who can do it well and effectively under adequate supervision. You see the beginning of this when a dental hygienist and not the dentist cleans your teeth, when a technician and not a radiologist X-rays your chest, and when an aid and not a nurse makes up your hospital bed.7 But in medicine in general we may not be using quickly trained help as widely and as intelligently as the Armed Forces did nearly a quarter of a century ago, and as they are continuing to do today. Third, we must use machine systems-and this is vital todaymachine systems that utilize computer systems, for any repetitive tests that would be drudgery and an uneconomical use of the time of health personnel, particularly the health personnel that is highly trained or permanently scarce. These categories are registered nurses and physicians. The optimum use of machine systems that utilize computers as an aid and a backup to physicians and nurses, would relieve the shortage of professionals that we have today and would enable the existing ones to serve at their highest level of patient care. Today we are going to try to illustrate some of those general concepts with a model that was begun at the heart disease control program in the Division of Chronic Diseases in the late fifties. The heart disease control program and the Division of Chronic Diseases have long known of need for integrated health services to the elderly. This has been one of their principal areas for research and development these past few years. As a model for national delivery of health services, we have chosen the electrocardiographic system. However, we are first going to show you another system, which was developed from the model after we were satisfied that the model itself was successful. The subject, Mr. Flaherty, is going to perform a forced expiration. He will blow into a spirometer that has been located at your left-hand side of the auditorium. The spirometer is a device that measures and records the volume of air expelled by the subject in specified units of time. These changes in the volume that are obtained from the spirometer are being recorded by the data-acquisition device, which Dr. Ridges is presently operating. The device records the data on analog magnetic tape for economical storage and later use, and also allows the signal to be sent to the computer over conventional telephone lines. The device also records the patient's identification number and information relating to his age, sex, height, and weight. It also will record the signal as a tracing on paper for monitoring by the physician. The computer system that we currently have at the instrumentation field station located on the campus of George Washington University has now received the signal from the test subject for this particular demonstration, and we will soon get back an analysis. The computer there takes roughly 30 seconds to do the analysis of the spirogram, and then starts transmitting the data back to us over the teletype. The teletype, as Dr. Slack has shown, is a relatively slow device, but it is economical. The computer system at the field station will have already printed out the answers long before they are available to us here, but the high-speed printer there is relatively expensive. We are now getting back from the teletype a printed page that gives the data in reference to the breath that was exhaled. (The print-out follows:) INSTRUMENTATION FIELD STATION HEART DISEASE CONTROL PROGRAM COMPUTER PROCESSED FORCED EXPIRATORY SPIROGRAM PROCESSING DATE 09/21/66 CALIBRATION CONSTANT 1,075 ML 23 YRS SEX N HEIGHT 73 IN Computer report of a spirogram taken on a patient at the Senate Office Building. The numbers are volumes and flow rates of the air expired by the patient and are a useful measure of a patient's pulmonary function. Senator YARBOROUGH. Doctor, how far away is the instrumentation field station on which this was being recorded? Dr. CACERES. The instrumentation field station is near Washington Circle. Senator YARBOROUGH. That is some miles away from here? Dr. CACERES. Roughly 3 miles. It is near the Virginia boundary of the Federal District. It is about 5 miles away. The signal leaves the data acquisition set in the auditorium over a conventional telephone line, a standard line with an analog data-phone interface. This type of interface device is now available from telephone companies, so that you can transmit analog signals from a specific recording device at the patient's side to the computer center. In other words, you don't have to have a computer center everywhere you record. Senator YARBOROUGH. Are some of the processes you have explained here used to implement the Regional Health Centers Act that the last Congress provided for? Dr. CACERES. In developing these systems we have hoped that they would be utilized in all regional health centers, and in all modern hospitals as well. As a matter of fact, these systems could be utilized by physicians in small clinics. The data-phones are small devices. I am going to ask Dr. Ridges to show the data-phone system that can be used with a conventional telephone. This is what a private nurse or visiting nurse could take into a patient's home, along with a small, portable electrocardiograph, to transmit the signals to a data center, and get back from the data center the results of the analysis by voice recording. If the signal were sent from a clinic, the results could be returned via a teletype device such as we have here. Senator YARBOROUGH. Then the nurse by attaching that to the phone could take the electrocardiogram right in the person's home? Dr. CACERES. Yes, sir. Senator YARBOROUGH. By attaching this device to the phone? Dr. CACERES. Yes, sir. With the same device, the spirometric analysis, which would take a physician about 20 minutes to do, can be available to the clinic immediately. Today not 1 person in 1,000 has had a spirometric examination. In this day when we know that emphysema, a disabling lung disease, is highly prevalent, and we know that smoking is a major cause, we can say with certainty that insufficient numbers of people are being tested for their pulmonary problems. This is so because the spirometric testing requires some degree of additional training for the physician. It also now requires an investment of physician