired.

Mr. ROGERS. May I ask just one more question, Mr. Chairman?
Mr. FRIEDEL. You may.

Mr. ROGERS. Perhaps you can supply something for the record, but I would like to ask you about this. I am concerned about the type and quality of emergency service. It seems to me we are moving more and more to where people are having to come to emergency rooms to get services that in the years past you would go to the doctor's office for.

I don't know why there has been such a move. Particularly on weekends you may not be able to locate a doctor, so you have to go to the emergency room. From what I have seen in some of the hospitals, and from what I have heard, often the man on duty there is a man that someone else has paid to take his place on the roster. Sometimes he is the man who is not too active in practice, so here he is.

Maybe he is not the most qualified doing the emergency service, and perhaps when emergencies come in, he is perhaps the least qualified to give emergency treatment at the time the person needs it.

Could you comment on that?

Mr. LADNER. I think that is a good point. We have felt in Rochester for a long time that the emergency room in our hospitals should be used for true emergencies, and that patients who can be cared for on an out-patient basis should not be sent or directed to the emergency

room.

If these patients are directed to this facility, the orderly care of patients who are in true need of emergency care cannot proceed promptly. In Rochester for many years we have had the philosophy that patients should be cared for as much as possible on an out-patient basis; that is, our doctors believe that only those patients needing hospitalization should be placed in a hospital.

Consequently, the major portion of our patients are cared for on an out-patient basis. They live in hotels or motels while they are being seen in our out-patient facility.

Mr. ROGERS. But I wonder if we will have to review our thinking and maybe have set up in a hospital a service for people who really don't have any emergency, as such, but need some help.

Mr. LADNER. Perhaps I didn't go into this in sufficient detail. We have in our out-patient buildings, which are separate from our hospitals, two facilities designed just to do this. One is called a children's health service and the other is the acute illness service, in which adults are cared for.

We try to direct as much as possible patients who do not need the elaborate services that are necessary in an emergency room to these other facilities.

Mr. ROGERS. If you would let us have the way you operate that, it would be helpful for the record.

Thank you.

Mr. FRIEDEL. Mr. Nelsen?

Mr. NELSEN. Thank you, Mr. Chairman.

First, I want to welcome my fellow Minnesotans to Washington. I would like to send back my personal greetings to Dr. McCarty. There were some very anxious moments in our family not too long ago and thanks to his skill, everybody is happy. I notice your reference on page 7 where you indicate that it would require $7 million per annum over a time of 7 years to develop this program.

Is this strictly in the area of study and research? Does this include equipment? What does it include?

Mr. LADNER. Mr. Nelsen, we estimate that of this total, approximately two-thirds of the cost would be brain work; that is, the design work and the research that is necessary such as Dr. Mayne talked about, structuring the medical records.

In addition, it would require a sizable number of man-hours of computer programers to create a system by which this information could be entered into a computer. About one-third of this cost or this total budget would be devoted to rental of computers.

Mr. NELSEN. You have no way of knowing what the net gain would be at the moment. It would take experimental processing before you would have any idea what the real costs would be in the future after you have gone through the experimental stage?

Mr. LADNER. Yes, sir. We are not far enough along at this time to give an intelligent answer to that question.

Mr. NELSEN. I recall the Methodist Hospital that came in here with a plan for a circular structure. Has this facility been completed? Mr. LADNER. Yes, sir. It was opened about the first of December last year. It has been accepted extremely well by physicians and patients. It is essentially fully utilized at this time.

Mr. NELSEN. Do you find it a satisfactory arrangement?

Mr. LADNER. Dr. Mayne can talk from the physician's standpoint about this.

Dr. MAYNE. My colleagues are very pleased with the facility, Mr. Nelsen. At present the people of Methodist Hospital are engaged in a research program to study the types of things you mentioned, for physicians and nurses, to compare the efficiency of work in different sizes and shapes of medical units.

Then there is the patient and physician satisfaction. Everyone seems enormously pleased not only with the physical facility, but with the

opportunity to experiment for the first time in finding out what is the best type, shape, and size of room, and so on, for caring for patients with different types of illnesses.

Mr. NELSEN. Getting back to the computer approach, the subject we are discussing, could a small-town practitioner, in order to get this information back, feed his file card index through a machine? How would this be transferred from his office, we will say from Hutchinson to Minneapolis, and then returned?

Dr. MAYNE. Probably through somewhat like a telephone exchange at the present time. I rather imagine that in the future, and this is guess work, computer facilities in areas will be somewhat like telephone institutions are at the present time.

