give this drug or another drug which has to be given at specific time intervals?

The electronic equipment preheats in transit to the bedside so no time is wasted with instrument warmup and stabilization. Another electrical impulse is sent to the elevator shaftway, to override the automatic elevator programer which shifts to emergency alert status. Logic circuits select the best elevator in the bank, based on proximity and other factors, send it to the floor and lock it where the emergency cart is located. The elevator unlocks only when the cart is in its cab because of an electronic command interlock between the cart and elevator. Other elevators respond to pocket size command transmitters carried at all times by emergency team members.

For emergency surgical cases brought to the accident ward, a different dialing number is used-for example, automobile accidents, poisoning cases, and so forth. Various vital telephones are used to call different categories of personnel, while the elevator goes to the appropriate floor to receive the patient.

For large multipatient accidents or disasters, the system also links to telephones outside the hospital and can thus summon physicians and supporting personnel from their homes and offices.

The separate events which take place when the hospital emergency command system is triggered by an alerting telephone call have taken some minutes to describe. They are actually simultaneous electrical events which take only several seconds. We have, in effect, substituted simple electrical circuits to provide communications and mobilization in parallel rather than relying on humans to act swiftly and consistently in series.

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This is not an esoteric research project. The significance of the hospital emergency command system is simply that it meets a very real need in a very practical manner. Because it utilizes the existing tele

communications equipment and lines within the hospital and requires relatively minor changes in elevator programers, it will be economically feasible for most existing hospitals over 30 beds. The cost is even lower when planned for new construction.

In addition to the specific technical advantages of speed, simplicity, and reliability, the hospital emergency command system requires the hospital to reevaluate, rethink, and refine its internal organization for emergency care. This in turn will tend to upgrade personnel training, professional competence, equipment maintenance, and other important factors.

When a system like this is brought into a hospital, it has a number of spinoff factors that raise the level of competence for handling emergencies within that hospital.

In the ultimate analysis, however, the true worth of the hospital emergency command system must be measured in terms of decreased patient mortality and the increased number of long-term survivors who return to a meaningful and productive life.

We shall soon begin a 2-year evaluation phase to determine the change in survival rates so that we have specific data.

We feel that the hospital emergency command system will have a significant effect on patient mortality. It is our contention that there should be no such thing as emergency care in a hospital. Emergencies within a hospital are expected and should merely evoke an effective routine response.

Senator NELSON. Thank you, Dr. Nobel.

What is the cost of installing such a system in a hospital?

Mr. CALLAHAN. Mr. Chairman, I think that I can estimate that for

you.

In a hospital of 600 to 800 rooms, the cost would be about $150 a month, and for each additional alert arrangement, another $10, so that if you had two different alerting arrangements it would be around $160, and so forth.

Senator NELSON. You mean that in a hospital that has already been built with the elevators operating on their own system, this system can be brought in at a cost of $150 a month?

Dr. NOBEL. We should clarify this a bit. The communications phase can be brought in at that cost. There will be a cost, depending on the number of elevator banks used and installation costs for reprograming, in the range of $10,000.

Now, in the overview for hospital costs, $10,000 is not terribly significant for a refined emergency call system, and a monthly charge of $150 for a large medical center, which may have a telephone bill in the $20,000 range, does not appear to be very significant.

Senator NELSON. Well, so that it is clear for the record, you have certain equipment, emergency equipment, for example, that is electronically activated upon the code call of the nurse in the room in which the emergency occurs. Then when that piece of equipment is brought onto the elevator, the elevator will not move until activated by the electronic relationship between that piece of equipment and the elevator. Can you take the hospital's emergency equipment and add this telecommunications equipment to it?

Dr. NOBEL. That is correct.

Actually, the electronic interlock on the resuscitation or emergency cart is a simple add-on black box. In effect, the cart says to the elevator electronically, I am here, and the elevator responds and says, OK, we will go.

Senator NELSON. Are you saying, then, that if a hospital of 500 or 600 beds wished to install the system that you have described here, they could install the basic system for about $10,000?

Dr. NOBEL. That is correct, sir.

Senator NELSON. And then the cost of servicing or maintaining the system is about $150 a month?

Dr. NOBEL. That is correct.

Senator NELSON. How many hospitals in the country have installed this kind of a system?

Dr. NOBEL. We should tell you that the system is in development and that we are currently installing three prototype test systems for long-term evaluations. We do not feel that we will go ahead with general availability until we have specific patient mortality data that shows how justifiable the system is.

Now, looking forward, it will be a relatively short time before we have this data and we hope that the systems will be generally available throughout the country within the next year or two. Senator NELSON. Has this equipment been tested yet in an operating hospital?

Dr. NOBEL. Not at present. We have operating laboratory models, we have a computer simulation of the system underway, but the first full scale operating system will not be operating for severa months yet. Senator NELSON. Do I understand you to say that you are installing this system in three hospitals; pilot tests, so to speak?

Dr. NOBEL. That is correct.

Senator NELSON. Are you free to say what three hospitals they are? Dr. NOBEL. Yes; the hospitals are all located in the Philadelphia area-Jefferson Medical College Hospital, Hahnemann Medical College Hospital, and Pennsylvania Hospital. These three hospitals were chosen because they represent a very broad spectrum of different problems in architecture, elevators, communications, and so on.