time that might be excessive in view of the numbers of people that require testing, and in view of the large amount of computation time needed to do the analysis by manual methods. This means, then, that we are not giving the best information that we can for the detection and followup of lung diseases. The solution to the problem in reference to spirograms is obviously not for the physicians to go back to school to try to learn some very difficult techniques, or to impose upon them the need to do computations that they are not set up to do in their clinics, but to have nonphysicians run the tests and a machine system to do the computations. We have, then, a system that helps us to reject two unacceptable proposals. One is the notion that when our scarce physicians are working full-time caring for the sick, so-called luxury services, like disease prevention, disease detection, and periodic physical examinations, should be cut back or elminated. Dr. Slack has shown some of the reasons why we don't have to curtail some of these services, and these demonstrations and those of Dr. Thiers will show others. The second false notion is that nothing is wrong with today's health practices except that some people can't afford to pay for them. The answer is that even unlimited money would not buy quality services for everyone today, because our present modes of organization and delivery do not take advantage of all the modern concepts of organization and management that have begun to tap the potentials of automation technology. Now we will begin to receive data sent from a hospital outpatient department in Hartford, Conn., to our computer in Washington. The question that Senator Yarborough posed to us about distance can now be more properly answered. The electrocardiographic interpretations being printed out on the teletype now are of signals recorded in Hartford Hospital this morning. They were received at the field station a few minutes ago, and you are seeing the answers here. These same interpretations are also being transmitted back to Hartford Hospital. This means that if we have a patient anywhere in the country, with a machine system, we are capable of giving him the types of services that the most experienced cardiologist could give. By having stored within the computer the cardiologist's available knowledge of the electrocardiogram, we are in effect bringing the services of a cardiologist to the bedside of the patient. This is a demonstration of what can be done by the modern use of computers and other available electronic and communications technology. To show you what was done in Hartford today, we will now record an electrocardiogram on a subject here and simultaneously transmit it to the computer. Additionally, the data is being recorded on analog magnetic tape, in the data acquisition device that we have shown, and will be available for later use. Each EKG has been interfaced with appropriate codes, so that the signals can be easily identified by the computer system. The computer system will receive the signals from this patient as the signals are being recorded. It is receiving them over a conventional telephone line. When the recording of the electrocardiogram is completed, a procedure requiring 3 minutes, the computer will start sending back answers with a delay of only 15 seconds. This is done even before the technician can begin to remove the electrodes from the subjects. The answers are now available here, and in another situation could be available for use by physicians in practical circumstances. In our current screening examinations, as part of the trials of this procedure, we have found that roughly 30 percent of individuals that walk into a screening system will have some type of cardiographic abnormalities. This doesn't necessarily mean clínical abnormalities. I hope Dr. White will take a look at the electrocardiogram that we have recorded here. We will match his interpretation with the computer's. We have found that even on individuals in the younger age brackets, we have findings in the electrocardiogram that can be used for later analysis. Dr. White just mentioned that it would be wise to store information from the young for use later on when they are older. The subject here today, Mr. Flaherty, happens to have some nonsignificant clinical findings in his electrocardiogram. He is among the 20 percent of 22- to 29-year-old men that happen to have these findings. These would be good to know now, because if he were later examined for heart disease, the physician would have this background information and would not inappropriately do certain things on the basis of the later data alone. With a preliminary electrocardiogram, he would know that the patient falls within a category in which certain types of data do not indicate heart disease. The two electrocardiograms from Hartford are here, and the one from the subject will be forthcoming. VENTRICULAR RATE OVER 100 IN 2 OR MORE LEADS; TACHYCARDIA Two computer processed electrocardiogram reports sent to the Senate Office Building from the Instrumentation Field Station in Washington, D.C. The electrical signal was recorded from a patient in Hartford, Conn., relayed over the telephone to the field station, analyzed by the computer, and sent by teletype to the Senate subcommittee hearing. The total procedure took place during the hearing. Incidentally, in our tests done at the American Dental Association last year by telephone from Las Vegas to Washington, we were able to screen 1,200 dentists at their national convention. The data that were available the day after the meeting allowed tabulation of abnormalities by age of the subjects-something that cannot be done in current academic or clinical circumstances unless one uses computers. We found in these screening tests that as one increases in age, abnormalities in electrocardiograms tend to increase. By age 40 to 49 over 30 percent of the subjects will have abnormalities of some type, not necessarily abnormalities that disable, but things that the physician should know. By the time we are 50 years old, over half of all of us will have certain abnormalities that the physician should know. They could be precursory to disease and should be evaluated, or perhaps are useful in followup of patients. |