This will be necessary if there is to be communication of large amounts of data, needing large processors over long distances. It is sort of like a telephone system or a local heating or electric plant. Mr. NELSEN. Thank you very much.

Mr. FRIEDEL. Mr. Keith?

Mr. KEITH. I have no questions, Mr. Chairman.

Mr. FRIEDEL. Thank you very much, gentlemen.

Our next witness will be our colleague from Maryland, the Honorable Edward A. Garmatz, chairman of the Merchant Marine and Fisheries Committee.

Mr. ROGERS. Mr. Chairman, I want to join you in welcoming the chairman of the Merchant Marine and Fisheries Committee to our committee. I have the honor to serve on the Merchant Marine and Fisheries Committee as well.

I know our committee will benefit from his testimony today.
It is a pleasure to see you, Mr. Garmatz.

Mr. MURPHY. Mr. Chairman, I also serve on the Committee on
Merchant Marine and Fisheries and have served for the last 5 years
with the distinguished chairman of that committee, Mr. Garmatz.
I hope by his appearance here today he understands why sometimes
I am absent from that committee because I am over here.

Thank you.

Mr. KEITH. Mr. Chairman, I am delighted to see our distinguished colleague here today.

Mr. VAN DEERLIN. Mr. Chairman, I will apologize for being late by stating that I was just over testifying before Mr. Garmatz. Mr. FRIEDEL. You may proceed, Mr. Garmatz.

STATEMENT OF HON. EDWARD A. GARMATZ, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MARYLAND

Mr. GARMATZ. Thank you, Mr. Chairman.

Mr. Chairman and members of the committee, I want to take this opportunity to thank you for affording me time to testify in connection with H.R. 6418.

It is my understanding that the purpose of this bill-amongst other matters-is to extend and expand the authorizations for grants for comprehensive health planning and services, et cetera-and to authorize cooperative activities between the Public Health Service hospitals and community facilities, and for the other purposes.

Presently the law affording medical care and treatment of seamen is set out in 42 USC section 249 (a), and covered under Public Health

Service Regulations, Part 32, found in PHS Manual Laws and Regulations TN-137.

Copies of the code citation and pertinent excerpts from the PHS Manual Laws and Regulations are attached as exhibits 1 and 2. Briefly the present law covers—

1. Seamen employed on vessels of the United States-and in some cases-American seamen of foreign-flag vessels.

2. Cadets at State maritime academies, or on State training ships.

3. Cadets at the Kings Point Maritime Academy.

However, the law does not now cover seamen trainees who are participating in maritime training programs such as those jointly sponsored by labor management groups.

These cooperative programs are set up to help overcome the current serious deficiencies of seagoing personnel.

The labor management groups within the maritime industry has directed its attention to various maritime training programs designed for both the licensed and unlicensed seamen.

In my city-the great Port of Baltimore-which is part of my district-the MEBA apprentice program is operated jointly by the National Maritime Engineers Beneficial Association District No. 1, and Pacific Coast District, AFL-CIO and the Nation's leading steamship companies.

Basically this is a 2-year program, offered to young men generally, without any sea service experience, leading to a position as a licensed marine engineer.

The first 6 months at the apprenticeship school are devoted to academic studies, conducted at their facilities on shore.

The following year, the students sail aboard U.S. merchant marine vessels as apprentice engineers.

The remaining 6 months, the students are returned to school-and at that time qualify to sit for their Coast Guard licensing examination. These students do not have the availability of medical care at public Health Service facilities during the first 6 months of their schooling-because they are not bona fide seamen at this point.

However, during the year at sea, according to the interpretation of the now existing law, the same students would be eligible for medical care at Public Health Service facilities.

And this same student would still be eligible for benefits for at least 90 days thereafter-once he then returns to school shoreside.

But he would not be afforded medical care at Public Health Service facilities during the last 3 months of this 2-year training program. Because, unfortunately, the existing regulations do not extend coverage to the seamen trainee beyond 90 days from his last discharge from a ship.

In order to include students engaged in maritime training program within the scope of H.R. 6418, I propose-and urge-the adoption of the following amendment to H.R. 6418.

The text of the proposed amendment is as follows:

(d) subsection (a) of section 322 of such act is further amended by adding at the end thereof the following new paragraph:

"(8) Seamen-trainees, while participating in maritime training programs to develop or enhance their employability in the maritime industry."