puters in the laboratory, and the evaluation of the so-called Laboratory Profile. I think, however, that before I go into an outline of these plans, I should discuss briefly our reasons for the changes we are making. The concept of the laboratory playing a role in preventive medicine with socalled "multiphasic screening programs," "biochemical profile" or a "Laboratory Profile" is not a new one to pathologists. As an early form of screening tests to detect unsuspected diseases, pathologists have been doing urinalyses, tests for the diagnosis of syphilis and routine blood counts on all patients admitted to their hospitals for years. Since 1960, pathologists concerned with the Section on Pathology and Physiology of the American Medical Association have been surveying by screening tests those physicians attending the annual American Medical Association convention. There are numerous pilot studies already published of the results of laboratory screening tests and the relatively high percentage of pickup of abnormal results noted on routine screening tests on both in-patients and outpatients. Here in our hospital a small pilot study was done utilizing four different procedures in studying 348 patients routinely admitted to the hospital. We noted in one or more of the tests that 43 percent of the patients had abnormal findings. Thus, it became apparent to us that there was an important medical need for the performance of a routine laboratory testing profile on all patients admitted to our hospital. It further became apparent that these services should be available for all patients on a routine and economical basis. Certainly with our present methods of providing this, the cost for the patient would be exorbitant. Consequently, our interest in automation and the use of computers. We now have nine different test procedures automated in our laboratory. Recently, the availability of automation and the application of computers for use in the laboratory has allowed us to perform a greater number of patient tests without an increased cost to the patient. It is our intention and hope that when our complete program is finished, we will be offering approximately twenty-five routine laboratory determinations for every patient admitted to the hospital. However, this will cost the patient no more than the routine five tests we now administer. The program has been developed in several phases as follows: PHASE I-PROVIDE A LABORATORY ADMISSION PROFILE ON AN ECONOMIC BASIS FOR ALL PATIENTS ADMITTED TO PERTH AMBOY GENERAL HOSPITAL STEP 1 Provide, within a few hours after admission, a laboratory admission profile consisting of twelve tests (fasting blood sugar, blood urea nitrogen, sodium, potassium, chloride, carbon dioxide, lactic dehydrogenase, hemoglobin, hematocrit, white blood count, complete urinalysis, and V.D.R.L.). In order to accomplish this shortly after admission, a separate crew of laboratory workers will be hired to work from 3:00 P.M. to 11:00 P.M. so that these tests can be drawn when the patient is admitted to the hospital and the work done in the afternoon and evening shift and the reports placed on the patient's chart before midnight so that the doctor will have them the following morning. This we intend to have in effect by October 15, 1966. STEP 2 Introduce additional automated tests by at least eight tests, i.e.: Total protein. albumin, S.G.O.T., uric acid, akaline phosphatase, calcium, red blood count, and bilirubin. Target date-January 1, 1967. Note: These tests will be done by the use of automated equipment, that is, autoanalyzers. PHASE II-THE AQUISITION OF COMPUTERS FOR THE DEVELOPMENT OF A DATA PROCESSING SYSTEM STEP 1 Development of the Data Acquisition System. This system consists of acquiring a computer or computer-like equipment to obtain the electrical signals generated by the automatic chemical analyzers and either converting them to machine readable form to be handled by a second computer as described in Phase II for reporting, or reading them directly into a computer to handle Steps 1 and 2. Target date-October 1, 1966. It is expected that by May, 1967, the necessary equipment will be installed in the laboratory and working effectively. STEP 2 The development of the so-called Laboratory Information System. This includes the acquiring of a computer and the writing of programs so that all information concerning the patient is stored in the computer. On a periodic basis (daily) all of the laboratory information about this patient including the present day's work and all previous work on the patient can be listed in easily readable form, with the test arranged in medically logical order. In addition, throughout the day so-called "ward reports" will be rendered. PHASE III-EXPANDING SCOPE OF PROGRAM TO INCLUDE MASS SCREENING STEP 1 We plan an expansion of the above program to provide these benefits with large mass screening capabilities to handle (1) private out-patients, (2) out-patients from our own out-patient care clinic, as well as patients in cooperation with various public health programs for preventive medicine, and (3) industrial health care programs in relation to local companies. Target date-July 1, 1967. STEP 2 We hope that numerous physiologic data will be available, such as the routine chest X-ray, cytology screening, EKG, spirometry tests, routine eye examinations, hearing examinations, etc. This program would necessitate construction of additional space, including a large out-patient clinic and additional staff consultants in the various specialties involved in these tests. In addition a paramedical personnel would have to be added. Planning target date-October 1, 1966. Pilot program target date-July 1, 1968. PHASE IV-JOINT RESEARCH The research related to this program has already begun on a limited basis in affiliation with the School of Engineering of Rutgers University. There are numerous potentialities for vitally important research projects, such as the establishment of normal values based on patients' age, sex and other variable factors. When all our laboratory data is in machine readable form with the ability to store, evaluate, retrieve and correlate findings with disease patterns, the possibilities for practical research will be unlimited. At present, in conjunction with Professor Walter Welkowitz, Ph. D., who is in charge of the Biomedical Engineering Program of the School of Engineering of Rutgers, the State University, the following research applications have been undertaken : 1. All of our surgical pathology diagnoses since January, 1965, and all of our autopsy diagnoses since May, 1964, have been coded and converted to machine readable form and are now stored in the central facility at Rutgers. We thus have the ability to evaluate and correlate diagnoses based on numerous variables. 