The system is quite adaptable. For example, if you have only manually operated elevators, we go right into their telephone and speak to the elevator operator who makes an appropriate response. In the older hospitals with manually operated elevators, there is no requirement for a $10,000 change in elevator programers. The cost is actually lower.

Senator NELSON. But I did understand you to say that to institute the whole system, not just the elevator part, you are talking about an investment of $10,000?

Dr. NOBEL. Assuming that we are going to use automatic elevators. If we are not going to use automatic elevators, then there is no $10,000 additional cost.

Senator NELSON. Just the $150 monthly maintenance; is that it? Dr. NOBEL. Just the monthly cost; yes, sir.

Senator NELSON. Then how long do you expect to test this system to find out whether or not you are prepared to make it available to any hospital that wants it?

Dr. NOBEL. We will complete a preliminary evaluation within 1 year and the actual study is a 3-year one, involving installation of systems and total evaluation. But within the first year of operation, we will have a very clear idea as to how justified we are in proceeding ahead on a broad basis.

Senator NELSON. Well, what is the main factor in consideration? If you cut the time in half, that is factor enough; is it not?

Dr. NOBEL. We will do considerably better than cutting the time in half. We estimate, for example, at one of the hospitals that we can reduce mobilization time from about 9 to 12 minutes. Now, this is certainly significant.

However, even though the hospital emergency command system is desirable in terms of its fixed organization and its routinization of response, we have to show decreased mortality rates-increased survival rates. In the ultimate analysis, this is what is important to us. These statistics take a little more time to gather.

Senator NELSON. Well, I guess the doctors would have to decide that. I would assume that if you cut the time by 7 or 8 or 9 minutes in any emergency, you are going to find that sometime you save a life. I guess I could assert that.

Dr. NOBEL. We are convinced of this, but we want to see it in numbers.

Senator NELSON. Thank you very much for your very interesting presentation. We appreciate it.

Dr. NOBEL. Thank you, Mr. Chairman.

Mr. CALLAHAN. Thank you, Dr. Nobel.

Mr. Chairman, the systems we have described so far illustrate some of the ways that modern communications can help the medical profession fight heart disease more effectively.

In New York, at the Memorial Hospital for Cancer and Allied Diseases, a relatively simple communication system permits computer planning of radiation treatment for other hospitals.

Furthering the concept of regional medical programs, Memorial Hospital, serving as one of the regional cancer centers, has already extended the benefits of its unique, highly sensitive, and accurate treatment planning facilities to two other institutions, one located in the Greater New York metropolitan area and the other in San Francisco. The hospital plans to make this program available to other hospitals nationwide.

Communication between the collaborating hospital and Memorial Hospital, which is a clinical unit of Memorial Sloan-Kettering Cancer Center, is via teletypewriter using the telephone network and a DataPhone data set. Patient medical data will be sent to Memorial Hospital via the teletypewriter from the participating hospital, describing certain data about the patient contour, the treatment parameters such as the size of the field to be irradiated, the number of portals through which the radiation will be given, the angles at which X-rays will be

delivered, and the kind of radiation equipment for which the computation is to be made.

The data is received at Sloan-Kettering, both in printed form and recorded on punched paper tape.

Since the teletypewriter is also equipped with the Data-Phone, the verbal communications can also be used when needed. The tape is fed into the computer, which is programed to prepare a complete treatment plan. The plan is then transmitted back to the hospital via teletypewriter. Total computer time for the complete treatment plan runs between 5 and 10 minutes, according to the complexities of the computations involved.

Representatives of Memorial Hospital state that before the advent of computers, radiation treatment planning was performed to the best of the ability of the professional making the computations. However, the plans had to be much more grossly calculated, because the time required for highly refined figures would have delayed the treatment of the patient. But even with computer computation, it previously took approximately 4 days for hospitals outside of the New York area to avail themselves of this service by mailing or bringing pertinent patient data to Memorial Hospital.

The two hospitals who have already availed themselves of the program are St. Luke's Hospital in New York, and Mount Zion Hospital in San Francisco.

This program will make Memorial Hospital's advanced computerized system and technical staff available to other hospitals, avoiding costly duplication of staff and equipment. Thus Memorial Hospital, functioning as a regional cancer center, will service institutions across the country. It is planned that this service will include guiding and advising collaborating hospitals via education and staff exchange

programs.

As more and more of such regional cancer centers are developed, technical information will be transmitted from one center to another, thus assuring every patient accurate quality radiation treatment whenever and wherever indicated.

The radiation center service will make possible the practical and rapid diagnosis and determination of treatment planning that is so vital to the treatment of cancer patients by radiation.

I have asked Dr. John Laughlin, Attending Physicist at Memorial Hospital for Cancer and Allied Diseases, to describe for us the kind of treatment the computer prescribed. Dr. Laughlin has been associated with Memorial Hospital for Cancer and Allied Diseases for many years. To augment his Telelecture communication, Dr. Laughlin will also use some telewriting. Telewriting with Data-Phone data communication service makes it possible for a speaker to supplement his telephone presentation with handwritten notes or drawings projected on to a screen.

(The telewriting illustration performed in New York follows:)

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