2. All of the results of our bacterial cultural studies and antibiotic sensitivity studies since January 1, 1966, have been similarly coded and placed in machine readable form. We have already made several studies with this data that will help the physician in picking the appropriate antibiotic with which to treat a patient two days before he will have any definitive cultural or antibiotic studies. The results of this work are in the process of being submitted for publication. 3. Utilizing a terminal to a large computer in New York City (Quik Tran Service), we have now devised a system to calculate and give preliminary diagnosis from our routine protein electrophoresis studies on a daily basis. I, as a pathologist, am excited about the most recent advances in automation and data processing and the prospects they hold for enhancing our roles as physicians and for improving medical health care at a cost the patients can afford. I must, however, offer a word of caution. First, I have been particularly fortunate at Perth Amboy in obtaining the help and support of a forwardlooking dynamic hospital administrator, Mr. Robert Hoyt. Not all pathologists are as fortunate. Most pathologists must compete with other medical facilities for the hospital dollar, and at least in the past they have not had a free hand in developing expensive programs such as I have outlined above. Secondly, I have also been fortunate in obtaining certain limited donations and I have applied for foundation grants. Again, this simply is not practical for most pathologists. Thirdly, these programs may not be practical in the setting of the small hospital. And finally, I want to make clear that we are, in a very real sense, pioneering. The programs we have instituted are largely experimental. It is neither wise nor practical to bring about widespread change in this vital area without the proper foundation, and without an adequate testing period. Nevertheless, even with these qualifications in mind, I think we can all look forward to exciting and rewarding advances in this field-advances that will require even greater skills, industry and knowledge on the part of pathologists and yet that will greatly advance the care of patients. Sincerely yours, HUGO C. PRIBOR, M.D., Ph. D., Senator WILLIAMS. I hope I can spend a lot of time with you, Madam Chairman, in these hearings, and you have a group of witnesses that could not be excelled. The witness list is one of the best I have seen. I think that we can be very hopeful that we can be helpful to a healthier Nation through these discussions, these hearings, and legislation that might follow. Senator NEUBERGER. Thank you. Senator Williams has long been in the forefront on this very subject matter that we are discussing today and we do appreciate his continuing interest in the subject. Today we are beginning hearings and receiving testimony from a list of very distinguished witnesses who have had experience with modern health testing methods. I will repeat again for those who have just come in that this is the Subcommittee on Health of the Elderly of the U.S. Senate Special Committee on Aging. Let me emphasize that this committee has no legislation before it. It is rather unique in holding hearings of this kind to have such distinguished witnesses as we have. It is an unusual approach to a hearing of this size, so it is very gratifying to me as chairman to have had the response that has been forthcoming from the doctors, deans, and social workers who have come to explore an idea with us. It is not so much a new idea with some of them, but for Members of the Senate, including Senator Moss of Utah who has joined us, the record that we hope to develop and the idea we are here to explore is whether or not it is possible to apply modern testing methods such as automated or semiautomated procedures to the detection of chronic illnesses. There may be no easy answer to the question, but we need the light of informed discussion. As I studied the need for this hearing and made preparations for it, three factors became apparent : 1. We in the United States live within, as one doctor has put it, a golden age of treatment and a dark age of preventive medicine; and that 2. There are significant stirrings and some practical work now underway on screening programs intended to alert the public and practitioners to the need for early recognition of chronic disease; and finally 3. That it is time that we explore the national interest in all efforts that will reduce the price we pay for permitting disease to debilitate its victims before we finally deal with it. In the United States the cost of illness, disability, and death is now about $93.5 billion annually. That sum, the latest available estimate from HEW, includes the probable losses in income related to death or disability. If we were to do absolutely nothing about reducing the incidence of chronic disease within the next 10 years, our total for the direct costs of death and disability would almost double by 1975. We have passed Medicare and medicaid. One program rescues the elderly from calamitous costs of some health care after 65. The other assures some treatment to those most in need of it. You know, we have provided for a heart, stroke, and cancer treatment coordination program. President Johnson has promised that early next year he will offer new ideas for better delivery of health treatment. He has also appointed a commission to study medical manpower shortages. But when do we turn the corner from treatment to prevention? When will we maintain health as devotedly as we now fight disease? When will we make the most of our medical manpower by reducing the time spent in taking routine tests and histories? What we are here to explore is, can we adapt our computer and automation technology to screen millions of Americans every year and thus finally encourage an entire Nation to think in terms of preventing illness? I will move at this point to include those letters and supporting material in our hearing record, if there is no objection. I will also say that the authors of many of the letters responded with an enthusiasm which is most encouraging. (See Appendixes.) We are very sorry that Congressman John Fogarty will not be present to testify. The press of business in the House of Representatives requires his presence there. He has however, submitted a statement which will be included in the record at this point. (The statement referred to follows:) STATEMENT OF HON. JOHN E. FOGARTY, A MEMBER OF CONGRESS FROM THE STATE OF RHODE ISLAND Madam Chairman and members of the Subcommittee on Health of the Elderly: during the next few days, you will hear much about preventive medicine, about early detection of chronic diseases, and about the "new look" in health testing with electronics and automation. What you hear may not sound as dramatic as the story of some new "miracle cure." A relatively simple pressure test on the eye, a blood test, an X-ray or cell smear may sound routine and unexciting. But, when these are combined with other procedures of preventive medicine we create great power to delay, minimize or prevent the crippling, the blinding or even the fatal consequences of many chronic diseases. Add all this to the fact that the chronic diseases are fast emerging as the greatest health threat confronting the Nation today, and we begin to see how truly enormous and far-reaching are the implications of the health protection story. Each year I listen to the testimony of the Public Health Service with respect to the appropriations needed to strengthen our attack on the chronic diseases. Each year I become increasingly concerned with the seriousness of the problem and with its continued growth. We simply are not moving fast enough even to stand still against the insistent menace of cancer, heart disease, arthritis, diabetes and a whole host of their fellows. We have yet to turn the tide of chronic diseases, and we cannot do it by merely reacting to these conditions after they have hit full stride. The key is to catch them before they start or when they are just appearing. As long ago as 1947 four major professional organizations issued this joint statement: "The basic approach to chronic disease must be preventive. Otherwise the problems created by chronic diseases will grow larger with time, and the hope of any substantial decline in their incidence and severity will be postponed for years." In the 20 years since this deciaration many others with similar conclusions have followed. But our progress toward broad application of preventive medicine has been halting and painfully slow. We have in fact had more endorsements of the concept than action to back it up. Furthermore, we are told and it is true that we don't have enough trained manpower to meet the immediate demands for treatment of those already sick and in distress. We are told that we don't yet know enough about the chronic diseases to deal with them effectively. We don't have to be told of the depth of public resignation and apathy to the chronic diseases. So many people have for so long accepted arthritis or heart diseases or other serious chronic ailments as just as much a part of growing old as baldness or bifocals. Certainly, our knowledge is incomplete. We have to give the research scientist time and full support to find more answers. We have to care for those already sick-we have to deal with apathy and resignation. But we also have to break a vicious chain. We have to stop the upward climb of the chronic diseases in order to catch up with the burden of sickness and disability we already bear. And we are not helpless in this effort. We have vast, untapped potential as well as considerable knowledge of chronic disease. We already know, for example, how to prevent thousands of deaths from cervical cancer; we can stop many of the personal and social evils caused by unnecessary blindness or sight impairment caused by glaucoma; we do not have to permit the hopeless invalidism we now accept in thousands of survivors of stroke or heart attack. But with mounting demands for treatment from the already sick and with proportionately fewer professionals to provide the care, how do we meet the problem? Endorsements, slogans and exhortations alone will not succeed. We learned this long ago in providing better care for the young. With our children we are not content merely to preach the values of preventive medicine. Neither are we willing to accept excuses about manpower shortages and incomplete knowledge as a substitute for action. As a result, serious sight and hearing impairments are prevented, crooked limbs are straightened, and rheumatic hearts repaired. We are not doing enough, no doubt, but by comparison, vastly more for children than for adults. What makes the child when he becomes 40 or 50 or 60 less worthy of protection, less entitled to all that medical science makes possible to keep him productive and useful and free from suffering and death before his time? What I have said is not to belittle the spectacular gains that have been made in therapeutic medicine. We can be justifiably proud of the achievements in this area-and we continue to be challenged to find still more effective ways to treat illness when prevention has not or cannot be achieved. Medicare is truly a major part of our progress in providing better care to adults. It is heartening to know that at least a part of the burden of sickness is being lifted from the shoulders of older people. More than this, most of us believe that many of our senior citizens will now get needed treatment which before was unsought through fear of financial embarrassment. We hope that the current attack on the killer diseases-heart, cancer and stroke through development of the Regional Medical Centers concept will extend the best and latest curative methods throughout the Nation, not just within the walls of the relatively few and most advanced teaching hospitals, clinics and research centers. All this is solid progress-and vital. Certainly, I am not saying we need less progress in treatment. Rather, we need more progress in prevention. For in a very real sense, the long-range goal of medical science is not the treatment of disease but the preservation of health. One pioneering development in preventive medicine I had the privilege of observing not long ago is an imaginative program being carried out by the Kaiser Permanente Health Foundation in California. There we saw a health testing program which utilizes automated equipment and computer techniques for providing a comprehensive battery of tests to large numbers of persons with a 69-803 0-662 |